The RemedyUK Blog

War of the Woeful.

2007-12-21T11:11:00.001Z

“We know now that in the early years of the twenty first century junior doctors were being watched closely by intelligences greater than their own. We know now that as house officers busied themselves about their various concerns they were scrutinized and studied, perhaps almost as narrowly as a man with a microscope might scrutinize the transient creatures that swarm and multiply in a drop of MSU…

With infinite complacence juniors went to and fro all over the UK about their little affairs, serene in the assurance of their dominion over this small foundation post which, by chance or design, they had inherited from the lucky sod who landed a run-through place last year.
Yet across an immense ethereal gulf, minds that are to our minds as ours are to the beasts in the jungle, intellects vast, cool and very unsympathetic, regarded our previous training programme with envious eyes and slowly and surely drew their plans against us.
In the seventh year of the twentieth first century came the great disillusionment. It was near the end of October. Business was better. Morale was picking up. On this particular evening, we estimated that thirty-two million people were listening in on radios…”
Was H.G. Wells predicting the current MMC situation when he penned War of the Worlds? Perhaps not thirty-two million, but each day hundreds of junior doctors now check the MMC website, eagerly news regarding “the design, implementation and timing of MMC recruitment to specialty training 2008”.

Yet, there is only that picture of the little man with his hands in his pockets in the top left hand corner to greet us. Is this apt? Will today be the day we wonder? “Detailed information for applicants is expected to become available in early December 2007” I didn’t even have to highlight the “early December” bit. It’s already highlighted.

Please pardon the Orsonian introduction and I know MMC has been flogged to death (and my word how we wish it really had been), but at the moment I find myself in junior doctor limbo. With the next cohort of juniors due to start application for specialty training next month, we wait anxiously. Has it really been a year since the gears of MTAS began to creak and groan…and promptly crash we ask ourselves? My, doesn’t 12 months fly when you’re worrying your pants off about your career?

So, what next from the DoH? How will the latest news regarding recruitment manifest itself in the application process? Devolution (I’m one step ahead of you). No national IT system for applications (cue January postal strike and all submissions via carrier pigeon being made mandatory). Staggered start dates. Staggered? Consider the Oxford Dictionary definition of the word; “walk unsteadily, shock confuse, cause to hesitate or waver…” We can only speculate as to what explanation Prof Pierson would offer us.

Despite the obvious concern, especially when last years events are considered, we all continue with our daily duties to the best of our ability. And each day we check the MMC site like love sick teenagers checking their mobile phones… but Patricia left us long ago. In the mean time we shall amuse ourselves with the ever popular “alternative definitions for abbreviations” game. Hmm, MTAS… My Trainings All Stopped? Suggestions on a postcard please…

Dr David McCarthy, FP2 in Trauma and Orthopaedics

The RemedyUK/ HCSA Contract Clinic

2007-11-20T13:16:00.000Z

Having just spent a day (Friday 16 November) at the
offices of Remedy UK advising its members on
contractual and employment issues I was struck by just
how difficult and upsetting the current plight of
trainees has been. From my discussions with members of
RemedyUK my impression is that all too often employers
and Deaneries are concerned more with cost savings
than the provision of quality teaching and looking
after the professional and personal lives of doctors
in training.

The evidence? Well what about the trainee who still
has no contract of employment from her Trust despite
being told that no longer would the provisions of her
earlier contract with the Deanery apply. Or the
trainee who at three days notice had to drop
everything to move 120 miles yet was told that
expenses would not be paid. Or the trainee whose
concerns with colleagues about the poor standard of
training were being ignored? And throughout the day
these and other similar tales of woe were being
received into the RemedyUK Office.

I have seen and heard for myself in just one day in
the RemedyUK office some of the many and real problems
they are facing. The discredited MTAS system has done
a huge disservice to the senior doctors of tomorrow. I
just hope that Trusts and Deaneries can find it within
themselves to show considerable more support to
trainees than would currently seem to be the case.

Stephen Campion
Chief Executive
Hospital Consultants and Specialists Association

Another March Anyone? by Dr Nick Edwards

2007-10-29T13:14:00.000Z

RemedyUK are delighted to welcome Dr Nick Edwards to our Blogging Team

Nick is the author of the new book, In Stitches.

Read more about it here and buy it here

Most people don’t start their rebellious phase in their late 20s early 30s. But that is what has happened to me. In March this year, I found myself at the remedy march – It got the public at last interested into the plight of junior doctors. I am now thinking about my second march – and this one is just as vital – in defence of the NHS.

The March is on November 3rd - 1pm at Trafalgar square. So why am I going on a march in defence for an organisation which has mucked my career around, ruined the lives of my friends and forced loads of colleagues to emigrate to Australia ? Why would I go on a March to support of the NHS when quite frankly despite all the extra money being pumped in, things are a bit pants. . Where money is wasted, staff are treated like crap and managers seem more obsessed with targets than patients. Then there is ridiculous political correctness, and politicians changing what we should do every two minutes. And don’t get me started on how the recent reforms have destabilised and disenfranchised a whole generation of doctors.

So when I talk to people who are pissed off with work and I go on about how marvellous the NHS is, I usually get thought of as an irritating fool and told we would be better off, if it was privatised and they they add ‘no they are not going to join me on the march comrade’. Lots of arguments get thrown at me about why the NHS is failing and I end up agreeing with them – the NHS isn’t great, and in many ways it is failing to provide quality care.

Where I disagree is that this is an argument against the NHS as a whole. What it proves to me is NOT that the concept of the NHS is crap, but that the NHS is being run crapily. The concept and ethos of the NHS is what makes it great – it just needs to be run properly. So why do I believe it is a great service model for providing care. We are one of the few countries with a truly socialised model of health care. So what is so good about it? Four main points – among many.

1) The fact that it is free at the point of need is something we should treasure. I am an A&E doctor and often see people who have no money and homeless, but they are entitled to the same standard of care as Lord Hawawawawa ‘I was born with a silver spoon in my mouth’ gets. Health is something we should all be entitled to, as a fundamental right, and the NHS provides for that.

2) Then there is the fact that we provide appropriate care without having to worry about profit margins i.e quality care is not put in front of profit margins. When we see patients we do not think - how am I going to treat the patient so that my company can make lots of money? If they are a complicated patient we don’t think – Nah I’ll leave that customer to someone else - they won’t make me money. Rightly so we still treat patients in their best interest and not a company’s/hospital trust’s best interest.

3) The fact that charging patients doesn’t come into it means that on the whole it is quite an efficient system. In America where every swab is charged for and accounted for, they spend nearly double per person than what we do on health care, and by and large 30% of their population get terrible treatment (see the new film Sicko by Michael Moore). The insured ones often get unnecessary tests and unnecessary treatment and a lot of hospitals budget is spent on advertising for new patients. Going down the American route is something I dread.

4) In a NHS where we don’t think about profits, then institutions can concentrate on teaching juniors as opposed to the private treatment centers where getting cases done asap is all they care about.

So if the concept of the NHS is great, then why are patients worried about its future and why are most workers miserable and why should we march in defence of it? How the labour government have doubled the money going into the NHS whilst still pissing everyone off and not improved things that much, all at the same time is an amazing skill. (Don’t get me wrong, it is much better than it was ten years ago and I honestly believe that without the extra resources and commitment from Labour we would have seen the NHS completely screwed by now. It is just that so much more could have been done and moral could have been so much higher if they hadn’t have been so bad at running the NHS. )

So what is so bad about the way it is being run? There are a number of issues affecting us all, but I think the main ones are that the government have forgot about running the NHS along its original ethos and have been blind to the law of unintended consequences.

Changes such as Private Finance Initiatives seem great on the surface – new money to build new hospitals with. But when you look at the rules - it is a very very expensive loan, which private companies are making a fortune from and which hospitals have to pay back each year and it is crippling them. Their budgets are de facto being cut. Why wasn’t there just up front government money for these new buildings – paid for from normal borrowing but at a fraction of the cost? Why involve the private sector.

Then there are private treatment centres being built. They take money for easy cases and leave the NHS hospitals with the rest. That means NHS money is paying for big profits for private companies and NHS hospitals loosing money.

Other factors are payment by results and patient choice. On the surface it seems to make sense that money follows the patient. But hospitals won’t be able to make plans not knowing if they will loose patients to other hospitals. We also need hospitals to have the full complements of specialities for emergency cases and not have 1 hospital being experts in knee operations but not having a hip surgeon; it is ok for elective cases but what about emergency admissions.

Then there is hospital reconfiguration. They say that centralised care is the future. But what evidence do they have to back it up. Yes for major trauma, heart attacks and stokes major centres are the way forwards but that it is only 2% of cases. The rest of patients need good local District General Hospitals which care for the other 98% of patients. These DGHs cant loose their elective services to Private treatment centres or the new Lord Dazari polyclinics models, as otherwise they wont have the personnel and resources to look after the emergency patients. And the smaller DGHs shouldn’t loose their A&E departments as all but the sickest would benefit form local emergency care.

Then there is the way the government have introduced targets without thinking about the consequences. For instance the two week cancer target, the 48hr GP target and the 4 hour A&E target – great in principle but the law of unintended consequence means that targets are becoming thought of as more important than clinical care.

And finally the way the staff is treated. I am not talking about pay – although it is disgrace how the government have tried to worm themselves out of the agreed pay deals for nurses. It is a the way as health care staff we are not respected - the fiasco of junior doctors training is the prime example.. Thoughtless planning has left doctors moved at the last minute from their family, having to change career and in many cases give up medicine altogether.

I love the NHS but hate the way it is being run and I am concerned about its future. I would like to see the NHS run by non-politicians. Make it run by a quasi independent board along its original principles and ethos. Take the politicians and targets out of health care (just let them agree on a guaranteed funding stream which is planned for a long time in advance) and let staff and patient’s care be the important thing. Remove competition and replace it with co-operation. Remove payment by results and replace it with regional planning and remove patient choice and give patients the excellent local GP and DGH that they want and that we have the money to pay for.

Can we make a difference? Can we make this utopia become real? I don’t see why not. – it is being a hot political issue at present and we just need to start expressing our views. There are various support groups out there such as the NHS Support Federation (www.nhscampaign.org) and many local groups fighting for the future of the NHS. They all need your input and your knowledge about how the NHS is being run and how it could be improved. I personally have written a light hearted book looking at my work and how the politics can pervade down to individual patients care. I doubt it will make any difference but at least it is getting some attention. But anyone can do it. Write to your local Mp and councillors. Get involved with reconfiguration meetings and write to papers so that they know what is happening. We are all at the coal face of the NHS and we know where and how it can be improved. We need to start making our voices heard.

I urge you to speak out and make a difference. Even if the government ignores you then at least we have tried and can sleep easier at night.
Regards
Nick Edwards – Author of In stitches; the highs and lows of life as an A&E doctor.
Any comments/questions/help with publicity please email drnickedwards@gmail.com

RemedyUK Welcomes Our First Guest Blogger: Professor Morris Brown.

2007-07-15T00:47:00.000+01:00

Last month our campaign group, of 50 professors and presidents of specialist societies, was belatedly baptised – or whatever the politically correct name for naming is! Our name, Fidelio, is taken from a story about one victim of the arbitrary exercise of power, and victory against the odds of oppressed innocence. More loosely knit than RemedyUK, and more intermittently active, we will seek whenever possible to influence senior colleagues whom we perceive to be treading a wrong path. At a time when a conspiracy of silence could not have been more effective than the current apathy – not only among the media and public, but even most of the medical profession – we need to keep telling each other and those most hurt by MMC/MTAS that they are not forgotten. Otherwise we play into our opponents’ hands.

Pressure groups like Fidelio and RemedyUK are unlikely ourselves to achieve justice or solutions. We can hope that the Tooke Review will surprise us with fundamental doubts about the validity of MMC and strong recommendations for righting the wrongs of this year. The latter seems particularly implausible given that its date for reporting is before the official end of round 2 – allowing Tooke (like the Colleges, below) to express optimism that there will be no wrongs after round 2. The BMA has largely disqualified itself as a meaningful voice by its opposition to RemedyUK. Our poll found 80% of junior doctors would like RemedyUK not the BMA to represent them. The new BMA leadership cancelled a scheduled meeting with us last week, and failed to answer requests to speak out against the slippery practices of round 2, and against disqualification of many doctors from continued employment on 1st August.

We believe therefore that the hope and responsibility for a resolution to this year’s crisis resides in the Royal Colleges. If what follows sounds faintly critical, it is only to encourage debate and because this is permitted. The DoH, by contrast, whom some see as our friends, have banned us from participation in their new MMC advisory board – ‘unlike the recently defunct Review Body, this will be a genuine expression of the views of the profession, from whom most members will be drawn’. Free speech is alive and well at the Elephant Castle – freedom, that is, to echo the Minister’s views.

On the 8th June, by when all first-choice job offers should have been made, it became apparent that some 40-45% of doctors were empty-handed. We sent an open letter to the presidents of all the Royal Colleges asking for strong, united action, ‘regardless of red faces in the Department of Health’. Irritated, the presidents replied to the effect that it was too soon to be anxious, that all would be sorted (they hoped) by the 22nd June – or, if not, in round 2. On 22nd June, by when it was apparent from our rolling poll – and leaks from the DoH – that some 40% were still without jobs, and that almost one third offered jobs had been offered only FTSTAs – we published our open letter in the BMJ. About 100 online responses to this, at http://www.bmj.com/cgi/eletters/334/7607/1285#170337, unanimously chided the Colleges for their approach.

A good-humoured response to this by two presidents prompted us to seek a meeting which was held between three of us and about eight presidents (including the Chairman of the now defunct Review Body, but not the PRCSEng) plus the Chairman of AoMRC on 28th June. Although clearly useful in breaking the ice, and generally good-natured, the meeting was depressing in confirming the lack of collective will among the presidents to take any affirmative action that differed substantially from existing DoH policy. We were not there seeking favours for ourselves – Fidelio has no self-interest; rather we were suggesting to the presidents a possible solution to the crisis which the change of government and SoS offered a one-off opportunity to pursue, and in the process redeem the Colleges’ recent reputation (according to the BMJ posts) for submissiveness. Yet one president seemed to think this reputation was Fidelio’s fault!

While Fidelio believes that, in a time of discord between the profession and DoH, there needs to be blue water between us and leaders who clearly speak on behalf of the profession, the Colleges appear to believe the better strategy is to be part of the DoH dialogue behind the scenes. If this strategy were working, we would fully support it. But it isn’t. The results of our poll, published in full at http://www.fidelio.org.uk/index.php?option=com_content&task=view&id=25&Itemid=44, show that round 1 has resulted in a disproportionate failure of the best candidates – assessed by the traditional markers disallowed under MTAS, e.g. 1st class degree, distinction in finals, PhD. We believe this is a consequence of the single interview, and the tradition that the best candidates apply for the best (and therefore most sought after) posts. Many of these will end even round 2 empty-handed, or with a FTSTA at best. As things stand, thousands such doctors face an end to their career in UK medicine. The DoH promised an instant resume of results after round 1. This has not happened. Indeed invidual applicants hear of their failure inhumanely through failure to receive an email.

Our summary of the current problem, and possible solution, is shown below. We will include this in our evidence to Tooke, together with fundamental objections to the inflexible top-down, minimal-competency philosophy of MMC. We have written to the new SoS, and surgeon health-minister, summarising the solution and requesting a meeting. Realistically, however, it needs concerted action by the Colleges for a chance of success.

Meanwhile, round 2 in many areas would come second to car-boot sales in their level of organisation and fairness. ‘Now you see them, now you don’t’ adverts, lack of any of the promised information about numbers and whereabouts of jobs, and continuing lack of CVs or references at interviews, almost makes one nostalgic for the MTAS computer! Is chaos better centralised or served up with a regional flavour?

The presidents of the Colleges are good people. They are affected by individual letters and stories. Indeed they say they prefer private to public pressure. Please write to your president, ask your colleagues to write to their President … and to their colleagues asking them to write etc etc. “The tyranny of a prince in an oligarchy is not so dangerous to the public welfare as the apathy of a citizen in a democracy.” (Montesquieu)

MMC/MTAS 2007: Diagnosis and Treatment

Problems
1. The new system of promotion is a parallel ladder on which the width of each rung is the same as the one below.
a. Therefore the number of ST(n) posts is the same as the number of doctors already appointed to ST(n-1) posts.
b. Therefore there is little or no opportunity for doctors appointed to FTSTA posts to rejoin ST training and gain a CCT.
c. About one third of posts offered in round 1 were FTSTAs, many of these going to very bright doctors (1sts, distinctions, PhDs) who under the old system could expect careers in teaching hospitals or academia
d. These very bright doctors are now effectively excluded from mainstream medicine in the UK
2. Run-through forbids trainees to move to a different part of the country for the rest of their training.
a. For partners in different regions, this is a domestic disaster
b. Because doctors were permitted only one application per specialty in a region (e.g. whole of London and SE), it was much more difficult for partners to obtain posts in the same part of the country than under the old system
c. In Medicine, where entry to run-through is to Core Medical Training without a guaranteed specialty, they will be restricted subsequently to those specialties with vacancies in their region.
d. The opportunity will be lost for a bright doctor to join a specific sub-specialty and/or department pertinent to their field of research, unless that department is in the region of their original run-through appointment
3. If Tooke accepts the recommendation from the RCP (and many others) that run-through is dropped for medical specialties, there will be a one-off cohort of run-through doctors, many unhappy with their apparent windfall

Possible solutions
1. Suspension of run-through for non-shortage specialties.
a. This is the cleanest solution, popular with many of those appointed to RT posts, for the reasons above.
b. However, it is easily dismissed by legal and quasi-moral objections
c. The legal position is untested, since the contracts (most not yet issued) are for 1-2 years with the employing hospital
d. The moral objection – ‘these doctors were promised run-through’ – ignores
i. the competing claims of doctors cheated of any appointment by an unfair (including single-interview) process, and
ii. the asymmetrical distress of
1. doctors deprived of a windfall that will not have existed either before or after, vs.
2. doctors deprived of any future career prospects
e. Suspension of run-through might be seen as analogous to re-appropriation of stolen goods from a 3rd party customer who bought them in good faith

OR

2. A guaranteed level playing field for all eligible doctors applying for ST3 or ST4 posts
a. ‘Eligible’ is likely to mean all ST or FTSTA doctors, but may need to expand to include any doctor who’s CV has been reviewed by an independent appeal board
b. This solution could be restricted to those specialties, e.g. Medicine, Surgery, Anaesthetics, where there is strong evidence of many good candidates not being appointed
c. The guarantee should be made now, and its implementation worked out over the next year
d. Implementation is likely to include one or more of:
i. Temporary expansion of ST3/4 posts in competitive specialties
ii. Raising the barrier of competency testing required for promotion from ST2 to ST3, or ST3 to ST4
iii. In Medicine, restriction of run-through (which is not promised into any particular specialty) to less popular specialties, e.g. geriatrics
e. Expansion of posts in popular specialties is in any case highly desirable in order to accommodate and encourage a floating cohort of numbers used for doctors entering and leaving research
f. The cost of expanding numbers is limited to that of the temporary bulge required to fix this year’s problem – unless, as in (e), the bulge is then found desirable for other reasons.