This is a letter written by Dr. Hoong-Wei Gan to their MP, Neil Coyle.
Dear Mr. Coyle,
I am a Specialty Registrar in Paediatric Endocrinology who has served the NHS full-time for 7 years, with an additional 2 years of part-time, honorary (unpaid) service whilst I complete my PhD.
During this time, I have worked 2 Christmas Days, 3 Boxing Days, 3 New Year’s Eves, 3 New Year’s Days and countless weekend, night and other bank holiday shifts whilst missing 12 friends’ weddings, 13 of my parents' birthdays, and countless of my own and my wife’s birthdays. I am also one of your 22000 constituents who voted you into office in the recent general elections and am therefore writing to you to express my concern at the attitude of the Secretary of State for Health, the Rt. Hon. Jeremy Hunt and other members of the current government, including the Secretary of State for Justice, the Rt. Hon. Michael Gove in the hope that these concerns will be expressed in the House of Commons through transparent, fair debate.
Additionally, I have the privilege of having been both a doctor and a patient in the NHS. In December 2014, at age 31, I was diagnosed with a rare congenital brain cyst that lay adjacent to my brainstem, an area of the brain vital for controlling breathing, heart rate, and consciousness; in other words, keeping me alive. This required complex surgery under the highly skilled hands of two consultant neurosurgeons and, two months after my diagnosis and four days after my operation, I was, thanks to the NHS, convalescing pain-free at home, during which time I published a reflective piece on the high standards of care I received, even over the weekend (1). I have therefore been on both sides of the fence, and have had the experience of taking time out of my own busy, health professional schedule to wait - for emergency NHS dental/ maxillofacial appointments (we thought my pain was initially due to a misbehaving wisdom tooth), for my MRI, for pre-operative assessment appointments and for a date for my surgery. Waiting is, and always will be, a fact of any healthcare system, more so in a socialised healthcare setting, due to the need to prioritise finite resources with emergency and more urgent cases ahead of elective, less urgent ones. I accepted this readily as I paid nothing but income tax for this service.
On 16 July 2015, Mr. Hunt suggested that the NHS needed to be a fully-working, 24-hours-a-day 7-days-a-week service. Whilst on face value this seems like something all health systems should strive for, his premise was that a major barrier to providing this service was due to the ability of new consultants to “opt-out” of providing weekend cover as part of their contracts as well as the attitude of our union, the British Medical Association (2). His suggestion subsequently led to a united social media campaign from a wide variety of health professionals (including consultants) demonstrating their presence in hospitals up and down the country over the weekend, and culminating in an e-petition via the government’s newly revamped website calling for a vote of no confidence in his leadership which gained over 100000 signatures within 48 hours of its creation, miles ahead of any other petition. At the time of writing, the petition now has over 210 000 signatories and remains the most frequently signed (3).
The backlash generated from Mr. Hunt’s suggestion was due to the weakness of the evidence it was based on, leading to speculation amongst healthcare professionals as to his motivations behind this suggestion. The e-petition is still the only one to have received a “response” from the government which has only served to fuel this backlash further due to continued repetition of the same misquoted evidence. To summarise these:
- Both Mr. Hunt and the government’s response primarily quotes the study by a group including Professor Sir Bruce Keogh, Medical Director of NHS England, on the effect of being hospitalised on the weekend on deaths, showing that mortality for patients admitted on a Sunday is 16% higher than that of a Wednesday (4). Whilst this difference is significant, death occurred anytime within 30 days of the initial admission, even after discharge. In actual fact, the same study quoted that patients were 8% less likely to die if they were in hospital on a Sunday compared to a Wednesday. One of the authors of the paper has in fact responded that the “work does not identify that the NHS neglects patients at the weekend causing harm. Instead we identify that high risk patients are admitted at the weekend at a time when we all know that the availability of services to care for them may not be optimal. We have updated our work on weekend mortality which hopefully will be published soon” (personal communication). Further detailed analysis of this complex dataset by people well-versed in medical statistics is widely available (5, 6).
- The proportion of consultants who actually opt-out of providing weekend cover is, in fact, infinitesimally small. Freedom of Information (FOI) requests from 15 acute NHS trusts across the country of over 4000 consultants demonstrated that not a single consultant has in fact opted out in these organisations (7, 8). The reason for a difference in weekend services is therefore not due to a lack of consultant cover. My consultant regularly stays on a completely unpaid basis beyond the number of hours stipulated in his 10 programmed activities (PAs) per week contract - the maximum contract that most NHS trusts will pay consultants for, regardless of how much overtime they do. Just last week he was in his office till 9-10 pm completing clinical, academic and supervisory work and missing his wedding anniversary when he was not on-call. In my entire career, I have never worked in a department where there wasn’t a consultant on-call at the weekend. Mr Hunt’s insinuations additionally do not just scapegoat consultants, they are a subtle backhanded insult to all the other health professionals and support staff who are required to keep the NHS running - from nurses and midwives who administer medications and deliver babies to porters and secretaries who transport patients and ensure smooth communication between primary, secondary and tertiary NHS departments. Mr. Gove’s experience trying to get an X-ray at a community hospital on the weekend exemplifies this - although it is absolutely clear to the rest of the NHS-using British public that he would have been able to obtain an emergency X-ray performed by a radiographer should he have attended a proper, NHS-run Accident & Emergency department since he had had an accident (9).
- It is unclear where Mr. Hunt and the government have gotten the figure of £118 000 as the average pay for a hospital consultant. The maximum basic annual earnings for a hospital consultant after 19 years in service by which time most are in their 40s is £101 451 (the first year being £75 249). On top of this, consultants who perform duties above and beyond their contracted hours can be awarded Clinical Excellence Awards (equivalent to bonuses) of up to £75 796, the highest four tiers only being awarded for nationally/ internationally-recognised work which has had a positive impact on the wider society (10). This would amount to a maximum salary of £177 247 after 29 years of NHS service (19 years of consultant service and 10 years of NHS junior doctor service in training). It is worth noting, with regards to the “worthiness” of the consultants receiving this highest level of pay, that of the 40 consultants nationally who achieved the highest Clinical Excellence Award in 2013, 39 are full-time professors, 18 are Fellows of the Academy of Medical Sciences, 7 are members of the Order of the British Empire, 5 are directors or deputy directors within the National Institute of Health Research, and 1 is a life peer in the House of Lords and Fellow of the Royal Society (11). All still provide NHS services alongside the exemplary amounts of work needed to achieve these awards. In comparison, the top basic salary (without bonuses) of British Airways pilots (after 20 years’ service) is £140000-150000, senior financial brokers £150000-230000, and chief executive officers £180000-200000 (12-16). For the level of training required, the amount of unpaid extra hours already contributed and the cumulative costs of training, exam and medical defence fees (none of which are supplemented by the government), NHS consultants are therefore significantly underpaid compared to other professionals of similar if not less number of years’ experience.
It is extremely important to note that no sensibly-minded NHS healthcare professional is against a 24/7 service. As demonstrated by the #ImInWorkJeremy campaign, the NHS already provides an excellent emergency service 24 hours a day, 7 days a week, should one choose to access it. However, emergency services are already over-stretched and over-burdened, and since beginning my career I have never worked on a single paediatric rota which has been fully staffed and not had to rely on long-term locum cover. Such over-stretched rotas, constant scapegoating by politicians and the general sense that we are not being listened to has resulted, even in the absence of frank strikes, with NHS medicine no longer being an attractive career for students and doctors quietly leaving the NHS in droves. Just under 20% of doctors who graduated with me in 2006 are now considering moving abroad permanently (17), serving only as a vicious cycle to further burden current services. Additionally immigration restrictions on international medical graduates such as I once was has resulted in a further drain of students who have paid only upwards of £120000 for training that costs £290000 - the NHS and universities are therefore training these students at a loss and must therefore do more to make it attractive to remain (18).
The NHS recently ranked as the best and yet most cost-effective healthcare system in the world in comparison to 11 other developed nations, including the USA (19). No other healthcare system in the world, whether public or privately funded, runs a full service running 24/7 for both elective and emergency cases as the costs are simply too high. The King’s Fund has already indicated that the current government’s pledge to increase the NHS budget of £8 billion is only enough to maintain standards of care and insufficient for creation of a 24/7 NHS (20). Running a full 24/7 service requires not just extra doctors, but even more importantly nurses, midwives, healthcare assistants, radiographers, physiotherapists, occupational therapists, speech and language therapists, play specialists, laboratory technicians, social workers, hospital cleaners, switchboard operators and secretaries amongst many others - the NHS team. Additionally, the government has yet to demonstrate that adding elective services to an already over-burdened emergency NHS service on the weekend will actually be effectively taken up by patients. The department I work in already offers elective NHS appointments on Saturdays on a regular basis and yet patients still do not attend.
Scapegoating by Mr. Hunt, questioning my profession’s vocation and professionalism as well as statements such as one “doesn’t have a spare half-day to sit around awaiting the pleasure of the hospital radiographer” (9) from Mr. Gove’s wife can therefore only be described as inflammatory. Mr. Hunt himself has been known to attend his local paediatric A&E with his children because he "couldn’t wait for a GP appointment” (21). Both are bad examples by our country’s leaders only serving to promote a consumeristic, entitled culture with regards to the use of a finitely-resourced, socialised healthcare system.
Concurrently, a quiet debate is being held in the House of Lords led by Lord David Prior, outside of public eye, on the sustainability of the NHS and the introduction of user charges (22). One can only speculate therefore that Mr. Hunt’s statement is aimed at subconsciously preparing the public for this idea whilst having doctors and NHS staff being used as roadkill. The remarkable lack of press coverage on this issue further makes one wonder how truly “free” our press is.
Mr. Hunt's mistake is that NHS doctors are expensive and time-consuming to train, and are highly skilled and easily employable in other countries where there is potential to earn more. Those of us who stay only do so because we believe we contribute to a health system that “everyone - rich or poor, man, woman or child - can use”, but change this concept at the heart of the NHS and constantly insult the professionals who keep it running and you will be left with a privatised, fragmented healthcare system with wide population health inequalities running on zero fuel.
The public must be made fully aware about the far-reaching consequences of the decisions this government is making about their healthcare, whether the ultimate decision is to continue with the NHS as it currently stands or to introduce co-payments or privatisation. I urge you therefore, as a member of the Opposition, to challenge these ideas in the House of Commons, to ensure that the first and most rapidly signed e-Petition to date does not go undebated, and to ask for a fairer, more transparent and democratic consultation regarding the future of the NHS with patients and doctors as the primary stakeholders at its core.
Many thanks for your time.
Dr. Hoong-Wei Gan BMedSci(Hons) BM BS MSc MRCPCH
Clinical Research Fellow & Paediatric Endocrinology Specialty Registrar
University College London Institute of Child Health & Great Ormond Street Hospital for Children NHS Foundation Trust
References
1. Gan HW. Will the general election decide whether the NHS is a right or a privilege? The Guardian, Apr 16 2015. Available from: http://www.theguardian.
2. Department of Health. Health secretary Jeremy Hunt sets out the direction of reform for the future NHS. Jul 16 2015.
3. Petition: To debate a vote of no confidence in Health Secretary the Right Hon Jeremy Hunt. https://petition.
4. Freemantle N, Richardson M, Wood J, Ray D, Khosla S, Shahian D, Roche WR, Stephens I, Keogh B, Pagano D. Weekend hospitalization and additional risk of death: an analysis of inpatient data. J Royal Soc Med 2012; 105:74-84
6. Khan M, Furmedge D, Dean B, Harvey H, Silvey N, Norris Z, Vig S. Response to government’s petition reply - vote of no confidence in Rt Hon Jeremy Hunt MP. Brit Med J 2015; 351:h3950
8. Smith M. #ImInWorkJeremy: Only a handful of doctors actually opt out of working weekends. The Mirror, July 28 2015. Available from: http://www.mirror.co.uk/
9. Vine S. Michael Gove “could not get X-ray for broken foot”. The Telegraph, July 22 2015. Available from: http://www.telegraph.co.
10. NHS Employers. Pay and conditions circular (medical & dental) 1/2015.
11. Advisory Committee on Clinical Excellence Awards. Clinical Excellence Awards: successful candidates. May 19 2014. Available from: https://www.gov.uk/
17. British Medical Association. Cohort study of 2006 medical graduates (9th report). British Medical Association, June 2015.
18. British Medical Association. How much does it cost to train a doctor in the United Kingdom? British Medical Association, June 2013.
19. Davis K, Stremikis K, Squires D, Schoen C. Mirror, mirror on the wall, 2014 update: how the US health care system compares internationally. Commonwealth Fund, June 16 2014. Available from: http://www.
20. The King’s Fund. Our response to Jeremy Hunt’s 25-year vision for the NHS. 16 July 2015. Available from: http://www.kingsfund.
21. Dearden L. Jeremy Hunt: ‘I took my children to A&E because I didn’t want to wait for a GP appointment’. The Independent, Nov 25 2014. Available from: http://www.independent.
22. Campbell D. Jeremy Hunt raises doubts about long-term future of free NHS. The Guardian, July 16 2015. Available from: http://www.theguardian.
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