The government’s latest proposals to change consultant and junior doctor contracts has angered many in the medical community, and indeed there are many valid reasons why doctors should be concerned, as they stand to be doing more work for less pay if these proposals go through. However, the proposals are hardly surprising to most people looking at the bigger picture – they’re just the latest step in an ongoing campaign to squeeze more work out of doctors without having to pay them any more.
At some point in the 20th Century, we decided that a ‘fair wage’ was whatever you could leverage on the global market. In a country with one dominant healthcare employer, the bargaining power of doctors is significantly reduced and the government knows it: it doesn’t matter what they do, because where else will doctors go for work? In a different country, if one healthcare provider suggested changing their working regulations, they know they’d better be careful, because their employees can freely leave and find work elsewhere if they don’t agree with the changes.
In the UK, however, we have only one major healthcare employer. We’re playing a one-sided game where the employer is taking advantage of the free market approach, but doctors don’t have the freedom of choice usually presented by the free market, leaving them feeling trapped and these changes to their lives forced upon them. Add to this the fact that the vast majority of doctors in England believe strongly in the principles of the NHS and a sense of duty to support it, and a strong commitment against industrial action and you’ve got, in every sense of the word, a captive and subdued workforce.
The times, they are a-changin’
But what was true 20 or even 5 years ago is certainly not true today. Doctors have more extra-clinical opportunities than ever before, and the sense of duty to the National Health Service has been eroded years of mismanagement and broken promises. Whilst the previous generation of doctors enjoyed the benefits of a strong NHS pension, free education and largely avoided mass propaganda campaigns in the media, and were largely brought up in a time where spending your entire professional career in one organisation was the norm, none of this is true of the new generation who will be paying for the privilege of medical education long into their career.
The internet has made it easier than ever before to find new opportunities. What happens when doctors realise that, far from being ‘trapped’, they have skills and experiences that are incredibly valuable in a range of different fields. What happens when they realise that clinical practice, whilst important, is not the only way they can use those skills to help people? It doesn’t take a genius to realise that once this happens, many, many people will simply leave the NHS. Doctors discovering their true potential would be a nightmare for the government.
The numbers are already shocking. Doctors are burnt out and many are already looking for a way out – whether moving to private practice in the UK, emigrating to Australia or, increasingly, taking up roles in medical technology startups and using their clinical insights to shape technologies that can be distributed globally to improve the lives of millions of people in one fell swoop. When you consider that, compared to clinical practice, these alternatives offer doctors better pay, more sociable working hours, more creative input and arguably the chance to impact more lives – the question isn’t ‘why are some doctors leaving the NHS?’, but ‘why are some staying?’.
The NHS has inefficiencies, sure. But these inefficiencies are not the root cause of the problem. The problem is that model the NHS was built on is no longer sustainable, given the ageing population and the shift in acute to chronic care. The only thing that will save the NHS is a real budget increase. Politicians will try to make this sound impossible – it may not be easy to do, but it is simple. If the money has to come from the ‘waging indefinite wars in the middle east’ budget, the ‘indiscriminate spying on our own citizens’ budget or even the ‘locking people up for minor drug offences’ budget then so be it. Keeping a population of 60 million people alive and healthy is a noble task, but it costs what it will cost, and there’s only so much fat you can trim before, like a spectacularly morbid game of Jenga, the whole thing buckles and collapses under it’s own weight. It’s disheartening to think, but it may well be that the NHS, like antibiotics were a one-time opportunity.
The NHS was set up in a a historical anomaly. The burgeoning post-war economy – a time of radical re-building, restructuring and virtually 100% employment. If the original proposal had been lost and only brought to light today – or any time outside of that immediate post-war period, it seems hard to imagine that it would have ever been implemented at all. If we lose the NHS, we also lose any chance of getting it back. American-esque private healthcare providers will swoop in to fill the gap, forming the same lobbying groups and barriers to entry that makes healthcare provision such a nightmare for hundreds of millions of Americans already. You only need to look to America and the tension over the Affordable Care Act (‘Obamacare’) to get some idea of just how monumentally difficult it would be for an industrialised nation to set up anything remotely resembling the NHS again.
Chronic Short Sightedness
For all the advantages the democratic process brings, long-term thinking is not one of them. Our politicians perspectives are tragically constrained to 4 year cycles, meaning they are only interested in approaches that can bump up the statistics in time for the next election. Delivering a sustainable healthcare solution requires a much longer term strategy. 4 years is barely a blip on the radar. Increasing working hours and recruiting cheaper but less-qualified staff may help in the short term, but they are not addressing the root cause of our problems. At best they are an adrenaline shot to keep the NHS alive long enough to work on a better solution, at worst they are painkillers masking the symptoms of a fatal tumour until it’s too late. No matter what we do, the population is going to continue ageing, they are going to accumulate more chronic conditions and more complex medical needs – an adrenaline shot may well be in order, but in the absence of a longer term plan in place to address the root causes, the NHS as we know it is doomed. Politicians either fail to realise this, or they do realise it but think that nothing can be done so the best they can do is to keep administering adrenaline and hope it dies on the other party’s watch instead of theirs. In other words, our politicians are either incompetent or they’re playing a game of political hot potato with our healthcare. Again, the solution would be pretty simple: devolve control of the NHS to a non-partisan organisation. This has already been done with The Bank of England having control over interest rates, so why not separate the long-term planning of our nation’s health from the 4 year political cycle and the petty debates and grand-standing that comes with it?
Our politicians need to save the NHS from themselves. The problems it faces lie far deeper than their 4 year perspective allows them to see. If they continue on the path they currently are doing, doctors and other healthcare professionals will leave and seek a better life for themselves elsewhere.