Monday, June 6, 2016
What the Junior Doctors' strike in the UK can teach us on this side of the pond
The United Kingdom's National Health service has been facing something of a crisis over the last several months. For those of you unfamiliar with what's been happening (the issue hasn't really gained any media traction here in the U.S.), a majority of the country's 55,000 junior doctors have been holding regular strikes. In the UK, the way in which doctors train is very different from the U.S., with often over a decade spent as a “junior doctor” before reaching Attending level. So-called junior doctors therefore deliver most of the nation's frontline care.
What's the dispute all about? In a nutshell, the Conservative Party which won last year's general election, led by Prime Minister David Cameron, did so with a manifesto pledge to deliver a “7-day NHS”. Various figures were quoted by the Department of Health for why care at weekends was inferior to weekdays, including increased mortality rates (which junior doctors heavily disputed). The government then proposed a new contract for doctors, which would essentially try to increase staffing at weekends. Unfortunately, this was without allocating any extra resources or staff for the change. In fact, the government was actually trying to class weekends as “normal working days”, so that they wouldn't attract a premium pay rate as they currently do.
Junior doctors were outraged, claiming that this would actually decrease their pay by up to 40% (no wonder they threatened strike action). Neither are they paid staggering amounts in the first place. The Secretary of State for Health, Jeremy Hunt—who incidentally has no background in health care—became the most vilified person in the UK within the medical profession.
Negotiations between the government and the main doctor's union, the British Medical Association (BMA) broke down, and Jeremy Hunt then enraged doctors further by threatening to simply impose the new contract from August. A wave of industrial action and strikes followed. After a major impasse, with untold damage done to the morale of the profession, the government as of last week finally agreed to return to negotiations.
All along the junior doctors argued their case from the perspective of patient safety, and the general public on the whole have been supportive. However, it would be disingenuous to pretend that pay wasn't the major issue (and to be fair who wouldn't be outraged if their pay was slashed by so much along with an increase in workload?). If the exact same contract had been proposed along with a very significant pay increase for working more weekends, we unlikely would have seen such a fuss.
Following the news in the UK closely, I felt very sorry for the doctors. I left the NHS shortly after graduating from medical school but still have lots of friends working over there. Many are junior doctors who will be greatly affected by the new contract. Their plight can teach us a few things on this side of the pond:
1) The danger of over-centralized control
The UK's NHS is one of the most heavily centralized health care systems in the world. Founded after World War 2, few other countries have followed this model. What it is, however, is very fair. But as idealistic as the principle of the government delivering high quality care absolutely free at the point of use, the danger of a system like this is that the healthcare system will be used as a political football by politicians. One of the first commentaries I ever wrote on this subject, almost 10 years ago, was about how the Prime Minister of the UK can almost be blamed for the spread of methicillin-resistant Staphylococcus aureus (MRSA), whereas blaming the U.S. President for this would be unthinkable! Doctors in the UK are completely at the mercy of the prevailing political winds, and politicians likewise maintain a ridiculous amount of control. Another example was when the UK Secretary of State for Health announced several years ago that no health care worker could wear anything below the elbows (a “bare below the elbows policy”). This grabbed the newspaper headlines as the politicians wanted, and overnight the UK went from having some of the smartest dressed doctors in the world, to banning all suits, shirts, ties, white coats, and even watches—in every hospital across the country (with flimsy evidence as to its effectiveness).
2) Leaders with no experience of health care
In the United States, despite the problems we face, at least CMS/Medicare do have many current and former clinicians in prominent positions. The UK's health service is, on the other hand, totally at the whim of an executive that has no experience whatsoever in healthcare. Most of them are career politicians who frequently shift between different cabinet positions every year or 2.
3) The power of physicians banding together
The latest news from the UK is that the government is returning to the negotiating table. This is after months of junior doctors piling on the pressure by banding together. Although I am not in favor of unionizing and believe that it would lower the prestige of the medical profession, there is a lot to be said for organized action under any umbrella.
4) Getting everyone on side
The doctors in the UK successfully gained public and widespread media support by framing their argument as one of great patient care and safer hospitals. Nobody—no bureaucrat or business person—can ever argue successfully against that.
One of the things that first drew me to the U.S., and still holds true even after the big changes in health care over the last decade, is that physicians in America hold a massive and unprecedented degree of freedom in choosing their working environment. There's working for a multi-specialty group, university, academics, VA/government, locum work, non-clinical endeavors, and yes—even today—private practice. Compare that to the UK, where the private sector is tiny and doctors are essentially stuck with contracts that are dictated by the government, fewer job opportunities, and less room to innovate.
Hopefully, speaking with solidarity for the UK's doctors and fully aware of what a demanding and challenging profession medicine is, their problems will be sorted out very soon. But as different as the American and UK health care systems are, there's indeed a lot of lessons U.S. physicians of all specialties can draw from what's happened on that side of the Atlantic.
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care. This post originally appeared at his blog.
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