Sunday, July 26, 2015

What They Really Think of Us, UK Version - Health Secretary Derides NHS Doctors for Not Working Enough on Weekends

A new story from the UK suggests what top leaders of health care really think about health care professionals.  I realize that I risk showing my shallow understanding of UK politics when I comment on this, but I believe that the story is straightforward enough for someone from the US to understand, and has  lessons for the US and other countries.

UK Health Secretary Says Doctors Do Not Work Enough on Weekends

The story started earlier in July, 2016, when the current UK Health Secretary within the current Conservative government told National Health System (NHS) doctors they must work seven days a week, as reported by the Guardian,

The health secretary, Jeremy Hunt, has accused the main doctors’ union of walking out of NHS consultants’ [equivalent to US attending physicians] contract talks aimed at preventing 'catastrophic consequences' for patients at weekends.

Hunt said he recognised the efforts of consultants, many of whom already work on Saturdays and Sundays, but that he would impose weekend-working contracts by September if an agreement could be reached.


The proposed contract would have at its core the controversial weekend working provision, but would include the abolition of overtime payments that Hunt has described as extortionate.

 Under the current contract, last negotiated by Labour in 2003, consultants can opt out of non-emergency work outside the hours of 7am to 7pm Monday to Friday.

Mr Hunt implied that insufficient physician presence on weekends was leading to catastrophe.

Hunt will say: 'Around 6,000 people lose their lives every year because we do not have a proper seven-day service in hospitals. No one could possibly say that this was a system built around the needs of patients and yet when I pointed this out to the BMA they told me to ‘get real.’ I simply say to the doctors’ union that I can give them 6,000 reasons why they, not I, need to ‘get real’.'

However, UK Doctors, Including Consultants, Do a Lot of Work on Weekends

Within a few days, there was an amazing response from UK physicians showing that what the Health Secretary seemed to believe about how NHS hospitals work was, not to put too fine a point on it, wrong.

From the Guardian came a piece by an anonymous trainee physician,

Last weekend, for the first time ever, I managed to make something trend on Twitter. It wasn’t a witty comment about Andy Murray triumphing in the Davis Cup, nor was it a retweet of a picture of somebody else’s cat.

I simply told a man called Jeremy that I was at work that night.

Three days later, thousands of people were telling Jeremy that they too were at work that weekend, using the hashtag #iminworkjeremy. Day and night, Friday to Monday, a large group of people felt Jeremy simply had to know what they were up to.

Because Jeremy is fairly important in the running of the country. Well, part of the country anyway – that part where the sick can just turn up and be treated without money changing hands. The part I work in, in fact, as a junior doctor.

Jeremy is concerned about how his part of the country is being run. He is upset that the ones who keep the sick alive – the doctors – aren’t there at weekends.

It’s just a pity Jeremy is wrong.

The Jeremy in question is, of course, secretary of state for health, the Rt Hon Jeremy Hunt, who last week announced he would bring in a 24-hour health service, seven days a week. To do this, he would alter consultant contracts to stop them including an 'opt-out' from weekend working – by force, if need be. To bolster his point, he told the public that there were not many consultants in at the weekends, and also that you were more likely to die if you came to hospital at a weekend.

I am not a consultant, far from it, but I do know that if and when I become a consultant, I will work weekends and I will be in at night. I accepted this when I took the role on.

So why did I, and the rest of my campaign group, tell the nation’s health workers to tell Mr Hunt that we were indeed working over the weekend?

I think, firstly, it was in answer to the claim that consultants do not work on Saturdays and Sundays. Our campaign has demonstrated that, day and night, there are doctors of all grades at work, often working unsociable hours.

The article also pointed out that having a consultant (the equivalent in the US of attending physician) available on the weekends may not lead to true seven day service if what the consultant orders is not available on weekends.

Two days later, another junior doctor's response to Mr Hunt had gone viral, as reported by the Mirror,

In an open letter, paediatric junior doctor Benjamin Carter, said health professionals felt 'upset, demoralised and feeling entirely unappreciated' after Mr Hunt painted them as 'lazy, money-grabbing, unprofessionals' who were opposed to 24-7 healthcare.


He said: 'Please allow me to paint a picture for you, as I am sure you are aware by now due to the #‎IminworkJeremy movement, a great many doctors work weekends. I for one tend to work 1 in every 3.

'This includes juniors and consultants, my consultants in particular have a rota for who is covering the weekends day and night because we need that expertise. When on call for that weekend, my consultants do ward rounds, they see sick children, they are present for the emergencies that their wealth of experience and knowledge helps resolve.

'They do not opt out, they do not complain, and they certainly do not go straight back to the golf course. They might not always be on site for the whole 72 hour weekend, but they are never more than a phonecall away.

'I look up to my consultants as pillars of excellence and professionalism. For you to say that we as a group operate with a lack of vocation and professionalism is not only false, it is gravely insulting.'

Dr Carter posted his letter to Facebook, where it has been shared more than 5,000 times in just a few hours.

In addition,

In a moving section, he explained that much of the anger aimed among doctors is because they have to deal with life and death on a daily basis, for a relatively modest wage.

He said: 'Already our pay is comparable to a high street manager [equivalent to a manager of a shop on Main St in the US], and that it pails in comparison to a city [equivalent in the US to Wall Street] worker and that neither of those professions require their workers to deal with life and death daily, to endure aggression from those we are trying to help and to be reduced to tears that result from exhaustion and the sheer emotional burden of our daily work.

'I invite you to come to my place of work and be there holding a dying child's hand and then tell me afterwards that I don't have a sense of vocation.'

A day later, a UK consultant calculated just how "extortionate" his overtime payments were, per the Independent,

A consultant angered by Health Secretary Jeremy Hunt's claims that a 'Monday to Friday' culture exists within the NHS has published an honest account of exactly how much he earns on call and at weekends.

Karan Kapoor posted the no holds barred letter to his Facebook page, describing what he takes home as a newly-appointed NHS ENT (Ear, Nose and Throat) consultant when working outside his usual hours.

His on-call supplement per month, he reveals, pays just £313.54 [currently = $532.49] - the equivalent of £2.61 [currently = $4.05] per hour and significantly less than the minimum wage. 

He concluded,

'I am genuinely offended that you have openly questioned my professionalism and vocation or that of my colleagues,' Mr Kapoor writes.

'I am no different to the thousands of Consultants, Junior Doctors, Nurses, Physios, Pharmacists, Secretaries, Speech Therapists, etc.

'We don't go on strike, we don't hold the country to ransom, we don't compromise patient care because we were meant to go home 2 hours ago, instead we go above and beyond, understanding the true meaning of professionalism and being exemplar to any health service in the world.

'Without this silent and diligent commitment, the NHS would have crumbled many years ago.'

The story also noted the groundswell of anger inspired by Mr Hunt's implication that today's NHS doctors do not work on weekends,

Last week a petition to call a debate on a vote of no confidence in the Health Secretary hit 100,000 - the required number of signatures to be considered for debate in Parliament - in less than 24 hours.

The petition, which was started by Dr Ash Sadighi, argues that Mr Hunt has 'alienated the entire workforce of the NHS' with his plans 'to impose a harsh contract and conditions on first consultants and soon the rest of the NHS staff.'

Finally, the Independent documented another online outburst generated by a consultant surgeon posting a picture of "himself moping a hospital floor" on Facebook.

What Generic Managers Really Think of Health Professionals

We have frequently discussed how US health care has been taken over by generic managers.  In 1988, Alain Enthoven advocated in Theory and Practice of Managed Competition in Health Care Finance, a book published in the Netherlands, that to decrease health care costs it would be necessary to break up the "physicians' guild" and replace leadership by clinicians with leadership by managers (see 2006 post here). Thus from 1983 to 2000, the number of managers working in the US health care system grew 726%, while the number of physicians grew 39%, so the manager/physician ratio went from roughly one to six to one to one (see 2005 post here). As we noted here, the growth continued, so there are now 10 managers for every US physician.

The managers who first took over health care may have had some health care background.  Now it seems that health care managers are decreasingly likely to have any health care background, and increasingly likely to be from the world of finance.  Meanwhile, for a long time, business schools seem to have been teaching managers that they have a God given right to manage every organization and every aspect of society, regardless how little they know about what the particular context, business, calling, etc involves.  Presumably this is based on a faith or ideology that modern management tools are universally applicable and nigh onto supernatural in their powers.  Of course, there is not much evidence to support this, especially in health care.

I have every reason to believe the idea that "professional" managers and business people should be in charge of all parts of society and all economic sectors has spread well outside the US.  UK Health Secretary Jeremy Hunt seems to be an example.  His background, according to the Gov.UK website, is that "Before his election as an MP, Jeremy ran his own educational publishing business, Hotcourses."  A Financial Times article noted that in 2014, he still had a major financial interest in the company,

Jeremy Hunt, the health secretary, has suffered a setback in his attempt to sell his education listings business after private equity group Inflexion pulled out of a proposed £35m deal.

Hotcourses, which claims to be the world’s largest database of educational courses, was set up by Mr Hunt and his business partner, Mike Elms, in 1996, before he entered parliament.

The article noted further, ironically in regard to the Mr Hunt's recent controversy,

The deal was an awkward reminder for the coalition of the large personal wealth of many cabinet ministers at a time when Labour has criticised the government for being 'out of touch' with ordinary voters.

As far as I could tell, before his political  career, Mr Hunt was a businessman with no experience or expertise in health care or biomedical science. And as of May, 2015, according to the the website, Actually, he still seemed to be a businessman.  Mr Hunt still owned nearly half of the company, and was still receiving large dividend payments from it.

Nonetheless, Mr Hunt is now in charge of the whole of the British NHS.  However, his recent public pronouncement that NHS doctors do not work on weekends, and that is why the health service does not provide adequate services on weekends, reveals that he seems not to be very familiar with the organization he is supposed to be leading.  Again, we have seen many examples of leaders of big US health care organizations who seem ill-informed about their organizations, and sometimes hostile to their organization's health care mission.

However, we have not often heard a generic manager simultaneously publicly express so much hostility to health professionals  and so little knowledge about what those professionals actually do.  I suspect that is merely because many US managers are reined in better by their public relations departments and legal counsel. 

We are well into our global experiment involving handing control of virtually everything to managers, administrators, executives, and business people.  I submit it is not going well, and maybe leading us to some ultimate ruination.

As we have said again, again, again... It is way past time for health care professionals to take back health care from generic managers.  True health care reform would restore leadership by people who understand the health care context, uphold health professionals' values, are willing to be held accountable, and put patients' and the public's health ahead of self-interest. 

In the UK, doctors finally seem to be rising in protest against a particularly ill-informed businessman who is currently their boss.  It is past due for US doctors to hold to account similarly ill-informed, and sometimes also mission-hostile generic managers to whom they report.


Judy B said...

These generic managers seem to have become a new subset of Homo Sapiens which I will call, "CEO." Some of the characteristics of this subset are greed, hubris and mendacity....

Anonymous said...

My experience with the non-medical manager in hospitals and pharma is that they do not base their belief system on facts or findings but instead on the talk they hear Problem is the talk they hear is part of the echo chamber set up around them to amplify what they think and tell them what they want to hear. I've heard some at the VP level say "I am trying to figure out what the CEO wants to hear." Sad, but that's they way they survive and get promoted.

So it's not surprising at all to me that what business folk say about medical folk is not accurate.

The evidence is clear that additional managers do not lower cost and improve quality of healthcare or patient health at all.

If they must follow evidence based medicine like they preach daily, then how can that evidence be ignored?