The biggest victim of a doctors’ strike would be trust in the medical profession

http://www.theguardian.com/commentisfree/2015/oct/21/doctors-strike-medical-profession-nhs

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When I was a junior doctor, in the 1970s, I used to work what my colleagues and I referred to as “one in one” or “one in two”: I worked a full working week and was on call either every night and weekend or every alternate one. It could be exhausting work, and I don’t doubt that I sometimes made mistakes because I was tired. But I took a certain pride in it.

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Doctors’ work schedules were reduced to 48 hours a week in 2003, bringing them into line with the European Working Time Directive – a move that has had many critics since. The government is currently proposing a change that some fear would revisit the kind of intense weekend shifts of the 1970s. With a view to his vision of a “seven-day NHS”, health secretary Jeremy Hunt is insisting on a contract where weekends will, more or less, count as normal working days, and some shifts might last 11 hours with only a 20-minute break. Junior doctors and the BMA say this will lead to reduced pay for the juniors and put patients at risk. Hunt denies this. The junior doctors are threatening industrial action.

The current reduced hours have had many benefits, the greatest being that more women can now enter the traditional male preserves, such as surgery. I have always suspected that the average female doctor makes a better doctor, alas, than the average male one.

But while I would not for a moment argue for a return to the long hours that I used to work, like many senior surgeons I think that for surgery the current 48-hour week is too short. The long hours I worked meant I became very experienced very quickly, and there is obviously a balance to be struck between experience and how hard you work. Surgery is a practical craft, and you learn it largely by doing it – simulators and training courses can take you only part of the distance.

The long hours, which I felt entitled me to the respect of my patients and of society, were accompanied by being part of the tight-knit medical unit known as a “firm”. This was the small team of trainee doctors led by an individual consultant. There was a real sense of belonging, analogous to the regimental spirit that is such an important part of training soldiers. This, along with the all-important continuity of care, where patients and doctors got to know one another as individuals, has been largely destroyed by a combination of the short working week and the gradual displacement, but not replacement, of the senior doctors as a principal source of authority – at least in the hospital service. (I am in no position to judge general practice).

This, it seems to me, is the real problem underlying the junior doctors’ grievances – they have become alienated, and no longer enjoy the respect their predecessors had. They have been treated by successive governments as no different from assembly-line shift workers, and it is not surprising if they are starting to become bloody-minded. They no longer have a sense of belonging or of being respected. They have become salaried employees, no longer true professionals with an ethic of (moderate) self-sacrifice. And yet they still have immense responsibility for their patients, and this tension between responsibility and having little power or respect is deeply stressful.

So I feel both sad for, and sympathetic towards, the junior doctors. I wish they could have had the training I enjoyed, although perhaps with shorter hours. I don’t know whether the proposed pay structure will mean that they will earn less, in real terms, than I did when I was in training. These are difficult historical comparisons to make, and obviously house-price inflation puts them in a very different position from the one I was in 40 years ago.

I remain sceptical about the arguments claiming that patient safety will be put at risk by the new contract. My understanding of sleep deprivation research is that we make mistakes when we are tired if we are doing boring, repetitive tasks, and medicine is never boring – though perhaps this is no longer the case now that junior doctors must spend so much of the day sitting in front of slow and stumbling NHS computers with software thoroughly unfit for purpose.

I remain deeply unhappy about the idea of doctors going on strike. There is talk of many junior doctors abandoning their careers or going abroad. This, ultimately, is the only sanction the medical profession has if we are to retain both our own self-respect and the respect of our patients.

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I cannot see any way in which industrial action would not harm patients, even though a strike would presumably only be directed against non-urgent work. “Work” still ultimately means patients. Opinion polls regularly show that doctors in the UK still enjoy a high reputation and are trusted, and part of this trust is based on the belief that doctors are not primarily motivated by money in their dealings with patients. It is, of course, one of the greatest virtues of the NHS that doctors have no pecuniary interest in how they treat patients, and do not have to compete for patients.

This can certainly sometimes lead to complacency and laziness. But if you have worked, as I have done, in many countries where medicine is essentially commercial and competitive – wealthy countries such as the US, and poor countries such as Ukraine and Nepal – you cannot help but see the immense value of socialised healthcare systems (of which the NHS is only one). If I have learned anything from working abroad, it is that doctors are easily corrupted.

A strike, even if it was supported by only a small number of junior doctors, would – somewhat paradoxically – run the risk of helping the government in its determination to replace an independent medical profession with a subservient workforce of doctors who are only motivated by financial self-interest, and managed by economically efficient managers.

As Keynes observed of “madmen in authority”, the present government is “distilling its frenzy from some academic scribbler of a few years back” – in this case the ideology of the so-called Washington Consensus, with its cult of competition and markets and its absurd belief in rational choice. Time and time again, it has been shown that these egregiously fail to work well with welfare and health services.