The doctors’ strike, or ‘industrial action’, as the strikers prefer to call it, has happened. On the day after the longest day (2012 is a leap year), a smaller than expected number of striking doctors turned up for work sporting ARP style armbands declaring ‘I’m caring for patients’, which was a bit rich if you happened to be a non-urgent patient, and smugged their way through their day. As own goals go, it was a corker, more Rear Admiral Hamish McMayhem taking his entire fleet the wrong way up the Windward Passage, than a solitary cocoa bean going the wrong way up Bournville Boulevard. On the radio, you could hear Langho rubbing his hands with glee at the gift of anti-doctor propaganda, while the media at large took turns to shy coconut after coconut at the ‘my pension or your life’ protesters. If proof was needed that Dr No’s former colleagues had lost the plot, then this was that proof.
Don’t get Dr No wrong – he fully accepts the doctors have a grievance. Having accepted new and less favourable pension terms four years ago with the last government, doctors now face the imposition of even less favourable terms by today’s government. To add insult to injury, doctors have been singled out for special treatment: harsher terms than comparable groups. All that much is true, and all of it is indeed unfair.
The trouble is – and this is the first point on which the doctors lost the plot – while it is indeed true and unfair, it is only one part of the broader picture: that doctors, once out of training and in career grade posts, are not only handsomely paid in post, they also have, however you look at it, remarkably lucrative gold-plated pensions. To the vast majority looking at the broader picture, the doctors’ whinge looks somewhat like the man with two Aston Martins whingeing at a hike in payments for the third Aston Martin. Many ask, very legitimately, how many Aston Martins does one man need?
To which the doctors will no doubt reply: that’s not the point. We agreed it was going to be three, on such and such terms, and now the government wants to renege on the deal, in what amounts to a breach of contract, in spirit if not in law. Again, on the narrow picture, this much may be true; but to the outsider, such moans sound little different to the banker moaning that losing his bonus is a breach of agreement if not contract. To the outsider, the cat is already quite fat enough. What the outsider sees instead is greed – unbridled and unprincipled greed.
So the public and the media, it can confidently be said, were never going to be sympathetic, in anything but the narrowest sense, if at all, to the doctors’ concerns. The failure to grasp that few, if any, would warm to the woes of the wealthy being forced to pay more for their wealth was Big Mistake Number One. Big Mistake Number Two was to decide to take action that would directly affect, and so harm, innocent third parties: patients.
Dr No fully accepts – see above – that the doctors (Dr No excludes himself, since his NHS pension is deferred, and so unaffected – but don’t even think about commenting that that is why Dr No is unsympathetic, because he is not; he just thinks the doctors have made grave tactical errors) have a grievance. But it is a private grievance, about money, between doctors and government. There cannot be any justification for taking action that will cause – whatever the striking doctors may say – direct harm to patients. Not only is there the inconvenience, not to mention considerable distress, of cancelled appointments, tests and operations; there is also the inescapable risk that a number – albeit a small number – of patients with red-flag symptoms, say passing or coughing up blood, who had reluctantly decided to see their doctor last Thursday, will further delay, with potentially disastrous results. Even if only one such patient is so delayed, it is one too many; and the doctor with the armband ‘caring (but not caring) for patients’ will bear the mark of it on his conscience.
Dr No does not, as it happens, support an absolute ban on doctors’ strikes. If a strike is directly related to a threat to patients, then, somewhat paradoxically, a careful case can perhaps be made for limited striking, on the grounds that not to strike will in the longer term cause greater harm. But the doctors’ current grievance is not about threats to patients, it’s about money. Far smarter, if only the doctors had the brains to see it, would be not to indulge in a midsummer’s day of madness (not to mention what happens next? more days of madness?) but to take action that will seriously irk the government, but leave patients unaffected. There is even an obvious candidate: block revalidation.
Most patients care not one jot about revalidation, preferring instead to make up their own minds about their doctor’s competence. Why – some might even support a stand against revalidation, seeing it as a futile exercise that distracts doctors from looking after patients. Heaven forbid! – it could even deliver a win-win: the doctors hurt the government in support of their pension claim, and the public support (or at the least don’t object to) the doctors’ action. Instead of appearing like Bottom in the play, an ass and yet unaware of it, not to mention being away with the fairies, doctors at last might be seen to have their heads screwed on right over their pension dispute.
As a tactician in politics it is important not to fight a battle that is going to be lost. We would never get public sympathy, and the fact that 90% of British docs worked normally shows that there was a lot of hot air spoken on the subject.
I would suppott a revalidation boycott, whether or not pensions were preserved. I suspect that the BMA would not. They are up to their necks in it, so never going to oppose it.
Boots
Mmmm, I tend to agree that the medical profession has shot itself in the foot here.
Average Joe Publics view of GPs (although perhaps not his own GP) is that of what has been fed to him by the press – and no doubt to some extent, these reputation-damaging attacks fuelled by those (of whatever hue) who lead us (for their own aims)…
Joe sees GPs as greedy, Ferrari driving golfers and unfortunately the industrial action compounded this view.
Last Friday I had occasion to pass through a few towns and cities on my travels and it was clear that GPs were almost exclusively held to blame as newsagents’ billboards screamed “GP STRIKE CAUSES DISRUPTION” or words of a similar ilk.
Oh how Lansley must have loved this gift on a plate.
I can’t help thinking if docs had raised such a fuss re the HSCB they would now be regarded as the heroes of the NHS…
As to revalidation it is perhaps true that most patients are unaware of it – but if needs be (by those who govern us) I am sure the press will make them very aware…
I subscribe to many things as I like to be knowledgeable of diverse opinion, one being the Patients Association. A poll last week asked whether doctors should be reassessed every five years to ensure they continue to be fit to practice: Yes votes – 98.2%, No votes – 1.8%.
Of course it could be argued that members of the PA have a real or perceived gripe with the medical profession but nevertheless they have a very real voice and indeed Ann Lloyd (PA trustee) was a speaker at the NHS Confederation conference on ‘Reaping the strategic rewards of revalidation’…
So it goes and the hounds are still out to tear apart the medical profession (especially GPs) and last week’s industrial action ensured a fine feed.
Anna :o]
The Unite members that are by far less well paid, have fewer benefits and considerably smaller pensions, had a far far more valid for going on strike the day before this “caring for patients” strike. In a country that has 2.2 million working families that are afraid of a large electricity bill, doctors moaning about pensions is small fry.
Boots – it’s not just the BMA. The recent RCGP comedy-election (around a 10% turnout, with about 3 % of the total electorate voting for the winning candidate) recently returned Professor Mike Pringle as President. Until recently, Pringle was chief ravildation pongo at the College; so the result, despite the comedy mandate, has been to ’embed revalidation at the very top of the College’, as those who say things that sort of way would say.
Anna – this year, so far, doctors (not just GPs) have had a minimum of three things they could build a case (with which we may or may not agree) on which to strike: the Health and Social Care Act, pension ‘reform’, and revalidation. Of the three, pension reform is the most trivial, and self-centered, and as you, and others, have pointed out, if pensions were worth striking over, then surely so too was the HSCA? But, in effect, in practice, the BMA did nothing practical – took no action – about the HSCA. They were like blind traffic cops waving through the tanks of Armageddon…
Make no mistake – the HSCA will destroy the NHS largely from the outside, but revalidation will destroy the profession from the inside. Sure, 98% punters will say docs (like pilots and all the rest) should have annual/five-yearly checks, but such surveys remind Dr No of WSC’s remarks about five minutes chat with the average voter. Docs aren’t like cars, or even pilots, in what they do, and revalidation wont just be a simple MOT. Yet to average Joe, revalidation is, like screening – a Bush style no-brainer – so let’s ‘bring it on’. Indeed, in its way, revalidation is a form of screening (intended to catch ‘malignant’ docs at an ‘early’ stage before they do any ‘real harm’) but like screening, it is nothing like that simple. Yes, of course there are cases when screening makes good sense, but often, especially with mass screening for ill-defined conditions, which is what revalidation amounts to, screening can do far more harm than good. Punters who say yes to revalidation in PA surveys should be careful what they vote for…
Dr No has written extensively on revalidation, but at its core the problem is one of destruction of trust. It will not only (and admittedly on the face of it paradoxically) erode trust between doctors and patients (doctors will be presumed incompetent until ‘proved’ competent by revalidation), but just as harmfully, it will destroy trust within the profession, between the ordinary doctor, and the GMC Gestapo and their agents who police the profession. It will be a dark and chilling new world or corridor assassinations and ritual career executions ‘pour encourager les autres’. You have been warned…
I forgot to mention the strike I mention by Unite members was at the BMA offices.
“strike: the Health and Social Care Act, pension ‘reform’, and revalidation. Of the three, pension reform is the most trivial, and self-centered, and as you, and others, have pointed out, if pensions were worth striking over, then surely so too was the HSCA? But, in effect, in practice, the BMA did nothing practical – took no action – about the HSCA. They were like blind traffic cops waving through the tanks of Armageddon…”
I don’t think you can strike over a bill of any sort, can you?
” ‘pour encourager les autres'”
Qui sont ‘les autres’ Dr No?
Revalidation, if that’s it’s intention, to push older docs out, will also leads to the younger ones leaving the profession altogether since they too will be subjected to the same tests whatever those are … so I think it means what it says on the tin; getting those who need more training to train and those beyond repair out. Correct me if I’m wrong please
Dr No has no idea what tactical let alone strategic thinking went on amongst the BMA pongos and their confederates-in-strike (did they even seriously contemplate the long game, or even consider basic what-ifs: what if we strike for a day, and nothing changes: what do we do then?) but, Anonymouse, to answer your question about striking over a bill: at the most basic level, any worker can strike over anything. If striking is the withdrawal of normal labour (in contrast to work-to-rule, the withdrawal of extra-normal labour), then any labourer can ‘down tools’ in protest. It may be wise or foolish, legal or illegal, to do it, but it can always be done. Even the Armed Forces can do it: take the Naval Mutinies of 1797, which, although called mutinies, were in effect strikes, ironically about pay and conditions. So yes, doctors can strike over the Bill, or Act as it now is, and indeed there is a groundswell of grassroot opinion in favour of boycotting CCGs. Whether such a boycott is a strike or a work-to-rule depends on whether you view CCG work as part of the normal work of a doctor. No doubt some do, and others don’t. That said, Dr No considers, as others do, that boycotting CCGs is not without risk, most notably that commercial interests will rapidly step in to fill the void.
Les autres sont les médecins ordinaires: the ordinary doctors who do the everyday work, and are not part of the GMC-Gestapo machinery. If only revalidation was so simple as you suggest! It almost sounds as simple as gardening: picking out the weak seedlings, feeding those that need it, and letting the rest get on with it. But that is to consider doctors as plants – perhaps they are, Dr No sometimes wonders, given recent form – but the reality is that doctoring is a hugely complex activity, and doctor-patient, and, in the context of revalidation, doctor-doctor relationships, are correspondingly complex. Who decides, for example, what is ‘good enough’, and what tests might they use to make that decision? Dr No has personal experience (detailed elsewhere) of a test that was patently absurd, and agreed to be so by the testers, but they still used it anyway – and so got a bad result.
The primary problems with revalidation are conceptual, but even at a pragmatic level, it is about as ludicrous a proposal as one could possibly imagine. For starters, it fails the evidence based policy test (there is no evidence it delivers its intended ‘on-the-tin’ outcomes). Then there is the opportunity cost, in money and time, both significant and considerable. And then there is the blowback on professional morale, and through that on recruitment and retention – at a time when both traditional Cinderella specialities and general practice are facing ongoing and in some locations severe recruitment difficulties. Yes, the crude numbers (over-supply of medical graduates) may change that in a decade or so – but we still have the short and medium term to get through. Revalidation will do nothing to help, and has everything to hinder, our progress. It must be binned.
Damian – it is, ahem, striking that the more ‘traditional’ unions seem altogether more sophisticated and modern in their use of strikes than the supposedly clever doctors. Interestingly, there were indications yesterday in McMayhem’s BMA Conference speech that he has (somewhat after the first foot has been shot off) come to see that most doctors only have two feet, and shooting off the other one makes no sense. So he is back-pedalling on further strikes, albeit it not very efficiently, given he has already lost one foot…but then, it was also a swansong speech; and his likely successor is said to be far more bullish. If that is so, he may have four legs to the swan’s two, but all that may mean is that it will take a bit longer and be a lot more painful to shoot off the what feet remain. The end result will still be the same: the BMA rendered a footless and so in effect legless beast.
Dr No on revalidation: “It must be binned”
But we know that there are some doctors who are not up to the job out there, and we know what happens to whistle blowers if they tell of those, so the majority don’t, hence, you do have a problem that needs solving. What do you suggest instead Dr No?
Shoot the bastards – simple, but effective.
Seriously, though, revalidation falls into the category of evidence-lite imperative-heavy policy which develops like this:
1. There is a perceived problem
2. Something must be done
3. Something can be done
4. Something will be done
No doubt this is all very politically convenient and expedient, but it starts to look distinctly dodgy when one asks:
1. Where is the evidence for the nature and scale of the problem?
2. Where is the evidence the proposed solution will work?
Ben Goldacre posted recently on similar problems with evidence-lite policy here. If a sound randomised trial persuasively showed revalidation to be effective against a real problem, then Dr No supposes he would have no alternative but to be persuaded. But he doubts that will happen, and so he continues to have grave misgivings about revalidation.
Revalidation is also part of the wider plot to deprofessionalise medicine. As it happens, Dr No is already minded to write a post about deprofessionalisation woes (which include revalidation) and what might be done about them – and so begs leave to stay alternative suggestions pending that post.
Just that 🙂
“A poll last week asked whether doctors should be reassessed every five years to ensure they continue to be fit to practice: Yes votes – 98.2%, No votes – 1.8%”
The 98.2% result is not at all surprising. Any sensible person wants doctors who have sound basic background medical knowledge as well as being experts in their own field. If they public knew exactly the antics that will be involved in revalidation, I wonder how many would support it as the way to sort out the wheat from the chaff. I suspect many would perceive it as a waste of doctors’ time and public money.
It could be argued that a more sensible approach would be to have a five yearly exam, but what knowledge should be examined? By the time they function as independent medical practitioners, doctors have sat and passed many exams and indeed it could be said that most doctors are pretty good at passing exams if they have the time and inclination to study for them and learn all the necessary exam quirks. However, after a while, many doctors would regard yet more exams as a pain in the neck. After all, it is said “one fool can ask more questions than seven wise men can answer” and Dr No has touched on this in one of his comments.
In my view, at least in the clinical specialties, a doctor learns every day of his/her working life, and the main thrust of continuing professional development comes from the patients themselves. Every patient is a focus of learning, In fact The Witch Doctor over the years has often used the term “focus patients.” The trouble is if a doctor does not take an adequate medical history, examine a patient properly, have the benefit of beds in wards with on-going discussion during ward rounds, and informal communication with other experts over lunch about the diagnostic and management problems of the day, then the quality of continuing professional development diminishes as does optimal patient care. These staple forms of learning are being eroded by reorganisation and dumbing down. As a result, those who prefer to sit on committees rather than spend time with patients, pontificate about things like 360 degree appraisal and all the other fluffy junk that has no function other than to keep people employed and fuel little “Revalidation” businesses that cream off taxpayer’s money. Remember MTAS. Revalidation is a repeat of the madness.
Anonymouse – Dr No is not trying to dodge the question, just trying to avoid burying what should really be a new post in a comment in an existing post. He has even written a new post, and will probably publish it shortly. It is even possible it will be one of several posts. Dr No is, for example, also intrigued by what he calls the Macavity problem. Will Stilton’s goons end up like Yates from the Yard:
Macavity’s a Mystery Cat: he’s called the Hidden Paw –
For he’s the master criminal who can defy the Law.
He’s the bafflement of Scotland Yard, the Flying Squad’s despair:
For when they reach the scene of crime – Macavity’s not there!
‘Smart’ bad doctors will run rings round Stilton’s goons, while the ‘dim’ ones will already be obvious (and could be managed, if one put one’s mind to it, very adequately without recourse to global revalidation).
WD – the problem with the PA question (and so why the answer is irrelevant) is that it contains a hidden question/assumption in it, that is: should doctors be competent to practise? and so the only surprise is that the result wasn’t Yes: 100%.
Dr No also agrees that the old coherent way of practising naturally (and painlessly) encouraged informal continuous learning, while today’s fragmented way of working impedes natural learning. Oh, what we have gained from progress, from ‘no change is not an option’!
Dr No’s ‘Problem-Solving Suggestion’ of Jun 27th omits, or perhaps re-words, the famous Yes, Minister syllogism about ‘Something Must be Done’-driven policy making:
1. Something must be done
2. THIS [Bill/Policy/Revalidation Scheme] IS something; therefore
3. THIS must be done.
A particularly popular one with govt departments, and perhaps with bureaucracies of all stripes.