At the eleventh hour, the BMA suspended the junior doctors’ strike. It hasn’t been called off entirely, it may still happen, but probably won’t. As a conspiracy theorist, Dr No suspects the whole shebang was a clever ruse by the doctors: a strike that was not a strike, a neat foil to Absolutely Stilton’s tanks lining up in the hospital car park; as a cock-up theorist, he suspects the whole bang shoot is further evidence that, even if it wanted to, the BMA couldn’t fire a rocket on Guy Fawkes Day. Apart from some bizarre even by Daily Mail standards doctors’ leader in love nest in Neasden style hackery, not to mention its doctors on dark web exposé, media coverage has been thin for what is after all serious domestic news. At the coming up of the sun, the Today programme looked the other way, and at the going down of the sun, Hoo Wedwards and his harem of squawking reporterettes hardly ever mentioned the conflict. There was some coverage of the ‘overwhelming’ 98% in favour ballot result, but few pointed out that 98% of those who voted is about just over half of all junior doctors, though even that is still an eye-watering result. For the BBC in particular, the junior doctors’ contract was, like the Health and Social Care Bill before it, to be just another ship that passed in the night.
Elsewhere, there was some politically correct hand-wringing over language, as in why are junior doctors, some of whom are quite senior, called juniors? Answer: because they are in training: the term is a long-established blanket term for any qualified doctor in a training as opposed to career grade post. Hardly anyone focused on the primary reason for the escalation from a long-running terms and conditions dispute to the strike ballot, Heremy Junt’s you can have any contract you like, so long as it’s mine stance. Nor has there been anything like sufficient analysis of why junior doctors, who are by definition dedicated to the care of their patients, should feel as strongly as they demonstrably do. Commentators of the Adam Smith tendency had it that it was all down to pay, but even a cursory look at junior doctors’ pay – it is all in the public domain – reveals that, while not up to bankers’ standards, it is certainly by and large adequate. The juniors – and a number clearly said so – weren’t about to strike over more pay, though in fairness part of the ballot decision may have influenced by threats of pay cuts. Instead, and indeed ironically, the imminent threat of the removal of medical labour was primarily about patient safety.
How can that be? After all, a doctor’s first duty is do no harm, and on the face of it a walk-out must cause harm. But the juniors, who only make up about half of the hospital medical workforce, knew they had strong support from other doctors, who had already agreed to step up to mitigate the impact of any junior strike, making the threat more one of patient inconvenience, possibly serious inconvenience, than serious harm. Furthermore, Dr No suspects the juniors also had a hunch the public were largely on their side. Yes, a few unnecessary deaths could quickly turn that tide, if indeed there were any, but a public faced with whether to believe doctors desperate enough to consider striking or ministerial mumbo-jumbo about seven day working are generally likely to find in favour of the doctors.
But isn’t inconvenience – a delayed operation or cancelled and rebooked out-patient appointment – harm? The short answer is yes, the longer answer is it is relative. In their daily work, doctors are already very used to doing short term harm in the hope of long term benefit. Though rarely expressed, doctors know that first do no harm really means do the least harm, or do no long term harm. Every time a doctor sticks a needle in an infant to vaccinate it against disease, the doctor trades off short term harm – a bawling baby – against long term benefit – an immunised child. Whether it’s chemotherapy, or post-operative pain, in every case the doctor inflicts short term pain to gain long term benefit. Viewed this way, there is nothing particularly odd about a junior doctor deciding, given a particular set of circumstances, that a short term strike may be necessary to prevent long term, and possibly far more serious, harm.
The practical question now becomes: will the imposition by government of an un-negotiated contract on junior doctors harm the profession, and so in due course patients? Junior doctors clearly think the answer is yes, and on one level that is sufficient answer in itself. Junior doctors are not a bunch of hot-headed fire-crackers, they are the intelligent and committed members of a demanding profession. If they who spend their days on the wards and in the clinics say there is a problem, perhaps we should accept there is a problem. But even if we are minded not to accept that doctor knows best, we do not have to look far to see that there is ample evidence of an impending, if not already present, serious threat to patient safety. The two main front line services, A&E and general practice, not to mention the less visible front-line specialty of psychiatry, already face serious staff recruitment and retention problems. The imposition of a contract that worsens pay and conditions in those services can only aggravate the situation, by causing doctors to vote with their feet, to choose other specialties, or to work abroad, or perhaps even to leave the profession altogether. These vital services, already stretched to breaking point, face a real prospect of collapse. When A&E services implode, or the psychiatrist has locked him or herself up in the asylum, or the doctor won’t see you now (or ever), who can hand on heart say there won’t be extensive and significant patient harm?
Juniors were right to expose the gravity of the situation by voting to strike. At the eleventh hour, ministers removed the threat of contract imposition, allowing the juniors, who never wanted to strike in the first place, to suspend the threat. We must now hope that the strike that passed in the night leaves sufficient turbulence in its wake to shake up the government into some pragmatic thinking towards an agreed contract. Ministers reflexly minded to assume doctor doesn’t know best might care to refect that, when it comes to patient safety, generally doctor does know best. On the other side, juniors will be hoping for the best, but prepared for the worst. The BMA may not be able to fire a rocket on Guy Fawkes Day, but the health minister has already shown he has a dangerous habit of lighting fireworks in the petrol station.