Sunday, June 16, 2013


How far can you stretch a rubber-band? How far can you take it before it snaps? It's always one of those million dollar questions in an every day life of a Consultant nowadays. The question that I always face, while doing job plans is how far does one absorb before it snaps? Or does it ever snap at all?

Even more to the point, would it ever get to the point where a Consultant refuses to see a patient because its beyond their contract? Would there be anybody who would have said "that's enough"? Intriguing questions as the demand increases, politicians fuel the more for less demand and everyone is asked to go that extra mile.
On one hand, there is the contract itself- in some eyes, its generous- especially the Supporting Professional Activity bit. In a 40 hours job, about 10 hours per week is supposed to be devoted to this. For revalidation, for appraisal, for teaching...some say its generous, some say its not enough. The problem is that it never takes into account individuals while applying a blanket rule. Not every one wants to teach or be an educational supervisor, so why should they be allocated time in their contract for this? On the other hand, there are some fabulous teachers- and the whole community is better served by allocating more time for teaching.
But perhaps there is a way- perhaps its worth considering the strengths of individuals within the department and annualising their job plans? Perhaps the allocation should be spread accordingly? Perhaps each is given a set time for revalidation (indeed Des Spence raises the question why we can't do so in our leave period like teachers)- and then see what can be allocated based on need of junior doctors, services? Why not use SPA time to create accessibility, create time for education and support for primary care, create time for governance issues or trust/local healthcare priorities?

But beyond the SPA itself, are we heading to a future where doctors would say "I have had enough"...would they turn away from a patient? To a lot, it would be unthinkable wouldn't it? A naive simplistic view would be that you get paid, and paid well to be a Consultant on a public sector, tax funded with it comes the issue that you have to do something extra, take a bit on the chin, knuckle down and do "a bit more". The opposite view would be that...isn't that what the old contract was about till we moved to a time based contract? The worry I have is to what extent the reliance on the benevolence on doctors will continue.

What if at some point doctors decide not to see patients as they are not paid for it? What if they down tools- behave like a trade union? The analogy could be that if this was a car industry (and we know how much we love giving examples of the airline and car industry in the NHS...!!) and the workers down tools, the theory is that production stops, car sales go down, the management suffers losses and they come to the table to negotiate. Problem is in that example, no one really suffers harm except the bottom line of the management...try that in a healthcare sector and there's a real life human being who suffers, the patient...due to no fault of theirs. On one hand, immediately the doctors are "greedy" while the reality maybe that they may have been stretched to breaking point and can do no more...while on the other hand, downing tools in a healthcare sector is nothing short of a nuclear option, making all of us deeply uncomfortable,entering into a challenge with our conscience...a deeply disturbing territory- and part of the reason why the pensions strike achieved such poor turnout.

And it makes me worry- that as a system we may not be too far from it. I see colleagues exhausted, on the verge of burn out...and I am not sure how far they can be far that rubber-band can be stretched. And I also know they are colleagues who are not mercenary minded, who are not driven by money..and how much it pains them to think of the unthinkable. I am a born optimist but I see a worrying trend developing. It's not about the money earned...its about how much you use the benevolence of clinicians and how you use it. I keep on hearing about "wastage"...but I hear very little about how much the NHS is fuelled by goodwill...the ability of doctors and nurses to do "that little extra bit".

Let's all be a bit careful how far we stretch that rubber-band...the day it snaps completely, I can guarantee you the NHS will end. And it will be nothing to do with structures of the NHS. It would be to do with burning out one of the most valuable and non-measured qualities,that particular trait you can't quite quantify in a job plan, the oxygen on which this system runs in spite of all the toxic's called..goodwill.
To colleagues who contemplate that option, there must and must be an option out there which does not involve compromising patients. The frustration I understand, the pain I appreciate but never went to medical school to walk away from a patient..and I exhort you, nay plead with you, not to go down that road. Once that is done, an irreparable harm will be done to the reputation of a physician- otherwise known as a healer.We must find a way around that. Must.

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