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An open letter from a doctor to Jeremy Hunt

Your plans are neither safe, nor sustainable, nor morally okay. 

“Make the care of the patient your first concern.”

This is the cardinal rule of Good Medical Practice, the handbook issued to every medical student by the GMC at the dawn of their training. Ask any doctor: we have this rule as deeply ingrained throughout medical school as any physiological action or pharmacological mechanism. We probably mumble it in our sleep.

And we try to. We try so damned hard. Along with the nurses, the allied healthcare professionals, and all the auxiliary teams – we do what we can with meagre staffing levels and stretched resources pitted against relentless “efficiency savings“. We work and work and work, in a miasma of demoralisation that has only thickened over the past weeks and months as the true depth and breadth of the cuts has become horrifyingly apparent.

The patients are more numerous and sicker than ever before; partly due to the ageing population, but also because the patients getting admitted to hospital have been disproportionately disadvantaged by the decimation of health and social care provision both in hospitals and nationwide in the community. The estimated funding gap for adult social care this decade? £4.3 billion.Charity funding cut by £1.3 billionpersonal care cutmental health services cut disability benefits cutcarers in crisisbenefit caps inexorably tighteningall welfare increasingly inaccessible to the most vulnerable members of society: the unwell, the poor, the young, the disabled.

Given the above, it is indisputable that the actions taken by this government and the last have made the British population sicker.

The knock-on effect on healthcare resources is both predictable and inevitable.

Vulnerable, isolated older people are arguably the worst hit; the sterling work by Age UK shines a light on the shameful state of things for this demographic. These are the patients who bounce in and out of hospital and “bed-block“, often due to multiple morbidities and complex psychosocial needs.

Hospital admission should always be a last resort. Unfortunately, in so many cases, things are so bad in the community that last resorts are all we have.

Throughout my years as a junior doctor, I have become heartbreakingly familiar with the phrase “we don’t have capacity at the moment” from the various theoretically excellent community-based services designed to manage patients wherever possible in their own homes. There aren’t enough nurses, enough midwives, enough healthcare assistants, enough technicians, to safely run such services for as many patients as need them – so those patients stay in hospital. There aren’t enough GPs to provide enough emergency appointments to give everyone who requests one an urgent medical review – so those patients come into hospital as well. There aren’t enough days in the week or hours in the day to ensure flawless care for every patient who seeks help. There are never enough.

Healthcare professionals still strive to make the care of all these patients our first concern; far above our concerns for our own physical and mental health. In my first job as a junior doctor I unintentionally lost 8kg in three months, my BMI dropping to an unhealthy 17.2, because I was regularly working 14 hour shifts without a break. Any food grabbed was eaten whilst poring over blood results or typing discharge summaries with the other hand. I’ve lost count of the number of times my incredibly supportive husband has said “you’re too ill to go to work – take a sick day” and my first thought has always been: “yes if I worked somewhere else, but this is different – I’m not as sick as the patients, and they will suffer if we’re even more short-staffed”. Patients don’t want sick doctors, but most of them would rather that than no doctor at all, and that is essentially what it comes down to; short-notice cover is rarely arranged due to budget constraints, and instead the remaining staff stretch themselves thinner to try to cover the gaps. These examples are just from my early career – I know of countless others, because healthcare professionals make many larger sacrifices than these in the name of patient care and the public good every single day.

It is not safe.
It is not sustainable.
It is not morally okay.

You are correct that medicine is a vocation with myriad non-financial rewards; you are misguided if you think systematically disenfranchising the workforce won’t make people leave.

I’m referring to the move to change the definition of antisocial working hours, so that evening and Saturday work up to 10pm will be valued the same as weekdays 7am-7pm (the core hours many doctors work at baseline, albeit often involving multiple hours of unpaid overtime). I’m referring to the proposed stripping of the financial parity incentive from GP training – arguably one of the specialties in which recruitment is most in crisis. I’m referring to the recent toxic rhetoric surrounding weekend working, apparently designed to foster the attitude that doctors are at best lazy, at worst negligent. Summary of these proposals here.

Commonly heard from the most senior medical staff: “At least I’m retiring soon.”

Commonly heard from the most junior medical staff: “Have to admit I’m increasingly tempted by working overseas.”

I’m a born-and-bred British graduate of a medical school which regularly ranks in the top 5 in the country. I already had a BSc therefore didn’t get any help with paying my tuition fees; I took a loan and used the savings my father left me when he died, and I still amounted significant debt (I couldn’t have afforded to retrain if the fees had already been £9k per year). My university place was competitive, with approximately 8x the number of applicants than studentships available, and the cost of training me was approximately £300k. I was highly motivated, I worked very hard to get here, and I am devoted to both the NHS and to this country. And yet in the light of recent developments, I am considering working abroad. What an absolute waste of resources that would be.

It is in vogue at the moment to talk about “the patient’s journey“, to focus on how improvements could be made to the narrative of their illness: prompter diagnoses, minimising unscheduled care, maximising doctor-patient concordance in management; better outcomes, fewer recurrences and – as always – lower costs. “Customer satisfaction” will always vary, and the nature of illness means that disappointment, fear and anger will inevitably be factors in some people’s experience of the NHS. But the fact is, even if you make your journey from A to B via the smoothest possible route – in the shortest possible time – the experience of travelling in a creaking overcrowded bus running on low-budget fuel will always be more stressful than travelling in a well-maintained vehicle. At risk of labouring the metaphor, none of us are asking for the NHS to be a sportscar. But we wish for our patients to be able to make their journeys in a vehicle that promotes individualised care: that means more staff, more beds, more resources.

None of your proposals for 7-day non-emergency-care service address this unmet need. (We already run a 24/7/365 urgent care service, as you may remember from taking your own kids to A&E rather than wait for their GP practice to open after the weekend.)

As doctors, we are trained in the art of deduction: the ability to pick out important signs and symptoms from the background noise of normal physiology, to find a meaningful pattern in a group of data; to see not merely stars, but constellations. It is difficult not to look at your history, Mr Hunt, and to examine the statements you have made and continue to make, and come to certain conclusions:

1. You do not intend to keep the NHS free at the point of use
2. You intend to make this more palatable to the general public by systematically defaming and devaluing healthcare professionals – divide and conquer, if you will
3. You are willing to sacrifice the existing NHS workforce on the altar of “efficiency savings”, irrespective of the consequences

If I have come to the wrong conclusions here, please do not hesitate to correct me. My suspicion is that you would be unable to provide evidence to support a rebuttal of the above impression.

If this were about points-scoring, I would leave it there, but it is about so much more; so many people’s lives are being detrimentally affected, and frankly endangered, by the decisions you are making and the policies you are pushing through. I find it difficult to believe that anyone could lack compassion to such a devastating degree as it seems, from the outside, that you do.

So I will finish instead by making a request. I ask you to take a leaf out of our book, Mr Hunt: please, for all our sakes, prove me wrong, and make the care of the patient your first concern.

This article originally appeared on Left + Write

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The rise of the green mayor – Sadiq Khan and the politics of clean energy

At an event at Tate Modern, Sadiq Khan pledged to clean up London's act.

On Thursday night, deep in the bowls of Tate Modern’s turbine hall, London Mayor Sadiq Khan renewed his promise to make the capital a world leader in clean energy and air. Yet his focus was as much on people as power plants – in particular, the need for local authorities to lead where central governments will not.

Khan was there to introduce the screening of a new documentary, From the Ashes, about the demise of the American coal industry. As he noted, Britain continues to battle against the legacy of fossil fuels: “In London today we burn very little coal but we are facing new air pollution challenges brought about for different reasons." 

At a time when the world's leaders are struggling to keep international agreements on climate change afloat, what can mayors do? Khan has pledged to buy only hybrid and zero-emissions buses from next year, and is working towards London becoming a zero carbon city.

Khan has, of course, also gained heroic status for being a bête noire of climate-change-denier-in-chief Donald Trump. On the US president's withdrawal from the Paris Agreement, Khan quipped: “If only he had withdrawn from Twitter.” He had more favourable things to say about the former mayor of New York and climate change activist Michael Bloomberg, who Khan said hailed from “the second greatest city in the world.”

Yet behind his humour was a serious point. Local authorities are having to pick up where both countries' central governments are leaving a void – in improving our air and supporting renewable technology and jobs. Most concerning of all, perhaps, is the way that interest groups representing business are slashing away at the regulations which protect public health, and claiming it as a virtue.

In the UK, documents leaked to Greenpeace’s energy desk show that a government-backed initiative considered proposals for reducing EU rules on fire-safety on the very day of the Grenfell Tower fire. The director of this Red Tape Initiative, Nick Tyrone, told the Guardian that these proposals were rejected. Yet government attempts to water down other EU regulations, such as the energy efficiency directive, still stand.

In America, this blame-game is even more highly charged. Republicans have sworn to replace what they describe as Obama’s “war on coal” with a war on regulation. “I am taking historic steps to lift the restrictions on American energy, to reverse government intrusion, and to cancel job-killing regulations,” Trump announced in March. While he has vowed “to promote clean air and clear water,” he has almost simultaneously signed an order to unravel the Clean Water Rule.

This rhetoric is hurting the very people it claims to protect: miners. From the Ashes shows the many ways that the industry harms wider public health, from water contamination, to air pollution. It also makes a strong case that the American coal industry is in terminal decline, regardless of possibile interventions from government or carbon capture.

Charities like Bloomberg can only do so much to pick up the pieces. The foundation, which helped fund the film, now not only helps support job training programs in coal communities after the Trump administration pulled their funding, but in recent weeks it also promised $15m to UN efforts to tackle climate change – again to help cover Trump's withdrawal from Paris Agreement. “I'm a bit worried about how many cards we're going to have to keep adding to the end of the film”, joked Antha Williams, a Bloomberg representative at the screening, with gallows humour.

Hope also lies with local governments and mayors. The publication of the mayor’s own environment strategy is coming “soon”. Speaking in panel discussion after the film, his deputy mayor for environment and energy, Shirley Rodrigues, described the move to a cleaner future as "an inevitable transition".

Confronting the troubled legacies of our fossil fuel past will not be easy. "We have our own experiences here of our coal mining communities being devastated by the closure of their mines," said Khan. But clean air begins with clean politics; maintaining old ways at the price of health is not one any government must pay. 

'From The Ashes' will premiere on National Geograhpic in the United Kingdom at 9pm on Tuesday, June 27th.

India Bourke is an environment writer and editorial assistant at the New Statesman.

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