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Junior doctors aren't just going on strike. They're trying to warn us

There's a bigger story than just pay and conditions, warns Benedict Cooper.

On a bitterly cold afternoon in Nottingham’s Old Market Square, a group of junior doctors stood shivering together, banners in hand, pleading with the people hurrying by in thick winter coats and scarves to listen to their reasons for why they and colleagues throughout England are on strike. A few stopped, tapping their feet in the chill air; some even signed their petition.

On the surface it’s about pay. But there’s something more serious going on – a lesson we ignore at our peril. Doctors are deeply concerned about safety on the wards. Why do they feel they have to take to the streets to tell people, rather than going through the official channels? Because that’s a dangerous game as well.

Take the case of Dr Chris Day. When Day qualified in 2009, the idea that he was destined to cross swords with the Secretary of State for Health would have seemed ludicrous. Now he is embroiled in a dispute with the highest levels that has implications for the future of the controversial, and often misunderstood practice of ‘whistleblowing’.

It all started one night back in January 2014. Day was working through the night on ICU at Queen Elizabeth Hospital, part of Lewisham & Greenwich NHS Trust. When two locum doctors failed to turn up to work on another ward, Day found himself dangerously stretched having to treat critically ill patients outside of ICU. Under what’s known as ‘protected disclosure’, he raised the matter and urged his manager to find locums ready to come in. It sounds innocuous enough - it’s been anything but since. Why? Because his case has revealed a major flaw in the system; a flaw that has cost him dearly. Unlike almost every other branch of the medical profession, junior doctors aren’t protected when they blow the whistle in the way Day did that night.

As they progress through their post-medical school training on the way to consultant level, junior doctors find themselves in the invidious position of being on a series of  temporary contracts with whichever trust they are working for, usually only for a year at a time, with Health Education England (HEE) – formerly the Post Graduate Deanery - overseeing the whole postgraduate programme. The problem comes when they encounter an issue, the type Day raised the alarm over. If the trust in question doesn’t like what it’s being told it can make life very hard for a whistleblowing doctor – 17.3 per cent of NHS staff that speak out are victimised, according to Sir Robert Francis’ Freedom to Speak Up Review.

Then if they want to defend themselves they fall between two stools. As employees on a temporary contract with the trust they are not covered by the sort of protections that a formal employment arrangement would give, while HEE, technically an education body but with ultimate power over long term employment, is not bound by the so-called ‘catch-all’ 43K employment laws which protect nurses and agency workers, but not doctors. This is what makes Day’s case so pivotal. If it fails, it will set a precedent that any unfair dismissal claims are impossible for the majority of doctors below consultant grade.

Two years of legal battles have led Day to launch an appeal to the public for support in the next, and hopefully final clash with HEE and Lewisham & Greenwich trust over this crucial gap that is preventing his case being heard. This, he says, doesn’t just affect his own career path, but the whole future of the notion of transparency in the NHS. Day is arguing that HEE and the Department for Health are leaving 54,000 junior doctors out in the cold, refusing to provide protections for whistleblowers, effectively intimidating them into silence.

 “It’s about so much more than just my career,” he tells me. “I'm thinking about the big picture. They are using taxpayer money to stop part of a court case being heard, and they will do the same to other doctors as my appeal will be binding on all other junior doctors bringing whistleblowing claims. If I can secure 43K status for deanery doctors they will be free to act in their patients’ best interest.

“My protected disclosure isn't about someone writing a letter after the event, it's more fundamental than that, it's about a doctor being able to speak freely and openly in real time.”

His case has gained traction online, with the Crowd Justice campaign alone gaining 5,000 supporters in one week over Christmas. And despite the pressure – at one point he was up against four separate law firms appointed by the NHS, HEE and Jeremy Hunt - he has taken it to the highest levels. If there was ever any question over what the government’s quiet removal in 2012 of the ‘duty of care’ from the Health Secretary’s remit was going to mean in practice, that has now been answered.

“Hunt has used the Care Act and the Health and Social Care Act to run a mile from this,” says Day. “He has denied legal responsibility over something that he has power over, but he’s always talking about patient safety. I think he and the HEE thought they would never be taken to court over this.”

One of Day’s supporters is litigator Peter Stefanovic, a prominent voice against the government’s handling of the junior doctor contract dispute. He says that the way Day and other doctors are being handled when they raise concerns is “nothing less than bullying”.

He tells me: “Chris and his family have been through hell because he had the courage one night to stand up and say ‘this is not safe’. Everyone should be getting behind him. He’s being fought with taxpayer money; we are all paying out of our own pockets to create a culture of fear among doctors.”

And Day’s solicitor, employment specialist Tim Johnson of Tim Johnson Law, argues that the case raises an even more fundamental issue, about the ways in which the government has changed its relationship with doctors.

 “It’s a classic case of power without responsibility”, he says. “The government talks about its contract with junior doctors. The reality is that it has made sure it doesn’t have a contract with junior doctors.  It puts them on a series of one-year placements with the hospital trusts. As a result junior doctors lose basic statutory rights, for instance the right to claim unfair dismissal.  The relevant government agency is arguing in Chris’s case that they also lose whistleblowing protection. “

“In short, the government wants to treat junior doctors like agency workers - tell them how many hours they work and how much they are paid, but it doesn't want to hear from them about what's going on in the wards.”

With the removal of the duty of care from the Secretary of State, and the lack of a proper contract for junior doctors, it’s not just people like Day that have been left out in the dark: the health system itself has been left in a no man’s land. Junior doctors feel betrayed, insecure and stretched beyond what’s safe for them or their patients. The few that do have the courage to speak out about safety very quickly find themselves in hot water, with insidious threats about their future career being made.

When Day’s case comes before the Employment Appeal Tribunal (EAT) on February 10, it will be a key moment, potentially affecting the future safety of all NHS whistleblowers. If HEE can argue that it doesn’t have responsibility to protect him, then the current limbo-status of junior doctors will remain; if he wins, it could set a precedent that the organisation is bound to support them better.

Ostensibly the current dispute is over terms and conditions of pay. But as one junior doctor tells me, it is part of a culture of fear and intense pressure, of which the lack of whistleblowing protection is one element. She says: “This strike is about patient safety; I have had two colleagues break down in tears at work in the last two weeks, and I have often worked through migraines.

“That’s just not safe, but we can’t speak out. This strike isn’t just about pay; this is us blowing the whistle.”

Benedict Cooper is a freelance journalist who covers medical politics and the NHS. He tweets @Ben_JS_Cooper.

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Calais Jungle: What will happen to child refugees when they leave?

Hundreds of unaccompanied child asylum seekers are being taken to Britain where they face an uncertain future.

Hundreds of unaccompanied child asylum seekers are being taken to Britain, moved from a camp in Calais, northern France, as its closure begins. There were 387 unaccompanied minors in the French refugee camp known as “the Jungle” with links to the UK and they are arriving in England in groups of 70.

Upon arrival, the children are taken to a secure unit for 72 hours, before being reunited with families already living in the UK. They are from a group of more than 1,000 children who have been living in the camp in recent weeks. And now, some of those without links to Britain, but who are regarded as particularly vulnerable, are now also being taken across the English Channel.

The youngsters were granted asylum under the Dublin Regulation. The children’s move to Britain has stalled twice already, over delays in accommodation and establishing proof of age. Migrant children have been subjected to intense media scrutiny upon arrival in recent weeks. Calls for dental checks to verify the true ages of youngsters who looked older were called for, but the UK government branded such a practice as “unethical”.

For a long time, the minors living in the camp faced an uncertain future, but the move to take some children to the UK signals a change of tack by the British and French governments. Britain has been criticised for its lack of humanity, but it now seems that the pleas of these children at least have been heard.

Impact of war

While the youngsters may have escaped serious physical injury, the conflicts in the Middle East will have taken a psychological toll on them. Living in the midst of war, many have witnessed unspeakable horror, losing family members in brutal circumstances. Consequently these youngsters are now incredibly vulnerable to mental illness, with research indicating that more than 80 per cent are likely to develop issues such as post-traumatic stress disorder (PTSD).

It is important to remember a child’s trauma extends far beyond the experiences that resulted in them fleeing their homes. The children going to the UK now endured prolonged exposure to stress-inducing conditions in the Calais camp, and will now need to adjust to their new cultural surroundings.

War directly affects millions of children everyday. Exposure to conflict and acts of terrorism can lead to the development of acute or chronic stress reactions. Research also indicates that the psychological impact of war on children is likely to have long-term effects – they don’t simply “grow out” of their stress-related symptoms. Continued exposure to traumatic events, as these children have experienced, carries a cumulative impact too, that can worsen the severity of post-traumatic symptoms.

Funding challenge

The children going to Britain will need the right sort of trauma-based therapeutic support so they can successfully move forward before chronic conditions take hold. However, mental health services in the UK are desperately underfunded. More than 850,000 children and young people have a diagnosable mental health disorder, and half of all lifetime cases of mental illness begin by the age of 14. But just seven per cent of the total mental health budget is allocated to child and adolescent mental health services, with one in five young people refused treatment because they do not meet the criteria for care.

A recent poll of specialist nurses found 70 per cent thought child and adolescent mental health services in England were inadequate due to historic under-investment. The government is under growing pressure to invest more, and it is hoped that the arrival of these children will see additional money allocated to the services. When, or even if, this will happen, remains unclear.

Post-traumatic growth

While many of these children are likely to suffer form long-lasting psychological symptoms, there is a possibility that some may emerge stronger than they are now, benefiting in some way from the experience resulting in positive post-traumatic growth, or PTG. PTG is possible in children who have been affected by war trauma, particularly if they are young, as they are more open to learning and change. Interestingly, research has revealed that even the negative aspects of PTSD do not “block” growth when children are placed in a supportive environment – found to be the most conducive thing for PTG.

Receiving the proper social support will play an important role in helping these children deal with the psychological effects of war trauma. The complex situation that the young and unaccompanied migrants have faced calls for help that addresses both the trauma and grief, and will secure continuity in their new lives in the UK.

Losing loved ones is just one of many extremely traumatic experiences these children may have faced, and it could prove quite difficult to disentangle the effect of the loss from other stresses and changes. Time does not simply heal the long lasting scars of prolonged stress that they have experienced. However, it is vital that society does not write these children off as ill or broken. With the right support they can lead full lives and make strong contributions in their new homes.

Leanne K Simpson, PhD Candidate, School of Psychology | Institute for the Psychology of Elite Performance, Bangor University

This article was originally published on The Conversation. Read the original article.