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The answer to the NHS crisis is treating its staff better

For too long the government has allowed goodwill and vocation to mop up funding shortfalls and bad policymaking.

The NHS is suffocating under huge pressure. Even the regulator of the UK’s doctors, the General Medical Council - which is not normally known for speaking out - has offered with stark words. The NHS is struggling to cope with the demand placed on it, the GMC says. The "growing number of people with multiple, complex, long term needs" who needed treatment at a time of "severely constrained funding" was made "significantly worse by the fragility of social care services". This is exactly right. The NHS is doing more, with less, with the added pressure of the financial and bureaucratic costs of service fragmentation under the Health and Social Care Act 2012.

The junior doctor strikes were ostensibly about a new contract, which has now been imposed. But the unrest in the medical profession was and is not confined to that one issue. Doctors are also concerned about Jeremy Hunt's repeated use of misleading statistics about weekend death rates, continuing even after he had been corrected; and his claims that medicine had turned into a 9 to 5 job, which meant he wanted a “sense of vocation and professionalism brought back into the contract”.

To the doctors routinely working nights, weekends and regular unpaid overtime, this was insulting. Put simply: workers who are well resourced and respected will repay their fulfilment by routinely going beyond the letter for their contract. When staff are treated badly, how can patients be treated well? Morale is the burning, unignorable safety issue in the NHS and yet its governing powers seem unable to admit their responsibility for contributing to its decline. Morale is not just affected by simple unkindnesses - such as the junior doctors unable to know, thanks to the vagaries of the rota system, if they can have time off to get married. It is a systematic problem, with chronic understaffing, frequent rota gaps, fatigue and stress and avoidable mistakes in a toxic mix. No wonder there was such anger when Hunt told parliament that he would arrange a review into why junior doctors morale was so low - ironically on the same day as imposition of the new contract was announced.Good morale usually comes with the feeling that one is doing a good job.

In 2013, research was published in BMJ Quality and Safety which found that staff had an “almost universal desire to provide the best quality of care” and “deeply felt personal professional commitment”. But they also found professionals wasting time over poorly designed IT systems, conflicts between different teams (even within single organisations), heavy workloads and staff shortages, with multiple external agencies creating mess about where time and effort should be spent. Yet, as they wrote “the wellbeing of staff is closely linked to the wellbeing of patients”. It makes sense: staff who are stressed and distressed are not going to give consistently high quality care. Yet sickness rates of the staff in the NHS are higher than the general population and 59 per cent of GPs in the UK describe their work as very or extremely stressful, the highest of any country surveyed by the Health Foundation. There are high levels of burnout.

A target-driven culture is exacerbating this problem. A typical example was when the government seemingly became convinced by poor quality data which suggested that dementia was under diagnosed So it decided to offer GPs £55 per new diagnosis of dementia. Targets were set for screening to take place - despite the UK National Screening Committee having said for years that screening for dementia was ineffective, causing misdiagnosis. And when better data on how many people had dementia was published - which revised the figures down - it was clear that the targets GPs were told to meet were highly error-prone. The cash carrot was accompanied with beating stick, with the results - naming and shaming supposedly poorly diagnosing practices - published online. Setting doctors harmful tasks, leading them almost to "process" patients, fails to respect patient or professional dignity, let alone the principle of "do no harm".

The rocket fuel of the NHS is the staff. But even the most fundamental part of running the NHS - making sure there are enough people working - has been badly managed. Safer staffing research being done by NICE was stopped by NHS England. And, as the Commons Select Committee put it, there has been “no coherent attempt to assess headcount implications of 7-day NHS". There is, though, evidence that fewer junior doctors are applying to specialist training. Jeremy Hunt’s response to the ongoing recruitment crisis - a fifth of GP training posts were vacant last year - was an announcement that doctors would be compelled to work for four years for the NHS after graduation. Indeed, a conservative MP has previously proposed this because "investment of taxpayers' money demands a return for the taxpayer". This sort of fiscal guilt trip ignores the debts for fees and maintenance accumulated by graduates via the Student Loans Company - over £110,000 for the average male doctor. As an evidence-free policy, who knows what the effect will be - it’s difficult to see long term loyalty nurtured with these terms and conditions.

Working in the NHS should be joyful, a matter of love. But for too long the government has allowed goodwill and vocation to mop up funding shortfalls and bad policymaking. These are now chasmic. As Bevan said, the NHS does not run “as a creature of magic, called out of the void by the wand of the Minister for Health". Treat the staff better, and patients will be treated better too.

Margaret McCartney is the author of The State of Medicine - keeping the promise of the NHS (Pinter and Martin)

Margaret McCartney is a GP in Glasgow who broadcasts for Radio 4's Inside Health and is author of The Patient Paradox: Why Sexed-Up Medicine is Bad for Your Health.

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The man who created the fake Tube sign explains why he did it

"We need to consider the fact that fake news isn't always fake news at the source," says John Moore.

"I wrote that at 8 o'clock on the evening and before midday the next day it had been read out in the Houses of Parliament."

John Moore, a 44-year-old doctor from Windsor, is describing the whirlwind process by which his social media response to Wednesday's Westminster attack became national news.

Moore used a Tube-sign generator on the evening after the attack to create a sign on a TfL Service Announcement board that read: "All terrorists are politely reminded that THIS IS LONDON and whatever you do to us we will drink tea and jolly well carry on thank you." Within three hours, it had just fifty shares. By the morning, it had accumulated 200. Yet by the afternoon, over 30,000 people had shared Moore's post, which was then read aloud on BBC Radio 4 and called a "wonderful tribute" by prime minister Theresa May, who at the time believed it was a genuine Underground sign. 

"I think you have to be very mindful of how powerful the internet is," says Moore, whose viral post was quickly debunked by social media users and then national newspapers such as the Guardian and the Sun. On Thursday, the online world split into two camps: those spreading the word that the sign was "fake news" and urging people not to share it, and those who said that it didn't matter that it was fake - the sentiment was what was important. 

Moore agrees with the latter camp. "I never claimed it was a real tube sign, I never claimed that at all," he says. "In my opinion the only fake news about that sign is that it has been reported as fake news. It was literally just how I was feeling at the time."

Moore was motivated to create and post the sign when he was struck by the "very British response" to the Westminster attack. "There was no sort of knee-jerk Islamaphobia, there was no dramatisation, it was all pretty much, I thought, very calm reporting," he says. "So my initial thought at the time was just a bit of pride in how London had reacted really." Though he saw other, real Tube signs online, he wanted to create his own in order to create a tribute that specifically epitomised the "very London" response. 

Yet though Moore insists he never claimed the sign was real, his caption on the image - which now has 100,800 shares - is arguably misleading. "Quintessentially British..." Moore wrote on his Facebook post, and agrees now that this was ambiguous. "It was meant to relate to the reaction that I saw in London in that day which I just thought was very calm and measured. What the sign was trying to do was capture the spirit I'd seen, so that's what I was actually talking about."

Not only did Moore not mean to mislead, he is actually shocked that anyone thought the sign was real. 

"I'm reasonably digitally savvy and I was extremely shocked that anyone thought it was real," he says, explaining that he thought everyone would be able to spot a fake after a "You ain't no muslim bruv" sign went viral after the Leytonstone Tube attack in 2015. "I thought this is an internet meme that people know isn't true and it's fine to do because this is a digital thing in a digital world."

Yet despite his intentions, Moore's sign has become the centre of debate about whether "nice" fake news is as problematic as that which was notoriously spread during the 2016 United States Presidential elections. Though Moore can understand this perspective, he ultimately feels as though the sentiment behind the sign makes it acceptable. 

"I use the word fake in inverted commas because I think fake implies the intention to deceive and there wasn't [any]... I think if the sentiment is ok then I think it is ok. I think if you were trying to be divisive and you were trying to stir up controversy or influence people's behaviour then perhaps I wouldn't have chosen that forum but I think when you're only expressing your own emotion, I think it's ok.

"The fact that it became so-called fake news was down to other people's interpretation and not down to the actual intention... So in many interesting ways you can see that fake news doesn't even have to originate from the source of the news."

Though Moore was initially "extremely shocked" at the reponse to his post, he says that on reflection he is "pretty proud". 

"I'm glad that other people, even the powers that be, found it an appropriate phrase to use," he says. "I also think social media is often denigrated as a source of evil and bad things in the world, but on occasion I think it can be used for very positive things. I think the vast majority of people who shared my post and liked my post have actually found the phrase and the sentiment useful to them, so I think we have to give social media a fair judgement at times and respect the fact it can be a source for good."

Amelia Tait is a technology and digital culture writer at the New Statesman.