25 February 2015
Meningitis B Vaccine, Junior Doctors and Budgets
A minefield of emotion
by Lynda Goetz
I fear that I might make myself very unpopular here, but I do feel that there are some aspects of certain current preoccupations and situations that might benefit from further discussion. I have three children, now all grown up. None of them ever had meningitis, although we did many years ago, on holiday in North Wales, twice in 24 hours visit a GP with our middle child, quite convinced that she was displaying all the symptoms. Twice we were reassured that she did not have meningitis, but mild encephalitis. We were, unsurprisingly, anxious and fearful. Two hypothetical questions arise here; firstly, would we, should we have sued the doctor had he turned out to have been wrong and secondly, as the child was four years old at the time, would we have signed an online petition (had such things existed) demanding that the meningitis vaccine (had such a vaccine been found), available only to babies, be made available free on the NHS to all children under the age of eleven?
The answer to the first question is that I don’t think so, although it is of course almost impossible to know how one is going to react to any given situation. Certainly suing professionals, especially doctors, was far less prevalent then than it is now. Anybody can make a mistake. The answer to the second is also, ‘I don’t think so’. ‘Why on earth not?’ I hear you cry. Well, the expression ‘free on the NHS’ does not make anything actually free. As with everything there is, of course, a cost. The cost, if not to the public at the point of delivery, is nevertheless incurred somewhere along the line. That somewhere is in the NHS Budget, already strained beyond capacity. Dr Sarah Wollaston MP (and formerly a GP), currently chair of the Commons Health Committee, made the point a few days ago that decisions about vaccinations should be made by science and cost effectiveness. Her sensible and measured words however seem to have been rather lost in the ‘knee-jerk’ reaction to the death of four-year old Faye Burdett from the disease. Dr Wollaston pointed out, “This is a very serious condition, but if we were to run vaccination policy purely on the size of a petition then we would run ourselves into very difficult territory”. In her interview on the BBC Radio 4 Today programme last Friday, she added that “there is a case to review the formula that is used to weigh up cost-effectiveness and I think this is what should now happen”.
However, as the numbers who had signed the petition rose to over 700,000 it was announced that a Commons Debate would be held. At first sight this looks like modern-day democracy working at its best. What is there not to like? A social media storm has been whipped up by a very sad case. A celebrity has added his weight with the story of his own son’s lucky escape. A petition is raised and ‘hey presto’ a result is achieved when it is agreed the matter should be addressed in Parliament. Stop for one or two seconds however and the downside of this approach becomes apparent. It is very, very easy to sign an online petition. No underlying research is required (although it can of course be undertaken). There are no repercussions. You can effectively remain anonymous. You undertake no further responsibility.
However, the cost of supplying the vaccine for Meningitis B to all children under eleven would be millions of pounds. Where is that money to come from? Can the Government produce it from some other budget or is the NHS to provide it by cutting back on some other aspect of health care? If so, which one? Even the Meningitis Research Foundation has expressed the view that the programme should not be extended to all children until more evidence has been gathered about its effectiveness.
At the same time as all this is going on, we have the ongoing confrontation between junior doctors and the Government represented by the Health Secretary, Jeremy Hunt. Jeremy Hunt wants a ‘proper seven-day service’ for the NHS. Doctors point out quite correctly that they already work weekends and that in order to get a proper seven-day service what would be more necessary is for support staff, such as radiology, to be available at weekends. A limited review paper published in 2013 by the NHS (https://www.england.nhs.uk/wp-content/uploads/2013/12/costing-7-day.pdf) does consider this. Although radiologists in particular are in short supply, one of the points made was that it was ‘clear that widespread seven-day services will require a change in the attitudes and expectations of NHS staff’. Another was that more consultants would be needed to be available at weekends, which would on current pay-rates be expensive.
It is the issue of how unsociable hours’ payments are made which lies at the crux of the current dispute. The detail of the contracts the junior doctors are currently working and the proposed new contracts is complicated and not entirely relevant to the discussion here, but for anybody interested, there is useful information on the following website https://fullfact.org/health/junior-doctors-pay-short-introduction-dispute/. What is relevant is the public understanding of exactly what constitutes a ‘junior’ doctor and what sort of responsibilities they have.
Basically in the UK a ‘junior doctor’ is any doctor who is not a consultant. All are qualified medical practitioners and most are working whilst engaged in postgraduate training to become consultants. Some, mostly women, have many years’ experience but have never taken the exams which would give them the entitlement to higher status and salaries as consultants, usually because of family commitments. The level of responsibility they all have, even in the first one or two years after completing Medical School, is high. Their pay, compared with many in industry, law or finance is not. The stress of training, the amount which needs to be learnt and the onus on individuals to always get things right is not only high, it can literally be a matter of life and death. As a lawyer, an accountant or a manager in a company one usually has the luxury of time in which to make a decision, even perhaps the chance to consult a reference. At worst you may lose a client some money, a deal or possibly even their liberty. As a doctor, junior or otherwise there is often not that luxury and a mistake can cost a life. It can too in some cases cost you your career should a member of the public decide to sue. Hours worked these days are indeed less than they used to be in the ‘bad old days’ when doctors could be on duty for a ‘one in two’ duty rota. However, they can still be onerous and can hardly, as I have heard some suggest, be compared with the long hours frequently worked in the hospitality industry. Mistakes are more likely to be made when people are tired.
The concern is now that our existing shortage of doctors (not to mention other health staff, such as radiologists and midwives) in the NHS will be exacerbated by the Government’s intransigent approach to the junior doctors. The General Medical Council (GMC) figures in September 2015, when details of the new contracts were produced, showed that nearly 3,500 applications had been received to work abroad in the space of 10 days. The normal number would be between 20 and 25 per day. Dr Wollaston revealed last November that her own daughter and eight of her friends (all junior doctors) had quit the NHS to work in Australia. Amongst the reasons given for moving by three doctors interviewed in The Guardian last autumn were ‘feeling undervalued’, ‘better work-life balance’, ‘better lifestyle and working conditions’, ‘good training programme’ and last, but presumably not least, ‘better pay’. What should the Government and the NHS therefore be doing to keep junior doctors from defecting wholesale to places where they are better appreciated and better paid?
We all know how lucky we are to have the NHS. Other systems around the world have been modelled, more or less successfully, on it. Nevertheless, it is becoming increasingly clear that the public’s expectations just keep growing. As more technology, more medicines and more treatments become available, people simply expect all those things to become available ‘free at the point of delivery’, the mantra to which the NHS and its unconditional supporters are so committed. Most are unaware of the costs of any of these things, nor indeed the benefits or drawbacks of a particular treatment against those of another. Nor, in many ways, do they need to be. That is the job of the professionals. We do however need to reward those professionals commensurately for their skills and knowledge. In the same way as we should not be allowing emotional reactions to determine policy regarding vaccines, we should not be allowing emotional attachment to the NHS in its current form to destroy it in its entirety by refusing to consider how other nations, such as Australia, appear to have effectively combined a state-funded system with a private health insurance system to ensure that the funds are there both for vaccination programmes and to pay the doctors, without whom there can be no system at all.
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