Partnerships in paediatrics: renegotiating the contract Richard Smith Editor, BMJ

What I want to discuss The unhappiness of doctors Why might they be unhappy? Renegotiating the contracts between doctors and government and doctors and patients What’s needed for success

Are doctors unhappy? Unhappy is a crude word “We are never so happy nor so unhappy as we imagine” La Rochefoucauld “Happiness is the light on the water. The water is cold and dark and deep.” William Maxwell

Are doctors unhappy? “Happiness: a good bank account, a good cook, and a good digestion.” Jean Jaques Rousseau “Happiness is essentially a state of going somewhere, wholeheartedly, one directionally, without regret or reservation.” William H Sheldon

Anthony Trollope on happiness “It is the grind that makes the happiness.”

Anthony Trollope on happiness “It is the grind that makes the happiness. To feel that your hours are filled to overflowing, that you can barely steal minutes enough for sleep, that the welfare of many is entrusted to you, that the world looks on and approves, that some good is always done to others,-- above all things some good to your country;--that is happiness. For myself I can conceive none other.”

Anthony Trollope on happiness “The happiest man is he, who being above the troubles which money brings, has his hands the fullest of work.” “A broad back with a heavy weight upon it gives the best chance of happiness here below.” “There is no human bliss equal to twelve hours of work with only six hours in which to do it.”

How unhappy are doctors? Do you need convincing? Friend who is an orthopaedic surgeon who has retired early. Every time he visits the hospital, colleagues ask him how can they retire early. Consultants contract BMJ Careers Fair

Job satisfaction of senior doctors: a questionnaire "I find enjoyment in my current post.” "I am doing interesting and challenging work.” "I feel dissatisfied in my current post." Most days I am enthusiastic about my work” "I am often bored with my work." Totalled the scores for all five statements: 5 strongly agree; 1 strongly disagree 20 or more represented a high level of satisfaction

Job satisfaction of senior doctors

GPs intending to quit patient care in the next five years

League of unhappiness

Why might doctors be unhappy?

Overwork Perhaps nothing new Doctors feel like hamsters in cages, but they actually have more time with patients--but there is more to do in that time Who isn’t overworked? If Trollope is right this is happiness

Why might doctors be unhappy? Underpaid Doctors have lagged behind some comparable professionals--for example, barristers But still much better paid than most other public sector professionals--like teachers Many doctors have greatly supplemented incomes from private earnings Doctors have much less variability in earnings than other groups--for example, solicitors

Why might doctors be unhappy? Inadequately supported Most work in teams Some doctors seem to think that nurses have “lost their way” Singlehanded doctors are increasingly unusual, and even they have support staff Relationships with managers are sometimes fraught Many doctors feel unsupported by politicians

Why might doctors be unhappy? Their status is falling Still much more valued than, say, social workers In Britain doctors are still the most trusted professionals (politicians and journalists are at the bottom)

Why might doctors be unhappy? They are exhausted by too much change Doctors are not alone in this There will probably be more change in the next 10 years than in the past 10

Why might doctors be unhappy? They have declining control over their work Doctors, particularly GPs, have more control than many other groups Nevertheless, they have less “freedom” than before--revalidation, audit, CHI, NICE, guidelines

Why might doctors be unhappy? They are increasingly accountable They are, but they were probably insufficiently accountable before The NHS now runs on Hobbesian rather than Lockeian lines

Thomas Hobbe’s philosophy People are essentially bad If you don’t control them carefully then they will do wrong

John Locke’s philosphy People are essentially good Give them enough space and support and pay them well and they will do wonderful things

Why might doctors be unhappy? Their job is not what they were trained for Most doctors practising now were not trained in management, leadership, improvement, communication, ethics, etc Some doctors may be “phobic” about education

Why might doctors be unhappy? They have to pick up the pieces in a society unable to cope The NHS is almost the last of the “socialist” institutions Doctors do find themselves trying to help the marginal (poor, unemployed, homeless, addicts, prisoners, asylum seekers, etc) but with very limited ability to do much Life’s problems are increasingly being medicalised; doctors are now the victims not the perpetrators of medicalisation

Why might doctors be unhappy? Close contact with patients are disrupted Little support for this explanation This remains much of the joy of the job

Why might doctors be unhappy? The health service is falling apart Many doctors in Britain seem to feel this The BMA begins to look at alternatives to the NHS Mind you, the BMA maybe falling apart as well

Why might doctors be unhappy? Patients are too demanding Politicians are stoking patients’ expectations Modern medicine promises more than it delivers

The bogus contract: the patient's view Modern medicine can do remarkable things: it can solve many of my problems You, the doctor, can see inside me and know what's wrong You know everything it's necessary to know You can solve my problems, even my social problems So we give you high status and a good salary

The bogus contract: the doctor's view Modern medicine has limited powers Worse, it's dangerous We can't begin to solve all problems, especially social ones I don't know everything, but I do know how difficult many things are The balance between doing good and harm is very fine I'd better keep quiet about all this so as not to disappoint my patients and lose my status

The new contract: both patients and doctors know Death, sickness, and pain are part of life Medicine has limited powers, particularly to solve social problems, and is risky Doctors don't know everything: they need decision making and psychological support

The new contract: both patients and doctors know We're in this together Patients can't leave problems to doctors Doctors should be open about their limitations Politicians should refrain from extravagant promises and concentrate on reality

Spin offs from the “new contract” Because there is so much we don’t know and don’t do well we need continuing research We need to do this together, sharing uncertainty--but also planning together You and your children need to be willing to participate in experiments

Spin offs from the “new contract” Much experimental research “fails”-- because it’s experimental Risk can never be abolished We need information from you and specimens from you We must be clear what is acceptable, sometimes privacy may be compromised

Would you like to join my new political party? It’s called “The life is tough we have no solutions” party Death is inevitable, prepare for it For every problem there is a simple solution. Unfortunately it’s wrong

The old contract What doctors give Sacrifice early earnings and study hard See patients Provide god care as doctors define it What doctors get Reasonable pay Reasonable work/life balance Autonomy Job security Deference and respect

New imperatives Greater accountability Patient centred care Be more available to patients Work collectively with other staff to improve quality Evaluation by non-technical criteria and patients’ perceptions A growing blame culture

Creating new contracts: doctors and the NHS From doctors Work within guidelines Be accountable for key objectives and improving quality Actively support and contribute to achieving the goals of the organisation Work within resource constraints Engage in team and collaborative working

Creating new contracts: doctors and the NHS Doctors get The opportunity to shape the goals of the organisation Participation in resource allocation and major decisions The resources to do the job expected Training and technical support Time to step off the "hamster wheel" High quality data A supportive culture that uses information for learning rather than judgment High quality appraisal and support for personal development

Creating new contracts: doctors and government Doctors required to Follow nationally agreed standards and guidelines Work to improve quality Work within available resources Account for their work

Creating new contracts: doctors and government Doctors get Participaton in developing the standards Realistic targets A manageable number of targets No micromanagement

Building new contracts Recognition that contracts exist Mutual respect Trust Conversation Encouragement of creativity, personal renewal, and learning

Building new contracts Greater geographical and career mobility Chance to restart career paths, retrain, and diversify without attracting criticism Portfolio careers Greater flexibility Better career advice

Can this be true? “Negative media coverage might represent the world's waking up to the limitations of doctors and medicine, andthough it's uncomfortable now it may lead to a much more honest, adult, and comfortable, relationship.”

Renewal: Dutch style in the 16th century

T H White on learning

Learning “The best thing for being sad is to learn something. That is the only thing that never fails. You may grow old and trembling in your anatomies, you may lie awake at night listening to the disorder of your veins, you may miss your only love, you may see the world about you devastated by evil lunatics, or know your honour trampled in the sewers of baser minds. There is only one thing for it then - to learn. Learn why the world wags and what wags it. This is the only thing which the mind can never exhaust, never alienate, never be tortured by, never fear or distrust, and never dream of regretting.”