When Elephants Fight: How patient engagement could help the Junior Doctor dispute

When Elephants Fight: How patient engagement could help the Junior Doctor dispute

By David Gilbert, Director, InHealth Associates and Jeremy Taylor, Chief Executive, National Voices

This article first appeared in the Health Service Journal online, 15th January 2016


“When elephants fight, the grass gets trampled”. African Proverb.

The junior doctors’ strike is all about us – the patients. It’s about what constitutes a safe and effective health service for us. It’s about how long doctors should work for and with us through the week and at weekends – and for what reward.

It’s about how to organise a 7 day NHS where my chances of survival don’t depend on what day of the week I fall ill. It’s about whether the status quo is safe enough and whether the government’s alternative to the status quo is safe enough. It’s so about us.

Both sides to the current dispute ground their argument in what is important to patients. The government says it wants a new contract for junior doctors to improve patient safety. The BMA rejects the new contract on the grounds that it doesn’t provide enough safeguards for doctors – and patients.

As central players in this dispute, patients have, of course, been very closely involved in all the negotiations as per the rhetoric of ‘no decision about me without me’.

Wise Heads

We have been engaged with, and consulted by, both sides from the start about the critical components of a 7 day NHS and contributed detailed insight and evidence about the experience of inpatients at weekends. We have helped frame the negotiating mandates of both parties. Wise heads from the patient world have exerted an important moderating influence at the negotiating table. What? No, of course we made all that up. The fact is patients have had no voice at all in this dispute.

There is nothing new in this, sadly. Patient and public involvement is now part of the orthodoxy, at least in theory. There are admirable examples where it has been embraced in practice, for example the recent reviews of cancer and mental health. But there are areas of policy and decision making where it just doesn’t apply. It didn’t apply in Andrew Lansley’s car-crash reorganization of the NHS. It didn’t apply in the care.data fiasco. It didn’t apply to the government’s latest “mandate” to NHS England. And especially it doesn’t apply in negotiations of any kind.

In the current dispute, the BMA fancies it can speak on behalf of patients while The Secretary of State sees himself as the champion of patients. But actual patients don’t feature. Isn’t it time for a different approach?

Had patients been involved earlier, the content of the new contract might have been different and the process might have gone better. The benefits of having patients as partners include reframing the problem so as to ensure the focus is truly on what matters to patients, generating a richer menu of potential solutions, shifting power dynamics so as to model trusting relationships and changing practice.

The history of the NHS decision making is one of a tribal battle between clinical and managerial/policy interests claiming to be the ‘voice’ for patients. But while paternalism is shifting at clinical level – witness the rise of self-management and shared-decision making – political power remains in the hands of the few.

So, why do we have a so-called patient-centred NHS that excludes patients?

A new dialogue

It is high time for a tri-partite vision of healthcare leadership, one in which clinical, managerial and patient leaders bring their own truths to the table, where we model the very relationships in policy that are so crucial to patient-centred healthcare in the consultation rooms.

This is a model that could help usher in a new era of dialogue. But a system that is predicated on a binary ‘us and them’ approach and that excludes patients, carers and citizens is bound to create polarisation. A two-legged stool falls over.

Prevention of the current dispute is better than cure – patients could have helped avoid this situation in our view. And, whatever your opinion on the rights and wrongs of the dispute, no-one is arguing that it has been well handled. On the contrary it has been very confrontational.

The BMA has appeared to many as obstinate. And it was surely a mistake for the Secretary of State to lead the employer side (a mistake implicitly acknowledged in the decision to hand over this role to Sir David Dalton).

So, Sir David, there is now an opportunity for some fresh beginnings. How about patients at the negotiating table this time? Otherwise we may be need to dig in for a long battle…

David Gilbert, Director, InHealth Associates

Jeremy Taylor, Chief Executive, National Voices