What’s it like for clinicians working through the Covid-19 pandemic? And what really happened during the junior doctor dispute in 2015? Anna Charles talks with Dr Jeeves Wijesuriya, GP trainee and former chair of the BMA Junior Doctors Committee.
AC: Anna Charles
JW: Jeeves Wijesuriya
AC: Hello and welcome to The King’s Fund Podcast where we talk about the big issues and ideas in health and care. I’m Anna Charles and I’m the senior policy advisor to the Chief Executive here at The King’s Fund and I’ll be hosting this episode. Our regular host, Helen McKenna, is currently on secondment to the Department of Health and Social Care to help out with the Covid-19 response, so I have the great pleasure of picking up the microphone for the next few episodes and today I’m sitting down with a fantastic guest who has very kindly agreed to join us remotely on his afternoon off. We’re going to be talking about the role and experience of junior doctors in working through the Covid-19 outbreak, looking into the inside story of the junior doctors dispute from a few years ago and how that was resolved and talking about the wellbeing of clinical staff and how that can be supported, particularly during this extremely challenging time and that guest is Dr Jeeves Wijesuriya, so Jeeves welcome to the podcast.
JW: Hi, thanks so much for having me.
AC: And Jeeves, can you tell our listeners a little bit about who you are and what you do?
JW: Of course, so I’m a junior doctor. I am in my last year of training to be a GP, so I work in East London in Hackney and I was Chair of the Junior Doctors Committee at the British Medical Association for three years.
AC: So what was it that led you to that role, how did you end up doing that?
JW: I suppose I sort of fell into it. So I’ve been a doctor now for something like eight years and I actually only really got involved with the Junior Doctors Committee, the British Medical Association, in 2016 at the height of the dispute. We had a gentleman named Johann Malawana who had just become Chair of the Junior Doctors Committee and he got in touch and asked me to get involved and I sort of did and ended up helping with negotiating the educational aspects of the contract in 2016 and then you know, as time went on, obviously we had our own sort of referendum around the contract and actually it was rejected by junior doctors and Johann actually stood down from his role as Chair and we actually cycled through quite a few different people who took on that role during the period of time that followed, the unprecedented strike action that took place and in all honesty, virtually everyone had resigned and I was sort of the only person left and I found myself essentially the kind of person that could take on the role of Chair and I sort of had a vision of how I thought we needed to move on from the dispute and how we needed to move forward and how we could, if you like, solve some of the problems that existed and so I sort of fell into my role.
AC: And in the end, was it what you expected it to be when you first took that role on and first came involved?
JW: Well, I think I knew it was a very difficult time and I think I, you know I think we were very fortunate to have some really great leaders who had done that job in, probably really unenviable circumstances in which the profession was really divided. Obviously, morale was at, what I describe as, an incredible low and you know, we were in the midst of this dispute where relationships and bridges had been burned with lots of organisations, whether it was the colleges, health education bodies, government and yeah, I think I knew it was going to be a really, really difficult job. That dispute for so many people was about feeling valued, it was about what was happening within the health system, as much as it was about the terms and conditions of junior doctors and finding a way to work around those problems, rebuild those relationships and get back constructively to some solutions, but it was very, very difficult. I think it was probably even more difficult than I anticipated when I first took it on.
AC: So I’m going to come back to ask you a lot more about that period of time and what you learnt from it later on, but first I want to find out a little bit more about you, because for most people being a junior doctor is probably busy enough by itself but you’ve had all these additional commitments alongside your clinical work, so with all of that going on, how do you keep yourself well when you’re juggling all of those things? What do you do to switch off?
JW: So I think balance is really important. I know that some of my predecessors actually took time out from clinical practice. I really wanted to keep going alongside any roles I did, so I tried to split my time between the two and I think really that comes down to organisation and scheduling. I was very fortunate to have really understanding supervisors and employers that helped rota and plan my time around both but even then, both roles will bleed into all of the other time that you have and they take up as much space as you will give them. I wasn’t, when I started, spectacularly good at balancing, I think you know, I recognised that there were times in those three years where actually I was really, really burnt out by trying to do both and it was only kind of going through it that I started to develop mechanisms for not doing that and I think a big part of it is making sure you make time for the really important things. So speaking to your family and your friends, particularly people who are not involved in the world that you are working in because it gives you a wonderful sense, or dose of, perspective. I think it’s also about knowing yourself. So checking in with yourself and knowing you know, what your triggers are for when you are stressed or when there’s a bit too much going on, but also knowing the things that help keep you going. So, I’m very lucky I have great flatmates and great friends. We play a lot of board games, which I know sounds absolutely bizarre but I think everyone has their different thing for stress relief. I cycle quite a lot and I find that’s quite good for my wellbeing, knowing your triggers and knowing what you do to help yourself, you know take some time for yourself really matters.
AC: I’m really struck by that reflection about it being about knowing yourself and what works for you. It’s quite a personal thing actually, isn’t it? I guess self-care is particularly important at the moment for everybody given the unprecedented challenges we’re facing, but particularly for clinicians and others like yourself that are working so hard on the frontline of the response, so really helpful to hear your reflections on that. So, I think at the moment you’re working as a GP trainee, so what’s your experience been of working during the Covid-19 outbreak? How have things changed for you over the last few weeks?
JW: Yeah, I think it’s been wonderful watching the response of junior doctors. I think across the health service everyone, you know every type of healthcare professional, whether it’s nurses, porters, you know people feel like they want to help and they want to respond to this crisis and I think it’s been astonishing watching that and obviously there are huge pressures and there are, you know, increased commitments that people are feeling and people are doing more sessions or more hours to try and help out and that’s their first kind of objective. Honestly, and I tend to focus on these things because I think people hear a lot in the news and on the media about the challenges and how difficult things are, what I really like talking about is how necessity has meant that we have come up with solutions to problems that we’ve been talking about for years. Video and telephone consultations almost overnight, functionality that we have talked about being able to implement in, not just general practice, secondary care, remote consultations. You know, patients who actually are not having to travel miles and miles to their local hospital or indeed to us in their GP practice for things they may not need to have a physical appointment, I can send prescriptions electronically to the pharmacy directly so all they have to do is collect it. With some vulnerable patients, pharmacies have been astonishing and been delivering to people’s home for people who are housebound. I think there really have been some incredible advances and I really think that medicine won’t be the same when this is over.
AC: So you’re focussing there on some of the positive and the really encouraging changes that have been taking place over this time, but there are also, as you say, significant challenges associated with what’s going on at the moment for people that are working on the frontline. So, as a doctor in training of other forms of professions who are also in training, what kind of support has been on offer to help people through this period of time?
JW: I think what’s been interesting is the evolution of the team during all of this. You know, actually I think it’s really brought people together within their communities of practice. You know, I don’t think trainees have been closer to their colleagues, their bosses, their peers. The level of pastoral support, the checking in on one another has increased, obviously the difficult thing is in lots of environments we have put to one side lots of educational time and training time, so actually you know, I think, losing that time is really hard, especially for people’s progression and wanting to advance within their knowledge and skill base within their teams, within their careers, so that is difficult but it’s interesting the balance of how those two things have worked hand in hand with one another.
AC: I’m really struck there by the sorts of support that you describe is so much about cultures and behaviours in small teams or between individuals, it’s not some sort of big systemic support structures, it’s actually all those day to day interactions between people and their colleagues that are making the difference, for you it sounds like. I want to rewind a bit now, back to the junior doctors’ dispute in 2015 and 2016 which you mentioned right at the beginning of the podcast. So for listeners that aren’t familiar with that dispute, for several months junior doctors and the organisations that represented them, particularly the BMA were locked in a dispute with the government about changes to their contracts, which led to strikes the like of which hadn’t been seen for 40 years or more and Jeeves, you were right at the heart of that dispute, so tell us a bit about that experience, what was it like?
JW: I mean I think it was astonishing, because you know effectively comments were made about junior doctors working 24 hours, 7 days a week. Things were said about junior doctors not providing service at the weekends and I think everyone remembers, or most people that were involved certainly remember, just the level of offence across the health service and I think what was also very difficult, I think it spoke about more than just terms and conditions, I think it spoke about the morale of the workforce, it spoke about how they felt valued at the time or rather that they didn’t feel valued at the time and if you ask junior doctors, and you could ask five junior doctors, they have ten different reasons for why that dissatisfaction wasn’t there. It was always very different from person to person and I think that over-spilled in the dispute and actually relationships broke down and things became very conflict-driven because we had you know a government Secretary of State who were trying to force through a particular policy and a set of changes that just did not resonate at all with the reality of how people felt their working lives operated and that’s sort of boiled over for a period of years and I sort of inherited my role at the Junior Doctors Committee and chairing it after the last round of strikes and the imposition of a contract by the Secretary of State on junior doctors and actually the impact that had on morale was astonishing and it took us a period of years to kind of rebuild relationships to kind of get back to constructively addressing some of those underlying issues that had sat there. There is one Trust in Lincolnshire where junior doctors were being asked when they were too tired to drive home after a shift to rent a blanket from the Trust so they could sleep in the mess and I just think there was a point at which, I think it was enough for junior doctors to hear some of the things that were being said and the idea that their pay was being reduced at the weekend or out of hours as well as some of the safety limits being eroded, I think was a bridge too far for all of us actually, certainly how I ended up how I ended up becoming involved in that side of things.
AC: And it must have been a really complicated negotiating process to move on from that. So, different NHS bodies, the Secretary of State for Health and Social Care were very involved, lots of media interest, what was the negotiating process like? How did you actually end up with a deal?
JW: I think the best thing we did was we completely changed the way that we went about negotiating. Previous negotiations have always been one side and the other side, arguing with each other and it was entirely based on conflict. We started by approaching then Secretary of State Jeremy Hunt and laterally working with his successor Matt Hancock and rebuilding relations and saying, ‘Look how do we work collaboratively’ and you know, what we did was, we actually re-wrote the process for negotiations. We did what we called the review process, where we looked at the contract and we brought in external experts. We brought in working groups with people from different areas that we knew through surveying members and talking to employers were the issues with our working and training lives and we looked beyond just the contract as well and looked at training elements and we created these working groups as part of that review with those experts and we asked them to come to conclusions and our negotiations would be on the basis of what those groups identified as the problems and how we solve them, and we asked them to make proposals. So we changed the negotiating process to use those kinds of groups, so it was collaborative instead of conflict driven. So actually, it became less about two sides arguing and more about, okay what does the evidence tell us. Things like the Fatigue and Facilities Charter that we wrote in that time, some of the work we did to say, okay people aren’t, you know were looking at a, you know obviously a really tragic number of junior doctors that were dying trying to drive home too tired on the way home from night shifts and what we agreed on was a set of rules of how facilities should be provided to prevent that. What things should be in place to make sure rest facilities are available and then obviously getting the investment from government signed off to say, okay in every Trust in the country we’re allocating, you know £30,000 to £60,000 to invest in those facilities with junior doctors helping decide on how that funding is spent to make sure those facilities are there. So backing up the work that we were doing to show people actually we do want to value them as people and recognise some of the risks that they’re facing, and doing all of those things along the way really helped to start to address these, the dissatisfaction that sat underneath all of this.
AC: And you mentioned before, the really significant impact on staff morale that there was throughout all of that, which is not surprising, particularly when you look at some of the media coverage and comments that came out at the time. How do you think junior doctors came back from that? Have they come back from that or is it still having repercussions today?
JW: I think we’ve made big strides. Some of the changes that we’ve made I think are hugely positive but I think that when we talk about junior doctors in this, we’re talking about sort of the canary in the mine if you like. I don’t think, when we talk about issues with morale you know, the lack of say staffing that we have, that’s not just junior doctors that’s almost every service, every professional in the health service, every profession in the health service that feels that. I think what’s been interesting amongst junior doctors is there’s a greater willingness to speak up. There’s greater awareness of the problems and I think that can only be a positive thing as long as it’s applied constructively and that’s really the key, is how do we start to engage with that population who want to improve things and give them a voice. How do we start to help people understand the health system better in their training, because you know the barriers we face or the challenges are as much about the system we are working in as the diagnoses we face or the patient groups that we are working with. That’s something that’s still sorely lacking within medical school curriculums or training itself, because we are still seeing a lot of that dissatisfaction and that really, that can be harnessed because you know, I’ve seen in the last three years just how incredible junior doctors can be at helping the system to solve problems because they see things that other teams won’t necessarily see. Their perspective is very different and that provides a really unique opportunity. One of the things we did was work with the CQC to do things like create the junior doctors forums as part of well led inspections, so that people were actually asking junior doctors, ‘what is it like to work here? What’s it’s like being very junior within these teams and working in these environments?’ and that, you know, I’ve always said will give you a really unique insight into what it’s really like in a Trust or hospital setting, creating those junior doctor special advisor roles that I think are so important and give unique insights.
AC: And it’s so interesting because on a similar theme, way back in May last year, we spoke to Professor Don Berwick on this podcast, you might have heard it at the time, and he shared his thoughts with us on junior doctors and this is what he had to say:
‘Among the resources the NHS has for continual improvement, few are as promising as the junior doctors. They see everything, they’re everywhere. They move around. They have tremendous knowledge. They have fresh eyes, a lot of energy and they see what’s wrong and they know what’s right and I think one of the great potentials here that I would encourage leaders to take advantage of is to incorporate the insights and energies and contributions of junior doctors centrally in the effort to design and redesign care.’
And I think what we were hearing from you just then Jeeves is example of where that’s starting to happen already.
JW: Yeah, I mean I think that’s right. I think people make the mistake of thinking that because, you know perhaps something in the title of junior doctor, but that that means that they cannot offer skills and insights into these roles but actually you look at programmes like Royal College of Physicians where they created these Chief Registrar programmes, just what powerful influence junior doctors can be and that’s really the thing that I think lacking is how do we start to create time in the system that is obviously under staffed, under resourced to actually help them solve some of those problems and create efficiencies and that’s really hard when you’ve got systems under pressure but actually you know, people talk about junior doctors after foundation programme. We know now that 37% of trainees carried on after their first two years of medical training and went into a specialty training programme, so that’s 60% of people choosing not to do that and taking a break from training but they’re largely going into other NHS Trust roles where they have educational or leadership responsibilities. The time really has come to integrate those into the training programmes we have and actually creating those opportunities for junior doctors embed them in a system that helps introduce that creativity, I mean obviously I’m going to say Don Berwick is right because it’s very hard to disagree with Don Berwick, but you know, it really is a huge opportunity that I think is missed in lots of places, where they’re only looking at the problem in front of them in terms of staffing, instead of what would be long term better solutions, better outcomes and better care.
AC: And you’ve touched already on some of the work that you did while you were at the BMA on improving pretty basic things around working conditions for junior doctors and it makes me think about a report that you’ll be well aware of that the GMC published last year about the wellbeing of doctors and I was reminding myself of some of the findings of that a few days ago and they’re pretty alarming, high levels of work related stress, burnout, really significant numbers of people saying they intend to leave the NHS in the near future. So, with all of those issues and we know that working conditions and culture are some of the key drivers for that, what are you seeing now as the key things that are being done or need to be done to address that?
JW: Well I think it’s interesting because part of it is about rostering, part of it absolutely is about culture. You know, when we did the changes to the contract, yes we addressed areas of pay, we looked at increasing weekend pay, out of hours pay and we, you know obviously started recognising people in senior leadership roles and addressing that, and we also introduced safety limits but the reality is, a contract gives you rules, it doesn’t make you a good employer and equally it doesn’t make it a good place to work to simply adhere to the rules. It’s about how you administer them and it’s about humanity within the system. All the rules in the world doesn’t make someone sort out the problems that exist within departments and within teams. A part of that is the culture of those environments. It’s empowering those staff. We talked about creating kind of leadership opportunities and input into the way systems are run but also it’s about flexibility. One of the things we’ve seen in the last few years is the rise of the terminology around a snowflake generation of doctors that, you know, want to go less than full time and I’ve heard examples like, and paint their canal boats and what have you and I just find it so bizarre that we’re talking about creating flexibility in systems for people to, to do things that will keep them in the profession or add value to the profession and people talk about it being generational but they’re exactly the same kind of things we need to introduce to keep people towards the end of their careers in the profession. So I think there is something about empowering people. I think there’s something about creating opportunities for them but there’s also something about valuing them and that takes various forms. It’s valuing their training, let’s start to recognise the individual skills that they bring. If you’ve got someone that’s done A&E for a year in Australia, let’s count that towards their training. If you’ve got staff who have gone and you know that want to get involved in leadership and management, let’s incorporate that into their training programmes. It’s also valuing them as human beings and people, giving them flexibility to do things like look after their children when that’s what they need to do. It’s also valuing their wellbeing. You know, I still remember some of the best jobs I ever had, I still remember one of the best things about it, no matter how busy it was when the consultant used to come round in the morning and by everyone a coffee and just have a bit of a natter and tell them, you know, what they’re doing and how their job works, the benefit that had on their future career, understanding the job but also feeling part of that team were astonishing and it’s incredible how simple little things like that can be.
AC: And the imperative to support staff wellbeing is even greater now given the pressures that people are under working as clinicians during the Covid-19 outbreak and actually will be afterwards too because there’ll be a big backlog of routine care that the NHS will need to catch up on, so those sorts of you know, paying attention to those small things, treating people as human beings, thinking about their wellbeing, making their lives easier rather than making their working lives harder, I think there’s some really important points in there that you’ve made, and I do want to just flag to our listeners that we’ve recently published some short practical resources on The King’s Fund website related to this. It includes some guidance on responding to stress and trauma and how to practice self-care and to sustain your energy among other things. So, do take a look at those short practical resources if you’re interested in thinking about how to look after the wellbeing of yourself and your teams as well. I’d like, Jeeves if I can now, to move on to understand a bit more about your experiences of leadership and leading change. So can you tell me a bit about what it was like taking on a leadership position so early in your career?
JW: I think it’s, I think actually it was a really valuable experience and I think you know, I look back at that time and the amount that I learned from taking on that role and learned about how to work with other organisations, you know the insights that gave me into the healthcare system and working with different people and actually I think what you learn is, I think people see it as heroes and villains and black and white as that within healthcare, everyone wants to do the best for patients. They might disagree on the how but if you can agree on the principal of what you’re trying to achieve, there’s so much that can be achieved by working together. It’s about achieving that, what is your objective, what direction are you pulling in. For me, yes it was relatively early in my career compared to some of the other people that have done things of this scale but, actually, I think it allows you to bring the experiences that you have as a junior doctor to some of these roles. What you can bring, quite often, especially early in your career, if you’ve worked in lots of different departments and you’re still in that stage of your career where you’ve been working in lots of different environments, you bring that sense of perspective, you’ve seen what it’s like on the ground dealing with patients and systems and the bureaucratic and administrative processes that you go through and it’s how you can bring those experiences to the fore and actually you do bring fresh perspectives and insights into how systems work and I felt like I could offer that enthusiasm and that energy during my time doing it. Obviously, I finished doing that role now after three years but I think there’s a lot of value in what you can offer people.
AC: So, looking to the future, what kind of leader would you like to be, if you look forward to yourself in 20 years’ time?
JW: I think it’s hard to know. I think I’m still in a place where I’m learning from the leaders I encounter. I was lucky to have had, you know, great bosses, Parvin Kumar was my first clinical boss. I think when I look at some of them, the key strand that I notice is that they tend to be calm. They tend to be empathic leaders, they’re not kind of that heroism model of leadership where they, you know, destroy themselves as some kind of example to others. I think it’s people who care about individuals, that remember people’s names, that take time for a chat and you know, get to know their teams as individuals and try to empower and give them responsibility. That’s what I’d love to be one day, but obviously I’m still on that journey, shall we say.
AC: And you say there that you’re still at the stage where you’re learning from the leaders that you encounter, but I think even for leaders at the very end of their careers, if they’re effective leaders, they’re still learning from people they encounter and I’m sure when you were working with very senior leaders during your time on the committee, they were probably learning as much from you as you were from them. So working through the Covid-19 outbreak will be a hugely challenging time for all clinicians and I’m sure it will be a career defining moment for many. So thinking about your own development as a clinician, what difference do you think this will make for you, that you’ve been through this experience? What learning will you take away from this period?
JW: I think it’s taught us all a lot about innovation under pressure and how you work with people to solve problems quickly and think outside the box, but also, just how incredible it’s been watching people step forward to solve those problems and throw themselves at those issues to try and help. You know, watching so many of my colleagues step forward to volunteer has been astonishing. You know, only a few years ago during the dispute, people said would junior doctors respond if there was an emergency and I just, you know I’ve always said, that I just don’t think that’s an issue and I think we’ve seen just how spectacular across the health service people have been in stepping forward to help deal with this for the good of their patients.
AC: And I think we’ve all been inspired by what we’ve seen in terms of the response right across the health and care system, it’s just been amazing. Well thank you Jeeves for being with us today and good luck with the really important that you and your colleagues will be doing over the coming weeks and months.
JW: Thanks so much. Thanks for having me.
AC: That’s it from us. You can find the show notes for this episode and all our previous episodes at www.kingsfund.org.uk/kfpodcast. Thank you, as always, to our podcast team, particularly our produces Ian Ford and Sarah Murphy and thanks to you for listening. If you enjoyed this episode please subscribe, rate and review us on Apple Podcasts or wherever else you get your podcasts because it helps others to find us and helps us improve the show and of course, we hope you can join us next time.
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