There is a question that has been troubling me for some time now. I think I have worked out the answer but if I am right it is deeply disturbing.

Why does our government have such a fixation about providing a 7 day elective (non emergency) NHS?

Now let me be perfectly clear about this. They are talking about non emergency services – getting your family planning advice on a Saturday afternoon and your varicose vein operation on a Sunday morning. Cameron was unequivocal in his speech to the Tory Spring Conference in Manchester last year. He said “with a future Conservative government, we would have a truly 7 day NHS” and that “everyone will have access to the NHS services they need 7 days a week by 2020 – the first country in the world to make this happen”.

Let me also be perfectly clear that the proposed changes in senior and junior doctor contracts are about elective working. The “opt out” clause in the consultants contract, which is hardly ever used but which Jeremy Hunt is adamant must be removed, refers to elective work. The proposed junior doctors contract does not refer to emergency work, it refers to all aspects of what they do.

The government have tried to muddy the waters by repeatedly quoting out of date or over-interpreted statistics about higher weekend death rates. Every one of these claims has been refuted by academics (including the editor of the BMJ) but Mr Hunt has continued to peddle his scare stories to gain political leverage.

NHS staff have reacted strongly to the implication that people are dying because they do not work at the weekend culminating in the hugely successful #Iminworkjeremy campaign on Twitter.

Anyone with half a brain can see that the NHS is already stretched to its limits. The majority of hospital trusts are in financial meltdown, wards areimage understaffed, targets are being missed and staff morale is at an all time low. The planned investment of £6B next year does not even scratch the surface when the government’s own 5-year plan talks of the need for £22B of efficiency savings just to tread water. GP services are near to breaking point and pilots of 7 day working in primary care have been abandoned because the public demand was not there.

It may be that the government intends to use the confrontation with the junior doctors to undermine public confidence in the NHS and hasten its demise. If this is the case then it is a high-risk strategy. To date the general public has shown massive support for the doctors. It will take a long and corrosive campaign to change the public mood, which will ultimately be damaging for everyone involved – including the government.

A 7-day elective NHS is clearly not achievable without significant new investment and several years of accelerated staff training and recruitment. The government knew this when they put it in their pre-election manifesto and they know it now.

So why does the government continue to peddle the myth that we can have the worlds first truly 7 day health service? They have frightened patients to the point where some have come to harm (see the Hunt effect) and they have provoked doctors to the point of striking. It seems to make no sense at all.

At least it makes no sense in the context of the NHS as it is currently configured.

But cast your mind ahead a few years to a time when the combined effects of the Health and Social Care Act, TTIP, chronic underfunding and increasing demand have taken their toll on the NHS and its staff. Private healthcare providers will run large chunks of the NHS, though these services will still be badged as NHS and it will not be clear to patients who is providing their treatment. Voluntary financial top ups for “enhanced” treatment (as opposed to freely available but by that time second rate basic NHS treatment) will become the norm. Everyone who can afford it will have healthcare insurance.

Healthcare provision in the UK will become a profitable enterprise, not just for insurance companies and private health providers but also for the government, which will benefit from increase tax revenue. The NHS will move from socialised to commercialised medicine where the main driver is the bottom line on the balance sheet.

Every consultation, every operation, every prescription will be an opportunity to make money. The NHS will become a for-profit business and a very lucrative one at that.

It is important to consider the rate-limiting steps for this massive state run healthcare gravy train. What caps the amount of profit it can make?

  • It is not the available cash. Insurance companies will be able to squeeze megabucks out of an anxious population which is terrified the failing NHS will not meet its needs.
  • It is not the demand for healthcare. An ageing population and an unlimited supply of new and expensive treatments will see to that. And if demand does seem to be flagging it can always be pumped up by advertising campaigns designed to increase health anxiety.
  • It is not the availability of (most) healthcare professionals. The majority of NHS workers are so poorly paid that they will grab any opportunity for overtime with both hands.

The main rate-limiting step is actually the available infrastructure. Existing hospitals and GP surgeries are already working at full capacity for 5 days of the week. The only way to increase throughput without a significant building programme is to extend the working week to 7 days. Moving from 5 to 7 day working increases the maximum output (and profit) from the existing real estate by 40%.

But why is the junior doctors contract so important to the government?

All doctors, both junior and senior, are essential for the provision of 7 day services so they are one of the few groups that can offer effective resistance to the government’s plans. Doctors are relatively well paid – or at least in the case of junior doctors have the prospect of being well paid – and unlike most staff they can afford to pick and choose when they would like to work.

Many doctors have a strong commitment to the NHS and socialised medicine. They are well organised, motivated and articulate.

If they don’t want to play the game then the service stops. The NHS cannot function without them. This is why the government is so committed to changing their contracts. It wants to be able to force them to do elective work at the weekends.

This is not about benefits for patient, this is not about safety; this is about potential future profits.

In a commercialised health system the nursing bursary story starts to make sense too.

Trained nurses are expensive. In a profit driven health economy it will be much cheaper to fill the wards with untrained staff. You can’t get away with doing this in the name of profit but you have to do it if the trained staff simply doesn’t exist.

It seems we have a government that wants to dismantle the most efficient and equitable health service in the world and replace it with a 7 day a week, state run, profit generating healthcare production line. To achieve this they are prepared to lie to the public, to misrepresent medical research, to frighten patients to such a degree that some have come to harm, to wreck budding clinical careers and to alienate over a million NHS workers.

I have changed my mind. This is more than disturbing.

This is chilling.





  1. It is being done for profit but I’m not sure it’s so complicated. The private sector has no junior doctors and insufficient Consultant staff to expand. The plan – make NHS contracts unworkable – offer [marginally] better contracts to juniors and consultants in private sector. Medical staff depart, NHS finished. Junior’s threats to leave NHS actually music to Hunt’s ears.


  2. Relatively good summary of the events. However it is not the case that doctors in training or consultants ‘can afford to pick and choose when they would like to work’. Under NHS contracts doctors in training have no say in their working hours – they are assigned to a rota for 6 months and they work the shift pattern in that rota – they cannot opt out of any shifts.

    Nor is it any longer the case that that ‘at least in the case of junior doctors have the prospect of being well paid’ given the proposed changes to the Consultant contract which reduces starting salary by approx 8% from its current level which has been frozen for many years. This reduced salary is also fixed for first 5 years.

    In addition, they will have imposed more ‘portfolio’ requirements to continue to undertake paper collecting exercises for the 1st 5 years of their consultancy – an imposition which had previously ceased when securing a consultant job. The continuing erosion of autonomy and imposition of further hurdles does not make the UK consultant’s role a particularly desirable one for many doctors in training.


  3. I can never understand why a consultant is allowed to work full time for the NHS and then do private work ‘on the side’. If I did a second job in my profession my primary employer would have a real (and reasonable issue) with this.
    I reckon a lot of consultants don’t want to work more weekends because that is more often than not when they do the bulk of their private (and handsomely paid) private work. Seems to me they are happy enough to work weekends in that situation.


    1. I think it was a sweetener to enable Consultants to want to join the NHS when it started, allowing them to keep their lucrative private work going…


    2. Many people do paid work outside their main job! Why exactly shouldn’t they? I’m a consultant and although I don’t do very much private practice I do write medical reports for the legal profession. I do this in the evenings or weekends in my own time – and what I do in my free time is my business. Incidentally, I qualified in 1981 and have worked weekends from that time to the present day.


  4. Anyone with half a brain can see that the NHS is already stretched to its limits. The majority of hospital trusts are in financial meltdown, wards areimage understaffed, targets are being missed and staff morale is at an all time low. The planned investment of £6B next year does not even scratch the surface when the government’s own 5-year plan talks of the need for £22B of efficiency savings just to tread water.

    The same thing happened with Stalin’s five year potato plan, Of course the Russians learned that for the state to try to run anything centrally was a recipe for rationing, shortage and inefficiency and the NHS is just the latest example of this. The sooner we realise our colossal error and move to a market driven bottom up healthcare model, the better.


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