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At some point in their training, most medical students will encounter palliative care during their placements. In the UK nearly half of all deaths happen in hospital and therefore end of life care is a core skill for junior doctors.1 This article outlines the importance and relevance of palliative care and offers advice on how to use a palliative care placement to optimise the future management of patients who are nearing the end of life. Palliative care is more than caring for patients at the end of life. It is an approach to terminal illness that focuses on holistic, individualised care and symptom control, rather than cure or prolonging life.2 Palliative care teams support patients with incurable chronic diseases or life limiting illnesses. Adult palliative care teams can attend to patients from age 16 upwards. Although many of the patients will have cancer, the teams also support those with incurable, progressive conditions, such as heart failure, chronic respiratory disease (chronic obstructive pulmonary disease, fibrosis), progressive neurological disease (motor neurone disease, dementia), and end stage renal and liver failure. You might be exposed to palliative care during many of your medical school placements, particularly general practice and medical specialties such as respiratory or geriatric medicine. Although doctors and nurses often provide palliative care without being specialists in the discipline, you might spend time with dedicated palliative care specialists in a variety of settings. You could be placed in a hospice, an establishment dedicated to supporting patients receiving palliative care and their families and friends.3 Services offered by hospices are variable; some have only outpatient …

ObjectiveTo study the effects of recent political events on mood among young physicians.DesignProspective cohort study.SettingUnited States medical centres.Participants2345 medical interns provided longitudinal mood data as part of the Intern Health Study between 2016 and 2018.Main outcome measuresMean mood score during the week following influential political and non-political events as compared with mean mood during the preceding four week control period.ResultsWe identified nine political events and eight non-political events for analysis. With the start of internship duties in July, the mean decline in mood for interns was −0.30 (95% confidence interval −0.33 to −0.27, t=−17.45, PConclusionsMacro level factors such as politics may be correlated with the mood of young doctors. This finding signals the need for further evaluation of the consequences of increasing entanglement between politics and medicine moving forward for young physicians and their patients.

Nearly three years ago, Rimmer reported that senior doctors needed to do more to boost the morale of junior doctors.1 I am nearing the end of my first year working in medicine, and there is one frustration that I …

The BMA junior doctors’ vote against professional equivalency for medical associate professionals is counterintuitive and shortsighted.1 What is professional equivalency? Doctors are doctors, with their own terms and conditions, pay, regulator, and undergraduate and postgraduate courses and exams, and physician associates and surgical care practitioners are what they are. In cardiothoracic surgery, surgical care practitioners have performed surgical tasks such as conduit harvest since the early 1990s. Senior house officers …

Objectives To evaluate the changes in productivity when scribes were used by emergency physicians in emergency departments in Australia and assess the effect of scribes on throughput. Design Randomised, multicentre clinical trial. Setting Five emergency departments in Victoria used Australian trained scribes during their respective trial periods. Sites were broadly representative of Australian emergency departments: public (urban, tertiary, regional referral, paediatric) and private, not for profit. Participants 88 physicians who were permanent, salaried employees working more than one shift a week and were either emergency consultants or senior registrars in their final year of training; 12 scribes trained at one site and rotated to each study site. Interventions Physicians worked their routine shifts and were randomly allocated a scribe for the duration of their shift. Each site required a minimum of 100 scribed and non-scribed shifts, from November 2015 to January 2018. Main outcome measures Physicians’ productivity (total patients, primary patients); patient throughput (door-to-doctor time, length of stay); physicians’ productivity in emergency department regions. Self reported harms of scribes were analysed, and a cost-benefit analysis was done. Results Data were collected from 589 scribed shifts (5098 patients) and 3296 non-scribed shifts (23 838 patients). Scribes increased physicians’ productivity from 1.13 (95% confidence interval 1.11 to 1.17) to 1.31 (1.25 to 1.38) patients per hour per doctor, representing a 15.9% gain. Primary consultations increased from 0.83 (0.81 to 0.85) to 1.04 (0.98 to 1.11) patients per hour per doctor, representing a 25.6% gain. No change was seen in door-to-doctor time. Median length of stay reduced from 192 (interquartile range 108-311) minutes to 173 (96-208) minutes, representing a 19 minute reduction (P Conclusions Scribes improved emergency physicians’ productivity, particularly during primary consultations, and decreased patients’ length of stay. Further work should evaluate the role of the scribe in countries with health systems similar to Australia’s. Trial registration ACTRN12615000607572 (pilot site); ACTRN12616000618459.

Rosamund Snow and David Gilbert detect a sea change in the way patients and the public have started talking about the junior doctors’ strike

Organophosphorus pesticides are used widely for agriculture, vector control, and domestic purposes. Despite the apparent benefits of these uses acute organophosphorus pesticide poisoning is an increasing worldwide problem, particularly in rural areas. Organophosphorus pesticides are the most important cause of severe toxicity and death from acute poisoning worldwide, with more than 200 000 deaths each year in developing countries.1 Although the incidence of severe acute organophosphorus pesticide poisoning is much less in developed countries, many patients with acute low dose unintentional or occupational exposures present to health facilities.2 3 We provide an evidence based review of the management of acute organophosphorus pesticide poisoning. Risk assessment in patients with acute unintentional poisoning is discussed, in addition to special considerations for severe poisoning. #### SUMMARY POINTS #### Sources and selection criteria We searched several resources to identify relevant information on the diagnosis and management of acute organophosphorus poisoning: Medline, Embase, the Cochrane Library, and the Chemical Safety Information for Intergovernmental Organizations database (www.inchem.org/pages/pds.html); websites for registration of clinical trials, including the Current Controlled trials website (http://controlled-trials.com/) using the m RCT search feature; personal archives; and attendance at, and review of abstracts from, workshops and conferences on pesticide poisoning. #### Levels of evidence in the review The evidence supporting specific therapeutic approaches to patients with acute organophosphorus poisoning is listed after each management recommendation. We have adopted the classification used in the BMJ publication Clinical Evidence 4

Problem Introduction and evaluation of evidence based medicine (EBM) into routine hospital practice. Strategy for change Routine EBM meetings introduced in 1997. Design Review of outcomes of meetings from 1997 to 2004, focusing on their effect on clinical practice. Setting Referral centre for tropical and domestic infectious diseases. Key measure for improvement Outcome of meetings, classified as resulting in a change in practice; confirmation or clarification of existing practice; identification of a need for more evidence; and outcome unclear. Effects of change Examples include a change from inpatient to day case treatment of New World cutaneous leishmaniasis; development of guidelines on the treatment of coinfection with visceral leishmaniasis and HIV; and identification of the need for more data on the efficacy and toxicity of atovaquone-proguanil (Malarone) compared with quinine plus sulfadoxine-pyrimethamine (Fansidar) in the treatment of uncomplicated falciparum malaria, which resulted in a clinical trial being set up. Lessons learnt Incorporation of EBM meetings into our routine practice has resulted in treatment guidelines being more closely based on published evidence and improvements to care of patients. Written summaries of the meetings are important to facilitate change.

Objective As a result of recent failures in clinical governance the government has made a commitment to bring individual surgeons9 mortality data into the public domain. We have analysed a database to compare crude mortality after coronary artery bypass surgery with outcomes that were stratified by risk. Design Retrospective analysis of prospectively collected data. Setting All NHS centres in the geographical north west of England that undertake cardiac surgery in adults. Participants All patients undergoing isolated bypass graft surgery for the first time between April 1999 and March 2002. Main outcome measures Surgeon specific postoperative mortality and predicted mortality by EuroSCORE. Results 8572 patients were operated on by 23 surgeons. Overall mortality was 1.7%. Observed mortality between surgeons ranged from 0% to 3.7%; predicted mortality ranged from 2% to 3.7%. Eighty five per cent (7286) of the patients had a EuroSCORE of 5 or less; 49% of the deaths were in this lower risk group. A large proportion of the variability in predicted mortality between surgeons was due to a small but differing number of high risk patients. Conclusions It is possible to collect risk stratified data on all patients undergoing coronary bypass surgery. For most the predicted mortality is low. The small proportion of high risk patients is responsible for most of the differences in predicted mortality between surgeons. Crude comparisons of death rates can be misleading and may encourage surgeons to practise risk averse behaviour. We recommend a comparison of death rates that is stratified by risk and based on low risk cases as the national benchmark for assessing consultant specific performance.

Doctors in training grades can gain experience ranging from independent, lightly supervised practice to a more constant, “helicopter” presence of consultants directing most decisions.1 Is the current balance right, or has it tipped too far towards the hands-on boss? Helping junior doctors to feel ready for more senior, unsupervised roles as they ascend the training ladder means allowing them to work more in difficult scenarios involving team leadership, autonomy, and risk acceptance.2 If opportunities to step up are limited, the lack of opportunity becomes self reinforcing as doctors lack the confidence to take on more senior roles. In adult internal medicine specialties, surveys have shown that doctors are very concerned about their capacity to take on medical registrar roles. This isn’t just because of …

One of the biggest stressors in work for me and my colleagues, junior and senior, is the relentless demand for information—not from patients themselves but from their relatives. It’s taboo to talk about this in public for fear of appearing callous and uncaring. But it comes up whenever a group of medics unburden themselves in a safe space. I’m happy to break the taboo and to be found wanting for doing so. The source of this stress is rarely visitors who are involved carers, supporting the patient day in, day out. They are often highly present on the wards, making frequent interaction and updates easier. It’s crucial to involve …

Some NHS trusts are being too heavy handed in enforcing the new junior doctor contract, the BMA has warned, after juniors at one trust were found to have been threatened with referral to the General Medical Council for refusing to take on locum work. Jeeves Wijesuriya, chair of the BMA’s junior doctors committee, told The BMJ that several trusts around the country had been “misinterpreting” a clause in the new junior doctor contract requiring trainees to initially offer the spare hours they wish to work as a locum to an NHS staff bank.1 Wijesuriya said that he had recently asked University Hospitals Birmingham NHS trust to …

Appleby gives a good summary of the top down economics relevant to consultant productivity.1 But the question the NHS should be asking isn’t the abstract, “How productive is the workforce?” but the practical, “How can we improve productivity of the workforce?” For example, if the problem is …

Objective To examine the impact of the publication of clinical outcomes data on NHS Trusts in Scotland to inform the development of similar schemes elsewhere. Design Case studies including semistructured interviews and a review of background statistics. Setting Eight Scottish NHS acute trusts. Participants 48 trust staff comprising chief executives, medical directors, stroke consultants, breast cancer consultants, nurse managers, and junior doctors. Main outcome measures Staff views on the benefits and drawbacks of clinical outcome indicators provided by the clinical resource and audit group (CRAG) and perceptions of the impact of these data on clinical practice and continuous improvement of quality. Results The CRAG indicators had a low profile in the trusts and were rarely cited as informing internal quality improvement or used externally to identify best practice. The indicators were mainly used to support applications for further funding and service development. The poor effect was attributable to a lack of professional belief in the indicators, arising from perceived problems around quality of data and time lag between collection and presentation of data; limited dissemination; weak incentives to take action; a predilection for process rather than outcome indicators; and a belief that informal information is often more useful than quantitative data in the assessment of clinical performance. Conclusions Those responsible for developing clinical indicator programmes should develop robust datasets. They should also encourage a working environment and incentives such that these data are used to improve continuously.

At a time when workforce unity is perhaps the only thing keeping the service on its feet, pay inequity seems unwise, says Kushal Patel

The health secretary’s proposal to bring back the medical “firm” is broadly supported, but doctors point out that shift patterns and working hours are different now. Abi Rimmer reports

Objectives: To evaluate the impact of the Calman reforms of higher specialist training on trainee satisfaction. Design: Questionnaire surveys using portable electronic survey units, two years apart. Setting: Postgraduate, teaching, district general, and community NHS trusts in North Thames. North Thames deanery includes London north of the Thames, Essex, and Hertfordshire. Participants: Trainees in all grades and all specialties: 3078 took part in the first survey and 3517 in the second survey. Main outcome measures: Trainees9 satisfaction with training in their current post, including educational objectives, training agreements, induction, consultant feedback, hands on experience acquired, use of log books, consultant supervision, and overall satisfaction with the post. Results: In the second survey respondents were more likely to have discussed educational objectives with their consultant, used a log book, and had useful feedback from their consultant. They were more likely to give high ratings to induction, consultant supervision, and hands on experience acquired in the post. Each of these elements was associated with increased satisfaction with the post overall. Improvements were most noticeable at the level of specialist registrar, but changes in the same direction were also seen in more junior grades. Conclusions: After the reforms of specialist training, trainees in all grades reported greater satisfaction with their current posts. The changes required extra training time and effort from consultants.

OBJECTIVES: To survey operating theatre and intensive care unit staff about attitudes concerning error, stress, and teamwork and to compare these attitudes with those of airline cockpit crew. DESIGN:: Cross sectional surveys. SETTING:: Urban teaching and non-teaching hospitals in the United States, Israel, Germany, Switzerland, and Italy. Major airlines around the world. PARTICIPANTS:: 1033 doctors, nurses, fellows, and residents working in operating theatres and intensive care units and over 30 000 cockpit crew members (captains, first officers, and second officers). MAIN OUTCOME MEASURES:: Perceptions of error, stress, and teamwork. RESULTS:: Pilots were least likely to deny the effects of fatigue on performance (26% v 70% of consultant surgeons and 47% of consultant anaesthetists). Most pilots (97%) and intensive care staff (94%) rejected steep hierarchies (in which senior team members are not open to input from junior members), but only 55% of consultant surgeons rejected such hierarchies. High levels of teamwork with consultant surgeons were reported by 73% of surgical residents, 64% of consultant surgeons, 39% of anaesthesia consultants, 28% of surgical nurses, 25% of anaesthetic nurses, and 10% of anaesthetic residents. Only a third of staff reported that errors are handled appropriately at their hospital. A third of intensive care staff did not acknowledge that they make errors. Over half of intensive care staff reported that they find it difficult to discuss mistakes. CONCLUSIONS: Medical staff reported that error is important but difficult to discuss and not handled well in their hospital. Barriers to discussing error are more important since medical staff seem to deny the effect of stress and fatigue on performance. Further problems include differing perceptions of teamwork among team members and reluctance of senior theatre staff to accept input from junior members.

The incorporation of lay perspectives in research and development in the health service is not only politically mandated in recent white and green papers but also has the potential to improve the relevance and impact of research and the quality of subsequent services.1 There are many ways of identifying lay views and incorporating these into decisions, but the methods used to achieve this need further evaluation. Traditional methods to encourage public participation—such as public meetings, patient participation groups, and complaints procedures—have met with limited success.2 During the past decade the technique named “rapid appraisal” has begun to make important contributions in the assessment of local needs and planning in the developed and developing countries (see box on p441). Its use in the United Kingdom has been guided by the work of Chambers,3 Annett and Rifkin,4 and Ong,5 and Manderson and Aaby have described an “epidemic increase” in the use of this method.6 Rapid appraisal has now been used by community workers and primary healthcare teams to gain public involvement in the assessment of needs from the Isle of Skye to inner city London and from Belfast to Norway. Initially used for assessment of global needs it has also been used with specific groups of patients and to gain broad perspectives on accident and emergency services.7 #### Summary points

Objective: To assess the relation between male and female medical leadership. Design: Cross sectional study on predictive factors for female medical leadership with data on sex, age, specialty, and occupational status of Norwegian physicians. Setting: Oslo,Norway. Subjects: 13844 non-retired Norwegian physicians. Main outcome measure: Medical leaders, defined as physicians holding a leading position in hospital medicine, public health, aacademic medicine, or private health care. Results: 14.6% (95% confidence interval 14.0% to 15.4%) of the men were leaders compared with 5.1% (4.4% to 5.9%) of the women. Adjusted for age men had a higher estimated probability of leadership in all categories of age and job, the highest being in academic medicine with 0.57(0.42to 0.72) for men aged over 54years compared with 0.39(0.21to 0.63) for women in the same category. Among female hospital physicians there was a positive relation between the proportion of women in their specialty and the probability of leadership. Conclusion: Women do not reach senior positions as easily as men. Medical specialties with high proportions of women have more female leaders.

The importance of lifelong learning in medicine is well recognised. This article explores how junior doctors can develop learning strategies for use throughout their working life

Objective: To see whether care provided by general practitioners to non-emergency patients in an accident and emergency department differs significantly from care by usual accident and emergency staff in terms of process, outcome, and comparative cost. Design: A randomised controlled trial. Setting: A busy inner city hospital9s accident and emergency department which employed three local general practitioners on a sessional basis. Patients: All new attenders categorised by the triage system as “semiurgent” or “delay acceptable.” 66% of all attenders were eligible for inclusion. Main outcome measures: Numbers of patients undergoing investigation, referral, or prescription; types of disposal; consultation satisfaction scores; reattendance to accident and emergency department within 30 days of index visit; health status at one month; comparative cost differences. Results: 4684 patients participated. For semiurgent patients, by comparison with usual accident and emergency staff, general practitioners investigated fewer patients (relative difference 20%; 95% confidence interval 16% to 25%), referred to other hospital services less often (39%; 28% to 47%), admitted fewer patients (45%; 32% to 56%), and prescribed more often (41%; 30% to 54%). A similar trend was found for patients categorised as delay acceptable and (in a separate analysis) by presenting complaint category. 393 (17%) patients who had been seen by general practitioner staff reattended the department within 30 days of the index visit; 418 patients (18%) seen by accident and emergency staff similarly reattended. 435 patients (72% of those eligible) completed the consultation satisfaction questionnaire and 258 (59% of those eligible) provided health status information one month after consultation. There were no differences between patients managed by general practitioners and those managed by usual staff regarding consultation satisfaction questionnaire scores or health status. For all patients seen by general practitioners during the study, estimated marginal and total savings were £Ir1427 and £Ir117005 respectively. Conclusion: General practitioners working as an integral part of an accident and emergency department manage non-emergency accident and emergency attenders safely and use fewer resources than do usual accident and emergency staff. Key messages Key messages A study extending this innovation shows that the care provided to non-emergency patients by general practitioners working as an integral part of an accident and emergency department also differs substantially from the care provided by the usual staff in terms of process Compared with the usual accident and emer- gency department staff, general practitioners investigate fewer patients, refer to other hospital services less often, more often refer patients back to their own general practitioners for follow up, admit fewer patients, and prescribe more often General practitioners within an accident and emergency department have no apparent effect on reattendance rates to the department within 30 days, patient satisfaction, or health status one month after the initial attendance As yet there are no explanations for these differ- ences, which warrant further research

The number of hospital doctors choosing to work as locums has almost doubled since 2009, National Statistics data show (fig 1). Between 2009 and 2015 the number of locum doctors in hospitals rose by 96%, from 8176 in 2009 to 16 002 in 2015. This represents a 12% average annual rise. On average, 1304 more doctors each year are choosing …

Researchers at a conference on the effect of sleep on fitness to work discussed how sleep deprivation can affect patient safety and doctors’ training. Abi Rimmer reports Junior doctors working night shifts should be allowed to take regular short naps, says Jim Horne, a sleep neuroscientist and emeritus professor of psychophysiology at Loughborough University. Horne was speaking at a conference held at the Royal Society of Medicine in London on 16 November about the effects of sleep deprivation on workers. He told the conference that a lack of sleep could affect a person’s ability to work and deal with emergencies. Speaking to BMJ Careers, Horne said that “there’s absolutely no doubt” that junior doctors should be allowed to take short naps. He said, “It’s safer for everyone concerned; it makes the doctor safer to work, it improves patient safety, it reduces accidents, and …

Bruce Keogh, national medical director of NHS England, speaks to Abi Rimmer about the need to rebuild junior doctors’ trust The frustration and disillusion experienced by a generation of doctors have featured prominently in media coverage of the dispute between junior doctors and the government over the new contract. Bruce Keogh, NHS England’s national medical director, says that the NHS’s failure to value its juniors is one cause of these doctors’ unhappiness. “Successful companies and successful organisations really spend a lot of time in harnessing the energy, the creativity, the enthusiasm, and the commitment of people in their 20s and 30s—the young professionals who have the energy and the vision,” he says. “I genuinely think that we don’t make the best use of the junior doctors in our NHS.” He adds, “I think that’s become clear in some of the discontent …

As the junior doctors behind Justice for Health prepare for next week’s judicial review of the decision to impose a new contract in England, Clare Dyer looks at the case

Senior doctors must ensure that their junior colleagues feel supported while the dispute over the junior doctor contract continues, leaders of the medical royal colleges have said. Last week the Royal College of Anaesthetists issued a statement saying that it was “crucial that trainees are, and feel, supported at this time.”1 The college said that doctors who felt “overwhelmed” should talk to fellow trainees, family, and friends, meet their supervisors, tutors, or mentors, and use available support schemes. “It is important that as a profession we remain united in caring for each other,” it said. “Look after yourselves and each other.” The statement was signed by Liam Brennan, president of the Royal College of Anaesthetists, along with other senior members of the college, the Faculty of Intensive Care Medicine, and the Association of Anaesthetists of Great Britain and …

Abi Rimmer looks at the roles carried out by this new breed of healthcare worker Physician associate roles have been proposed as a way of filling workforce gaps and freeing doctors’ time. But doctors themselves have raised concerns about the scope of physician associates’ practice, their length of training, and the possibility that their training will encroach on that of junior doctors. The first UK trained physician associates graduated from the University of Birmingham in 2009. Health Education England announced in 2014 that it would create a further 205 posts to support emergency medicine and primary care.1 The next year, the National Physician Associate Expansion Programme (npaep.com) was launched in England, seeking to employ 200 physician associates to work in the NHS for one to two years. Currently 27 UK universities offer postgraduate training for physician associates, with further courses in the process of development. Most require at least a 2:1 honours degree for entry into the postgraduate diploma course, as well as some prior health or social care experience. Alison Carr is director of postgraduate studies at Plymouth University Peninsula …

Expanding the work of non-medical staff can give doctors more time for training, says Matthew Limb , but it also prompts concerns about the boundaries of different roles

Thank you for an interesting retrospective on junior work. There is no straightforward solution. Not so long ago, treatment for many conditions was rest, as treatment options were limited. Today, smaller hospitals have only those inpatients who need active, often complex, intervention. Therefore, all patients covered by juniors are really sick. Reduced hours are intense hours. Reduced hours …

After the announcement that a new contract for junior doctors in England will be introduced despite their opposition, many believe that the support of senior doctors will be crucial to help improve morale. Abi Rimmer reports

Having voted to reject the proposed new contract, junior doctors now need to work with each other and senior colleagues to tackle the problems that lie ahead, says Kaanthan Jawahar

Trainee anaesthetist Janis Burns has modelled pay under the old and new junior doctor contract to see what the new contract will mean for doctors’ pay and working hours

A far reaching clause in the new NHS contract for junior doctors in England allowing employers to vary the terms and conditions unilaterally is highly unusual and could well be successfully challenged if acted on, employment law experts say. Under the clause, NHS employers “reserve the right from time to time in our absolute discretion to review, revise, amend or replace any term or condition of this contract and to introduce new policies and procedures, …

Born into a house that frequently provided hospitality to Aneurin Bevan, the local MP, and perhaps influenced by him, Margretta Eleanor Addis-Jones (“Lynne”) was always anxious to practise medicine. She spent the war years being schooled at Malvern Girls’ College in rural Worcestershire, away from the bombs, before proceeding to study classics at St Andrews University in Dundee, places for medical school being in short supply. On leaving St Andrews she spent a year attending …

England’s health secretary, Jeremy Hunt, has offered to meet with the BMA’s chairman of council, Mark Porter, in a last ditch attempt to avert this week’s plan for an all-out strike by junior doctors. In a letter to Porter sent on Saturday 23 April,1 Hunt said that he would be willing to meet to discuss “a range of issues that can improve the terms and conditions for junior doctors” if the BMA agreed to call off the full withdrawal of labour by junior doctors on Tuesday 26 and Wednesday 27 April. But Porter said that talks could take place only if the health secretary removed his threat to impose the new contract on junior doctors. Against this backdrop, the heads of 13 medical royal colleges wrote to the prime minister, David Cameron, on Monday 25 …

The Department of Health has published the contract about to be imposed on junior doctors in England, along with a related “equality analysis” and a “family test.”1 2 Even with an imposed contract, the government has duties under the Equalities Act: UK law forbids direct discrimination against women and disabled people. And the department’s self penned analysis concludes that the contract is “fair and justified as good for both staff and patients.”1 But, in the Department of Health’s own words, this contract may “disadvantage women working part time.” Indirect discrimination, however—something that puts someone …

With experts assessing that the NHS is in the grip of the biggest crisis in its history, The BMJ hosted a roundtable discussion during the Nuffield Trust health policy summit this month to discuss whether today’s medical workforce is fit for the future needs of the health service. Gareth Iacobucci reports

The basic needs of a vulnerable workforce are not being met Today I’ve been working as a sessional GP in a village practice near Cambridge, seeing the usual mixture of common colds, hot children, lumps needing urgent referral, heart attacks, depression, and the worried well. Around me, in leafy Cambridgeshire, GPs are worrying about the recruitment crisis in primary care, with as many as 40% of GPs due to retire in the next five years. Junior doctors are going back to work after a 48 hour strike over the imposition of their new contract. Administrators are trying to fill rota gaps without spending any money, and patients are trying to negotiate the complex bureaucratic barriers we’ve put in their paths to …

As NHS Employers takes forward its plan to impose a new junior doctor contract, Abi Rimmer asks doctors what should happen now

Jeremy Hunt’s imposition of a new junior doctors’ contract in England, after negotiations failed over pay for Saturday working and a second strike took place,1 is unlikely to mark the beginning of the end of this dispute. If clinicians and politicians remain as polarised as they are now, this could be only the end of the beginning. Patients, the NHS, and its less politicised clinicians may get stuck in a place of strife. Both sides leaked to the media throughout, deepening mutual mistrust. The failure of NHS Employers (the representative body tasked with negotiating new contracts on behalf of the government) to make meaningful progress in talks with junior doctors’ leaders saw the senior NHS manager David Dalton take over negotiations, at Hunt’s request. Hunt’s actions put him firmly in the frame of this dispute: intervening here (and elsewhere) contrary to the 2012 Health and Social Care Act’s intended political devolution. Dalton’s public letter to Hunt,2 supporting his contract offer and apparently encouraging its imposition, unravelled with embarrassing haste, as 14 of its 20 NHS chief executive co-signatories publicly insisted that they did not support imposition of the deal.3 Successful negotiators avoid entrenching their positions, enabling give and take. Running commentary in the traditional and social media saw both sides contesting the moral high ground of patient safety. …