Junior Doctors are Drowning in the New Fear Culture of the NHS

When junior doctor Hadiza Bawa-Garba was convicted of manslaughter in 2015, it sparked a controversy that would consume the medical world for years. The case revolved around the death of six-year-old Jack Adcock, who died of sepsis at Leicester Royal Infirmary in 2011. For prosecutors, Jack's death was the result of Bawa-Garba's gross negligence. But for the thousands of doctors and nurses across the UK who opposed the ruling, it was a tragic human error, brought on by the systemic failings of a health service stretched to its limit.

Three years later, the case has come to embody the grievances of NHS staff, in particular junior doctors, who feel overworked and under-supported. In March of 2018, Bawa-Garba was granted leave to challenge the High Court ruling to remove her from the medical register – an important victory for her and her supporters, who crowdfunded over £360,000 to support her legal battle. And yet the culture of fear created by the case remains etched in the minds of many junior doctors, who are terrified of what will happen to them if something goes wrong.

"It's really scary," says Aisha, a junior doctor. "I feel the culture now is that you have to deal with the pressure, but no one will have your back if something goes wrong."

This fear, it seems, has manifested itself in a newly punctilious approach to documentation. An incident report system called Datix allows doctors to log concerns and clinical errors, encouraging them to be honest and promoting a learning culture. Doctors can now also use so-called "exception reporting" to record incidents when they’ve worked beyond their scheduled hours.

These measures are a positive move, but it's clear they have arisen from a culture of fear. Bawa-Garba's reflective note from the day of Jack Adcock’s death was reportedly used against her in court, and litigious language has crept into doctors' vocabulary, as they frequently refer to gathering "evidence" in their notes.

"You do have that fear in the back of your mind, and that’s a very everyday thing," says Aisha. "Be careful, make sure you write it down, document everything."

Katie, a junior doctor at a hospital in the north of England, echoes these feelings. "I think ever since I’ve practised medicine I’ve noticed that we practise very defensive medicine; we are very scared of litigation," she says. "And it’s definitely heightened since the case and the ruling."

She continues: "I think there’s definitely more awareness that, even though you’re always trying to act in the best interest of the patient, the public and the justice system may not see it that way."

In addition, doctors are worried that the over-stretched condition of the NHS makes mistakes more likely and puts patients at risk. An increase in patient numbers and lack of social care provision mean hospitals across the country are only just emerging from one of the worst winter crises on record, when bed shortages were so severe that all non-urgent operations had to be cancelled.

"You’re tired – by the time you see your 50th patient; you're exhausted," says Katie. "So I don’t think that poor person gets the best care compared to the first person you saw at the beginning of the day. And you’ve been constantly working, from 9AM 'til about 2PM without a break, trying to make people better."

Sunita, a junior doctor in London, agrees. "It is a bit worrying when you see the state of the hospitals and morale is massively low," she says. "I think it’s almost like fighting against the system, and it does feel like a losing battle sometimes."

This notion of individual doctors struggling against the larger system is perhaps unsurprising in the wake of the Bawa-Garba case, which Hadiza's supporters say has set a worrying precedent of scapegoating individuals for mistakes brought on by wider problems. The verdict has also raised serious questions in the medical profession about where the line should be drawn between normal mistakes and criminal lapses in judgement.

Health Secretary Jeremy Hunt believes this lack of clarity is a significant problem. "In other industries they have a much clearer dividing line, so everyone knows where they stand," he says. "I think for many doctors they don’t know what the difference is between gross negligence and ordinary human error, and are never quite sure if they’re going to get crucified for something they think was a mistake that anyone could make."

This concern about mistakes is reinforced by the fact that junior doctors are considerably more exposed to receiving disciplinary measures than their senior colleagues. A Freedom of Information request to the General Medical Council, which oversees the UK medical register, revealed that although there were over six times more complaints made against senior doctors than junior doctors between 2015 and 2018, the proportion of junior doctors who received regulatory action (ranging from a warning, to erasure from the medical register) was twice as high (33.6 percent compared with 15.6 percent).

The data does not specify the nature of each complaint, and a spokesperson for the GMC explained that a major reason for the disparity is that "junior doctors' supervisors are able to pick up and act on less serious concerns as part of their direct supervision and training. This means that concerns that are referred to the GMC are likely to be more serious." She added: "Another factor is that junior doctors are far less likely to be referred to us by members of the public than GPs or specialists."

Nevertheless, the figures show that it is junior doctors who most often receive disciplinary action, and supports their fears about what will happen if they make mistakes, especially in the light of the Bawa-Garba case.

Coupled with the fear of punishment for mistakes is a growing lack of trust in the British Medical Association (BMA), the trade union for doctors in the UK. The union has come under criticism for its role in the new junior doctors' contract, as well as individual cases such as Bawa-Garba and whistle-blower Chris Day, raising questions as to whether it is providing adequate support for junior doctors.

"I feel like my hands are tied, because I don’t have much faith in the BMA," says Katie. "People were not happy with the contract we ended up agreeing to, and there’s a lot of hostility towards the BMA now. I’m still a member, but I know a lot of people who have withdrawn their membership."

One of the problems, Katie says, is that many doctors are so stretched by their day-to-day work that they simply do not have the time or energy to campaign for their own rights. "Most of the time you’re just too exhausted and you need to have quite a lot of energy to press on with these things," she says. "So it's partly our fault as well, but the BMA aren’t very strong in their voice against the injustices that happen to doctors."

Some doctors, however, are addressing the dissatisfaction with their union directly. Doctors For Progress, a group that aims to "defend the NHS, seek union reform and protect the rights of doctors", entered candidates into the recent BMA Council elections, four of whom were successfully elected.

Doctors' concerns about reporting mistakes and support from their union are not, however, merely self-interested. At the heart of the matter lies patient safety, which many believe is compromised by the highly pressurised environment and lack of clarity over the handling of mistakes. While most junior doctors maintain that they enjoy their jobs, and speak passionately about their colleagues and the NHS more widely, many argue that the ingrained culture of blame and fear needs to be addressed to protect both doctors and their patients.

"It's really difficult to feel like you've done a good job for every patient," says Sunita. "It’s draining and it saps your energy. At the end of the day I do enjoy it, I just think it could be a lot better."

@jwarrington01