Healthcare worker strikes

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The withdrawal of labour has moral implications for healthcare workers. When it has happened there may be implications for the entire population depending upon many factors. The effects seem to be much less than some other political decisions such as war and income distribution within a population. Some authors have noted that as the USA moves towards healthcare reform on a national basis it is possible that workforce unionisation will lead to the national strikes seen in other countries with a national health plan[1]. The ethics have been reviewed[2].

The most frequent cause of notable strikes appears to be failure to honor collective bargaining agreements by employers. The impact of taking strike action may be disproportionately deleterious on doctors and other health care workers when compared to patients. Whether or not their demands were met, doctors who have been involved in strikes usually end up disillusioned and demotivated and appear to end-up emigrating overseas or relocating within a country. Such brain drains have been well described in Malta, New Zealand and Israel where major disruptions in healthcare service delivery resulted[2].

Contents

Effects of Doctors Strikes

Health effects

  • Generally strikes result in the maintaining of emergency services either by the striking doctors or by colleagues. If so there does appear to be the potential for a decrease in mortality, due it is believed to the reduction in elective work.
    • 20% decreased mortality (Israel 2000) [3]
    • 55 to 153 deaths did not occur because of the number of elective operations not performed secondary to the strike easily hid any impact from increased patient transfer to other facilities on emergency admission mortality(California 1973)[4].
    • Similar reductions were seen in California and UK decades earlier

The decrease in mortality does not affect routine perinatal statistics

  • No change in the perinatal mortality (Israel 1983) [5]

And does not appear at a macro level

  • No increase or decrease in population mortality (Croatia 2003)[6]
  • County mortality statistics not affected(California 1973)[7]

But it is possible some of the effects are long term

Some of the effects of a junior doctors strike may be superficially attractive in a management target driven culture:

  • Resident strike (Spain 2000)[9]
    • Fewer clinical tests
      • Pathology
      • X-rays
    • Shorter lengths of hospital stay
  • The argument that some of this effect of mortality is a result of removing from health care those felt most likely to have competency deficiencies is only partially supported by medical staff cohort turnover studies that tend to demonstrate fairly minimal or no impact on mortality.

Disruption

The disruption caused by a 2012 UK 24 hour strike of doctors with maintained emergency services has been described. This was locally patchy involving about 8% of the NHS doctor work force on the issue of pension reform. An analysis of the national impact was that emergency admissions fell by 2.4%, elective admissions decreased by 12.8%, outpatient activity dropped by 7.8% and A&E attendances dropped by 4.7%. In hospital mortality did not increase significantly[10]

Malta had a ten year doctor strike from 1977 when health care became a state responsibility and the government amended legislation governing medical licensing. This had major consequences, with the political decision not to employ striking doctors aggravating the doctor brain drain. This was partially reversed in 1987 when a change of government attracted many Maltese doctors with useful overseas experience back again. It is said Maltese politicians are now very cautious in their dealings with doctors, the scars run so deep, but, whatever the history, by 2000 the healthcare system was quite functional on international comparative measures.

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In 2016 due to continued and escalating industrial action by junior doctors the GMC issued guidance on some relevant issues:

Effects of Nurses Strikes

Midwife availability can impact perinatal care(Canada 1994)[11]:

  • Adverse outcomes 10.2 vs 8.1/100 deliveries, (OR 1.27, 95% CI 1.07 to 1.52)
  • Reduction in cesarean section rate to 12.5 per 100 deliveries, from 14.6 per 100 deliveries

Specific disputes

NHS strikes

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Many unionized groups of NHS employees took industrial action in 1975 and this continued to the 1978 and 1979 Winter of discontent. This lead to the Clegg commission on public service pay, the Standing Commission on Pay Comparability as a political compromise with the unions which was abolished in 1980 when change in Government resulted in curbing of union power

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Junior doctors took industrial action in November 1975. The main issues were hours of work (80-120/week) and pay, with the rate of pay falling after the first 44 hours - reducing by about two-thirds. Much of the strike action involved working to a 40 hour week. Some pay concessions were made by the NHS.

The strike action followed the Labour government (Barbara Castle, social services minister) issuing a unilateral new junior staff contract (Oxford code). It had a number of complex issues including delay in implementation of pay scales that were to be implemented in October, as a result of enforcement of a subsequent national general pay policy (freeze). At this time trainees often worked 1:2 rotas and tended to have responsibility for a single firms patients. The dispute was resolved within 1 month with a final resulting contract specified for the first time:

  • Number of hours which junior doctors were expected to be on duty
  • Basic salary plus extra payment for additional hours. The extra payment rate was determined from a £12 million national settlement and was not "overtime".
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In 2012 there was a 24 hour doctor strike involving in a locally patchy fashion about 8% of the NHS doctor work force on the issue of pension reform. An analysis of the national impact was that emergency admissions fell by 2.4%, elective admissions decreased by 12.8%, outpatient activity dropped by 7.8% and A&E attendances dropped by 4.7%. In hospital mortaliity did not increase significantly[12]

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A number of health unions with nurses and midwives as members took or threatened industrial action in the UK during November 2014 which was resolved by a pay settlement aimed at the more lowly paid

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NHS junior doctors took industrial action in 2016 when the UK Conservative government (Jeremy Hunt, secretary of state for health) issued a unilateral contract for England. The UK action was limited to England as the devolved countries did not attempt to impose a changed contract

North America

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Saskatchewan physicians strike in 1962 lasted 28 days with defeat due to popularity of new Medicare program and the provincial government implementing it.

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Quebec specialists struck in 1970 against Medicare and lost

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In 1974 after 12 days Howard University housestaff at Freedman’s Hospital in Washington, DC were successful in obtaining a salary increase, improved laboratory facilities and nursing coverage, and better fringe benefits plan including paying for malpractice insurance

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In 1975 New York public hospital house staff struck for 3 days on issues that included excessive hours and effectively won. However, also in 1975 although housestaff in Chicago’s Cook County Hospital obtained much of what they wanted with respect to quality of patient care, working conditions, and work hours after 18 days, their leaders were jailed

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In 1976 75% of Los Angeles County physicians struck over malpractice insurance reform and after 35 days some minor reforms occurred but major demands never meet. There was also a dispute in New York that year in which 30 physicians were fired and rehired

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Quebec specialists in 1980 wanted to opt out of Medicare or extra-bill patients beyond fee schedule but strike collapsed after 1 day when generalists colleagues did not support.

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Ontario had banned extra billing for services in 1984 and by 1986 physicians tried a 25 day strike to resolve issue. They lost as no public support

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Ontario obstetricians and orthopedic surgeons stopped taking new patients as malpractice insurance subsidies were ended. Colleagues supported their actions and issue was won

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New Brunswick physicians struck for 3 days in 2000 to obtain parity in pay with other provinces, with only partial success

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Industrial action in West Virginia in 2003 because of large increase in malpractice premiums effectively failed when examined retrospectively

Australasia

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The 2003 Timaru senior doctors strike left local hospital services in a mess for years

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A 2008 junior doctors strike showed that one senior doctor could easily carry the workload of two junior doctors in internal medicine or accident and emergency if outpatient clinics and elective admissions were mostly cancelled. Waiting times and length of stay were markedly reduced.[13]

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In September 2014 nurses and midwives took industrial action over a pay freeze with in due course resolution

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In October 2016 resident doctors announced strike action because of concerns working hours were unsafe.[14]

Europe

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Poland had nursing strikes in 2009 which were widely supported

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The German mid-March 2006 university physicians strike, as a result of an increase in the hours of the official workweek when most doctors were already working well over these hours was resolved after 3 months of collective action and negotiation

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In France between December 2014 to March 2015 groups of doctors, mainly those in general practice took industrial action in an attempt to modify government plans to introduce third part payments which meet some of its aims

References

  1. Cruess RL, Cruess SR. Commentary: professionalism, unionization, and physicians' strikes. Academic medicine : journal of the Association of American Medical Colleges. 2011 May; 86(5):548-51.(Link to article – subscription may be required.)
  2. a b Chima SC. Global medicine: is it ethical or morally justifiable for doctors and other healthcare workers to go on strike? BMC medical ethics. 2013; 14 Suppl 1:S5.(Link to article – subscription may be required.)
  3. Siegel-Itzkovich J. Doctors' strike in Israel may be good for health. BMJ (Clinical research ed.). 2000 Jun 10; 320(7249):1561.
  4. James JJ. Impacts of the medical malpractice slowdown in Los Angeles County: January 1976. American journal of public health. 1979 May; 69(5):437-43.
  5. Bukovsky I, Herman A, Sherman D, Schreyer P, Arieli S, Caspi E. Perinatal outcome following physicians' strike of 1983. Israel journal of medical sciences. 1985 Oct; 21(10):804-7.
  6. Erceg M, Kujundzić-Tiljak M, Babić-Erceg A, Coric T, Lang S. Physicians' strike and general mortality: Croatia's experience of 2003. Collegium antropologicum. 2007 Sep; 31(3):891-5.
  7. James JJ. Impacts of the medical malpractice slowdown in Los Angeles County: January 1976. American journal of public health. 1979 May; 69(5):437-43.
  8. Marcovici OA, Slater PE, Ellencweig AY. Effects of the Israel doctors' strike on hypertension control in Ashdod. European journal of epidemiology. 1987 Mar; 3(1):30-4.
  9. Salazar A, Corbella X, Onaga H, Ramon R, Pallares R, Escarrabill J. Impact of a resident strike on emergency department quality indicators at an urban teaching hospital. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2001 Aug; 8(8):804-8.
  10. Ruiz M, Bottle A, Aylin P. A retrospective study of the impact of the doctors' strike in England on 21 June 2012. Journal of the Royal Society of Medicine. 2013 Sep; 106(9):362-9.(Link to article – subscription may be required.)
  11. Mustard CA, Harman CR, Hall PF, Derksen S. Impact of a nurses' strike on the cesarean birth rate. American journal of obstetrics and gynecology. 1995 Feb; 172(2 Pt 1):631-7.
  12. Ruiz M, Bottle A, Aylin P. A retrospective study of the impact of the doctors' strike in England on 21 June 2012. Journal of the Royal Society of Medicine. 2013 Sep; 106(9):362-9.(Link to article – subscription may be required.)
  13. Robinson G, McCann K, Freeman P, Beasley R. The New Zealand national junior doctors' strike: implications for the provision of acute hospital medical services. Clinical medicine (London, England). 2008 Jun; 8(3):272-5.
  14. Resident doctors call 48-hour strike after talks fail. NZ Herald Monday 3rd October 2016
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