Looking after hospital doctors
The government probably has not noticed that morale amongst junior hospital doctors, even those who have jobs, is at an all time low. If it has noticed, it does not care.
As well as "awarding" the juniors a below inflation pay "rise" (sic) the government has introduced another stealth tax. Hospital accommodation used to be provided for resident doctors for free. Indeed, residency within the hospital when on call was compulsory. Gordon Brown has had a brilliant idea. From next year, residency within the hospital will not be compulsory. All the doctors can go home at the end of the day. Those who chose to stay in the hospital are now going to be charged £400 a month for the privilege. So, no more quick naps in your own little room when you get a lull during a long on call shift. And if you live in Coventry but have to do a six month job in Watford, which is too far too commute from your home, well tough. That's £400 a month additional expenditure, please make your cheque payable to Gordon Brown. And, yes, you do have to keep paying your mortgage in Coventry and, no, you cannot claim that £400 a month against tax because of duality of purpose. You might use that room for recreational purposes.
The government announced yesterday (07/04/08) that it would implement in full the recommendations of the DDRB (Doctors and Dentists Pay Review Body) – which means FHO1s (foundation house officer 1s) will not be compensated for losing the right to free accommodation. BMA council chair Hamish Meldrum said the treatment of junior doctors was an 'outrage' and 'completely unacceptable'. ‘The loss of free hospital accommodation means doctors graduating from medical school with massive debts will effectively be losing £400 a month – a 20 per cent pay cut. (BMA)Medical students from less privileged backgrounds who cannot rely on Daddy to pay their way through medical school are already saddled with a student loan debt of approaching £30,000. Now they face a 20% cut of a salary that was already way below that which they could obtain in other professions.
Very soon, we will have no doctors left. And then what do we do?
Labels: junior doctors, stealth tax
70 Comments:
Wrong target, Doc. This is the EU again, I'm afraid.
As you will know, as from next year, junior doctors fall under the Working Time Directive and are allowed to work no more than 48 hours a week.
Under the Directive, being "on call" or being in the building count as being "at work". As the government is going to have problems staffing hospitals anyway, they don't want to waste the precious doctor hours through sleeping...
DK
One is tempted to say that junior doctors now work shifts the same as any other healthcare professional and therefore have no need of a room. They can work a day shift and go home the same as everyone else, and if they work a night shift then they should damn well be awake like the rest of us. In the "good old days" it was acceptable for the on call doctor to go get some sleep during the night, as they'd been on all day and would be on all day the next day, these days it's simply not the case.
If they take a job too far from their home it's their own business to pay for it. Deaneries are not that big, and as FY1/FY2 jobs will all be within the same deanery (and probably the same hospital), it's not unreasonable to expect those holding the posts to have secured their own accomodation.
This isn't a pay cut, it's simply a perk of being on call being removed now that people are no longer doing that job!
John
Could I ask you to link to this for us please
http://www.generalmedicalcouncil.com
Also, you may like to cover this
Motion for RCPCH AGM – York University, April 2008
The College has grave concerns about the actions of the GMC relating to proceedings involving child protection work directly or indirectly. These actions include:
1. The GMC erased from the register one paediatrician acting as an expert witness in a case where two children had died and where the mother was tried for murder. The erasure was quashed by the High Court, but the GMC have not acknowledged that the erasure decision was wrong and have not satisfactorily explained why they consider it is not related to the child protection field. As a consequence, paediatricians have been deterred from acting as expert witnesses in cases involving child injury or death, many of which would be classified as possible child protection cases.
2. The GMC sanctioned a paediatrician for reporting concerns to the statutory authorities for child protection and, describing the doctors’ behaviour as "precipitate" and criticising his evidence-based opinion given in good faith, found him guilty of serious professional misconduct and suspended him from further child protection work. This contravenes the stated professional and public duty to report child protection concerns and the latest guidance issued by the GMC itself. As a consequence, paediatricians now feel less certain of the correct way to proceed and may therefore be less likely to report child protection concerns.
3. The GMC erased from the register a paediatrician who was exploring with a parent the mechanism of death of their child at the request of social services in the context of care proceedings. The parent alleged that the paediatrician had accused her of murder, despite evidence to the contrary from the senior social worker present who along with the paediatrician took notes throughout the interview. As a consequence, many paediatricians are now more reluctant to participate in child death reviews or indeed explore with parents possible mechanisms for sudden death.
4. The GMC have repeatedly relied on an expert witness known to have opposing views to the doctor being investigated and who had advised contrary to that doctor in the first of the above cases. This raises serious questions about the impartiality of this expert, particularly as the GMC did not use any other expert evidence. As a consequence, paediatricians feel that GMC hearings in the field of child protection have not had the benefit of truly impartial advice representing current mainstream professional practice.
5. The GMC have undertaken a number of investigations on paediatricians who have already been the subject of investigations by other bodies and have been exonerated. The GMC have not inquired about such investigations, or have failed to take account of these previous investigations. We consider that this represents double jeopardy and demonstrates an unfair and incomplete process. As a consequence, paediatricians have become less willing to be involved in child protection work, knowing it may result in multiple complaints and investigations.
6. GMC registered doctors working in other specialties, who were convicted of various crimes, including assaults on children and viewing child pornography (offences which would render them unemployable as paediatricians) have been reinstated to the register. As a consequence, paediatricians feel treated more harshly than other specialties by the GMC.
7. The GMC does not automatically inform the doctor when it decides not to proceed with a complaint. College members know that complaints in child protection are rising and are under extreme and often public stress when they receive such a complaint. As a consequence, paediatricians are poorly informed by the GMC of progress in their own personal case.
8. The GMC is unwilling to state whether it has received multiple complaints from the same person(s) acting as part of a campaign against factitious and induced illness, quoting data protection legislation. Paediatricians have been asking the GMC to develop a policy for dealing
with vexatious complaints and serial complainants. As a consequence, paediatricians feel the GMC is not taking their concerns on board.
For the above reasons, the College considers it has no confidence in the current GMC procedures for dealing with cases related to child protection. We call upon the GMC to review these procedures as a matter of urgency and involve in the review this College and other bodies such as the Department of Health, Department for Children, Schools and Families, Social Services Inspectorate and National Children’s Bureau, who have an understanding of the relevant legislation and practice, in order to support continued quality work by paediatricians in this field to the ultimate benefit of children and their families.
Thanks
RP
I can see your point studentnurse, but reality is that not all deaneries are small.
I will be working in at least three, if not four, different hospitals during foundation. But they are 145 miles apart on small, twisty roads. Google estimates 3 hrs 36 min drive, but that doesn't take into account the b*?%y caravan drivers that don't know what passing places are for in summer and the weather in winter.
I'm not complaining because it's the rotation I really wanted to do in an area of the country I want to spend time in. I am worried about the cost - I have to maintain the flat I'm living in now, then pay for (mostly poor) hospital accommodation for the next two years. I don't know what my pay will be. Basically I've got my fingers crossed that since it'll be partial shifts I'll hopefully get some sort of banding (extra pay over and above the basic wage), the hospital accommodation isn't too dear and that my car doesn't die before the end of foundation!
DK
No, for once YOU are wrong.
Interesting question. Who does the DK hate most, the EC or Gordon Brown.
Most hospital accommodation is very tatty. No one would use it through choice. If you are on a 3 year medical rotation, you might have to work in 6 hospitals 50 miles or more apart, making commuting virtually impossible. Yes, the hours are not as long, but they are still unsocial. And you need a bit of a private room. You often need a change of clothes. You need somewhere to have a shower. What do you do if a patient throws up all over you and you have nowhere to go and change?
It is just another slice of salami of doctor's morale
JOhn
"You often need a change of clothes. You need somewhere to have a shower. What do you do if a patient throws up all over you and you have nowhere to go and change?"
Whilst changing facilities in hospitals are poor, there is usually somewhere - in my hospital there are showers, changing rooms and a plentiful supply of scrubs in theatres, A&E and ICU. Other staff get thrown up upon, but they don't require their own private room to deal with it!
I'm a final year medical student and both myself and many of my collegues feel totally let down by the government and the GMC. I applied to medicine 6 years ago, before MTAS/MMC fiascos. Having free accomodation (be it grotty, nasty and cramped) was seen as a good way to help pay off debts gained as a student (mine's around £30,000, I don't have rich parents to help me out, and I only get a limited bursary unlike some student nurses). Paying £400 for a single room in shared accomodation is a rip off. Both myself and many of my collegues are rapidly coming to the conclusion that whilst the government has paid for our training, it really doesn't want us or value us as doctors.
Studentnurse -
What a pathetic post that was. Given that you are a "student" from your name, I suspect that you have absolutely no idea about this or what you are talking about.
- "One is tempted to say that junior doctors now work shifts the same as any other healthcare professional"
An SHO
Yes, most of us now work "shifts". A typical shift will have no set aside breaks - we are constantly on call. We will also being seeing all of the sickest patients, and doing jobs which can't wait and be put off. This is not like the rest of you. By the way, I regret the implication that we are "health care professionals" - we are doctors, not the sort of jumped-up under-qualified and dangerous individuals who describe themselves as an HCP to try to hide these deficiencies.
Despite the EWTD and due to how the New Deal works we often end up working much longer than anyone else. Doing 7x 13 hour night shifts in a row for example (91 hour week) is a common occurrence. As is working for 12-14 days without a day off.
"If they take a job too far from their home it's their own business to pay for it. Deaneries are not that big"
Due to the MTAS fiasco, my partner and myself were forced to move to somewhere that we were both randomly given jobs in the same deanery. We currently work over 100 miles apart, and my next move will be to work a >100 mile round trip every day. This is common. There are very large deaneries in many parts of the country outside the South East.
So it's not "my own business" that I live somewhere that is impracticable to commute due to the conditions of my employment.
"This isn't a pay cut, it's simply a perk of being on call being removed now that people are no longer doing that job!"
Junior's pay is becoming absolutely dire. In London now, a newly qualified nurse's salary (for 37.5 hours) is more than for a first year house officer (for 40 hours). Given the differing level of responsibility, training, student debt (no cushy grants/fees paid for us), no "key worker" status and having to move bloody jobs every 4 months, this is a joke. The loss of a benefit worth 20% of the salary is an outrage.
So, next time you are "tempted" to says something - do us all a favour and don't.
Student nurse,
Your very wrong.
Scotland is one deanery, east anglia is one deanery, my home deanery has a 3 hour commute from one end to the other in the morning.
As for "doing the same shifts as everyone else" we do 48 hours a week. this is clevely calculated so that in effect you can do about an extra 8-9 hours a week (where i am teaching is not considered work..even if it is cancelled).
As for "taking the job" we don't in many cases. You apply to a deanery, if you get it (some people i know are hundreds of miles from where they applied).
You then rank all the jobs and get allocated one.
So if you apply to the north west deanery (say your from Manchester or studied there or have a wife and kids there) you can be placed anywhere upt o and including the lake district (i use this example as i know some people who have this situation).
Fair?
I am not sure what the opting out clause is from next year but it seems there will be one so that cross cover will be possible.
If we had protected break times and didn't have to be in work early then it would be easier.
Lots of the grads from here are in unbanded jobs next year that used to carry good banding. So 21K (maybe 22K with the rise) for about 48-60 hours a week.
The number of applicants for medicine will decrease in the coming years. I think its sinking in that the old model is on the way out, its a shame as the doctors i know are great. Many want to do the job and love it, still many are not set up for a job bext year and trying to get out of the country.
It seems from here that the nurses are saying there has been a drop in the standard of applicants (and those accepted) to nursing school.
This is they way medicine is heading. I don't think anyone wants that, there is a lot of prejudice flying around on both sides but at the end of the day i believe the current high standards of doctors is something we all want to maintain.
Interesting, isn't it.
I have done several posts over the last few days supporting nurses, and their poor pay, and I don't recall a single comment from a doctor saying "they get what they deserve" or generally bitching about them.
This post is about hospital doctors. It is not about student nurses, or air hostesses, or shop assistants. It is about doctors.
Of course, these days, as soon as you say anything about doctors the full panoply of paranoid nursing fuckwittery moves in and starts saying that "well, WE don't get this, and WE don't get that..."
It is all completely irrelevant. We are not talking about what nurses deserve. We did that last week. But, you modern nurses are so paranoid, so anxious to prove that they are just as important, and clever and so on that they wade in and, once again, make complete tits of themselves.
John
Very good point Dr C. and student nurse your are quite frankly wrong on this one.
I am a med student and Mummy and Daddy don't pay for medical school so I will be graduating with £30K worth of debt.
Nursing is a hard job and should be paid better (at least actual nurses who do nursing). However, at the same time nurses are better paid than ever, Dr's get pay cuts and we had to pay for uni and take out loans not bursaries.
This is going to sound arrogant, but med students are a fairly clever bunch and could have done pretty much anything after school. I don't it would be accepted in any other field keeps shitting on their current and future staff like this.
Studentnurse is a total twat. He/she/it will fit right in among all the nurses with big ideas about being quasi-doctors who have no idea of their own limits. Doctors are often accused of arrogance but the reality is we are taught one thing above all, or we were on my course: "Know when you are out of your depth". The whole emphasis was on knowing when you need help and respecting the expertise of others. Sadly this essential self-awareness is lacking in a number of the jumped up shits now entering nursing and allied professions.
Jason.
I agree with most of the comments above (excluding student nurse). I would also point out that the renegotiated pension arrangements have increased employee contributions to 1.5% to essentially stay on the same "final salary" scheme thus further diminishing the 2.2% "payrise" in actual terms.
Mark
Sorry, should read "BY 1.5%"
Mark
Seriously guys, chill.
The simple fact is that whilst having a free room provided for you on site might be nice, you do not NEED it due to the work that you're doing now as compared to, say, 10 years ago.
There are plenty of places for you to get showered/changed if you need to. If you really feel the need (and have the time) to sleep on a night shift you can use the on-call room or a staffroom, and if you live a way away from the hospital then tough - so do plenty of other people. If you want to make your life easier by having a room on site which you don't need, then quite frankly you should expect to pay for it.
As for doctors vs nurses pay - newly qualified nurses bring in roughly 19k + unsocial hours payments, FY1s bring in 20k, which is slightly higher but not much different. Given the level of responsibility given to a staff nurse compared to that of an FY1 (particularly in their first placement), that sounds about right.
Student nurse is an ignorant b*tch with a chip on her shoulder!
Hey, nurso! Do you know the difference between a nun and a nurse?!
The nun has only one god!
Go adore!
I trust 'studentnurse' is now feeling like that woman in 'Airplane' with lots of people lining up to slap her
http://www.youtube.com/v/Y_GJkKMPHxw&hl=en">
However his/her comments do demonstrate their ignorance. For a start many deaneries are large - within mine there are hospitals which are 1.5 hours by country roads, and I'm in one of the smaller ones. Junior doctors rarely have any choice over which hospitals they rotate to, and frequently move every 4-6 months.
We are now at the point where the salary for a house officer is only marginally higher than a newly qualified nurse - by the time one accounts for the extra 2-3 years of university education (thats 2-3 years less earning, 2-3 years less pension contributions), lack of training bursary, poorer London weighting, lack of 'key worker' status etc... pay for junior doctors looks pretty poor. For the past 5-6 years the Government has used the 'benefit in kind' of free hospital accommodation for Juniors as a reason to keep pay down. Now it has been removed, suddenly is it no longer a benefit in kind according to the Government. I do not begrudge newly qualified nurses their recent and significant pay uplifts - they've been a long time coming. Sadly Junior Doctors have been treated like S**** once again, suffering year on year pay cuts whilst the costs of training rise and the ammount of support for key training courses falls and falls, GMC fees rise and we get clobbered by fees from the colleges and PMETB purely for the pleasure of training.
Other than that studentnurse is completely correct.
Anyone for tennis?
Student Nurse
FY1 5/6 years of uni (degree)
£30,000 debt (could be even higher now £3k tuition fees)
High academic demands thoughout training and at entry so could do pretty much anything
Continuous studying (in their own time) to keep up and progress)
Nurse 3 years of uni (diploma or degree)
Debt presumably none (bursary plus no tuition fees)
Much less academic requirements at entry
And with regards responsibility --> as a result of hospital at night and other crap doctor cover is shit at night responsibility is even higher.
Being a nurse is a very responsible job --> but when there is an emergency or problem who takes over????
Finally, I want more than £1,000 a year over a nurses salary for compensation for all the crap doctors have to take about how well off and easy they have it.
Like hell it's the same responsibility! How often is a newly qualified nurse responsible for being the first one to assess a critically ill patient and implement those crucial first interventions? How many prescriptions does a newly qualified nurse write and have to take responsibility for if they are arsed up? How many newly qualified nurses carry a crash bleep as part of the cardiac arrest team? How many newly qualified nurses are responsible for looking after the documentation (the part that actually gets looked at in court) and getting the results of investigations and interpreting them?
Doctors (even when they are FY1) take histories and order investigations, diagnose problems and initiate management.
Try to tell me that a newly qualified nurse has this level of responsibility.
Oh, and has previously been mentioned ad nauseam - doctors do not get fees paid, do not get grants and have an extra 2 years in training not only racking up debt, but also missing those 2 years of earnings.
The low salary of an FY1 doctor reflected that they had the benefit of free accommodation for a year. Now that benefit has been removed, effectively cutting the salary by 20%.
I'm not saying that nurses are overpaid, but I certainly think that a newly qualified doctor should earn more than a newly qualified nurse.
An SHO
PS - Expenses are also an issue. GMC fees (not optional) are £375 per annum. BMA (i.e. union) fees are ~£100. MPS fees are ~£50. We have to pay for any courses we might wish to go on. Oh, and we don't have a uniform, so we have to buy clothes for work. Add costs of textbooks, journal subscriptions, exam fees. It all adds up to a lot.
Guys, guys! You're talking to a wall! With 3 GCSEs at E grade and a B-Tec for A levels, she should thank her lucky stars she made it to wiping bed pans!
hallelujah,
You're talking to a wall!
I'd rather talk to a wall than a swellhead medical student, tbh.
'PS - Expenses are also an issue. GMC fees (not optional) are £375 per annum. BMA (i.e. union) fees are ~£100. MPS fees are ~£50. We have to pay for any courses we might wish to go on.'
While nurses get paid to study, get paid while medics are still at uni stuck in their books for a further 3 whole years! Wouldn't it have been a much easier life if I had taken nursing instead? All this money and plenty of time to get laid on a nightly basis too!
Lost nurse, go get lost you stupid, ignorant moron!
So eloquent.
DJ 'Under the Directive, being "on call" or being in the building count as being "at work". As the government is going to have problems staffing hospitals anyway, they don't want to waste the precious doctor hours through sleeping...'
... and charging 400 pounds a month will not count as 'at work' when these rooms are used to sleep while on call?
And again, the merits of going into banking or accountancy shine through
Alas.
Murk
This post has been removed by the author.
NO need for all the aggro, guys. Student nurse has made a mistake. But it's a mistake that is all too common, even amongst other healthcare workers. She thinks, fairly enough, that if I live in one end of the deanery and choose to then take a job 4 hours away, then I don't have an automatic right to free accomodation.
The reality is, studentnurse, that we just get moved, whether we like it or not. So, I could have been living and working in Dundee for my whole career. I coud have a house there, on which I'm paying a mortgage. Next thing I could find myself being put into a hospital in Glasgow.
Now, if any other employer did that, they would have to provide somewhere to stay. The NHS doesn't. They don't even tell ius how much we're going to get paid until we arrive at the job, so it's difficult to even plan for these things financially.
And that, ladies and gentlemen, is why I now work in Oz :)
Dr. Thunder
www.twoweeksonatrolley.blogspot.com
The lack of training posts, insulting pay and working conditions are a real disgrace that will lead loads of young doctors to either leave the profession or leave the country! And now with the rise of the dangerous tribe, the quacktitioners, watch as patients die en mass while complaints as well as litigation with sebsequent compensation hit the roof! Sad state of affairs.
Dr Crippen, where did you get this photo from?! Hospital accommodation does not look or come near that, you know! You wouldn't put up an animal in the hospital accommodation I saw, for the first time, last month up in The Midlands! It was unmodernised, gloomy, filthy and full of ex-ward junk. Even the beds were ex-ward, complete with polysteren cover! Truly awful. I hear this is the standard of accommodation everywhere not just in the Midlands. Not worth ONE pound, let alone 400 pounds per month! This is a rip off by any standard! On that level, the Samaritans should charge 1000 pounds 'per night' for their accommodation for the homeless! Shameful, to say the least.
angrygasman gets it spot on.
The notion that the responsibilities of a F1HO and a new nurse are even remotely the same is ridiculous and studentnurse's remark that the tiny pay differential is about right beggars belief. I wish nurses were paid better (although I also wish some of them would take more pride in nursing rather than trying to do medicine-by-protocol and neglecting CARE OF PATIENTS) but that doesn't make any difference to the fact that we have just been shafted with the below-inflation rise and loss of accommodation. I'm not some arrogant doctor type, I've worked my arse off from a humble background to get here and I am in the NHS because I think it's the greatest achievement of the civilised world. Yes I could go away and earn shedloads in the City but I DON'T WANT TO and it is absurd to suggest that because I have chosen to work in medicine that I should just put and shut up with being treated like crap for that reason. Keep saying that and you'll get the doctors you deserve - incompetent, underskilled and utterly careless, because the conscientious folks who saw it as a vocation will run for the hills.
Jason Holdcroft.
My Gawd
Not for the first time on NHS Blog Doc, I find myself thanking my lucky stars I don't work in the NHS. And that I've got BUPA.
Clearly in any workplace, different groups feel a certain antipathy towards their "colleagues". That's natural human warmth, and only to be expected.
But in my experience the real workplace hostility generally relates to "colleagues" who are the other side of some Chinese Wall (eg City fund managers hate and despise their firm's investment bankers, because they get paid much more and generally end up in charge).
In the NHS, the hatred - no, I don't think that's too strong - is directed at colleagues who have to work side by side if the organisation is to have any chance of delivering properly.
The sooner the NHS is broken up into competing units, the sooner minds will get concentrated.
But on the Doc's original point- very interesting. This is but one example of where the public sector is imposing charges for services that used to be "free"- see- http://burningourmoney.blogspot.com/2008/04/charging-creep.html
Wat
I agree
This post was about another slice of salami of junior docs morale. It was not about nurses, nor was it critical of nurses and yet, as soon as doctors say that perhaps they have been badly done by, a certain sort of nurse wades in with a tirade of jealous indignation. And then the battle commences.
The reason for this is simple. There has always been a little friction on the interface between junior doctors and nurses, most classically seen on Labour Wards with the midwifes. You see it in all works of live when highly intelligent graduates move into the work place for the first time to work with lesser qualifed staff who are long on experience. The first class honours fast track banker may spend two days on the counter of a bank and have to be shown by the bank clerks how to do paying in. Three years later, he will be managing the branch.
The junior doctors need to acquire all sorts of practical skills that nurses do in their sleep.
It was always so.
But what has happened now is that the nursing hierarchy has declared that nurses are too clever to do nursing and has "upskilled" (yuk) then into quasi-medical roles as doctor-lite. They are in no mans land. They are no longer nurses, and the real nurses hate them, and they are not doctors, and so are paraonoid about their status when they interact with real doctors.
You are right. This is one of the many thinks that is destroying British healthcare. The relationship between junior doctors and nurse quacktitioners is doomed to failure ab initio. Trouble is, for the consultants, it is easier to use the quacktitioners. There are not enough doctors around any more to do all the jobs juniors used to do, and so they have to rely on the quacktitioners. And the quacktitioners stay in post for 10 years and perform in a predictable fashion. So much easier to use an automatic washing machine, isn't. Trouble is, it can't think.
Keep paying the BUPA
John
The rooms that are being taken away/charged for are NOT on call rooms.
They are live in accommodation.
The on call rooms are long gone in most hospitals.
This is where the junior house officers (now called FY1s) live. This crappy substandard accommodation has been used for years to justify the poor rate of FY1 basic pay and is now being taken away or charged for with no compensation.
This is not about whether or not the accommodation is needed. It is about an employer who is essentially unilaterally removing a job expense that they have always covered with no recompense. And as they are a monopoly employer (junior house officers, in fact all junior doctors up to consultant level can ONLY be employed by the NHS if they want to continue training) there is no choice involved for the employee.
A similar situation might be someone whose job sends them away to business meetings regularly and usually the company pays for the flights and hotel. If suddenly the employer stopped paying for that, and the cost amounted to 20% of your pay most people would object.
That's the only issue here guys, quit with the infighting and obstreperousness.
I agree with Rachel
This post was only about a small but essential benefit in kind for junior doctors, and a mean, penny pinching decision by the government.
It has now become a brawl.
John
Interestingly, my first impression on seeing the picture of the oncall room was that it looked better than any of the rooms I have ever had (in public hospitals).
just noticed - 400 pounds per month! I paid 465 for a room at the very top of Hampstead village with a view to Greenwich. Jeez.
"for the consultants, it is easier to use the quacktitioners. There are not enough doctors around any more to do all the jobs juniors used to do, and so they have to rely on the quacktitioners. And the quacktitioners stay in post for 10 years and perform in a predictable fashion. So much easier to use an automatic washing machine, isn't. "
The consultants use the quacktitioners, not only because there are not enough juniors but because they work with them, as you say, all the time, unlike the juniors who spend only 4 months on the rotation. With nurse bullying doctor at an all time high these days, who would you side with if you were a consultant?
Wat Tyler: The sooner the NHS is broken up into 'competing units', the sooner minds will get concentrated.
------
You mean 'competing units' as in privatisation?
If so, I think your suggestion would make matters much worse but maybe you can you please explain why you believe this?
For the last 3 years it really has been one hit after another for junior doctors.
Fact is there are now very few who would advise anyone to go into medicine. Most even say if they had their time over again they would have chosen a different career.
A rather sad situation isn't it.
It can only have one outcome -a decreasing quality of doctors.
Because where once there were more than enough inteeligent go getters to fill every med student place, they will increasingly be wise to the failings of their aspired career and chose different fields.
So who will become doctors instead? The dross, the people who were never motivated or intelligent enough to do well at school or uni. And yes, that is a form of snobbery sure, but medicine is a really active learning process continuously. You have to keep up to date with advances and changes in practice, and do exams until you are well into your thirties.
"loss of hospital accommodation amounts to a 20% pay cut'
If you take this into account, a graduate nurse on 19k actually earns more than a graduate doctor on 20k who spent 6 years reading medicine, in comparrison to the three years in nursing school (Not forgetting the hours, costs, loans and depth of study.) and, while a doctor is still at uni, nurse will graduate to earn for 3 years. By the time a doctor graduates to earn 20k minus cost of accommodation, memberships, fees, courses, exams, etc, nurse would probably be earning near enough to 30k! ... and, with grants and paid tuition fees while at nursing school and no loans to pay back! After all this, doctors are also not considered 'key workers' but nurses are! That's medicine for you!
But why on earth are you all comparing the pay of nurses and doctors? What do they have to do with each other? As a cardiac anaesthetist I know exactly how difficult, and how much training my position requires (a lot, if you're wondering). If I had to benchmark my salary against somebody else's it would be that of a senior executive or a partner in a law firm or accountancy practice. Not even the most senior nurse imaginable. Or I could compare my work to that of Oprah Winfrey and complain I earn so much less than her. But I don't do that; I set my fees based on the intrinsic value of my work. No-ones interested in listening to people complaining about how much money they make. As long as there is a monopoly employer and no alternative, they'll pay you whatever they like. At least in a federal system there would be the option of moving to a different state/county.
The moral is, if you like socialised medicine, get used to working for peanuts, especially when the government realises it is broke.
Oh and :
"I've worked my arse off from a humble background to get here and I am in the NHS because I think it's the greatest achievement of the civilised world"
hehe
This IS the NHS, have you not noticed?
Ignore the silly nurses spouting shite on this website. Their views are irrelevant, as they are in real life - hence their anger.
The real enemy is the government and the quislings within our own ranks. You can fight, lie back and take it, or leave. I've left and Australia is mighty fine.
Ignorant, silly nurse here I'm afraid.
The BMJ says NHS GPs and consultants are the highest paid doctors in Europe.
http://www.bmj.com/cgi/eletters/333/7558/98-b
Average GP earnings in 2005/6 was £95,350 pa, while consultants did slightly better averaging £109.974.
http://www.civitas.org.uk/nhs/download/NHS_staff.pdf.
A year later the median average income (for men) was £25,896 pa.
http://www.statistics.gov.uk/cci/nugget.asp?id=285
Incidentally the average pay for nurses in 2006 was £21,000.
http://news.bbc.co.uk/1/hi/health/473145.stm
There is certainly more money in the NHS pot than ever before but given the well documented furore over pay (to medics) maybe this is a backlash ?
I do agree, by the way, that it is inhumane not to provide basic ameanities (such as a crash pad) whenever circumstances dictate.
A&ECN
Problem is many doctors never make it to consultant or GP principle.
Thus the loss of a small but important benifit early on just makes things that much harder.
COI: i earn just enough to pay my loans and rent plus council tax on a juniors wage.
Another important aspect people seem to be missing is that not all juniors spend their whole FY years in one hospital, therefore accommodation is an even more important issue.
If you end up in the Highlands for foundation chances are you will have to work in Inverness, Fort William and Wick (Inverness to Wick 104 miles on a horrible A road and Inverness to Fort William 65 miles on one of the most dangerous roads in Scotland)
so where are you supposed to live for each of these 4 month placements? 4 month leases do not come cheap if at all.
Removal of free hospital accommodation looks like an easy way to make the trusts some cash.
A&E CN,
Unfortunately MMC will prevent a large proportion of juniors from ever becoming GPs or consultants. From the rather hard nosed way HMG has negotiated the staff grade contract they are well aware of this.
For years the government has awarded low/no-pay rises to junior doctors. The main reasons given for this included 'you get free accommodation so you don't need the money' and 'you'll have a secure future as a consultant/GP so we can pay you less now'. Both of these are untrue now, but still no payrise in sight.
Backlash? I would be disappointed if a nurse couldn't tell the difference between a junior and senior doctor...or take out their frustrations at the latter onto the former...
Thanks antipodean doc (always enjoy your observations) - yes, there are frustrations at certain medical attitudes, but as I mention above I fully accept that such draconian measures are inhumane.
Those responsible for the MMC debacle need to take a long hard look at themselves - fat chance, eh ?
No, I'm with the junior doctors in so far as their working conditions are being made increasingly difficult - but I will not keep my big mouth shut when certain attitudes are exhibited by some of the (presumably medical) posters: see anonymous at 6:12, 13th April as just one example.
The stats I quote are factually correct AFAIK although it is is possible to construe different motives as to why the junior docs are getting shafted (again) - but if you care to look you will find that life for junior nurses in the NHS is hardly any better these days (either in terms of job prospects or working conditions on the wards).
Jam tomorrow is not really an excuse for underpaying hard working, highly trained and increasingly indebted professionals.
As I said above, I do not begrudge newly qualified nurses their recent and significant improvements in pay. Equally I do not think that saying 'look at AfC band 8d/9' is an argument for keeping down junior nurse pay.
Even if we leave aside inflation -which hits everyone -the costs of being a doctor, and especially a junior doctor, have risen inexorably over the past 10 years. GMC fees, PMETB fees, exam fees, college subscriptions, defence union membership up, up, up. Budgets for courses down and proportion of courses one is expected to undertake -up again. If we then add in 5-6 years of student debt, no bursary for training etc.... and add in the effective paycut of £4800 via this latest wheeze then 'Jam tomorrow' looks even less appealing. That the prospects of ever getting to such a tomorrow are also receeding fast (see Darzi doctors, sub-consultants etc..).
AE charge nurse, this thread is not about nurses! As Dr C said, no doctor budged in or begrudged nurses their pay rises when he recently discussed same. To do so when doctors are the topic is beyond vindictive IMO
Well, perhaps the jam could be spread a little more evenly, angrygasman ?
And at the risk of upsetting anonymous (at 2:27) some might take issue with your definition of 'significant improvements in pay' for newly qualified nurses.
At November 2007 rates the Band 5 scale commenced at £19,683 pa, rising to a giddy £25,424 after a mere 9 years - a figure which still lags behind the national average wage (see above)despite nearly 10yrs on the shop floor.
http://www.nhscareers.nhs.uk/details/Default.aspx?id=766
Perhaps the recent NHS feast is turning into a bit of a famine - as you know many are already questioning value for money given that nearly 100 billion is now being pumped in the NHS each year.
At the risk of repeating myself I consider myself to be on the same side as the junior docs but we must ALL accept that we live in times of increasing financial uncertainty, and this translates into the vindictive sort of measures highlighted in the original post.
If the 'jam' is to be evenly spread, junior docs should earn at least twice what a nurse of the same age earns, given that docs have much more responsibility and spend twice as much at uni. Not forgeting their life long record of achievement either.
As has often been pointed out here, "life-long record of achievement" and "years at Univ" are a sticky one for justifying big wages. We always hear the same comparison to lawyers and bankers. But to take a different example, it takes 6-7 yrs to get a PhD in science, following which you can get a postdoc research job paying in the low 20 Ks (if you are lucky) Followed, if you are VERY lucky, and after six-eight more yrs experience (which one might "analogize" to medical training), by a non-tenured junior academic job, aged mid 30s, on low-to mid 30 K.
The difficulty is this: if you push "lifelong achievement and time spent training" as a reason for doctors' pay, then you can find comparable people who (at least historically) earn less. If you push "working conditions" (rotten hours, work under continuous pressure) then you can find other folk in the NHS who do the same shifts, also report being under pressure and (at least historically) earn less. So one is left with "level of responsibility" (mostly). The question is, what is that now seen to be worth?
In the past a lot of this discussion never got "front and centre-d" because consultants were well-paid, House Officers got free accomodation, and OOH payments for 1 in 5 rotas meant that SHOs and registrars did pretty well in take-home terms. And (perhaps more importantly) nobody but doctors really knew what wages doctors actually took home.
Of course ETWD and shifts killed the 1 in 5 payments, so it became much easier to see what junior medics actually earned...
And...
There is also another more cynical view of doctors' pay, which is "what the market will bear". The expansion of the medical schools means a glut of junior doctors. As they are now not a scarce commodity, a downward pressure on wages (or at least on wage rises) is hardly a surprise.
Having said all that, to remove a long-standing benefit like free accommodation unilaterally is breathtakingly dishonest, and it is hard to read it as other than a calculated slap in the face. It would worry me as a member of the public who might have to be treated by a now-utterly fed up and disillusioned junior doctor.
I would much rather the accommodation stayed free and that the system somehow invented a way for the HOs to gain extra experience or even do more actual hours. From what I hear a lot of them would probably be pleased.
Is this all the fault of EWTD? That reminds me of an old EU joke, which one hears frequently in France and Germany.
"Why do the British always have such problems with EU laws?"
"Oh, a misunderstanding... you see, unlike all other EU countries, the British seem to feel that once these laws exist then they have to actually implement and enforce them"
* Cue general laughter *
Scientist married to doctor: 'it takes 6-7 yrs to get a PhD in 'science, following which you can get a postdoc research job paying in the low 20 Ks (if you are lucky) Followed, if you are VERY lucky, and after six-eight more yrs experience (which one might "analogize" to medical training), by a non-tenured junior academic job, aged mid 30s, on low-to mid 30 K.'
But this is not fair too! I once stumbled upon some lecturer jobs on the cambridge uni website and was appaled at the wages on offer to people with exceptional qualifications! Maybe this is also why home grown talent are no longer interested in PhDs in science! Two wrongs do not make a right of course.
http://www.independent.co.uk/student/postgraduate/postgraduate-study/how-can-the-hard-sciences-attract-more-phd-students-806720.html
And, the EWTD's will impact heavily of the duration and quality of training which is more important than the financial loss for the juniors, although this futher reduction in earnings will hurt them badly and may send messages to youngsters considering medicine to reconsider too.
I spent three years training to be an RGN, 18 months converting to RMN, a further 18 months to get my degree and another 18 months to get my postgrad cert in education. I make that 7.5 years studying. I earn just over 30k a year as a senior lecturer. The "time spent in uni" argument is, as 'scientist married to doctor says', a sticky one for justifying big wages.
First of all, I think that academics in the UK are scandelously underpaid - however no one asks them to get up in the middle of the night (or infact during the day, weekends etc..) to make decisions about life or death. I know it sounds a bit dramatic, but that is the reality of the decisions made by even pretty junior doctors on a daily basis. Quite why people should be expected to make such responsibility without being rewarded for it is beyond me - certainly the reason why many NPs are paid at band 8 AfC (basic salary above many junior doctors) is due to the level of responsability.
The point about newly qualified nurses pay was not about their pay progression, but rather the significant increases in starting point (it was about £15,000 only a few years ago) to the point where the differential between them and newly qualified nurses is very narrow despite significant differences in level of education and level of responsibility.
Length of time at university is not the sole measure by which people should be paid, however it undoubtedly accumulates debt -especially if one is not on an NHS Bursary and has to pay tuition fees.
'market forces' is meaningless when one works for a monopoly employer, and the lag time between juniors being kicked in the Baws and this filtering through to medical school applications (which fell for the first time in years this year) means that it is a sluggish feedback mechanism at best.
The sooner the NHS is broken up into competing units, the sooner minds will get concentrated.
Could somebody please outline the role of the much-vaunted "choice and competition" in the following (I'll take three, for starters) areas:
* Paediatric Intensive Care
* Acute Mental Health
* Emergency Surgery/Trauma
Concrete answers, please - not just vague platitudes about "letting the market decide..." Also, a brief explanation of how going into hypovolaemic shock is just like buying fruit n' veg.
I have enornmous sympathy for junior docs (not least as one of my sisters is among their number, and my dad is an old dog of a consultant, after a lifetime at the NHS coalface). Verily, you have been screwed by MTAS, MMC etc. That said, I dinnae care much for boorish medical students.
Well it is trivial to explain how competition helps. In Australia we have half a dozen odd (in same cases very odd) states and territories. Each has its own health system. If Queensland decided that it would pay junior doctors less than the local cleaners, the doctors would apply to jobs in New South Wales instead (maybe only a 2 hour drive away) and move there. Once Queensland noticed that its best and brightest were all going into cleaning or leaving the state, it would face intolerable pressure to raise doctors' pay to ensure school-leavers saw medicine as a viable career.
Actually I am finding the whole tenor of this discussion very frustrating. The anguished comparisons of incomes in different underpaid professions is self-defeating (especially when you are choosing the lowest-paid occupations that intelligent people enter). So is the bickering as to whether doctors "deserve" on-call rooms. The fact is, they were provided before and represented 20% of a total pay package. You need to recognise that in any job, it is unacceptable for the employer to unilaterally reduce a compensation package like that. In the private sector the result would generally be a massive loss of workers. Obviously in the NHS it won't happen to the same extent (and even here in Australia there aren't jobs for the entire NHS cohort). What is the solution? I can't say. But a combination of political pressure and shortages of doctors due to resignations would seem the only way.
And re competition and standards, I would love to build, say, a private neonatal hospital with a private NICU, train or import the staff and charge private insurance companies or patients or both and run an efficient unit that could compete with the local public hospital (compete = get the business because patients prefer to use my hospital). Aside from any financial considerations, I think this would be immensely rewarding. Why is this so difficult to grasp?
As for fruit and veg, well, good evening Straw Man, thanks for the visit. But I think patients should be able to choose not to go to some of the revolting hospitals I was forced to work at. People aren't made to eat rotten apples just because they live in this or that town. Why should they be forced to visit a rotten hospital?
Why should they be forced to visit a rotten hospital?
No argument from me there. But that doesn't excuse some of the crass rhetoric being thrown about (esp NuLab's pseudo-market tosh - i.e. PBR, bloody "choose and book" etc), or the simple view that dealing with polytrauma is "just like" going down the shops. Supermarkets work because informed (and often mis-informed) consumers are able to make repeated decisions (i.e. switch). In the heady daydream of a management consultant, the same might be true of bowel obstructions, triple-As and acute MIs, I suppose.
Why is this so difficult to grasp?
Well, to some extent, I think you conflate funding and delivery. In my view, charitable/N-F-Pft instutitions would play a sizable role in any post-NHS system - however smooth the market in, say, elective surgery (which ain't necessarily that smooth, judging by the number of re-admissions one sees). Whatever, it won't be the beloved Market that takes all the slack. Admirable as hospital planning can be, I still don't buy the vision of competing NICUs - set out like so many market stalls...
In the heady daydream of a management consultant, the same might be true of bowel obstructions, triple-As and acute MIs, I suppose
It is no dream. Behold, early on a summer morning, in the distant Southern Land of Australia, my own grandmother developed rapid AF and chest pain. The ambulance arrived - I chose the hospital, yea verily, with my own brain.
Admirable as hospital planning can be, I still don't buy the vision of competing NICUs - set out like so many market stalls...
See above. In my own hometown, public and private ICUs (so far, only level 2 neonatal units) set out, just as you say, like traders' tables at the Temple.
Behold...the distant Southern Land of Australia...
Much of my mother's (Irish) family followed that dream, back in the nineteenth century. The way things are going, most NHS nurses seem to be following... :)
I agree with Angry Gasman - I think the key things are "level of responsibility" and "work pressures and working conditions". When I compare my job (bioscience academic) and my wife's job (hospital doctor) those are the things that really make the difference.
I was only commenting about the other stuff because one routinely gets at least some doctors saying that the years in training, or the "top quality people"/ educational attainment required, are the reasons for the historically quite high medical pay rates. This is one of the lines that gets the nurses maddest, and causes the discussion to generate into shouting, and it would be better if it could be put to rest for good. It is surely what doctors DO that counts, not whether you have to be "the country's elite 0.1%" to become one.
I mentioned "market forces" because, despite everything, there are far more applicants than jobs in MTAS, and non-EU doctors still want to apply for jobs in the UK - so total supply exceeds demand. One of the reasons, most academics grudgingly accept, that we are so poorly paid is that Univs don't HAVE to pay more: "We advertise the job at this rate, we get X applicants, ergo there is no recruitment crisis and no need to raise pay. Full stop." The subtler arguments are about quality, but that is notoriously hard to assess.
But as I said before, to remove unilaterally a well-established part of the current "compensation package" for FY1s is really disgraceful. No argument there. I would call it "exploitation", myself.
I suspect what is really going on is that hospitals simply don't want to run any on-site accommodation, as it is a pain to manage and non-revenue generating. Personally I wouldn't be surprised to see people like Opal putting up new managed accommodation blocks for the FY1s - or taking over the current ones - and charging a bit less that £ 400 a month for much superior accommodation. Which will make the FY1 year a lot more like being a "year 6 student", though clearly won't help with the debt reduction.
'years in training, or the "top quality people"/ educational attainment required, are the reasons for the historically quite high medical pay rates. This is one of the lines that gets the nurses maddest, and causes the discussion to generate into shouting, and it would be better if it could be put to rest for good. It is surely what doctors DO that counts, not whether you have to be "the country's elite 0.1%" to become one. '
Allow me to differ here Scientist married to a doctor, I believe both ability as well as level of responsibility go hand in hand and can not be seperated. And, yes, doctors are of the top 1% and are therefore academically elite. Once you let go of this fact, then you allow standards to drop and this will harm patients. You need the best people if you want to entrust them with your life regardless of whether this will anger others, which is irrelevent when we are talking about life and livelihood. Based on this notion, pay should also reflect ability as well as level of responsibility.
I watched something very similar to this happening in the hospital where I did my house jobs. They closed the nurses accommodation at Xmas, and moved management offices in (it was the nicest old victorian building). The nurses lost their cheap accomodation. Within a month, the young UK trained career nurses left, no longer having the carrot of cheap accommodation. Overnight the hospital became staffed by bank and agency staff.
If you make jobs unattractive, relative to what else people can do, they will do something else.
At the moment, good UK doctors are experiencing what builders and plumbers experience: they can be undercut by capable immigrants, or less able people from the UK, who are willing to accept poorer working conditions.
Ultimately this breeds an atmosphere of selfishness, and looking out for oneself. I had never heard my colleagues (10 yrs out of medical school) talk about private work with approval until the last year or two. Similarly it was unheard of for people to consider leaving the country or the job.
Medicine is changing.
.... to the worse!
Interesting article , this article make some interesting points .
Hospital web
So the government has replied to our petition (http://www.pm.gov.uk/output/Page15530.asp). Current verdict: tough shit.
I hope the public cotton on to the governments plan and support our upcoming protests. The anxiety caused by all this uncertainty in my coursemates and I is real. As if we don't have enough to deal with. The government knows we are unlikely to mount much of a fight as it is already vitally important for us to spend time studying. Our nights out are few and far between - that's why they've got a reputation for being raucous. No multiple quiet evenings down the pub for us or dates with an imperfect boyfriend or girlfriend. No time!
Figure out that you've got the attributes to be a doctor and think you'd like to use your skills to help people rather than just for capital gain? Bad luck. You'll be penalised for that idealism.
As a bit of background:
I'm a third year 23yr old medical student who intercalated last year. My debt is going up by £25 a month even now and I'll graduate owing £33k. And that's with earning nearly £11 an hour as a medical secretary in the summers and having to compete against my peers (in a county with deplorable public transport) without a car. In theory I'd love to encourage those from backgrounds like mine to consider a career in medicine. (Education is the key to the empowerment and improvement of a whole family's position and quality of life.) But I don't think it would be fair. People like me stand even less chance anyway (- my old school can't even interview people now). Fair enough - maybe I should have given the local comp better exam results. BUT I wouldn't have met my lifelong friends and their supportive parents and got into medicine. Diversity will defintely go downhill in medicine. Point 2: yes medical students and junior doctors are demoralised. Something has got to break. Hopefully it will be the government's shortsightedness and not the junior doctor's decreasing suicide rate.
http://student.bmj.com/issues/06/04/education/138.php
Anyway, I'll end on a light note. Because we med students are obviously meant to be superhuman. Good post and comments - at least I'm properly informed of what I'm up against. Problem is, I quite like england and my family and think oz is full of lager-swilling louts.
Previous informative post:
NO need for all the aggro, guys. Student nurse has made a mistake. But it's a mistake that is all too common, even amongst other healthcare workers. She thinks, fairly enough, that if I live in one end of the deanery and choose to then take a job 4 hours away, then I don't have an automatic right to free accomodation.
The reality is, studentnurse, that we just get moved, whether we like it or not. So, I could have been living and working in Dundee for my whole career. I coud have a house there, on which I'm paying a mortgage. Next thing I could find myself being put into a hospital in Glasgow.
Now, if any other employer did that, they would have to provide somewhere to stay. The NHS doesn't. They don't even tell ius how much we're going to get paid until we arrive at the job, so it's difficult to even plan for these things financially.
And that, ladies and gentlemen, is why I now work in Oz :)
This is quite a belated post but hopefully some subscribers will be notified and choose to read it. I am a 3rd year medical student in Australia. Traditionally, the brightest students entered medicine straight out of school. They accessed a living allowance and delayed education costs (Higher Education costs scheme-HECS) until they earnt a certain income. After 5/6 years of well delivered curriculum, dedicated teaching and hospital space and opportunity-you would graduate and move onto your internship. You would then have the pick of jobs all around the country, and internationaly, as a well trained and well supported junior. you would do this for a few years until you dropped out and opted for the GP lifestyle (which was very rewarding for community minded doctors) or went back to the hospitals to pursue specialty training; at great contribution to the government. You would then enter private/public split practice (which made the wealthier pay and the poor not). By no means was this a perfect system but there was a clear demarkation between the role of doctor and the quasi-professionals who envy the power and pride that doctors have in themselves (for good reasons) and try and rip it off by infesting the system as HCP and so forth.
Sadly, Australia is heading the same way as the UK. I am in a course at a University that is the best in the country. However my curriculum is designed by 'learning consultant's with 5 x '50 ' minute lecures per week, 28 weeks a year for 2.5 years. I learn sententious concepts with random chunks of irrelevent science because the university found it cheaper to leave it to the underpaid academics to teach the course. I know next to nohting about anatomy-but can tell you all 12 enzymes of the glycolysis pathway. And yet, nobody looks on and thinks about this; nobody stops it.
I am forced to do a research year in the middle of my degree-in nothing at all beneficial to medicine. It is designed to 'learn research methods'. I calculated that it brings 4 million dollars to the faculty for more research for our dean. Who is not a medical doctor might I add.
This year, 1200 doctors graduated nationwide. When i leave the system, after a cramped education with too many itnernationals to pay the fees, there will be 3600.
I don't need to explain what that will do to my job prospects. We will have a hospital system crawling with over ambitious undertrained alied health amateurs and overpopulated by bright doctors who were ripped off a chance at having a real medical degree. We will be forced to work lower hours, for pitiful pay and the progression that those before me had and the opportunities they enjoyed will not exist.
This is not why i went on to get 99.70/99.95 in my final year. This is not why i gave up my social life. I didn't do this to be lumped as a HCP whilst my government leave me to rot and not access trainig progrmas. Already, with our doctor shortage, good doctors are in their late 20's and are still living off their parents and spending evenings studying. No way, no thankyou..
I am leavin the system and am planning to join the navy as a cadet-for the money, for a way out. Perhaps i will be sequestered from the failing and cumbling hospital system here as the navy opens new doors for me and protets my income.
My advice for UK doctors-get to Australia as quickly as possible and take the lucrative rural jobs-you have a 10 year head start before my lot come through and you can easily make 400$K a year.
GOod luck-don't waste your talent. this is no way to reward true intelelct
"Very soon, we will have no doctors left. And then what do we do?"
You say that, but at the moment it seems there are too many juniors for the amount of places available.
In theory, there should be a mass of them before there are none...
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