It's been one month since the Department of Health announced their official intentions to recommend NHS employers impose a new contract on junior doctors. Television, radio and social media have been awash with strong feelings, stern warnings and cries of disbelief. Last week the department of Heath shared this letter from Mr Hunt, Health Secretary to Dr Johann Malawana, Chair of the BMA junior doctor's committee.Understandably, Junior doctors will have waited with baited breath for a targeted response from Mr Hunt, but is it all we have hoped for? What does it really say?
Mr Hunt begins by stressing that his priorities for a new contract are patient safety and fairness for juniors. His stated belief that junior doctors are vital to the NHS and deserving of both equity and fairness is welcome. It is also entirely justified and of course every allied health professional within the NHS is worth of such praise. I have stated before, my belief that the Doctor's & Dentist's Review Body (DDRB) report is in parts fundamentally insulting to medicine as a profession and the decision to stage an imposition added exponentially to this injury. While I sincerely hope that this is not just a resort to flattery, accepting these comments at face value is now sadly difficult. Trust is not just like riding a bike, as they say - I can't simply just hop back on. As Ronald Reagan liked to succinctly put it "trust, but verify".
The first assurance is that the new contract is not a cost-cutting exercise. Mr Hunt affirms he is not seeking to save any money from the junior doctor's pay bill. The 'normal working window' for a junior doctors is 7am to 7pm Monday to Friday. The new contract specifically sets out to increase the plain time of doctors to include up to 10pm Monday to Friday and all of Saturday until 10pm. Mr Hunt apparently has plans for a better supported 'seven day NHS'. To do this he is not increasing the number of doctors available to work around the clock but forcing those already in the NHS to spread themselves more thinly. Junior doctors are already working as hard as they can for the NHS. The redistribution of shifts that will inevitably occur as a result of the increase in plain time is categorically a plan to deliver their elected health manifesto on the cheap. Junior doctors do not have any issue working unsocial hours. We do however refuse to accept reclassification of our time in this way. Saturday and evenings after 7pm are simply not normal social hours.
Mr Hunt goes on to mention the seemingly reasonable plan of tying annual increments to 'taking on more responsibility'. The fact remains that the 'training grades' of doctors were not designed to dictate pay. They do not reliably correlate with responsibility or experience and the NHS employers have no real evidence based and reproducible way to make this a reality. Perhaps if the DDRB panel had any clinical experience training as doctors, they would be aware of the difficulties with this. The obvious benefit of this idea, from the point of view of the department of health however is that the significant amount of trainees that work less than full time will now take longer to reach the next pay bracket. They will miss out on pay-rises they were entitled to on the current contract and the effect for that individual doctor is that over time, NHS employers would have saved significant amounts on the cost of that doctor's employment. The plans are specifically de-incentivising less than full time training in a time when the NHS is already struggling to fill training posts and haemorrhaging money to expensive locum doctors.
While on the topic of undersubscribed specialities, I think it is abundantly clear that robbing Peter to pay Paul is not at all the answer to filling those training posts. The fact that junior doctors do not chose their speciality solely based on financial incentive however is a point that seems to have been overlooked. If the Department of Health feel that an extra payment is the best way to attract appropriately motivated doctors into accident and emergency medicine, they are sorely mistaken.
As I suspected, Mr Hunt does indeed already know junior doctors work seven days a week and he gives welcome assurance that the new contract will not mean doctors are expected to work, on average more than 48 hours a week. So what is the issue you ask? The very next paragraph epitomises what is the matter with this contract: "I recognise that there will be exceptional circumstances in which an individual doctor should be compensated for hours worked outside the work schedule" Again, let me say that any person with significant and current knowledge of working lives of junior doctors would know that "working outside your work schedule" is the opposite of exceptional, it is very firmly the norm. This is of course not because as NHS employers suggested, there is 'incentive to work slower' or as one particular opinion piece in The Times suggested there is "perverse incentive to work outside contracted hours". The reason junior doctors are systematically forced to work outside their contracted hours is because they are trying to keep their patients safe. That 'perverse incentive' is a patient. Attempting to fund a service where doctors are now expected to spread themselves more thinly is not a step forward for patient safety. Mr Hunt wants more doctors at the weekend, I say wonderful! But then there needs to be more doctors.
The letter continues to suggest that in these 'exceptional circumstances' where remuneration of overtime is due, it needs to be 'authorised by an appropriate person'. Which begs the very serious question of who is indeed authorised to tell me that it is ok if I have to stay an hour to treat my patient about to tip off into septic shock? I presume I am employed by the NHS by virtue of my clinical competence? Am I expected to work in a system where my professional judgment with respect to patient care requires routine 'authorisation' from management? Is my word not good enough? Junior doctors stay late and come in early because the current demands within the NHS gives them no choice. Let me re-iterate, it is not 'exceptional', it is the norm. This fact is common knowledge and any plans which fail to recognise that are toxic. I would venture what is actually exceptional is a junior doctor actually claiming money for that time and so while a junior doctor is very unlikely to take their good-will work away from the patient on front of them, the department of health continue to create a situation where defending the principle of 'pay for work done' has become very important.
Interestingly, both of the plans above mandate a close working responsibility between employer and employee. As a junior doctor who has had 12 jobs in 4 years, let me make it very clear that this is not possible for the majority of junior doctors. We are tremendously vulnerable within our workplaces and even if these plans were fair in theory, the chances of a junior doctor being in one place for long enough to able to rely on an internal review process like this are slim.
Mr Hunt goes on to refer specifically to pay. He assures us that he has asked for the new contract to ensure the great majority of junior doctors are as well paid as they would be now. Our stance on this is firm; doctors, like many professionals in public service have take a 'real terms' pay cut year after year, not one doctor in training should now be subjected this type of pay cut. That is the strength of assurance that was necessary from this point and it was lacking. Majority of course just guarantees more than 50% and I don't believe there is a quantifiable element to 'great'.
So what is the verdict? My optimistic side wants to believe not that Mr Hunt necessarily wants to destroy the working lives of every junior doctor in the country, but that perhaps the evidence is showing us that he genuinely just does not understand? Thankfully, there is a simple remedy to that, one I am more than happy to help with. The gateway to progress has been left wide open, if it would be taken. The BMA have five prerequisites for negotiation, on the back of Mr Hunt's letter I continue to stand by them. I sincerely hope the BMA do too.