As a child, I remember my parents going to evening meetings organised by the British Medical Association (BMA). In medical school, our summer holidays were organised around the location of the annual BMA conference, so that we could travel around places like Brighton and Blackpool while they attended conference sessions. A very different childhood to most, I would guess. I had no real idea about medical politics and my only recollection of such events was being seated in a session that proposed a vote of no confidence for something or the other and I recall fudge being handed round one session as a metaphor for the way in which that situation had been handled by the government.
I experienced a true maelstrom of medical politics, combined with the fact that my parents as treated very much like permanent junior doctors. Both came to England when I was two years old at a time when the government found it difficult to fill medical posts in specialties such as geriatrics and psychiatry. Perhaps it's no surprise that my father was a geriatrician and my mother a psychiatrist. Even less of a surprise that I became an old age psychiatrist with strong feelings about the way that both doctors are treated if they are not at the top table of politics, as most of my parents' consultant colleagues were during their own careers.
Now let's fast forward several decades. After helping to set up a system of national continuing professional development for doctors in non-training grades like my parents, I then took over the role of Chair of my Local Negotiating Committee. Little had changed. I sensed that that there still remained a poor appetite among consultants for medical politics. The perception seemed to be that there was something called the BMA that dealt with terms and conditions of doctors' contracts. Little did they know that for junior doctors, this whole area would turn from a ripple into a tidal wave.
In 2012 the UK government asked the BMA to begin negotiating a new contract for junior doctors. In July 2013, BMA's UK junior doctors committee agreed to enter formal negotiations that began in October 2013. A year later, contract negotiations stalled as the BMA believed that there were insufficient safeguards for doctors' welfare and patient safety. The BMA submitted evidence to the Doctors Dentists Review body (DDRB), an independent body that makes its recommendations directly to the Prime Minister and the Secretary of State for Health. The DDRB undertook a review and provided recommendations for a new contract. Sadly, these recommendations were still not sufficient to be regarded by the BMA as safe to patients or fair to junior doctors. The government did not appear to budge an inch and contract negotiations stalled once again in the Summer of 2015.
In September 2015, the BMA junior doctors committee decided to ballot junior doctor members on support for industrial action. More than 37,000 junior doctors were balloted. On November 19th 2015, the results were announced. More than 99 per cent voted in favour of industrial action short of a strike and 98 per cent for full strike action.
Although direct contract negotiations took place again (this time under the auspices of the Advisory, Council and Arbitration Service (ACAS), the outcome was not better. Two 24 hour strikes have since taken place by junior doctors across England, whilst maintaining emergency cover.
The system is clearly broken. The current stalemate made me think of the 2007 banking crises, with the current government now propping up an NHS with dwindling resources but peddling the notion that all is well and still trying to expand it. So what's behind the government's intransigence? Well, not surprisingly, it is cut-throat politics at its worst.
In July 2015, the UK Secretary of State for Health delivered a keynote speech to the King's Fund. In it, he stated that "...by the end of this Parliament, we expect the majority of doctors to be on 7 day contracts...". Behind this is a government mandate to deliver 7 day services, at the same time introducing new contracts for junior doctors so that they will not just be covering emergencies, but also routine NHS work at weekends. The plan was that once the contract had been negotiated for junior doctors, consultants would be next in the firing line, so that they would no longer be allowed to opt out of non-emergency work at weekends. The often quoted studies from the government about an excess of weekend deaths that has been used to back up the mandate for a 7 days NHS has finally stumbled and fallen. An internal Department of Health draft report, leaked to a national newspaper this week stated that they "cannot evidence the mechanism by which increased consultant presence and diagnostic tests at weekends will translate into lower mortality and reduced length of stay".
The 'Hunt logic' for the junior doctor contract is clearly flawed. The grand plan to have the same number of junior doctors stretched across 7 days and carrying out both routine and emergency work at no extra cost to the government would challenge even the most liberal economist. Indeed, the BMA itself suggested a cost-neutral solution that would have ensured a smoother contractual ride, but this was again met with smoke and mirrors by the Health Secretary earlier this month.
The fallout from the perceived obfuscation by the government has been without precedent, fuelled by anger over both social media and on radio and television, by both formal and grassroots BMA members expressing their indignation over a contract that is clearly being forced through to meet a mandate that has neither the reasoning nor resources behind it. An online petition for Jeremy Hunt to resume meaningful contract negotiations with the BMA has now gained over 100,000 signatures, with a further petition for vote of No Confidence in Jeremy Hunt as Health Secretary attracting over 300,000.
The government might think that they have called the bluff of the junior doctors by using flawed logic as a defence against as the imposition of a junior doctors contract, but they have been wrong-footed once again. It is estimated that if all 482 junior doctors who applied to work abroad this month alone actually do leave the UK, it will be at a cost of £144 million to the taxpayer.
The clock ticks on, but it is likely to be a time bomb and not an alarm.