After over 2 years of review and negotiation, junior doctors have had employment contracts imposed upon them by the Secretary of State for Health. The Health Secretary supposedly had the backing of 20 NHS Trust Chief Executive Officers, 14 of whom have withdrawn their support on the matter of imposition. The misrepresentation by government is the latest in a line of aberrations made during negotiations, which have eroded trust with doctors and students soon to enter the profession. All at a time when the government has declared the need to increase doctor recruitment in order to overcome staffing shortages and accommodate urgent service provision requirements.
The health secretary has been put under examination, and found to have manipulated the facts and coerced opinion, by: declaring these contracts represent an 11% pay rise; conflating the need for contract renegotiations with the provision of a 7-day NHS and patient safety; and threatening to impose contracts as early as November 2015 in need of urgent revision. In taking on the junior doctors, the health secretary has met an intellectual force that demands the respect attained through transparent communication of the terms and rational policy making decisions.
The 11% pay rise figure refers to normal working hours, which has been extended by 2 hours on weekdays (7am to 9pm) and from 7am to 5pm on Saturdays. In real terms, this represents a fall in out-of-hours pay, which hits doctors working in emergency services hardest (such as those in A&E, surgery and paediatrics), where service requirements are already highest. This contract may better support elective weekend services, but evidence suggests patient demand for this is low. Weekend service deficiencies have been reported but causative effects have yet to be found. Further progress needs to be made on the nature and necessity of 7-day services. Thus it has been unhelpful for the health secretary to suggest doctors are putting patient lives at risk, by refusing to accept terms of the contract.
The cost availability and appropriateness of a 7-day NHS service has also been challenged. Government have front loaded an 8bn GBP real-term increase in NHS spending over 5 years and protected salary expenditure on doctors. At a time of cuts to other public service accounts, this spending should be seen as significant relief. However, efficiency savings of 20bn GBP also need to be made and are unlikely to be achieved, demonstrating the strain the NHS is under. That the government still seeks to expand services, has led to concerns that the government is jeopardising patient safety by exploiting doctors’ working hours. There has also been unhelpful speculation that these proposals are a means for the government to dissolve the NHS as a universal health care service.
In regard to the protection of working hours, the government have capped the number of consecutive night shifts doctors may work to 4 and have guaranteed no rostering on consecutive weekends. An uplift conceded on Saturday evenings will also be made available for all Saturday hours for doctors working at least one weekend in four, and attempts have been made to negotiate fines for NHS trusts which breach limits to working hours with reimbursement to the doctor.
Enforcing 7-day services within such financial circumstances has provided some with justification that the proposals are a step towards offloading elective NHS services to third party organisations. Such an option is suggested to carry significant risks for the maintenance of a universal health care system. Selling off high-income low-maintenance services such as outpatient diagnostic clinics, whilst attempting to continue providing low-income high-maintenance emergency services and specialist treatment facilities, may result in the loss of service viability – as is one typical discourse. Pilots currently underway trialling ‘Accountable Care Organisations’ (ACOs), in which Local Authorities receive complete autonomy over integrated health and social care services have potential. Such schemes would enable Britain to continue to boast a universal health care system, that is better equipped than present to deal with changing healthcare demands.
Given that the implementation of structural changes remains in development, greater public discourse is required regarding shorter-term development of 7-day services – this much is clear. However, in flatly rejecting these contract proposals, the BMA undermines its position that their disagreement is based on patient safety as opposed to pay. The goading of suggestions that the profession is being alienated and that doctors will leave the UK or the profession, makes it even more difficult to reconcile the BMA position. The governments’ “firm offer” in November 2015 warranted significant revision and the BMA’s position as of the first day of industrial action on 12th January 2015 was unfortunately justified. However, the BMA have not since advanced their position in response to the changes made by government to protect the pay packet and working hours. The given changes to the contract as detailed above were eleventh hour concession made by Sir David Dalton, a trusted NHS Chief Executive (Royal Salford NHS Foundation Trust) and were significant enough to call off a second day of strike action on 10th February 2016. It is as if the BMA does not understand the terms of the contract themselves, or are otherwise simply riling anti-government rhetoric. In so doing, the BMA has neglected its duty to provide reasonable support to its members and junior doctors.
The junior contract negotiations have been an unfortunate, prolonged and sorry affair. The BMA and government have misrepresented themselves, by contributing towards a clouded conflict that has resulted in both patients and doctors losing out – the very people these contracts are designed to protect. Further strikes have been planned but junior doctors must now clearly establish the terms of the contract they wish to alter. This may for example, include maintaining normal weekday working hours and expanding the compensatory mechanism on weekends. The government were voted into office on a manifesto proposal to substantiate a 7-day NHS, but should also further enhance details regarding its implementation. Insinuating comments and actions made by the Health Secretary have undermined trust in the government, which has however continued to make concessions in order to make the NHS a sustainable place to provide healthcare services.
Over the course of negotiations, there has been an unprecedented level of political engagement by medical students and doctors. These energies may be better used a springboard for change, as opposed to a defeatist mentality of exodus. The NHS faces significant challenges, in primary, social and secondary care, and clinicians present and future would do well to lead reform in these areas. Doctors’ duty is to their patients, and management roles provide immense opportunities to deliver appropriate care going forward. I would welcome greater numbers of doctors being involved in healthcare discussion from a broader range of positions. The negotiations may yet encourage aspirational medics to deal with the issue of delivering healthcare and maintaining the integrity of the NHS.