Take back your mink, take back your pearls

“Take back your mink, take back your pearls

What made you think that I was one of those girls?”

From the musical Guys and Dolls  

English and Welsh consultants last week rejected the new consultant contract by two to one.¹ Specialist registrars, the consultants of the future, rejected it by more than five to one. But consultants from Scotland and Northern Ireland voted for the contract, hastening the pace of devolution. The contract had been negotiated over two years and endorsed by the BMA's central consultants and specialists committee. Peter Hawker, chairman of the committee, resigned when the vote was announced. The resounding rejection of the contract in England and Wales raises difficult questions for the NHS, the government, and the BMA and probably starts a new era of local negotiation and possibly of a junior consultant grade.

Why was the contract rejected?

In essence, the new contract offered more money in return for accepting greater managerial control and the potential to be obliged to work unsocial hours.² Although those who negotiated the contract urged consultants to accept it, the junior doctors committee immediately rejected it.³ Feedback from consultants to the BMJ and other publications and websites was consistently negative,⁴,⁵ and it was no surprise when the contract was rejected.

It wasn't rejected because of money. Consultants famously had their mouths “stuffed with gold” at the start of the NHS, but this time they've sent back the mink and the pearls. Nor was it rejected because of minor restrictions on private practice. It was rejected primarily because it gave more control to managers, people who in many hospitals are neither trusted nor respected. This might be seen as a simple power struggle, with consultants refusing to be told what to do. Why shouldn't they get into line like most other workers?

All consultants work in teams, and most recognise that they are part of complex organisations and need to play their part. Unfortunately, they often have little confidence in the managers or the politicians who lead them. Managers come and go at a bewildering rate, pursuing targets that distort good care. Politicians likewise. Hospitals handed over entirely to managers and politicians will, consultants believe, be less responsive to patients' needs. Many managers believe the opposite. What's clear is that the NHS will not flourish unless doctors, managers, politicians, and all other staff can work well together and pursue the same goals. But perhaps this is best achieved by giving considerable autonomy to consultants. Most, after all, have done more than they are required to, even though some have abused their privileges. Consultants must accept, however, that managers play a vital role in complex organisations like health care. The beast will not run itself.

The contract was also rejected—and particularly by junior doctors—because of its potential to destroy family life. “I love my job and I love my family,” said one junior doctor at the BMA's annual meeting. “This contract will force me to choose between them, and I will choose my family.” This might be an exaggeration, but most junior doctors do not want to follow the path set by their seniors, many of whom describe how “I never saw my children grow up.” The Secretary of State for Health says rightly that patients want a 24/7 service, but the same social trend means that junior doctors want a better life-work balance. This is a problem for doctors and managers to solve together.

The rejection of the contract was also “a cry for help.” Doctors the world over are unhappy.⁶ This is partly because “the deal has been changed without my agreement.”⁷ The deal was to study hard, see patients, and provide good care as doctors defined it. In exchange doctors got reasonable remuneration, autonomy, job security, deference, and respect. Now politicians and patients are defining good care; the job is becoming much more complex; accountability is increasing; and deference and autonomy are disappearing. More money will not compensate.

Another problem is that consultants must ration care. Politicians promise the moon and won't mention “the ‘r’ word,” but consultants on the front line must explain to patients why something that could help them must be denied. This is uncomfortable in an age of intense public and media scrutiny.

By rejecting the contract, consultants may also have been trying to draw attention to their unsatisfactory working conditions (see table). The public and some politicians may still have the image of a male consultant with an expensive suit, a carnation, and a Rolls Royce lording it over adoring nurses. But the reality is more likely to be an overworked female geriatrician struggling to complete an overbooked clinic full of elderly patients with complex problems and demanding (and probably guilty) relatives.

What now?

The BMA wants to renegotiate the contract. The Secretary of State has said he will not and is offering no more money. But he has said that the government will return with an “extra incentive.” “Plan B” may also include the introduction of a junior consultant grade, which was mentioned in the NHS plan. Doctors oppose the junior consultant grade, and it has always been resisted by junior doctors, the group who voted most strongly against the new contract. The government has staked its future on modernising the NHS and reducing waiting lists, and it will not achieve much with an alienated workforce. It needs some sort of deal. It doesn't want a pitched battle with doctors. In the longer term it would probably like to break the power of doctors and the BMA, but reforming the health service must come first.

The answer for the government probably lies in local negotiations. The current rhetoric of the NHS is decentralisation and shifting resources to the front line. Local negotiations would fit with this rhetoric, even if the government might have some anxiety about inefficiency and “leapfrogging” (trusts paying more than each other to attract a scarce resource). One senior consultant said to me: “Rejection of the contract is the best thing that could have happened. Only the Department of Health and the BMA benefit from central negotiation.” Some think that the government is happy with (or even engineered) the rejection of the contract as it will allow local negotiation. Local negotiations would be conducted with the very managers that consultants, and especially junior doctors, distrust. By voting against the contract consultants may have acted against their own interests.

The most likely immediate outcome is that the government will allow individual trusts and even individual consultants to adopt the new contract. Trusts where relationships are good between managers and consultants (and there are some) may find this easy, and some consultants—particularly those near the end of their careers—may find that it's in their financial interest to accept the new contract.

The rejection of the contract was bad news for the BMA, perhaps the worst for 20 years. It showed that the leaders were out of touch with its members. Why should members bother to belong to an organisation that negotiates such a dismal contract? Why should the government negotiate with an organisation that cannot “deliver” its members? Some consultants have left the BMA and more will probably follow.

But when there is a battle to be fought there is strength in holding together, and even if local negotiation is the future doctors will need support in those negotiations. Politics will probably mean that the BMA becomes more aggressive in its relationships with government, demanding more. There will be a battle for public opinion. Unfortunately for consultants, they do not have the public sympathy that junior doctors win more easily. As the table shows, this is unfair: many consultants are working absurdly hard to keep an under-resourced service going. But if the battle is to be over the introduction of a junior consultant grade then junior doctors will be in the forefront. A battle between militant junior doctors and a desperate government with a large majority (and backbenchers hostile to consultants) could be very bloody.

Conclusion

Even if there is a period of bitter confrontation, everybody—politicians and doctors—must remember that the future will depend on working together. Both groups want to ensure that sick people receive good treatment and that the health of the British people is improved. This will not be achieved through an exploited and divided workforce. It is in the interest of employers, employees, and patients that those working in the NHS enjoy optimum working conditions. Leadership is needed from both the profession and the government to find a way through, and doctors must recognise that “the status quo with more money” is not an option. Reform is needed.

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