What does the junior contract mean for me, my patients and the NHS?

In 2013, the National Health Service Employers (NHSE) started a renegotiation of the contract for junior doctors (i.e. doctors of all grades except for consultants and SAS doctors; staff, associate specialists and specialty doctor grades).¹ Due to concerns regarding the contract, the British Medical Association (BMA) left negotiations in 2014. The Review Body of Doctors’ and Dentists’ Remuneration (DDRB) subsequently backed the NHSE’s recommendations which included redefining ‘sociable’ hours, and removing the banding system, safeguards protecting working hours and annual pay increments.² One of the main drivers for contract reform is the government’s plan for patient outcomes at weekends to match those on weekdays, a ‘7-day NHS’. It is far from clear from the evidence, however, whether these plans are viable, will achieve the desired patient outcomes or are cost-effective.³

As part of a ‘7-day NHS’, the Government plans to increase weekend non-emergency care. To facilitate this, the DDRB has recommended changing ‘sociable’ working hours from 7 a.m. to 7 p.m. on Monday to Friday, to 7 a.m to 10 p.m. on Monday to Saturday.² A guarantee has been made that longer hours will not be imposed. If ‘sociable’ hours are to include Saturdays, it follows that there will be a reduction in the number of doctors working during the week. To compensate for this, more doctors, be they locums or new recruits, will be needed during the week, inevitably disrupting the continuity of care that patients receive. Research demonstrates that continuity of care results in increased patient satisfaction and better health outcomes.

Further, it takes at least five years to train a doctor. In the meantime, foreign doctors or locums must be recruited to avoid rota gaps. This will increase costs in an already financially fragile NHS. The Government’s ‘cap on locum costs’ may keep a lid on expenditures (£3.3 billion in 2014) but is certain to lead to locum recruitment issues and potentially dangerous staffing levels.⁴

Another DDRB recommendation is that no more than 72 hours should be undertaken in any shift pattern.² Junior doctors are currently protected by the New Deal contract and the European Working Time Directive (EWTD).⁵ The EWTD states that doctors should work less than 48 hours a week, averaged over six months. These safeguards deter employers from timetabling dangerous shift patterns. Hospitals are monitored periodically and fined if rotas are not compliant. The NHSE proposes to remove the safeguards provided by the New Deal. Concurrently, the government is intending to ‘opt-out’ of the EWTD. Removing safeguards that protect working hours will mean doctors may work 90-hour weeks as they did in the 1980s and 1990s.⁶ It is imperative to ensure tamper-proof rotas to reduce the risk of exploitation of doctors by rota coordinators. Tired doctors are less efficient and more likely to make mistakes that will jeopardise patient safety.

In the current contract, pay banding is determined by both the number and nature (i.e. sociable or unsocial) of hours worked. The NHSE suggests replacing banding with a modest increase to basic pay, plus an hourly supplement for ‘unsocial’ hours. However, a first-year junior doctor will still receive less than the national average graduate starting salary of £28,000.⁷ Additionally, there will be no annual pay increments, with pay progression instead corresponding to responsibility on five or six levels, from a first-year doctor to a consultant.² Those who take time out for research, maternity leave, or are in less-than-full-time training, or who change specialty will, therefore, progress more slowly in careers and be financially worse off.

There are widespread fears about pay cuts with the removal of banding and annual increments. The Government is imposing a contract that has not been fully defined and has criticized the BMA and doctors for trying to calculate the financial impact. Junior doctors already pay for student loans, GMC registration, indemnity, college membership, courses, exams, conferences and relocation. On top of these self-funded expenses, many have mortgages, families and childcare to consider. Many doctors are unable to afford a pay cut and may need to consider extra locum shifts, changing jobs or even emigration. An exploited, demoralised and exhausted workforce will lead to increased sickness absence and an exodus of juniors, further affecting patient care.

In September 2015, the NHSE cancelled the UK roadshow set up to discuss the contract with junior doctors.⁸ On the evening of the first cancelled meeting, 5000 junior doctors, medical students and supporters protested outside Parliament. It was the first in a series of protests that have since taken place across the UK. On 17 October 2015, 20,000 protesters marched in London, making it the largest demonstration ever in the history of the NHS in England. In addition to the protests, angry, devalued junior doctors have written to local newspapers, lobbied Members of Parliament, spoken on national television and engaged with social media. Flyers, lanyards and badges have raised public awareness.

The BMA made it explicit that reassurances were needed before re-entering negotiations and balloted its members from 5 to 18 November for possible strike action.⁹ 37,155 members were balloted, with an astounding 76% return rate, 98% voted ‘yes' to take part in strike action. A strike is not the desired outcome for the BMA or junior doctors but until the Government drop pre-conditions for negotiations it is a bargaining chip to halt the contract being imposed in August 2016. Any proposed strike will be under the emergency care model (i.e. Christmas day staffing), potentially escalating to a full strike (i.e. removal of all junior doctors from staffing).¹⁰ At the time of writing, the first strike has been postponed in December 2015. If there is no resolution, more dates may be considered in early 2016 before any complications arise from enactment of the Trade Union Bill.

The government has handled the contract negotiations appallingly, which has sparked considerable discontentment and disappointment among doctors nationwide. To move forward, the BMA and the government need to continue negotiating the contract discussions without pre-conditions. The new contract must be safe for doctors, safe for patients and sustainable for the NHS.

Declarations

Competing interests

All authors declare: no support from any organisation for the submitted work; no financial relationships with any organisation that might have an interest in the submitted work in the previous three years; SM is a member of the British Medical Association. NR and JP have no other relationships or activities that could appear to have influenced the submitted work.

Funding

None declared

Ethical approval

Not applicable

Guarantor

All authors are guarantors.

Contributorship

SM and NJ designed the project. SM, NJ and JP all contributed to the first draft of the paper and further drafts and revisions to the paper. All approved the final version of the piece.

Acknowledgements

None

Provenance

Not commissioned; editorial review