The junior doctor contract in the National Health Service.

The progression of the junior doctor contract negotiations within the National Health Service (NHS) has been widely reported. We aim to provide a comprehensive summary of the current state of affairs with the contract negotiations and hope to inform those who may not be familiar with the situation affecting junior doctors in the NHS.

Background

In 2013, the National Health Service (NHS) employers (acting on behalf of the government) and the British Medical Association (BMA) entered negotiations over a new junior doctor contract in England's NHS. Talks had broken down in 2014 with concerns over patient safety and doctor welfare highlighted from the doctors’ union and a hindrance in achieving the NHS's goals to improve patient care and outcomes from the government's perspective. The introduction of the Advisory, Conciliation and Arbitration Service in late 2015 could not settle talks, and a mutually fair deal was not reached, thus further stunting progression. This ultimately led to an announcement on February 11, 2016, that a new junior doctor contract was to be introduced from August 2016.[1]

The Weekend Effect

The Conservative Party Manifesto 2015, headed by Prime Minister David Cameron, states that “we will continue to increase spending on the NHS, provide 7-day a week access to your GP, and deliver a truly 7-day NHS.”[2] This manifesto pledge alongside research on the “weekend effect” has driven the government to enforce a new contract despite strong concerns over its validity. The secretary of state for health, Jeremy Hunt, has argued that he wants to improve care on Saturdays and Sundays because research shows patients are more likely to die if they are admitted on a weekend.[3] To date, there is no clear evidence of the causation of the “weekend effect.” Associations have been made, but definitive conclusions have not been found with many contributing factors having not been accounted for. It is certainly not as simple as Jeremy Hunt is making it to be.[4]

Meacock et al. interestingly found that hospital death rates were higher at the weekend because only the sickest patients are admitted.[5] Those admitted on the weekend are on average sicker than during the week and thus more likely to die irrespective of the quality of care received. They conclude that the extension of services during the weekend may increase the number of emergency admissions and contribute to lower mortality; however, may not reduce the absolute number of deaths.[5]

A New Contract

The BMA and NHS employers agree that the current contract needs to be modernized so that it is safe, fair, and effective. The new proposed junior doctor contract was due to be implemented in England from August 3, 2016, as doctors’ entered into new training posts. However, specific changes within the new contract have caused unrest among doctors who argue it no longer serves to be safe for patients or for doctors. With regard to standard time and unsocial hour rates, The Review Body on Doctors’ and Dentists’ Remuneration (DDRB) has suggested an extension of “standard time.”[6] Routine (standard time) working hours are currently 8 am to 7 pm, Monday to Friday, with pay premiums as part of your banding payment for work beyond these hours. The DDRB recommends extending standard time from 7 am to 10 pm, Monday to Saturday, meaning work at 9 pm on a Saturday evening would be paid the same as work at 9 am on a Tuesday morning. The BMA opposed any extension to the standard time hours during contract negotiations and argued that junior doctors routinely work outside of standard times and that evenings and weekends are precious opportunities to spend with family and friends; the pay of which should reflect such sacrifice.

The current system is based on a banding system; providing pay supplements on the length and unsocial timing of duties. It also has inbuilt safeguards to prevent excessive hours, ensuring sufficient rest, and breaks for doctors. The new contract promises a basic pay increase on average but with the ending of banding payments, which may actually result in an overall reduction in pay. The removal of hospital safeguards means employers are no longer financially penalized against unsafe working patterns when planning rotas and staffing wards.[6] This could have detrimental consequences for junior doctors and their patients.

Under the current contract, pay increases every year in recognition of your experience that comes with time spent training. The DDRB recommends “pay should be based on stages of training and actual progression to the next level responsibility, evidenced by taking up a position at that level.”[6] There are concerns over those taking time out of training such as parental leave, sickness, or research training as it would take longer for these trainees to progress to subsequent training stages. In addition, according to the equality analysis of the new contract, certain features adversely impact those women working part-time, have responsibilities as carers and in specialties such as obstetrics and gynecology.[7]

Strikes and Legal Action

The junior doctor contract saga has been extensively covered in all forms of media, including social media. Negotiations hit a halt in late 2015, and the BMA subsequently underwent several days of striking action, including the first full walkout in NHS history where emergency cover was not provided by junior doctors who showed their opposition to the new contract. Many senior doctors stepped in to be fully behind their junior colleagues. The public support for the junior doctors striking was surprising bearing in mind thousands of operations, and outpatient clinic appointments were canceled.[8] Legal action was commenced against Jeremy Hunt for his decision to introduce a new contract despite the opposition and lack of support for it.[9]

Referendum

Both sides recently returned to the negotiating table after the government agreed to pause the imposition of the contract with the BMA suspending any further strike action. On May 18, an agreement on the contract was reached subject to a referendum of relevant BMA members.[10] The BMA have stated that improvements to the contract include recognition of a junior doctor's working week as well as proper provision of equality.[10] At the referendum, 58% of junior doctors and final year medical students voted to reject the government's proposed new contract with a deep mistrust toward the government cited as a significant reason.[11] The government has subsequently declared that they will not return to the negotiating table with the BMA and that they intend to impose the junior doctor contract agreed in May from this coming October.[12]

Legal action continues, the risk of further strikes remains and ultimately the future of tomorrows’ doctors in the NHS rests on what happens between now and the planned imposition.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.