Implications of the imposition of the junior doctor contract in England

Three years ago, the British Medical Association and National Health Service Employers entered negotiations about the contract for junior doctors working in England’s National Health Service. The discussions did not progress smoothly, and in late 2015, the government began to threaten imposition of a new contract of its own design. ¹ Mediated negotiation, between December 2015 and February 2016, nevertheless aided progress on the issue. Despite this, and even though the government did not have a fully developed proposal prepared, imposition of a new contract was announced by the Department of Health on 11 February 2016.

For doctors, the contract imposition is distressing for several reasons. First, the contract is incompletely developed, and there are errors in the associated ‘pay calculator’, ² and heavily criticised, unrealistic rotas have been published. ³ Doctors are therefore unable to determine the hours they are likely to work under the new contract, how these will be distributed across the week, and the impact on their salaries. This uncertainty is compounded by lack of clarity around the government’s rationale for imposition: provision of a ‘seven-day National Health Service’. The government has not clearly defined what it means by this, and the proposed rotas do not redistribute services evenly across the week. ⁴ Indeed it is unclear whether the new rotas will provide any enhancement of weekend cover. Nor is it known what impact the proposed new working patterns of junior doctors will have on clinical outcomes, mortality and National Health Service productivity.

A second source of frustration for doctors is the government’s apparent lack of understanding about the work junior doctors do, and its unwillingness to engage further on this issue. For example, in discussion pertaining to the imposed contract, National Health Service Employers suggested that, ‘Exceptionally, because of unforeseen circumstance, a trainee may feel a professional duty to work beyond the hours described in their work schedule’. ⁵ Junior doctors routinely supply the National Health Service with many hours of service additional to those they are contracted to work, because the service is insufficiently staffed. To suggest that doctors should not be undertaking such additional work except in ‘exceptional circumstances’ is unrealistic. What do National Health Service Employers think would happen to patients if surgeons and anaesthetists walked out of theatres at the end of their shift, and do they expect patients to be turned away from routinely overbooked clinics at 5 pm? If this was to happen through a loss of goodwill on the part of junior doctors – or if they were to insist on payment for any extra hours worked – this would have a substantial effect on the National Health Service.

A third concern for doctors is working for an employer that is potentially putting patient safety at risk with untested changes in working patterns. Although the government’s definition of a ‘seven-day National Health Service’ is unclear, the government wants to increase weekend services without reducing weekday services and while claiming to reduce the average number of hours that junior doctors will work. Without additional doctors, this means doctors will be redistributed from weekdays to weekends. This has implications for patient safety, and neither the clinical- nor the cost-effectiveness of this change in working practices has been tested. Any doctor would feel unable to use a new treatment without information on its effectiveness, cost and safety profile. Yet, this contract will force doctors to change their working patterns without evidence that this will improve clinical outcomes and with high-associated risks to doctors as well as patients.

These issues are such a concern that the new contract appears unworkable to most junior doctors. Many are leaving for better working conditions in other countries or other professions. ⁶ Others feel driven out by stress – concerned for both their own and their patients’ safety. Some will leave because the new levels of remuneration will mean it is no longer practical for them to continue working. This issue may particularly affect those required to make childcare arrangements – an effect that will be compounded by the introduction of more restricted pay progression for those working less than full time (a particularly regressive policy given that it will disproportionately affect female doctors, and those with health issues that prevent full-time working). The overall effect therefore of the new contract may be to reduce the number of junior doctors working in England’s National Health Service.

The National Health Service already has significant recruitment and retention problems. The National Health Service is critically dependent on the goodwill of staff to ensure it can cope with the demands it faces. Stress, anxiety, depression and sickness absence rates among National Health Service staff are high and rising. ⁷ There are large and growing gaps in junior doctor rotas. ³ Key performance targets are now consistently missed. ⁸ Many general practices are becoming unviable, and practices are closing at unprecedented rates. ⁹ Public health budgets have received large cuts, most hospitals are in deficit, and the Treasury has had to bail out a Department of Health expected to overspend by billions this year. ¹⁰

It is therefore difficult to understand why the government considers this to be an appropriate time to expect its junior doctors to deliver additional services without additional resources. Spreading junior doctors more thinly and introducing policies that encourage them to leave their posts threatens both patient safety and the survival of an increasingly fragile National Health Service. Hence, the imposition of the new contract poses a risk to the health of the English population. Emigration of doctors and penalties for undertaking academic work will hinder medical research, and there will be a knock-on impact on life-science industries. The government justifies all these risks because of its ‘seven-day National Health Service’ election manifesto pledge, but the pledge is not something that the electorate voted for at any cost.

As the imposed contract is not yet finalised, and because the new contract will not come into use until August 2016, the government could withdraw its imposition should it wish to do so. However, resolution of the associated contractual issues could only be achieved through successful negotiation, which would require that both the government and the British Medical Association are willing to openly communicate, including about their end goals. This would require the government to establish at what cost and risk it would back a ‘seven-day National Health Service’ – currently pledged without any definition or costing. As well as the government and the British Medical Association, this debate should include the public, to ensure there is broad societal support for any changes in how we fund and deliver National Health Service in England in the future.