The junior doctors’ dispute caught many of us by surprise, but it should not have done. The British Medical Association’s (BMA) withdrawal from negotiations about a new contract last year was a warning, but perhaps even the BMA did not anticipate the anger of junior staff about a contract that has been neither presented in detail nor costed. Tory MP Dan Poulter – a member of the Coalition health team until 2015 – told The Guardian that the government tore up an agreement that would have sorted out the contract problem. It looks as if both parties are looking for a fight.
Other people’s contracts are boring to most, yet the devil really is in the detail. The proposals from NHS Employers aim to increase the basic rate of pay for junior doctors but also to redefine ‘normal working hours’, whilst being cost-neutral. There is no extra cash on the table. The basic rate will go up for all, but annual increments will stop, being replaced by rewards for new levels of responsibility or skill. The redefinition of normal working hours means that the ‘7am to 7pm weekdays’ package will change to ‘7am to 10pm, weekdays and Saturdays’. Money saved from these two changes will allow funds to be used for ‘premia’ payments to hard-to recruit disciplines. NHS Employers reckon that actual hours worked will decrease further. Because no economic modelling has been done, it is not clear who will benefit and who will loose from this sketchy contract, which the Secretary of State for Health says he will impose (despite the lack of detail) if negotiations do not resume.
Some junior doctors currently working a lot of unsocial hours think they will lose a lot of income, since the uplift in basic pay is unlikely to compensate for lost hours of ‘overtime’. Others fear that their income will fluctuate unpredictably as they move from one training post to another (because of the complexity of the funding formulae). Lost and variable income matters most amongst those trying to live in the South East’s inflated housing bubble, or seeking to move into the golden triangle of Cambridge, Oxford and London. Others fear that hours they did not want to work – late evenings and Saturdays – will become part of their contract, and a slip along the slope towards seven day working. These seem to be the main objections to the new contract. Talk of rejecting it because it threatens patient safety is not plausible.
If the BMA breaches the ‘no new money’ rule imposed by the Government, other unions with members in the NHS will take it as a precedent and campaign for similar pay increases for other professions. The Government will oppose this, so the junior doctors’ industrial action (if it comes about) will have great significance.
As currently discussed, the new contract could aid workforce planning, because some of those doctors who do not emigrate or become bankers (most can’t) will reduce their income risks by moving to the low cost areas where doctors are most needed anyway.
Abolishing incremental increases in pay will affect more than salary bills. Awarding increases to some might send a signal to those who are perhaps performing less well, and dent the sense of entitlement that is so strong in medicine. It could be an expansion of management powers into clinical performance.
What would a Labour government do? Hopefully it would agree with NHS Employers and the Doctors and Dentists Remuneration Board that the junior doctors’ contract needs reforming. It would surely agree with the BMA that the government has handled the negotiations about reform badly. Most probably it would avoid seeing the problem as nothing but an attempt to drive down salaries and increase NHS productivity, although there are siren voices singing this reductionist song.
It is easy enough to see how, in the big picture, this government offers reactionary modernisation of junior doctor work patterns, but what would progressive modernisation look like? Pledging no loss of pay and restoring annual increments might be tempting. This would reduce doctors’ anxieties about income but maintain long hours for some, weaken workforce planning and lose the disciplinary and incentivising effects of selective increments. Perhaps the best outcome would be to keep the substance of the reforms but negotiate around stabilising doctors’ incomes in high cost areas. This could be done by offering benefits like key worker status for housing, by emphasising local flexibilities in salaries to mitigate losses to some individuals, and by providing funding for educational courses, specialist examinations and membership of professional organisations. The overarching aim would be to take the drama out of the crisis.