If you are from the United Kingdom I am sure you have heard about the uproar over the changes to junior doctors’ contracts over recent months, and the disputes between the government and the British Medical Association (BMA), who have been negotiating on behalf of the doctors. The changes to the contract were proposed by the government in a bid to provide a consistent 7-day national healthcare service (NHS). However, doctors argue that they already provide a 7-day service, and believe many aspects of the contract are unreasonable including contracted hours, salary and safeguards. There has been an enormous amount of support for the junior doctors from the general public during these debates, but despite this morale is low. To further disappointment, on 11th February 2016 the government chose to impose the new doctor’s contract despite the BMA’s concerns about the impact on morale and ever worsening recruitment and retention of junior doctors in the NHS. This has led to the current strikes; emergency care only from 6th-8th April and full withdrawal of labour from 26th-27th April 2016. But what exactly are the changes to the new contract and why are junior doctors so unhappy about it?
Originally, junior doctors were paid a basic salary for a 40-hour week within standard working times between 7am and 7pm on weekdays. More pay would be given for work outside these hours, and the amount varied depending on which ‘band’ your speciality was in. For example, a speciality with more unsocial hours might be given 50% banding and this is paid as a proportion of the basic salary; therefore if a doctor were to remain in this speciality for the whole year they would receive 150% of their basic salary.
What changes were made?
Adjustments were made with the aim that average pay would remain unchanged throughout training, and not vary like it does currently as doctors move from one job to another, i.e. from a 50% banded job, to a 0% banded job. Jeremy Hunt, the Secretary of State for Health, claims the average basic salary will be increased by 13.5%, and in fact the basic starting salary was raised from £22,636 to £27,000.
The way in which normal and unsocial hours are classed has also been changed. Everyday hours from 21:00-07:00 will be given a 50% premium, Saturday 17:00-21:00 and Sunday 07:00-21:00 a 30% premium, and Saturday 07:00-17:00 a 30% premium if any shift starting on a Saturday is worked more than 1 in 4. ST1-ST8 doctors will be paid an on-call availability allowance.
So, what are doctors unhappy about?
At first glance it could seem that junior doctors have been given a rather sizeable pay rise. However, when you take into account that many doctors currently work in banded specialities that have been abolished under the new contract, and that doctors would previously have made significantly more money by taking on out-of-hours shifts, their overall pay packet falls. In fact, the new contract involves cuts of up to 30% and reduced rates when working between 07:00-22:00 on every day excluding Sunday. Saturday shifts will be considered part of the normal working week unless you work more than 1 in 4.
There is also worry over the lack of safeguards in the new contract that protect doctors from working too many hours; working long hours not only affects the performance of the doctors, but also puts patients at risk. In the previous contract there were rules about how much rest and how many breaks doctors should receive, and it stated that no junior doctor should work beyond an average of 56 hours per week. There was a mechanism in place to ensure this was enforced, by monitoring hours twice a year and financially penalising employers who do not adhere to the limits. The new contract merely tells employers to follow the Working Time Regulations (WTR) with no precautions in place to ensure this. The number of breaks had been reduced during shifts down to 20 minutes every 6 hours, meaning a doctor could work an 11-hour shift with only one 20 minute break.
Further criticisms of the new contract include:
- Penalising doctors who take time out of training to pursue research or work elsewhere, as on their return they will not receive annual wage increments. It is thought this may deter the research and development of new treatments and could detract from the NHS’s world-class reputation
- Removal of pay protection for women on maternity leave could widen gender inequality in medicine and negatively impact on staff shortages in the long-term
- Removal of maintenance grants for medical students will disproportionately affect those from poorer backgrounds. At present only 6.3% of medical students are from deprived areas
- Changes to immigration rules require international medical students to reapply for a work visa which could put further pressure on the retention crisis in medicine
And this is by no means an exhaustive list of issues with the contract.
What was the response to the imposed contract?
On the day the contract was imposed the number of doctors applying for permits to work abroad surged by 1700%. The debate has also impacted future medical students; in a survey of approximately 1550 students who once wished to study medicine, 37% now say they no longer wish to as a result of the contract changes. Moreover, the former Labour Party health advisor Jon McTernan advised junior doctors to set up an agency that could provide services back to the NHS, which would allow the BMA to provide services on its own terms, allowing doctors to resign en masse and join the agency.
What happens now?
The government plans for a phased implementation of the new contract over 12 months beginning in August. England’s 86 non-foundation trusts will be obligated to adopt the contract, however the remaining 152 foundation trusts have the freedom to ignore the contract, as their semi-autonomous nature means they are able to negotiate contracts locally. The contract was also imposed in Northern Ireland, but Wales and Scotland have managed to reject the contract with help from the BMA.
The contract disputes have lowered the morale of junior doctors and their colleagues in an already high-pressured work environment. For years there have been reports of the NHS being stretched for resources and staff. Evidence shows that hospitals in the UK are not delivering equally high standards of care in the evening and weekends as compared to normal working hours; this is compounded by evidence of higher mortality rates for patients at the weekend, although – it is important to note – the authors of the much-cited study did not apportion blame for this finding. The United Kingdom can only watch as events unfold over the coming months to see whether the planned strikes will make a difference, and how the roll-out of the new contract for a ‘7-day-NHS’ will take shape.
Featured image © Garry Knight
Claudia Palmer works in Healthcare Strategy Consulting and has an interest in the pharmaceutical industry and healthcare systems. She was previously the Commissioning Editor of Expert Opinion medical journal series, and holds an MSc in Neuroscience from King’s College London and a BSc in Human Biology from University of Birmingham.