Imposition? This was never just about a contract.

Jeremy Hunt has gone nuclear and in a statement on 11th February announced forced contract imposition.

You may have heard the story of this dispute as told by Jeremy Hunt- it goes like this.
‘People have less good care at weekends in hospital, because junior doctors are not available. We should have a seven day NHS. We need more junior doctors on weekends but we can’t pay for this, so we will need to make it cheaper. We have to impose a contract to do this.’

This is mostly rubbish. juniordoctorblog explains the dispute so far.


Why aren’t there enough junior doctors at the weekend?
I personally work 1 in 4 weekends and nights already- every single patient admitted, 24/7, is seen immediately by a junior doctor – that might be the senior A&E registrar, or the general surgical or medical registrar. We have a ‘banding’ supplement that acts as a financial penalty to stop trusts rostering unsafe hours – trusts that breach this get fined, and therefore invest properly in hiring sufficient doctors to cover the rota. To suggest we don’t have junior doctors on the weekend is ludicrous.

Could there be more doctors on the weekend? Yes of course- but we don’t have many doctors to begin with; there are 2.8 doctors for every 1000 people in the UK- some of the lowest in Europe. There are also huge gaps where doctors should be already throughout the week- in A&E for example 1/8 training positions are empty, and GP posts are 1/3 unfilled. Applications for many training jobs continue to drop, and doctors increasingly migrate. This contract won’t create any more junior doctors.

So where will ‘more doctors on the weekend’ come from if there won’t actually be any more physical doctors?
Well, you could train more- but applications to medical school are dropping year on year, and this would take 7-10 years. You could hire more from abroad- but there are no plans to do this. The only place remaining is moving doctors from the week- leaving new gaps Monday to Friday, when activity and admissions are busiest. Due to imposition many doctors will also resign– meaning we have less doctors than we physically started with.

This doesn’t seem like a good idea.

Why is care less good at the weekend?
We are not sure it is. There been a few big studies that suggest patients admitted at weekends have a slightly higher risk of dying than those admitted during the week. Why this is nobody has researched. It might be the care in hospitals- but the same studies show patients already in hospital are less likely to die at weekends. It might have nothing to do with hospitals- patients are generally more unwell and more emergencies come in at the weekend- this could reflect less GP cover, less hospice access or longer delays coming in by patients- the truth is no one knows.

Is it worth finding out?
Absolutely- mostly because of the very large cost- both financially and in staff morale- in making huge changes without knowing if this would actually make care better and not worse. But this hasn’t been done. A summary of all the research done so far, if you are interested, is here.

What is a seven day NHS?
That’s a good question- no one really seems to know. David Cameron thinks it’s about having GPs 24/7. Jeremy Hunt says sometimes it’s about fixing the ‘weekend effect’ which is nearly exclusively emergency care, while other times it’s about routine care in hospitals. NHS management says it’s about emergency care and sets out 10 clinical standards – most of which are already nearly met, and none of which include junior doctors. So what exactly this means or why this is relevant to junior doctors- no one seems to know.

How is this going to be paid for?
Short answer- it isn’t. Long answer- the government announced an ‘extra’ £10 billion for the NHS in the autumn statement- and apparently this will pay for the 7-day NHS – although how it will pay for a service that no one knows exactly what it is I’m not sure. However- NHS trusts are running out of money trying to fund the services they already have- £2 billion in debt this year already. The NHS asked for £10 billion, which includes the £3 billion already announced, by 2020 just to keep the lights on- not to fund extended services. So – it isn’t being paid for.

Why can’t the government pay for more doctors at the weekend?
Well- we don’t spend a lot of money on healthcare. Currently 8.5% GDP– the lowest in the G7 amongst the lowest in Europe. By 2020 we will be paying 6.7% – amongst the lowest in the industrial world- nearly half what Germany spend, a third of what the U.S. Spends. There is therefore money available for the NHS but it is not being spent, and less and less is spent in relative terms every year. The government often say that a ‘seven-day’ NHS was a manifesto commitment, which is why it is so strange not to fund it properly. It’s not that they can’t pay for it, but they don’t want to.

Why did the government impose the contract?
They claim it was to end ‘uncertainty’ for August 2016- but there really is no reason the contract must be implemented by then. Talks have been going on for three years- contracts are reissued every August. It’s entirely political- to look ‘muscular’, to keep ‘political capital’. Nearly no one supports imposition other than NHS bureaucrats- the Royal Colleges, NHS Trust Executives and the entire medical workforce are all opposed.

So to summarise the government want to take away financial safeguards and cut pay at weekends to fix a problem we are not sure is either fixable or genuinely a problem but we do know will cost a lot of money that isn’t being invested and won’t actually be fixed because we still don’t have any more doctors- probably much less now.

Which doesn’t make sense.

So why do it?
Well the contract actually has many other advantages to the government – it increases pension contributions, and reduces the doctor wage bill to hospitals. It also means lucrative routine work can be done cheaply on the weekends, and for generations to come doctors will cost less. This is the real reason the government want this contract to happen- it will make the system much more attractive to private companies.

What’s going to happen now?
After the junior doctors the same terms will go to the consultants, the GPs, the nurses and the other health professionals.

And then?
In all seriousness- the end of the NHS. A beleaguered system which has been underfunded for years, with huge gaps in many areas, is now being squeezed one too many times.
The junior doctors have been trying to tell you that the NHS is in desperate trouble – not just from this contract alone, but as the start of a succession of workforce changes.
Private companies have taken 500% more contracts in the past year, the head of the NHS is a former U.S. Healthcare company executive, the last health secretary now works for a private health company having changed the law to make it far easier for private companies to get NHS contracts, and the current health secretary wrote a book idealising the privatisation of the NHS. 

With this latest development NHS morale will be even lower, and private companies will welcome the chance to ‘improve’ pay and conditions for staff.

What can I do about it?
If you want a free at the point of service public health system, where your taxes fund an efficient and equitable health service that you never have to worry won’t be there for you or your family, then you need to read this and understand. If we do nothing, by 2020 there will be no NHS.

Write to your MP- and tell them this is the single issue you will be voting on. Don’t accept anything less than the truth- you know now what is at stake.

Educate yourself more; read more about the health service, the contracts, the challenges it faces.

Sign this petition. Join up to local save your hospital groups and support their events.

Come to the junior doctor protests- I would love to talk to you.

Keep writing, come to protests, add your voice to every gathering, every social media group, every local council meeting.

Get on a box and shout as loud as you can. This is what democracy should be. Let’s hope it’s not too late.

I am ashamed to say Nye Bevan encountered incredible resistance from doctors at the beginning of the NHS. But that’s not the generation of doctors we have today- we all grew up with the NHS, most of us were born in it, and we all want to defend it as long and as fiercely as we can.

We can’t do it without your help.


  1. Worth repeating that the ‘weekend effect’ is not just an NHS phenomenon; but is seen in health systems around the world, none of which appear to be attributing it to junior doctors.

  2. Well written. My feeling is that you have a massive amount of public support right now.
    I think it would be a good idea to have a petition which will show that support….
    Better yet, a general strike & a refusal by junior doctors to sign this new contract – what will they do? Sack all of you…I think not….

  3. hate him but the long game just became clear. Very clever.

    Does anyone remember this :

    South West England Pay Cartel.

    Jeremy, the naughty scamp, has just made us all think that local arrangements can come to the rescue of the big bad wolf and make us grateful that local services can choose to pay us what we deserve whilst at the same time splitting us by who we work for.

    Goodbye national contract. Hello self-interest in pay and the destruction and splitting of the profession. Divided we fall. Divided by our saviour foundation trust employers.

    This is far worse than I thought. Now we have truly introduced pure pay-based competition at an individual staff member level whilst potentially making us grateful.

    This is the point at which we have to truly decide is thus about self interest or principles or else we will also all be toyed and cajoled by market forces.

    It is actually so obvious when you think of it- the destruction of national terms and conditions by their very imposition – just what they want.

    I wish I didn’t have some admiration for his stroke of evil genius.

    Or maybe it started with Lansley. He is a consultant now after all

  4. The status of doctors has been deliberately downgraded, by changing their titles to figures and numbers,like F1 and F2, so they are no longer recognised as dedicated professionals to be respected and who have varying experience in the health service. They should not all be called Junior Doctors either. How insulting for those with over ten years experience since graduating. How would the politicians like to be called P1s for their first 10 years in government?They would never reach consultant status anyway as they would be voted out before they got there, especially if they continue to behave like dictators whose only concern is for themselves and not our wonderful country. Don’t we have senior doctors anymore?Will the media please start to change this culture when referring to medics and treat them as people and not just human resources.

  5. If you already work 1/4 weekends then as I understand it you will see no decline. Quite the reverse. Your number of consecutive nights maximum will drop, your standing pay will rise 13% and your pension contributions will rise. What have I missed? The nhs is no longer fit for purpose. I agree on this. The reason the uk spends less than other countries per head of gdp is the cost of provision and the fact that the uk’s is the only free health care. In my mind a free health service cannot run for a population of this size. Change is coming toward a part free part charged service and as long as those who can’t afforded are safe guarded properly then it can’t come soon enough. As it stands the nhs will just get worse and worse and there is no amount of tax raised that will fix this. Good luck. If only shop workers had a 1/4 maximum weekend rosta…

  6. I agree with much but your figures are a little dodgy/misleading. For example 8.5%? that includes public and private health care spending! it is a low figure because private health care spending is so low in the UK, in fact 7.6% is public health spending which is relatively high. This just points out how little private spending there is, and so somewhat contradicts many of the anti government arguments flying about. I support Doctors being well paid with good working conditions so that we can attract enough talented individuals but it would be a lie to say the government is the only one misleading people.

  7. Thank you so much for writing this! I’ve always been against the proposed imposition on junior doctors and other healthcare pro’s (despite not being in healthcare profession myself I’ll add in case anyone thinks it’s only the doctors who oppose this imposition!) but the way you summed it all up is perfect!

    It would be so unsafe and unrealistic to ask healthcare professionals to work such ridiculously long weeks and then save lives at the same time. I work a 43 hour week including weekends in the theatre and I’m absolutely shattered everyday with no break but at least I’m not trying to save people’s lives!

  8. Brilliant blog, with issues well explained. Thank you. I am about to write to my MP but want to look at the actual text of the imposed contract first. Do you know of a link? I can only find summaries (cp an earlier offer which I read in full – apparently unlike almost every journalist at the time who believed the spin…). I am not a doctor but fully back your case: you are (dramatically) underpaid and overworked already which will do none of us any good in the long run, and the new contract would seem to exacerbate this situation.

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