In a two-part behemoth post, juniordoctorblog examines first the contract, and then the wider context the contract sits in. This is Part 2: The Context of the NHS. Read Part 1 here

The contract does not sit in a bubble, and there are many nuances that require some background knowledge of how certain parts may or may not be used, now and in the future, and how that will affect junior doctors working in the wider NHS.

The past

Junior doctors in the NHS have had a rough decade. We took a huge £6000 paycut at F1 with the loss of accommodation, we had two pension raids meaning we pay in more and get less paid out (Remember this), and we had the debacle of MTAS. Since 2009 we have taken a further 25% paycut already due to the pay freeze against inflation.

The origins of this contract date back to a group of NHS executives who were desperate to take ‘advantage’ of what they saw as an ‘oversupply’ of doctors – creating a contract that cut weekend and unsocial hours pay and conditions worsened across the board. This is well covered here.

In the meantime the NHS budget has been essentially flat for the past six years, while assets have been sold off and social care and public health budgets have been slashed. £20 billion of cuts estimated between 2010-2015. Demand however has risen and risen. The wheels are starting to fall off.

In 2012 the Health and Social Care Act opened up NHS contracts to private companies, and devolved the duty of the Health Secretary to provide a comprehensive state-funded service. Private contracting has increased 500% in the last two years.

The present

Back to junior doctors – the contract dispute has left deep scars on our collective psyche. F1 applications for first preference to Scotland and Wales nearly doubled this year, and the programme as a whole was 300 doctors under recruited – the first time in history. The numbers of applicants from F2 going straight into speciality training also dropped at an unprecedented rate – 8% in the last three years. Certificates to work abroad have reached record highs – nearly 8000 since this all began, and whether any of those doctors will return remains to be seen.

Looking a little wider, vacancies for doctors have increased in the last year by 60%. Rota gaps are rife, especially in hard to recruit specialties like paediatrics. 1/3 GP posts is unfilled, 1/8 A&E posts, and 50-60% of registrars in A&E quit after 2-3 years of training.

Looking wider still, the NHS is in real trouble. This year the final deficit was £2.4 billion – a record. Hospitals were told by no.10 in the past two years to cut their regular staff budgets – this led hospitals to find themselves in situations where they couldn’t staff themselves properly, and therefore hired temporary staff at a greatly increased cost. A&E waiting times this year hit a record high, the worst since records begin. This has been the most austere decade in the history of the NHS.

And the government response? Jeremy Hunt, during this whole debacle, said at a speech this week the NHS needs to go on a ‘ten-year diet’. No more money is coming. Things will only get worse.

The future

Inflation is set to rise by 1-2.5% by 2020. The contract stipulates that our pay will rises by 1%, 0.9% then 0.8% in the following three years. This will be a continued paycut. But something more important is going on.

In the 2007/8 financial crash, the economies of most of the OECD crashed. A recent study in the Independent showed those countries without universal healthcare, where healthcare depended on employment and wages, had a cumulative ‘excess’ death rate from cancer totalling 260,000. Let me reiterate that – because of illegal and reckless banking practices, for which only one person was every prosecuted, nearly a quarter of a million people worldwide died that otherwise wouldn’t. Did that happen in the UK? No it didn’t – because of the NHS. Money in healthcare means lives.

Don Berwick, patient safety guru, has publicly said the NHS spend on GDP is ludicrously low. “I know of no modern healthcare country attempting to fund the NHS on 8% GDP, let alone 7 or even 6%.” That’s including the ‘£10 billion extra’ funds by the way. By 2020, with Jeremy Hunt’s ‘diet’, NHS spending could be as low as 6%. People will die.

Why does this matter? Because the context of the contract is one that will ultimately determine how it is used. We are about to enter a decade, without drastic intervention, where hospital managers and NHS will become increasingly desperate, as health inflation raises costs by 3-4% each year and the budget rises by 0.9% or less. This won’t be so much a ‘diet’ as death by starvation. The caveats in the contract that you’ve read and never imagined would be used now, may one day soon become the routine.

What will happen when you are working in a failing hospital, with spiralling deficits, no staff, desperate conditions? I’ve worked in a failing hospital before, and let me tell you, it’s terrifying. I’m not scaremongering here – I just want you to understand. We are building a ship to sail on incredibly stormy seas – it better be watertight.

Lastly, the spectre of privatisation marches onward. The Telegraph ran a rather stupid piece about it very recently – claiming that the lack of 24/7 on-site palliative care meant the NHS state-funded model is failing. Private companies are coming into the NHS at an increasing pace, and with no sign of funding to match the future we need to ask where the government plan to provide healthcare from?

The contract has many advantages to private companies.

• Basic pay is pensionable – banding is not. If you look at the part 1 blog you will see that the pension contributions in the new contract are much larger than the old one. This means the pension pot for junior doctors is more profitable for those that own it.
• Basic pay is paid for by Health Education England. Health Education England are due a £1.1 billion paycut next year- how will this help recruit more juniors? Or more importantly, train more nurses. Hospitals pay the supplemental fraction – as this goes down, it makes things cheaper.
• Cheaper weekend work means more lucrative elective services 7 days a week, despite this being statistically less safe.
• There are clauses in this contract that stop a junior doctor talking about their organisation unless there is some failure. Is this a soft gagging clause to prevent reporting privatisation?

Will this contract even last that long? In June this year Simon Stevens will divide the NHS into 44 individual ‘footprints’ responsible for their own budgets, this is the sustainability and transformation fund or STF. The ‘leaders’ of these footprints will be completely unaccountable for their actions – and with no planned increase in funding it won’t be long before whole areas are sold off to private companies, just to keep them afloat. What contracts will be agreed with these footprints or even the companies that come after remains to be seen.

And don’t forget the GP and the Consultant contracts, the Agenda for Change re-negotiations, the pharmacists and beyond.

Don’t think a Yes vote will mean you will be able to go back to your old job, go back to looking after patients and forget all of this mess. You will be going back into a greater and more dangerous mess than before, and it will require more effort, not less, to keep our profession from collapsing, to keep our hospitals from doing the same.

Don’t think a No vote will mean that we will go back to striking and protesting, eventually toppling the government and saving the NHS. The BMA agreed to these terms – it would create a gargantuan effort of hitherto unseen proportions to successfully campaign again against them. Not impossible. But extremely hard. And will it change what happens to the NHS? No one can deny this contract fight has politicized a generation of doctors, and ignited the issue of the wider NHS in the minds of the public. But a fight over a contract alone won’t help us.

I’m not going to tell you how I’m going to vote – mostly because I still haven’t made up my mind. We are handing some large levers of control to some people who are about to be very desperate indeed. Whichever way you vote, be prepared to continue to fight; for your working conditions, for your patients safety, for a free-at-the-point of service, world-class NHS.

Make up your own minds, pick your own battles, do what you have always done and do your best for your patient.

That is all I ask.

juniordoctorblog.com