Brexit changes Breverything

I’ve never been one to make decisions lightly- I started this blog on the single principle that evidence based argument is the only way to discuss any issue.
A while back I posted my thoughts on the new contract; I made a decision that this new contract is unfair and unsafe, and won’t stand up to the world once it’s rolled out. The contract should’ve been voted down, and we should’ve campaigned for another year to tighten and refine the mechanisms we have so they truly do work. 
And then Brexit happened. The contract hasn’t changed, but the world has. 

We are heading into another recession, this time with a barebones NHS with literally nothing left to strip away. Both sides of the commons are a boiling hot mess right now- but no one new is coming to save it. Hunt is making a run for prime minister, Lord help us all.

The contract may have not been what we fought for, but now it must become the means we use to go on fighting. 

Juniordoctorblog votes Yes.

Just as before, I recognise the responsibility this path demands. I will join the local forum and run for position in the BMA. I will hold my trust to account – making sure their guardian role is fully funded and fully staffed. I will engage with the junior doctor body of my hospital, support them in their work schedules and exception reporting. 
We will need anonymous whistleblowing means for those that fear retribution we still aren’t covered for. We will need infrastructure- an app to log your hours and automatically exception report, a forum of educational supervisors to train and guide them, legal tools to challenge HRs that refuse to comply, or make exception reporting or TOIL exceptionally unnecessarily difficult. 

We will have to work out how our LTFT colleagues can be supported- we will need to lobby extra contractually to get them exempt from exam fees and indemnity fees. 

And most importantly of all- we all need to continue campaigning as a body of doctors for the future of the NHS. A free at the point of health service system saves lives, and is the last great thing about Britain I can think of right now. The NHS won’t survive another recession. 
We all have a duty of care- to our patients, to our health service, to each other. 
So Vote Yes. Then roll up your sleeves. 

There is work to do.


As an NHS doctor, I like Facts. Vote Remain.

I’ve just voted. I voted for the UK to remain in Europe.

Why? Well, here’s been a lot of partisan opinions and dog whistling on both sides of the debate- the level of discourse has been a lot like a mud wrestling much- both sides have smeared each other in so much muck that you can’t really tell them apart, and you stop caring.

That isn’t surprising. We have a government right now built on the principle public relations is more important than policy, that what you say and how you appear saying it is far more important than what you do. Sentiment over substance. Both sides of the Tory schism have led the same way, into farce. The whole thing has descended into an Eton schoolyard spat, with Nigel Farage the slightly odd kid no one plays with suddenly joining in, shouting “get him Boris” and other, more racist, things that make everyone uncomfortable.

So I’ve ignored it completely; maybe you have too. Instead I turned to social media, and through my own research made a decision to Remain, based on facts and figures and nothing else.

What’s my conflict of interest? Full disclosure; I am the son of a non-EU immigrant (who is voting Leave FYI), I was state educated and  trained and am a junior doctor in the state run NHS. I pay my taxes, vote left of centre, and have a cat from Latvia. As a junior doctor no one despises Cameron, Osbourne and Hunt more for what they are doing to the NHS.

So why on earth would I side with them?

As a doctor I like facts. Cold, hard, rigourous facts. I don’t like subjectivity, vagueness or b******t. I also like human beings. I don’t like discrimination, inequality or suffering.

So here are some myths and some corresponding facts that changed my mind. Maybe they will change yours.

Here are some great sources – read them for yourself.

1) Europe is undemocratic and run by faceless bureaucrats

2) Europe costs £350 million a week

  • No. This is the gross payment to Europe, but we rebate nearly half that every year- to farms and universities. So the ‘cost’ is variable, but much less – from £168million/week to £250million/week.
  • £250 million sounds like a lot/ week- but it works out about £4/person per week, or £16/person per month.
  • For £16/month we get easy access to a market of 500million people, which means many small businesses in the UK can sell to the EU as easily as to customers at home. This is a very good thing. We send ~45% of our exports to the EU. 
  • Renegotiating all the deals would be possible but: we would have p****d off Europe, we will have pound less strong against the Euro, and we would still have to allow free movement of labour.

3) We could spend that money better on health, like the NHS

  • This is wrong, but I welcome the support.
  • The NHS is drowning with Tory underfunding- but it’s the fault of our government, not the EU or immigration.
  • In 2008 illegal and fraudulent banking practices crashed the world economy.* As a consequence our Tory government decided that the way to repair the economy was to cut public services, and they took £20 billion out of the NHS in assets, and froze the budget, despite rising demand. They plan to take another £20 billion by 2020 (including their proposed ‘extra’ £10 billion), and create the least relatively funded decade for the NHS in it’s historyThe same banking practices have already started to return by the way, although what this means isn’t certain.
  • The economy will recede again if we leave the EU – I don’t really see how it can’t. Economists worldwide agree : but ignore that fact for the moment. A market we export 40% of our goods into, have extensive trade links and agreements from selling into, and have been a part of for 40 years just disappears from our economy overnight. Yes, perhaps we can recover – maybe we can trade more with Brazil, and China, and the US, maybe we can set up the same agreements again with the EU. In the meantime, which will be years, not months, Britain could lose as much as 10% of GDP – that’s around £180 billion, or 1.5 x the budget of the NHS.
  • During the last period of austerity, worldwide it is estimated 250,000 cancer deaths occurred that otherwise wouldn’t have if the financial crash hadn’t occurred. Let me reiterate that – 1/4 million people DIED, because of financial fraud, in health systems dependent on employment for health insurance. This didn’t happen in the NHS, because of it’s public nature. But if there are further cuts to public spending, further austerity, the NHS will collapse. It might anyway. Money in healthcare means lives- don’t underestimate austerity as merely an exercise in ‘saving pennies’. It saves money from the most vulnerable in our society, and some don’t survive. It’s a crime too big to see.

4) We have to stop immigration and take control of our borders

  • 330,000 people came to this country last year. Half came from the EU, half came from non-EU
  • We already ‘control our borders’- we have full control over non-EU immigration, and all EU migrants have to present ID and passports to enter the country.
  • The arguments over immigration are flawed – read this
  • a) Essentially, leaving the EU won’t alter immigration from non-EU, which may increase
  • b) immigrants contribute more to the economy than they take out: they help us survive periods of austerity and economic downturn, like right now
  • c) 1.2 million British people live in the EU, and around 3 million European citizens live in the UK. If we deported everyone, and all the Brits returned, our population would fall, but we would have replaced 2 million working people with mostly retirees, who will draw a pension and use extensive healthcare and contribute less to the economy than the working migrants they replaced. Good idea?

5) Other rambling

  • We have to bail out the Eurozone all the time. No we don’t – we opted out.
  • The EU is a capitalist wet dream designed to oppress working people. Maybe – but look at the government we have now. (see next point)
  • We must leave the EU to escape the threat of the Transatlantic Trade and Investment Partnership (TTIP). This clandestine trade agreement between the EU and the US has been negotiated for the past five years in total secrecy – public, press and even politicians involved aren’t allowed to look at any materials. The whole thing was recently leaked – and has many scary and ultra-neoliberal proposals for companies to essentially sue governments on issues that affect it’s profits – like health and safety regulation, or state-provided healthcare. The government recently backed down and exempted the NHS from TTIP – but we haven’t seen the detail yet. To be honest I was planning on voting Leave if I thought we would escape TTIP legislation – but remember who our government is. Cameron basically invented TTIP and would sign up to it ‘in a second’. If we leave Europe we will be left with an even more far-right, ultra capitalistic government, and TTIP would just be imposed under a different name.

I may not have convinced you – but that doesn’t matter. Politics in the digital age is changing, it’s up to us to take the responsibility for how it changes. Will it become a divisive society of online echo chambers, neither listening to each other except to engage in Twitter trolling? Or will we grow up, critically seek out and appraise the facts for ourselves, escape the influence of newspapers trying to sell us sensationalist politicised rubbish, and see the world how it really is.

Remember people literally died for your right to vote. Whatever you do today, go and VOTE.


*How? Well, watch The Big Short, but essentially banks were selling mortgages to people who couldn’t afford to repay them, and then selling those debts bundled together to other banks, who then bet on those bundles to never fail, which they obviously, spectacularly did. Imagine your friend set fire to a bit of paper, and said to you “Here, buy this bit of paper, and keep it with your other bits of paper.” Which obviously started a bigger fire, and then you said to another friend “Hey, buy this fire I just started and keep it in your house.” And then someone came along and said to HIS friend : “I bet you £1 billion that house doesn’t burn down.” Sound stupid? This is actually exactly what happened.

To Tweet is to sit in judgement of oneself

‘To write is to sit in judgement of oneself”Henrik Ibsen

I got into a not quite Twitter war with Julia Hartley-Brewer recently, more of a Twitter scuffle, if you will.

It was over the reporting and discussion of the events in Orlando over the weekend. In the worst shooting massacre in US history, Omar Mateen, a 29-year old US citizen, killed 49 LGBT people at a gay-club called Pulse, using an assault rifle he was legally licensed to own and operate. Mr Mateen was both very likely gay himself, and a Muslim man who phoned police prior to the assault and claimed the shooting in the name of Islamic State, the group based in Syria and Iraq.

These are the tragic facts.

The subsequent controversy was not over any of this, but over a review of newspapers on the night the news broke, between Owen Jones and Julia Hartley-Brewer on Sky News, in which Owen Jones left the live discussion in disgust at what he felt was the ‘downplaying’ of the homophobic motivation of the attack.

On Monday Julia Hartley-Brewer trailed a Telegraph article responding to this ‘tantrum’ as she termed it, on Twitter.

I caught this on my journey to work and tweeted the following;

To which I got the reply;

Now I’ve watched that clip again, just like Julia has. What I see is this;

In the initial few minutes, Owen Jones, raw from the news of what must’ve felt like a very personal tragedy, frames the events as ‘the worst attack in LGBT people since the Holocaust’. The presenter and Julia Hartley-Brewer attempt to focus on the fact that Mr Mateen was Muslim and draws parallels to the Bataclan attacks in Paris. Owen Jones takes issue with this, stating the most important part of this is it was a targeted attack on gay people.

Then it all goes sideways. The presenter and Julia try to defend their position, with increasing volume, to say this was an attack from many angles, on human beings, on people ‘enjoying their freedoms’. I can see their point- this was, and it’s part of their job to make the news relatable to their audience- a predominantly white, conservative, straight demographic. I can also see the emotional element- both Julia and the presenter don’t want to seem as if they are downplaying the homophobic element, even though they perhaps without meaning to, just have. In their backtracking all sides get heated, and it gets worse.

From the perspective of Owen Jones, he suggests this attack was chiefly homophobic in nature, and then is shouted down by two straight people. That’s his perspective and that’s how the Internet, rightly or wrongly, saw it too.

Owen Jones is silenced. A few minutes later it seems a word in the ear of the presenter tries to salvage the situation by pointing out the Telegraph article does mention a viewpoint from Stonewall, the LGBT group. But this conciliatory bone backfires.

Owen Jones walks out.

I can understand his frustration, and it isn’t just with the two presenters.

It’s with the medias obsessive fixation on framing all events into a single narrative. It’s with the predictable and sensationalist attempt to focus on this as an ‘Islamic’ terror attack. It’s with the lack of empathy the mainstream media shows to diverse groups, and how shoehorning this tragedy into a narrative that didn’t fit actually neglected the point- this was an act of hate against a specific community, and to downplay that fact is to ignore any meaningful lesson of tolerance from it. To downplay it in favour of another lesson of intolerance, towards Muslims, is a downright dishonour to the memory of those that died.

To Julia’s credit she does state this was a homophobic attack, more and more after Owen leaves. And she makes the key point- the access to guns, especially assault rifles, is what made this tragedy so utterly awful, nearly farcical in how preventable it could’ve been. But it seems like both presenters are put on the defensive, so they have to shout back, and louder.

Hence this deplorable and ridiculous Telegraph article, comparing Owen Jones to Islamic state.

I suggested it might be meaningful to be conciliatory – but that 140 character message fell on deaf ears.

If I’m perfectly honest I don’t think anyone in this situation acted particularly terribly. But it was a great example of what is fundamentally wrong with our society.

1. We as a collective don’t have a ‘knee-jerk’ reaction to intolerance of LGBT people like we do for racism, sexism or anti-semitism. That’s because ultimately mainstream society isn’t fully comfortable with the LGBT community. Tolerant, overall, perhaps. But not comfortable the way we are with race nowadays. It’s an ugly truth- but one that reared its head in this interview.

2. The fact this dissolved into a left wing vs right wing argument nearly instantly shows how divisive we have become as a society. I hate both words, they are simply different excuses for not listening to each other, and increasingly dangerous in the 21st century. Labelling every discussion as right wing or left wing renders the complexity meaningless.

Medicine teaches you that nothing is simple, nothing is 100% true- this world view simply doesn’t apply to humans. No one is 100% right. We can only make decisions based on the best evidence available.

“Your perspective on life comes from the cage you were held captive in.” ― Shannon L. Alder

This is the truth from my perspective;

– Omar Mateen was a repressed gay man in a culture he felt he couldn’t be himself in. This led to deep self-loathing and depression

– Omar Mateen had access to assault weaponry no country should allow such unfettered access to

– Omar Mateen latched onto a terror group ideal as a means to validate his lonely existence and violent death

But maybe I should just ‘stick to things I know about’.

Another Twitter ‘scuffle’ for another day. 🙄

The junior doctor contract? It is #timetovote

This junior doctor contract dispute has been built on a lattice of hashtags; #iminworkjeremy, #weneedtotalkaboutjeremy, #moetmedic, #timetolisten, #timetotalk.
Now it’s #timetovote.

The referendum on the new junior doctor contract opens this week: we as a body of professionals need to decide what it is we have been fighting for.

Was it the least worst contract we could squeeze from the nightmare we started with?

Or was it safe, fair and equal working conditions for junior doctors for the next generation?

The problem is it’s really not as simple as that. A vote No won’t automatically give you opportunity to renegotiate. A vote Yes won’t automatically mean the contract as it is now will work as you want it. We’ve covered this before.

So consider the work you are willing to put in.

And consider what is happening still with the NHS.

Despite a national news hiatus on this topic, local news picked up Jeremy many times last week;

In the Yorkshire Post Mr Hunt claimed the contract was a good one, and he hoped doctors would listen to the BMA JDC head, Johann Malawana. After a year of being told the BMA ‘misled’ us, now Jeremy tells us the opposite.

Then in a speech just as the contract was published, Jeremy Hunt claimed the NHS needed to go on a ‘ten year diet’, completely ignoring the gaping holes in service and funding that this government have created.

Lastly, this story in the Birmingham Mail. Jeremy Hunt defends cutting 450 clinical jobs from West Birmingham Hospital Trust because ‘some of the safest hospitals in the world actually had a relatively low number of staff’. One of the most ludicrous collection of statements in a spectacular career of lies and spin about the NHS. It’s worth ripping through this.

-“… after Mid Staffs …some trusts understandably staffed up very quickly…But in too many cases they did that by recruiting agency staff.” No- the substantive budget requests for staff were refused by no.10, as detailed in this PAC report, meaning hospitals had to hire temporary workers to make sure wards were staffed. Both the staff crisis and the agency overspend were the fault of government, not trusts.

-“Virginia Mason in Seattle, which is held up as a beacon in terms of safe care globally, actually has relatively low [staff] ratio”. No- Virginia mason has 480 doctors for 330 beds (1.45 doctors/bed)  the NHS has 110,000 hospital doctors to 150,000 beds (0.73 doctors/bed).

-“What they do is ensure that 90 per cent of nurses’ time is spent with patients. Not filling out forms or dealing with bureaucracy in the system,”. No- there are no studies looking at safety and paperwork, but plenty looking at nursing levels and finding a direct correlation with survival, for example in stroke.
Lastly this week again Virgin Healthcare was granted a huge NHS community project in Kent worth £126 million. The CCGs made the pick because it was cheaper, but acknowledged quality was poorer. NHS improvement meanwhile have covered themselves in glory by redefining ‘safe staffing’ despite explicitly promising not to.

The direction of travel in the NHS is clear: reducing costs by cutting quality and safety, and privatising the rest, while spinning a story to the public miles from reality. Bear that in mind.

Now I campaigned for a contract that was safe for doctors and patients, fair to our diverse workforce, and protected working conditions in a future NHS that will be very difficult indeed.
Is this contract safe? On paper yes – the new safeguards reduce runs of shifts and provide a system that could both address individual overworked doctors and collect data on understaffed rotas for the first time. But in practice? In practice there has been no groundwork laid for the expanded roles of educational supervisors, no realistic investment in the Guardian role in many trusts, and the financial pressures on hospitals right now are mounting. I simply cannot see hospitals having the will, the manpower or investing the resources to make this work. The old banding system was difficult enough- some trusts actively hid hours monitoring data, and flat out refused to sort out rotas that breached safe working. But where it did function, speaking from personal experience, it worked very well and effectively.
Is this contract fair? Without a doubt this contract discriminates against women, mostly through the negative impact on LTFT working. Both the government and the BMA have made some inroads to address this- while front loaded pay will level some losses, LTFT trainees previously were paid more per hour to mitigate the impact of child rearing on a career, and now this is lost – a huge paycut for this group.

Now you might not agree with positive discrimination, but I do, for two reasons. 1) I don’t care what the doctor working next to me gets paid more per hour, but I do care that there IS a doctor working next to me. We simply cannot afford a contract that pushes 60% of the workforce closer to leaving. 2) we don’t work in a job where time at work = experience = value. My LTFT colleagues have often been doctors for longer, have better personal development and are generally more experienced than me.

For academics there has been progress, and those changing specialties for partners, care needs or disabilities enjoy new protections. But for me, it’s still not better than what we have now.
Retention. The work-life balance of doctors in the current NHS is poor already. Service provision takes up an increasing part of training time, and this will only get worse as pressures increase. The new contract means moving doctors from 1:4 weekends to 1:2 weekends costs trusts nearly nothing, £60 per month over the training lifetime of a doctor. Weekends are inherently poor training periods, and working additional weekends will pull doctors from the weekdays, where training opportunities are plentiful. The negative impacts on both training and social-work balance will massively affect retention. Not to mention the toxic attitude the DoH and the SoS have taken to juniors- who will continue to provide goodwill in a system that has shown us we are not valued? Pay overall will remain the same, but for significantly worse conditions.
I don’t think this contract is safer, fairer or better than what we have now.

It has promise, but we cannot build a safe future workforce on promises alone. The safety aspects need trialling, tightening and evidencing that they can work in reality as they are supposed to. They shouldn’t require vast amounts of junior doctor time to function either; we have enough to do between service, and the little training we have, to be our own administration and human resources departments as well.

The contract needs to readdress it’s discriminatory stance on women, and provide better incentives to retain the LTFT workforce. We can’t slide back on equality in our profession, it’s unacceptable in the 21st century.

This contract doesn’t address fully HEE as an employment body- we all still remain without career whistleblowing protection.

This contract needs to remember what it was supposed to be about at the initial heads of terms- a fairer system for pay, that improved doctors working conditions and work-life balance, in recognition that the NHS is collapsing and the work environment becoming toxic.

There is no plan for ‘7-day’ NHS working that I have seen. The contract has made it cheaper for doctors to work weekends, but there aren’t any more doctors to cover the days or the additional hours. There is no evidence linking any element of the supposed ‘weekend effect’ to junior doctors, and the ‘weekend effect’ itself has fallen apart under scrutiny. So there is no rush to change any contract.

I’m going to vote No.

I’m going to campaign for a year moratorium on the new contract, to trial elements of the safety parts, to try and renegotiate elements of everything else, and to cool off this whole dispute so the politicians stop sniffing around it.

This is a sensible, considered, rational choice. I respect it might not be yours. It’s time to decide.

It’s #timetovote

The Choice Part 2: No

In another two part post, juniordoctorblog and guest writer Dr Hugo Farne look into the futures of a ‘Yes’ or ‘No’ vote on the junior doctors contract. 

Read Part I- ‘Yes’ here.
We don’t know yet what a ‘No’ vote for members will mean, or even what a referendum result will have to be to be truly accepted as a No by JDC and government. Let’s assume for this psychic exercise that it’s overwhelming. 

Here’s what might happen; 
– the JDC exec will resign- new representatives will have to come forth and a new negotiation team and strategy formed

– The government may impose the contract

– Justice 4 Health may proceed with a legal challenge to imposition. It’s uncertain if the BMA will proceed with their legal action

Here’s what definitely will happen; 

– Everyone will be angry
So what next?

We can model a No vote into five scenarios; 

1. Accept an imposed contract

2. Call for a delay while new negotiations and JDC committees are chosen

3. Campaign for a better contract from the May starting point

4. Campaign for a complete withdrawal

5. +\- Campaign for specialised contracts 

1. Accept an imposed contract 

This obviously is the worst outcome of a No vote. There were significant changes in the ‘imposed’ contract from the terms discussed in February, terms such as the Locum fidelity clause and the ‘we can change anything anytime’ clause. However, there wasn’t a full terms and conditions published at that point which we do have now. How the government would justify republishing terms and conditions without looking as if they are taking advantage would be tricky. It would also give ammo for further protests if the government were to backtrack on what was agreed with the BMA.

2. Call for a delay while a new negotiations committee is chosen

Slim chance of government listening if they think they can impose without a publicity storm. But if they do the BMA can have time to rebuild and reconsider their position and the ongoing strategy, realistically delaying events for six months. A long time in politics and also a cooling off period. Negotiations could start afresh- the govt may have more PR room to manoeuvre, concessions and changes more accepting to junior doctors could happen. 

3. Campaign for a better contract from the May starting point

This would be the single most difficult option of all. For the simple reason that justifying increasing protest for what would be small incremental changes from what the BMA accepted would be very difficult. Public support would be stretched, especially given the whatsapp leaks story, which has yet to be definitively addressed by the BMA. 

4. Campaign for a complete withdrawal; the ‘leave us alone’ option. 

A campaign predicated on this would bullet point to;

– the new contract is less safe and no better than what we have now. (This really comes down to the implementation) 

– The toxic contract has damaged morale and retention- the longer it is threatened the worse it will get

– The reasons for original imposition have been since found to be invalid: no link between junior doctors and weekends, no money for seven day services.

– If the new contract is cost neutral then why is it necessary given the above?

– The new contract is still discriminatory against women

But also remember that the public didn’t really get our message the first time. They supported us yes, but the safety message did not register in the polls: most of the public thought it was about pay and conditions. The real question is will they continue to support us?
This argument is particularly hamstrung by the fact that the BMA has accepted and promoted this contract. 

The counter message here would be;

– we didn’t accept it- the grassroots said No

– The BMA has to respond to the membership

– It was the best deal from a bad one- but why did it have to be a bad one to start with?
5. +\- Campaign for specialised contracts 

The difficulty with much of this dispute is in the increasing specialisation of medicine and consequent variability in working practices. What is right for A&E and ITU, providing essentially 24/7 services already, won’t suit GPs or clinic-based specialties (e.g. dermatology), with relatively little overnight work. Maybe it is time to move away from a one-size-fits-all contract, and from a single negotiating team. Let experts from each area design their own working patterns and contracts, within the same cost neutral envelope (Foundation doctors will need a separate deal). Invite BMA representatives with an appropriate background and/or representatives from the relevant Royal College, who set the training curriculum. Empower them to come up with the solution to their own speciality; how to remunerate the different duties of the week that is deemed fair and provide appropriate incentives to encourage retention. At the very least they will have no one else to blame, and in all likelihood they will find a better answer.

So that’s what ‘No’ might look like. If you haven’t read Part 1- ‘Yes‘ yet, go and do so here.


All of these scenarios will require work and time and support. If you want to vote no, be prepared to fight a very uphill battle. If you vote yes, be prepared to fight to make the contract function as it should in your hospital. This is your 99% perspiration- whatever you choose, it will require your blood, sweat and tears to make it work. 

Choose wisely. 
with guest writer Dr Hugo Farne

The Choice Part 1: Yes

In another two part post, juniordoctorblog and guest writer Dr Hugo Farne look into the futures of a ‘Yes’ or ‘No’ vote on the junior doctors contract. 
Read Part 2: No here.
Assuming a close vote, even a slim ‘yes’ majority will likely mean full implementation. 
What will that look like?
– the Guardian system is coming online this summer. Guardians are senior medical appointees not holding another board position- hours around 8/week. 

– The timetable for implementation as it currently stands looks like this.   

 – Pay protection will keep pay on the old system up to 2022 for current ST3+ registrars. However the other terms of the contract will still apply as above.

– New rotas to support the governments ‘seven day services’ should start to appear before that, and may apply before the new contract does, and definitely before pay protection ends. 

– Junior doctor forums should be formally convened by the DME and Guardian of each hospital. 

– You should be issued with ‘work schedules’ and notification of your educational supervisor in advance of starting. 

So far so good. But will this work? As Edison said, genius is 1% inspiration, 99% perspiration. Put another way, new ideas are easy to come up with but hard to make happen. Can the NHS and this contract actually achieve what we have been told it sets out to do?
Early noises coming from rota designers suggest not. Indeed, the new restrictions on hours may perversely result in rotas that are worse for work-life balance, continuity of care, and training opportunities. Combined with the need to maintain service provision levels, i.e. have the same number of doctors on at any given time as we do today, it is very likely that rotas will require more staff and hence cost the taxpayer more. 
Take the example of the limit of 8 consecutive days, with a minimum 48 hour rest period after. This will end the common practice of working 12 consecutive days from Monday to the following Friday. This sounds good, but in practice doctors will have to work more weekends to make up their hours. Why? These doctors are currently rostered to work an average of just under the maximum 48 hours a week. That is usually a mix of 9-5 or equivalent 40 hours/week and an additional 8-hours of on-call time. With the new regulations after an 8-day run two additional weekdays will be taken as ‘rest’. As a doctor is rostered up to 48 hours per week, these additional hours have to be made up somewhere, and all of the weekdays are already being worked. Hence doctors may go from working 1 in 4 weekends to at least one weekend day in almost 1 in 2 weekends to make up hours, a significant deterioration in work-life balance. 
The enforced weekdays off also limit training opportunities, which are predominantly on well-resourced weekdays, and continuity of care for patients. Moreover to maintain staffing levels during the week, more doctors will be needed on the rota to cover those now forced to take weekdays off. More doctors who would cost money – except for the fact that they don’t exist, so could not be recruited even if the fund were available. 

Another example is the stipulation that annual leave can only be taken on weeks when a doctor’s shifts fall entirely between 0700-2100. For those working in A&E, where service requirements are greatest in the afternoon and evening, rotas contain few if any weeks meeting these criteria. This essentially consigns A&E doctors to fixed leave.
How has this happened? It may be neither party could foresee all the permutations. What will be the result if trusts do not have the staff or the fund to provide junior doctors both training opportunities and safe working hours? It is not inconceivable that both sides may find themselves renegotiating the detail and pushing back the deadlines. What will happen then? Some possibilities for renegotiation are discussed in Part II- No
Perhaps the rotas will work out- through as yet unseen additional MDT staff or changes in working practices. Or perhaps breaches will start occurring regardless: what will happen then?
Well that will be up to you. If you vote yes and walk down this road you are taking away a No vote, and vice versa. In doing so you are taking on the responsibility to make this contract work.
– Firstly you will need to join your local junior doctor forum, and make sure every junior in your hospital does the same. 

– The JDF must actively engage your Guardian and encourage a close relationship

– The JDF must make a group management presence: a seat at the table in decisions about training, rota gaps and educational facilities

– The spending of penalty fines must have proper and rigorous oversight, with proper debate amongst trainees and consensus how these funds should be spent. 

– Any breach of the contract must be challenged by the forum as a whole; any individual trainee told to stop reporting breaches, any rota gaps hidden from view, any penalty money spent without forum involvement, any Educational supervisor not functioning as they should. 

– The JDF must work hard to improve the morale and working conditions of all juniors: this could include reinstating the mess,  providing emotional support and even whistleblowing protection, perhaps by coordinating group reporting rather than individuals.

Of course these are just more ideas. We will need more than inspiration if any of this is going to work. But if there’s one thing we’ve learnt from the last few months, it is that there are thousands of junior doctors willing to put in time and effort to fight for their contracts – more than enough to provide that 99% perspiration.
So yes or no?
Read Part II- ‘No’‘ before you decide. with guest writer Dr Hugo Farne.