Junior doctors are left with few options, none good. What now?

Today the independent judicial review into the junior doctor contract imposition legality, put forth by the five junior doctors who make up Justice 4 Health, closed.

Justice Greene found in favour of the government, upholding their peculiar defence that Jeremy Hunt never actually imposed a contract, leaving it up to local hospitals to decide if they want the new contract or not. This, despite the fact that Jeremy Hunt has repeatedly hit the ‘nuclear button’ of imposition in TV interviews, parliament and speeches. Here is a quick video with some obvious examples;

As ludicrous as it seems, legally we have told all of this was an ‘irrelevance’ and although the judge suggested Jeremy Hunt could’ve been less ‘ambiguous’, the High Court rules that the contract was never imposed in the first place. News to 54,000 doctors, and no doubt many patients who were adversely affected by strike action against imposition. This final legal clarity prompted the question; if Jeremy isn’t imposing, who is? Well it would seem hospital trusts are imposing , and therefore can we now negotiate directly with them?

NHS Providers quickly tweeted to crush this speculation – they want a nationally agreed contract, and suggest there will be no local negotiations.

This of course follows in the same week that the BMA JDC have decided to suspend further strikes, and instead are now calling a symposium to which they have extended Jeremy Hunt an invite- whether he will turn up or not remains to be seen. Seeing as how he hasn’t turned up  to any of SEVEN crisis meetings in the last year at his OWN organisation I’m not holding my breath.

So junior doctors are left with few options. None of them good.

The first question is – do you accept the contract or not?

 

If doctors accept working under this contract, that still disadvantages women and LTFT workers and still is worryingly untested, then they must actively engage to make it work. This means forming local doctor forum, helping develop easy apps to exception report and challenging behaviour anywhere in the hospital that doesn’t meet the terms of this contract. If things go south, as these early rotas from obstetrics and gynaecology and emergency medicine anecdotally suggest, doctors must be vocal, and the BMA must back it’s members, although their powers may be severely limited.

If you don’t accept thev contract;

You essentially have few options. A lot will depend on how well organised doctors are from this point forward – with the BMA in full retreat this seems unlikely.

  1. Leave training – the imposition of the new contract is for trainees – going out of programme, into locum work, into research, or even abroad will mean you continue working as a doctor, but you aren’t subject to the terms of the imposed contract. For those at the end of training, finishing up and then moving abroad is a sensible option.
  2. Try to negotiate locally- whether individually or en masse doctors could offer to stay on the current contract, or organise a mass resignation against rota and contract conditions. Despite the bluster of NHS Providers it seems unlikely that hospitals will force a new, ‘cost-neutral’ contract at the expense of all their doctors. That is contingent of course on Health Education England, the training body of doctors, not imposing the contract by the back door and pulling funding for trainees who do not comply with the new contract.
  3. Offer your own contract. This isn’t as mad as it sounds – making a counter offer is a standard employment arrangement in most industries, just unheard of in the NHS. A contract that doesn’t discriminate against women, pays for study and has fair and safe rota arrangements isn’t too much to ask. But it seems unlikely.
  4. Bide your time. The contract is scheduled for review in 2018 – rumour has it Jeremy Hunt will be gone by then, and this may no longer be such a contentious political issue. With sufficient evidence of poor patient care and unsafe rotas, a renegotiation may be viable.

However, consider the context of the NHS. Over the past three years by every indicator the NHS has fallen into decline – waiting times, deficits, and now even hospital department closures, due to lack of staff. A new Autumn Statement might bring more money to the NHS, but having been through it’s most austere decade in it’s history, it’s even-odds whether there will even be an NHS at all come 2020.

For me, I left full-time training in August and have no plans to return. This contract dispute highlighted a multitude of problems with training to start with – but the utter contempt our NHS leaders, our government and their solicitors, and even some of our own seniors have held their trainees in appalls me. It has become a toxic environment for training and working. As a flexible worker I feel appreciated and needed, train and study when I need to, and most importantly, see and look after my family.

It’s up to the individual doctor what they do from here. If you can live with the contract, live with it. If you can’t, then find some way to find someplace you can. I fear too many will find that place outside of the NHS. With a collapsing union, a rejected judicial challenge, a toxic training environment and a complete lack of political will to shore up the health system, can you blame them?

 

juniordoctorblog.com

 

 

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.


Summary

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.
Juniordoctorblog.com 
with guest writer Dr Hugo Farne

THE OFFER: Part 2- the Context

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

 

 

 

THE OFFER: Part 1- the Contract.

The decision to accept or reject these new terms and conditions is not only about the contract itself, but the context it sits in. In a two-part behemoth blog post juniordoctorblog looks first at the contract, and then the wider situation in the NHS.

Part 1: Let’s look at the contract. Read Part 2 here.

Unsafe?

There has been some movement between the March offer and the May offer on the safeguards for doctors working. The hours limits have been reduced, but realistically these are meaningless without a robust mechanism for enforcing them.

The new contract specifically removes ‘monitoring’, but more heavily involves the BMA/ local junior doctors in the process of ‘safeguarding’. This is a quick summary of the proposed new system for ‘breaches’ of hours.

  • The junior doctor reports a problem – this is called an ‘exception report’. This can be a problem about overworking on hours, or the post being inadequate training.
  • This ‘exception report’ goes to the junior doctors educational supervisor, with a copy to the guardian of safe working (see below) or to the director of medical education.
  • An initial meeting between the junior doctor and the educational supervisor occurs where the educational supervisor reviews the report and can remunerate the doctor, make changes to their rota or do nothing.
  • The junior can appeal up the chain – first to the guardian and DME and then to a panel – with the BMA or other sending a representative to sit on the panel.
  • The trust will collect data on rota gaps and report this to the GMC, HEE, and GDC. A copy should go to the junior doctors forum
  • The junior doctors forum will be formed by each DME and ‘advise’ the guardian on spending of funds produced from penalty fees paid to doctors who are overworked. The exact split of how much will be paid to the doctor and how much to the hospital is TBC

Here is a diagram from the BMA that outlines this process.

Hours diagram

I have a number of issues with this system

  • The process from first reporting to sitting before a panel if an exception report is not dealt with properly is approximately 16.5 weeks at a maximum. That’s through every level of escalation. Seeing as how most placements last 4 months, and the doctor isn’t going to report on day one, this seems wholly unfit for purpose
  • The process puts a huge onus of responsibility on the educational supervisor, assuming powers that they certainly do not have currently, namely;
    • The power to create ‘learning opportunities’ in a work schedule. Imagine an ITU consultant ‘creating’ a clinic for a trainee to sit in, or an Oncology consultant ‘creating’ a procedures list.
    • The power to give time off in lieu or renumeration – mostly ES don’t work in dept or with rota managers, let alone HR – so how will this work?
    • The power to remove doctors from posts and initiate system-wide changes, especially as “The educational supervisor may be in a different department, and occasionally in a different organisation, to the trainee”
  • The final decision on an ‘overworked’ doctor is ‘final’ at the panel
  • ‘Breaks’ – have to be taken at approx 30 minutes/5 hours or 2x 30 minutes in 9 hours. ‘Breaches’ related to missing breaks are to be ‘validated and found to be correct’ before any action will be taken. 1) Who covers during a break? Most shifts I’ve worked have been the bare minimum staff, so what is the arrangement to have a break? 2) Who is going to validate and find this correct? 3) Is it a ‘break’ when you are carrying a bleep?
  • Overnight rules regarding rest are welcome – if <5 hours rest or working continuously when on-call the doctor is ‘exempt’ from the next days work. But there is no provision in the contract for anyone to cover. How do you go home as the surgical registrar for example on a saturday after on-call if there is no surgical registrar covering?
  • The involvement of junior doctors in the running of their training is a good thing – but what is to stop them being sidelined in hospital? To my reading there are no mandated reporting of the guardian to the JD forum, no powers to stop a guardian appointee missing meetings and not engaging. Will this work in smaller trusts?
  • The entire removal of ‘hours monitoring’ is still the worst thing about this contract. But there may be a solution – see below.
  • There are many references to doctors being asked to make emergency cover arrangements, exceptional circumstances to cover rota gaps and accrual of ‘time in lieu’. Looking at the context (See linked post- Part 2) of the contract, I worry these are all clauses that will enable hospitals to stretch their workforces far farther than was previously safe. Despite the assurances that ‘breach’ penalties will be paid – the money now goes back to the hospital. This effectively removes any actual financial penalty to the hospital, and remains cheaper than hiring more substantive staff or hiring locums. In times of austerity I am concerned this will lead to hospitals relying on their juniors to plug gaps. But more on this in Part 2.
  • The guardian role. I have many issues with this;
    • The time commitment is ‘dependent on the size of the organisation’ but a singe guardian can still cover multiple trust sites. There needs to be a maximum number of trainees/guardian, the role has to be full time (previously advertised at 1-2 PA’s a week, equivalent to 4-8 hours work for a consultant), and must be completely independent from the board and HEE. Only independence is stipulated in the contract so far.
    • ‘Funds’ distributed from ‘penalties’ can go to ‘expertise in rota design’ and ‘service improvement projects’. There is nothing stopping trusts taking ‘penalty’ money from overworking doctors and funding more HR staff, or a ‘service improvement’ project unrelated to junior doctors conditions e.g. repainting A&E.
    • ‘Work schedule reviews’ are triggered when the trainee believes the rota breaches the contract hours. How a guardian, who will be a senior consultant most likely in an unrelated specialty, will change rota’d hours and work commitments in another specialty seems practically very dubious.

Overall on safety I welcome the headway that has been made on what was a travesty of a contract in March, but I still think it doesn’t go nearly far enough, facing the crisis the NHS is heading towards.

Unfair?

On equality – the contract makes some important in-roads

  • The Guardian is seconded to ensure equality and diversity are respected, and that a ‘champion of flexible working’ is appointed within the educational faculty
  • HEE have promised to make a review into married couples and civil partnerships, and those with caring responsibilities, to make joint applications or transfer between regions more easily. This is supposed to happen next year. We will have to watch this very closely.
  • Transferring specialties for those with disabilities or care responsibilities will attract pay protection.
  • The flat nodal pay structure doesn’t disadvantage women on maternity in registrar training
  • Additional proposed steps for women re-entering training from maternity, or academics returning to training receiving flexible pay premia.
  • Pay protection until 2022 will mean those in registrar training now will not lose out, even if they take further time out e.g. for maternity or academia
  • Changing specialties may be further improved by a ‘mutual curriculum’ recognition programme to review next year

There are still issues here;

  • Non-resident on-call pay allowance is proportional to the amount of time spent in work. This means that two junior doctors are paid at different rates for the same work. That is not acceptable.
  • If you are non-resident but feel that going home is unsafe, the hospital will charge you for on-site accommodation, therefore you will be paying the hospital to work for them. At LTFT rates this will actually cost a significant sum per hour.

On pay

This is the most complicated part of the contract, and it’s complicated by the fact that we as a profession all work very different rotas, with different time commitments, on-call arrangements and duties, plus the point at which they are now in training. Johann has posted this cumulative comparison chart – both general and per specialties to review.

chart

 

I still propose that everybody works out for themselves exactly their own earnings over their training lifetime – e.g. from F1 to ST8 or whichever, on both the old rates and the proposed contract. Remember to exclude NI (now 12%), pension pay (which is removed from your basic ONLY), and tax.

Here is a complex calculation I did – based on a medical rota of 40% 1B banding;

Night rotas

As you can see the lifetime take-home pay for a 40% 1B banding on the old rota, compared to a 1 in 6 weekends, 1 in 6 nights rota (4 nights every 6 weeks at 12/hr per night), is a very slight pay rise, over 10 years of training, of around £600/year. However on a 50% 1A banded rota, roughly 1 in 4 weekends, 1 in 4 nights rota (again 4 nights, 12hrs/shift, every 4 weeks e.g. typical ICU) it’s a slight pay increase, £300 per year take home pay. So while the ‘basic payrise’ disappears in take home pay, it does increase your pension however, I have yet to calculate exactly by how much. Whether or not this is acceptable to you is a personal opinion.

(Please post your individual calculations in the comments below with the conditions and your working, so we can get a collective sense of how everyone will be affected. Remember your vote is for yourself, but also for your colleagues.)

The real issue here is how out-of-hours work scales – the pay difference between a 1 in 4 weekends, 1 in 4 nights vs a 1 in 2 weekends, 1 in 4 nights, over your lifetime is about £500/yr. As in for working twice the weekends you were previously (and for work the definition is any hour worked on the weekend), you will be paid roughly an extra £60/month. That won’t really cover twice as much childcare for example. As pointed out previously, ‘acute’ specialties will lose out the most.

Inflation:

  • It’s important to remember that with the pay freeze since 2009 Junior Doctors have lost 25% of their income.
  • With further below inflation pay rises we stand to continue receiving this stealth pay cuts: 1%, 0.9% and 0.8% over the next three years, with inflation predicted to rise between 1-2.5% by 2020.

This doesn’t take into account non-resident on-call or flexible pay premia pay.

  • On NROC I see two main issues.
    • The ‘prospective’ average estimate is not going to actually work – shifts will vary wildly between having to be ‘at work’ and not, depending on several factors, some of them dependent on the individual doctor. The contract is very specific; ‘work’ is any clinical work, including telephone calls.
    • I can imagine pressures on judgement for doctors that preferred to ‘go in’, if they are outliers in a rota where most people don’t. This creates a mechanism for monetary considerations in clinical judgement. I find this unacceptable.
    • Again, the 8% on-call allowance is acceptable, as long as work done on-call is paid for at the prevailing rate, and it is still safe to regularly work the next day. This will take exceptional vigilance on behalf of individual trainees- more on that below. Again this will be overseen by educational supervisors and guardians of unsafe working.
  • On flexible pay premia; for academics this is good, and for hard-to-fill specialties this may be good, although I imagine the amounts spread over training and subject to tax would make very little difference to take-home pay on a monthly basis, especially in hyper acute specialties already losing out on unsocial hours like A&E.
  • Pay protection is rubbish. Please do not rely on this. The ‘cash floor’ is created by your earnings plus allowances on 31 October 2015 or 2 August 2016. This does not take into account the rise in salary you would be due if you weren’t on the new contract, and only protects your basic. Allowances for weekend and unsocial hours are calculated on your new basic, in the same way.
  • Locum work: this is going to be a disaster. The assumption is the majority of us are in training and doing sneaky extortionate locum work through agencies. Forcing us to work through a staff-bank for shifts isn’t going to change a thing. Why?
    • 1) Most full-time trainees cannot safely do agency locum work on top of their existing training commitments. I have probably done maybe 5 locum shifts in my career.
    • 2) Most agency locum doctors are not in training- therefore unencumbered by these clauses anyway
    • 3) Even if the odd shift we work on top of training was covered as an NHS bank instead of as agency bank, it would still leave the majority unfilled. Usually this worsens cover for substantive trainees, making conditions harder and dangerous.
    • 4) It’s also unnecessarily punitive, and generally annoys people to think that a contract can monopolise their personal time as well as the time they spend at work.
    • 5) I suspect this will actually diminish the part-time locum market, making posts harder to fill.
  • Again this comes down to the context of the NHS right now – see Part 2 of this linked post.
  • Pay for work done. Through the guardian system you will need to be ‘authorised’ for additional hours, either before, during or sometimes after the hours worked, if you want to be paid for them. This does not reflect our usual working practices, and the contracts refers us to our ‘manager’. I have never really known who my ‘manager’ is, and as for staying late it’s always been for emergencies, when seeking authorization is not practical or safe. Again any monetary concern interfering with clinical practice is unacceptable.
  • There might be ways to sort this – but it would need to have a clearly defined ‘manager’ who is reachable 24/7, and routine acceptance of ‘after-action’ authorisations for additional hours. I can already foresee this falling apart instantly.

Overall on pay I think most people will see no difference in pay, if they stay on current rotas. However, with the proposed rotas yet to be seen, you will see a substantial drop in pay for increased unsocial hours that you would’ve previously received. If your rota goes from 1 in 4, to 1 in 2 weekends, you will be paid pretty much the same. I’m happy to be corrected on this by anyone who sees flaws here – this will need to be a collaborative effort to try to ascertain the impact the contract will have.

What else?

  • There is a clause in the contract saying HEE actions are subject to reporting ‘without detriment’ to the individual junior doctor. This is regards to the Chris Day case – I have spoken with Chris and he doesn’t trust a contract clause like this to actually stand up in law. It needs a law change to back it, to protect trainees like Chris.
  • Leave is only allowed during ‘non-enhanced hours’ work – which now means only between 0700-2100 and no weekends. This isn’t dissimilar to current arrangements, but if rotas increase out of hours unsocial work then actually swapping to arrange leave will be difficult.

 

Summary

Overall I think it comes down to trust. Do you trust your hospital and your bosses to be able to implement this contract without compromising your safe working, and to listen to your concerns if it does? Do you trust your hospital and it’s managers to honour its agreement on pay for work done, and to not create rotas which are punitive and cover a lot of excess unsocial hours? Do you trust your hospital and your health secretary to listen to your concerns when the contract is reviewed in March 2018?

This is a comprehensive FAQ from the BMA : https://www.bma.org.uk/collective-voice/influence/key-negotiations/terms-and-conditions/junior-doctor-contract-negotiations/new-contract-faqs

Think on this carefully. Then think on your vote; remember the ‘referendum’ will only guide the JDC, so if it’s close it will be far more difficult than if it is clear-cut.

This won’t be a simple vote on whether you find this contract acceptable or not. Both options will require ongoing action to ensure that the terms and conditions don’t simply slide back without our input.

If you vote yes;

  • We will need a system to accurately monitor hours, to ensure not only that you are paid for work as you are supposed to be, but that hospitals are running safely, and not overstretching doctors. Without formal hours monitoring we will need to provide hard evidence, that is easy to record and easy to generate, that we need more doctors.
  • We will need to take an active part in our hospitals, ensuring that the LNC is a visible entity, with real power and real support. We must be prepared to escalate and see through proceedings about breaches and training
  • We must ask for reassurances that educational supervisors will evolve into the super-entities that this contract requires -that they will have power to actually do what the contract suggests they can do
  • We will have to be vigilant that the contract is implemented respectfully and honestly, and report incidences where it is not – to both the local LNC and the BMA and wider community.
  • We must no longer isolate ourselves if we hope to survive as a profession – don’t leave that Facebook forum even if you really want to.

If you vote No;

  • We must think about what comes next – what do you want to see, and how do you want it to be achieved?
  • Are you prepared to re-escalate strikes? To resign?
  • We must recognise that a close vote will mean the government will accept the contract on behalf of the minority ‘Yes’. They want this to go away, and don’t wish to concede any further.
  • We must recognise the ‘context’ of this contract. Will a No vote lead to benefits in the long-term? What would the junior doctor workforce look like in the future?

Now read Part 2 – the Context. Before you decide.

 

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