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

 

 

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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.

Juniordoctorblog.com