Dan Poulter, a Conservative MP and former Health Minister, writes:
A new junior doctor contract is a once-in-a-generation opportunity to improve the quality of medical training for the doctors who will be the GPs and consultants of tomorrow, and it provides a much-needed chance to put in place the right recruitment and retention incentives to address the workforce shortages facing many parts of our NHS.
A former junior doctor myself, this time last year I was the health minister overseeing the coalition government’s negotiations over the new contracts.
By September 2014, there were many areas of broad agreement with the British Medical Association (BMA): on the need to improve junior doctor training, particularly in surgical specialities, and to find a better way of remunerating junior doctors for on-call work at night and at weekends.
Negotiations ended abruptly when BMA representatives walked out of talks about consultant contracts last October, and the junior doctors committee followed suit in a gesture of solidarity.
However, the junior doctor contract that has emerged over the summer – the contract that the Department of Health now wants to impose – is very different from the one being discussed this time last year.
Then there was no talk of 90-hour weeks, no talk of large numbers of junior doctors having their pay cut.
There was instead a recognition by the Department of Health that now appears to have been lost: that better pay and work-life balance incentives were needed to ensure doctors were attracted to A&E and other gruelling specialities.
Now we are seeing junior doctors, for the first time ever, balloting for strike action over their contract of employment.
So why has the Department of Health’s position changed so dramatically?
In the face of increasing patient demand, driven primarily by rising numbers of those with multiple medical conditions, there was a political consensus at the general election that the NHS would require an additional £30bn by 2020.
Since winning, the government has rightly promised an extra £8bn over the next five years. But that still leaves another £22bn to be delivered by efficiency savings.
Most of the low-hanging fruit was picked between 2010 and 2015. So reforming national contracts for doctors is perhaps one crude lever available to a secretary of state looking for ways to close the gap.
The financial challenge is further exacerbated because the government doesn’t want the NHS to simply stand still. Quite rightly, it wants it to do more for patients.
There is a desire to improve mental health provision, and to train 5,000 more GPs to provide longer surgery opening hours and more primary care at weekends. The government’s vision for a seven-day NHS in our hospitals is also undoubtedly the right one.
However, I am unclear how a new junior doctor contract that will cut the pay of doctors entering GP training, cut the pay of psychiatry registrars because they are classified as being non-resident when on call, and cut the pay of A&E doctors, will help to deliver a seven-day service.
In my view it will further discourage doctors from choosing careers in specialities already facing acute recruitment and retention challenges.
At the end of last year, as the health minister responsible for workforce, pay and pensions, I tasked the independent doctors and dentists remuneration body (DDRB) to examine the barriers to seven-day working in the NHS.
It is important to be clear that the DDRB was not asked to recommend new contracts, but to make observations about some of the challenges to delivering more NHS services on all days of the week.
The DDRB reported back this summer, and suggested that there needed to be a fully multi-disciplinary and integrated approach to seven-day working across primary, secondary, and social care.
In that context, the consultant “opt out” was identified as one of a number of barriers to seven-day working. But to blame consultants (many of whom already work seven days a week) for a lack of seven-day services would be to present only a small part of the story.
The DDRB also recognised that the government was unlikely to achieve its ambition for seven-day services without substantial investment – at a cost previously articulated by Prof Sir Bruce Keogh, the medical director of NHS England, of being somewhere between £2bn and £3bn.
The DDRB also commented on the junior doctor contract, and in particular on the need to align the incentives correctly to attract and retain new doctors in specialities like A&E, psychiatry and general practice, where there are increasing workforce challenges at a national level and workforce shortages at a regional level.
I am not a professional politician, but one of an increasingly rare breed among MPs: someone who has experience of the world outside politics.
I worked as a junior doctor in London, the south-east and the east of England for about 10 years across a range of specialities including A&E, rheumatology, general surgery, orthopaedics, obstetrics and gynaecology and mental health.
I have always been impressed with the compassion, altruism and dedication to patient care of the overwhelming majority of doctors I have worked alongside.
Medicine has never been a nine-to-five job for any doctor, particularly junior doctors, who are the true workhorses of the medical team, routinely working night-times and weekends and often working extra hours they are not paid for in order to do the right thing by patients and their relatives.
Junior doctors are not easily roused. They are rightly upset about proposed cuts to their pay, but the recent unprecedented decision to ballot for strike action is not fundamentally about money. It is rooted in very valid concerns about a contract that could compromise patient safety.
When negotiations began with the BMA in 2012, there was an implicit agreement that a new contract would not involve forcing doctors to work the excessive hours of the past.
The contract that the Department of Health is threatening to impose on junior doctors once again raises the prospect of 90-hour weeks being written into rotas.
Leaving aside the issue of legality, it is impossible to reconcile these excessive working hours with safe patient care.
A newly qualified doctor will now leave medical school with total debts greater than almost any other graduate of about £80,000, and start work on a basic salary of £22,636.
They will then need to train as a junior doctor for between five and 12 more years on a basic salary of between £30,002 and £47,175 before becoming a GP or a consultant.
Most junior doctors also receive additional payments for extra hours that are worked on call in the evenings, nights and weekends.
Given the many years of undergraduate and postgraduate training that it takes to become a consultant, the level of graduate debt, and the relatively modest basic salary compared to other professional groups such as accountants and lawyers, it is understandable that junior doctors are upset at being asked to work more nights and weekends, but for less pay.
The gravity of the current situation is summed up by the fact that almost all of the royal colleges have taken the unprecedented step of writing to the secretary of state to raise concerns over the contract.
If the colleges are listened to, the opportunity to design a contract that will improve the training available to the next generation of consultants still remains, as does the chance of ensuring medical careers in general practice, A&E and other hard-to-recruit specialities become more attractive.
No doubt more money will be needed to deliver more NHS services seven days a week, and some of that extra money will need to be spent on doctors.
The government must get this right, because a new junior doctor contract is not primarily about doing right by doctors. It’s about doing right by the patients we care for.
A new junior doctor contract is a once-in-a-generation opportunity to improve the quality of medical training for the doctors who will be the GPs and consultants of tomorrow, and it provides a much-needed chance to put in place the right recruitment and retention incentives to address the workforce shortages facing many parts of our NHS.
A former junior doctor myself, this time last year I was the health minister overseeing the coalition government’s negotiations over the new contracts.
By September 2014, there were many areas of broad agreement with the British Medical Association (BMA): on the need to improve junior doctor training, particularly in surgical specialities, and to find a better way of remunerating junior doctors for on-call work at night and at weekends.
Negotiations ended abruptly when BMA representatives walked out of talks about consultant contracts last October, and the junior doctors committee followed suit in a gesture of solidarity.
However, the junior doctor contract that has emerged over the summer – the contract that the Department of Health now wants to impose – is very different from the one being discussed this time last year.
Then there was no talk of 90-hour weeks, no talk of large numbers of junior doctors having their pay cut.
There was instead a recognition by the Department of Health that now appears to have been lost: that better pay and work-life balance incentives were needed to ensure doctors were attracted to A&E and other gruelling specialities.
Now we are seeing junior doctors, for the first time ever, balloting for strike action over their contract of employment.
So why has the Department of Health’s position changed so dramatically?
In the face of increasing patient demand, driven primarily by rising numbers of those with multiple medical conditions, there was a political consensus at the general election that the NHS would require an additional £30bn by 2020.
Since winning, the government has rightly promised an extra £8bn over the next five years. But that still leaves another £22bn to be delivered by efficiency savings.
Most of the low-hanging fruit was picked between 2010 and 2015. So reforming national contracts for doctors is perhaps one crude lever available to a secretary of state looking for ways to close the gap.
The financial challenge is further exacerbated because the government doesn’t want the NHS to simply stand still. Quite rightly, it wants it to do more for patients.
There is a desire to improve mental health provision, and to train 5,000 more GPs to provide longer surgery opening hours and more primary care at weekends. The government’s vision for a seven-day NHS in our hospitals is also undoubtedly the right one.
However, I am unclear how a new junior doctor contract that will cut the pay of doctors entering GP training, cut the pay of psychiatry registrars because they are classified as being non-resident when on call, and cut the pay of A&E doctors, will help to deliver a seven-day service.
In my view it will further discourage doctors from choosing careers in specialities already facing acute recruitment and retention challenges.
At the end of last year, as the health minister responsible for workforce, pay and pensions, I tasked the independent doctors and dentists remuneration body (DDRB) to examine the barriers to seven-day working in the NHS.
It is important to be clear that the DDRB was not asked to recommend new contracts, but to make observations about some of the challenges to delivering more NHS services on all days of the week.
The DDRB reported back this summer, and suggested that there needed to be a fully multi-disciplinary and integrated approach to seven-day working across primary, secondary, and social care.
In that context, the consultant “opt out” was identified as one of a number of barriers to seven-day working. But to blame consultants (many of whom already work seven days a week) for a lack of seven-day services would be to present only a small part of the story.
The DDRB also recognised that the government was unlikely to achieve its ambition for seven-day services without substantial investment – at a cost previously articulated by Prof Sir Bruce Keogh, the medical director of NHS England, of being somewhere between £2bn and £3bn.
The DDRB also commented on the junior doctor contract, and in particular on the need to align the incentives correctly to attract and retain new doctors in specialities like A&E, psychiatry and general practice, where there are increasing workforce challenges at a national level and workforce shortages at a regional level.
I am not a professional politician, but one of an increasingly rare breed among MPs: someone who has experience of the world outside politics.
I worked as a junior doctor in London, the south-east and the east of England for about 10 years across a range of specialities including A&E, rheumatology, general surgery, orthopaedics, obstetrics and gynaecology and mental health.
I have always been impressed with the compassion, altruism and dedication to patient care of the overwhelming majority of doctors I have worked alongside.
Medicine has never been a nine-to-five job for any doctor, particularly junior doctors, who are the true workhorses of the medical team, routinely working night-times and weekends and often working extra hours they are not paid for in order to do the right thing by patients and their relatives.
Junior doctors are not easily roused. They are rightly upset about proposed cuts to their pay, but the recent unprecedented decision to ballot for strike action is not fundamentally about money. It is rooted in very valid concerns about a contract that could compromise patient safety.
When negotiations began with the BMA in 2012, there was an implicit agreement that a new contract would not involve forcing doctors to work the excessive hours of the past.
The contract that the Department of Health is threatening to impose on junior doctors once again raises the prospect of 90-hour weeks being written into rotas.
Leaving aside the issue of legality, it is impossible to reconcile these excessive working hours with safe patient care.
A newly qualified doctor will now leave medical school with total debts greater than almost any other graduate of about £80,000, and start work on a basic salary of £22,636.
They will then need to train as a junior doctor for between five and 12 more years on a basic salary of between £30,002 and £47,175 before becoming a GP or a consultant.
Most junior doctors also receive additional payments for extra hours that are worked on call in the evenings, nights and weekends.
Given the many years of undergraduate and postgraduate training that it takes to become a consultant, the level of graduate debt, and the relatively modest basic salary compared to other professional groups such as accountants and lawyers, it is understandable that junior doctors are upset at being asked to work more nights and weekends, but for less pay.
The gravity of the current situation is summed up by the fact that almost all of the royal colleges have taken the unprecedented step of writing to the secretary of state to raise concerns over the contract.
If the colleges are listened to, the opportunity to design a contract that will improve the training available to the next generation of consultants still remains, as does the chance of ensuring medical careers in general practice, A&E and other hard-to-recruit specialities become more attractive.
No doubt more money will be needed to deliver more NHS services seven days a week, and some of that extra money will need to be spent on doctors.
The government must get this right, because a new junior doctor contract is not primarily about doing right by doctors. It’s about doing right by the patients we care for.
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