Dear Mr Hunt – I have some more questions

Dear Mr Hunt & Mr Mortimer

Mr Hunt, I wrote to you last week with respect to my worries surrounding your announced imposition of the new junior doctor contract. I sent it also to the conservative MP in my constituency. I am not sure if you’re read it? To my surprise over 22,000 people did, so perhaps you are in that number. I chose the form of an open letter because I find that sometimes when you find yourself in a difficult situation, knowing that you’re not alone is therapeutic in itself. I have now realised I am not at all alone in my concerns. But I do have some further questions and I thought perhaps it would be useful to copy Mr Mortimer in this time also.

I read with surprise in the DDRB report that NHS employers expressed a concern that doctors would have ‘incentive to work slower’. I don’t believe I have read another piece of information about this entire saga that has shocked or saddened me more. So let me tell you a little bit about how I work:

One day I saw a man on my ward dying, it was early in the morning before ward round. Most junior doctors come into work before their working day begins. This was a natural death, he was more than ninety years old. He needed me and so I sat with him until he died. My preparation was for ward round was delayed, things happened slower than they would have been the day before. I make no apologies for that.

One day I was the house officer on call for surgery. It was a weekend, I did a twelve and a half hour shift. I had more than a hundred patients on my wards. It was busy. So busy that I could not take a break because everywhere I went there were patients who needed me for cannulas, fluid assessments, observation reviews. So I worked quickly and I did not stop.

One day I was intubating somebody for surgery. I knew that they needed me to get it right. I wanted to get it done as quickly as possible, but my consultant told me to work slowly and take my time, because keeping that patient safe was most important.

I think you might be getting my point? Medicine is not a conveyer belt. I am a professional, I am licensed, endorsed by the General Medical Council and I work to the standards of good medical practice. My incentive to work slowly is the patient. My incentive to work quickly is the patient. The prerogative to choose which is mine.

I read with interest the questions the British Medical Association (BMA) had about the potential for discrimination of certain groups; female doctors, disabled doctors, those that become temporality unwell or choose to devote some time to research in medicine. You might also recall that I mentioned them in my last letter too. I found it surprising that the response from NHS employers was not that the BMA were wrong, but that if different groups were affected differently then it was ‘reasonably necessary to achieve business objectives’. I understand that NHS employers even felt it necessary to obtain legal advice on the matter. While it isn’t my aim to confuse ethics with law, I have to say if I needed legal advise on something similar, it would be because I was not actually sure I was doing the right thing at all. I also have some issues with the idea of ‘reasonable necessity’. The current contract does not create these questions of discrimination and so some might say surely it isn’t necessary at all? I will leave this point I think by asking if you might like to contemplate all of the other unjust practices in history that were thought to be ‘reasonably necessary to achieve business objectives’ at that time.

The next question I have is about the ‘cost neutral’ stance of this contract. Using the very best information available to us, most junior doctors are anticipating a pay cut. Additional to this it is clear from the DDRB report that there will be actually be cost savings for NHS employers over time. I have mentioned in my previous letter that there is already a crisis in recruitment to specialties. The example of medical registrar is from my own experience but A&E, psychiatry and GP are also among those worst affected. The term ‘flexible pay premia’ crops up a lot. From what I understand they are to be used to plaster over many of the holes in these proposals. I find it absolutely unfathomable that despite this contract creating savings for NHS employers that those savings will not be recycled back into the pay envelope to help us deal with the recruitment crisis and pay discrimination this contract creates.

I also wanted to discuss with you comments in the DDRB report that highlighted NHS employers desire not to create a system where ‘doctors in training could claim additional money for every extra minute spent carrying out their duties’. The NHS is held up by the good will of its staff, not just doctors but all NHS professionals. If there was a risk of doctors claiming money for ‘every extra minute’ I am fairly certain that the health service would have crumbled long ago. As it is, we are falling to our knees; I should think that you would be better engaged in helping us up not pushing us further into the ground.

I have more questions, but I think that is enough for now. I hope I have now explained to you at least in part why I feel so disrespected and undervalued. I think you will find I am not alone. Someone told me that the key to negotiation is that neither side looses face. I think that perhaps at first, it is reconciliation that should be prioritised here. As Nelson Mandela rightly said ‘only free men can negotiate’. If we wish to say in our homes in England, we as doctors do not have anywhere else to turn, you have the monopoly on our talent and skill. I’m sure you will understand therefore why, with the threat of imposition hanging over our heads, we do not perhaps feel free to negotiate.
Yours Truly,

Dr Aoife Abbey

PS – If you have not yet had time to read my first letter, I would very much be obliged if you could read it now.


Dear Mr Hunt

Dear Mr Hunt

This is not a letter about the ‘7 day service’ shaped political football which seems to be is perpetually in play. This is not a letter about the consultant opt-out clause. It is not a letter about the difference between elective and urgent care. This is a letter about the unjust and unsafe contract which the junior doctors of this country have been threatened with. I am by no means unique or particularly special among my profession, but as I stand aghast at the proposals being thrust upon us, I can only presume that you do not truly understand what they will mean for my colleagues and I. As Atticus Finch told us “You never really understand a person until you consider things from his point of view…until you climb into his skin and walk around in it.” This is a philosophy we often use in medicine, it helps us deliver patient centred care. I thought perhaps a personal story would help you understand why we have come out in force against the proposed junior doctor contract.

I am junior doctor in the West Midlands. I left medical school in 2011 and went straight into training, I worked hard to secure my higher training number and I am now an intensive care trainee at ST3 level. I am a junior doctor that works a minimum of forty eight hours a week. This of course does not include the hours outside of this spent developing my knowledge and skills. I hold myself to high standards. I participate in research and audit. I take exams. I care about patient safety and I try my best to be an agent for change wherever I work. As a junior doctor on an training programme, I work side by side with locum staff who do my work for four times more pay than me.

I am an junior doctor who takes time to hold her patient’s hands. I listen to patient narratives. I reflect on and learn from my mistakes. I support my junior colleagues. I engage in teaching the new generation.

I am an asset to your NHS.

I am a junior doctor who has not been able to plan my life further ahead than four months since I graduated in 2011. I cannot plan to go on holiday next summer or RSVP for my friends wedding in the Spring. I am a junior doctor who has not been on a summer holiday in the past five years. I am a junior doctor who does not yet even know if she will be spending this Christmas with her family or in work.

I am a junior doctor who cannot afford to stand down while your party impose a new contract.

Do you know that you are giving me a pay cut? The new contract will cut my pay by somewhere between 12 and 15%. I cannot understand how any government can look the doctors of this country in the eye and say we deserve this sort of pay cut. I feel this reality has been glossed over and dressed up as something else. Perhaps it is too uncomfortable or impossible for you to defend and so you have chosen to pretend it is not the case. Unless the bank are willing to take the equivalent sum off my student debt and mortgage repayments, I do not have the luxury of pretending anything.

Do you know that we have huge concerns that the new contract deliberately discriminates against women in medicine? That the contract will make it even more difficult for not only women, but those unable to do full time training for any reason to work within the NHS? Have you considered the effects of inhibiting this diversity in medicine? Do you understand that to place the massive burden of financial penalty on any doctor who realises that their skill is best suited to another speciality is not in the best interests of the NHS?

Do you know that the new contract would mean it would be perfectly reasonable for me to do a 12 hour shift with just two twenty minute breaks and if I start a shift at 8am I would not be entitled to any break until after 2pm that day?

Do you know what it is like to work in an understaffed district general hospital? My most recent medical placement had 4 filled slots on a medical registrar rota for 12. Do you think this new contract will attract more doctors into these jobs?

Do you think you could consider what it is like to have the weight of person’s life in your hands? Not in an abstract sense, not from the point of view of having to make decisions that affect a body of people’s lives as I understand you do. I want you to consider what it is like to stand beside a patient and their relatives and tell them that you will do your very best to look after them in hospital. Or tell them that your team has done all they can and you think they won’t survive. To hold their hand while they die or take on the responsibility of letting their family know that they have an incurable disease. To know that if you are too tired or too distracted by personal things you can make a judgement call that brings about a death. Can you picture it? What do you think your emotions might be? I can tell you that contrary to some opinions, I, like most junior doctors happen to be quite good at these things. We have gotten to where we are by displaying both strength and resilience. I am not however a machine and I do require to be well rested, supported, adequately recompensed and valued in my work place. As a doctor, I somehow feel ashamed that I have to say that, yet regrettably this is where I have been pushed.

During the London Olympics we watched the NHS held up as an ideal for the whole world to see; shiny happy doctors, dancing and singing with their colleagues. I am imploring you that if this government impose this unfair contract you will break us. Please understand that broken doctors do not dance, they do not sing and they certainly do not deliver a first class service.

Yours Truly,

Dr Aoife Abbey