Why We Will Win This Battle

It has been one month since the Department of Health announced their intention to impose upon junior doctors a contract which, to it’s core, is both unfair and unsafe. The DDRB report we know contains the rotten bones of a contract who’s only achievement could ever be to further demoralise an already over-stretched medical workforce. I stopped at the traffic lights on the way home from work on the day the news of imposition broke. I was surprised, and perhaps ashamed, to realise as I listened, my eyes had begun to betray all the feelings of frustration a junior doctor who works in the NHS comes to live with. I sat at the traffic lights and cried.

CRiJSNpWUAECWIUThat evening I wrote a letter to Jeremy Hunt. To my surprise 24,000 people read it and in that instant, I knew ’a terrible beauty’ had been born. Terrible of course because I realised I had not underestimated the seriousness of what I had heard and beautiful because I knew that I was not alone. Yesterday 20,000 doctors stood in Waterloo Place, over a thousand more in Belfast and Nottingham. I was one of many. As W.B Yeats put it, ‘A terrible beauty is born’.


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Jeremy Hunt’s proposed changes have been repeatedly conflated with his party’s manifesto promise of a ‘7 day NHS’. The actual plans for this goal remain difficult to pin down. Those we do know appear poorly conceived and oddly skeletal. But for junior doctors already providing an around the clock service, this has never been a battle against a ‘7 day NHS’. It is not a fight against progress. This is a battle against an unfair contract, one that would in every sense be a regressive move for the profession, for patient safety and by default for the NHS as we know it.

5 demands of junior doctorsYesterday as 20,000 doctors made their journey to London, we were dealt another insult by the department of health, with calls that we had been ‘whipped up unnecessarily’ and ‘mislead’ by the British Medical Association (BMA). Apart from the anguish I felt at this accusation, I also find it odd that this is the strength of defence from Mr Hunt. If his proposals are indeed reasonable and fair then there is no reason of course why the plans wouldn’t already fall in line with the BMA’s own five very reasonable requests. Proper assurance from Mr Hunt that these five things would be respected could have the BMA back at the negotiating table in a matter of days.

The department of health however, would rather suggest that tens of thousands of professionals do not have the faculties to read what is clear in the DDRB report and digest the information for themselves. Which takes me to another quote, from some writing of no less significance to me than the words of W.B Yeats and it is one that has entered my mind many times over the past month. They are the words of JK Rowling, from the mouth of Dumbledore who tells us; ‘we must try not to sink beneath our anguish, Harry, but battle on”. And so I will not seek to dwell on the many insults that have been thrown our way. I will not dwell on the rhetoric, shameful data manipulation or empty party lines. I will tell you why we will win this fight.

Junior doctors already have in their armour all the advantage we will ever need. We have already spent every day of our working career balancing and respecting the needs of patients against our own. We know that mainstream media may chose to be our friend or foe. Indeed, as history has taught us, their allegiance may change on a daily basis. We are grateful for an immense amount of public support, yet we could never forget and so will continue to respect that there are millions of vulnerable, sick patients and their families who do not have the luxury of prioritising anything but their next few hours. Patient care is our business. We have the ability to interpret data correctly. We are in the business of respecting evidence base and facts. We are in the business of protecting patients. We are in the business of ethics. We are in the business of effective communication, even in the most difficult of circumstances. We are in the business of high moral standards, accountability and integrity. We are in the business of dealing effectively with uncertainty.

We have more than enough within us to win this battle. We simply have no need for for rhetoric, shameful data-manipulation or party lines. That is not our fight song and we will not sing it.

Politics is from the Greek word politikos; ‘of, for or relating to citizens’. Junior doctors are of course not politicians, but like every other citizen in a democracy, we have a stake in politics. This junior contract issue has awakened many to a responsibility to engage with healthcare policy and over the past month we have finally added strength and unity to the tools of our trade. To the department of health we say 50,000 junior doctors; 50,000 reasons to listen. To the 64 million people of the United Kingdom we say you can count on us to do the right thing.

We will win this battle.

Trojan Horse or Olive Branch? – A letter from Hunt

It’s been three weeks since the Department of Health announced their official intentions to recommend NHS employers impose a new contract on junior doctors. While devolved Governments in Scotland and Wales have chosen to reject this plan, Stormont has yet to venture. The government in England have also yet to retract this plan and as strike action hangs in the balance, junior doctors will have waited with baited breath for this targeted response from Mr Hunt, Health Secretary.

Mr Hunt begins by stressing that his priorities for a new contract are patient safety and fairness for juniors. His stated belief that junior doctors are vital to the NHS and deserving of both equity and fairness is welcome. It is also entirely justified. I have made no secret of my belief that the DDRB report is in parts fundamentally insulting to medicine as a profession and the decision to stage an imposition added exponentially to this injury. While I sincerely hope that this is not just a resort to flattery, accepting these comments at face value is now sadly difficult. Trust is not just like riding a bike, as they say – I can’t simply just hop back on. As Ronald Reagan liked to succinctly put it ‘trust, but verify’.

The first assurance is that the new contract is not a cost-cutting exercise. Mr Hunt affirms he is not seeking to save any money from the junior doctor’s pay bill. The ‘normal working window’ for a junior doctors is 7am to 7pm Monday to Friday. The new contract specifically sets out to increase the plain time of doctors to include up to 10pm Monday to Friday and all of Saturday until 10pm. Mr Hunt apparently has plans for a better supported ‘seven day NHS’. To do this he appears not to be increasing the number of doctors available to work around the clock but forcing those already in the NHS to spread themselves more thinly. Junior doctors are already working as hard as they can for the NHS. The redistribution of shifts that will inevitably occur as a result of the increase in plain time is categorically a plan to deliver their elected health manifesto on the cheap. Junior doctors do not have any issue working unsocial hours. We do however refuse to accept reclassification of our time in this way. Saturday and evenings after 7pm are simply not normal social hours.

Mr Hunt goes on to mention the seemingly reasonable plan of tying annual increments to ‘taking on more responsibility’. As I have said previously, there is currently no evidenced based, fair, reproducible and therefore reliable way to actually make this a reality. Perhaps if the DDRB panel had any clinical experience training as doctors, they would be aware of the difficulties with this. The obvious benefit of this idea, from the point of view of the department of health however is that the significant amount of trainees that work less than full time will now take longer to reach the next pay bracket. They will miss out on pay-rises they were entitled to on the current contract. Even if that money saved is used as suggested to support undersubscribed specialties, the effect for that individual doctor is that over time, NHS employers would have saved significant amounts on the cost of that doctor’s employment. The plans are specifically de-incentivising less than full time training in a time when the NHS is already struggling to fill training posts and haemorrhaging money to expensive locum doctors.

While on the topic of undersubscribed specialities, I think it is abundantly clear that robbing Peter to pay Paul is not at all the answer to filling those training posts. The fact that junior doctors do not chose their speciality solely based on financial incentive however is a point that seems to have been overlooked. If the Department of Health feel that an extra payment is the best way to attract appropriately motivated doctors into accident and emergency medicine, they are sorely mistaken.

As I suspected, Mr Hunt does indeed already know junior doctors work seven days a week and he gives welcome assurance that the new contract will not mean doctors are expected to work, on average more than 48 hours a week. So what is the issue you ask? The very next paragraph epitomises what is the matter with this contract: “I recognise that there will be exceptional circumstances in which an individual doctor should be compensated for hours worked outside the work schedule’” Again, let me say that any person with significant and current knowledge of working lives of junior doctors would know that ‘working outside your work schedule’ is the opposite of exceptional, it is very firmly the norm. This is of course not because as NHS employers suggested, there is ‘incentive to work slower’ or as Ross Clark in The Times suggested there is ‘perverse incentive to work outside contracted hours’. The reason junior doctors are systematically forced to work outside their contracted hours is because they are trying to keep their patients safe. That ‘perverse incentive’ is a patient. Attempting to fund a service where doctors are now expected to spread themselves more thinly is not a step forward for patient safety. Mr Hunt wants more doctors at they weekend, I say wonderful! so do I! but then there needs to be more doctors.

The letter continues to suggest that in these ‘exceptional circumstances’ where remuneration of overtime is due, it needs to be ‘authorised by an appropriate person’. Which begs the very serious question of who is indeed authorised to tell me that it is ok if I have to stay an hour to treat my patient about to tip off into septic shock? I presume I am employed by the NHS by virtue of my clinical competence? Am I expected to work in a system where my professional judgment with respect to patient care requires routine ‘authorisation’ from management? Is my word not good enough? Junior doctors stay late and come in early because the current demands within the NHS gives them no choice. Let me re-iterate, it is not ‘exceptional’, it is the norm. This fact is common knowledge and any plans which fail to recognise that are toxic. I would venture what is actually exceptional is a junior doctor claiming money for that time and so while a junior doctor is unlikely to take their good-will work away from the patient on front of them, the department of health continue to create a situation where defending the principle of ‘pay for work done’ has become very important.

Interestingly, both of the plans above mandate a close working responsibility between employer and employee. As a junior doctor who has had 12 jobs in 4 years, let me make it very clear that this is not possible for the majority of junior doctors. We are tremendously vulnerable within our workplaces and even if these plans were fair in theory, the chances of a junior doctor being in one place for long enough to able to rely on an internal review process like this are slim.

Mr Hunt goes on to refer specifically to pay. He assures us that he has asked for the new contract to ensure the great majority of junior doctors are as well paid as they would be now. Our stance on this is firm; not one doctor in training should be subjected to a pay cut. That is the strength of assurance that was necessary from this point and it was lacking. Majority of course just guarantees more than 50% and I don’t believe there is a quantifiable element to ‘great’.

So what is the verdict? I think I will have to sleep on it. My initial reaction however is not that Mr Hunt necessarily wants to destroy the working lives of every junior doctor in the country, but that perhaps the evidence is showing us that he genuinely just does not understand? Thankfully, there is a remedy to that and the gateway to progress remains open, if it would be taken. There are five prerequisites for negotiation, on the back of this letter I continue to stand by them. I sincerely hope the BMA do too.

5 demands of junior doctors

#JuniorContract – Foundations for Progress

It’s been two weeks now since junior doctors felt like their world imploded. Television, radio and social media have been awash with strong feelings, stern warnings and cries of disbelief. Ballot for industrial action is looming and the BMA have stuck to their guns and continue to demand that their five core demands are guaranteed in writing before they return to the negotiating table. This is a stance which is supported by most junior doctors. There can not be any doubt that the strength of feeling doctors would have on the issue of their new contract was underestimated. As a cohort we have shown ourselves to be highly motivated and for the most part, united. Quite frankly, junior doctors tend not to ‘pipe up’ that often. But over the past few years, as professionals we find ourselves more and more burdened by debt and struggling to balance the demands of our work with the ever increasing demands of a formalised training process. The fact is that this really is a case of it being the last straw that broke the camel’s back.

All well as that may be, I think that as a cohort of professionals we have a very strong case for our initial demands. Exploring the wider issues facing junior doctors in today’s NHS is of course important, never again should we leave it this late to stand together, but what is of vital importance with a view to progress is making an argument which allows everyone to focus in on and see our demands for the reasonable requests that they are.

  • Proper recognition of unsocial hours: Each time this argument is ventured on an official platform, it is lost in the clamour of the department of health saying they want a seven day service and junior doctors crying ‘we already work seven days’. Both of these things are true but neither is the argument at hand. The relevant point here for discussion is of course that if you are going to request a body of professionals work unsocial hours you need to provide appropriate remuneration. If a father works three Saturdays, giving him two Mondays and a Wednesday off in return is not of comparable value to his family. It is not of comparable weight in his work-life balance. Similarly, working until 10pm is not social. No amount of diversion tactics will change that.

I am a junior doctor, I will continue to demonstrate commitment to a safe NHS, seven days a week, if you commit to remunerate me appropriately.

  • No disadvantage for those working antisocial hours:  Taking into account the speciality short falls, this point should of course be a given. Junior doctors have read the DDRB report. They view the idea of ‘flexible pay premia’ with suspicion. They feel the proposals systematically disadvantage those working antisocial hours. The government I will presume would also not want to disadvantage those working antisocial hours already, not given their stated goals of a ‘seven day service’. So the point for discussion right here and now is not whether or not the DDRB report adequately provides for this section of doctors, but whether or not the government can agree not to disadvantage them. Agree to this and negotiation is within sight.

I am a junior doctor, I will support the BMA returning to the negotiation table if you commit not to disadvantage those working antisocial hours.

  • No disadvantage for those working less than full time: This is a difficult point. The section of doctors affected by such change would be broad and includes parents, doctors with disability and those participating in research. The government have a seemingly reasonable plan to link pay to actual responsibility. The fact remains that they have no real evidence based and reproducible way to make this happen. The section of ‘less then full time trainees’ might include doctors who actually work up to forty hours a week; full time by an other industry standards. They simply cannot link grade of training to responsibility to a way that it is reliable enough to dictate a doctor’s pay. The meer fact that they have created a situation where such broad swathes of the medical profession could be so adversely affected is illustrative that these plans have not been thought through to a point that would make imposition anything but grossly unfair and misguided.

I am a junior doctor I will continue to devout my working life to the NHS if you remove the threat of disadvantage to those working less full time.

  • Pay for all work done: I would venture that doctors will always work in excess of what they are contractually required to. It is the nature of our profession; we know that and the department of health knows that too. NHS employers openly saying that they did not want to create a situation where junior doctors could claim for ‘every extra minute spent carrying out their duties’ was a horrendously ill advised statement. It has whipped up the mistrust junior doctors have in their plans to a whole new level. The BMA ask that we are paid for all work done. I do not know a single doctor who would ever take their good-will work away from the patient on front of them but NHS employers created a situation where the principle has become very important.

I am a junior doctor, I will invest some trust back in this process if a principle that supports expectation of pay for work done is respected.

  • Proper hours safeguards protecting patients and their doctors: What history has taught us is that the introduction of proper safeguards to prevent the exploitation of junior doctors made our work environment safer. Mr Hunt told the independent that the constraints are punitive to trusts when it comes to staffing a seven day service. This is true of course, but for very good reason. Tired and overworked doctors make mistakes. Perhaps the department of health actually feel that by removing the safeguards and leaving this issue to local relationships between doctors and their hospital, they are giving everyone an opportunity to work closely together. If that is the intention, I think doctors would say thank you for it, but it is still wrong. Junior doctors are the vulnerable members of the hospital work force that are shunted from hospital to hospital. They have no on-going relationship with their local employers and often feel like those contractual safeguards are all that they can depend on.

I am junior doctor, I will feel protected by my new contract if proper safeguards are kept.

This situation has awakened junior doctors to the responsibility they have to engage with healthcare policy; as WB Yeats put it ‘All’s changed, changed utterly: A terrible beauty is born’. On a personal level, I am thankful for that. I think in the end those responsible for healthcare policy could be too. We are of infinite more use when engaged in reasoned discussion.

So there you have it, five reasonable requests which will bring the BMA back to the table. Yes its a ‘simplification of the issues. Yes there are many more complicated discussions to come. But if the department of health truly wish to achieve their goals for the NHS with junior doctors on their side, this has to be the start.