Between a Rock and a Hard Place

The news came yesterday that junior doctors are once again on the brink of a season of industrial action. Disappointing as the news was, it was not unexpected. For many of us there is a persistent feeling that our real concerns are not actually being entertained by the Department of Health. There is a underlying current of worry that the ill advised contract reforms presented during the Summer of 2015 are part of a bigger and much more worrying plan for the NHS. It is undeniable at this stage that there really is scant bedrock of trust left to build a relationship on. Indeed yesterday the Department of Health accused Dr Mark Porter, chairman of the BMA, of refusing to discuss a revised offer which had been provided to him over the course of the weekend. The BMA claim they did not in fact receive this offer until 11am yesterday….small things, seemingly chipping away at the hope of rebuilding a relationship between junior doctors and the Department of Health. I have quoted before Einstein who told us that “whoever is careless in the truth with small matters cannot be trusted with the important matters”. Did he have a point? At times like this, it certainly feels that way.

Mr Hunt’s most recent correspondence heralded a new player into negotiations; Sir David Dalton. Sir David is a long-serving NHS chief-executive officer (CEO) once named as being in the top ten most highly paid employees in the English NHS. The trust he is responsible for has I am told has gone from strength to strength under his leadership. Salford NHS trust has indeed received an ‘outstanding’ CQC rating on multiple elements of their care. I am not for a minute doubting that Sir David is good at his job, nor would I claim to be able to refute that he is anything but a dedicated hardworking and valuable member of the NHS team. The climate of change in the NHS however has unfortunately left those at the coal face with the skills to actually deliver care, in real time, short changed by the focus on corporate solutions to leadership and change. Earlier this week the Telegraph told us that five CEOs earned an average of £238,000 last year. To put that in context, it is ten times the average nursing annual salary. There were in fact incidences apparently where bonus payments alone constituted more than a nurse’s yearly salary. The national health service is a institute which requires many of its workforce to accept lower pay than they would otherwise earn privately. The idea of ‘value of money’ when it comes to corporate leadership is too ambitious an issue to unpick here but safe to say that in the context of NHS austerity measures it is obvious that health care staff will wonder why management continue to be treated so differently. These stories represent a difficult pill to swallow. When it comes to interacting with top down leadership in the NHS, the junior contract row is if anything drumming up large pockets of mistrust and skepticism among junior doctors. The interface between corporate and coal face is crumbling; if the way becomes blocked, I very much worry for the future of leadership within the NHS.

Salford’s most recent annual report reads very well. It talks positively about respecting safe staffing targets and creating opportunities for junior doctors to become engaged in education and leadership opportunities. The CQC specifically commended the trust on their success in dealing with increased demand for Accident and Emergency (A&E) services. This achievement is of course sure to be on the wish list of doctors and the Department of Health alike. Their successful strategy, we are told, included increased investment, redesigning supportive infrastructure for patient flow, developing new models of care outside of hospital, re-designing the estate to separate minor injuries and re-aligning staff to this. It did not necessitate any contract reform for junior doctors. Indeed they have apparently become one of the most exemplary trusts in the country using the current contract.

The report does however go on to lament that investing in capacity to increase activity levels appropriately left them dependent on a temporary workforce paid at increased rates. The suggestion that temporary staffing are draining the finances of the NHS will not come as a surprise to junior doctors; we routinely work along side those getting paid twice, three times or more our equivalent hourly rate to do the same job we do on a training contract. It is also worth remembering that planned contract changes will not only be irrelevant to locum staff, but are also exceedingly unlikely to tempt any out of locum work and into vacant training posts. Salford’s productivity improvement project ‘Better care for lower cost’ has resulted. At least we can say this plan is what it says on the tin. Better care for lower cost; a cost saving exercise with the idea of improving care. This plan too has presumably been created without changes to junior doctor contract. Salford recognised that supporting increased activity required more money and now going forward, they need to save money. The Department of Health continue to tell us that junior contract reforms are not a cost saving exercise at all. Is it a wonder we don’t believe them?

In an interview on BBC radio 4 today, Mr Hunt again extolled the Department of Health’s promise of pay protection for 99% of junior doctors.  With respect to this however there are some obvious questions which unfortunately media outlets seem unwilling to ask:

1. If this is not a cost saving exercise, why do large swathes of junior doctors require pay protection in the first place?

2. When the pay protection time frame runs out, won’t we in essence just have sold out thousands of our colleagues who remain in training or are yet to graduate?

As a junior doctor, I continue to rely on the effectiveness of the BMA to negotiate on my behalf. As the row continues I remain firmly stuck, between a trade union I have come to trust and a government I am struggling to maintain any faith in. I stand between the two with my hopes, my dreams and most importantly I stand there with my patients.



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