Bigger battles ahead
James Linney analyses the junior doctor contract dispute
On December 1 we were due a visit from that rarest of creatures - the striking doctor. Not for over 40 years had this elusive animal been seen in the UK.
Government officials were busy warning us to beware, telling us that this was an animal that would no doubt leave chaos in its wake, whilst journalists waited eagerly to give maximum coverage to their hapless victims. Alas, it was not to be and at the 11th hour the strike was called off - and for the time being anyway the public were safe. The hero of the hour? Health secretary Jeremy Hunt, and he took to Twitter shortly after the announcement to claim a “victory for common sense”. He added: “Strike shouldn’t have been called without talking to government first, but great victory for seven day services.”
This is the story that the Tories would have us believe, but, given how close we did get to the first doctor strike since 1975 and the extent of support the proposed strike achieved, it is worth looking at how the junior doctor contract dispute came about and what it has achieved.
The dispute began back in 2012 with negotiations for a new contract of work for junior doctors (ie, any doctor not yet a consultant or a fully qualified GP) between the British Medical Association, NHS employers and the department of health. The BMA withdrew from the negotiations in 2014, citing a lack of any willingness on the part of the government to deviate from its proposed contract, which the BMA declared “unsafe” and unfair. The government then referred the contract to the ‘independent’ Doctors and Dentists Review Body, which was given a remit to redraft the contract, giving special consideration to implementing a ‘seven-day NHS’. But with one slight catch: it should be ‘cost-neutral’.
Now, the average person might, given the task of massively increasing the NHS workload at no extra cost, have raised a few small reservations. But not the DDRB, and the resulting proposed new contract led to the BMA refusing to re-enter the negotiations on the basis that this was even worse than the government’s original proposal. The government’s answer was to state that as of August 2016 it would impose the contract anyway. The BMA put forward its conditions for renegotiation: namely, the removal of the threat to impose the contract, keeping the safeguards against overworking doctors and recognition of the need to pay at higher rates for unsocial hours worked.1 It need not have bothered - by now Hunt was telling them to talk to the hand.
Hence the decision by the BMA’s junior doctor committee to ballot its members to take the “extreme” (in Hunt’s words) decision to strike - three dates were chosen. The first, on December 1, would have involved junior doctors providing only emergency care, as on bank holidays. The second two strikes, set for December 8 and 16, would have meant a full withdrawal of labour between 8am and 5pm, something that has never happened before. Of the 76% of the junior doctor workforce who took part in the ballot, a massive 98% voted to support industrial action. These strikes have now been delayed for a month, whilst the two sides enter into mediated negotiations again.
So what led to such a huge percentage of doctors voting in favour of an action that they have refused to consider for the past 40 years?
To get to the bottom of this, let us first turn to the details of the proposed new contract. Currently junior doctors’ jobs are banded: the higher the number of anti-social hours, the higher the pay banding above the basic wage. This currently starts at £22,636 for a newly qualified doctor, rising to £30,002 for a specialist registrar (usually reached about six years after qualification). Thus for a job with lots of on-call shifts - ie, nights and weekends - the basic wage could increase to £25,461 and £39,693 respectively. The new contract proposes an 11% increase in basic pay, but an end to banding, so that basic pay would be extended to cover 7am-10pm weekdays and 7am-7pm on Saturday. For all other working times there would be a more modest additional pay rate.
The government has thus sold the new contract as an 11% pay increase, but the reality is that, whilst some doctors would get a slight increase, the vast majority would see their pay decrease - in more than a few cases by as much as 30%-40% after the abolition of banding is taken into account. The contract is also biased against women, as pay increases would be based on the level of career progression, not years since qualification, so women who work part-time in order to raise children would suffer more than others. The BMA has pointed out that such pay cuts - added to the huge student debt, cost of insurance indemnities for practising medicine and the costs of exams and training courses required to progress - would make it more difficult to recruit future doctors and thus leave the NHS, which is already facing huge staff shortages, in even more trouble. And this is before we come to Hunt’s fantasy of a 24/7 NHS service, which I will discuss shortly.
However, a reduction in junior doctors’ pay, as their leading representatives have been at pains to point out, is not the only reason for striking. As Johann Malawana, chair of the BMA’s junior doctors committee, has said, “the safety of patients will be much worse affected if we don’t try to find a meaningful solution to the issue of the contract.”2 The new contract would remove safeguards protecting junior doctors from being made to work very long hours and without breaks. Currently the European Working Times Directive limits them to 48 per week, averaged over a six-month period, and is enforceable by fines against employers who do not comply. The new contract would limit sanctions for non-compliance essentially to a stern look of disapproval, whilst allowing employers to force doctors to work for up to 11 hours with only a single 20-minute break.
Now, I was in my first year as a junior doctor in 2008, and I can remember having to work 12-hour shifts, when I would be so busy that my only ‘break’ would consist of the time spent walking between patients on different wards. By the end of my shift I would be barely able to tell you my own name, let alone treat a patient with a complicated, serious illness. This is probably not of much concern for most Tory MPs, whose only reason for spending time in an NHS hospital is for a publicity photo shoot, but for the rest of us it is clearly in our best interests to have doctors who are not overworked, dehydrated and blurry-eyed.
The message that the strike was for the sake of patient safety and the future staffing of the NHS is one that has on the whole been conveyed successfully by both BMA representatives during media interviews and the junior doctor population itself, via a well organised social media campaign.
Yet, whilst this has been a successful campaign, which has won substantial support, the government has been able to rely on its old ally - the rightwing media - to paint the junior doctors as money-grabbing, reckless and prepared to risk patients’ lives, because they can’t be bothered to work on the weekend. Yet most people have not bought into this - mainly because we all get unwell some time and get a first-hand look at how hard doctors work (as well as everyone else working within the dangerously overstretched NHS). Let’s face it: there are plenty of easier ways to make money for mostly well-off, straight A graduates (to pick one way at random - being a career politician). Despite what the Tory-media collusion would have us believe, most people working in the NHS do it out of a genuine desire to help sick people; which is why the decision to strike was a very hard one. But the junior doctors have been clear in their message - the attacks on the NHS by the Tories are an infinitely bigger threat than striking for a few days.
Meanwhile Jeremy Hunt hit a new low by threatening junior doctors with being referred to the General Medical Council and potentially being struck off on the grounds that their action could be harmful to patients. Helpfully the BMA’s British Medical Journal published an article summarising a recent systematic review of the mortality data during five doctors’ strikes around the world - all saw patient mortality remain the same or actually fall during industrial action.3
Another new low saw Bruce Keogh, medical director of the NHS, using the terrorist killing in Paris to point-score against striking doctors, by questioning whether they would be on hand to help in the event of a terror attack taking place during planned strike action. More than 3,000 junior doctors countered this by signing a letter highlighting it as the pitiful political spin it is:
the insinuation that doctors would not return to work in the event of a major incident, such as a terrorist attack, is not in keeping with the inherent duty that junior doctors have to serve the public … The use of the horrific attack in Paris to articulate your concerns is deeply disrespectful to those who lost their lives, their families and friends.4
But that was not the most significant contribution that Bruce Keogh has made in the current dispute - this is the very same man who co-authored the controversial study which Jeremy Hunt has based his entire ‘seven-day NHS’ campaign on. The one he disingenuously claims has proved that more than 11,000 deaths could be avoided if the NHS were to run a full-strength service at the weekend.5
In fact the very authors of the study concluded: “… it is not possible to ascertain the extent to which these deaths are preventable. To assume they are avoidable would be rash and misleading.” This could be the case because, for example, the study’s methods underestimated the possibility that people admitted over the weekend tend to be much sicker than those admitted mid-week. To add to the controversy, the paper was leaked to and quoted by Jeremy Hunt before it was published, leading some to claim that Keogh’s study had a contrived political intention from the beginning.
However, this is not the main argument. For the record the NHS is obviously already a seven-day service - except that over the weekend many routine procedures not carried out and so there are less staff working. It is worth noting, however, that only one percent of consultants have opted to enforce their contracted right to opt out of weekend work.
The main point is that the NHS is generally in a very bad way; it has been chronically underfunded and there have been huge cuts in its budget under the Tory government. Its workforce and resources are already spread desperately thinly, so that to have more staff working a full service all week would lead to no kind of improvement. Such a scheme would only reduce the relative risk of dying at the weekend by simply raising the risk of dying on every other day. This is a common-sense conclusion and one that Jeremy Hunt and his advisors are clearly aware of.
Which leaves us looking for the real intentions behind the current dispute and Hunt’s ‘seven-day NHS’ fantasy - it is part of the plan to prepare the NHS for its privatisation. Perhaps Hunt has been taken aback by the extent of opposition to his proposed new contract and he may have been gambling that he could blackmail the junior doctors into not striking. But the government’s refusal to negotiate with the BMA since 2012 may well be part of a carrot-and-stick attempt at softening up doctors so that they become becoming resigned to privatisation when the time comes.
We must therefore show solidarity with the junior doctors in their current dispute, whilst continuing to link this fight with the defence of the NHS in its entirety. But a defence campaign is not enough. All those who work in the NHS, from the cleaners and the admin staff to the nurses, deserve to work humane hours and they all deserve more pay. It has been hugely encouraging to see doctors marching alongside other NHS workers with banners demanding “Save the NHS”. This is perhaps another example of the slow awakening of working class consciousness and a move towards organising a challenge to austerity - as has been demonstrated most clearly by the massive victory of Jeremy Corbyn in the Labour leadership contest.
1. ‘BMA response to NHS employers’ contract’: www.yumpu.com/en/document/view/54583420/bma-response-to-nhs-employers-contract-nov-2015.
3. ‘What are the consequences when doctors strike?’: www.bmj.com/content/351/bmj.h6231.
5. ‘Increased mortality associated with weekend hospital admission: a case for expanded seven day services?:www.bmj.com/content/351/bmj.h4596.