Junior doctors call for ballot on industrial actionConsultants reach agreement on £50m awardBMA will review healthcare fundingToo many junior doctors are working too long hoursTalks continue on new consultant contractHealth secretary sets out NICE's programmeMedical school selection: greater care neededBMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7226.62 (Published 01 January 2000) Cite this as: BMJ 2000;320:62
Junior doctors call for ballot on industrial action
Representatives of the United Kingdom's 35 000 junior hospital doctors have rejected the latest pay proposals from the health departments and overwhelmingly called for a ballot of junior doctor members of the BMA unless the government improves its offer.
In September the Junior Doctors Committee (JDC) sent its leaders back to the negotiating table to push for a better deal (2 October 1999, p 869). The negotiators have spent many hours with officials, but after a six hour meeting on 11 December the JDC decided that the current offer was not good enough. It wants its chairman, Mr Andrew Hobart, to seek an urgent meeting with the secretary of state for health to brief him on the problems of junior doctors.
The health departments have proposed four bands to replace the current system of additional duty hours (9 October 1999, p 1010), and last month the JDC agreed that a banded contract was the best way to recognise the antisocial and intensive nature of junior doctors' work.
Negotiations should continue
The JDC hopes that negotiations will continue on trying to improve the banding criteria and on the other differences which remain between what officials have offered and the negotiators have called for. Agreement has not yet been reached on the contractual obligations to monitor the new deal arrangements, under which no juniors are supposed to actually work more than 56 hours a week; on the dates on which compliance with the new deal must be incorporated into contracts; on shifts; and on flexible trainees. If satisfactory progress is made speedily a ballot may not be necessary.
A ballot should be held only to further a trade dispute. In order to take this action negotiations between the parties should be exhausted. If the correct procedures are not followed a trust or the Department of Health may try to halt the process by an injunction.
The chairman of the negotiators, Mr Nizam Mamode, said, “Junior doctors deserve to be treated fairly for the work they do. It is no longer acceptable for them to work excessively long hours for derisory rates of pay. If the Department of Health does not deliver we will ballot our members on industrial action.”
Consultants reach agreement on £50m award
The BMA and the health departments have reached agreement on the £50m award which the Doctors' and Dentists' Review Body recommended should be paid to consultants in the United Kingdom from April 2000 to recognise their increased workload and intensity of work.
It will be recommended to the BMA's annual representative meeting in June 2000 that Sir David Carter should be elected president of the association for the year 2001-2. Sir David, who is 59, has been chief medical officer for Scotland since 1996. He was professor of surgery at Glasgow University 1979-88, and regius professor of clinical surgery at Edinburgh University 1988-96
From next April £37.5m a year will go on new payments to recognise the volume and intensity of consultants' workload. Detailed criteria to decide which consultants will get intensity payments and the level of them are still to be agreed. They might recognise the unsocial nature of being on call at night and the level of actual call outs as well as intense daytime working. The rest of the money will be put into increasing the ratio of discretionary points, which are awarded by NHS employers for contributions to professional excellence. The criteria have been extended to allow greater recognition of service achievement. The five point scheme (£2500 per point) will be extended by three points. In future there will be 0.35 points available for each eligible consultant.
The agreement has been reached despite the fact that the government refused to implement the review body's recommendation, which was based on evidence from two independent workload surveys, until negotiations on the consultant contract had been completed. Negotiations on the contract have been going on in parallel, but the chairman of the Central Consultants and Specialists Committee, Dr Peter Hawker, assured the committee last month that the negotiators had “not sold the contract for the implementation of the £50m award.”
The health minister at the Department of Health, John Denham, said, “This deal will give consultants the recognition they deserve. We are rewarding consultants for the work that they do for the NHS and the intensity of that work. Our agreement is good for patients and good for the NHS.”
BMA will review healthcare funding
The BMA is to undertake a wide ranging review of healthcare funding in the United Kingdom.
The proposal, initiated by the chairman of council, Dr Ian Bogle, was unanimously supported by the council last month. Dr Bogle, who expects the review to last at least a year, said that despite the fact that the present government had substantially increased funding in the NHS, there was a large and widening gap between the resources available for health care and the demands and needs of patients.
Dr Bogle told the council that it was not true that the NHS was the envy of the world. There was a workforce crisis, there was low morale, and there was covert rationing. The government had refused to initiate a debate on rationing. “We cannot seriously go on like this. Patients deserve a better service than they are getting. Doctors are working under enormous pressure and the workload is rising.”
The BMA will invite representatives of patients, other health professionals, managers, and health economists to take part in the review, which will consider what kind of health service the public wants, what resources are required to provide this, whether these resources can reasonably be expected to be provided under present funding arrangements, and what mechanisms could be used to bridge any affordability gap.
Dr Bogle believes that the government would welcome such a review, even though some of the conclusions might be unpalatable.
The chairman of the Joint Consultants Committee, Mr James Johnson, pointed out that the NHS was good value because such low wages were paid and everything had now been cut to the bone. “We must,” he said, “be careful how we present this exercise to the public. We will be blamed for abandoning the founding principles of the NHS.”
Sir Anthony Grabham, chairman of the journal committee, advised that unless the council accepted that one of the conclusions might be that some patients would have to pay for services that were now free it should not embark on the exercise.
The review may look at restricting the services provided by the NHS. Dr Bogle told a press conference, “Universal coverage means cover for all. It does not necessarily mean cover for everything.”
The NHS Confederation said that it would be happy to take part in the review, but emphasised that funding health care from general taxation was the fairest way to provide a service.
Too many junior doctors are working too long hours
One in three junior hospital doctors in England are working in excess of nationally agreed limits.
Under the new deal on hours no junior doctor should be working more than 56 hours a week or 72 hours on call, with adequate rest periods. Recent monitoring of the new deal shows that over 10 000 doctors (35% of monitored posts) are working beyond the maximum number of hours. The figures show variations between geographical regions and specialties. The worst reported rate of non-compliance is in the West Midlands where over a half of all junior doctors are working too many hours. There is a non-compliance rate of 45% in paediatrics, with surgery, obstetrics and gynaecology, medicine, and anaesthetics following close behind.
The joint deputy chairwoman of the Junior Doctors Committee, Miss Fiona Kew, said, “Junior doctors in their first year are hardest hit. The figures show that a half of all first year junior doctors are working hours in excess of the new deal. The government has promised to allocate £5m of extra money to deal with the issue, but this is a small sum to tackle a huge problem and will have little impact.”
Talks continue on new consultant contract
The health departments and the consultants' negotiators hope that changes to the existing contract can be implemented from April 2001.
The current contract has remained largely unchanged since 1948 and talks have been going on for several months on producing an updated contract. Last month the two sides produced a progress report on the points which are being discussed. Employer based appraisal linked with regular job plan review will be a contractual requirement. There are plans for a more explicitly defined contractual commitment, including recognition of the support necessary to undertake this commitment. There will be better job planning which will have to take into account the consultants' views on resources and priorities. The new contract will also include mandatory, nationally agreed procedures for handling disciplinary matters and poor performance by consultants.
The chairman of the negotiators, Mr Derek Machin, told the Central Consultants and Specialists Committee in December that no substantial details had yet been worked out, but he gave an assurance that all specialties would be treated on an equal basis. In answer to the comment that the new contract would mean tighter controls over consultants, Mr Machin said that if there were proper annual job plan reviews trusts and the government would see that most consultants were exceeding their contractual commitment.
There will be a further review of the local operation of awarding discretionary points and their link with distinction awards, and the criteria and procedures for distinction awards are being reviewed to ensure a proper balance between clinical excellence, service achievement, and academic merit. Other items for future discussion include temporary additional notional half days and accommodation of portfolio careers, including the ability to work flexibly.
Health secretary sets out NICE's programme
The secretary of state for health, Alan Milburn, has set out the timetable for the results of the first work programme of the National Institute for Clinical Excellence (NICE). NICE is a special health authority with direct responsibility to the health secretary and to the National Asembly for Wales.
Mr Alan Milburn wants to tackle “the lottery of care”
During 2000 the institute will issue guidelines on the following:
Breast and ovarian cancer (Taxenes): April
Coronary heart disease (coronary artery stents): April
Cervical screening (liquid based cytology): May
Multiple sclerosis: August
Hepatitis C: October
Colorectal cancer: November
Alzheimer's disease: December
Mr Milburn said that the programme represents “our Year 2000 Battle Plan for tackling the lottery of care in the NHS.” The health secretary said, “I want to make clear today that I expect health service organisations systematically and consistently to take account of NICE's guidelines. Both clinical governance locally and the new Commission for Health Improvement nationally will help ensure this happens.”
Medical school selection: greater care needed
To ensure that Britain is getting the right doctors there needs to be more work on widening the social basis of medicine; graduate entry to medical school; streamlining the admissions process; improving information on the different types of courses and on different entry requirements; and on the use of the halfway degree as an “honourable exit” from medicine for students who have made the wrong choice.
These were the conclusions of a conference on selection for medical school organised last year by the BMA's board of medical education: a report has now been published.
The conference looked at the different ways that schools select their entrants. Some use interviews. Some give points for extra-curricular activity, such as sports and musical activity. The profession remains overwhelmingly middle class, and an outreach scheme in Sheffield and a mentoring scheme in Manchester were cited as examples of efforts to encourage pupils from less advantaged backgrounds to consider medicine.
Some speakers at the conference questioned the need to make radical changes, as it was the quality of the training which shaped the doctor. Students' characters and attributes were not fully formed and it might be more relevant to concentrate on screening out the clearly unsuitable students than on manipulating the composition of medical school intake. There was consensus that processes needed to be more transparent.
The chairman of the board of medical education, Dame Fiona Caldicott, said, “The number of disappointed applicants every year and the number of disaffected doctors mean that questions are often asked about the processes which admissions tutors use to select students for medical school. The government's commitment to creating an extra 1000 places for medical students by 2005 will focus attention on how the students will be selected to the new schools and courses.”
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