Junior doctors’ contract: the sticking points in negotiations

Dr Spence has misinterpreted the issues and ends up recommending solutions that would exacerbate the NHS’ current problems.

The apples and oranges comparison he makes misses the point. The fact that junior doctors in the UK are no longer prepared to work 50 hours or more a week is a sign of progress, mandated by the EU Working Time Directive, and reflecting their greater awareness that if they don’t have a reasonable work life balance their job satisfaction and performance falls, and the risk of mistakes rises. Another form of progress is the much higher standard required of the modern junior doctor by the Royal Colleges. The work of a junior doctor is far more complex than during Dr Spence’s training, and technology enables them to achieve far more in the average working day, bringing with the increased efficiency, additional sources of stress. None of this justifies lower remuneration for junior doctors in the future than what they have rightly fought for over recent decades nor a move to have them work antisocial hours for standard hourly wages.

The pressure for seven day working, including in primary care, is not an ‘unstoppable cultural juggernaut of expectation’ that junior doctors should accept. It is yet another ploy of the Government to weaken and destabilise the NHS, bring clinical staff to heel and further open it up to privatisation when it fails. Throughout the UK, the government has disinvested in general practice, district nursing and social care whilst promoting the concept that the public should expect to access all these services whenever they need them. When the community services fail and the most vulnerable, frailest and palliative care patients pour into A&E for lack of alternative care in the community starting at 5 pm on a Friday, the government then blames the higher weekend hospital mortality on the hapless clinical staff including junior doctors and consultants who might be taking call from home.

Instead of exploiting findings of raised weekend hospital mortality by launching an unaffordable and unnecessary plan for seven day working, the government should have rigorously studied how much of that excess was due to overstretched community health services versus deficient hospital services. They should also have paid attention to existing evidence and commissioned additional studies of the cost effectiveness of remedying the latter and then implemented evidence based changes to out of hours care, in conjunction with clinical staff. Instead they used a heavy handed approach with both consultants and junior doctors, bound to lose the trust of the doctors with whom they pretended to negotiate.

The government has deliberately raised unrealistic public expectation at every opportunity instead of consistently providing advice on how to responsibly use the NHS. Healthcare is expensive and can do harm if injudiciously provided; its provision should be controlled, not promoted like a 24 hour supermarket. Furthermore, the more the state spends on healthcare, the less it can spend on other health promoting initiatives including good quality pre-school education which would transform the health prospects of the UK, more effectively than would more health care, despite Dr Spence’s belief that ‘vastly more doctors would reduce the unhealthy status and entitlement that blights so many lives’.

And yet he argues that the UK should plan to ‘vastly’ increase the number of doctors overall by doubling the number of doctors that it trains in the hope that this would also provide the work life balance doctors seek, solve medical staffing shortages and, via the law of supply and demand, drive down the wages for all doctors, fully qualified and in training. He favours a model where the medical recruitment market is flooded with junior doctors, akin to a large flow of perishable fruit, but makes no mention of how to raise the required sums to pay for additional hospital consultant and GP posts to make up the ‘vast’ numbers he would like to see.

He also fails to recognise that the UK already trains many doctors, at the considerable expense he mentions, who leave the UK, reportedly because they don’t feel respected or sufficiently paid. Scotland is a good example of a country that produces a disproportionately large number of doctors begging the question of why it has widespread vacancies.

The solutions to the NHS’ problems lie in careful analysis of the plentiful data it collects, mutually respectful working relationships and discussion between doctors and managers, exclusion of purely ideological influences from health service planning (privatisation being an obvious example in England), resisting the temptation to use the NHS as a political football, managing the public’s expectation and remunerating all staff appropriately. If more money is required, the government should look at improving its ability to raise tax from the wealthy and from large corporations.

Such analysis demonstrates that investment in general practice, district nursing and social services would solve many of the problems. Instead, over the past 20 years we have seen a steep rise in the number of hospital consultants in the UK, including Scotland, with no evidence of increasing job satisfaction despite the more generous terms of their 2004 Contract. Perhaps his demand should have been for more GPs specifically to balance the consultant provision and moderate the demand on hospital services.

The fact that he suggests that a much larger pool of doctors would eventually be happy to do these increasingly difficult jobs, in either hospital medicine or general practice, for less money is extraordinary and smacks of the tendency seen in some older doctors to kick the ladder out from underneath them and deny future generations of doctors the benefits they enjoyed. Many consultants would simply do even more private practice to supplement the reduced NHS income he has in mind. Recruitment and retention in general practice, his own area of work, would fall still further.

Finally, the use of phrases including ‘milk and honey’, and ‘gold plated pensions’ belies an unhelpful cynicism toward his own profession that gets in the way of objectively studying the reality.

Dr Helene Irvine
Consultant in Public Health Medicine
Directorate of Public Health and Health Improvement
NHS Greater Glasgow and Clyde
Gartnavel Royal Hospital.
4 February 2016

Dr Spence has been roundly criticised here for his views about the strike and his assertion that it is inevitable that the NHS will change to a 7 day working week.

But consider: Twenty years ago access to my local GP practice was possible 6 days a week, and the GP, or one of their close colleagues, was easily telephoned 24hrs a day, 7 days a week. Meanwhile the bank, shops, travel agents and public utility offices adhered to a strict opening times (9am to 5pm - 5 days a week) and were not easily contactable outside these hours. Now the situation appears to be more or less reversed.

Whatever the “rights and wrongs” of the details of the current dispute, doctors need to acknowledge that the public are uncomfortable about the quality of “out of hours” medical services and do not consider doctors underpaid.

In my opinion Des is correct: “Doctors would be best to simply accept this [a 7 day style service] as the new cultural norm and negotiate from this position.” Young doctors should worry more about the bigger picture. The real threat is not the imposition of a new doctors employment contract, but is the widespread introduction of private health care providers and HMOs into the NHS. The strike will hasten this development rather than prevent it.

Was Dr Spence's article on the junior doctors' strike really intended to be satirical?
The proposed contract will affect hospital doctors - but Spence works in general practice.
It will only apply to doctors in England - but he works in Scotland.
He refers to 7 day working as an "unstoppable cultural juggernaut" - and yet his practice website shows no routine 7-day service provision and a surgery that was closed for 8 out of 11 consecutive days over the recent Christmas / New Year period.
Spence is entitled to his opinion, but his well-insulated views do not reflect the vast majority of doctors who are directly affected by these issues.

I agree that increasing medical workforce in the UK will improve services, reduce strenuous on calls, eliminate burnout of NHS personnel, respect the European Working Time Directive, solve many existing organizational problems.
Training many more medical students and young doctors though, is not the solution, since it would take decades to produce results, and standards of entry would be inevitably lowered in order to boost enrollments.
Immediate employment of massive numbers of new, quality medical doctors in the NHS is possible, through active recruitment from debt ridden South European Countries, with ongoing brain drain of well educated Specialists and Consultants.
Thus, education and training costs are paid from foreign Countries, and NHS receives ready to work professionals.
Reference
http://www.bmj.com/content/350/bmj.h3479/rr