Re: What will junior doctors earn under their new contract?
Madam,
Burns attempts to provide a comparison of pay and working conditions between the current and proposed Terms and Conditions of Service for Junior Doctors (Careers, 25 June)[1], but via a series of unacknowledged biased selections and miscalculations undermines the validity of her conclusions.
Weekend pay rates
Critical contributions are neglected in Burns’ weekend pay calculation. The “amount per weekend” calculation (figure 4) only calculates the explicit weekend supplement, neglecting raw hours worked and any “enhanced hours” supplement. For a standard long-shift pattern with half the shifts at night (common currently), the amount per weekend for nodal point 4 (ST3-8) is thus understated by £649.82, so that instead of the author’s claim of weekend pay ranging from £0 to £263.94 in her examples, it in fact ranges from £649.82 to £913.76 (she also misses a rounding rule that some average hours are rounded up before pay is calculated). Furthermore, under the proposed contract, the weekend allowance is banded, and Burns fails to account for the full range of work in each frequency band and compare average values. Whilst with a comparison of median frequencies 1:2 weekends would still appear proportionately less remunerated, this is because one is not comparing the top of one band with the bottom of the next.
The two sections “Working one in two weekends” and “Working one in four weekends” use misleading examples. Without explicit statement, these sections take as baseline comparison minimal ways of incurring their respective bandings (with a 40-hour working week)[2], which are seldom (if ever) used in practice. At present, a doctor who works a 48-hour average weekly rota including every weekend and has a heavy proportion of night shifts would receive a 50% banding supplement. Compared to this maximum rota, a doctor could also earn the exact same pay under the proposed contract by working half as many weekends, half as many night shifts and eight hours a week fewer, for example. The comparison offered by the author uses an unrealistic extreme rather than a representative middle or stating the entire range, in a way that presents the new contract unrealistically as detrimental.
The bigger picture
The arithmetic errors and unfortunate baseline selection mask a yet more fundamental issue. Burns has entirely neglected the important interaction between pay, rostering, service needs and workforce numbers. With an hours-based contract it is theoretically possible to pay doctors for any bizarre combination of hours, yet in practice only certain combinations are achievable though rota designs that cover the required service.
Most services do not require doctors to work one in two weekends. An increase in weekend working with current workforce numbers would reduce weekday working. The negative impact on weekday elective services and therefore trust income would make this economically inviable. If there were an increase in Full Time Equivalents (i.e. more doctors working) to provide more weekend services, this would be outside of the agreed pay envelope, requiring extra cash from government. It is therefore unlikely that there will be any significant change in the pattern of working. Currently, the majority of doctors work 1:4 to 1:5 weekends. The choice of 1:2 weekends for major illustrations of this article is therefore highly misleading.
On making comparisons with the current banding system, Burns falls into the trap of missing the bigger picture by stating that to avoid losing money on a rota with 50% banding, a doctor should “work one in four weekends, one night shift per month, and eight additional hours a week”. Doctors working that theoretical combination of hours would be working on a 30-week rota cycle, which is unrealistic in even the largest of hospitals. Under the current banding system[2], it is theoretically possible that doctors could be rostered to work one in four weekends and this by itself to trigger a 50% banding, but in practice this is an expensive option for trusts who instead roster doctors to work evenings and night shifts too. Similarly, Burns states an alternative option would be to “work one weekend in two and seven night shifts a month”. Whilst not explicitly stating so, from the tables it is clear that this working pattern would be for doctors working just 40 hours per week. We would be interested to see whether Burns could demonstrate any working pattern where a 24/7 service could run on a rota with this curious pattern of working. Moreover, it is important to note that this entire paradigm presumes doctors have a level of control over their working hours that permits such selection of hours, which is untrue and has been one of the key public misconceptions throughout the contract dispute.
Online tables
In the online tables, Burns compares the banded mean salary on the current contract taken over ST3-ST8 for a trainee on the minimum node for each grade. This choice removes the gain from front loading for the majority of trainees who never reach the ST8 grade. Further, front loading makes it critical to consider pay over the whole of training, and including pay from the start of training (i.e. from the Foundation Programme) would be far more representative. Trainees who reach the ST7-8 grades on the new contract will do so only after 2019, when funds currently allocated to transitional protection will be reallocated to increase the ST3-8 nodal values. Further, some of these doctors will receive the new Senior Decision Maker allowance[2]. Even before correcting for a missed rounding up rule meaning every entry in the tables is low, these tables are misleading as to who will gain financially and who will not. The results from these tables are used in the underlying assumptions of the main article and thereby bias the overall conclusions.
In summary, Burns begins her article by talking about the complexity of the current and proposed contracts, but poor choices in an attempt to unravel this complexity coupled with oversimplification and errors in the interpretation of the contract lead to a misleadingly negative view of the proposed contract.
Steven M. Bishop
Jordan P. Skittrall
Katharina Kohler
Danny J. N. Wong
Hoong-Wei Gan
Melody G. Redman
Johann Malawana
References
1) J. Burns. “What will junior doctors earn under their new contract?” BMJ 2016;353:i3453
2) Terms and Conditions of Service NHS Medical and Dental Staff 2002 (version 10: March 2013). NHS Employers.
3) Proposed Terms and Conditions of Service for NHS Doctors and Dentists in Training (England) 2016, Version 2. http://www.nhsemployers.org/~/media/Employers/Documents/Need%20to%20know... (accessed 26 Jun 2016).
Competing interests:
Steven Bishop, Jordan Skittrall and Katharina Kohler are local junior doctor BMA representatives, have advised on contractual and pay matters during negotiations and developed an online pay calculator using the figures for the new contract.
Danny Wong and Hoong-Wei Gan are junior doctors and BMA members.
Melody Redman is a member of the BMA Junior Doctors Committee executive.
Johann Malawana is the chair of the BMA Junior Doctors Committee 2015-16 and was involved in the junior doctor contract negotiations.
27 June 2016
Jordan P. Skittrall
Academic Clinical Fellow
Steven M. Bishop, Katharina Kohler, Danny J. N. Wong, Hoong-Wei Gan, Melody G. Redman, Johann Malawana
Rapid Response:
Re: What will junior doctors earn under their new contract?
Madam,
Burns attempts to provide a comparison of pay and working conditions between the current and proposed Terms and Conditions of Service for Junior Doctors (Careers, 25 June)[1], but via a series of unacknowledged biased selections and miscalculations undermines the validity of her conclusions.
Weekend pay rates
Critical contributions are neglected in Burns’ weekend pay calculation. The “amount per weekend” calculation (figure 4) only calculates the explicit weekend supplement, neglecting raw hours worked and any “enhanced hours” supplement. For a standard long-shift pattern with half the shifts at night (common currently), the amount per weekend for nodal point 4 (ST3-8) is thus understated by £649.82, so that instead of the author’s claim of weekend pay ranging from £0 to £263.94 in her examples, it in fact ranges from £649.82 to £913.76 (she also misses a rounding rule that some average hours are rounded up before pay is calculated). Furthermore, under the proposed contract, the weekend allowance is banded, and Burns fails to account for the full range of work in each frequency band and compare average values. Whilst with a comparison of median frequencies 1:2 weekends would still appear proportionately less remunerated, this is because one is not comparing the top of one band with the bottom of the next.
The two sections “Working one in two weekends” and “Working one in four weekends” use misleading examples. Without explicit statement, these sections take as baseline comparison minimal ways of incurring their respective bandings (with a 40-hour working week)[2], which are seldom (if ever) used in practice. At present, a doctor who works a 48-hour average weekly rota including every weekend and has a heavy proportion of night shifts would receive a 50% banding supplement. Compared to this maximum rota, a doctor could also earn the exact same pay under the proposed contract by working half as many weekends, half as many night shifts and eight hours a week fewer, for example. The comparison offered by the author uses an unrealistic extreme rather than a representative middle or stating the entire range, in a way that presents the new contract unrealistically as detrimental.
The bigger picture
The arithmetic errors and unfortunate baseline selection mask a yet more fundamental issue. Burns has entirely neglected the important interaction between pay, rostering, service needs and workforce numbers. With an hours-based contract it is theoretically possible to pay doctors for any bizarre combination of hours, yet in practice only certain combinations are achievable though rota designs that cover the required service.
Most services do not require doctors to work one in two weekends. An increase in weekend working with current workforce numbers would reduce weekday working. The negative impact on weekday elective services and therefore trust income would make this economically inviable. If there were an increase in Full Time Equivalents (i.e. more doctors working) to provide more weekend services, this would be outside of the agreed pay envelope, requiring extra cash from government. It is therefore unlikely that there will be any significant change in the pattern of working. Currently, the majority of doctors work 1:4 to 1:5 weekends. The choice of 1:2 weekends for major illustrations of this article is therefore highly misleading.
On making comparisons with the current banding system, Burns falls into the trap of missing the bigger picture by stating that to avoid losing money on a rota with 50% banding, a doctor should “work one in four weekends, one night shift per month, and eight additional hours a week”. Doctors working that theoretical combination of hours would be working on a 30-week rota cycle, which is unrealistic in even the largest of hospitals. Under the current banding system[2], it is theoretically possible that doctors could be rostered to work one in four weekends and this by itself to trigger a 50% banding, but in practice this is an expensive option for trusts who instead roster doctors to work evenings and night shifts too. Similarly, Burns states an alternative option would be to “work one weekend in two and seven night shifts a month”. Whilst not explicitly stating so, from the tables it is clear that this working pattern would be for doctors working just 40 hours per week. We would be interested to see whether Burns could demonstrate any working pattern where a 24/7 service could run on a rota with this curious pattern of working. Moreover, it is important to note that this entire paradigm presumes doctors have a level of control over their working hours that permits such selection of hours, which is untrue and has been one of the key public misconceptions throughout the contract dispute.
Online tables
In the online tables, Burns compares the banded mean salary on the current contract taken over ST3-ST8 for a trainee on the minimum node for each grade. This choice removes the gain from front loading for the majority of trainees who never reach the ST8 grade. Further, front loading makes it critical to consider pay over the whole of training, and including pay from the start of training (i.e. from the Foundation Programme) would be far more representative. Trainees who reach the ST7-8 grades on the new contract will do so only after 2019, when funds currently allocated to transitional protection will be reallocated to increase the ST3-8 nodal values. Further, some of these doctors will receive the new Senior Decision Maker allowance[2]. Even before correcting for a missed rounding up rule meaning every entry in the tables is low, these tables are misleading as to who will gain financially and who will not. The results from these tables are used in the underlying assumptions of the main article and thereby bias the overall conclusions.
In summary, Burns begins her article by talking about the complexity of the current and proposed contracts, but poor choices in an attempt to unravel this complexity coupled with oversimplification and errors in the interpretation of the contract lead to a misleadingly negative view of the proposed contract.
Steven M. Bishop
Jordan P. Skittrall
Katharina Kohler
Danny J. N. Wong
Hoong-Wei Gan
Melody G. Redman
Johann Malawana
References
1) J. Burns. “What will junior doctors earn under their new contract?” BMJ 2016;353:i3453
2) Terms and Conditions of Service NHS Medical and Dental Staff 2002 (version 10: March 2013). NHS Employers.
3) Proposed Terms and Conditions of Service for NHS Doctors and Dentists in Training (England) 2016, Version 2. http://www.nhsemployers.org/~/media/Employers/Documents/Need%20to%20know... (accessed 26 Jun 2016).
Competing interests: Steven Bishop, Jordan Skittrall and Katharina Kohler are local junior doctor BMA representatives, have advised on contractual and pay matters during negotiations and developed an online pay calculator using the figures for the new contract. Danny Wong and Hoong-Wei Gan are junior doctors and BMA members. Melody Redman is a member of the BMA Junior Doctors Committee executive. Johann Malawana is the chair of the BMA Junior Doctors Committee 2015-16 and was involved in the junior doctor contract negotiations.