Feature

The impact of the junior doctor contract—one year on

BMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j4125 (Published 06 September 2017) Cite this as: BMJ 2017;358:j4125
  1. Abi Rimmer, news reporter
  1. The BMJ
  2. arimmer{at}bmj.com

This October will mark 12 months since trainee doctors began to sign up to new terms and conditions. Abi Rimmer looks at how it has affected trainees and employers

The October 2016 implementation of the new contract for junior doctors in England marked the end of a long period of unrest. Though the BMA remained in dispute with the government, ongoing strike action over the changes brought by the contract came to an end with its introduction. Since then most junior doctors eligible to move onto the new contract have done so.

The process began in October 2016, with obstetrics trainees in their third year and higher. Then in November and December doctors in the two years of the foundation programme who were taking up new appointments also started on the new contract. Between February and April this year trainees in psychiatry, pathology, paediatrics, and surgery began to work under the contract. Any remaining eligible trainees are expected to be working under the new terms and conditions by the end of October.1

Paul Wallace, director of employment relations and reward at NHS Employers, says that the transfer has gone smoothly overall but that it has created a lot of extra work for trusts’ human resources departments. “We’ve had lots of real hard work done by medical staffing colleagues to ensure that the contract was implemented in the way that we anticipated,” he says. “And so far I think it’s going well.”

The contract’s implementation has also created an opportunity for employers to reflect on junior doctors’ working conditions, Wallace adds. “Clearly, the world of work is very different from what it was 30 or 40 years ago, and as employers we need to reflect on that. In this case we’ve got a group of staff we need to be reflecting on in terms of what that employment experience needs to look like.”

Such reflection on working conditions might help trusts meet many of the concerns raised during last year’s dispute, which often ranged beyond details in the new contract to broader issues about doctors’ working lives and careers.

Exception reporting

Steve Gill, consultant in intensive care medicine and anaesthesia at Nottingham University Hospitals NHS Trust, says, “The contract negotiation brought a lot of things to a head which are not contractual but are about working conditions, rest facilities, food out of hours, and all of those sorts of things.”

Gill is his trust’s guardian of safe working hours, a role created by the new contract. The guardians are responsible for overseeing their trusts’ compliance with the contract’s safeguards on working hours. They are also expected to ensure that “exception reports,” another creation of the new contract, are properly dealt with.

Exception reports were designed as a mechanism for junior doctors to raise an alert when their actual hours or working varied significantly or regularly from their schedule. The work schedule, again a new concept introduced by the 2016 contract, sets out junior doctors’ rota template and the training opportunities that must be included in their placement.

Gill says that, as far as it goes, the exception reporting system is working well at his trust. “I think that those who are exception reporting have been satisfied with how they have been managed and how we have responded,” he says.

But he says that he is aware of instances of trainees thinking that they are working too many hours but aren’t submitting an exception report. In some cases, Gill says, this could be because of a department’s working culture: “For some specialties that have only just come on to the new contract, and are only just getting to grips with it, I think there is a ‘you do the work however long it takes’ or ‘put up and shut up’ kind of attitude that has persisted for a long time.”

Simon Fleming, president of the British Orthopaedic Trainees Association, has also seen varying attitudes towards exception reporting. “I have met people who are being completely encouraged to exception report everything, identify anywhere that the unit could do better,” he says, but adds, “You also hear other more disappointing reports of places where exception reporting is frowned on and not encouraged.”

Fleming is hopeful that exception reporting will bring about positive change for junior doctors. “I think exception reporting, if used properly, will be one of the most powerful tools for enabling trainees to get the best possible training at all stages in all situations,” he says. “But it needs to be used properly, which means the guardians need to be empowered and supported to do their job properly, and it means trainees need to be encouraged to exception report at all levels.”

At Great Ormond Street Hospital, trainee anaesthetist Ged Manning has seen exception reporting working in practice. “There’s quite a lot of time off in lieu that has been given [as the result of exception reporting],” Manning says. “There’s been a case of financial compensation for a trainee who worked too much, and there’s one rota that is being reviewed after there was a series of exception reports for one part of it.”

Like Fleming, Manning thinks exception reporting is a good thing. “I think it’s a really powerful tool for positive change. It’s a great way of highlighting when the work that we are doing on the ward and in the department isn’t the same as the work that our supervisors, and their supervisors, think it is. It’s a way of closing that misunderstanding.”

Teething problems

Although the introduction of exception reporting has been seen as positive, there are undoubtedly ongoing problems with the new contract. Jeeves Wijesuriya, chair of the BMA’s Junior Doctors Committee, says that the way the contract has been implemented has created problems in some places. “We know there are bits of the contract that we fought for which we think are positive and important, and we have been trying to ensure that those safety protections and limits are there and work,” he says. “But there are, because of the fact that this contract was imposed, huge teething problems.”

Wijesuriya says that some trusts have created junior doctor rotas that don’t fall within the safe working limits set by the contract and that they don’t facilitate exception reporting. Other trusts have misinterpreted the contract’s new rules on locum working, he says. Wijesuriya recently wrote to University Hospitals Birmingham NHS Foundation Trust asking it to retract briefing notes sent to junior doctors suggesting that they might be referred to the General Medical Council if they didn’t take on locum work.2

Two key concerns raised by trainees about the new contract during the dispute were that it would disproportionately affect trainees who work less than full time and that there would be a sex divide, as most of these trainees are women.

Wijesuriya says that the BMA is still trying to tackle the longstanding pay gap between the sexes in medicine. “We’ve done a huge amount of work to create less than full time pilots to improve access to less than full time training. We’ve also created a less than full time forum to enhance the representative voice of our less than full time trainees.”

He adds that that BMA is still calling for a review of the gender pay gap, promised by the health secretary and the Department of Health last year.

And there continue to be problems with junior doctors’ rotas, Wijesuriya says. “There are a lot of fundamental employment practices that we aren’t doing [in the NHS] that we need to,” he says. “For example, we need to build rotas that have the capacity for juniors to take annual and study leave. We need to make sure that we identify which staff should be on a particular rota and define what a rota gap is.”

Unfilled rotas

Many junior doctors are already finding that the contract’s restrictions on working hours are making it more difficult to fill junior doctor rotas. Tom Oates, a senior specialty trainee in nephrology and general medicine, says that constraints in the new contract are creating additional staffing problems.

“I know people who are trying to run rotas who are finding it very hard to staff wards under the working hours constraints of the new contract, regardless of the rota gaps that we know exist anyway,” he says. “What the contract has done is add an additional layer of complexity for you in using the doctors that you have to [provide] staff 24 hours a day, seven days a week. Before you even tackle the problem of there not being enough doctors, you’ve now got this additional problem.”

Despite these problems, and others, among many doctors there is a distinct feeling that, in general, junior doctors are back at work, doing their day jobs as usual.

Sam Dobson, a year 5 specialty trainee in obstetrics and gynaecology, has been working under the contract for just a few weeks. So far he hasn’t seen many changes to the way he works as a result of the contract. “I’m working a pretty similar rota to what I was doing,” he says. “It’s the same number of weekend days, we’re not doing clinics at the weekend or in the evenings—it’s exactly how it was. That may change in the future. At the moment we are rotaed to do the same pattern and number of weekends and nights as we did previously.”

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