Junior doctor contract wish listBMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f4425 (Published 18 July 2013) Cite this as: BMJ 2013;347:f4425
The junior doctor contract is out of date, but how could potential negotiations improve it? Helen Jaques asks some of the trainees at this year’s BMA Annual Representatives Meeting
The current junior doctor contract—which covers all doctors in training, including GP trainees and academic and public health doctors—was agreed years ago in 2000. Although this contract achieved its main goal of reducing the average hours worked by trainees, NHS Employers’ recent “scoping report” went so far as to brand it “not fit for purpose,” prompting the government to call for the junior doctor contract to be renegotiated.1
NHS Employers, on behalf of the government, and the BMA have since held preliminary talks on the junior doctor contract and have thrashed out “heads of terms” that outline what any potential negotiations might cover.23 The key areas on the table are work planning, hours, and pay, with work-life balance, time for training, leave, and professional costs all getting a mention.
Most junior doctors will agree that their current contract is far from ideal, and the trainees at the BMA’s Annual Representative Meeting in Edinburgh last month were no exception. BMJ Careers hears from several representatives at the meeting about the problems with the current contract and how new terms and conditions might solve them.
Zoe Greaves—foundation year 2 doctor, Middlesbrough
Employers keep tabs on the hours worked by junior doctors by collecting detailed diaries for a two week period twice a year. The information from these monitoring exercises is used to work out what sort of unsocial hours doctors are working and thus the banding supplement they should be paid.
This is all well and good, says Zoe Greaves, a foundation year 2 doctor in Middlesbrough. But some employers do not get a sufficiently high return rate to monitor their doctors’ hours properly. “In the trust where I am working at the moment, the medical rota in particular hasn’t been successfully monitored for several years,” she says. “This means that [for] all the jobs we’re working at the moment, no one has any idea whether they’re correctly banded or not.”
Asking doctors to clock in and out of work is one approach that has been put forward to improve monitoring of trainees’ hours, but some doctors feel that this method might deprofessionalise medicine, says Greaves. A better option might be for any new junior doctor contract to have financial penalties for trusts that don’t monitor hours properly, she suggests.
Pay for hours worked
Tom Berry—specialty trainee year 5 in surgery, Glasgow
Another problem with this system of keeping track of junior doctor hours is that some trainees feel pressurised to under-report the hours they’re working, says Tom Berry, a surgical trainee in Glasgow. “Banding was deliberately punitive to encourage hours to be kept down,” he explains. “If a couple of [doctors] during a two week monitoring period were to exceed their hours or not get their breaks, everyone in that rota would get paid a huge increase in their banding and the hospital would have costs for that.” If junior doctors are bullied or pressurised into not reporting their hours correctly they can end up underpaid, he cautions.
One option that could be introduced by a new contract would be a system of exception reporting for junior doctor hours, he suggests. Under this system, doctors would have a base salary to pay them for the hours they’re supposed to work, and they would get paid on top of that at a higher rate for any extra hours. “But it’s complicated because we get paid a different amount for out of hours than we do for lunchtime on a Monday, and all those kind of things need to be taken into account,” he adds.
Jamie Green—specialty trainee year 3 in general practice, Northampton
Junior doctor hours are not only monitored to determine banding, but they are also recorded to monitor compliance with the European Working Time Directive (EWTD), which limits doctors’ hours to 48 a week. For EWTD monitoring, working hours are tracked over a period of 26 weeks and an average calculated. This approach means that doctors can still work for up to 90 hours in one week, providing that they work a sufficiently low number of hours in subsequent weeks to keep their average hours down.
This is a huge problem for doctors on hospital rotations, says GP trainee Jamie Green. “I think it is wrong that junior doctors are being burnt out by inappropriate numbers of night shifts in a row,” he says. “The existing system, although it was a huge step forward, has still allowed what I consider to be dangerous working hours, dangerous for the doctors and also dangerous for our patients.”
Once GP trainees reach their GP rotation, things become more stable and junior doctors work a five day week, says Green. But GP trainees need to book in out of hours shifts on top of that, “which means that sometimes we will be working a day shift followed by an evening shift on the out of hours service.” Introducing some form of rota system for out of hours responsibilities would be one way any new contract could fix this problem, he says.
Anish Amlani—specialty trainee year 1 in neurosurgery, London
For Anish Amlani, a specialty trainee year 1 in neurosurgery in London, pay fluctuations are the biggest problem with the current junior doctor contract. Banding supplements mean that doctors in the same grade get paid different amounts, he says, but pay can also fluctuate over a year for one doctor thanks to changes in banding with every rotation.
“Your pay changes by a significant amount on a four month by four month basis, but your expenses such as your rent and your bills don’t change during that time,” he explains. “This means it’s quite difficult to budget across a year if your pay is fluctuating.” A potential solution might be calculating a doctor’s pay and banding for a whole year and then dividing it by 12 so there’s an equal pay across the whole year, he suggests.
The BMA should also negotiate for a minimum timeframe by which the employers have to tell doctors how much they are going to be paid, he adds. “Employers may have a monopoly on your careers, but they should have enough respect for us as working professionals that they will give us four weeks’ notice,” he says.
Notice of working arrangements
Ganan Sritharan—core medical trainee year 2, London
Ganan Sritharan, a core medical trainee year 2 in London, agrees that it would be helpful if junior doctors were told their banding details, and about their working pattern, sufficiently early before starting a rotation. Employers are meant to send trainees their rotas six weeks in advance and their contracts four weeks before they start, he says, but this rarely happens.
“When you look at your colleagues in the private sector, they would never in a million years be given one week’s notice—or one day’s notice—of what their working hours will be for the next four months,” he says. “It’s incredibly depressing to have worked so hard to get a registrar position, to get the job, to be incredibly happy about it, yet not know when your start date is, let alone which of several potential hospitals you’ll be starting at.”
One approach to improving this situation would be introducing penalties in any new contract to make sure that employers give trainees sufficient notice of their new posts, suggests Sritharan.
Protected time for training
Farah Jameel—specialty trainee year 3 in general practice, Chichester
Another big problem for trainees at the moment is making sure that they have time to access the training they need against the growing demands of service delivery. This is a big problem in hospital training, says GP trainee Farah Jameel, who has worked in both hospitals and general practice during her three years of specialty training.
“During my hospital rotations, a lot of times I could be the only doctor on the ward, and how do you get your teaching then? You can’t,” she says. Although there was plenty of teaching on offer, she couldn’t necessarily make it to all the sessions because patients come first. “If patient is crashing on the ward, you can’t exactly get away to your teaching,” she says. “It’s not bleep-free teaching.”
In general practice, junior doctors’ time is divided into 10 sessions a week, three of which will be educational, so teaching is built into the way trainees work, Jameel says. “How amazing would it be if that was actually the way it was safeguarded in hospital medicine?” she says.
Tim Yates—specialty trainee year 2 in neurology (academic clinical fellow), London; and deputy chair of the BMA’s Junior Doctor Committee, with responsibility for education and training
Exactly what training is meant to be delivered in any one junior doctor post can be quite hard to elucidate, says Tim Yates, a specialty trainee year 2 in neurology. “We all have a vague idea of what training we’re going to be doing for, say, a gastroenterology trainee at a certain level, but that doesn’t always reflect what’s on our curriculum or what we’re supposed to be learning,” he says.
The heads of terms the BMA has agreed with NHS Employers propose introducing a work schedule for junior doctors that will describe how trainees should spend their time. This schedule will outline time for service provision, training, formal and organised study, and rest breaks. “That’s useful because if trainees report that they’ve not had access to the training opportunities they need, we’ll be able to hold the employers to account,” says Yates.
This approach will get the trainee “off the hook” in terms of making sure that they are getting the training they need and will transfer the responsibility of ensuring training provision to the employer, he adds.
The next steps
The heads of terms document commits the BMA and NHS Employers to exploring many of the issues raised by these trainees during any negotiations for a new contract for junior doctors.4 The reference period for monitoring hours both for banding and EWTD will be scrutinised, with the potential introduction of a work schedule, hours based contract. Any new contract will support “a more predictable pay bill for employers and more predictable earnings for junior doctors,” the document adds. The heads of terms also include a commitment providing junior doctors adequate notice of where they will be working and what they will be doing.
Neither NHS Employers nor the BMA has yet agreed to enter formal renegotiation of the contract, which would require a mandate from the UK health departments and from the union’s Junior Doctors Committee. The areas up for negotiation look promising, but we’ll have to wait until autumn to find out whether real change is likely.
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.