Junior doctor contract reform—as bad as it seems?
BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h4386 (Published 17 August 2015) Cite this as: BMJ 2015;351:h4386
- Janis Burns, junior clinical fellow, Department of Anaesthesia and Critical Care, Royal Brompton and Harefield NHS Foundation Trust
- janis.burns{at}cantab.net
Abstract
Janis Burns argues that the proposed radical changes to the junior doctor contract will be detrimental to doctors’ training, work-life balance, and earnings
The Review Body on Doctors’ and Dentists’ Remuneration (DDRB) recently published its report on proposed changes to the standard national contract for NHS consultants and junior doctors.1 Junior doctors have raised concerns about several of the changes that have been proposed for the new contract. These include pay elements, basic pay points and progression, work schedules, reviews, exception reporting, and a new definition of unsocial hours. In reviewing the contract, the DDRB tested issues against six criteria that reflect their standing terms of reference (box 1).
Box 1: Six criteria reflecting the DDRB’s standing terms
Improved patient care
Maintaining respect and trust for consultants and junior doctors as leaders and professionals
Credibility and practicality of local implementation
Appropriate remuneration (to recruit, retain, and motivate)
To help facilitate constructive, continuing relationships
Affordability
Negotiating parties
The proposed changes to these contracts are being negotiated by two parties. NHS Employers negotiates on behalf of the government and the BMA does so on behalf of doctors. The government’s main driver for contract reform is to facilitate a comprehensive seven day service, but this is not the sole driver. Contract reform is necessary to prevent medicine falling further out of line with other skilled professions and to ensure that junior doctors can be recruited to, and retained in, the health service’s workforce and that they remain motivated professionals (box 2).
Box 2: Timeline of junior doctor contract negotiation
2000—Current contract introduced. Aimed to improve working conditions for junior doctors by decreasing hours and ensuring minimum rest breaks
June 2011—Scoping report on contract for doctors in training. Ongoing viability of the 2000 contract assessed. A vision and five principles for a new contract were set out. NHS Employers would seek an overall national framework within which a locally determined approach could be applied, while the BMA wish to continue with comprehensive nationally applied standards
December 2012—Health secretary accepted scoping report as basis for negotiations between NHS Employers and the BMA
June 2013— Heads of terms for possible negotiations agreed. Chancellor announces public sector pay reform with an end of automatic pay progression related to time served
October 2013— All UK health departments mandated NHS Employers to begin negotiations with the BMA, aiming to complete negotiations by October 2014 and implement new contract by April 2015
February 2014— Interim joint report submitted that agreed that the contract should be cost neutral and offered high level definitions around pay. Discussions to develop a set of principles underpinning pay elements were continuing
October 2014—BMA withdraws from negotiations because of lack of credible evidence underpinning the proposed changes and because it was being asked to make changes that had a considerable impact on patient safety, doctors’ welfare, and the sustainability of the NHS
July 2015—DDRB publishes Contract Reform for Consultants and Doctors and Dentists in training—Supporting Healthcare Services Seven Days a Week
Cost neutrality
Both NHS Employers and the BMA have agreed that contract reform should be cost neutral. There is a reasonable argument that the changes to the contract should be cost neutral where they are aimed at improving recruitment, retention, and motivation of the workforce. However, the case for cost neutrality should not be applied to the introduction of a comprehensive seven day service, the other main driver behind the contract negotiations.
An increase in funding is needed if the health service is to provide a comprehensive seven day service. Seven day services cannot, and should not, be funded from the current pay envelope. Nor should they be resourced by increasing the burden of unsocial working across the current workforce. However, Jeremy Hunt, the secretary of state for health, has so far failed to provide details of how seven day services will be funded or staffed.
Availability allowance
Under the proposed new contract, junior doctors’ pay would be made up of five elements, replacing the current banding system (box 3). The DDRB has accepted NHS Employers’ proposals for the introduction of an availability allowance for doctors working on call. According to the DDRB recommendations, out of hours working would be rewarded with a premium hourly rate in addition to the standard hourly paid rate. It is not clear, from the description of the availability allowance given by the DDRB, what working patterns would be eligible for the allowance. Specialty registrars currently provide out of hours cover from home and their sleep can be disturbed with calls from colleagues seeking advice.
Box 3: Five elements of junior doctors’ pay, as proposed by NHS Employers
Basic pay—Rate of pay for working up to 40 hours a week with pay progression according to a nodal basic pay scale based on stage of training and responsibility
Rostered hours—Up to eight additional hours per week, averaged over a reference period, that will be paid at the same rate as basic pay
Out of hours—Hours worked outside “plain time,” attracting a premium hourly rate
Availability allowance—A sum that is paid in return for an obligation to be available, on standby, to return to work
Recruitment and retention premiums—A sum that is paid to a group of doctors on top of the basic salary but not included in calculation of other payments
What is unclear from the DDRB report is whether these doctors would receive payment for this as an availability allowance or whether they would be paid an out of hours hourly rate. Similarly, it is unclear whether a surgeon who is on call at home and then required to return to work would receive their hourly pay rate for the hours they worked in the hospital in addition to the availability allowance. A clear definition of the availability allowance is needed to ensure that junior doctors are safeguarded against exploitation by employers who may seek to reduce their bill for out of hours cover through inappropriate use of this new concept.
Pay progression
In its evidence to the DDRB, NHS Employers proposed three pay progression scenarios (fig 1⇓). The DDRB said in its report that it was unable to comment on which scenario would be the most appropriate. However, it recommended that “pay should be based on stages of training and actual progression to the next level of responsibility, evidenced by taking up a position at that level.”
Three pay progression scenarios proposed by NHS Employers
Under all of the proposed scenarios, a doctor’s salary would increase when he or she takes up a post at the next stage on the pay scale, corresponding to an increased level of responsibility. This would be related to his or her annual review of competence and progression (ARCP). It is important that this change does not lead to junior doctors being exploited by their employers or disadvantaged when training is inadequate. Currently, there is no allowance when a trainee fails to achieve the required ARCP outcome because their institution has provided inadequate training.
The proposed system places more emphasis on perceived responsibility than on the experience, skill set, and professional achievements of an individual doctor. It is relatively common for junior doctors to be unsuccessful in gaining places on their desired training programme, particularly in competitive specialties and geographical areas. Often these doctors continue to work in posts that are not formally recognised for training, but they continue to gain experience and acquire useful practical skills that improve patient care. This will not be recognised with remuneration under the proposed changes. A commitment to ensure that an adequate and appropriate number of training posts are made available each year is required. Without a guarantee of accurate and fair workforce planning/projections, and a commitment that this will be reflected in the number of training posts offered, employers could be free to create artificial recruitment bottlenecks, allowing experienced and skilled doctors to be employed without appropriate remuneration. NHS Employers and the Department of Health should make a commitment that this will not occur.
The BMA has also raised the issue of indirect discrimination, and this requires further exploration to ensure that those taking maternity or paternity leave and those engaging in less than full time training are not disadvantaged. Currently, less than full time trainees progress at the same rate as their peers, preventing a pay gap between the sexes. The abolition of automatic pay progression and introduction of a system based on appointment to posts with increased responsibility disadvantages not only women taking time out for maternity reasons but also trainees with health issues. While NHS Employers has received legal advice that “its proposals were objectively justified, and that provisions that affected individuals differently were reasonably necessary to achieve business objectives” it has not been rigorously challenged. If this challenge is upheld, it then places a fundamental barrier to adoption of this proposed model of pay progression.
Automatic pay progression with time served has allowed doctors to receive an annual increase in their salary, despite austerity measures imposed by the previous coalition government and the current government. It is questionable whether the current government would commit, via legislation, to ensure that the entire NHS workforce would not be subjected to these measures again and that it would receive at least annual pay rises in line with inflation.
Work schedules and reviews
Work schedules, as proposed by NHS Employers, are designed to provide a doctor in training with the hours they would work, where they could expect to work those hours (including on-call arrangements), clinical services expected, and training opportunities available during a placement. They would be developed in partnership by the employer and the doctor in training and personalised to take account of an individual’s training experience and competencies.
Work schedules seem to be a positive step, providing doctors with a personalised plan for each placement and specifically outlining their role in service provision but also detailing training opportunities. However, questions remain around whether there would be any accountability on behalf of the employer if agreed training opportunities were unavailable or missed through variations in the proposed schedule.
Another proposal supported by the DDRB was the introduction of work reviews. These would take place, as a minimum, at the beginning and end of a post but could be requested at any point by an employee or employer. The proposed review process is supported by the Department of Health.
One issue with work reviews is that using local grievance procedures has negative connotations. It suggests that there has been a breakdown in the relationship between employee and employer rather than facilitating a constructive, continuing relationship between the two. The BMA has suggested that the third stage of the review process would require external arbitration to remove perceptions of bias, and this seems reasonable.
Exception reporting
Exception reporting is a means of triggering a work review, with the purpose of informing employers of variations to a work schedule, primarily relating to hours of work and rest, patterns of work, and educational opportunities. The proposals are similar to the current monitoring process but will allow a trainee to alert their employer when training opportunities fall below what is agreed in their work schedule.
Both negotiating parties disagreed in regard to payment of unplanned exception reported work. According to the DDRB report, NHS Employers believed that a professional contract would be “undermined if a system were in place where doctors in training could claim additional money for every extra minute spent carrying out their duties, that it would create an incentive to work slower, and would unfairly reward trainees who did not keep pace compared to their colleagues.”
NHS Employers clearly have a case from a business perspective. However, their comment is at odds with the General Medical Council’s Good Medical Practice guidance, which requires all doctors to “be honest, open and act with integrity” and “never abuse your patients’ trust in you or the profession.”2 If there is no requirement to pay doctors when their work schedule is breached, then there is no incentive for NHS Employers to ensure that junior doctors are not exploited.
Plain time
Under the proposed new contract, unsocial hours have been redefined, and four different scenarios have been proposed (fig 2⇓). The DDRB supports scenarios C and C+, differing only in their increase to basic pay (15.3% and 14.9%, respectively). Currently, no clearly defined uniform approach to unsociable hours pay exists in the United Kingdom. Plain time commonly ends between 8 pm and 10 pm.
Four unsocial hours scenarios proposed by NHS Employers
In tandem with the proposed changes to junior doctor and consultant contracts, NHS Employers is proposing to amend plain time definitions for Agenda for Change staff. Unsocial hours would begin at 10 pm every day of the week for all NHS staff. It is not unreasonable to bring doctors’ contracts in line with other NHS staff with unsocial hours starting at 8 pm. However, shifting the start of unsocial hours for the entire workforce to 10 pm is unreasonable and will impact on a junior doctor’s right to a private and family life. 3Although this option would be more affordable for employers it will harm recruitment and retention, jeopardising the long term sustainability of the NHS.
UK society continues to regard the weekend as premium leisure time. Saturday has not been fully normalised into plain time in other UK sectors. How this is incentivised varies according to the sector and the demand for labour—that is, engineering and manufacturing have different needs compared with retail and hospitality sectors and therefore different approaches are adopted. Internationally, the Incomes Data Service found that for doctors the highest premiums were paid for, in descending order, Sundays, Saturdays, and night hours. It would therefore seem reasonable that the UK’s largest workforce should not be forced to accept Saturday as plain time. Saturday working hours should continue to be considered as unsocial and doctors working them should receive appropriate financial remuneration.
In evidence to the DDRB, the Incomes Data Service made an interesting, but irrelevant, observation. They said that some highly paid employees in certain industries do not receive any pay enhancements for weekend working. Basic pay and bonuses, where paid, were considered sufficient compensation for this, they said. NHS Employers are not proposing high rates of pay for junior doctors or the introduction of a bonus scheme; junior doctors therefore need protection from excessive working hours to ensure patient safety.
Complex and difficult
Contract reform is complex and fraught with difficulty. The secretary of state for health, with the aid of the chancellor of the exchequer, should outline exactly what services will be provided as part of a seven day service and how these will be resourced, both in terms of finance and workforce. This will allow further, meaningful negotiations between the BMA and NHS Employers to take place.
In the light of the DDRB’s report, a pay progression model that recognises the experience and skills of an individual doctor, in addition to increasing levels of responsibility, is a key area for negotiation. Financial safeguards for trainees who are failed by the system should also be included. Assurances that artificial training bottlenecks will not be created also need to be provided. The BMA, supported by the DDRB, should continue to push for mandatory safeguards to be included in any new contract, to protect junior doctors from excessive working hours.
Footnotes
Competing interests: I have read and understood BMJ’s policy on declaration of interests and declare that I am a junior doctor in training and member of the BMA.