Intended for healthcare professionals


Problems with the new junior doctor contract

BMJ 2015; 351 doi: (Published 23 September 2015) Cite this as: BMJ 2015;351:h5077
  1. Jessamy Bagenal, editorial registrar, The BMJ (NHS national medical director’s clinical fellow scheme 2015-16), and general surgical registrar, North West Thames,
  2. Tom Moberly, editor, BMJ Careers,
  3. Fiona Godlee, editor in chief, The BMJ
  1. Correspondence to: J Bagenal jbagenal{at}

Why junior doctors need to channel their anger

Junior doctors are angry. In August 2016 the UK government plans to impose a new contract on doctors in England that threatens to extend their standard working hours while cutting their pay by up to 15%.1

Over 54 000 people have already signed an online petition calling on doctors to take strike action to oppose the imposition of the contract.2 Some medical royal colleges have also taken the unusual step of commenting on contractual terms and conditions, an area usually reserved for trade unions. The Royal College of Paediatrics and Child Health, the Royal College of Physicians of Edinburgh, the Royal College of Psychiatrists, the Royal College of Surgeons, the Association of Surgeon in Training, and others have raised concerns about the potential effect of the changes on the safety of patients and on recruitment and retention.

Although many details about the proposed changes are missing, they may look fairly harmless at first sight. Changes are based on recommendations of the independent Review Body on Doctors’ and Dentists’ Remuneration. Among other suggestions, they include contractual safeguards to ensure that hours and rest periods are maintained; a separate hourly payment for unsocial hours, with an end or change to pay banding; an extension to the normal working day; and for pay to be based on actual progression to the next level when junior doctors take up a new post.3 As always, the devil is in the detail. Under the proposals, unsocial hours are likely to be redefined so that working up to 21:59 on a Saturday night attracts the same rate of pay as working from 9:00 on a Tuesday morning.4 The BMA says that it has struggled to find any junior doctor who would be financially better off in the new contractual system. And indeed it has estimated that even high intensity specialties such as anaesthetics and emergency care will see a pay cut.5

Junior doctors are also concerned about the effect of the new reward structure on doctors who are not in a training scheme and those who take time out to do research or for illness or parental leave. The proposed changes mean that annual pay increments will be directly linked to appraisal and will be given only on progression to the next level of a recognised training programme. Many doctors work in roles that are not included in any such training programme, and so under the proposed changes they would be excluded from annual pay increments. The BMA is also concerned that a direct link between training progression and pay increments could exacerbate the gap between the sexes in NHS pay for doctors or deter trainees from training less than full time.6

Tired of doing more for less

Resentment over the proposed changes to the junior doctors contract has fed into wider frustration across the NHS, with staff generally reporting that they feel demoralised, disenfranchised, and undervalued.7 As the NHS struggles to deliver the efficiency target it has been tasked with meeting, its workforce is tired of being asked to do more for less.

It doesn’t have to be like this. Enlightened employers such as Google and the consultancy firm Deloitte focus on their employees’ happiness as a means to improve their business outcomes.8 The NHS needs to do the same. Results of staff surveys correlate with mortality rates and patients’ satisfaction.9 10 And staff satisfaction is inversely related to staff sickness, which has been gradually increasing since 2009.11

NHS Employers has acknowledged that staff morale is low and that work-life balance and staff wellbeing need to be improved.12 NHS England and NHS Employers have committed £5m (€6.9m; $7.8m) towards improving staff health, wellbeing, and support.13 Welcome though this is, it works out at £3 per employee, and the proposed changes to the junior doctors contract are likely to undermine, rather than improve, doctors’ work-life balance and their ability to work flexibly.

Late to the debate

Most junior doctors’ ignorance about negotiations over their pay and conditions has not helped. Negotiations between NHS Employers and the BMA ended abruptly 11 months ago when the junior doctors’ negotiators walked out. Yet the great majority of junior doctors have only now begun, largely through social media, to participate in the debate. NHS Employers is holding meetings throughout the country to connect with doctors directly. Having got things so badly wrong, it now has a clear responsibility to listen and respond to concerns over patient safety. And to recognise the pressure that doctors and NHS staff are under.

Now that junior doctors have turned their attention to the proposed changes to their pay and conditions, they need to understand the contractual process and engage with it constructively to ensure improvements in working conditions. Doctors need to be careful about taking strike action. Media coverage of a possible strike by doctors has been relatively favourable so far. After all, 72% of members of the public are proud of the NHS, and doctors are still ranked as the most trustworthy profession in opinion polls.14 But public attitudes can quickly change, and focusing on pay may alienate the public, especially when politicians undermine doctors and their work.

The proposed changes seem to be harsh and lacking in clarity and planning. It’s important that junior doctors dispute aspects that will affect patient safety and workforce retention. But they need to turn their frustration and anger with the current proposals into meaningful engagement so that their contract develops in a way that is beneficial to patient care, the health service, and doctors themselves. Junior doctors should focus their argument on the need to enhance the wellbeing and work-life balance of all NHS staff for the quality and safety of patient care to be improved. This is more likely to capture the public support that they otherwise risk losing.


Cite this as: BMJ 2015;351:h5077


  • Competing interests: None declared.

  • Provenance and peer review: Commissioned; not externally peer reviewed.


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