Megaphone diplomacy fails in junior doctor contract disputeBMJ 2016; 352 doi: https://doi.org/10.1136/bmj.i961 (Published 18 February 2016) Cite this as: BMJ 2016;352:i961
Jeremy Hunt’s imposition of a new junior doctors’ contract in England, after negotiations failed over pay for Saturday working and a second strike took place,1 is unlikely to mark the beginning of the end of this dispute. If clinicians and politicians remain as polarised as they are now, this could be only the end of the beginning. Patients, the NHS, and its less politicised clinicians may get stuck in a place of strife.
Both sides leaked to the media throughout, deepening mutual mistrust. The failure of NHS Employers (the representative body tasked with negotiating new contracts on behalf of the government) to make meaningful progress in talks with junior doctors’ leaders saw the senior NHS manager David Dalton take over negotiations, at Hunt’s request.
Hunt’s actions put him firmly in the frame of this dispute: intervening here (and elsewhere) contrary to the 2012 Health and Social Care Act’s intended political devolution.
Dalton’s public letter to Hunt,2 supporting his contract offer and apparently encouraging its imposition, unravelled with embarrassing haste, as 14 of its 20 NHS chief executive co-signatories publicly insisted that they did not support imposition of the deal.3
Successful negotiators avoid entrenching their positions, enabling give and take. Running commentary in the traditional and social media saw both sides contesting the moral high ground of patient safety. Hunt claimed that studies have shown a “weekend mortality effect,” stemming in part from contractual inflexibility—despite a public rebuke from The BMJ’s editor in chief that his statements misinterpreted the published data.4
Junior doctors, incensed by Hunt’s incorrect implication that they didn’t work at weekends, outlined risks that clinicians tired by over-rostering would be more prone to error.
Time and money
Why has this fight happened now?
One reason is electoral timing: the lack of evident urgency on the part of the BMA’s Junior Doctors Committee before the May 2015 general election suggests that they hoped to face a different, more generous administration.
Another is money, out of which the NHS is running at scale8 and pace.9 Although Hunt claimed that the Dalton offer was cost neutral, at a 13% uplift to basic pay,10 many observers were confused that Hunt said likewise when the previously offered uplift was 11%. The big outstanding disagreement—the issue of increased “plain time” (non-overtime) hours on Saturdays—may favour NHS employers, financially and logistically.
Why fight junior doctors? It escapes nobody’s attention that negotiations over the consultants’ contract remain incomplete. Intent to send a message to all the medical workforce may not be absent from the government’s thinking.
More politically engaged junior doctors stiffened their leaders’ resolve. Media briefings reported that the prime minister and chancellor of the exchequer encouraged Hunt to be “deeply muscular” with the BMA.11 Rugby pitches may be good places for stiff resolve to meet deep muscularity; the field of NHS politics less so.
Both sides’ negotiating tactics have been equally wise and strategic—that is, not at all. Privately, NHS leaders veer between hilarity and horror at the intemperate and personalised attacks, particularly once the Dalton offer moved considerably towards dealing with junior doctors’ sources of discontent with the 2015 proposals.12 If junior doctors’ leaders had been less entrenched and politically and strategically smarter, Dalton’s concessions on the government’s behalf could have been sold as a success.
Another worrying possibility is that Hunt and junior doctors’ leaders are enjoying the “power trip” of the dispute. It’s a small step from posing in negotiations to imposing a contract, but a deeply damaging one.
There is no alternative workforce of junior doctors waiting to step in. Alienating an in-demand group of highly and expensively trained staff who are (mostly) at an unusually mobile point in their lives may prove unwise. The market for healthcare staff is global.
Hunt’s term as the previous, coalition government’s health secretary blended one part admirable concern for patient safety, one part aforementioned interventionist tendency, evident in his weekly (sometimes twice weekly) meetings with NHS system leaders and phone calls to NHS providers that missed targets, and one part acclaim for not being his predecessor, Andrew Lansley, architect of the Health and Social Care Act.
David Cameron’s loyalty to his former boss Lansley blinded him to the chaotic scale and unpopularity of the 2012 act’s technocratic reorganisation. The prime minister may not be a details man, but he has rarely made exactly the same mistake twice.
The clock may already be ticking to see who next wins acclaim for not being his or her predecessor.
A new YouGov poll of 1751 adults finds broad support for the striking junior doctors.15 Half (52%) of the sample said that doctors were right to go on strike (32% were against, 17% didn’t know).
On responsibility for the dispute, 12% of respondents blamed the BMA and 45% the government. A third (30%) blamed both sides equally, while 12% didn’t know.
A fifth (22%) said that the government was right to impose the new contract, while 54% said that it was wrong (23% didn’t know). Given various options, a majority of 44% agreed that “the government should have continued negotiating with the doctors, given time a deal was possible.”
Offered a range of options of how junior doctors should respond to imposition, 29% thought that juniors should refuse to sign the new contract, while 25% thought they should accept it, and 18% said that junior doctors should continue to protest and take strike action.
More than half (59%) replied affirmatively to the question, “The government have said that a new deal was necessary in order to expand the level of service offered by the NHS at weekends: generally speaking, do you think that NHS services at the weekend should or should not be expanded in this way?” A fifth (23%) disagreed, and 12% were unsure. Interestingly, the respondents were tied on whether changing the junior doctor contract was necessary to expand weekend services: 35% said that they thought it was and another 35% said that they thought it wasn’t, with the rest unsure.
Those protesting against the new contract will find these survey data palatable.
Competing interests: I have read and understood BMJ’s policy on declaration of interests and declare the following interests: I am a self employed journalist and editor, specialising in health policy and politics. My regular clients are listed at www.healthpolicyinsight.com/?q=node/1507.
Commissioned, not externally peer reviewed