Junior doctors hunt for the truth

Over the last week, the issue of the junior doctors contract has been eclipsed by the debate over Britain’s membership of the EU. Heated public debate always suffers from fatigue, and the media eventually run out of interesting photos to accompany their articles, so they move on. However, the dispute over the contract is still very much unresolved — negotiations have broken down and Jeremy Hunt is still trying to impose the new deal against hostile opposition from the BMA. So as we gaze into the future and wonder what will happen next, how do we begin to make sense of the mess?

It can be hard to see clearly through the blur of conflicting statements surrounding the proposed contract. Opposing groups often appearing to be talking about such different deals that is leads you to question whether they are even reading the same document. What is clear is that the debate has drawn incredibly strong emotions from both doctors and the public. With the first doctor strikes since 1975 and the risk of alienating an entire generation of junior doctors, the stakes could not be higher.

It is worth starting off by looking at the facts, but the devil is in the detail, and however anyone may try and put it, the contract is complicated. Will doctors get a pay cut? Well, probably not. Most junior doctors will either be paid more than they were this autumn, or the same amount, for at least three years. This is due to “pay protection” measures that were introduced to the contract in November, but doesn’t completely eliminate the possibility of some loosing out, particularly if their salary in the autumn was for some reason lower than usual. It is also true that the protected salary will not rise with experience or inflation, so their salary may end up lower than it hypothetically would have been and they get more experienced. It all gets even more complicated when you try to consider the huge variation in the out of hours patterns of different specialities.

Adding to the confusion is that there have been a number of different proposals made at different points in the negotiations. The proposals in July would have meant a pay cut for some junior doctors, but the NHS employers have stated that the deal put forward at that point was never considered perfect, but rather somewhere to start negotiations.

As devoted as the team at Cherwell is, it would be near impossible to try and apply the details of the deal to every single junior doctor to see whether they would be losing money, and it doesn’t get any easier when you turn to the big organisations for help. The BMA stand defiantly with their objection to the contract, and on the other side of the fence, Jeremy Hunt accuses them of misleading doctors. NHS Employers (firmly on the government’s side) talks about it positively, but they are drowned out by the numerous medical organisations who have come out against it. It is hard to get either side to put down an unbiased and systematic argument in their favour, and it therefore seems to boil down to a game of trust. As one would perhaps expect, the BMA current has the favour of the public.

It is also worth looking at the commonly quoted issue that patient safety will be compromised by the removal of the pay banding system for unsocial and its associated safeguards. Unsurprisingly, the camp is once again divided. The BMA argues that the removal of financial penalties for employers subjecting doctors to “fatiguing” work patterns will put patients at risk — The Royal College of Paediatrics and Child Health and The Royal College of Obstetrics agree. NHS employers says that it is not these safeguards that are responsible for reducing working hours, but rather it is down to the European Working Time Directive.

All this talk of fact is beginning to make me weary, but it is also unlikely to help us in a dispute that is as much about sentiment as it is about details. The major factors contributing to this is the state of the current NHS, the way in which the government has gone about the negotiations, and suspicion over the motivations of the government.

The NHS is under huge strain, with rising patient numbers and shortages with regular staffing, to name but a few of its many symptoms. This has left many NHS staff, from consultants to GPs to junior doctors to nurses, feeling under immense stress and pressure. The changes in the healthcare system under the conservative government have created strong feelings of resentment towards the government and this has inevitably made negotiations difficult.

It is also impossible to ignore the actions of Mr Hunt in this debate. The fact that the negotiations have got to this point is a very poor reflection on his skills as a mediator, and at some points, his rhetoric has been outright misleading. This leads us to the greatest point of contention in this debate: the inclusion of Saturdays in what are considered ‘normal working hours’. The health secretary continues to claim that poor care on weekends is responsible for excess deaths, and that the solution to this is a 7 day NHS. This is misrepresentation of data. Although it is true that research suggests that there are ‘excess deaths’ at weekends, to claim that this is due to sub standard care is simply incorrect. There are many possible explanations for increased weekends deaths, for example those that wait until the weekend to go to hospital may be more unwell, and in the case of strokes (another claim recently made my Mr Hunt) it is possible that people who suffer less serious stokes on the weekend do not seek immediate treatment. As the researcher put it: “It is not possible to ascertain the extent to which these excess deaths may be preventable; to assume that they are avoidable would be rash and misleading”.

During the strikes, Mr Hunt also claimed that doctors were putting patients at risk by going on strike. Consultants covered much of the extra work and this attempt by the government to win over public support is not substantiated by evidence, nor is it agreed with by most medical organisations. Mr Hunt has also appeared to deliberately avoid debate with doctors over the issue, only increasing suspicion that he is unwilling and unable to defend his ambitions.

The suspicion among many health professionals is that this deal is the first step in a series of changes to all NHS employees that will gradually see the erosion of standard working hours and weekend pay in order to make it easier for hospitals to roster staff in the weekends. Junior doctors were perhaps the easiest targets for the government to start with, and the fear is that the continual ambition to make a 7 day NHS on the same funding as a 5 day one is only possible by making the staff cheaper. These feeling and resentment among junior doctors meant that the BMA has felt unable to move on this disagreement.

So, we can safely conclude that it is a mess. Short term ideology sailing on the prevailing economic winds continues to plague health policy (and let’s face it, this is politics, it always will) and the NHS continues to go from crisis to crisis. David Cameron has already tried to draw attention away from the dispute with a ‘new’ focus on mental health, and the EU debate is helping distract the press. Meanwhile, the BMA are still standing strong, and have recently announced they will be mounting a legal challenge against the imposition of the deal. So here is my prediction: the government will water down the contract as they realise that the fight isn’t really worth it, the new contract will go through and both sides will claim victory. Jeremy Hunt will be promoted to a cosy cabinet position as a thank you for withstanding the abuse, and all will be calm before the government think the time is right to push for another reform. Some doctors will leave the country, or leave the profession — how many is hard to say. The morale may increase for while (depending on the rhetoric surrounding the final deal), but otherwise continue as before and the NHS will continue to suffer the same problems that have been plaguing it for years.

I would argue that responsibility for this conflict mainly lies with the Department of Health, but neither side have acted in the most honest of manners. Whatever happens, having a health service workforce that is at odds with the government will help no one. This must change if the NHS is going to make any progress at a difficult time, and the duty lies on both sides to try and make it work.