Doctors NHS Funding

“Junior doctors” are doctors who are fully qualified, independent practitioners who have not yet reached GP partner or consultant level. This includes many doctors who may have been practising for 10, 15 or even 20 ears and who hold very senior positions. They comprise a group of over 50,000 doctors in the UK. “Juniors doctors” includes many grades of doctor – registrars, SHOs, house officers, F1s, F2s, clinical fellows etc – anyone who is not a GP partner or consultant.

Junior doctors are some of the most important members of front line NHS staff. They are the people we see day to day in clinics, who look after patients on wards and often may be the people who put us asleep for operations and who do the operations. They deliver our babies. They care for critically ill patients on intensive care. They are also the doctors who deal with emergencies in A&E and see patients in GP practices as well as providing medical cover for football matches, outdoor events, mountain rescue etc.

Currently junior doctors work on a contract which gives them a basic salary plus a bonus – called banding – which is up to an extra 50% of their salary. Doctors who do the most hours overall and spend the most hours working “unsocial” shifts get the highest banding (this is up to 50% in England). Doctors in specialities such as A&E, anaesthetics and intensive care, who are regularly in at the weekend and at night get paid more than doctors who do predominantly mid week daytime shifts (e.g. microbiologists and pathologists).

In recent times the EU introduced something called the “European Working Time Directive” – this is a system in place to ensure that no-one in any job works unsafe hours. It limits people to working a maximum of 48 hours per week. In reality, many people do more than this, a lot more, but they cannot be “contracted” to do more than this. A special caveat to this is, introduced for UK doctors, is that doctors can work many more hours than this (up to 92 hours per week), as long as their average weekly hours do not exceed 48 hours over a 6 week period (this includes days off and leave). Again, this only applies for contracted hours – the time someone actually spends in work may be significantly more.

Obviously doctors, like most professionals, often have to come in early or leave late due to the demands of the job and patient needs. Many doctors routinely finish several hours late – if a theatre case overruns or someone needs help, they cannot and would not leave. This time is unpaid. It has never been paid and never will be. Doctors are not, and never have been, paid overtime. They simply get paid based on their contracted hours, which consequently may often well understate what they actually do.

It is of course of the utmost importance that doctors are happy and willing to give up their own time to stay late or come in on their days off – to ensure patients (us, the public) get the care they need when they need it. Imagine if an older relative was deteriorating on a ward and a doctor didn’t go to review them at 4.55 as they were due to clock off at 5pm. This would not be ok. But then no doctor would refuse to do this – and in reality, doctors knew this is what would be expected of them when they started work.

However, it is also very important for doctors to stay sharp and focussed, to ensure their patients get the best care. A tired doctor is not a safe doctor – not for their patients or themselves. Currently systems exist to protect patients from over worked doctors, and to protect doctors from burn out. Essentially, if a hospital schedules a doctor to work over their maximum allowed hours (92/week, with an average of 48/week) then they get fined – this prevents this from happening and keeps patients safe. The news contains many stories of young doctors who have died in a car crashes or made mistakes after long night shifts or had a breakdown due to the stress and demands of work – we must do all we can to avoid these sorts of things happening. The current system just about achieves this.

The new contract proposed by the government removes these financial penalties on trusts. There is therefore no reason for hospitals not to extend doctors hours beyond what should be allowed,  leaving patients with unsafe care and putting doctors’ own safety at risk. Given the current recruitment crisis in many specialities (most notably A&E and GP) this is a likely scenario. Rather than train more doctors (this government has actually cut medical school places) they are planning to simply further stretch their already over stretched workers – and with the new contract there is nothing to stop them doing so. This is in a time when demand for NHS services is rising exponentially due to an ageing and growing population, rapidly increasing obesity and increasing patient demands and expectations (a result of the NHS’s own success!)

This is clearly an unsustainable policy and doctors can only be stretched so far before their patient’s care and their own health starts to fall apart.

The new contract for junior doctors should therefore be viewed as simply not safe – for anyone. Patients or doctors.

Furthermore the new contract is also not fair. Not fair on doctors and not sensible if we want the NHS to continue to exist as it does.

In a Commonwealth Fund report the UK was recently calculated as having the best healthcare in the world, with the NHS the best healthcare system. This was based on a study that looked at all sorts of markers of health from access to GP services, vaccination rates, degrees of health inequality and sophistication of available treatments. It was also interesting to note that we, as a country spend a lot less of our GDP on healthcare than many similar countries – including for example the USA – who actually have population health and healthcare systems inferior to ours, but spend a lot more on it. We achieve this with less spending and less doctors and less nurses per capita and less hospital beds per capita than many other similarly developed countries. A recent article in the Economist reviews this quirk and comes to the conclusion that the NHS is not only an extremely good model of healthcare but it is an extremely cost effective way of delivering healthcare. We pay less and have less resources, yet get better care than many other countries. In fact, the Economist notes that the NHS offers a level of productivity not seen anywhere else in the public sector and quite above other countries’ (privately run) healthcare systems.

The reasons behind this are complex and multifactorial, however it is likely a combination of the fact that the NHS does not have shareholders and so does not have to pay out dividends (all the money goes to patient care) and that frontline staff (doctors, nurses, paramedics etc) work many many extra unpaid hours, work very hard, miss breaks and work effectively and efficiently. Watch 24 hours in A&E and see how smoothly things run and just how much these people give to their patients. They work hard and selflessly and we get great healthcare at a great price as a result.

Richard Branson once said that to run a successful company you shouldn’t focus on customers, but instead must “look after your staff, (as) they’ll look after your customers. It’s that simple.” The NHS runs on this principle. Their staff give everything. They must be looked after to keep this up and keep having a good quality and good value health service.

Like all NHS staff, doctors have had a pay freeze since 2009. The basic starting pay of a junior doctor (around £23000) has not changed since then. This represents a 17% “real terms” pay cut over the last six years. It also begs the question, is this a fair amount? Is this a reasonable amount to pay a doctor? For someone who works weekends, nights and often nearly 100 hours per week. Someone who trains for five or six years and has up to £70k of debt at the end of it. Someone who has to make life and death decisions – and then explain these, and their consequences, to distraught families. Someone who gets sworn at, spat at and peed on (and worse). Is this a fair pay scheme for these people? Is this an amount of money and a pay deal that will motivate these people to deliver us (their patients) the care we hope for?

Surprisingly, it is. It is enough. It is enough because doctors, on the whole, love their jobs, care for their patients and are passionate about their NHS. We should count ourselves lucky for this! Some of the popular press have claimed that it doesn’t matter how much money doctors start on because one day they will all earn huge amounts. Jeremy Hunt has claimed that the average consultant earns £118k per year – this is simply untrue. The NHS pays full time consultants £72k, which may rise up to £101 – as a maximum, and after at least 19 years consultant level service (for most doctors this equates to being 55-60 years old at least). Either the health secretary knows very little about the health service workers, which is worrying, or he is a liar – which is even more of a concern.

Now that the economy is growing and demand on the NHS is rising rapidly, one might think that the government would be starting to think about paying NHS staff a little more – to keep their morale and their work rate at the high level it has been for a long time. To ensure that staff continue to go the extra mile and the NHS continues to deliver excellent and efficient care.

Indeed, all NHS staff, apart from doctors, are to get a 1% pay rise for the next few years. Yes this is well below inflation, but it is a symbol. A symbol of goodwill and respect and a symbol that the government care about their frontline employees – hopefully ensuring that these employees continue to give their all and keep us all in good health.

Doctors however are getting a whole new pay package. This is a package that will involve most doctors earning quite a lot less and working a lot more hours. This proposed changed has understandably completely destroyed morale amongst doctors. Especially when the British Medical Association tried to negotiate the deal and the government stated that they would only negotiate if “22 of the 23 points of the contract were non negotiable.” Who could blame the BMA when they walked away from negotiations?

Jeremy Hunt however claims that this contract will be “cost neutral” and “no-one will lose out” and “it is a good deal for doctors and patients.”

In essence, the new deal is this;

  • A small increase in basic pay
  • A massive cut to what is considered “out of hours work”
  • A consequential small pay rise for those who do little out of hours work and a big cut in pay for those who do a lot of out of hours work (e.g. A&E)
  • As a result, under the new deal, all doctors will receive a lot more of their pay as “basic pay” and a lot less as “extra/banding”. Doctors’ pension payments are calculated solely on their basic pay, so under the new deal doctors’ gross pay will drop for most doctors, but their take home pay will drop even more.

For many doctors’ the cut to take home pay is expected to be around 10-40%, with it being worst for those who do the most out of hours work.

So, we have a contract that removes the safeguards that stop doctors working unsafe hours – exposing doctors and patients to unsafe care – and cuts the pay of most doctors, particularly those who do the most unsociable and emergency work (e.g. A&E). This contract, and the government’s ridiculous “pre-conditions” on any negotiations, have completely destroyed the morale and work ethic of doctors all around the country. The work ethic and goodwill that keeps the NHS working as well as it does despite it’s budgetary and resource limitations.

The contract reform has created a situation where many doctors will be forced to go abroad or go to Scotland or Wales (whose governments have rejected the contract reforms as not fit for purpose) or quit the NHS and medicine completely – remember these people are, to a man/woman, very highly qualified and highly motivated people who are often highly sought after in the private sector. When polled recently only around 25% of doctors said that they would stay in the NHS if the contract reforms are imposed – the other 75% indicated that they would either go abroad, work privately as agency staff or leave medicine altogether.

How can these contract reforms be described as safe, fair or good for patients or the NHS? How can they possibly be supported if we want the NHS to exist as it currently does.

Doctors work hard. They work long shifts. They give everything for their patients. Do they get paid a fair rate for what they have to do to get to that position and what they have to put up with? Perhaps not. But they do what they do because they care – and we, as patients, reap the benefits.

If we let the government impose these contract reforms that they have forced the BMA to walk away from negotiating on, what will happen to the safety of the care that we and our relatives get in hospital? What will happen to the goodwill and “extra mile approach” that keep the NHS the amazing service it is? What will happen to all the doctors?

This contract is not fair and not safe and, if allowed, will pull the NHS apart.

Please back your junior doctors. This dispute is not about them and their pay, it is about us, their patients, and our health and our NHS.

Addendum 1

Doctors have been trying for the last few months to get the government to relent on their “22/23 points will be non-negotiable” pre-conditions and get back around the table to properly discuss this contract. They have been on TV, they have lobbied parliament, they have held marches up and down the country. None of this has worked and the BMA has been forced into balloting its members on industrial action.

At the eleventh hour Jeremy Hunt has written to all junior doctors and asked then to reconsider. He has said that he “guarantees no one will lose out.” So how has he done this? Doctors have run the hours from multiple rotas through the new pay system and invariably come out losing out. Are they wrong?

What Mr Hunt has done is this; He has added in a clause to the new deal that states that if a doctor, who already has a job when it is introduced earns less money due to the new deal, their pay will be topped up to that previous level.

However, this “pay protection supplement” will only exist until 2019 – then it will be removed. It is a lip service, at best, to doctors’ concerns.

Furthermore, what if a doctor has completed one block of their training (e.g. a two year  “foundation job”) and is applying for the next stage in their training and expecting to earn more but the new deal gives them a less? Will they have their pay guaranteed to be what it was? No. That pay will not be protected, as the doctor was not “already in that job” when the deal came in, instead they were only about to start it. And what about medical students, our doctors of the future, who may be expecting to start on a certain figure when they qualify – indeed they too will get a cut, as they will not already be in post when the changes come in.

Truly this contract is going to over stretch doctors and compromise patient safety. It is going to see doctors working more hours and earning less, which is fundamentally unfair. It is going to push doctors out the NHS and out of medicine, causing our health service to fall apart – although perhaps this is the overall goal? This 11th hour action from Jeremy Hunt to doctors does not represent a good deal for them, patients or the NHS – it is spin and nonsense and we owe it to ourselves and our health service to oppose it and instead support our healthcare givers.

Addendum 2

It is important to also discuss the government’s reasoning behind all these changes.

The reason the government want to change the contract, they say, is that they want a contract which will allow them to make doctors spend more weekends at work for no extra cost. This is based on their claims that weekend in-patient care is currently inadequate and this is in turn due to a lack of doctors in hospital at the weekend.

The government claim that a lack of doctors at weekends leads to 6000 deaths per year. By removing the current safeguards on doctors’ hours, they will be able to make doctors work more out of hours shifts – increasing doctor numbers at the weekend and, they claim, saving 6000 lives per year.

But where does this figure come from?

Certainly, expanded weekend services is, undoubtedly, a fine idea. To be able to see a GP easily at a Saturday would undoubtedly be really convenient for a lot of people. To have elective clinics running on a Sunday would really cut down on waiting times, which would also be great for everyone.

However, rather than just being a “nice idea” is a 7-day elective NHS actually something we need? Is it something we have to introduce to save lives? The government claim it is – their claim is based on the results from a paper published by Freemantle et al in the BMJ.

In this paper the authors showed that if a patient was admitted to hospital on a Saturday or Sunday, they had a 10 and 15% (respectively) increased risk of dying within the next 30 days, as compared to admission on a Wednesday.

The authors of the paper conclude that why this is the case is unclear. They speculate that this “weekend effect” is probably due to the fact that almost everyone who comes in to hospital at a weekend is someone who is either very unwell or has had a serious accident and has come in through A&E – whereas in the week these patients still present, but a whole load of extra patients also come in for elective procedures and investigations – who are, by definition, much less likely to die.

The authors also conclude that the provision of staff in hospital at the weekend is unlikely to be have any bearing on these figures.

In fact, if lower staff levels at weekends did increase the risk of death, one would assume that not only would people admitted at the weekend be more likely to die in the next 30 days, but also (and even more so) patients would be more likely to die in hospital at the weekend. Actually, the opposite is true – if you are in hospital on a Sunday you are less likely to die than on a Wednesday.

The data clearly does not “prove” that we need more staff in hospital at a weekend. The people who wrote the paper even state this in their conclusions. However, despite the conclusions of the scientists who did the research, the government feel that this is what the paper means.

Again, either our health secretary cannot appraise and understand a basic scientific paper properly, which is worrying, or like with consultant’s pay, he is lying – an even more concerning possibility.

So, we have a contract that is not safe, not fair, bad for the NHS and based on completely inaccurate conclusions.

Please do not let it go through.

Please support your doctors and your health service.