The junior doctors’ dispute

Doctors Staffing

The defeat of the junior doctors was ignominious, and made worse by a failed legal challenge to the Secretary of State’s right to impose a contract. As the dispute collapsed, senior members of the medical Royal Colleges, who had tried to walk a fine line between supporting junior doctors and ensuring the health service could function, began to speak(off the record) about ‘Generation Me’ – entitled young people who want lots of money but not to work hard, and feel they should have it all. Some hospital managers who noticed how much more efficient their services were when consultants delivered them are wondering if having so many junior doctors is the best option for the NHS.

junior doctors

A new contract has been introduced despite being rejected by many thousands of junior doctors. Important concessions were obtained from the government, but no doubt loopholes will need to be closed and snags removed. Local, hospital level, bargaining will help tailor the new contract to circumstances, and local vigilance by the BMA should counter attempts to increase junior doctors’ hours. Already local payments have been made to juniors losing out under the new contract, and junior doctors’ complaints will be used to identify poorly-performing hospitals. Overall, however, the government achieved its desired re-categorisation of Saturday working as normal working hours, taking it a step closer to 7 day working. It seems unlikely that there will be any further national dispute over junior doctors’ working hours in the near future.

The pressures inside the NHS are building up, as cash-flow crises are averted just in time, and managers struggle to streamline services or just keep up with demand. This is a political dispute that may well overshadow the 2020 general election, but it is not amenable to industrial action within the health service by a section of one profession, and its outcome was never in the junior doctors’ gift. At first sight it seems remarkable that they thought it was. This identification of the needs of some doctors with the needs of the NHS as a whole, and of the public it serves, exemplifies LeGrand’s analysis of medical professionalism as a game of Knights and Knaves. In Knight mode the profession draws attention to its altruism, its central concern with the patient, and its willingness to go beyond the usual limits (including overtime working) to help others. In Knave mode it points out that its altruism will not be sustainable without more income. Much of the confusion in the junior doctors’ dispute arose from this dualism.

Debates on NHS funding will dominate politics up to 2020, but the other problems revealed by the junior doctors’ dispute will not go away, and there are many questions left unanswered. The tensions inherent in modern medicine are the province of the medical and surgical Royal Colleges, whose brief it is to define and nurture professionalism. At the very least systems of mentoring and support for doctors in training need to be invigorated and applied. There may also be a case for a wider debate about the effects of immaterial labour on medical, nursing and allied health professional workforces, all of which have problems of recruitment and retention of staff, and how to ameliorate them.

Do we have in the NHS a high-end precariat, becoming used to less secure employment than their predecessors? If yes, will this be a problem that a future Labour government could solve? Stabilising the medical labour market, perhaps even restoring the old firm system, might be possible, at a price. The price will need discussion, for trading off shorter working hours for less income security may become acceptable to doctors who are, after all, on their way to affluence.

Finally, there is the hapless BMA, defeated repeatedly by successive governments but now facing contract negotiations for hospital consultants and general practitioners. It was intoxicated by the energy of the junior doctors, only half grasping the impossibility of their aims. Now it is challenged industrially by the Hospital Consultants and Specialists Association, which has gained negotiating rights for hospital doctors, breaking the BMA’s monopoly. Will the BMA recover its power?

This is the conclusion of Steve Iliffe’s review of the junior doctor dispute, A tale of three disputes: junior doctors against the government 2015-2016, published in Soundings 64 winter 2016.  A fuller version is available at Health Matters.