Cancel the panic..?

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Since I published “contract killers” a few days ago, I’ve had a very positive response via facebook and twitter. Thanks.

While most junior doctors share serious concerns about the new contract, not everyone is so convinced that it will be a disaster. I offered one “dissenter” junior doctor a platform to argue his case – here’s what he wrote.
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In much of the discussion about the proposed Junior Doctor contract, there are 2 overlooked points that are crucial to a full appraisal.

The first is that the reforms are, by common consent, cost neutral. This means that no money is being taken away from combined doctors’ and dentists’ wage pool. It is just being redeployed.

The second is the introduction of Retention and Recruitment payments or ‘flexible pay premia’ as they are elsewhere called. The introduction of R&R payments is intended to address directly the problem of recruitment shortages in specific specialties. Wages in specialties with doctor shortages will be supplemented by this income stream, hopefully making them financially more attractive than alternatives. Where will this money come from? Since the reform is cost neutral, it must come from existing pool, meaning that oversubscribed specialties will lose out.

Almost none of the comparative pay calculators have included this R&R stream so it’s not surprising that it shows that people will lose out. They’re not including one of their income streams. So for the purpose of seeing whether you’ll be paid less or the same, the calculators are useless. Here’s a graph from the report illustrating how things MIGHT work – though, importantly, the rates are not yet set.

DDRB graph

The bar charts shows a possible pay structure, and the line shows what these specialties currently earn. Any stack above the line is a winner, any below is a loser. As you can see, some win, some lose. A higher resolution version is in the DDRB report.

Stepping back, a structural change emerges. Under the current system, pay is related to:

  1. Years worked
  2. Seniority
  3. “Antisocialness” (nights and weekends)

Under the proposed system it will be based on

  1. Seniority
  2. Undersubscription
  3. “Antisocialness” (nights and Sundays)

There’s a strong case that this is a reasonable underpinning.

First, ultimately the value of a doctor is related to their experience and the responsibility that they take for patients’ care. This correlates closely to seniority. As the report notes, it may be unfair if two doctors in the same speciality with the same levels of experience and responsibility have different wages.

Secondly, modifying this very simple principle is that some specialties are undersubscribed, and so regardless that we want to pay doctors with the same experience and responsibility similar wages, the government needs to give some specialities extra cash to compensate for whatever it is that is objectionable in them. Supplementing undersubscribed specialties is a good use of the available cash pool.

Thirdly, medicine has always been a profession of unsociable hours for junior doctors, a profession of shift work. The pay should reflect this disruption, sure, but need not track the exact hours worked. Lawyers and others who regularly work late hours don’t change their hourly rate – it’s just part of getting the job done.

It’s been suggested that the removal of banding will lead to doctors being forced to work more hours. But if the Working Time Directive remains in force as a standard part of contracts it’s hard to see how this fear will materialise. Why is it a ‘weaker’ protection than banding? If your employer rotas you for more hours than you are contractually obliged to work – point this out politely to a tribunal or your union.. They’ll soon correct the error. Neither system provides protection against being expected to work beyond contracted hours.

Of course, there are many unknowns in all of this. What exactly is included in the wage pool that the new system will match? What is the exact basic pay rate going to be increased by, and what will the actual overtime rates be? Which specialities will receive the R&R? And will they be paid just for one year (which would be useless), or for all the years of training? If there are no shortages, or shortages everywhere, what will happen to the money?

Finally, it is worth considering how junior doctor’s pay today fits historically. The following figure is reproduced from a House of Commons Library Report from 2010.

historical doctors wages

It shows that junior doctors’ pay has remained broadly stable (in real terms) over the last 40 years (declining slightly from a peak in 2007), despite the fact that hours worked have decreased dramatically since the introduction of the Working Time Directive. Are doctors being historically shafted? No, not really.

If I were the BMA, I would get back to the negotiating table to answer some of the questions I’ve posed above. Above all, I would demand a clear timeline for publication of actual proposed pay rates, so that we can debate with real numbers and not the DDRB’s “for examples”.

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Comment from Abrainia:

There are some valid points here and it’s great to see the argument for the new contract presented in such a logical and persuasive way. But here are my issues with this argument:

The overall average pay for junior doctors is projected to be the same under the new contract. But there will be winners and losers. Look at the graph of proposed pay and compare dentists (no antisocial hours, big pay rise) with anaesthetists (lots of antisocial hours, big pay cut).

Junior doctors pay may not be at a historic low, but pay has been falling in real terms for nearly a decade, while fees and costs for medical students and trainee doctors are at historic highs. Doctors in the 1970s and 1980s had student grants and no tuition fees, so they would have had a fraction of the debts of today’s medical graduates.

The “recruitment and retention” payments have been ignored by many of the irate articles in the media and the blogosphere, and they have the potential to make up some of the lost earnings caused by the new contract. The concern is that the details are so sketchy about how much they would be, who would control them and how permanent they would be that it is hard to take them seriously. More details would really help. But I do agree that many of the headline figures quoted for pay cuts under the new contract are exaggerated.

And the current pay structure is not perfect – few would argue against the theory of paying people by responsibility and seniority instead of simply by years served. But there are doctors who are relying on their current levels of pay for their mortgages, and to support their families. It seems harsh to suddenly announce that their pay will be cut.

My guest blogger discusses earnings, but doesn’t mention other issues such as pensions, or discrimination against women on maternity leave or working part time.

The biggest disagreement I have with this argument is about the safeguards offered by the current banding system. It was designed to be punitive to employers who forced their staff to work unsafe hours, so that breaking the rules of the European Working Time Directive triggered what was effectively a huge fine for the employer, as well as a bonus for the employee. This ensured that “rota compliance” was a priority for all hospitals. With the new contract, overworking the junior doctors would only trigger a metaphorical slap on the wrist, if that. We don’t trust our employers to abide by the rules without anything there to enforce them, especially in the current economic climate where any costs are being mercilessly squeezed. Many people feel that getting rid of banding is the government’s main priority in pushing through this new contract.

What’s more, currently if a whole group of doctors find they have to work longer than they are supposed to in order to keep their patients safe and get their work done, they report this to their employers and get paid for the extra work. But the DDRB report specifically says that doctors working longer than their rostered hours won’t get credit for them under the new system, since this would “encourage doctors to work more slowly”…

I do agree, as I wrote in my original piece, that we need to know the full details of the proposed new contract as soon as possible. And it would be best for everyone if the end result could be a contract we can all agree on, acheived through negotiation and not industrial action.

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