Back in September Abrainia published “Contract Killers”, a summary of the contract being offered to junior doctors.
It covered who junior doctors are, how much they earn now and how the mysterious banding system works. It covered some of the safety issues with the contract – in particular how it scrapped the banding payments that act as a brake on hospitals overworking their doctors. It covered how it would adversely affect women and people doing research. And it covered how the new contract would inevitably be a pay cut for many doctors, with those working the most out of hours shifts losing out the most.
That was before the BMA balloted for strike action, before 98% of respondents voted in favour, before the two strikes, and before the negotiations that have led to the announcement by the Government that they will impose the contract in August.
The contract that is now apparently going to be imposed is not quite the same contract that was suggested by the DDRB, and that I discussed in Contract Killers. Have the strikes, and the two months of negotiating achieved anything? The BMA believes the new contract offer is still not good enough. But we should also look for ourselves at the offer we can’t refuse.
What has changed in the new new contract?
The fundamental pay shift between the current and the new contract is still the same.
At the moment, junior doctors get a basic salary plus an additional banding payment, which is calculated as a percentage of their entire salary. The percentage depends on their out of hours work. So a brand new doctor in their first job after qualifying would currently earn a basic salary of £22,636 per annum. If they work a decent chunk of their hours during nights and weekends, they might get 40% “banding” on top of their basic salary, meaning total pay would be £31,690 per year.
In the new contract, doctors will be paid a higher “basic salary”. For instance, a newly qualified doctor will now get £27,000 per annum (up from £22,636 now, and from £25,500 in the previous offer). But this will be offset by a complete change to the way they are paid for out of hours work. Instead of getting an extra percentage of their whole basic salary, they will get paid an extra percentage on a per-hour basis for just the work that is out of hours. So, if 20% of their time is outside normal working hours, they’ll get a 30-50% higher rate for just those hours. That brings the total salary to around £29,000. The Government would like to call this a payrise, but in this example the total salary is actually down by over £2500 per year.
This “better deal” is still not going to be a better deal for everyone. The exact calculations are different for each doctor (an updated pay calculator by Dr Bishop can be found here). It will be great for people who don’t work weekends (have you wondered why you haven’t heard anything about dentists protesting against the new contract?) but the doctors in emergency specialties (the people who look after you when you have your heart attack on a Saturday night) will still lose out.
Since doctors are going to be paid extra just for the specific hours they work outside the normal working week, it is important to define which hours those would be. And the latest version of the contract still wants to call Saturday a normal working day. Which, as everyone knows, it is not.
Jeremy Hunt has repeatedly claimed that no doctor will have a pay cut with the new contract. He has also claimed that the contract is “cost neutral” – in other words, the amount the NHS spends on junior doctors salaries won’t change with the new contract. Of course, as Andrew Marr pointed out recently in an interview, you can’t give some people a pay rise, and keep overall spending the same, unless some people also get a pay cut. So this is nonsense – it couldn’t possibly work.
The explanation is that the latest shiny new version of the contract includes something called pay protection. If a doctor’s salary would fall on the new contract, they will be paid their old salary instead, for up to three years.
This means that the introduction of the new contract won’t actually be cost-neutral – in the short term, it will cost the Government more than the old contract, as some people get a pay rise, and those who would have had a pay cut are kept on their old salary.
Great, you may think. Problem solved! And yes, pay protection helps. It means that doctors who have a mortgage to pay won’t suddenly find they can’t keep up with their payments. It means that many of the older and more senior “junior” doctors will never suffer under the new contract, because they will no longer be junior doctors by the time it kicks in. But the fact that pay protection is necessary proves that the new contract is not a better deal. The older junior doctors worry about the mess they might be leaving behind for their successors. The people who lose out will be the junior doctors of the future.
Banding payments serve two separate functions. One is to pay doctors for the out of hours work they do. The other is as a safety valve for doctors and their patients. If doctors find they are being forced to work more than their official hours, the hospital has to increase their banding payments (which, remember, are a percentage of their whole salary). This is a big financial punishment for hospitals that overwork doctors, which was very common in the past.
The previous new contract, as set out by the DDRB last year, had very little to say about this. The new new contract has a lot to say – there are multiple layers of bureaucracy suggested to replace the banding system as a safety mechanism. Hospitals will have a “guardian” of safe working, assessing “key performance indicators” feeding “multisource feedback” to a “board level director”. What does this all mean? I don’t know. Will it work? I don’t know that either. But if doctors are overworked, under the new contract it will be much less of a costly problem for hospitals. It will still be just as costly for the patients who are seen by an overtired doctor.
There are some other details that have shifted in the latest version of the contract. People taking time off to do research will now get some extra pay, acknowledging their greater knowledge and experience. Top-up payments will be made to some specialties that struggle to recruit enough doctors, and more details have been released on this. There is a flatter nodal pay structure (which is as dull as it sounds, but will be helpful for part-time workers). These are all small moves in the right direction.
The bigger picture:
Junior doctors don’t like the new planned contract. They don’t like it for a number of reasons. Once pay protection wears off, they think it will be a pay cut. And salaries have already been frozen, not even keeping up with inflation, for many years, while the cost of training to be a doctor is increasing year-on-year. They think it robs them of their power to insist on safe working. They think it undervalues the sacrifices they make when they give up their evenings, nights and weekends for their job, and that hospitals will use it to make them work more antisocial hours for no increased pay.
It is less bad than the previous version, but less bad doesn’t seem good enough.
And part of the problem is not the contract itself, but the way it is being introduced.
Trust, goodwill, and the nuclear option
In a parallel world somewhere, a wiser Health Secretary than Jeremy Hunt might have handled the introduction of a new junior contract a bit differently. He might not have begun by laying into doctors, accusing them of lacking vocation and professionalism, and laying thousands of extra deaths at their door. He might not have followed this up by announcing the imposition of a disastrous contract, pay cuts for many, penalties against those doing research or working part time, and the demotion of Saturdays to normal working days, leading to strikes and protest marches. He might have spoken to a few junior doctors about their concerns, rather than running away from them.
In that parallel world, after some genuine negotiation, he might have come up with the latest version of the contract as a starting point. And junior doctors, recognising that the NHS needs to move forward, might have considered it. Some parts would have caused concern – like the Saturday issue, and controls on over-working doctors. There might have been some constructive criticism. Perhaps some further negotiations would have been needed. But strikes? Protest marches?
A couple of weeks ago, there was a cautious hint of optimism in the air. Negotiations were progressing. Hunt was staying away. Perhaps a solution could be found…perhaps Wednesday’s strike would be the last… and then (in the media, of course) it was announced that the contract would be imposed. BANG. What Hunt himself called “the nuclear option”.
Any negotiation needs trust and some goodwill on both sides. You have to believe what you’re told across the negotiating table, you have to believe there will be some give and take. There were signs that was starting to happen, until Jeremy pressed his red button.
What would an acceptable contract for junior doctors look like? I think it could look quite similar to the offer that’s currently on the table, next to the big red button, a ticking timer and a diagram showing the fallout zone.
If I was in charge of the Government team I would take the nuclear option off the table, and agree that Saturdays are part of the weekend. And then, with a little reshuffle for Mr Hunt, we might be heading towards a speedy resolution.
Since I’m not running the Government, the future is a little less certain. There may well be more strikes, or a legal challenge in the courts. Some hospitals might ignore the new contract and stick with the old version – it seems very few hospital bosses support imposition, despite what was originally claimed.
Meanwhile some doctors have simply had enough, and are walking away.
There are more twists and turns to come in this saga.
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