Contract Killers

If you’re a UK doctor, you’ll already be aware of the fuss surrounding the government’s plans to alter the contracts between doctors and the NHS. If you’re not a doctor, you might not have noticed, but it’s likely you will soon…

First, Jeremy Hunt announced plans to replace senior doctors’ contracts, while at the same time he accused doctors of shirking out of hours work and causing extra patient deaths, a claim not backed up by the evidence. I wrote about that here.

Now, the Government plans to introduce new contracts for junior doctors. Their proposals were considered so far off acceptable that the British Medical Association declined to participate in negotiations. So the contracts are now going to be imposed unilaterally. Doctors are so upset they are talking about strikes, which would be the first such action in over 40 years.

Here’s a primer on the conflict…

What is a junior doctor?

The contracts in question cover all doctors from the moment they qualify (after medical school) until they become a fully trained specialist (including a consultant or a GP). For a typical doctor in the UK, this takes between 5 and 10 years.

From a practical perspective, if you are admitted to hospital, your interaction will mostly be with junior doctors. You’ll be admitted by a junior doctor. You’ll be seen daily by a junior doctor, sometimes with a senior consultant and sometimes without. Your medication will be prescribed by a junior doctor. Your discharge paperwork will be written by a junior doctor. If you have a cardiac arrest, you will be resuscitated by a team of junior doctors.

Junior doctors may be young – a newly qualified doctor may only be 23 or 24. But by the time they stop being a junior doctor they will probably be in their mid to late 30s.

How hard do junior doctors work?

Junior doctors are limited to working an average of 48 hours per week, by European law. This works out at around 5 x 10-hour days, which doesn’t seem too bad. However, in any given week the hours may be much longer, for example if working a series of 13-hour night shifts. It is accepted that junior doctors stay at work until the work is done – how can you leave without ensuring your patients are safe? So, many work unpaid overtime.

What’s more, working at anti-social times is a part of the job. When you go out on a Saturday night, fall over and bang your head, it’s a junior doctor who will assess you in A+E, a junior doctor who will stitch you up, a junior doctor who will review your brain scan, and if you need surgery you’ll probably be anaesthetised and operated on by a junior doctor… Despite what you may have read in the media, or heard from Jeremy Hunt, junior doctors are at work 24 hours a day, 7 days a week, 365 days a year.

In addition to rostered hours, they are expected to take part in clinical audits, to get involved in scientific research, to publish scientific papers, to read and study the specialty they are working in and prepare for their stipulated professional exams. This “work” is unpaid.

How much are junior doctors currently paid?

Currently, every junior doctor gets paid a basic salary. This starts at £22,636 per annum for a newly qualified doctor, and rises with each year of experience. The maximum basic salary is £47,175 – to earn this basic salary would require a minimum 9 years of working in hospitals after qualifying.

On top of the basic salary, doctors currently get paid an extra “banding” payment based on antisocial hours worked. So someone who only works during normal working hours (currently 7am to 7pm, Monday to Friday) gets no additional payments. Others get an additional percentage on top of their basic salary for working antisocial hours.

As an example, a doctor working in an emergency department with 4 years of experience might earn a basic salary of £34402, but also be paid 40% banding payment for working lots of weekends and nights, meaning a total salary of £48162. To reach that salary they would have spent 5-6 years at medical school, 2 years working as a foundation trainee doctor, and 2 years as a specialist trainee and be working lots of weekend and night shifts. A doctor with the same experience working only within normal working hours would only earn the basic salary of £34402.

Rates of pay have been frozen for many years, which of course means a significant pay cut in real terms. This pay freeze has been enforced despite independent advice from the DDRB recommending a pay-rise. MPs, take note.

How much does it cost to become a doctor?

Once you have got your excellent A-levels and been offered a place at medical school, you just have to knuckle down and study. And pay for the privilege. Each year as a medical student now costs £9000 in tuition fees. The National Union of Students website recommends allowing a further £1700 for books, travel and study-related expenses. They also suggest living expenses should come to around £12000 to £13000.

Adding all this up, very conservatively, training as a medical student costs the student £20,000 per year.

Over a minimum 5 year course, a medical student with no financial help can expect to be £100,000 in debt by the time they qualify. In case you missed it, that is £100,000.

As you probably know, tuition fees have been rising over the last decade or so, but there has been no similar rise in doctor’s salaries to offset the extra debt.

How much does it cost to actually be a doctor?

This is not a joke. All doctors have significant professional expenses. They have to pay fees to the regulatory body (the GMC) which are usually a few hundred pounds per year. They are obliged to have insurance against negligence, which usually costs about the same. Professional expenses could well reach £1000 per year.

They are obliged to take exams, which must be passed to progress in their careers. These are eye-wateringly expensive. A medical trainee, wishing to be a consultant in a medical specialty, would have to pass these exams:

MRCP part 1: £419

MRCP part 2: £419

MRCP PACES: £657

Specialty Exam: £861

That’s a minimum of £2356, if you passed first time on each exam. Many people have to repeat at least one exam. The costs can double because many people also pay for teaching courses to have a better chance of passing, as it’s very hard to find time to study in addition to working full time.

Doctors have to obtain some mandatory training (for example, many doctors need training in Advanced Life Support). These courses also cost hundreds of pounds, and are rarely paid for by employers.

All these expenses come out of a junior doctor’s salary.

So what’s different about the new contract?

The main change is that it abolishes the concept of “banding”. Banding, as explained above, means that doctors get paid an extra percentage of their salary for being forced to work antisocial hours. Instead of the banding system, the baseline salaries will be increased but out of hours payments will be reduced.

It’s worth remembering why banding was introduced in the first place. Doctors were working unacceptably long hours, in ridiculous rotas. Banding was introduced as a financial penalty for trusts with poor working patterns for their doctors, to encourage reform. And it worked – banding payments have come down hugely since their introduction, as hospitals reformed doctors’ working patterns. That’s one reason why doctors are concerned about abandoning the system – without this financial restriction, won’t hospitals revert to old and unsafe working patterns?

One particularly controversial decision has been to change the definition of “antisocial” time. This is currently defined as 7pm until 8am on weekdays, plus all day Saturday and Sunday, but this will change to only include 10pm until 7am every day except for Sunday. Thus a shift from 8am until 9pm on a Saturday is considered normal working time. Doctors could be asked to work every single Saturday, and not get paid a single penny extra for working antisocial hours.

But there are some other changes that shouldn’t go under the radar. Career progression safeguards for women needing maternity leave are being axed. Salary progression will be based on tests of responsibility and seniority, rather than simply on time served, although no-one has decided exactly what will be tested. Doctors switching specialty will be demoted back down the pay-scale to reflect their experience in their new field, instead of continuing to climb. Doctors will no longer get any payments for additional tasks they perform, such as filling in cremation certificates or employment forms, which have traditionally been small extra earners. Patients will still have to pay for these things, but the money will now go to the hospital, not the doctor. Pension contributions will probably be higher, but that won’t lead to higher pensions after retirement.

I’m a junior doctor – what will my salary be next year?

The government says junior doctors will be getting a “better deal”. Various facebook rants by doctors are claiming pay cuts of 25-40%. Which is true?

The simple answer to this is… nobody knows.

One of the biggest problems with the new contract is the uncertainty around salaries. The DDRB report offers various different scenarios, but lots of details have not been announced.

So while the Government has announced it will impose a new contract that is “a better deal” for junior doctors, no junior doctor has any idea how much they will be earning under this “better deal”, in less than a year’s time. And remember, junior doctor is a broad term. Many junior doctors have mortgages, families and significant financial commitments. The uncertainty is not pleasant.

Overall average salaries won’t increase, since the new contract has to be “cost-neutral”. We know that some doctors (working no antisocial hours) will get a pay-rise. So doctors who currently do work antisocial hours are feeling a little anxious…

The best attempt I’ve seen to model what will happen to salaries is here.

Let’s talk about money

Doctors and money is a difficult topic. For many, doctors are high earners who shouldn’t complain. For some (including Jeremy Hunt), doctors should show more “vocation” and not worry about how much they earn, or how hard they have to work. (His vocation to be an MP hasn’t stopped him taking a 10% pay-rise, funded by the taxpayer, during a time of massive austerity).

In fact, as the DDRB frequently (and somewhat gleefully) note in their report, doctors don’t go into medicine for the money, and certainly not for short term gain. So the implication is that they can pay junior doctors badly, save on the NHS budget, and it won’t affect recruitment.

And that is probably true – people don’t go to medical school because they want to earn massive salaries, and the other benefits of medicine will still pull punters in. But what about attracting the best and smartest people? What about attracting people from disadvantaged backgrounds who can’t see past £100,000 of debt, which will take a decade or more to pay off on a junior doctor’s salary? And what about keeping the doctors we have trained? What about the people with 6 years plus of training, and £100,000 of debt suddenly being told their salaries are being reduced? Will they stay and work hard for the NHS? Or will they take their highly specialist and highly transferrable skills to somewhere that values them more?

Newly qualified doctors in the UK earn a basic salary lower than the average graduate (who has only done a 3 year degree). And that statistic doesn’t take into account that doctors are among the highest achieving students, otherwise they wouldn’t be able to get into medical schools, which are still amazingly competitive. Without a sense of vocation, we would all be working for banks. Or going into politics, where we could expect inflation-busting payrises.

Doctors accept that their salaries will start later than our graduate peers (5-6 years of studying versus 3), will be lower than our graduate peers, and will rise less quickly than our graduate peers. They have accepted that payscales have not risen in the last 5 years even to keep up with inflation. But there is a limit to what they can accept.

I’m not a junior doctor, so why should I care?

If you think this doesn’t affect you, think again.

There is already a major recruitment crisis in the NHS. For example, one third (yes, one third) of GP trainee places in the country are unfilled. It may not come as a massive surprise to know that GP trainees grow up to be… GPs. Yes, GPs, the type of doctors that the Government has pledged to increase by 5000. And remember, GP trainees are one group that is likely to have a big pay cut under the new contracts. At a time when the government are promising to increase the numbers of GPs throughout the country, this is madness. If you want to be able to see your GP promptly in 10 years’ time, you want GP trainees to be offered a decent incentive now.

And other junior doctors grow up to be…senior doctors. If we want to have enough physicians, GPs, psychiatrists, A+E consultants, surgeons and paediatricians in 10 years’ time, we need enough junior doctors now.

There are hundreds of unfilled posts in lots of specialties, all around the country. Understaffing is one of the main reasons that Adenbrooke’s, one of the UK’s best hospitals, has been put into special measures. Understaffing of medical rotas is unpleasant for doctors, but it is dangerous, or even deadly, for patients. And it is a ticking time bomb for the future.

The DDRB suggests that problems with recruitment can be addressed with “recruitment and retention payments” – essentially top-ups to the salaries of doctors in unattractive and under-recruiting specialties. But the report is incredibly vague about how this will be assessed, implemented and paid for, or how often these awards would be revised. There’s a healthy scepticism about any pay component that seems “optional” in the current financial climate. And doctors in popular but hard-working specialties could reasonably object to their colleagues earning more for the same amount of work.

Doctors are already leaving the NHS to retire, or move abroad (the numbers of doctors applying for accreditation to work abroad has already reached record levels this year). Meanwhile, recruitment problems are making the news, even before the new contract is enforced. Wales and Scotland have rejected the new contracts, so we might have the bizarre situation of doctors migrating from England to Wales or Scotland to earn better salaries. Those that are staying are increasingly disillusioned. And a demoralised, understaffed, overtired, overworked and underfunded workforce is not in your interest.

What happens next?

It would be nice to see the full details of the proposed contract, so we could all work out what it will really mean to us. Perhaps nobody has actually worked out the details yet (this doesn’t usually stop the Government from announcing new policies). Perhaps they have, but they don’t want to release the details for everyone to scrutinise. But whatever the details turn out to be, at least some junior doctors are going to get a pay cut. And all junior doctors are losing the protection they currently have on antisocial hours, losing the (very limited) financial perks of the job, and losing maternity safeguards for women.

Doctors are considering industrial action, which might include a full strike, working to rule (essentially leaving on time instead of working free overtime), or refusing to sign death certificates. All of these would be a disaster for the NHS, and in particular for the people we take pride in looking after. Many others are voting with their feet, and looking to move abroad. I’ve seen posts from women currently working part time, who feel that the new contract would lead to them quitting completely.

This story has to be viewed in a larger context – that of Government attacks on senior doctors a couple of months ago, repeated anti-NHS rhetoric from Government and media, and the biggest NHS funding crisis in any of our working lives. Expect this dispute to play out amid headlines of more and more failing hospitals, record failures to meet waiting time and A+E targets, record numbers of unfilled posts, while the Government brags about imaginary plans to extend current routine services to include weekends, without any extra funding.

One thing is for certain. Unless the UK Government backs down, or sweetens the bitter pill significantly for junior doctors, you haven’t heard the end of this story.

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ADDENDUM 24/9/15:

Since I published this post 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 a platform to argue his case – here’s what he wrote.