The government is currently in the process of unilaterally imposing a contract on the junior doctors of England. The Scottish, Welsh and Northern Irish government have decided it is not in the public interest to do the same. The Review Body on Doctors’ and Dentists’ Renumeration (DDRB) report published in July 2015 forms the backbone for the government’s rationale for contract reform1. This report involves the ‘delivery of healthcare services seven days a week in a financially sustainable way’. Unfortunately for those intending to analyse the rationale behind these ‘7 day reforms’, many key details remain hidden including the precise meaning of ‘7 day services’ and the specifics of the junior doctor contract. This summary attempts to synthesise the available information in an easily digestible manner.
Contradictory cost neutral expansion of services with no more doctors working less hours?
A leaked Department of Health (DH) report recently revealed that the 7 day reforms could not be done without extra funding and more doctors2. Specifically, it calculated nearly £1bn and 6000 extra doctors were required per annum to deliver 7 day services safely; notably this report has still to be published. However the government has repeatedly stated that overall the junior doctor contract is ‘cost neutral’ and that doctors will work ‘fewer hours’ under the new contract3, 4. This information is contradictory, the government has yet explain how services can be expanded with no more doctors and with doctors working less hours; this sum simple does not add up. Salient to this point is the fact that the funding stream to HEE for doctors in training is being decreased in real terms and when combined with the new contract’s increase in basic pay5, 6, this means that the government has to be cutting junior doctor numbers in forthcoming years, again this is utterly incompatible with delivering a service expansion safely2.
New contract creates new problems and current contract’s main issues remain unaddressed
The new contract is being delivered within a pay neutral envelope1. A widely acknowledged problem with the current contract is that unsocial hours are not always adequately or fairly rewarded. However, the rise in basic pay means that the groups to gain the most from the new deal are those doing zero unsocial hours and zero weekends. The perversity of a pay rise for those without unsocial hours means that on average less money will be available to reward those working unsocial hours. In the context of overall pay neutrality, this means that once pay protection is gone those working unsocial hours will on average have their pay cut. This will exacerbate the recruitment and retention crises in the specialities which are already the hardest hit5-13, making it impossible to deliver 7 day services in a safe or sustainable manner.
Safety is likely to be compromised by this unfunded expansion and watering down of safeguards
Evidence demonstrates a clear increase in mortality as funding is decreased14. The extent of rota gaps within current junior doctor rotas is highly worrying and appears to be deteriorating5-13. Recruitment and retention crises are already rife, particularly in the specialities with the most unsocial hours. The new contract removes the truly independent system of hours monitoring and replaces it with a weaker, less independent ‘Guardian’ based system which is far more open to abuse by employers. Not only are the financial penalties paid to trainees smaller, but the Guardians are direct employees of the Trust and part of the financial penalty for overworking junior doctors will be paid by the Trust to the Trust itself. The impact of deteriorating recruitment and retention upon rota gaps in combination with less robust hours safeguards poses considerable safety risks to patients by the mechanisms outlined by the Cass Business School’s recent submission of evidence to the Public Accounts Committee (PAC)15.
Un-costed, cost ineffective and unnecessary, as well as totally unassessed for both risk and impact
The Director General of the DH recently admitted to the PAC that no formal costings have been carried out for the government’s 7 day reforms16. Recent research has demonstrated that the 7 day reforms are not cost effective17. Over 90% of NHS Trusts stated the current junior doctor contract was not a major block to 7 day working18. The Department of Health has also recently admitted that the junior doctor contract has neither been assessed for risk not impact. This is despite the Francis report making it clear that any major health reform should be both risk and impact assessed, and that these assessments should be debated in the public domain prior to considering implementation of such reforms19.
Overall the junior doctor contract is undermined by the fundamental fact that services cannot be safely expanded at weekends without adequate funding and increased staff numbers. The government’s 7 day reforms remain undefined, they have not been costed, they have not been impact or risk assessed, and they represent a cost ineffective waste of tax payer’s funds which pose a very serious and real threat to patient safety. Not only will this poorly designed contract exacerbate the widespread recruitment and retention crises in the NHS, leading to more unsafe rota gaps, but this bullying imposition will drive morale rock bottom, and this alone will have catastrophic consequences for our hopes of improving services in safe and sustainable manner.
1. DDRB. Contract reform for consultants and doctors and dentists in training – supporting healthcare services seven days a week. Office of Manpower Economics 2015.
2. Elgot JaC, D. http://www.theguardian.com/society/2016/feb/15/weekend-effect-on-hospital-deaths-not-proven-say-hunts-own-officials. Guardian 2016.
4. NHSEmployers. http://www.nhsemployers.org/your-workforce/need-to-know/junior-doctors-contract/faqs. 2016.
5. BOTA. Position Statement: The Worsening Crisis of Medical Recruitment and Retention in the NHS. http://wwwbotaorguk/position-statement-the-worsening-crisis-of-medical-recruitment-and-retention-in-the-nhs/ 2015.
6. Donnelly L. One in 3 trainee GP posts are empty, amid warnings of crisis shortage. http://wwwtelegraphcouk/news/health/news/11517019/One-in-3-trainee-GP-posts-are-empty-amid-warnings-of-crisis-shortagehtml 2015.
7. RCPCH. Children’s unit closure fears as rota vacancies pose threat to patient safety. http://wwwrcpchacuk/news/children%E2%80%99s-unit-closure-fears-rota-vacancies-pose-threat-patient-safety 2015.
8. Rimmer A. Gaps in trainee rotas cause patient safety problems, say consultants. BMJ Careers 2016; http://careers.bmj.com/careers/advice/Gaps_in_trainee_rotas_cause_patient_safety_problems,_say_consultants.
9. Cooper C. NHS hospitals pushing young medics to brink of 'burnout' by relying on them to work extra hours. Independent 2015; http://www.independent.co.uk/life-style/health-and-families/health-news/nhs-hospitals-pushing-young-medics-to-brink-of-burnout-by-relying-on-them-to-work-extra-hours-10333064.html.
10. RCOG. RCOG statement on new contract proposals for junior doctors. https://wwwrcogorguk/en/news/rcog-statement-on-new-contract-proposals-for-junior-doctors/ 2015.
11. Donnelly L. A third of A&E doctors leaving NHS to work abroad. Telegraph 2015; http://www.telegraph.co.uk/news/health/news/11883559/A-third-of-AandE-doctors-leaving-NHS-to-work-abroad.html.
12. Mukherjee K, Maier M, Wessely S. UK crisis in recruitment into psychiatric training. The Psychiatrist 2013; 37(6): 210-4.
13. Campbell D. Almost half of junior doctors reject NHS career after foundation training. Guardian 2015; http://www.theguardian.com/society/2015/dec/04/almost-half-of-junior-doctors-left-nhs-after-foundation-training.
14. Budhdeo S, Watkins J, Atun R, Williams C, Zeltner T, Maruthappu M. Changes in government spending on healthcare and population mortality in the European union, 1995-2010: a cross-sectional ecological study. Journal of the Royal Society of Medicine 2015; 108(12): 490-8.
16. Bloom D. Top Jeremy Hunt advisor admits he has no idea what 7-day NHS will cost. Mirror 2016; http://www.mirror.co.uk/news/uk-news/top-jeremy-hunt-advisor-admits-7435383.
17. Meacock R, Doran T, Sutton M. What are the Costs and Benefits of Providing Comprehensive Seven-day Services for Emergency Hospital Admissions? Health economics 2015; 24(8): 907-12.
19. QC RF. The Mid Staffordshire NHS Foundation Trust Public Inquiry. 2013: http://www.midstaffspublicinquiry.com/sites/default/files/report/Executive%20summary.pdf.