There is no urgent need to change the junior doctors’ contract. It probably could be improved, but the complexities are such that it’s impossible to tell whether a new contract would be better without a proper comparative trial. Both the government and the BMA have put forward new contract proposals. They need to be properly tested in a variety of hospitals against the existing contract. Bad science is at the heart of the junior doctors’ dispute with health secretary Jeremy Hunt. His unsubstantiated conclusions about weekend mortality rates were inflamed by the fact that he appeared to have privileged access to this data before it was published in a peer reviewed journal. This may sound trivial but the scientific process is very clear that data should not be made public before it has been peer-reviewed. It made junior doctors very suspicious that NHS England was ganging up against them too. Hunt then quoted outdated data on variation in stroke care to justify imposing the new contract as part of the Tory election pledge of ‘a truly 7 day NHS.’
This uncosted pledge may yet undo the government. A ‘truly 7 day NHS’ has the same high quality routine and emergency care – 7 days a week – in hospitals, community care and general practice. In most cases this would require a 40% increase in routine care at weekends. Staff can’t be spread more thinly than they are at the moment. Clearly it needs more staff and ‘truly 7 day funding’ to match.
The fact that the government has made this pledge without identifying any resources to implement it is absurd. The junior doctors too are right to be suspicious of a contract offer which will apparently see most of them get a pay rise and work fewer hours whilst somehow extending weekend cover for no extra funding or staffing. As one junior doctor put it: ‘This is pure Huntenomics.’ The dispute, was predicated on an astonishing 98% vote in favour of industrial action, which is a very loud smoke alarm about the current state of the NHS. In the midst of 10 years of flat-line funding, rising demand and big cuts in social care, NHS staff are struggling to provide 5 day routine treatments and 24/7 emergency care as it is. No-one currently provides routine services 7 days a week, although hospitals such as Salford Royal NHS Foundation Trust have managed to improve the quality of urgent and emergency care across 7 days using the existing junior doctors’ contract. This suggests the junior doctors contract has very little to do with 7 day services and the battle over Saturdays makes no sense when – at least according to Hunt’s figures – the highest number of excess deaths are on Sundays (see letters). The most likely agenda is simply to get junior doctors to work at weekends for less, and then roll this out right across health and social care.
The government’s biggest error would be to impose the contract. The fragile goodwill the NHS relies on would vanish, and resentment and resignation would follow. Likewise, junior doctors must be wary of an all-out strike which risks harming patients particularly in those hospitals that are already unsafe and perilously short-staffed. The government has cleverly manipulated the argument to be about ‘Saturday pay’ but for doctors it’s ensuring that there are financial disincentives to protect them from abuse. Contracts on paper are often very different from contracts in real life, which is why a proper trial in a variety of hospitals is essential to see if it really is – in Hunt’s words – ‘better for doctors and better for patients.’
Hunt may or may not turn out to be right that his reforms will reduce mortality rates, but the evidence is against him. An excellent study of all the political reforms of the NHS since 1974 concluded ‘centrally led NHS reorganisation has never had any detectable effect on either male or female mortality and must be considered ineffective for this purpose. But some evidence that increased funding improves outcomes is found.’1 Ultimately doctors will leave the NHS if they feel it is too stressful and unsafe for patients and their own mental health. The government has also promised to make the NHS the safest service in the world, but again it hasn’t promised the money to do it. Unrealistic expectations, inadequate funding and bad science are a truly dangerous mixture. But whatever happens, junior doctors will refuse to be silenced, even if they pay a heavy price. 1 Has NHS reorganisation saved lives? JRSM 2016 Jan;109(1):18-26
MD’s book, Staying Alive – How to Get the Best from the NHS – is available here