There is a lot in the news about the contract negotiations between NHS employers and the British Medical Association (BMA). While the BMA's consultant negotiating committee has returned to the negotiating table, the junior negotiating committee have not.
The junior doctors state a lack of monitoring over work hours, a significant pay cut, potential gender discrimination and a poor reflection of professional experience. NHS employers will point the doctors and dentists remuneration body (DDRB) report as the basis for the offer. Whatever is right, there is an argument that this contract is simply bad business.
Let’s start with a bit of background.
Firstly, what is a junior doctor. A junior doctor is anybody who is not a consultant and currently in training. So a junior doctor can be straight out of university, or be ready to be appointed as a consultant after 10 - 15 years of training. ‘Junior doctor’ is broad term for broad employment group.
The UK currently lies 24th out of 27 for the number of doctors per person in the EU.
There are reports of junior doctor training places being vacant throughout the country. Up to 40% of GP training places are empty in the north of England, competition ratios for previously uber competitive hospital rotations have dropped to 1:1 in many specialities (eight years ago the same places were 8:1) and up to 40% of 2nd year doctors did not continue their training in the UK last year. This creates a patient safety issue in the short and medium term. A significant proportion of weekend and night medical staff are junior doctors. Ensuring adequate staff numbers is a basic principle of adequate and safe medical care. Shortages lead to delays in your care, delays can lead to complications, especially in emergency situations. Asking consultants to deliver this care is one option but, it will remove capacity from other parts of the NHS. As you can see from top of this paragraph, there aren’t many to spare.
Training a doctor is expensive. The figures quoted vary, but without doubt, it is a significant cost.
Recent changes to university fees mean that the average medical student studying now will leave with approximately £70,000 and £100,000 of debt.
This would be repaid in repackaged student loans, meaning a fixed percentage of future earnings are paid each year (above an earning threshold). However, the debt has a shelf life of 30 years and crucially, will not be collectable if the graduate leaves the UK for employment elsewhere. Currently, there is no mechanism to lock UK graduates to UK employment post university. As a result, all graduates are free to leave as they would for any degree. In any event, restricting free movement would likely contravene European law.
Medicine is an international workforce.
UK graduates are seen as desirable within the medical community. The recent spike in requests for certificates of good standing illustrate a growing unease in these proposals and potentially, a desire to leave the UK. It can be argued that recruitment from overseas could fill the void. The ongoing financial problems in Europe have strengthened the NHS' ability to recruit recently. However, this is not a long term strategy. In addition, countries from which the NHS has historically recruited from are now emerging economies. The move to the UK as doctor is not as lucrative and beneficial as it was. In fact, I have personally seen reverse migration, where foreign trained doctors have returned to their country of origin. In addition, the government’s position on working visas in unlikely to change any time soon and acts as a block to non - EU immigration.
The contract and its potential imposition, will rightly or wrongly potentially disenfranchise an entire generation junior doctors, who will not view the NHS as their trainer and passion, but as an source of angst. Given the ability to escape astronomical debt, achieve better terms and conditions abroad whilst simultaneously achieving greater control in their work / life balance, many will leave. In the face of a medical recruitment failure, this would not seem wise. Creating a situation where leaving the UK benefits the doctor financially, personally and professionally makes no sense. It is unfair to doctors, patients and the taxpayer. It would seem wiser to create a contract that doctors and patients feel is a balance of valuing them and the responsibility taxpayer.
Terms and conditions would be one element of a royal commission for the NHS. Sustainable contracts for all staff will help ensure a return of investment from their training which is in everyone's best interests. With a contract that helps value staff, important and difficult workforce planning decisions can be properly managed for the short, medium and long term future. After all, the NHS is the business of good healthcare, and what good business doesn't trade for a lack of staff?
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