Junior doctors are caught in a maelstrom; voting for or against a contract that is the best offer yet proposed, but with questions about its fairness, safety, and practical application especially now in the post Brexit era. Since the contract was published, as one of the public facing grass roots junior doctors over the past ten months, I am increasingly alarmed and dismayed at the nature and content of the debate that has raged over social media platforms by my profession. In many ways this bitter and protracted dispute has captured many years of simmering discontent, anger, and angst over junior doctor working conditions. Declining morale has come to the fore, within the context of ever-increasing public and societal expectation.
We have had unprecedented unity amongst junior doctors which has crossed speciality, grade, and sector. We have had unity between junior doctors and seniors that allowed for the first junior doctor strikes in 40 years and a historic emergency walk out. The public have supported the cause of junior doctors as they have recognised us as the workhorses of the NHS at the coal face. And all of this has secured a negotiated contract between the BMA and NHS Employers (working on behalf of the Government) that will not be imposed in August 2016, as the government had previously threatened. In the past two weeks, final terms and conditions have been published and members of the junior doctor committee have valiantly presented the facts to junior doctors at over 120 road shows across the country. They have detailed the reasons for the dispute, the “red lines” that were crossed by the BMA in the interests of the membership and how the third iteration of this contract has provided accountability, transparency, and contractual levers that will protect junior doctors in the workplace from excessive hours, prevent increased weekend rostering without adequate resources, and ensure junior doctor voices are integral to the safety mechanisms within a hospital. Now it is up to the membership to vote.
One would have thought this would be a cause for celebration—a resolution tantalisingly close. Yet, amongst junior doctors the debate has become increasingly factious, angry, and frustrated. Two main issues have exercised junior doctors in the process of making this choice—equality and safety.
Equality aims to promote fairness, but it can only work if everyone starts from the same place and needs the same help. Equity is giving everyone what they need to be successful. In terms of equality, the government has made a public commitment to remove a time based automatic pay progression system. As public service contracts come up for negotiation, these are removed. This has been a loss for those in less than full time training (LTFT) since automatic pay progression had created positive discrimination for those LTFT compared to full time (FT), as those that take longer to train pick up more pay increments by virtue of being in the system longer. The new contract removes this, however every LTFT individual will be paid exactly the same per hour of work as their FT colleague. Additionally, due to the flat ST3-8 scale, those that opt for LTFT for whatever reason will be less disadvantaged than those doing this earlier. To help with the fixed costs of training, a stipend of £1500 per annum will be paid to qualifying LTFT trainees during transition. It does not solve the gender pay gap issues but it attempts to address it. So is the contract fair? Yes. Does it unduly disadvantage those that are LTFT compared to FT—sadly yes. But, the new contract treats men, women, FT and LTFT equally. It does not favour one group over any other. So equality has been preserved but equity potentially sacrificed. This is a difficult societal question and as a junior doctor I would have rather that equity had not been a casualty in promoting equality.
In relation to safety, the local role of “guardian of safe working” who will act as a “champion of safe working hours” has come under much scrutiny. This role is jointly appointed by junior doctors, advised by an elected junior doctor forum, must not have a role within the management structure of the employer organisation, and report at least quarterly to the Board on exception reports from junior doctors, which could include excessive working hours, rota gaps and training infringements. Everyone agrees that, in principle, this is an excellent system, but there are fears that it will be toothless; it will highlight individuals who submit too many exception reports making them vulnerable in direct opposition to the intended aspiration of transparency and accountability at a board level. The fear of recriminations for training, progression at ARCP and for being the individual that places your head above the parapet at a local level is still very evident among doctors that have been vocal on social media.
This has saddened me deeply. As a group, we have challenged government rhetoric at a national scale, yet when it has come to local implementation of the contract, there is genuine belief and experience that this will be blocked. Is this symptomatic of junior doctor disappointment in senior medical leaders who urged us to settle earlier and not continue the quest? Our trust in these establishment figures who previously have applauded us as “agents of change” is so damaged that we are understandably sceptical of our seniors supporting us locally. Junior doctors agree the guardian role is a laudable aim, but fear that the PAs needed for this role will be insufficient to ensure the role is robust. They doubt the transparency and most of all they do not believe that they will be recompensed for their excessive hours or that their training will be addressed. Has it really come to this? Are we so afraid of the local environment that we would rather continue the current monitoring exercises, which provide a snapshot view and require 75% return for there to be an adequate resolution. Why do we not trust that by coming together as a collective we can protect our rights and change this endemic culture of pervasive and presumed bullying? We have shown that junior doctors are the next leaders of the NHS. We have questioned and challenged senior medical leaders, have asked to debate the Secretary of State for Health, we have even started legal proceedings against the government, yet we still fear the local training environment.
So how will I vote? For me, it was never a question of winning – it was always about obtaining a safe and fair junior contract. I think we have achieved that and the contract will need strong implementation that is nationally driven but locally delivered. But the fight continues. Society and medicine are discriminatory, where it is still expected that women are generally the prime caregivers. The barriers we need to address are not those in the junior contract but those extra-contractually, where we ensure childcare is affordable, parental leave is equally shared, fixed costs of training such as GMC fees are pro-rated and opportunities are equivalent. There is a fear that if this contract is instituted, the guardian role will adversely impact our long-term careers. Together as junior and senior doctors we must come together to address this. Something has indeed gone very wrong when the junior doctors who have shouted the ills of the NHS from the rooftops feel so silenced locally.
Reena Aggarwal is a specialist registrar in Obstetrics and Gynaecology. Twitter @drraggarwal
Competing interests: None declared.