Comment / Beyond the picket line

The European Union referendum campaign officially got under way in April, with fear the defining characteristic of both the remain and leave sides of the argument – fear over expanding EU membership and the impact on immigration and the burden on public services, to fear of the financial cost that would result from making a break.

Many claims have been challenged or exposed as telling only part of a story – leaving the poor member of the public struggling to find hard facts that they can rely on to inform such a key decision.

There are parallels with the current dispute over junior doctors’ contract. Public opinion on the ongoing contract dispute is unlikely to be as close as we are told is the case for the in/out referendum – junior doctors seem to continue to enjoy substantial public backing.

But there is more fear and sloganeering in the two sides’ ‘campaigns’ than hard fact. In such circumstances, the public could hardly be blamed for basing its judgement on gut reaction and who it trusts more.

Neither side – the Department of Health or the British Medical Association – has covered itself in glory in making its case. The Department has to a large extent failed to articulate its case for change. As we report this month (news analysis, page 10), the arguments seem to have boiled down to two core issues – safety and pay.

The BMA says the contract threatens safety. The government rejects this, saying it is the strikes that will have an impact on patient care and pointing to numerous safety features that are being added that in fact prevent ‘unsafe’ rotas.

The BMA argues that with no increase in the junior doctor workforce, increased working at the weekends – to support the government’s seven-day service ambitions – must mean fewer doctors to man existing weekday rotas. This ‘five-day funding, seven-day services’ argument would, it claims, make these rotas (already operating with gaps) even more stretched, which would have an unavoidable impact on patient care.

The government says the BMA agreed to 90% of contract changes and the union’s objection is all about pay – in particular for weekend working. It argues that this objection is despite an increase in basic pay and a commitment that average earnings will stay the same and there will be no change to the junior doctors’ pay bill.

For the public, and many in the service, it is all very confusing. If the doctors say this will lead to unsafe care, why wouldn’t they be believed? If the government says the pay bill won’t fall, why is it so committed to reform? How can a contract that apparently has so much agreement cause this much unrest?

The collateral damage is huge. Cancelled elective lists will clearly impact on access targets and could lead to higher costs as hospitals look to catch up, potentially further increasing the use of agency staff at a time when the service is pulling out all the stops to reduce this expenditure.

It also has the potential to inflict untold damage on management-clinician relationships at a local level. This would be destructive at any time, but even more so at the moment. The ability to roster more staff at weekends may be important for transforming some aspects of NHS services, but the transformation needed in the NHS goes much further than this. And the revised pathways and changes to point of delivery will need a clinical workforce that works right alongside management to make the changes.

Clinical engagement (see HFMA president Shahana Khan’s comment) is also crucial to the broader development of sustainable services that deliver better value measured in both outcomes and costs. The Department must avoid winning the battle, only to lose the war.

Given the public stances taken, it is hard to see how the two sides can be brought back to the negotiating table. But it needs to happen. And quickly.