News / Finding an end to the gridlock

Impasse. Deadlock. Stalemate. As Healthcare Finance went to press, junior doctors in England had carried out the first all-out strikes in the history of the NHS, and the only thing that seems to have changed is that positions have hardened. It is now a question of which side will blink first.

The dispute is about a new contract that the government insists is needed to implement its manifesto promise of a seven-day NHS.

Looking back, it’s difficult to see how we got to this point. Both sides want a seven-day NHS, both believe the juniors need a new contract and, according to reports, 90% of the contract has been agreed. So how have we reached a point where thousands of scheduled operations and outpatient appointments have been cancelled as juniors stand on verges outside hospitals?

Two days before the all-out strike, doctors’ union the British Medical Association (BMA) wrote to health secretary Jeremy Hunt offering to call off the action and return to talks if he agreed to lift the imposition of the new contract in August. Mr Hunt (right) refused, saying a union should not be able to hold to ransom a government that was merely attempting to implement its manifesto.

It’s become a highly politicised situation, with claims both that the BMA has been trying to bring down the government and that the government has been attempting to privatise
the NHS. But headline-grabbing statements like these do little to solve the dispute or
explain what it’s all about.

When not slinging mud, the high-level discussion carried out in the media often boils the dispute down to two issues – the BMA says the new contract threatens patient safety; the government refutes this, implying the unions’ opposition is purely down to pay.

Both safety and pay are important factors, but teasing these apart reveals a number of other issues, including working hours and cost. Taking a step back, the government insists the contract is needed to implement seven-day services. But what does a seven-day NHS mean?

It is often explained as giving patients the same level of care at the weekend as they get on a weekday. Mr Hunt has clarified that this does not mean elective treatments at the weekend as well as the emergency and inpatient care already provided. On the eve of the latest industrial action, he said: ‘Our plans are not about elective care but about improving the consistency of urgent and emergency care at evenings and weekends. To do this, the Academy of Medical Royal Colleges (AMRC) has prioritised four key clinical standards that need to be met.’

He went on to say that these include:

• Ensuring patients are seen by a senior decision-maker within 14 hours of arrival

• Twice-daily high-dependency reviews

• Seven-day availability of diagnostic tests with a one-hour turnaround for the most critically ill patients

24-hour access to consultant-directed interventions such as interventional radiology or endoscopy.

He added that around a quarter of the country will be covered by trusts meeting these standards from next April, with the whole country by 2020.

The BMA said the AMRC clinical standards had implications for the way doctors work, as well as funding. It agreed that urgent and emergency care should be prioritised but said that only when this was improved should the debate about extending elective services into the weekend begin.

So, there is broad agreement about the scope of seven-day services in the immediate future. The dispute lies in questions of staffing, safety and funding.

Both sides insist safety is the key reason behind their stance. The government says the juniors’ industrial actions are threatening patient safety, while the doctors believe that the new contract will do the same by spreading the existing workforce across the week.

Mr Hunt said numerous academic studies had shown a ‘weekend effect’ – essentially there are more deaths following weekend admissions.

He believes part of the issue is lack of medical staff, though there are other contributing factors such as reduced diagnostic support. Some academics and the BMA cast doubt on this conclusion, arguing that the studies have not presented evidence for this.

The BMA highlighted the fact that junior doctors provide most medical cover at weekends already. Some people would argue that, if there is an issue with medical cover, it is a lack of senior doctors in work on Saturdays and Sundays.

There are gaps in current rotas. According to research by the Royal College of Physicians last year, one in five of their consultants reported gaps in junior doctor rotas.

Doctors are worried that such gaps will be exacerbated by the new contract and a shift to seven-day services. They fear they will have to work longer – and thus an unsafe number of hours – to meet patient need.

However, the government said it has included safety features in the new contract:

• A maximum 48-hour working week (down from 56 hours) for those not opted out of the working time directive

• A maximum 72 hours in any seven-day period (reduced from 91)

• Various controls on the number of shifts that can be worked on consecutive days.

Although the BMA has complained about plans to end formal penalties for unsafe working hours, an independent guardian in each organisation will have the power to levy fines and oversee enforcement of the new rules.

Funding and cost are obviously closely linked to staff numbers and pay. The HFMA undertook a small study of the cost of seven-day services for acute and emergency care, together with supporting diagnostics in 2014. It found that costs would be typically 1.5% to 2% of total income or, put another way, a 5% to 6% increase in the cost of emergency admissions.

However, the health secretary wants the new juniors’ contract to be cost-neutral – and there lies one of the contract’s sticking points. To facilitate this, the new contract redefines
the hours that attract premium pay and the amounts paid.

Under the current contract, normal time is defined as 7am to 7pm, Monday to Friday, with payments in six bands (between 20% and 100% of salary) to reflect hours worked outside this. However, the new contract redefines normal time as 7am to 9pm, Monday to Friday, and 7am to 5pm, Saturday. 

Under the new deal, hours worked after 9pm and before 7am on any day will receive a 50% supplement on basic pay. Saturday hours between 5pm and 9pm and Sunday between 7am to 9pm will attract a 30% supplement.

Doctors rostered to work a shift starting at any time on Saturday at a frequency of one week in four or more will get a 30% enhancement for plain time hours worked on Saturday (7am to 5pm). Automatic pay progression has been removed and there will be new on-call pay arrangements. In return for this, juniors would receive an average basic pay rise of around 13%.

NHS Employers, which led the negotiations on behalf of the Department of Health, said around 25% of junior doctors would be eligible for pay protection. But once these doctors have moved through the system and been replaced by new juniors, will the overall pay bill reduce by the amount of pay protection being paid initially? This could allow the NHS to employ more doctors to cover seven-day services.

However, an NHS Employers’ spokesman insisted the contract was not designed to deliver savings. ‘There may be a slight cost pressure at the start but otherwise the money used to cover pay protection is intended to be recycled back into the pay envelope each year, as it is freed up by doctors’ protection coming to an end and the need for the protection diminishes. There are not intended to be any savings and no reduction in the pay bill is planned,’ the spokesman told Healthcare Finance.

Only doctors in foundation year one (mostly those straight out of medical school), plus perhaps a handful of others – around 10%-15% of all doctors – will begin on the new terms in August, he added. Implementation will be phased and all juniors are expected to be on the new contract by December 2017.

Juniors, never mind the general public, have found it tricky to work out what it all means. Last September, juniors said the (now changed) contract could lead to a 40% pay cut, although Mr Hunt insisted that only a handful would receive less. But much will depend on how the new rotas are structured.

The BMA firmly rejects any suggestion that the dispute is now just about the premium paid for working on a Saturday, as the health secretary has suggested.

‘There are a number of outstanding issues other than this, including how safe working hours would be regulated, ensuring that doctors have access to adequate breaks and changes to definitions of what is regarded as unsocial hours,’ a spokesperson for the union said. It does not believe the seven-day NHS can work without further investment.

It’s a confusing picture, with little real-world information to go on. For now, patients are collateral damage and trusts, charged with implementing the contract, will hope to remain on relatively good terms with their junior workforce. But for the BMA and the government the question is, what now? And can either party afford to back down?