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February 13th 2016
There are some posts I write here that I'm confident will not be well-received amongst my (admittedly small) readership, and I think this may be one of them. I have no direct connection with the NHS apart from using it - using it regularly, for a couple of years some time ago - but I have several friends who work in it, and so it is with some trepidation that I wade into the debate on the new contract for junior doctors. I don't pretend to be entirely impartial, as a Tory voter and also as someone who has benefited greatly from NHS care, but I can offer an outsider's view of the dispute. My view is not informed by personal experience, but it is not totally uninformed, I hope: while my instincts are always to believe a Tory cabinet minister over a union official, and I know that many people's instincts are diametrically opposed to this, I have tried to find information from a number of sources.
There is going to plenty in this post that runs contrary to the anger against the government that appears to be the prevailing view in the country - or at least on my Facebook newsfeed - so let me start with Jeremy Hunt. It is clear that he has failed about as absolutely as a health secretary could fail. He is not the first health secretary to incur the wrath of the British Medical Association (BMA) - it seems to have been forgotten amid the opprobrium that's been directed towards Hunt, but it wasn't that long ago that they passed a vote of no confidence against the previous incumbent, Andrew Lansley; they were similarly ill-disposed to Nye Bevan, de facto patron saint of the NHS - but Hunt was specifically brought in to calm troubled waters. Like Nicky Morgan taking over from Michael Gove in education, he was supposed to continue Lansley's work but quell the associated anger; instead he has become public enemy number one. Whether or not the animosity towards him is warranted is almost irrelevant at this point; he has indisputably lost the trust of a significant proportion of the NHS and of the public, and it is impossible to see that as anything other than a failure.
There is, of course, the question of whether any health secretary could have succeeded given Hunt's remit of implementing a truly 24/7 NHS (which was, of course, a Conservative manifesto pledge). I don't know the answer to that one, so I'll leave it as a hypothetical for the reader, but I suspect not.
So, how did we get to this point? Many of the accusations that have been thrown back and forth over recent weeks and months concern the failure of negotiations, with both sides claiming that the other has walked away from the negotiating table. At one point many doctors were saying that Hunt had 22 "pre-conditions", and that this was what stood in the way of a satisfactory conclusion; in November last year Hunt said that he had no pre-conditions, but I'm not sure if he was believed, and this did not result in a breakthrough. The truth is, I think, that both sides came to the table with non-negotiables, and it also seems clear to me that neither side has negotiated well. Both, therefore, must take responsibilty for the collapse of talks. That being said, I think there is clear evidence that the BMA has to take more responsibility.
In the words of Sir David Dalton, who was brought in by the government in the hopes of agreeing a deal: "the BMA has refused to compromise on its insistence that the whole of Saturday must be paid at a premium rate. In contrast Employers' position has moved several times, on each occasion offering more hours attracting premium pay." While the government has attempted to find a compromise on this issue - the final version of the contract offers a 30% premium for any doctor working one in four Saturdays, and guaranteed that no doctor would ever be rostered on consecutive weekends - the BMA has been intractable, and its counter-offer was truly risible; I've shown it below (copied from the BBC site; since this graphic, it has been confirmed that the 11% figure should actually be 13.5%).

As the diagram shows, the BMA offered to take about two fifths of the previous offered basic pay rise, but rather than apply it to an additional 20 hours a week as proposed by the government (from 60 hours to 80 hours), they wanted it to apply to literally the same number of hours as currently, just shifted down a bit. Then the non-standard hours would be paid at 150% of the new basic rate, rather than (as presently) 120-200% of the old basic rate; roughly the same total. As I say, this offer was truly risible, and I don't see how it could have been offered in good faith - it was so far away from the government's proposal that it could never have been accepted. I am not given to cynicism, but I do wonder if it was proposed solely so that the BMA could say that their proposal had been rejected.
So much for negotiations. Following the imposition of the contract - and, as an aside, Hunt could never have realistically withdrawn the 'threat' of imposition; it was the only leverage he had, and equivalent to the BMA withdrawing the 'threat' of strikes - Jeremy Corbyn said: "Patients, doctors, the BMA and the public want an agreed settlement. What is now keeping this dispute going are the actions of the Secretary of State himself". In fairness, I would never expect any leader of the opposition to be even-handed about government failure (particularly not one who wears a '❤ UNIONS' badge) but I do wonder if Corbyn understands that what he's said is untrue. A question for another day, I suppose.
Speaking of Corbyn, though, I'm not as worried as some seem to be about the Corbynistas within the supposedly apolitical BMA. While it has not exactly been helpful to hear Yannis Gourtsoyannis (on the BMA's junior doctors committee) frame the argument as a strike against austerity, or Kailash Chand (deputy chairman of the BMA council) compare Tories to Nazis, I can't pretend to be surprised that a major union contains Labour supporters, nor do I think that its leading figures should be forbidden from having and sharing their own views.
Actually, if I had any advice for the BMA, it wouldn't be to keep the likes of Gourtsoyannis or Chand quiet. It would be to tell its members to stop claiming that Jeremy Hunt has an ambition to destroy the NHS. This claim may rally the more excitable troops, but it's self-defeating because nobody of sense can possibly believe it. Even if you're sure that Hunt's actions will lead to the destruction of the NHS, it is ridiculous to say that this is Hunt's aim, or - as I've seen claimed elsewhere - that this aim is shared by the Sun newspaper. I'm fairly confident that, if Jeremy Corbyn were Prime Minister of the UK, he'd destroy the economy; and that, if Donald Trump were President of the USA, he'd destroy... well, the USA. But in neither case do I think it's their ambition to do so, and any sensible consideration would confirm that Hunt doesn't want to destroy the NHS - killing people in the process.
If I were to offer a second piece of advice to the BMA, it would be to admit when it had got things wrong. Early in the dispute it put a pay calculator on its website indicating that junior doctors' pay would go down by 30% - this was before any figures had even been announced, let alone agreed - and even as recently as this week I've seen that figure repeated in anger on Facebook. In the same comment thread I saw someone else claim that there would definitely be no pay rises. The government has stated that 99% of junior doctors would be in the same position or better off; while I know that that figure has been questioned (and this is where it's very difficult to draw any impartial and informed conclusions, as each side flatly contradicts the other) it is clear that the 30% figure is plainly wrong. The BMA should admit this.
Of course, for the majority of doctors this dispute is not really about pay. For many it might be about extra Saturday work - I know I wouldn't be happy if I had to work on Saturdays - but the main thrust of the BMA's argument has been about patient safety. That is certainly the best form of the argument, given that patient safety is bascially what the NHS is about, and I have no trouble in believing that it is the number one priority for doctors (and any other NHS staff, come to that). Similarly, the public's sympathies may not have been engaged by a dispute solely about pay and hours - although, given that (as Jeremy Hunt rather gracelessly, but accurately, point out) doctors are rather more popular than politicians, even that might have succeeded - but if it's about patient safety then national support is guaranteed. Indeed, I think it's possible that the BMA's reluctance to be more flexible in negotiations may have been partially driven by this confidence.
However, the link to patient safety has not, I think, been made particularly clear. For a long time the BMA said the key issue was that the new contact removed the system whereby fines were imposed on hospitals if doctors' agreed working hours were breached. The problem, from the government's side, was that this was arbitrary ("if 1 doctor works just 1 hour over the maximum shift length it can trigger a 66% pay rise for all doctors on that rota" according to Hunt), and also that the payments went directly to the doctors, thereby theoretically providing a perverse incentive for working dangerously long hours. In response to the BMA's concerns about the removal of this safety net, the government offered instead "a new Guardian role within every Trust, who will have the authority to impose fines for breaches to agreed working hours based on excess hours worked. These fines will be invested in educational resources and facilities for trainees.". This was rejected by the BMA.
With that key objection dealt with, it's unclear to me what the safety concerns are. Indeed, Hunt has made the argument that the new contract improves patient safety: "Tired doctors risk patient safety, so in the new contract the maximum number of hours that can be worked in 1 week will be reduced from 91 to 72; the maximum number of consecutive nights will be reduced from 7 to 4; the maximum number of consecutive long days will be reduced from 7 to 5; and no doctor will ever be rostered on consecutive weekends. Sir David Dalton believes these changes will bring substantial improvements both to patient safety and doctor wellbeing."
However, as my brother pointed out, doctors surely know more than politicians about patient safety, and I have tried to find specific and up to date comments from the BMA on this topic, but without success. The new contract does appear to reduce junior doctors' breaks (e.g. 30 mins after 5 hours rather than 30 mins after 4 hours - still well within the European Working Time Directive of 20 mins after 6 hours) and that is certainly a concern, so perhaps that is the issue here. There are also, I'm sure, other controversial elements of the contract that have not become public knowledge because they've been drowned out by louder issues; I welcome further information on those. Given that 98% of responding junior doctors voted to strike (76% of those balloted in November responded), there must be significant concern among a lot of intelligent people, and it surely can't all be a result of BMA misinformation or Hunt mishandling the situation. Can it?
I'll finish as I started, by turning my attentions once again to where Hunt and the government have erred. Highlighting the number of cancelled operations that strikes would cause was a mistake, because it only served to emphasise how keenly doctors feel about this dispute: doctors do not cause their patients difficulty lightly, and we all recognise that. Also, it was unwise of Jeremy Hunt to use statistics that purported to show that mortality rates increased at weekends. This is where, finally, I can bring some professional experience to bear, as I am well aware that firm conclusions can rarely be drawn from such stats, and it was always going to be the case that people found holes in his case (and it is a short step from that to claiming that Hunt's conclusions were wilfully inaccurate).
As I said at the beginning of this post, Jeremy Hunt has certainly failed in his role as health secretary. The BMA has also, I would contest, failed in its role as representative of junior doctors. My own view is that a greater share of the blame sits with the BMA, but either way there are certainly no winners here. The most interesting response to the whole issue, I think, has been from my brother, who's wondered how future generations will view this dispute. Will it be seen as one more nail in the coffin of publicly funded healthcare in this country? Or an embarrassment in the BMA's history akin to its reponse to the introduction of the NHS?
I don't know. I just pray for peace.

what was I listening to?
Shining Like a National Guitar - Paul Simon
what was I reading?
So You've Been Publicly Shamed - Jon Ronson
what was I watching?
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