Jeremy Hunt arrived at the Department of Health three years ago, instructed to smooth over Andrew Lansley’s disastrous NHS reforms and sell the Tories as the party of the NHS. Now he is weeks away from industrial action by junior doctors that will disrupt, and could endanger, patient care in the run-up to Christmas. The ballot papers seeking authorisation for the first junior doctors’ strike for 40 years will arrive from Thursday morning. The fault is not all Mr Hunt’s, but he holds the purse strings. He will not survive a winter crisis. Everyone would gain if he backed down now.
Doctors’ pay is notoriously tricky. That is partly because doctors themselves are the workhorses of the health service. They are loved and admired by the public. In the BMA, they have a tough and effective negotiating body with a membership that is notorious, at least among health secretaries, for its solidarity. When it comes to a standoff, no politician stands a chance. In this context, a wise health secretary should suppress all macho urges to embark on negotiations in anything other than a spirit of caution and conciliation. This is all the more important when the NHS is, despite the relative protection for its budget, facing the most acute financial squeeze in its history, after five years of below-inflation pay awards and with morale reported to be at an all-time low, while emergency departments in Australia and New Zealand are now often staffed by young British doctors.
In periods of extreme pressure, it is the junior doctors who traditionally operate as a buffer between supply and demand. That is why there was an era when the 100-hour week and the 72-hour shift were commonplace. Thanks to the European working time directive, that is (mostly) in the past. But other changes to introduce more flexible working for doctors left many newly qualified doctors feeling that their private lives were no longer their own (as the GP-turned-MP Sarah Woollaston reported), while at work – particularly at weekends – they were left carrying a heavy burden of responsibility alone. Worse, a series of investigations from 2009 onwards showed that outcomes for patients admitted at weekends were significantly less good than for those who went into hospital midweek. Part of the reason, it is now clear, is that patients admitted at weekends are sicker; but the shortage of backup or support services plays a role too.
So there were a lot of challenges facing the NHS employers when they began to negotiate three long years ago. Yet, according to the former health minister Dr Dan Poulter, talks with the BMA’s junior doctors committee were making good progress when the plan for a 24/7 NHS unexpectedly became a key Conservative manifesto pledge. Mr Hunt is now insisting that it is non-negotiable, and that the new junior doctor contracts are essential to delivering it. That doesn’t add up.
No one disputes that an NHS that never sleeps would be a wonderful innovation. It would also be unique in the world and, as doctors can only do so much on their own, expensive: it would add at least £3bn to a budget that is already under-resourced. As analysis of the current excess mortality rates for weekends suggests, unless there is also money for all the backup services that are indispensible to patient care, there is little point in having more doctors on call. Nor has Mr Hunt explained how the extra hours will be covered, without denuding wards of daytime medics; nor how young doctors working long hours under pressure and under-supported are supposed to learn the skills of their seniors.
Throw into this toxic brew cuts in pay for antisocial hours, loss of incentives for the Cinderella services like emergency medicine and psychiatry, and an erosion of control over the number of hours that they work, and it is no surprise that junior doctors are angrier than they have been since Barbara Castle reneged on a promise to introduce extra-duty payments in 1975. The BMA now accuses Mr Hunt of bad faith. It wants him to lift the threat of imposing the contract, which he first made in September. And it wants him to promise that any contract will be fair to doctors and safe for their patients. The doctors may be the most effective lobbying organisation in the country, but that doesn’t mean they don’t have a powerful case. Mr Hunt has needlessly dug himself a large pit. He needs to work out an escape route before he is submerged – and patients are endangered by an unnecessary strike that may have considerable public support.
