Of all the reasons to end a long and bitter industrial dispute, imposing an unwelcome contract on a demoralised workforce to “end the uncertainty” has to be the most bizarre, given the inevitable outcome of the imposition will be not less, but more uncertainty. The demoralised workforce, our junior doctors, are already in bad shape, overstretched and in poor morale. Record numbers are considering – though we don’t yet know how many will pull the ejector seat lever – working abroad. Late last year we learnt that almost half of juniors completing their foundation training chose not to proceed directly with their training – a sure sign of ambivalence about the direction of their chosen career. Hospitals face unprecedented recruitment problems, winter pressures are now being mirrored by summer pressures, with the imminent prospect of all year round pressures. The health service is in a critical way, at risk of implosion. So what does the Health Secretary do when he doesn’t get his own way with the juniors? He hits them on the head. Hard.
The junior doctor bear now has a sore head. Many in the media, including notably the usual BBC goons, frame the dispute as one over marginal pay and conditions. Hugh Squimm, the BBC health editor, who seems almost so hygienic as to be unhygienic, inclines to present the story as if he were reeling off results from the local flower show, with a cheerio-for-now manner better suited to benign weather forecasts. But this dispute isn’t about the banalities of marginal pay on Saturday afternoons. It’s about something, or rather two things, that run much deeper. The first is safety, and the second is morale, or more precisely, though Dr No doesn’t normally warm to the modern street use of the word, respect. The two are heavily connected. However hard individual members try, a thinned out, demoralised workforce that feels it lacks due respect is always going to struggle to provide as safe a service as one that is well staffed, and content in its daily round.
The government line is that it has a manifesto commitment to deliver a seven day NHS, and that the new contract will go some of the way (consultants and other hospital staff will be next in line) towards facilitating this, by making it easier for hospital managers to roster juniors to work over weekends. Never mind that juniors already do work at weekends, or that the questions about admission day of the week mortality are far from answered. It’s a simple common Tory plug, no doubt aimed at hard working patients, who also have to work weekend hours. Add in beefed up basic pay for juniors – only today the government ‘discovered’ an extra two and a half percent on top of the existing eleven percent increase – and further optimistic, though in reality likely to be more notional, limits and safeguards on over-working, and, well, what could be fairer than that?
But consider this. The new contract is set to be neutral on the overall bill for junior doctors’ pay. There are no plans to recruit, at considerable expense, large numbers of new junior doctors; indeed, all the indications are that a combination of factors, now aggravated by the contract imposition, are causing attrition in junior ranks. This means that the reality of a seven day NHS is that the juniors who currently provide a seven day emergency/five day elective service are going to be spread thinner, to provide a seven day emergency and elective service. The already thin over-stretched gossamer of junior doctor cover is to be spread even thinner. It is only a matter of time before splits appear, and patients start to fall through the cracks.
It is here that the BMA, rarely the sharpest scalpel in the dissecting room cabinet, missed a big trick. Instead of allowing the dispute to be portrayed as one of pay and conditions, with the inevitable consequence that opportunistic opponents would cry ‘greed’ and ‘self-interest’, the doctors’ leaders should have focused much harder on the real threat to patient safety inherent in spreading too few doctors over too many days.
If the BMA was thick, then so too it seems has been the government. Though the conspiracy theorists have it that the Tories are cynically and deliberately compromising the day to day safety of the NHS, as a prelude to calling in the private sector cavalry – and in this respect there is that rather awkward 2005 pamphlet co-authored by the current Health Secretary, along with other notorious Tory coves, that called for the denationalisation of the health service – it seems more likely to Dr No that the junior contract imposition announced today ‘to end uncertainty’ is more of a bull-headed cock-up than part of a running conspiracy. The Health Secretary, who spends too much time talking as if he were trying to explain how school meals work to a slow-witted child, appears simply not get that imposing a unwelcome contract on a stretched demoralised workforce is a recipe for disaster. A tale of two thickies then, but without the best of times, only the worst, to come.