Like many other junior doctors, I spent the first few weeks of 2016 using the majority of my free time (and multiple hundreds of pounds) on courses and exams in the hope of securing my next training job in London. But following Jeremy Hunt’s imposition of a new contract on junior doctors, I’m now facing a sobering dilemma: even if I manage to land my dream post in August, will I actually be able to sign my new contract in good conscience?
On 10 February, junior doctors went on strike for the second time. The previous weekend, thousands of doctors and their supporters had protested across London and Bristol, many of them waving additional blue placards to represent colleagues who would have also marched if they weren’t, that weekend, already working, despite the government’s claims about not having a seven-day NHS. The strength of feeling was undeniable: doctors objected to the threat of the new contract, to a degree that this unlikely population of protesters – normally too busy or exhausted to take to the streets – was now vocal, motivated and angry.
The day after the strike, the news broke that the long-contested contract was going to be imposed unilaterally by the government after all.
Imposition had been widely regarded as the government’s “nuclear option”—a move of political obliteration, sweeping the intricacies of debate clear off the table. It meant war. Within hours, there was a fresh surge in applications for Certificates of Good Standing – the necessary documentation for doctors pursuing a medical career overseas – and public declarations of job offers being accepted in Scotland, Wales, further afield. “Alternative Careers for Doctors” events abruptly garnered a lot more social media interest, and ever-more-heated online discussion turned to what the doctors should do next. Capitulate? Or counterstrike? Rapidly, it became clear that the overwhelming majority was in favour of nuclear retaliation.
Indefinite strikes. Full walk-outs – including emergency services. Mass resignation.
Drastic actions like these would clearly be a disproportionate response if the dispute were only about pay. But for many doctors, accepting the imposition is tantamount to accepting the dismantling of the NHS as we know it, and to oppose that we will go to any extreme.
The new contract is ostensibly designed to provide more routine weekend services without spending more money; mathematically, the only way to do that is to pay staff less or make them work more hours for the same wage. The government wants to be seen to do more – without paying more. As there is a finite number of doctors available to fill the new rotas, from a doctor’s point of view this equates to a pay cut per hour worked, and/or more evenings and Saturdays worked “for free” throughout the year. The result: less continuity of care, more arduous shift patterns, fragmented teamwork and negligible clinical gain.
Weekend working and antisocial rotas are nothing new in a doctor’s life, of course, but for many people these changes are a step too far. Over the past decade, doctors have choked down various bitter pills without much political arousal: the removal of on-site hospital accommodation in 2008 (equivalent to an estimated £6k/year pay cut per doctor); a pay freeze since 2009; the MTAS debacle in 2012. But imposition of the new contract, for many, is too bitter a pill to swallow, and now people are starting to walk.
The fact is, being a doctor in the NHS is at baseline stressful and can border on dangerous; patients are often very sick, time very tight, and tired doctors either make mistakes or live with the fear of doing so. The downsides inherent to the job have historically been compensated by rewards ranging from the psychological to the intellectual to the financial, with safeguards in place to discourage hospitals from scheduling excessively grueling rotas. The new contract stands to make the job less rewarding on both a qualitative and quantitative level, and weakens or outright removes those safeguards. For a lot of people, myself included, it is difficult to imagine being motivated to continue this stressful role under such circumstances, which undermine the central tenet of primum non nocere: first, do no harm.
We aren’t idiots. We are trained throughout our careers to weigh up the risks and benefits of proceeding with a decision, and to take responsibility for the consequences of that decision. The risks inherent in the working style promoted by the new contract – of mistakes, of malpractice suits, of chronically neglected social or family lives – increasingly look too great. The benefits, too threadbare.
If people weren’t already stretched to breaking point, there might more room for compromise, but there is no slack in the system to be taken up. The NHS has been running on the marrow of goodwill for far too long, and this year it’s been completely sucked dry.
It seems inevitable the changes will be rolled out across other NHS staff in due course – exacerbating unsafe staffing levels and reducing morale throughout the entire hospital, from A&E to the discharge lounge. Every junior doctor is looking at one-to-eight years (or longer if they are working less than fulltime for whatever reason) of poorer working conditions and perpetual uncertainty about the future; if a contract can be imposed now despite a 98% mandate for industrial action, there is nothing to stop further imposition in years to come. There is no guarantee it won’t get worse, and worse, and worse; meanwhile we’re forced to watch helpless as the ever-present agents of privatization encroach further upon the NHS each year, picking off more low-hanging fruit at every opportunity.
In the face of this, our nuclear options of indefinite strikes or mass resignation become so much more palatable; it feels like this is our only chance to prevent drastic, irreversible damage being perpetuated across the entire NHS. Cameron and Hunt have already started launching their missiles; unless their next move is a genuine call for a ceasefire, mutually assured destruction seems like the only adequate response. Our careers, for theirs.
Which brings me back to my dilemma. If contract imposition goes ahead, can I in clear conscience accept my next training post in August? I’m afraid my answer may have to be no; and I suspect I won’t be the only one.