I have great respect for junior doctors; it has always been a demanding role. Alongside my clinical practice, I spent over a decade teaching them before changing my initials from GP to MP. I should also declare a personal interest as my daughter is one of them, albeit currently working in Australia.
There is a long tradition of juniors spending a year or two abroad early in their careers before settling down to specialist training back in the UK, but now there is a genuine concern about the balance between leavers and returners. Many of my daughter's colleagues are not planning to join her on the journey home next year and there has been a marked increase in the numbers applying for certificates to work overseas.
The toxic dispute between the government and our core medical workforce risks driving an exodus of skills that we cannot afford to lose.
The contract sits like a festering boil with neither side ready to agree a way forward, and the dispute looks set to erupt into a dangerous full walkout by junior doctors. The British Medical Association (BMA) claims that the contract will harm patients by stretching doctors too thinly across seven days while reducing their take-home pay. The government insists that patients are being put at risk by understaffing at the weekends and that the contract reduces doctors' maximum hours and consecutive shifts while increasing basic pay by 13.5%.
The Department of Health and the BMA have spent so long shouting at cross purposes that they have forgotten their common purpose. In using them as pawns, both sides have lost sight of patients, the very people both claim to want to protect.
It was perfectly reasonable for the government to try to tackle the higher mortality at 30 days for those admitted to hospital at weekends, but entirely unreasonable to blunder on asserting that the new contract is the answer. Ministers are undermining their case and inflaming tensions by misquoting the evidence, which points more to the need to improve senior decision-making, nursing cover and rapid access to investigations at the weekends than to increase junior doctor cover. If the objective is to tackle excess weekend mortality at 30 days, the government should have followed the evidence and focused elsewhere.
It seems to me that the contract is more about the manifesto commitment to a seven-day NHS and the perceived barrier of premium Saturday pay rates. There needs to be a far clearer and more consistent definition of what the government means by a seven-day NHS and how it will be staffed and funded. Is it about convenient seven-day access to routine services and surgery, or about making sure that urgent and emergency care is available to the same standard every day of the week?
The Department of Health should have been more robust with No 10 that a routine seven-day NHS is unachievable within the current workforce and financial pressures and refused to accept underfunded new commitments.
Mine was the last generation of doctors to endure crushingly unsafe 120-hour working weeks and I have no romantic nostalgia for the 72-hour shifts commonplace in the late 1980s. Tired doctors can be dangerous doctors. What struck me, however, from the juniors I taught before coming to parliament, was that they felt every bit as exhausted and demoralised, not through lack of sleep but because while on duty they too often felt stretched to the limit. Medicine has also lost the supportive team structures and flexibility to work near partners and accommodation that once compensated for the stresses of the job. Today's juniors, feeling powerless and undervalued, are now prepared to walk out on their patients – but that will have lasting consequences.
A failure to recognise this until too late in the negotiations, alongside a disastrously timed and clumsy announcement, risks scuppering an important opportunity for change. The appointment of Professor Sue Bailey, chair of the Academy of Medical Royal Colleges, to examine how to improve juniors' working lives, should have been unequivocally welcomed by the BMA. Anyone who knows her will know that Prof Bailey is no mouthpiece for government and would be a powerful advocate for change.
Pressing ahead with a full walkout however, will serve only to harden attitudes and solves nothing. Most importantly, it will be disastrous for patients. The BMA has no doubt calculated that people will blame the government, but a strike that leaves patients without junior cover even for emergencies puts lives at risk. It cannot justify such drastic action by claiming to protect patients.
Given the agreement to pay the premium rate all day to any doctor working one Saturday or more every month, how can it be argued that patients will be safer only if all Saturdays are paid at the premium rate, however infrequently worked? Given the scale of concessions and protections on maximum hours and consecutive shifts, the BMA could have declared victory and moved on to focus on the deeper and longstanding causes of discontent.
Junior doctors are understandably concerned about being pressured into working unsafe hours despite the proposed safeguards, but this was all the more reason to work with Prof Bailey and new provisions in the contract to make sure that whistle-blowers are confident to come forward and fully protected when they do.
Both sides now need to put patients first and step back from this dispute. The government should do as it promised under the Health and Social Care Act and to stop trying to micromanage the NHS. If there was a clearer definition of their purpose behind a seven-day NHS, the service could better design the solutions and set out the costs.
It would also help for the government to make a clear statement of the obvious: that come August, junior doctors will see little change to their shift patterns. The simple reason is that there are not yet enough of them to achieve a truly seven-day service. That ambition requires a change in the workforce and a commitment to supporting and working alongside it rather than in an atmosphere of conflict.
NHS England, Health Education England and the BMA should work with Prof Bailey to undertake a fundamental review of junior doctors' training programmes, responsibilities and working lives, including facilitating them to coordinate placements with partners. Many more of their duties could be shared with others such as pharmacists, physician associates and admin staff. Patients are already benefiting from the greater use of the professional skills of specialist nurses and far more could be achieved.
In some hospitals, such as Salford Royal in Manchester, electronic patient records are finally reducing the scandalous waste of time and resources that come with duplication and paper trails. More could be done to make sure that best practice benefits patients everywhere.
A constructive relationship between doctors and government will take time to rebuild; it cannot be imposed and it will not happen unless both sides put patients first and start listening. Saving lives must take priority over saving face.