Recent coverage of the NHS has focused largely on the battle between the Government and the junior doctors over their new contract – a struggle that inflamed opinion on both sides of the argument.
But if we’re going to fix the NHS, we need to focus on a different issue. Not the terms of the junior doctors’ contract, but whether there should be a contract at all.
Healthcare in England is provided locally, with each NHS trust or GP surgery providing its own diverse form of provision.
Yet junior doctors’ contracts are not with these bodies, but with a good old-fashioned monopoly provider: Health Education England. It administers the training programmes on which most young medics enrol, rotating them from job to job within the various trusts.
This is the process by which we doctors normally go from “postgraduate fresh out of medical school” to being an experienced GP or consultant with our own specialised field. The training programmes are divided up into broad geographical regions such as “Kent, Surrey and Sussex”: some regions or specialities are more popular than others, with places being allocated via a competitive application process.
What this all means is that the power is all with Heath Education England – or rather, with the training programme directors, usually a senior doctor working in one of the local NHS trusts. Junior doctors have no control over the jobs they get. Although you can try to negotiate, if you refuse your allocated post, you have to leave the training programme.
Often, the first time junior doctors have direct contact with their employer, the NHS trust, is on their first day of employment (usually “black Wednesday”, the first Wednesday in August when most junior doctors rotate).
During my career, I have been employed by four NHS trusts – but I have never applied to one for a clinical job, or been interviewed by its staff. I have never been able to predict with any confidence which NHS trust I will be working for in a few years’ time, and whether I’ll have to move; what my hours might look like, in terms of how many nights and weekends I’ll have to work; even what my take-home pay will be. I only discover these apparently trivial details when I find out which job I have been allocated, every six to 12 months.
You can see why, from the doctor’s perspective, this isn’t ideal. It’s hard to make financial plans, to arrange a mortgage or a family life, when your pay could vary by up to 30 per cent and you could be working pretty much anywhere. If you’ve already got children, you may need to put complex childcare arrangements in place – especially if you’re part of a two-medic family, as many of us in the health service are. And this all continues for at least six years if you’re training to be a GP – considerably longer for other specialities.
From my experience, it’s the uncertainty of the process, the psychological toll, that’s most draining. Applying for these training programmes involves a game of sifting rumours and local intelligence from colleagues, since nothing official is released about the working conditions and pay. The most basic job characteristics that anyone working in any other sector would expect to know up front are not even officially advertised to potential employees.
The result is that junior doctors are left with the impression that they are not valued as employees – that they should be thankful for what they are given. No wonder they are then easily persuaded by the glossy ads in the British Medical Journal promising a better life in New Zealand or Australia, or are seduced by militant trade unions.
In fact, the much maligned national contract for junior doctors is a consequence of this system. Junior doctors are put in a position where, because of the monopoly status of training programmes within the NHS, a national contract is essential. It ensures that wherever they are sent to work they will not be made to work excessive hours, and whatever hours they do work will be appropriately remunerated.
Both sides argue the dispute is about patient safety. The contract regulates the shift patterns that doctors can work (albeit mainly through the amount they are remunerated for them, a powerful tool in the current financial environment), setting a permitted level of “tiredness” within the system.
But with this comes a cost: the national contract is a leash for both doctors and employers. It might protect junior doctors from their employer, but it sets a dynamic in which the only relationship between employer and employee is one of prescribed obligation. It stops employers being able to incentivise their workers by offering them better hours or more money. Trusts know that they’ll always be sent more junior doctors providing that Health Education England, the GMC, and various other bodies are kept happy that the trust is providing an appropriate training experience.
The result is that there is no natural mechanism through which variations in nature of work and geographical location are accounted for. So rather than opening up a conversation between employer and employee, junior doctors vote with their feet and don’t apply to training programmes. The NHS trusts are then forced to make up the deficit with either non-training doctors – also on their own national contracts – or more expensive locums. Or they just leave gaps in the rota.
National contracts, in other words, cripple trusts’ ability to recruit staff and compete with locum agencies. This doesn’t just apply to doctors, but to nurses and allied health professionals too.
Why do we allow NHS trusts so much independence in how they run their services, only to apply a yoke in the form of national contracts?
If we dismantled the current system of training programmes, and allowed junior doctors to apply for individual or sets of jobs on a competitive basis, each NHS trust would be able to set its own contracts. Junior doctors would be free to apply to exactly where they wanted to work, doing jobs they wanted to do. NHS Trusts in areas already struggling to recruit would be free to properly incentivise junior doctors to come to work for them.
The result would be an easing of the worsening recruitment crisis, which stems from the way a lack of choice over one’s working conditions hits morale and turns good people away from the career.
Training programmes were originally set up to stop doctors getting “lost” within the system and not progressing in training. So naturally, any change like this would need safeguards to ensure that junior doctors develop the correct range of skills and experience on the way.
But why not let junior doctors make these serious decisions impacting on their lives within the NHS? Or are they only allowed to make these decisions for their patients?
Monopolies work brilliantly for those in control of them – provided they do in fact have an absolute and total monopoly. But that’s not the case here. If they want to meet the minimum required standards of care, NHS trusts have to fill vacant posts – meaning that locum agencies can take advantage of a market with an artificially inelastic labour supply and demand. Even OPEC would be impressed.
As for junior doctors, there’s no law that they have to train in England – or indeed continue working in medicine. Sure enough, many of them leave. This creates a vicious cycle: people go abroad or work as locums, because the working conditions and remuneration are better. That leads to spaces on the training programmes where they would have been, which leads to gaps in rotations, which leads to worse working conditions.
As always, the natural response of the monopoly is to try to strengthen its monopoly. So rather than allowing in market forces, the NHS imposes payment caps for locum agencies – an attempt, in effect, to bring them into the national contract. What happens then? People don’t bother working the locum shifts, leading to gaps in the rotations, setting the whole cycle going again. The only way to break that cycle is to break the NHS’s monopoly.