The last year has seen the vocation of junior doctors questioned by the Secretary of State for Health, the emergence of ‘grass-roots’ junior doctor activists with social media as their weapon of choice, industrial action with an unprecedented mandate, bitter political and academic disputes over the weekend effect and the ‘truly 7-day NHS’, a contract referendum and a judicial review.
Where has this left us? If you’re of the glass half-empty persuasion then you may say nowhere; we are staring down the barrel at imposition even with a recent judicial review highlighting the fact Jeremy Hunt was, apparently, never imposing anything, the profession is divided and our trade union is acting more like a think tank, organising a symposium to discuss patient care. If you prefer your glass half-full, you may see that the contract now is markedly different to that which was presented in November 2015, junior doctors are no longer apathetic and apolitical to the context in which they work and new leaders have emerged, shouldering responsibilities that belie their clinical experience.
Though I feel imposition is bullying in all but name, I do feel the new contract’s terms and conditions are a relative improvement on what we have now. Whether or not it works in practice is a different matter; it’s a policy experiment after all, but one which I’ve made no secret of advocating trying. There are however two areas that will directly impact my specialty (psychiatry) that I wish to focus on here – non-resident on call (NROC) remuneration and Mental Health Act assessment fees.
NROC in psychiatry is mainly carried out by doctors at ST4 level and above. NROC by its very nature is unpredictable and invariably busy. Currently we are paid an annual base salary with a banding salary multiplier dependent on the level and intensity of ‘antisocial’ hours worked (e.g. 20%, 40% etc.). But actually, even if you picked a senior registrar on current T&Cs at the top of the pay scale on a 40% rota (the example I’ve used is that of a colleague’s on a 1 in 6 with the out of hours commitments being solely NROC), calculating the hourly rate for an NROC 24 hour shift is upsetting to say the least; circa £10/hour*.
A substantial part of the work during an NROC shift comprises of Mental Health Act (MHA) assessments at the request of Approved Mental Health Practitioners (AMHPs). Typically between one and three hours of work, these assessments are fee paying, attracting circa £180 each. It is also important to note that MHA assessments are integral to training for higher trainees.
*This is calculated by taking the 40% banding total annually and dividing by the number of hours that are not classified as ‘normal working day’. I must stress that currently banding for NROC shifts serves to ‘compensate’ doctors for their time – it is not a true hourly rate, but rather akin to the availability supplement described in the new contract.
As with several other specialties, psychiatry suffers from its own recruitment and retention issues. Together with emergency medicine and GP training, psychiatry trainees will receive a flexible pay premia to aide recruitment and retention within the specialty. Whilst base salaries are higher earlier on the new contract, the on call supplement has decreased to an 8% salary multiplier and banding in its current form will no longer exist (20%, 40%, 50% etc.). In a simplistic way, and with the absence of fully formed rotas to make accurate direct comparisons, one can assume from this that the calculated hourly rate on an NROC shift will be less on the new contract than it is on current T&Cs. I must stress though that this is a simplistic view. As new T&Cs prospectively pay for hours worked (the true prevailing hourly rate – not the calculated figures I’ve mentioned thus far), and exception reporting will compensate where this is insufficient, doctors in theory will be paid for all work done.
The difficulty arises where pay for all work done on the new contract does not correspond to current levels of pay. The effect on individuals will be very different (e.g. a neurosurgical registrar perhaps will paid more than the psychiatry registrar, who will be paid more than the haematology registrar). An analogy I would use for current T&Cs is sending a letter to the next town and the other side of the country – both cost the same. To make this possible, someone is gaining and someone simultaneously losing. New T&Cs would pay for each mile travelled, unravelling an uncomfortable truth that some do more ‘work’ (measured in time) than others.
In addition, the new contract, in Schedule 7, states that a ‘doctor must not be paid twice for the same period of time’, and later explains how fees gained during salaried time should be either
- remitted to the employer; or
- should incur a salary reduction equal to the time taken for the fee paying work to be carried out at the prevailing hourly rate; or
- should owe clinical time to the employer equal to the time taken for the fee paying work to be carried out
MHA assessment fees would come under this definition of fee-paying work.
I sense that this whole contract schedule really existed to eliminate misuse of the system by those that routinely carried out fee-paying/private work during NHS time. This is very rare in my experience. However it has the potential to adversely affect higher training in psychiatry. This is because one interpretation will combine possible lower hourly rates of NROC pay and the need to remit MHA assessment fees back to the employer. For those with caring responsibilities, NROC is already a logistical struggle (e.g. arranging childcare for a weekend on call). Add in the interpretation above and the financial ramifications become significant. The worst case scenario is that higher training recruitment and retention worsens as it becomes financially unworkable for some. What follows from this are AMHPs struggling to obtain doctors, meaning vulnerable patients waiting longer for their MHA assessment.
The key here is that this is only one interpretation. One could argue that NROC shifts are not salaried time; that you are being paid prospectively for a calculated set number of hours and an availability supplement. Granted the set number of hours calculated will have to not include MHA assessments, but the combination of an availability allowance and MHA assessment fees does not technically constitute being paid twice for the same time. A doctor could then retain the fee, going some way to making NROC financially viable, as well as retain training opportunities and, perhaps, mitigate the risk of worsening recruitment and retention.
It sounds good on paper, but will an employer go for it? Absolutely – my employer has already agreed to the above. What I found in my previous role at NHS Improvement is that the vast majority of employers are not out to exploit the junior doctor workforce. They want to be desirable places to work, attracting junior doctors now as they will inevitably be hiring them as consultants in the future.
I go back to my earlier point that this new contract is a relative improvement on our current T&Cs. But this will only be a reality if the contract is implemented in the spirit to which it was intended. At present, the avenue to do this is via the employer’s Local Negotiating Committee (LNC). Joining one is easy if you are a member of the BMA, and its considerable decision making power has the potential to start on the long road to improving the working lives of junior doctors.
But is this form of engagement with implementation implicitly resigning ourselves to imposition? I do not know the answer to that. I worry that many of my colleagues feel powerless in this bitter dispute, waiting with baited breath whilst the central figures tussle with each other across the media. For me, holding employers to account on our terms and conditions of service is something we, as junior doctors, should have been doing for years. Doing it now gives me some solace and it does make me wonder whether if had been more engaged and politically astute over the years, would we be in the position we find ourselves now?