The secretary of state for health has caused quite a stir. The reason for this commotion was Jeremy Hunt’s plan to change doctors’ contracts regarding seven-day working.
By the end of this parliament, Hunt wants NHS contracts that allow consultants to opt out of weekend working to be changed and for the majority of hospital doctors to be on seven-day working week contracts. The issue has been particularly prominent because of reports about higher death rates for those admitted into hospital at weekends.
Hospital doctors have been protesting on social media – numerous staff posting images using #ImInWorkJeremy, a hashtag created by one particularly disgruntled doctor. The number of doctors speaking out has been described as “unprecedented”.
So why has this caused such a reaction? What is his motivation and is there an ulterior motive?
In one sense, the notion of seven-day working is appealing. Who could be against offering NHS services of equivalent quality throughout the week? Proponents make comparisons with retailing (as if there were a direct counterpart in the NHS). In another sense, and perhaps more significantly, Hunt’s speech offers an insight into a realignment between the government and the medical profession.
A rocky relationship
The health policy academic, Rudolf Klein, famously referred to the relationship between the government and the medical profession as “politics of the double bed” – the government secured an electorally popular and vital public service in return for the medical profession securing largely favourable terms and conditions (including pay). So, what do Hunt’s comments say about the state of this “double bed”?
The last major change to the hospital doctors’ contracts was in 2004. Although pay increases took most of the headlines at the time, the opt-out has become more highly significant in the current negotiation. Unlike junior doctors, consultants could choose whether or not to provide non-emergency care at weekends. Last week’s report on contract reform by the Review Body on Doctors’ and Dentists’ Remuneration states this opt-out is no longer appropriate.
A 2003 contract entailed significant “basic” pay increases (of 24% for lower grades, rising to 28% for higher grades). The consultants’ wage bill has topped £5.6 billion and the median annual total earnings of a consultant (from the NHS) were £109,000 in 2011-2012. These pay rises were not, however, matched by rises in NHS productivity. Current negotiations of this contract stalled in late 2014, an impasse which the new government hopes to break. With 66% of hospital trusts forecasting a deficit by the end of 2015-16 and public sector pay to be capped at 1%, austerity lies behind much of Hunt’s approach to next few years.
Jeremy Hunt has form here. Not long after he assumed office, Hunt referred, in 2013, to the “coasting” NHS; this did not endear him to staff. He was later more conciliatory. However, coming shortly after the election, last week’s comments point to a longer struggle with the medical profession for the duration of this parliament. But why would Hunt want to take on the medical profession this way? The next point suggests an answer.
Hunt’s speech was on the same day that the review body report on contract reform was published. Certainly, the report highlights the need to “improve patient outcomes across the week” but it also identified anomalies of other aspects of consultant pay such as Clinical Excellence Awards. In a written statement, also published last Thursday, Hunt reinforced this and promised: “We will also introduce a new performance pay scheme, replacing the outdated local clinical excellence awards”.
Currently, more than 60% of the 40,000 NHS consultants receive a (national or local) award, costing more than £500m a year. Yet, many organisations (including parts of the NHS) now refer to the “total reward” for staff groups. There is, however, no agreement as to what constitutes such a reward, with employers responding to local contextual factors. Such fragmentation of human resources policy accords with a decentralised NHS but it also undermines its collective approach to staff.
A sense of vocation
While it is easy to point to high (financial) rewards for consultants, two critical considerations also need to be borne in mind. Consultants (like most other NHS staff) have high levels of “donated labour”. In 2014, 84% of consultants worked unpaid beyond their contracted hours, with a third working more than six unpaid hours per week. Gains in contract reform may be achieved at the expense of eroding doctors’ sense of vocation (and donated labour) in the long-term.
However, we should also be mindful of the comparative position of the NHS. Many (if not all) of the challenges the NHS faces are facing other health systems. Although the NHS fares well in such comparisons, in this case, there appear to be few systems to compare it with, as the review body reported last week:
We also investigated the position in healthcare systems elsewhere in the world and it is our understanding that outside of accident and emergency services most international public healthcare systems are not providing a comprehensive 24-hour, seven-day service. We therefore conclude that the proposed new NHS arrangements would be trailblazing within healthcare systems.
Hunt (or his successor) may be able to reform the consultants’ contract but it is evident that such implementation will be far from straightforward and may well have unanticipated consequences.