Summary detail on safety, training and pay
Published 8 January 2016
Applies to England
© Crown copyright 2016
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3 senior NHS leaders:
- Dr Mike Durkin, National Director for Patient Safety NHS England
- Professor Ian Cumming, Chief Executive Health Education England
- Danny Mortimer, Chief Executive NHS Employers
wrote to junior doctors at the request of Sir David Dalton, Chief Executive of Salford Royal NHS Foundation Trust, who is now leading negotiations for NHS Employers and the Department of Health.
They provided more details on the proposed new contract for junior doctors in the key areas of safety, training and pay for which they have respective responsibilities in the NHS.
Below are summaries of the main points included in the full letter.
1. Safety
On safety, the existing contract provides inadequate safeguards for doctors, too many of whom still work unsafe hours. It allows work of up to 91 hours in any one week and to exceed other working time limits. There are insufficient safeguards against consecutive long shifts. And it can be very difficult to speak up when junior doctors believe that safety is being compromised as a result.
The new contract proposals will improve patient safety - with safeguards introduced in relation to hours worked, breaks between shifts, and accountability and oversight.
The contract proposals to improve patient safety include:
- introduction of new strict safeguards on hours worked with an upper limit of: 72 hours in a 7-day period (compared to 91 now), 4 consecutive night shifts (compared to 7 now), and 5 consecutive day shifts (compared to 12). The aim is also to provide greater flexibility on rotas, enabling doctors to better arrange working hours around their needs
- introduction of break shifts of 48 hours off after 3 or 4 consecutive night shifts or 5 long days, and a maximum of 8 consecutive days worked (also to be followed by a minimum 48-hour break)
- setting out work schedule contracted hours for junior doctors and employers will also identify the learning opportunities that will be provided to meet doctors’ learning needs
- creation of a new senior leadership role in every hospital, a “Guardian of Safe Working” whose appointment would be agreed with the BMA. Junior doctors would be able to report exceptions and concerns to this guardian without fear and request a review if they are not treated as promised
- scrutiny by The Care Quality Commission of junior doctors’ working time as part of their inspection process
In addition, the proposals make clear that financial penalties for employers would be put in place where there are consistent breaches of working time regulations. This money would be held by the Guardian at each Trust and would be spent on improving the working conditions or education of doctors in training in their institution.
2. Training
Under the current contract training opportunities are too often missed because of service pressures. Insufficient notice of the next training placement results in a requirement for fixed leave and this can make it difficult for doctors to plan their lives. The lack of consultant presence at the weekends may also contribute to a poorer training experience.
The proposals around work scheduling reflect the important of protecting training time within a post which is also delivering patient care.
For the first time, there will be an ‘exception reporting’ system which will identify when there are issues relating to training - including when training opportunities are missed. It will be the Trust Director of Medical Education’s responsibility to address concerns raised through exception reporting.
To improve junior doctors’ access to training opportunities further work with Health Education England has been agreed to:
- define training opportunities, including study leave, as an explicit part of work scheduling
- develop new arrangements to tackle issues for trainees rotating to different Trusts, for example by defining a lead employer
- identify and remove educational barriers to access to flexible training, liaising with others including the General Medical Council
- tackle rising training costs, for example through bulk purchasing of key courses and addressing variation in how these costs are met
- seek to address the costs both to employers and doctors – including a specific commitment by employers to explore the development of ‘salary sacrifice’ arrangements to offset some of the costs of their training against tax
A commitment has also been made to give better notice of deployment to posts, against which HEE will monitor performance and publish monitoring data.
To support this, it was agreed that there should be an aim of achieving notice to employers of 12 weeks for at least 90% of trainees by August 2016, with the expectation that this be achieved for everyone by October 2016. This should enable fixed leave to be removed by enabling NHS employers to commit to providing roster information to trainees 8 weeks in advance of starting a post.
Subject to service and training needs, HEE will introduce new measures ensuring that recruitment, selection and deployment processes for doctors in training supports those with partners or spouses who are also doctors in training.
3. Pay
The current contract does not meet the fundamental fairness test of paying doctors equal pay for work of equal value. This was recognised by the BMA as well as employers.
Annual incremental pay progression linked to time served means that pay is not directly linked to increases in responsibility.
Most junior doctors are paid banding supplements (which are not pensionable) of 40% or 50% of basic pay for overtime worked, on-call availability and recognition of unsocial hours. However doctors may work anything between 41 and 48 hours for that payment with significantly different amounts of unsocial hours working. Rotas with no night shifts get paid the same as rotas with night shifts. A rota with no Sunday working gets paid the same as a rota with Sunday working.
The November contract offer proposed a fairer pay system with a pay rise for 75% of junior doctors; and guarantees of income protection for a 3-year period for all junior doctors working within the current contract, after which nearly all will have moved to a higher pay grade. The proposals to protect pay have not been challenged by the BMA.
The overall cost of the new contract arrangements is higher than for the current contract. The addition to basic pay is pensionable (unlike current banded payments) so employers will pay more into doctors’ pensions.
The key elements of the package are:
- 11% higher base pay for the 40 hour working week
- additional pension contributions by employers and additional pension for doctors as a result of the increase in basic pay
- pay progression with 6 pay points linked to increase in responsibility rising from £25,500 to a maximum of £55,000
- payment for additional hours worked up to the maximum weekly average of 48 or 56 if doctors opt out of the Working Time Directive
- availability payments for on-call where doctors are required to be available at home
- higher pay rates for unsocial hours worked at nights, on Sundays and on Saturday evenings
- pay premia for trainees in hard to recruit specialties; initially general practice, emergency medicine and psychiatry
- transitional protection for foundation trainees and those in specialty and core trainee (ST/CT) years 1-2 to August 2019 which means that 99% of doctors will receive no less pay than as at October 2015 (with the exception of around 500 doctors on band 3 pay for whom the appropriate action is to reduce hours worked to safe levels)
- for higher trainees from ST3 onwards maintains present pay and banding (with the exception of Band 3 pay) until August 2019.
Junior doctors can see what the arrangements will mean for them by using NHS Employers’ pay calculator.
As part of the agreement reached with ACAS, all workings have been shared with the BMA so it is clear how the contract offer has been costed and that average pay for junior doctors will not reduce.
3.1 Definition of plain time and unsocial hours
The proposals in the new contract will protect pay and protect doctors from working unsafe hours as has been set out above.
The government has consistently set out the fundamentally important role that junior doctors play in providing clinical cover at weekends. But it has also been clear that the objective is to achieve the same consistency of standards throughout the week, and that this will involve all parts of the workforce being rostered to provide care through weekends as well as during the week.
The November contract offer designated plain time for pay purposes as 7am to 10pm Monday to Friday, and 7am to 7pm Saturday. The offer made clear all other time was to be paid at an enhanced rate. This would be time plus 50% for nights and time plus 33% for Saturday evenings and Sundays.
The DDRB (the Review Body on Doctors’ and Dentists’ Remuneration) report set out clearly that current plain time definitions are out of line with the wider economy and that comparator groups to doctors generally do not receive unsocial hours enhancements. In ACAS, however, NHS Employers confirmed as part of an overall agreement their preparedness to discuss their proposals. They also offered to discuss protections relating to the frequency of weekend working. Employers also take the view that night working is onerous and should receive a higher premium.
3.2 7 day services
The ambition to deliver more consistent standards of urgent and emergency care across 7 days will require change across every area of healthcare delivery, not just doctors’ contracts.
The 7-day services programme which started in 2009 is designed to improve the whole range of weekend services, from making diagnostic tests like MRI scans available, to providing better support services like pharmacy and physiotherapy so that patients can get the treatments they need in good time. There are also plans to integrate health and social care to make it easier for doctors to discharge patients at the weekend and improve flow across the hospital.
Employers are clear that they need to be able to roster staff when they are needed. However doctors in training can be assured that they will not be expected to work longer than an average 48 hours and average pay will not reduce.