Was a deal over doctors' contracts ever possible?

Nick Triggle
Health correspondent
@nicktriggleon Twitter

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On Tuesday, the eve of this week's strike by junior doctors in England, the government's negotiating team made a last ditch attempt to break the deadlock with the British Medical Association.

Sir David Dalton, the highly respected boss of Salford Royal Hospital, who was brought in last month by ministers to try to arrange a deal, was accompanied by NHS Employers chief executive Danny Mortimer and Clare Panniker, the chief executive of Basildon and Thurrock NHS Trust.

They met the BMA leadership at their London headquarters. Afterwards they left and put together a final "take it or leave it" offer which they, and ministers, hoped would win the doctors round.

It didn't, of course. Almost exactly 24 hours later with the strike in full swing the BMA responded by letter, turning the offer down.

The following day, Thursday, the government took the step that the wider health service had been dreading: imposition.

The move looks as if it will spark a long and bitter dispute between ministers and the medical profession. More strikes could be called. Doctors are threatening to walk. But just how close did the sides get to an agreement?

Bone of contention

The BMA had been adamant all along that Saturdays should not be classed as a normal working day. The union wanted any doctor working on a Saturday to get 50% extra above basic pay.

But ministers - who are keen to rota more doctors on at weekends - were clear that wasn't affordable.

In November they proposed that extra pay should only be available from 10pm. That was then brought forward to 7pm before 5pm was proposed. There was no further change on that this week.

A Saturday concession

But recognising that this was a totemic issue, the negotiators did convince ministers to agree to a more generous deal for doctors who work regular Saturdays.

Instead of those who work at least one in three getting extra - which was the offer on the table ahead of this week - the negotiators offered to pay 30% more to those who worked at least one in four. This was to be paid for all the Saturdays worked.

That would have meant over half the workforce would have ended up on higher pay - albeit at a rate that was less than the 50% extra the BMA was after.

And there's more…

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The contract is fiendishly complicated. It applies to 55,000 junior doctors working across a range of specialities at a variety of different grades.

There were lots of other areas where agreement had not quite been reached, such as payments for interrupted breaks, on-call allowances, safeguards on excessive hours and what exactly constitutes a night shift - to name just four.

But it's easy to look at these details and conclude the two sides were pretty close.

They weren't - and to work out why you need to look at the wider picture.

The Hunt problem

To say junior doctors are suspicious of Health Secretary Jeremy Hunt is to state the obvious. This week the BMA was using terms like "attacked" and "patronised". Perhaps with some justification.

There are plenty of people within the health service not associated with the BMA who privately acknowledge the health secretary could have gone about this much better.

There is also a belief among doctors that this contract is part of a wider desire to erode the terms and conditions of the entire NHS workforce to make it cheaper to increase staffing at weekends. To squeeze more and more from a workforce that believes it gives plenty.

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And while the government has made much of its claims that some doctors will be better off, a significant number - perhaps as many as one in four - would lose out if it wasn't for the government pledge to top up their pay for three years.

In short, the profession believes if staffing is to be increased at weekends it needs to be accompanied by an increase in investment.

But ministers are trying to do this for the same money. The sums simply don't add up, doctors say.

Unable to compromise?

Equally the government's side is exasperated with the BMA. Both the health secretary and Sir David Dalton have publicly claimed the union was unwilling to compromise.

One theory is it couldn't. That is to say, the membership were so adamant that they should not give an inch that the BMA leadership felt unable to do a deal.

While on paper the two sides may not seem a million miles apart, perhaps an agreement has been out of reach for some time.