Monday, 14 March 2016


The junior doctors’ contract dispute may seem on the surface to be a straightforward workplace dispute about terms and conditions (1). I argue here that it is much more than that, that it is a key battlefront in the efforts to save our NHS. If the battle to destroy/save the NHS can be likened to a chess match, then the junior doctors’ contract dispute marks the beginning of the 'end game'. Its outcome will determine the survival of our NHS. 

KPMG’s head of global health predicted in 2010 that ‘in the future, the NHS will be a state insurance provider and not a state deliverer of healthcare’ and that the 'NHS would be shown no mercy' (2). If we are not careful, the battle to save the NHS as the dominant provider of universal healthcare is about to be lost. The three stages of this battle are/were as follows:
The Opening Game:

The creation of an internal market within the NHS (2002) was an apparently benign opening gambit, followed by a much needed but poorly thought out hospital building programme. The public finance initiative (PFI) was worth £12 billion but turned out to be a hopelessly expensive mortgage that would eventually cost the NHS £80 billion in repayments (3).

Once elected in 2010, the present government began an expensive top down NHS reorganisation, dismantling PCTs (Primary Care Trusts) while appearing to hand over power to GPs in the form of CCGs (Clinical Commissioning Groups). This poisoned chalice would come into play during the end game.

In 2012, the Health and Social Care (HSC) Act removed the Secretary of State’s legal obligation to provide healthcare for everyone and meant that the NHS became subject to EU Competition law. This compelled CCGs to invite bids for ALL health services from ALL willing providers, leading to a free market based system where expensive tendering processes would consume much of the CCG budgets and time. The architect of this act, Andrew Lansley, now works for Bain and Company to ‘improve its odds of gaining access to £5.8 billion of NHS work that is commissioned to the private sector’ (4).

To add insult to injury, NHS funding almost froze after 2010 (rising by only 0.7% per year compared to the long term average of 3.7% per year). ‘Efficiency targets’, a pseudonym for funding cuts, brought NHS hospitals to their knees. Significant cuts in social care and district nursing budgets as well as the privatisation of NHS 111 led to increasing hospital activity and a critical shortage of hospital beds. As a percentage of GDP, UK healthcare spending (8.5% of GDP) fell even further below the average for OECD countries (below Slovenia and Finland) (5).

The Middle Game:

As predicted by many (see my ‘election plea’), the flavour of the contest changed after the 2015 election and the government chose to directly attack frontline staff. On 16 July 2015, the Health Secretary Jeremy Hunt declared that ‘6000 people lose their lives each year because we do not have a proper 7 day service in NHS hospitals’ and that ‘by the end of this parliament, the majority of hospital doctors will be on 7 day contracts’ (6). The implication was that hospital consultants were opting out of weekend work (later proven to be a wildly exaggerated claim), being overpaid if they did work weekends, and directly responsible for excess patient deaths. He also accused doctors of lacking a sense of vocation and professionalism. For reasons that are not clear, his attack then shifted onto junior doctors (consultants should not assume that we are off the hook). In a ‘shock and awe’ approach, the government has also removed training bursaries for student nurses.

Weekend mortality data was distorted (7) to justify what the government described as a ‘7 day NHS’. No mention was made of world class 24/7 emergency services that the NHS already provides and it is still not clear what the government means/meant by a ‘7 day NHS’. Provision of elective (non-emergency) services over 7 days instead of 5 would require a 40% increase in resources (at an extra cost of £900 million), yet the government insists on a ‘cost neutral’ approach that would stretch existing 5 day resources over 7 days.

At the same time, significant amounts of money were being spent on a number of chaotic, poorly thought out vanity projects including the creation of a ‘paperless NHS’.

By this stage of the contest, the ‘save the NHS’ camp was/is on the backfoot (Did I mention that the line between middle and end game is blurred?).
The End Game:

This stage of the contest probably began a while ago but media attention has been poor if not misleading, and most of us have been kept in the dark.

With CCGs struggling to cope, CCG support services run by companies like KPMG, McKinsey and US health insurer United Health will now carry out many of the ‘back office’ jobs (eg. the design of future services), previously done by the NHS for the NHS (8).

Following the HSC Act 2012, 40% of CCG contracts (worth £3.54 billion) have been awarded to private healthcare companies (compared to 41% awarded to the NHS) (9). This figure is set to increase to £20 billion over the next few years. Note at this point that private healthcare must cherry pick profit making services (for example, elective hip replacements rather than emergency trauma surgery; they have a legal obligation to their shareholders to do so) while the NHS is left to provide less profitable services.

When TTIP (an EU US trade deal) goes ahead at the end of the year, many of the above changes may become irreversible (according to Michael Bowsher QC, a former chair of the Bar Council’s EU law committee) (10). US healthcare companies have already begun to invest heavily in UK facilities (11).

To make things worse, the PFI burden is only just about to kick in for many NHS trusts. Annual PFI repayments will peak at £2.7bn in 2029/30.  

According to Professor Keith McNeil, former CEO of Addenbrooke’s Hospital, the ‘only thing holding NHS together now is the dedication, passion, commitment of frontline workers’. This is precisely why the junior doctors’ contract is such an important battlefront and why we should resist attempts to break the backbone of acute and elective NHS care. If the government imposes the current contract, recruitment and retention of high quality junior doctors to provide 24/7 care will become even more of a challenge. It doesn't take a rocket scientist to work out that patient safety will be compromised by this contract.

In many ways, shifting the attack from consultants to junior doctors after July 2015 was an error of judgement by government in this fight, a single mistake in what has otherwise been a powerful ‘shock and awe’ onslaught. The government underestimated the courage and political will of 54,000 junior doctors, and the conflict has highlighted the looming threat to the entire NHS.   

Anyone who says that the junior doctors’ contract dispute has nothing to do with saving the NHS is at best missing the whole picture, at worst cheering for the wrong team. In the ongoing battle to save the NHS, we should all be supporting junior doctors and at the very least hope for a draw. A check mate would be a huge but unlikely bonus.
Vinod Achan is a Consultant Cardiologist at a well known NHS Foundation Trust