Britain - NHS: striking doctors and "denationalisation"

Spring 2016

For the first time in 40 years, junior doctors in England have been taking concerted strike action, forming determined picket lines outside their hospitals.

The issue which drove them to this unprecedented action was a new employment contract, presented by Health Secretary, Jeremy Hunt as providing the basis for "a comprehensive 7-days a week NHS".

But for these doctors, who already work evenings, nights and weekends, this new contract, meant a pay cut. It reduces payments for those many unsocial hours which they have no choice but to work. What is more, these hours would be extended even further, and the existing medical workforce would be expected to cover them.

On their picket lines, doctors brandished hand-written placards saying "you cannot stretch us any thinner: 7-days NHS needs 7-days funding!"

Doctors are indeed being "stretched thinner". The new contract is not the only reason that they have suddenly become "militant". Working conditions in the NHS are pushing them - but also all other clinical staff - to the point of despair. When this contract was revealed, this despair quickly turned to anger.

There is a dire shortage of trained medical staff in the NHS as a whole. One doctor is doing the work of two or three. Many routinely suffer from exhaustion and are unable to carry out their duties safely, if at all. Doctors collapse on duty because they had not even had enough time to drink some water, let alone take a dinner break.

The various counselling services set up for the profession have been inundated with doctors who have symptoms of severe depression and anxiety. There have been a number of suicides. Blogs tell of decisions to leave the profession because individuals have been driven beyond endurance by overwork and long hours.

So this is the context of this junior doctors' strike in England: an NHS in crisis. And the reason that doctors are not taking action in Scotland, Wales and Northern Ireland, is simply because the devolved assemblies have decision-making power over their respective National Health Services - and for the time being, they have not agreed to implement a new contract.

Of course, the NHS in England has a larger population to serve and if there is a financial crisis in the whole of the NHS, which there is, NHS England has the largest black hole. Since the main driver of this new doctors' contract is cost-saving, it has chosen it as yet one more way to help alleviate its deficit.

Incredibly, there has never been any hint from the British Medical Association (BMA), which represents the doctors in this dispute, nor any other union, for that matter, that the doctors' fight needs and indeed deserves the active support of all sections of workers, both in the NHS and outside it. If they said anything it was to state the obvious: that the doctors' fight was not merely about their contract, but also about the undermining, under-staffing and under-funding of the NHS - something which affects all of its staff and the population at large. But the equally obvious conclusion, that doctors should not have been left fighting this lonely crusade, and that a collective fight back should have been organised, was never expressed.

In fact other NHS staff are actually fighting concurrent struggles. A case in point is the student nurses, whose training bursaries are being abolished, at the same time as the critical nursing shortage throughout the country is closing hospital wards!

But the big picture has not been lost on the doctors themselves - at least not all of them. From the start of their action their own hand-written placards appeared alongside those provided by the BMA, which spoke of the dire conditions under which they work and the need to fight the running down of the NHS, privatisation, and the unsafe practices which have become the order of the day.

At this stage it is probably expecting too much to ask them to identify with the "working class", even though they formally belong to it! But maybe later. Their vilification by the media because of the all-out strike (as they call it!) announced for 26-28th April - without emergency cover - may well make them feel some sympathy with tube workers and other workers who are slandered by the media every time they strike to defend their conditions. Especially since this strike is actually a 9-hour strike on each day from 8am to 5pm and not the "48-hour" strike without cover (consultants are covering) which "will put patients at risk"!

It's really 8-days a week

So first, what about the contract itself? The Doctors' and Dentists' Remuneration Body (DDRB), which was asked to come up with proposals for a new doctors' contract in 2012, was told it had to be "pay neutral" - that is, no additional funding would be made available by the government and it had to be self-financing.

In fact, the remit of the DDRB was somewhat suspect to begin with. It was to design a contract which would incorporate weekend working, ostensibly so that the Health Secretary Jeremy Hunt could launch his "7-day NHS".

This was backed up by research data from a number of "respectable" sources, (a study published by the Journal of the Royal Society of Medicine in 2012, data from the National Confidential Enquiry into Patient Outcome and Death, from the National Audit Office, and many others). All to prove that there were higher death rates among patients admitted to hospital at weekends. What was not entirely clear in these studies, however, was precisely why this was the case. Some of them cited low staffing levels, others, poorer management. But one of the authors of a research paper published by the British Journal of Anaesthesia countered that the data in their particular study had been misused. It had merely shown that fewer patients died after emergency surgery in hospitals that had more doctors and nurses, but this was the case at any time during the week.

Nevertheless, Hunt proceeded to made the case, both using and misusing research data, that a fully comprehensive, 7 days-a-week NHS would prevent an excess of 6,000 to 11,000 deaths - both figures were quoted at different times by him. And this meant that weekends should not just have "emergency" cover, but a full complement of doctors and other clinical staff. Of course, it is a "no-brainer", as they say, that with more skilled and experienced staff around, the outcomes for patients should be better. But the NHS has not employed a "full" complement of staff for some time, due to chronic underfunding. There is not merely a shortage due to unfilled vacancies, but also because there has been woefully inadequate "job creation" at all levels, but particularly at senior medical level.

Never mind. The DDRB was supposed to perform a miracle with the new contract - so that it would allow the same number of doctors (already stretched too thin), to now stretch even further and cover weekends as well. Since every NHS department would be extending its opening hours to weekends, staff would now be working many more unsocial hours. It followed that these unsocial hours would have to be redefined in the new doctors' contracts.

Consultants (specialists), who will also have new contracts, usually work unsocial hours only when called in by their juniors. Up to now, they have been allowed to opt out of out-of-hours work if they so wished, although only a minority actually exercise this right. Last year a proposal was made to scrap consultants' "opt-out" in their new contract. Not much more was heard of this, probably because in practice, forcing consultants to work weekends which command premium pay, would be expensive. So even if their opt-out is scrapped, they are unlikely to be called upon. This means that junior doctors will bear the brunt of contractual "reform", which, one way or another, given the "pay neutral" remit, involves a pay cut.

As for the 7-day NHS, presented by Hunt as a life saver and a "revolutionary improvement for a modern health service", it turns out that it is just the latest way to try to reduce the ever-lengthening waiting times for patients.

In practice (it has already begun rolling out in some NHS Trusts), it allows Trusts to cram as many more appointments into weekends as possible - thus eliminating the "down" time usually enjoyed by most of the workforce, but cutting patient queues. And while the recruitment of a lot more staff would be mandatory to provide this "revolutionary improvement", this is, predictably, not part of Hunt's plan. Yet more work is to be loaded onto the shoulders of existing staff. This, in short, is what the new doctors' contract is about.

The battle proceeds - in England alone, doctors alone

NHS England Employers accepted the DDRB's final contract proposals in July 2013, and thus began negotiations with the doctors' union, the BMA.

The negotiations went badly right from the start, stalling several times because the BMA officials found the terms unacceptable. The new contract proposed to count doctors' unsocial working hours from 10pm to 7am (with a 50% premium) instead of from the current 7pm to 7am (or 8am in some cases). Saturday would be paid as a normal weekday until 7pm, whereas before it had been paid at a 33% premium rate. The 33% premium would be paid between 7pm and 10pm when the night premium of 50% would begin. Sunday pay would be unchanged at time+33% until 10pm. This meant that the "plain time" which doctors work - time which attracts no premium - would have increased from 60 hours to 90 hours in a week.

There were other changes affecting pay progression - so that pay would not rise automatically with experience, but only when a trainee moves to the next phase of training. Eleven grades of training would be replaced by just six. Pay protection would be lost to those trainees who decide to change speciality - regardless of any other qualifications or experience. There would also be penalties for doctors who take time out - for instance for maternity leave.

Finally, in October 2015, the BMA negotiating team walked out of the talks and decided to ballot junior doctors for industrial action. This they did on 9 November last year. An overwhelming 98% of the 37,700 junior doctors who were balloted (the turnout was 76.2%), voted to strike.

But the cause of such overwhelming support for strike action among doctors was, as mentioned above, not only the cut in pay proposed by the new contract. This was merely the last straw which broke the camel's back.

The first strike, due in December, was called off when negotiations under the auspices of ACAS resumed briefly. When these broke down, however, new strike dates were announced for January and indeed 24-hours of action was taken on the 12th, with doctors displaying high morale on the picket lines and amid great public support. As a result, in fact, a slightly improved offer was produced. This was to be the "final offer".

Now the unsocial hours payments of time+50% were to begin not at 10pm but at 9pm. Time+33% would be paid on Saturday between 5pm and 9pm and 7am and 9pm on a Sunday. And if doctors worked 1 in 4 Saturdays or more, they would get a further 30% enhancement of their Saturday pay. Jeremy Hunt portrayed the deal as providing a 13.5% pay rise, despite the fact out-of-hours and weekend payments are cut by around 17%. The basic starting salary was now to be ?27,000, reaching ?52,000 at the most senior level (just before consultant) compared to the November offer of ?25,500 and ?55,000 respectively.

When most doctors' hours are weighted towards unsocial hours this means a really substantial pay cut for them. Accident and Emergency department doctors for instance, estimated they would be losing 4.3% of their pay.

However, the BMA called off the planned 48-hour strike scheduled for 26-28th January in order to resume talks, in an attempt to get the government to improve on this new offer. The main sticking point was that Saturday was to be treated as a normal working day.

However the government and NHS England's chief, refused to move any further. So another 24-hour strike went ahead on 10 February. Again, there was high morale on the picket lines - even though there were no supportive sounds, let alone action from any of the other health unions. Not officially, anyway. But of course many nurses - and especially student nurses supported the action. It was at this point that Jeremy Hunt declared that given the failure to agree, the doctors' contract was going to be imposed, starting 1 August 2016 - regardless.

The BMA was thus snubbed by the government. It responded by calling further action - and an escalation now, against the imposition of the contract. A 48-hour strike thus took place on 9th-10th March.

This still cut no ice with Jeremy Hunt. So two more strikes were called the first, on 6-8th April for 48 hours would provide emergency cover but the second, on 26-28th April, for 9 hours each day, would not.

Much was made of the fact that it would be "the first time in NHS history", that junior doctors would not be providing their own emergency cover. But while it provided the media (as well as the Royal Colleges of Medicine, the General Medical Council and others in the medical establishment) with plenty of opportunity to accuse doctors of "putting patients' lives at risk", the fact is, that patients probably received much better care than usual! Consultants (who, in the majority, morally support the strike) covered all of the junior doctors' emergency duties, and given that all routine operations and procedures were all cancelled, they had plenty of time to attend to patients! This is something which was also unprecedented!

The BMA has also in the meantime asked for a "judicial review" to "challenge the lawfulness of the imposition of the contract". Its negotiator, Dr Johann Malawana, had offered to call off this "first full walk-out" on 26-28th April, if the Secretary of State lifted the imposition of the contract. Writing on the 19th April, he stated "I believe your decision in February to give up on negotiations and impose a contract, reiterated in the House of Commons yesterday, marks a watershed in relations with the profession, but am happy to meet or discuss this offer with you any time between now and the start of next week's action."

At the time of writing, Hunt was committed fully to imposing the contract in August - in a phased manner.

The context is everything

Looking for ?22 billions-worth of cuts ("productivity savings") in the NHS by 2020/21, Health Secretary Hunt must have expected doctors' pay to be a safe target, given their "professionalism". He certainly miscalculated. But as usual, context is everything. Today, 75% of all Hospital Trusts are in deficit (with a combined total of ?2.8bn). The worst performance figures since records began were posted this January: 212,136 patients waited over 4 hours in A&E; 263,445 waited more than 18 weeks for procedures and 20% of cancer patients waited more than the 62-day target (already far too long!) for treatment. This is a fourfold increase in 5 years.

But no wonder NHS Trusts are in such a dire situation. Hospitals have been subject to almost three decades of commercialisation of health care. The practical consequence of this policy is the split between primary care (e.g. GPs) and providers of secondary care (e.g. hospitals), which can be private companies if the NHS is unable to step up to the mark. Today the doctors' fight has exposed, at very long last, the totally unacceptable conditions in which those who are training to become specialists struggle to carry out their role as doctors. Their hours of work have always been too long. The only way to compensate for the fact that doctors cannot just up and leave when the bell goes, so to speak, is to have enough of them. But there have never been enough. So doctors long working hours have always been a scandal.

When the European Working Time Directive (WTD) became law in Britain in 1998 (5 years after the rest of the EU!) and placed a limit on the working week of 48 hours, it caused near hysteria among NHS employers. At the time the average working week was 86 hours. How would they cover doctors' duties? But instead of training many more doctors, and despite the evidence that overtired doctors were endangering patients, junior doctors were exempted from the WTD until 2006, and then their maximum hours were limited to 56hrs/week. It was only in 2011 that the 48-hour working week came in for doctors - still averaged over 26 weeks, of course. So a 90-hour week is still possible - and common! Unbelievably, doctors are able to opt out of the WTD (or be "asked" to do?), because unlike security guards, long distance truck drivers and airline staff, their job is not considered "safety critical"!

$1A self-fulfilling prophecy

Yes, this is an NHS which is over-stretched: underfunded, understaffed and poorly organised due a long series of assaults on its centralised "public" institution. Despite its huge budget - the budget for the NHS in England alone, for 2015/16 is ?116.4 billion - a smaller percentage of GDP is spent on health in England than is spent in Portugal, France or the Netherlands. And it is not enough.

Recruitment has been cut. In 2012, the BMA agreed to limit medical student intakes, as there were fears there would not be enough jobs for doctors when they qualified. Of course, with budgetary cuts, not enough posts were created! But surely that was what should have been addressed by the BMA, rather than agreeing to cut student intakes?

Although the doctor shortage has become critical in the last two years, it was already estimated in 2014 that the NHS was short of 50,000 clinical staff (those responsible for patients) - a shortfall of 5.9%.

As for the shortfall of nurses, it is estimated to be around 11,000 in England. And why? Because the last (ConDem) government actually cut the number of training places by 17%! But previous (Labour) governments were just as bad, while promising more nurses and doctors - overall training places were cut by 20% between 2009 and 2012. And now, instead of being able to recruit 3,000 nurse-trainees for 2016/17 Health Education England has funding for just 331! On top of it all, is the plan to cut nurses' training bursaries as part of this year's ?8bn NHS cuts "package"!

The huge gap is being partly filled by overseas-trained nurses, as it always was. But even they are hard to retain in the NHS, given the dire cuts, which mean overwork, overtime, exhaustion and low morale.

In fact much has changed in the last 3-4 years since the Health and Social Care Act was passed. This was, at the time, said to be the last straw which was going to break the back of the NHS and it seems to be doing just that. Of course, the NHS is a gigantic public institution - still employing 824,000 full-time equivalent clinical staff nationally. Decentralising it, allowing the private sector to take over parts of it directly and to supply an increasing number of services can happen brick by brick, as it were. This has in fact been the case - since Thatcher first began its privatisation in the 1980s and since this policy was relaunched by the Blair-Brown government in 1997, after which each government in turn has merely made matters worse.

But to change the NHS from an institution which provides free healthcare at the point of use - so that it becomes a semi-private, individual insurance-based service - may be the objective of capitalists, but it is not so easy.

So the HSCA 2012 made a significant change to help this process along. It removed the obligation of the Secretary of State to provide and oversee free and universal health care in England. So the NHS is, in fact, no longer based on this principle. This Act also set in stone the NHS internal market - but on a commercial basis, establishing at the same time, a private external market for healthcare based on the inadequacy of the NHS - thanks to the government's serial cuts.

The pretext for all of this "reform" was always that the NHS was "too costly" and that the growing expense of an ageing population along with the demand for new and thus more expensive treatments would make the NHS unaffordable.

But now GPs have gained full control of the NHS budget - through their Clinical Commissioning Groups - allowing them to make referrals to all manner of private "services" which the NHS cannot provide in a timely manner (it's fair competition!) - reinforcing the vicious circle which NHS providers of healthcare find themselves in, due to lack of adequate funding. To the extent that the process seems almost irreversible. But it is not.

Reasons to be cheerful

Of course, doctors have never been a combative section of the workforce. They certainly never saw themselves as "workers" just like everybody else - and probably most of them still do not, even after the six strikes they have so far staged. Nevertheless, their politicisation and militancy has undoubtedly increased in the course of this dispute. So this generation of doctors (at least) will never be the same again, much like the generation of junior doctors who staged industrial action 40 years ago - and who provided, possibly as a consequence of that, the quasi-socialist ethic that prevailed among a layer of consultants at the top of the profession during the whole preceding period of NHS privatisation - and who clearly resisted that privatisation.

That said, the junior doctors are not being helped to see themselves as workers or even as part of a wider workforce, thanks to the deafening silence emanating from the other health unions, the TUC, and all other trade union leaderships, for that matter. Unison, for instance which is the largest of the health service unions with around 500,000 health sector members, most in the NHS, knows full well that its members are faced with unbearable conditions. At the time of writing, they are holding their annual conference, where Unison leader, Dave Prentis has claimed that Unison members "stood shoulder to shoulder with the junior doctors" - in spirit apparently , because they would only be joining them on the picket lines if the Jeremy Hunt didn't offer the pay rise he apparently promised last year! "If you come for our social hours payments, we will fight back", said Prentis. But otherwise the doctors must fight alone.

The same goes for Unite - which has 100,000 members in the NHS, and still has a section which organises doctors - what used to be the Medical Practitioners' Union. But this union leadership too, has little except moral advice to offer Jeremy Hunt: Unite national officer for health Barrie Brown said: "What Hunt needs to do is to withdraw the imposition of the contract and sit down and negotiate in a constructive manner with the BMA." (!!)

But workers on the ground, and in particular, of course, the (working) student nurses who are also being targeted by a government cut, have actually joined the doctors on their picket lines. And there has been unquestioning sympathy from many other workers as individuals, sympathy which continues today. What would it take to turn that sympathy into action? Not very much.

The money and the will is there to fix the NHS. And the working class is big and strong enough to force a turnaround. What is lacking is the initiative and the confidence to bypass the inert union bureaucracies in order to do so. This would be the only way to reinforce the doctors' and nurses' struggles, because above all, it is their isolation that needed (or needs) to be broken by the "all-out" participation of other health service workers - and the rest of us - who are affected by the same cuts and who have the same stake in this fight.