The UK Junior Doctors' Strike: Takeaways for the Rest of the World

Laurie Scudder, DNP, NP; Rajiv C. Wijesuriya, MBBS, BSc (Hon)


June 28, 2016

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Editor's Note: In May 2016, after 3 years of contract negotiations and three strike actions taken over the contract terms and concerns about patient safety, representatives of the approximately 37,000 junior doctors in England and the National Health Service (NHS) reached an agreement. Junior doctors returned to work while representatives from the British Medical Association (BMA) began a series of meetings with doctors around the nation to explain the contract terms. The agreement does require ratification by a majority of the junior doctors employed by the NHS, and a vote is anticipated in late June.

For our non-UK readers, we should note that the period of time in which a physician is identified as a junior doctor runs from the completion of medical school through residency and fellowship, and may extend for 7-13 years. Junior doctors account for approximately one third of the medical workforce in England.

Medscape: Today I am very pleased to be speaking again with Dr Rajiv Wijesuriya. Dr Wijesuriya is a member of the BMA junior doctors negotiating committee. We'll be discussing the issues involved in this dispute and some of the lessons learned. Rajiv, I thank you for joining us. Welcome.

Could you start by describing terms of the new contract? It has been described as a compromise by both sides, but how do you believe the new contract will benefit both you and your colleagues, as well as patients?

Rajiv C. Wijesuriya, MBBS, BSc (Hon): It's been an intensive but constructive set of talks. We are very pleased to have reached an agreement on a contract that we believe is now going to be safe, is going to be fair, and delivers for patients as well as for junior doctors and the NHS. Ultimately, what we feel this contract offers is a system that protects safe working patterns. It recognizes and values the contributions that junior doctors make to our health service, which is something that we wanted all along, and offers protections, such as work-hour limitations and reporting systems, in which junior doctors, and also patients, can have confidence.

Medscape: The Financial Times[1] opined that no one was a winner in this work action. Other reports said that the contract dispute has prompted both doctors and medical students to reconsider their future in the NHS, and have voiced some concerns that this potentially will worsen the physician shortage in England.[2] Do you think this concern is valid?

Dr Wijesuriya: I think the important thing to say here is that junior doctors have campaigned tirelessly over this contract for 3 years. Our patients have joined us, as have so many members of the public, on the basis of our concerns that the contract that was being proposed simply did not address those key safety areas. The proposed 7-day service [Editor's note: primary care services delivered 7 days per week] would require more staff, funding, and resources, which we believe could not be delivered within the structure that was being proposed.

What we tried to do through these negotiations, alongside the government, was find a solution that recognizes the work of junior doctors and offers a safe and fair contract and system of working. There are huge problems within the NHS beyond this issue, and that is clear from the response of the public and the doctors. These other issues include funding of our healthcare system and issues that affect training and morale. There is still a huge amount of work that we need to do.

Medscape: News reports made clear that exact point—that the issues in this dispute extend beyond the junior doctors and involve the entire NHS, your citizens, and patients, who, as you noted, strongly supported you and your colleagues despite some disruptions to patient care caused by the work actions. Do you think that public support was a factor in the two sides coming to terms?

The government had to take notice of the concerns—not just of the doctors, but of all of those patients who really stood together on this issue.

Dr Wijesuriya: What we saw throughout this dispute was a remarkable level of support from the public. We took action that doctors haven't taken in something like 40 years, an action that we didn't want to take and was not our first choice. It was something that we were pushed to do, because we felt that we were being forced into a position that was unsafe for our patients and was threatening our health service. We were all incredibly motivated by the support of our patients who understood the cause for which we were fighting. That support played a huge role in us coming back to the table. The government had to take notice of the concerns—not just of the doctors, but of all of those patients who really stood together on this issue.

Lessons Learned for the UK and Everywhere Else

Medscape: The issues that are raised by this action—you alluded to issues about funding, morale, and burnout—are applicable worldwide, including in the United States, with a healthcare system that blends public and private payers. What are the key strategies that you and the members of the negotiating committee learned that can be applied to healthcare professionals in the rest of the world?

Dr Wijesuriya: First, you have to identify what it is that's important. It was quite clear for us what our membership wanted. A huge part of that is making sure that you engage with your members and that you have the really hard conversations. What is it that is important to us? What are our priorities? In this dispute, we've clearly heard a very united voice from our junior doctors, 98% of whom said that they would not have accepted the previous terms of the contract because [those terms] were not going to be safe for our patients, were not fair for our profession, and tried to stretch us across a service that was already struggling to cope with a huge number of issues—a huge number of gaps.

In our new agreement with the government, we tried to address those issues, looking at remunerating more fairly the doctors who work the most antisocial hours, as well as addressing some of the issues we had with under-subscribed areas by creating retention and recruitment premiums to encourage people to go into our emergency medicine fields, for example. We also looked at the discriminatory attributes of this contract, specifically looking at gender inequality, which is something that, in 2016 with a growing female workforce in our country, needs to be addressed in order to achieve equality. I think these issues are going to be increasingly common worldwide.

It was important that we start to address these concerns, not just in our contract, but in terms of nursing and planing for care in our entire health system. This particular dispute has been about a junior doctor contract in which we have tried to address those issues of gender fairness, fair working patterns, and safety for doctors and for patients. The contract creates a reporting mechanism in which the public can have confidence, and it provides a means of addressing problems so that the next time we will not have to renegotiate the contract at a whole. We developed systems that allow us to revisit problems and concerns as they are identified, and to tweak and adjust areas that we don't think are working on a more regular basis.

Medscape: Your strategies included unity, equality, transparency, and putting patients first, which are powerful messages. Are there other key messages you would like to share with our audience? Any final thoughts?

Dr Wijesuriya: You have to have good communication and trust your membership. You have to present them with the information and allow them to come to their own conclusions. The terms and conditions of the proposed new contract have been released to junior doctors up and down the country; they will be looking at it and reading it. It is not a done deal. This is something that our members will decide on. They will be balloted on the terms and conditions of this new contract.

What has been incredible so often in our profession is that we accept terms and conditions of a contract without necessarily really understanding them. Culturally, that is something that is quite engrained, because we see ourselves as doctors first, rather than seeing ourselves as employees. This process, to be honest, has represented a real shift in which doctors have really taken an interest in their contracts. I think there is now a greater understanding of the system in which we work. And it's meant that doctors will have a lot more input and a lot more say in the way that healthcare is being delivered in our system. That can only be a good thing. As we approach this ballot and we see what the members think of this contract offer, we'll get a very clear steer as to where we are going from here.

Medscape: So it's healthcare that is managed by healthcare professionals. A pretty obvious solution, it would seem, to people throughout the world—not just in the UK.

Dr Wijesuriya: Yes. As we talk more widely about the healthcare system, I think it's important that it be not just clinician-led, but patient-led. But you need to have your clinicians involved in the organization and delivery of that system. We can't simply be employees; we need to be involved in the way that that system works, because our clinical knowledge gives us an in-depth understanding of the system. It is important, however, not to conflate that with the contract. Ultimately, what this contract does is define a way of working. What it's become is a means by which we have gained the interest and engagement of a generation of doctors who have started to realize the challenges of our healthcare system. We are really keen to take up the fight on that front.

Medscape: We certainly wish you well. We'll be following the events as you present this contract to your colleagues and bring it to a vote. I look forward to talking again in the future.

Dr Wijesuriya: Thank you.


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