Image: Flickr/Rohin Francis

This junior doctor contract dispute has been built on a lattice of hashtags. #iminworkjeremy, #weneedtotalkaboutjeremy, #moetmedic, #timetolisten, #timetotalk.

Now it’s #timetovote.

The referendum on the new junior doctor contract opens this week. We as a body of professionals need to decide what it is we have been fighting for.

Was it for the least worst contract we could squeeze from the nightmare we started with?

Or was it for safe, fair and equal working conditions for junior doctors for the next generation?

The problem is it’s really not as simple as that. A vote No won’t automatically give you opportunity to renegotiate. A vote Yes won’t automatically mean the contract as it is now will work as you want it. We’ve covered this before.

So consider the work you are willing to put in.

And consider what is happening still with the NHS.

Although the national news is only interested in the other referendum, local news picked up Jeremy Hunt many times last week;

In the Yorkshire Post Hunt claimed the contract was a good one, and he hoped doctors would listen to the BMA JDC head, Johann Malawana. After a year of telling us the BMA had ‘misled’ us, now Jeremy tells us the opposite.

Then in a speech just as the contract was published, Jeremy Hunt claimed the NHS needed to go on a ‘ten year diet’, completely ignoring the gaping holes in service and funding that his government has created.

Lastly, this story in the Birmingham Mail. Jeremy Hunt defends cutting 450 clinical jobs from West Birmingham Hospital Trust because ‘some of the safest hospitals in the world actually had a relatively low number of staff’. In a spectacular career of NHS spin, this is one of the most ridiculous.

Hunt told us: “… after Mid Staffs …some trusts understandably staffed up very quickly…But in too many cases they did that by recruiting agency staff.”

No, Jeremy. The substantive budget requests for staff were refused by no.10, as detailed in this PAC report, meaning hospitals had to hire temporary workers to make sure wards were staffed. Both the staff crisis and the agency overspend were the fault of government, not trusts.

He went on: “Virginia Mason in Seattle, which is held up as a beacon in terms of safe care globally, actually has relatively low [staff] ratio”.

No, Jeremy. Virginia Mason has 480 doctors for 330 beds (1.45 doctors per bed) –in other words, twice as per bed many as the NHS, which has 110,000 hospital doctors to 150,000 beds (0.73 doctors per bed).

“What they do is ensure that 90 per cent of nurses’ time is spent with patients. Not filling out forms or dealing with bureaucracy in the system”. Well, that’s a cheek, Jeremy. There are no studies looking at safety and paperwork, but plenty looking at nursing levels and finding a direct correlation with survival, for example in stroke.

Lastly this week again Virgin Healthcare's takeover of £126 million-worth of NHS community services in Kent resumed - despite being challenged in court that the CCGs picked Virgin's bid because it was cheaper, though poorer quality.

NHS improvement - the financial regulator formerly known as Monitor - has decided to redefine ‘safe staffing’ despite explicitly promising not to. This is the work that - post mid-Staffs - was given to a more clinically minded regulator, NICE - and then promptly shut down by Jeremy Hunt and Simon Stevens, post general election.

The direction of travel in the NHS is clear. Reducing costs by cutting quality and safety. Privatising where possible. Spinning like crazy.

Now I campaigned for a contract that was safe for doctors and patients, fair to our diverse workforce, and protected working conditions in a future NHS that will be very difficult indeed.

Is this contract safe? On paper, yes - the new safeguards reduce runs of shifts and provide a system that could both address individual overworked doctors and collect data on understaffed rotas for the first time.

But in practice? There has been no groundwork laid for the expanded roles of educational supervisors, no realistic investment in the Guardian role in many trusts, and the financial pressures on hospitals right now are mounting. I simply cannot see hospitals having the will, the manpower or investing the resources to make this work. The old banding system was difficult enough- some trusts actively hid hours monitoring data, and flat out refused to sort out rotas that breached safe working. But where it did function, in my experience, it worked very well and effectively.

Is this contract fair? Without a doubt this contract discriminates against women, mostly through the negative impact on LTFT (less than full time) working. Both the government and the BMA have made some inroads to address this and front loaded pay will level some losses. But LTFT trainees previously were paid more per hour to mitigate the impact of child rearing on a career, and now this is lost – a huge pay cut for this group.

Now you might not agree with positive discrimination, but I do, for two reasons. 1) I don’t care what the doctor working next to me gets paid more per hour, but I do care that there IS a doctor working next to me. We simply cannot afford a contract that pushes 60% of the workforce closer to leaving. 2) we don’t work in a job where time at work = experience = value. My LTFT colleagues have often been doctors for longer, have better personal development and are generally more experienced than me.

For academics there has been progress, and those changing specialties for partners, care needs or disabilities enjoy new protections. But for me, it’s still not better than what we have now.

The work-life balance of doctors in the current NHS is poor already. Service provision takes up an increasing part of training time, and this will only get worse as pressures increase. The new contract means moving doctors from 1:4 weekends to 1:2 weekends costs trusts nearly nothing - £60 per month over the training lifetime of a doctor. Weekends are inherently poor training periods, and working additional weekends will pull doctors from the weekdays, where training opportunities are plentiful.

The negative impacts on both training and social-work balance will massively affect retention. Not to mention the toxic attitude the Department of Health and the Secretary of State have taken to juniors. Who will continue to provide goodwill in a system that has shown us we are not valued? Pay overall will remain the same, but for significantly worse conditions.

I don’t think this contract is safer, fairer or better than what we have now.

It has promise, but we cannot build a safe future workforce on promises alone. The safety aspects need trialling, tightening and evidencing that they can work in reality as they are supposed to. They shouldn’t require vast amounts of junior doctor time to function either; we have enough to do between service, and the little training we have, to be our own administration and human resources departments as well.

The contract needs to readdress its discriminatory stance on women, and provide better incentives to retain the LTFT workforce. We can’t slide back on equality in our profession. That's unacceptable in the 21st century.

This contract doesn’t address fully Health Education England as an employment body- so we all still remain without career whistleblowing protection.

This contract needs to remember what it was supposed to be about at the initial heads of terms- a fairer system for pay, that improved doctors working conditions and work-life balance, in recognition that the NHS is collapsing and the work environment becoming toxic.

There is no plan for ‘7-day’ NHS working that I have seen. The contract has made it cheaper for doctors to work weekends, but there aren’t any more doctors to cover the days or the additional hours. There is no evidence linking any element of the supposed ‘weekend effect’ to junior doctors, and the ‘weekend effect’ itself has fallen apart under scrutiny. So there is no rush to change any contract.

I’m going to vote No.

I’m going to campaign for a year moratorium on the new contract, to trial elements of the safety parts, to try and renegotiate elements of everything else, and to cool off this whole dispute so the politicians stop sniffing around it.

This is a sensible, considered, rational choice. I respect it might not be yours. It’s time to decide.

It’s #timetovote