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Of smoke, mirrors, cartels, and a "7-day NHS"

Who’s really been behind the planning of the junior doctors contract? Not who you think.

Image: Flickr/Garry Knight

The news broke this week that the British Medical Association (BMA) will be staging three further 48-hour strikes over the planned imposition of the Junior Doctors' Contract by Health Secretary Jeremy Hunt. They’re also launching a legal challenge of his actions.

In a statement, the BMA said: “Imposing this contract will seriously undermine the ability of the NHS to recruit and retain junior doctors in areas of medicine with the most unsocial areas (sic), where there are already staffing shortages. The Government must listen to the chorus of concern coming from all quarters and reconsider this disastrous approach.”

But will the Government listen?

It is highly unlikely. The Conservatives seem set on bulldozing this through, even in the face of overwhelming public support for the Junior Doctors.

Their entire rationale for the battle is that it is essential to meet their manifesto pledge of a “7-day NHS”.

But is the contract all it appears to be? Where exactly has it come from? Who’s really been involved in the planning of it? And is it really about a “7 day NHS” – or something completely different?

Delving deeper into the history of the contract, one finds that all is not what it seems.

The timeline of proceedings appears fairly straightforward – the basis of contract negotiation (“heads of terms”) was agreed in July 2013; the Review Body on Doctors’ and Dentists’ Remuneration (DDRB) was given its negotiation remit in October 2014, published its findings and recommendations for the contract in July 2015, and we are then essentially up to the present day – more strikes.

But much more was going on in the background.

Crucially, in June 2012 13 NHS Trusts set up the “South West Pay, Terms and Conditions Consortium”, with the aim of setting up a regional system of pay, terms and conditions, which would operate separately from the NHS nationally. 

The plans included a reduction in maternity leave and sick pay, scrapping some on-call payments and an increase in contracted working hours. The 13 Trusts each paid consultants £10,000 for the project.

Trade Unions vehemently opposed the project, dubbing it a “Pay Cartel”, and it met with opposition in Parliament from both sides of the House. After several discussion documents and updates the Consortium reported its conclusions in March 2013 - making clear its scope had covered all doctors, and all other NHS staff (most of whom were covered by the previously negotiated 'Agenda for Change' terms). It then disbanded in April, with the results sent to each member’s board for consideration. Interestingly – no Trust ever proceeded with the plans.

This, however, has by no means been the end of the story.

Several names within the hierarchy of the Consortium are well-known industry professionals. Shaun Clee, a Director of the NHS Confederation; Kristin Crook, who went on to become the Programme Manager for the NHS’ Quality, Innovation, Productivity and Prevention (QIPP) cost-saving scheme, and one Chris Bown – the man accredited with turning around the fortunes of Mid Staffs.

The Consortium also included one David Amos as a Director. Amos is an independent Healthcare HR advisor with a heavyweight past – he was previously a member of the Cabinet Office under Brown, then Cameron – and before that Deputy Director of HR for the NHS.

But Amos is also an associate consultant for auditors KPMG, who had a plethora of meetings with Hunt and other members of the Department of Health (DH) in the run up to the DDRB being issued with the remit for the Junior Doctor’s contract brief and the publication of its findings – after having no recorded meeting in the previous 2 years. Amos was present at one, if not more, of these.

And that wasn’t the only way the Consortium’s work on cutting pay and anti-social hours payments was getting into the heart of government.

In November 2012, the right wing think tank Reform released a report tabling recommendations to Government on how to improve productivity and efficiency in the NHS – drawing heavily on the Consortium’s work. The document  stipulated that the apparent “surplus of doctors” in the UK “creates an opportunity to drive down pay and review medical ranks”. The same month, Reform chaired a conference at which Amos and fellow Consortium member Chris Bown, spoke about the Consortium’s work, and the fact it might lead to 6,000 job losses.

It’s at this point the links between the Junior Doctors Contract, the Consortium and other external players become apparent.

Nick Seddon, appointed as David Cameron’s Health Policy Advisor in May 2013, chaired the previously mentioned conference, and co-authored the report quoted above.

He also organised and chaired a Reform conference in January 2013, again on productivity and efficiency in the NHS, again with Bown and Amos giving evidence from the Consortium – and the “guest list” read like a who’s-who of the NHS.

Stephen Dorrell, Chair of the Health Select Committee (who would later go on to work for KPMG & Chair the NHS Confederation), 6 representatives from the DH, NHS Employer’s Policy Manager, the Head of Strategy from Health Education England, the Director of Workforce Development at the DH – and numerous reps from KPMG.

Key phrases from the conference included “Pay, terms and conditions may have a role to play in supporting organisational viability”, “How can car manufacturing methods apply to healthcare?” and most notably “We shouldn’t – and can’t afford to – let a good crisis go to waste” – all heartening to professionals and patients alike, I’m sure.

Furthermore, emails released under a FOI request show evidence of a meeting then numerous communications between Nic Greenfield (the Director of NHS Employers), the Department of Health, and Bown and Amos, in relation to the Consortium’s proposals.

The Consortium’s recommendations were always intended to be passed on to NHS Employers – the Consortium’s board meeting minutes make that clear. Nick Seddon has allegedly been heavily involved in the handing of the Junior Doctors’ dispute.

Emails also show that the then NHS Chief Executive David Nicholson and DH Ministers had been briefed on the Consortium agenda and were “content and grateful for the briefing”, and that the Consortium was asked to “work closely with NHS Employers”.

So, should it come as any surprise, that after direct communications between the Consortium and NHS Employers, DH advisers KPMG, the Department itself, the former Chair of the Health Select Committee and the PM’s Health Advisor, that many of the Consortium’s recommendations on pay, terms and conditions made it into the Junior Doctor’s contract?

Probably not.

However, it’s even less of a surprise when you realise that one of the founding members of the Consortium who sat on its steering committee, has also sat on the policy board of NHS Employers since 2010. Edward Colgan, Chief Executive of Somerset Partnership NHS Trust was involved in the Consortium from its inception.

Specifically, 5 proposals stand out as noteworthy as having being lifted from the Consortium’s report: changes in on-call payments; the linking of pay progression to performance; transitional pay protection; part of the changes in what are deemed unsociable hours and most notably the imposition itself (specifically that the contract should be installed before an agreement with existing staff has been met).

Moreover, while NHS Employers claim the new contract is “cost neutral” (while not releasing information to verify this), the Consortium remit was not – it was specifically a cost-saving exercise. Therefore, savings that the Consortium calculated for the 5 areas mentioned above can be applied - and show a minimum £2m cost reduction per Trust, per year. Is this contract really about what’s best for Junior Doctors and patients? Or is it about bridging a financial gap in an NHS plagued with deficits?

The Consortium’s brief wasn’t based on the “7-Day NHS” premise. But it’s an argument repeatedly used and wholly manipulated in terms of the Junior Doctor’s Contract – which seems to have been the Government’s ace in the pack regarding selling the changes to the public, even after Hunt’s wholly inaccurate claims about weekend mortality rates have been thoroughly debunked (now-disputed claims which were leaked to him by accountancy firm, Deloitte, before they were published by the BMJ).

A “7-day NHS” was never part of, nor anything to do with, the work of Junior Doctors.  

Sir Bruce Keogh states in the NHS’ initial findings  on a “7 day NHS”, that the issue was not the number of junior doctors working at weekends, but whether they had enough other staff around them, saying “our junior doctors feel clinically exposed and unsupported at weekends” –the onus in this report and its supporting evidence was on consultants working more flexibly. The DDRB report from July last year echoes a similar sentiment: “We note that junior doctors are already working across seven days: indeed, they play a vital role in the delivery of services, particularly in the evenings, at night and at weekends”, saying that any changes need to be to Consultants contracts regarding a 7-day NHS.

Even Simon Stevens’ report, “The 5-year Forward View (released in October 2014) states the NHS must be “Ensuring that hospital patients have access to seven day services where this makes a clinical difference to outcomes” – not across the board.

The government is trying to manipulate the public into believing that these contract changes are essential to providing a more complete and safer service across weekends, and also to give a fairer deal to Junior Doctors – which appears completely contrary to every piece of evidence the Government have been presented with.

Moving forward, there needs to be serious questions asked about the legitimacy of this contract, in terms of its claims over NHS services and the protection of both the doctors it’s being imposed on and ultimately the patients whom this will directly affect.

All sides need to seriously consider their positions, as this is turning into a confrontation which shows no signs of being resolved – certainly not in 7-days and probably not in 7-weeks, or months.

 

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