Junior Doctors: the moment of decision

Think hard and be bold

Britain's junior doctors have huge public and professional support in their struggle to improve the hours they work, their conditions, and their pay. The public is grateful to them for always being there, no matter whether it is the dead of night or Christmas Day; even the tabloid newspapers argue their case. The other parts of the profession, including the consultants and the general practitioners, gave unanimous support to the juniors for their battle at the BMA's annual meeting. Now after a tough summer of negotiation the junior doctors face a difficult decision. Should they accept an offer that is less than they demanded but which some regard as excellent? Or should they test their support and try for more, running the risk that they will lose what they've gained?

Junior doctors are on the front line of a National Health Service under enormous pressure. They are the ones who must comfort and treat patients in packed accident and emergency departments, overflowing admission wards, full intensive care units, and beds in the day rooms of wards. They, not politicians, are the ones who must explain to patients and their families the failures of the NHS. They are contracted for long hours yet often must work way beyond them - otherwise, they may practise a debased form of medicine, far removed from what the public wants and what the General Medical Council says is good practice. After making these sacrifices they may find that there is no hot food and no clean bed. Trained for six years, they discover that they are perhaps the most exploited of a workforce in which exploitation is routine.

It was, however, the double dealing of the government that finally caused the juniors to crack. It put out false information, went back on an agreement to negotiate over millennium pay, and secretly lobbied to have junior doctors excluded from the European Working Time Directive after saying it wanted them included.

So the juniors went on the warpath, threatening industrial action if they didn't get satisfaction. They wanted reasonable working hours and better conditions and pay. The dispute has always been about more than pay, but many junior doctors thought that a doubling of their overtime pay should be the target of negotiations. Not only would such an increase compensate doctors for long hours but also - importantly - it would provide a strong incentive to hospital managers to solve the problem of excessive hours. At the moment junior doctors are the cheapest labour in the hospital out of hours, meaning that managers have a financial incentive to get them to do the work of porters and others. Doubling overtime would cost the NHS about £580m in the first year.

The government responded to the juniors by offering a completely new contract that would do away with overtime payments. Instead, juniors would be paid in four salary bands according to the intensity of their work. By 2002 a doctor working in a very high intensity post could command a salary twice that of the current basic salary, while the average junior doctor would command a salary 50% greater than the current basic salary. These salaries would provide a strong incentive to managers to restructure such posts - or even to employ consultants instead. The offer from the government includes a contractual agreement to meet the new deal agreement of juniors not having to work more than 56 hours a week. There are also promises of better conditions and support. This deal would cost between £200m and £300m over three years.

Should the offer be accepted? Although the government claimed last month that a deal had been struck, the Juniors Doctors Committee neither accepted nor rejected the offer but asked their negotiators to push for a better deal on out of hours pay. In addition, they plan a special conference and want a referendum before any settlement is accepted.

Junior doctors will rightly make their own decision on what to do, but there are many complicated questions for them to consider. Is it better in principle to move from a complicated contract that depends so much on overtime payments to a professional contract that has a higher basic salary? Most senior doctors would probably favour the professional contract: it's how they are paid. Also, there is symbolism in the way that people are paid: in the past many have argued that professional work demands a professional contract, not one dominated by overtime rates. Can the juniors trust the government? Seemingly no. Might the juniors be able to squeeze more from the government? They might. The government is known to have a substantial war chest, and many in the Labour party favour higher expenditure on the NHS. Would the government square up to junior doctors? It would presumably hate such a battle, and its spin doctors would be working as much overtime as the juniors. But, at the same time, the government has a huge majority and tight control. Would public support for juniors hold in a battle? It might, but the government has formidable means to manipulate public opinion, and the tabloid press is notoriously fickle. Would support from other parts of the profession hold? Perhaps not. Consultants are arguably as unhappy as juniors, and they and general practitioners would bear the brunt of minimising the effect of any industrial action by juniors on patients. Would the mass of juniors, as opposed to the politically dedicated, vote in a ballot and sustain their commitment in a long struggle. They might. They are that fed up. These are all hard, perhaps impossible, questions to answer. To decide what to do in such circumstances is the essence of political judgment.

The BMJ isn't going to tell the juniors what to do, but they need to consider these questions. For industrial action is a high risk strategy.