Skip to main content

Junior Doctors Contract

Volume 611: debated on Thursday 19 May 2016

With permission, Mr Speaker, I will make a statement on the junior doctors contract.

For the last three years there have been repeated attempts to reform the junior doctors contract to support better patient care seven days a week, culminating in a damaging industrial relations dispute that lasted for more than 10 months. I am pleased to inform the House that after 10 days of intensive discussion under the auspices of ACAS, the dispute was resolved yesterday with a historic agreement between the Government, NHS Employers—acting on behalf of the employers of junior doctors—and the British Medical Association that will modernise the contract by making it better for both doctors and patients. The new contract meets all the Government’s red lines for delivering a seven-day NHS, and remains within the existing pay envelope. We will publish an equalities analysis of the new terms alongside a revised contract at the end of the month, and it will be put to a ballot of the BMA membership next month, with the support of its leader, the chair of the junior doctors committee of the BMA, Johann Malawana.

I express my thanks to the BMA for the leadership it has shown in returning to talks, negotiating in good faith, and making an agreement possible. I also put on record my thanks to Sir Brendan Barber, the chair of ACAS, for his excellent stewardship of the process, and to Sir David Dalton for his wisdom and insight in conducting discussions on behalf of employers and the Government, both this time and earlier in the year. The agreement will facilitate the biggest changes to the junior doctors contract since 1999. It will allow the Government to deliver a seven-day NHS, improve patient safety and support much needed productivity improvements, as well as strengthening the morale and quality of life of junior doctors with a modern contract fit for a modern health service.

The contract inherited by the Government had a number of features badly in need of reform, including low levels of basic pay as a proportion of total income, which made doctors rely too heavily on unpredictable unsocial hours supplements to boost their income; automatic annual pay rises even when people took prolonged periods of leave from the NHS; an unfair banding system that triggered payment of premium rates to every team member even if only one person had worked extra hours; high premium rates payable for weekend work that made it difficult to roster staff in line with patient need; and risks to patient safety, with doctors sometimes required to work seven full days or seven full nights in a row without proper rest periods.

The Government have always been determined that our NHS should offer the safest, highest quality of care possible, which means a consistent standard of care for patients admitted across all seven days of the week. The new contract agreed yesterday makes the biggest set of changes to the junior doctors contract for 17 years, including by establishing the principle that any doctor who works less than an average of one weekend day a month—Saturday or Sunday—should receive no additional premium pay, compensated for by an increase in basic pay of between 10% and 11%; by reducing the marginal cost of employing additional doctors at the weekend by about a third; by supporting all hospitals to meet the four clinical standards most important for reducing mortality rates for weekend admissions by establishing a new role for experienced junior doctors as senior clinical decision makers able to make expert assessments of vulnerable patients admitted to or staying in hospital over weekends; and by removing the disincentive to roster enough doctors at weekends by replacing an inflexible banding system with a fairer system that values weekend work by paying people for actual unsocial hours worked, with more pay for those who work the most.

The Government also recognise that safer care for patients is more likely to be provided by well-motivated doctors who have sufficient rest between shifts and work in a family-friendly system. The new contract and ACAS agreement will improve the wellbeing of our critical junior doctor workforce by reducing the maximum hours a doctor can be asked to work in any one week from 91 to 72; reducing the number of nights a doctor can be asked to work consecutively to four, and the number of long days a doctor can be asked to work to five; introducing a new post, a guardian of safe working, in every trust to guard against doctors being asked to work excessive hours; introducing a new catch-up programme for doctors who take maternity leave or time off for other caring responsibilities; establishing a review by Health Education England to consider how best to allow couples to apply to train in the same area and to offer training placements for those with caring responsibilities close to their home; giving pay protection to doctors who switch specialties because of caring responsibilities; and establishing a review to inform a new requirement for trusts to consider caring and other family responsibilities when designing rotas.

Taken together, these changes show both the Government’s commitment to safe care for patients and the value we attach to the role of junior doctors. While they do not remove every bugbear or frustration, they will significantly improve flexibility and work-life balance for doctors, leading, we hope, to improved retention rates, higher morale and better care for patients.

Whatever the progress made with today’s landmark changes, however, it will always be a matter of great regret that it was necessary to go through such disruptive industrial action to get there. We may welcome the destination, but no one could have wanted the journey, so today I say to all junior doctors, whatever our disagreements about the contract may have been, that the Government have heard and understood the wider frustrations they feel about the way they are valued and treated in the NHS. Our priority will always be the safety of patients, but we also recognise that to deliver high-quality care we need a well-motivated and happy junior doctor workforce. Putting a new modern contract in place is not the end of the story. We will continue to engage constructively to try to resolve outstanding issues, as we proceed on our journey to tackle head on the challenges the NHS faces, and make it the safest, highest-quality healthcare system anywhere in the world. Today’s agreement shows we can make common cause on that journey with a contract that is better for patients, better for doctors and better for the NHS. I commend my statement to the House.

I start by putting on record our thanks to Sir Brendan Barber and ACAS for the role they have played in finding agreement between the two sides in this dispute. I also pay tribute to the Academy of Medical Royal Colleges, which proposed these further talks and encouraged both the Government and the BMA to pause and think about patients.

I have not been shy in telling the Health Secretary what I think about his handling of this dispute, but today is not the day to repeat those criticisms. I am pleased and relieved that an agreement has been reached, but I am sad that it took an all-out strike of junior doctors to get the Government back to the table. What is now clear, if it was not already, is that a negotiated agreement was possible all along. I have to ask the Health Secretary why this deal could not have been struck in February. Why did he allow his pride back then to come before sensible compromise and constructive talks?

When he stands up to reply, he may try to blame the BMA for the breakdown in the negotiations, but he failed to say what options he was prepared to consider in order to ensure that the junior doctors who work the most unsociable hours are fairly rewarded. It was a “computer says no” attitude, and that is no way to run the NHS.

Why did the Health Secretary ignore my letter to him of 7 February, in which I asked him to make an explicit and public commitment to further concessions on the issue of unsociable hours? I was clear that if he had done that then, I would have encouraged the BMA to return to talks. Why did he insist instead on trying to bulldoze an imposed contract through, when virtually everyone told him not to, and the consequences of doing so were obvious for all to see—protracted industrial action, destroyed morale and a complete breakdown in trust?

On the detail of the new contract, will the Health Secretary say a little more about the agreed changes that will undo the discriminatory effect on women of the last contract he published? Does he now accept that the previous contract discriminated against women? Will he be clear for the record that he now understands this was never “just about pay”? Can he confirm that concessions have been made not only in respect of the mechanism for enforcing hours worked and breaks taken, but in ensuring that the specialties with the biggest recruitment problems have decent incentives built into the contract?

Moving on to what happens next, can the Health Secretary tell us what he will do if junior doctors vote against this offer? Will he still impose a contract, and which version of the contract will he impose—his preferred version or this compromised one? Can he say whether the possibility of losing a case in the High Court about his power to impose a contract had anything to do with his recently discovered eagerness to return to talks? We all know that the High Court told him he had acted above the law when he tried to take the axe to my local hospital, so I can understand why he does not want that embarrassment again.

Finally, let me caution the Health Secretary on his use of language both in this Chamber and in the media. His loose words and implied criticism of junior doctors is partly the reason why this has ended up being such an almighty mess. May I suggest that a degree of humility on the part of the Secretary of State would not go amiss? May I recommend a period of radio silence from him to allow junior doctors to consider the new contract with clear minds, and without his spin echoing in their ears? I remind him that he still needs to persuade a majority of junior doctors to vote in favour of the contract for the dispute to be finally over.

I hope with all my heart that yesterday’s agreement may offer a way forward. Junior doctors will want to consider it; trust needs to be repaired, and that will take time. I hope for the sake of everyone, patients and doctors, that we may now see an end to this very sorry episode in NHS history.

The hon. Lady is wrong today, as she has been wrong throughout this dispute. In the last 10 months, she has spent a great deal of time criticising the way in which the Government have sought to change the contract. What she has not dwelt on, however, is the reason it needed to be changed in the first place, namely the flawed contract for junior doctors that was introduced in 1999.

We have many disagreements with the BMA, but we agree on one thing: Labour’s contract was not fit for purpose. Criticising the Government for trying to put that contract right is like criticising a mechanic for mending the car that you just crashed. It is time that the hon. Lady acknowledged that those contract changes 17 years ago have led to a number of the five-day care problems that we are now trying to sort out.

The hon. Lady was wrong to say that an all-out strike was necessary to resolve the dispute. The meaningful talks that we have had have worked in the last 10 days because the BMA bravely changed its position, and agreed to negotiate on weekend pay. The hon. Lady told the House four times before that change of heart that we should not impose a new contract. What would have happened if we had followed her advice? Quite simply, we would not have seen the biggest single step towards a seven-day NHS for a generation, the biggest reforms of unsocial hours for 17 years, and the extra cost of employing a doctor at weekends going down by a third. We would not have seen the reductions in maximum working hours. We would not have seen many, many other changes that have improved the safety of patients and the quality of life of doctors.

The hon. Lady was also wrong to say that the previous contract discriminated against women. In fact, it removed discrimination. Does that mean that there are not more things that we can do to support women who work as junior doctors? No, it does not. The new deal that was announced yesterday provides for an important new catch-up clause for women who take maternity leave, which means that they can return to the position in which they would have been if they had not had to take time off to have children.

The hon. Lady asked what would happen if the ballot went the wrong way. What she failed to say was whether she was encouraging junior doctors to vote for the deal. Let me remind her that on 28 October, she told the House that she supported the principle of seven-day services. As Tony Blair once said, however, one cannot will the end without willing the means. The hon. Lady has refused to say whether she supported the withdrawal of emergency care, she has refused to say whether she supports contentious changes to reform premium pay, and now she will not even say whether doctors should vote for the new agreement.

Leadership means facing up to difficult decisions, not ducking them. I say to the hon. Lady that this Government are prepared to make difficult decisions and fight battles that improve the quality and safety of care in the NHS. If she is not willing to fight those battles, that is fine, but she should not stand at the Dispatch Box and claim that Labour stands up for NHS patients. If she does not want to listen to me, perhaps she should listen to former Labour Minister Tom Harris, who said:

“Strategically Labour should be on the side of the patients and we aren’t.”

Well, if Labour is not, the Conservatives are.

I congratulate both sides on returning to constructive negotiations and on reaching an agreement. I pay particular tribute to Professor Sue Bailey and the Academy of Medical Royal Colleges for their role in bringing both sides together. I welcome the particular focus, alongside the negotiations around weekend pay, on all the other aspects that are blighting the lives of junior doctors. I welcome the recognition that we need to focus on those specialties that it is hard to recruit to and on those junior doctors who are working the longest hours, as well as the focus on patient safety.

However, we are not out of the woods yet. We need junior doctors across the country to vote for this agreement in a referendum. May I add my voice to that of the Opposition spokesman on health to say that what is needed now is a period of calm reflection? We need to build relationships with junior doctors into the future. Will the Secretary of State comment on his plans for building those relationships with our core workforce?

First, I very much agree with my hon. Friend in her thanks to Professor Dame Sue Bailey for the leadership that the Academy of Medical Royal Colleges has shown in the initiative that, in the end, made these talks and this agreement possible. I know it has been a very difficult and challenging time for the royal colleges, but Professor Bailey has shown real leadership in her initiative.

I also very much agree with my hon. Friend about the need to sort out some of the issues that have been frustrations for junior doctors—not just in the last few years, but going back decades—in terms of the way their training works and the flexibility of the system of six-month rotations that they work in. This is an opportunity to look at those wider issues. We started to look at some of them yesterday. I think there is more that we can do.

It is important that this is seen not as one side winning and the other side losing, but as a win-win. What the last 10 days show is that if we sit round the table, we can make real progress, with a better deal for patients and a better deal for doctors. That is the spirit that we want to go forward in.

I absolutely welcome this agreement, and I pay tribute to the Academy of Medical Royal Colleges for bringing it about. I do wish there had been some response to the letter that I and other Members sent before the all-out strike, because it was a genuine attempt to create a space that both sides could step into. However, I am glad that we have got to that stage now.

I welcome the recognition of the equality issues, which, to us and to many junior doctors, appeared to have been dismissed in the impact assessment. On the idea of flexible training champions in each trust, I myself was a flexible training senior surgeon—indeed, the first one in Scotland—and the idea of accelerated training is important. However, one concern I have is about childcare. If women junior doctors are going to be working longer, more antisocial shifts—I remember what I had to fork out for childcare—I would like to know whether the NHS will respond to that. Will that be in the form of crèche hours or support?

I welcome the fact that the hours guardian will be linked to the director of medical education and that there will be an elected junior doctors forum. One concern of junior doctors was that they would have no voice in relation to the guardian.

I also welcome the idea of using modern technology in rota-ing. At the moment, rotas are sheets of paper, and often no one looks at the shoulder from one rota to the next, so people can end up with the very long periods on call. However, one concern that remains is rota gaps. We do not have enough junior doctors, and we do not have enough junior doctors in the most acute specialties. How is the Secretary of State planning to re-establish a relationship? How is he going to recruit people to fill that gap? That was the core fear of junior doctors: a lack of doctors, with doctors simply being spread further. How are we going to recruit and retain doctors after the painful clash that has been going on for the last year?

I welcome the tone of the hon. Lady’s comments; we might have wished for a similar tone from the shadow Health Secretary. Let me address the comments of the hon. Member for Central Ayrshire (Dr Whitford) as constructively as she made them to me. She is right about flexible training. We have to recognise that the junior doctor workforce is now majority female, and that a number of family and caring pressures need to be taken account of. We need to do that for the NHS not only because it is the right thing to do, but because we will lose people if we do not. Those people will simply leave medicine, even though they have been through very extensive and expensive training.

We have to look particularly at the responsibilities of doctors with young children. One of the things that we announced yesterday was an obligation on trusts to take account of caring responsibilities. If, for example, a doctor wanted to work fewer hours in school holidays and more hours in term time, we cannot guarantee that a hospital would always be able meet those needs—the needs of patients always have to come first—but they could at least be taken account of, in the same way as they are in many other industries that operate 24/7. The hon. Lady is absolutely right to say that modern technology is key to that. An air steward or a pilot who works for British Airways can go on to an electronic system and choose the shifts and hours that they want to work. Because we have failed to modernise the NHS, we have seen a huge growth in agency and locum work, which is partly driven by the fact that it offers precisely the flexibilities that people need. These are important changes, and we intend to take them forward.

My right hon. Friend’s actions and those of the Department and the BMA in reaching an agreement will be warmly welcomed and met with a sigh of relief. Does he accept that the fact that the BMA was prepared to think again on crucial issues, such as overtime at weekends, should be seen as a sign not of weakness but of maturity, in working with the Government to ensure that we have a seven-day NHS that is for the benefit of patients and patient safety?

I absolutely agree with that wise comment, and it befits someone who is experienced in working in the Department of Health. We always get further if we sit around the table and talk about such issues. The Government are determined to improve the quality and safety of care for patients, and it is important to recognise that if the Government are successful, it will be better for the morale of doctors. The happiest, most motivated doctors work in the hospitals that are giving the best care to patients. That is why it is a win-win.

I say to Labour Members that it was the refusal of the BMA for many years to talk about the issue that my right hon. Friend referred to that meant we reached a deadlock. The fact that the Government were willing to proceed with important reforms on our own if we had to meant that, in the end, everyone came together and had a sensible negotiation. We got to the right place. I am sure everyone wishes that we had not had to go on the journey we went on to get there, but now that we have got there, I think it is the time for being constructive on all sides.

I also thank the Minister and the BMA for coming to an agreement. The Minister said that it was a win-win for everyone, and so it is. It is always good to talk, and dialogue brings results. That happened in Northern Ireland, and it has happened with the conclusion of this process as well. A good deal has been reached, and some 45,000 junior doctor BMA members will now be asked to vote on it.

We have had eight days of strikes since January, and some 40,000 planned non-urgent operations and 100,000 out-patient appointments have been cancelled. May I ask the Minister what will be done to catch those up, and what discussions he has had with the Northern Ireland Assembly about the agreement?

I reassure the hon. Gentleman that we are in constant touch with the devolved regions and countries to make sure that they know the changes that we are making, and to share any learning that we have from the processes that we have been through, so we will certainly do that. Across the country, we are doing everything we can to catch up with the backlog of operations, procedures and out-patient appointments—all the things that have been affected by the industrial relations dispute. Trusts will always prioritise the areas where clinical need is the greatest, but I know that that work is ongoing across the country.

I very much welcome the agreement that has been reached. We know that the Secretary of State recognises the importance of having a happy and well-motivated workforce, and this contract addresses many of the causes of unhappiness for junior doctors. It is particularly good to hear the points made today about addressing the problems of couples who are both junior doctors. However, there is clearly more to do, as has been acknowledged, especially on the reasons why junior doctors feel unsupported and often not valued by their employers. My right hon. Friend commissioned Professor Sue Bailey to carry out a review of the underlying problems experienced by junior doctors during training. Will he advise us whether the review will now proceed?

The request from the BMA was to find a new way of proceeding with that very important work, and that is what we will do. We will do so with the input of Professor Bailey, because she has a very important contribution to make. My hon. Friend is absolutely right to say that, as well as more flexible working for people with family commitments, the big issue for many junior doctors is the way in which the training process happens. In particular, the issue is about the way that continuity of training has been undermined by the new shift system—we need that system for reasons of patient safety—and that often means that someone is given advice by a different consultant on different aspects of care from one day to the next, which is frustrating. We will look at all those issues with Professor Bailey, Health Education England and the BMA to see whether we can find a better way forward.

Is the Secretary of State aware that even my constituents struggling with the possible closure of their A&E at the hospital in Huddersfield nevertheless welcome this announcement and thank anyone and everyone who has brought it about? That includes, I must say, leaders from the Opposition parties—our health spokespeople—who have done so much to help maintain a positive spirit. Will the Secretary of State just not gloat about this, but keep a period of silence? This is part of the phenomenon of people’s deep unhappiness about the NHS. Problems will arise again because so many people working in the NHS know it is being privatised by the back door and know that the clinical commissioning system is not working. Those problems will come back again and again unless he confronts that issue.

That would have been a constructive contribution to this morning’s discussion if the hon. Gentleman had not descended into totally false slurs about this Government’s commitment to our NHS. I would just say to him that if people support and are passionate about the NHS, as this Government are, then they put in the money—we are putting in £5.5 billion more than his party promised at the last election—and make the difficult reforms necessary to ensure that NHS care is as good as or better than anything that can be provided in the private sector. That is what this Government are doing: we believe in our NHS, and we are backing it to provide the best care available anywhere in the world.

I strongly welcome this important statement and the Secretary of State’s leadership, and I congratulate all those involved in the discussions. On Tuesday, I spoke at my advice surgery in Eastleigh to a constituent, a new mum who is a junior doctor and is married to a senior nurse. She is unable to fast-track into working as a GP, and part of her concerns about the negotiations involve the future childcare arrangements for her four-month-old baby. Such concerns weigh heavily on her family, particularly in relation to on-call working. May I ask that agile working and family first issues are truly taken into account for nurses and doctors who are trying to bring up families together?

My hon. Friend gives one example, but there are thousands of such examples. Such people are totally committed to the NHS, have a bright future in it and can make a huge contribution to its success by doing a good job in looking after patients, but they also have home responsibilities that are difficult to fulfil when there are very inflexible rostering systems. One of the big wins from yesterday’s agreement is that we will be able to look at the way the rostering system works to try to bring in such flexibility. If we do not do so, more and more doctors will want to be locums or to work for an agency and we will lose the continuity of care for patients, which is one of the best things about our GP system. That is why there is an urgent need—from the perspective of patients, as well as from that of doctors—to address that issue.

I am interested in the Secretary of State’s thoughts about the serious impact on morale that the dispute has had. I was talking to a junior doctor in Sheffield the other day who said that before the dispute he had never looked at his contract, he had simply got on and done what was needed, whenever it was needed. Does the Secretary of State realise that even if the dispute is now settled, as we hope, it has had a serious impact on good will in the health service, which could affect service delivery in the future?

If the hon. Gentleman looks at the latest NHS staff survey, it shows higher staff motivation, better communication and more staff recommending their organisation as a place to work or be treated. But I accept that when big changes are made to a contract such as the junior doctors contract, they can be contentious and have a short-term impact on morale. In the long run, morale goes up when doctors are able to give better care to patients, and that is what this agreement will allow.

The Secretary of State has done a good job of explaining today, but let us look at this in the cold light of day. The BMA caused a problem that should have been resolved a long time ago. It decided it would make a political point. That is fair enough, and I know we want reflection. The Opposition should have been big enough to say, “We want to cause political trouble on this.” A lot of this has been caused by political shenanigans that should not have been allowed to get to this stage, and the failure means that the junior doctors have lost prestige throughout the United Kingdom because they have been used as political pawns by two organisations. Does the Secretary of State agree?

It is a great tragedy that the dispute unfolded in the way that it did, and I am sure that people with different agendas have not played constructive roles at various points. Given that we now have an agreement, I want to move forward positively and say that the lesson of the last 10 days is that when people sit down and negotiate about all the outstanding issues with a Government who are trying to make care safer and better for patients, we get a result that is good for everyone.

It is not the time to claim victory: this negotiated agreement now has to be put to the members of the British Medical Association. Will the Secretary of State acknowledge that his own refusal to negotiate exacerbated this crisis? Will he cease referring to the British Medical Association as a militant trade union, and will he heed the call from my hon. Friend the shadow Secretary of State for a period of silence in order to avoid antagonising the junior doctors still further?

Let us be absolutely clear: there was never a refusal to negotiate on the Government’s side. We have now developed a lot of trust between the Government and the BMA leadership, but until that point it balloted for industrial action without even sitting down and talking to the Government, and it refused to discuss the issue of weekend pay premiums, which was the crucial change we needed for a seven-day NHS. It was when the BMA changed its position in those areas that we were able to have constructive talks, and that is why it deserves great credit for coming to the table and negotiating—something it had not wanted to do previously—and that led to the solution.

I thank the Secretary of State for working so hard to bring about this resolution and for always putting users of the NHS at the heart of everything he does. Will he join me in urging junior doctors to consider the new contract with an open mind when voting, and to strip out some of the politics that we have heard? Let us consider what is best for patients, what is best for the NHS and then what is best for junior doctors.

My hon. Friend speaks wisely. I understand that in a contentious industrial relations dispute junior doctors will not necessarily look to me for advice on which way they should vote, but it was not just me doing the agreement. It was a negotiated agreement and the leader of the junior doctors committee says that it is a good agreement. He will encourage people to support it in the ballot and he thinks it is a good way forward for doctors as well as for patients. The people who have been closest to the detail of the negotiations think that it is the right step forward for junior doctors, and that is something that they will want to take account of.

I do not wish to invite the Secretary of State to provoke or pre-empt by presumption, but if the agreement changes the shape of services, it will have implications for other health professionals. Is he prepared to have the further conversations that will need to be had, and the wider conversations that will be needed with his ministerial counterparts across these islands on workforce planning, professional education and training?

We are, of course, willing to have those discussions with colleagues in other parts of the UK. The hon. Gentleman is right to say that having a seven-day service does not just involve junior doctors; it involves widespread changes across the service. I should say that nurses, healthcare assistants, porters, cleaners—other people who work in hospitals—already operate on 24/7 shifts, so the changes necessary to those contracts are much less profound than they are to some of the doctors contracts, which is why it is important that we change not just the junior doctors contract, but the consultants contract. The fact that we have been able to reach a negotiated agreement with the junior doctors bodes well for the consultants contract, which is the next step.

I congratulate both my right hon. Friend and the Under-Secretary of State for Health, my hon. Friend the Member for Ipswich (Ben Gummer) on their hard work in dealing with this protracted dispute with the BMA. Patients up and down the country, including those in my constituency, were somewhat concerned about the cancellation of operations, and I am delighted that the Department is going to try to ensure that we catch up on that. One thing that came out of this dispute was that some senior consultants ended up getting on to the front line for the first time in a long time. What can be done to try to make sure that that happens on a regular basis, so that they are getting experience on the front line, too?

If I answer that question directly, I will dig myself into rather a deep hole. I echo my hon. Friend’s thanks to my hon. Friend the Member for Ipswich, who has done an outstanding job by my side at every stage throughout this difficult period. I can certainly say that we would not have had yesterday’s agreement without his strong help and support at every stage. It is true that there are A&E departments across the country that, in having to plan for the two-day withdrawal of emergency care, found that having consultants more visible to patients had some positive impacts. I know that studies are going on to see what lessons can be learned from that going forward.

I, too, welcome the opportunity for a negotiated settlement, but let us take just a moment to reflect on one of the fundamental principles of our NHS—providing high-quality patient care. Will the Secretary of State take the opportunity today to offer a heartfelt and sincere apology for the significant and severe distress caused to patients as a result of this prolonged dispute?

With the greatest of respect to the hon. Lady, it was not my decision to take industrial action—to ballot for industrial action without even being prepared to sit around the table and talk to the Government. We are seeing dramatic improvements in patient safety under this Government, as we face up to the many problems in care that we inherited, not just at Mid Staffs, but at many other places. I know that she cares about patient safety, so she should welcome the difficult changes we have made, one of which is to have a seven-day NHS.

Like many colleagues in the House, I wrote to the Secretary of State on numerous occasions over the past six months to express the concerns of local junior doctors. May I therefore congratulate him and the BMA on reaching this deal? I hope that junior doctors in Wimbledon will wholeheartedly support it. He spoke in his statement about the role of the guardian and the ability to ensure safe working hours, on behalf of both patients and doctors. Will he give a few more details about how he expects that to work?

Yes, I am happy to do that, and I thank my hon. Friend for a lot of his correspondence. The principle here is that junior doctors want to know that there is someone independent they can appeal to if they think they are being asked to work hours that are unsafe and which mean that they cannot look after patients in the way that they would want to because they are physically or mentally too exhausted. We would all want to make that possible, but it means that they need to have someone who is not their line manager. They will go to their line manager in the first instance, but they need to have someone independent and separate. One area where we have made the most progress during the past few months, even before the past 10 days of talks, is on establishing how these guardians can work in a way that has the trust of both the hospitals and the doctors working in them.

The Secretary of State is absolutely right that we can always get further if we get round the table, so why, in response to the cross-party initiative back in February to get everybody around the table, did he not do exactly that and save us all this trouble, rather than trying to impose the contract?

The cross-party initiative was not to have a new contract, but to abandon plans for a new contract and to have pilots in a few limited places. If we had followed that advice, we would not now have agreed with the BMA the biggest changes in the junior doctors contract for 17 years. Our goal was to get the agreement that we secured yesterday—safer care for the NHS and a better deal for doctors. That was what we achieved, and we would not have got there if we had listened to that advice.

May I join the welcome for the agreement and the persistence and patience that eventually paid off? In previous statements, I have raised with the Secretary of State the problem involving married couples who are both doctors. There are difficulties with training when they are sent to different areas and with rosters that clash. Will he say a word about the progress that has been made in this important area of making work a bit more family-friendly?

I am happy to do that for my hon. and learned Friend. It is not an easy problem to solve, because junior doctor training placements operate on six-month rotations, and they are a competitive process. We get many more applicants for a number of posts than there are posts available. We must find a way of balancing the need to respect family responsibilities, which is something that we all want to do, with the need to have a fair process for the most competitive positions. We do not have the balance right yet, so we have said that Health Education England, which decides where people are to go on rotations, will now have a duty to consider family responsibilities when it makes decisions about those rotations.

I welcome the potential resolution of this dispute and thank the Government for negotiating it. We should also thank junior doctors for having the courage to go on strike, which no one does lightly, to get a better deal for the NHS. I ask the Secretary of State to reflect on this breakthrough, to take further steps to build on his difficult relationship with NHS staff and, crucially, to stop presenting NHS policy as a false dichotomy between the interests of patients and the interests of NHS staff.

If the hon. Gentleman had listened to some of the things that I have said, he would have heard me say repeatedly that I do not think that that dichotomy exists. As he says, it is a false dichotomy because, in the end, what is right for patients is also right for doctors. The thing that demoralises doctors, nurses and everyone working in our hospitals in different parts of the NHS is when they are not able to give the care that they want or that they think is appropriate to the patients in front of them. That is why hospitals that have moved closest towards seven-day services are also some of the hospitals with the highest levels of morale in the NHS. He is right that it is a false dichotomy and that we need to do both together.

As the Secretary of State knows, my brother and his wife were junior doctors when they made the decision to move to New Zealand a long while ago because of the long-standing cultural problems within the NHS. They will be very pleased indeed about the announcement yesterday about couples potentially being able to work together in hospitals. I have a question for the Secretary of State from my mother. She wants to know what he can do now to encourage my brother, his wife and their friends back into the NHS.

Let me say to my hon. Friend’s mother that I hope that the message of this new agreement will go right the way around the world. Any doctors who have moved to New Zealand and Australia are always welcome to come back. The thing that must unite this Government and the good doctors who work, or have worked, in the NHS is our commitment to make NHS care the safest and the best in the world. We had a terrible shock with what happened at Mid Staffs, but we are using that as a moment of decisive change in the NHS, and we are well on our way to higher standards of care than are available in many other countries.

I congratulate the Government and everyone involved on getting this deal in place. It will have a knock-on effect in my constituency in Northern Ireland. When I went around Antrim Area hospital, the concern was to do with the number of doctors, which we have heard about from other Members, and how to get seven-days-a-week cover from everything else that needs to go into the health service. Will the Secretary of State comment on how we will deal with that, and how we will work with the devolved Parliaments?

I agree. We need more doctors and we need more nurses. By the end of this Parliament, we will have over a million more over-70s in England alone, and I know that the demographic effects in Northern Ireland will be equivalent. We have a global shortage of about 7 million doctors, so we need to train more. We are training an extra 11,420 doctors over this Parliament as part of the spending review. The training is done on a UK-wide basis, so we will need to work closely with all the devolved regions on it.

I warmly welcome this draft agreement, which will be met with some relief in Cheltenham. Whatever our deeply held concerns about the behaviour of the BMA in the past, does the Secretary of State agree that it should be our ambition that the agreement will mark the beginning of a more constructive future? Will he join me in congratulating BMA negotiators, including Dr Malawana, for being prepared to address constructively issues such as Saturday pay?

I am happy to do that. I recognise that this was not easy for those people, because it involved changing a position that they had held for more than three years. When we looked at the details, the result that we got to was not difficult for them to sign up to because they could see that it really was better for their members, as well as better for patients. The lesson here is that the NHS faces huge challenges, and it can only be right to deal with them by sitting round the table and negotiating constructively.

I, too, warmly welcome the news of the agreement, and I hope that it leads to a settlement. If it is the Secretary of State’s intention to create a seven-day NHS, that will require the participation of more than the junior doctors, so does he intend to bring forward a new contract for consultants, hospital lab workers, ambulance workers, nurses or indeed ancillary workers and catering staff?

The hon. Gentleman is right. A seven-day NHS is not just, or not even mainly, about junior doctors, although they are a very important part of the equation. We will need a new contract for consultants and we are having constructive negotiations with them. Many other people working in the NHS are already on seven-day contracts, so there will not necessarily be a contractual change, but the hon. Gentleman is right to say that we will need, for example, diagnostic services operating across seven days so that the junior doctor who works at the weekend will be able to get the result of a test back at the weekend. Those are all part of the changes that we will introduce to make the NHS safer for patients.

I warmly congratulate both sides on reaching this agreement. Our NHS is different at weekends, and my right hon. Friend is right to inculcate Sir Bruce Keogh’s four key clinical standards on a Sunday and a Saturday. Does he agree that it is important not simply to rely on mortality data, which are often difficult to interpret, to underpin the case for a seven-day NHS? Will he look closely at other metrics based on clinical standards for things like routine lists for upper gastrointestinal endoscopy on a Saturday and Sunday? Will he also look at palliative care, which of course does not feature in any hospital mortality data?

My hon. Friend speaks, as ever, very wisely on medical matters. I particularly agree when he talks about palliative care; it has got better, but there is a long way to go. We have recent evidence that it is particularly in need of improvement where we are not able to offer seven-day palliative support.

I welcome this settlement and thank everyone involved for securing it. However, many junior doctors remain concerned that, as the hours worked at the weekend increase, cover is inevitably reduced during the week, unless more junior doctors are employed to bridge that gap. With many rotas already left unfilled around the country during the week, how can the Secretary of State guarantee that we will not make the situation worse during the week, thereby impacting on patient safety?

I understand the concern. The short answer is that we need to increase the NHS workforce, which we are doing. We will see more doctors going into training during this Parliament, as indeed we did during the previous Parliament. More doctors in the workforce will be an important part of the solution.

It appears that at the start of the recent negotiations the payment for Saturday working was the main sticking point for the BMA, but now the issue of weekend pay has been resolved. Will my right hon. Friend confirm that, now, the doctors who work extended hours over the weekend can get extra pay, and patients can get the seven-days-a-week NHS we all want?

My hon. Friend is absolutely right. This is not just a safer deal for patients, but a system that is much fairer for doctors than the current one. We are giving a pay rise of between 10% and 11%, for which we say that people are expected to work one weekend day a month, but doctors who work more than that get more, and it goes up, so more weekends worked means more extra pay. I think that is one of the reasons why the BMA was prepared to sign up to the agreement: it values the people who give up the most weekends.

I was contacted by a constituent who told me how his four-year-old daughter fell through a pane of glass, severely cutting her face. Unfortunately, the accident happened on a Friday evening, and because insufficient doctors were working over the weekend, she could not have an operation to remove any remaining glass from the wound until Monday, by which time the wound had started to heal and was misaligned. That four-year-old girl will suffer severe facial scarring for the rest of her life. Does my right hon. Friend agree that this is why we need a seven-day NHS?

I could not put it better myself. We all hear stories of that sort from our constituents and our families. That is why, in the end, yesterday’s agreement was a very positive step forward in that seven-day agenda.

I must confess to being rather puzzled. The BMA said all along that the strike and dispute had nothing to do with weekend pay and terms, yet after negotiations limited simply to weekend pay and terms, the BMA has come to a deal and advised against strike action. Can we take it that, despite much huffing and puffing from the BMA that this was about the future of the NHS and all the rest of it, at the end of the day it was all about weekend pay and terms?

I think my hon. Friend is right that that was the big sticking point. It was the BMA’s willingness to be flexible and negotiate on that that ultimately made an agreement possible, but it is also fair to say that the Government recognise that there are many other non-contractual issues in the way that junior doctors are trained and treated by the NHS, and we want to use this opportunity to put them right.

I congratulate the Secretary of State on putting patients first, but does he recognise that there are still people out there whose operations were cancelled due to industrial action? Will he look to the future and consider whether front-line medical staff should have the right to strike and so put people’s health on the backburner or postpone their medical care?

I know that that is a view that some colleagues share. Doctors have obligations even now under the Medical Act 1983 not to take action that would harm patients, and under their responsibilities to the General Medical Council; they have to be aware of those. What I hope is that that question simply does not arise again. We are now having constructive discussions with the BMA; I think that is the way forward and I hope that neither I nor any future Health Secretary has to go through what has happened in the past 10 months.

I applaud the tone and content of the Secretary of State’s remarks. I think this agreement will go down as a breakthrough in the NHS. It has been very uncomfortable to engage in dialogue with constituents who are junior doctors, who have felt aggrieved, so I particularly welcome the way my right hon. Friend has been able to look at non-contractual issues. I urge him to give serious consideration to the outcome of the Bailey review so that progress can be made on morale and the wider issues that have been raised.

I finish by saying that I completely agree with my hon. Friend. It has been a very sad dispute for all of us, because we all recognise that junior doctors are the backbone of the NHS; they work extremely hard and they often work the most weekends already. That we now have an agreement is a brilliant step forward. We all have constituents who work hard for the NHS. They are people we value, so dialogue, negotiation and constructive discussion must always be the way forward.