I beg to move,
That this House notes the stalled discussions between Government and the British Medical Association (BMA) about a new junior doctors’ contract; opposes the removal of financial penalties from hospitals which protect staff from working excessive hours; urges the Government to guarantee that no junior doctor will have their pay cut as a result of a new contract; and calls upon the Government to withdraw the threat of contract imposition, put forward proposals which are safe for patients and fair for junior doctors and return to negotiations with the BMA.
It is a privilege to be opening a debate from the Opposition Dispatch Box for the first time, and I want to start in a way that is perhaps untypical for these debates. I want the Secretary of State and me to agree on something. I want him to join me in saying thank you to everyone who works in the NHS and in the care system in our country—not just the junior doctors who are the subject of today’s debate but all the staff who work day in, day out caring for our loved ones as though they were their own. So, to our doctors, nurses, porters, care workers and paramedics I say this: I know how hard you work; I know that many of you already work nights, weekends and even Christmas day, and for that we are hugely grateful.
I have called this debate today because I am deeply worried about the current stand-off between the Government and junior doctors. I am worried that a new Government-imposed employment contract will be unsafe for patients and unfair for doctors. I am worried that if the Health Secretary gets his way, he will fast become the best recruiting sergeant that the Australian health service has ever had.
If the hon. Gentleman reads the motion, he will see that it talks about a return to the negotiating table, but the BMA and the junior doctors need to know that the Health Secretary is genuinely willing to compromise, and his performance over the past few months suggests otherwise.
My constituency has one of the highest proportions of doctors of any in the country. My junior doctors are worried that they are being asked to work in conditions that are becoming unsafe. They also point out that they have choices, and many do not think that their future lies in this country. They will make a different choice because the damage has already been done.
My right hon. Friend is completely right, and I will come to some of those challenges later in my speech.
When the NHS is facing unprecedented challenges, it cannot be right to pick a fight with the very people who keep our hospitals running. I come here today to ask the Secretary of State to do three things: to show that he is willing to compromise by withdrawing the threat of contract imposition; to guarantee that no junior doctor will be paid less to do the same, or more, than they are currently doing; and to ensure financial penalties for any hospital that forces doctors to work excessive and exhausting hours.
On that basis, given that the Secretary of State has indicated in terms that no junior doctor will be required to work more hours—rather, it is fewer hours—than at present and that they will not lose money, can the hon. Lady give me any reason why the doctors’ leader was able to say to me earlier in the week that he would not get round the negotiating table and talk?
I am afraid that the Health Secretary has given absolutely no guarantee that no junior doctor will be paid less.
I have set out the three things that I wish the Secretary of State to do today. Anyone listening to this debate would say that they were all reasonable things to request. Anyone who wants to avoid industrial action would want the Secretary of State to step up and do the right thing.
Is my hon. Friend aware that tonight in Leeds, 2,000 junior doctors are getting together to protest against this Government’s plans? Does it not come to something when 2,000 junior doctors get together in such a way? Why, despite the assurances from those on the Government Benches, does she think that that is happening?
I will not give way, because I wish to make some progress.
The Health Secretary may claim that he is doing all he can to make the contract fair and safe, but the truth is that he is not. He may say that the overall pay envelope for junior doctors will stay the same, but he will not say who the losers will be. He may say that no junior doctor will work excessively long hours, but he will not tell us that he is removing the very safeguards that were designed to prevent that. He may even say that he has some support, but he will not read out the range of independent clinical voices who have condemned his approach.
The hon. Lady is right to focus on the future contract, but does she recognise the inadequacies in the existing contract?
I am not saying that the existing contract is perfect—I do not think that the British Medical Association would say that either. A few months ago, an alternative contract was being discussed, the work on which was led by the former Health Minister, the hon. Member for Central Suffolk and North Ipswich (Dr Poulter). The answer is not the contract that is on the table at the moment.
The Secretary of State may say that the overall pay envelope remains the same, but, as far as I am aware, it has been really hard to fathom how the difference between the local education training board contribution and the individual trusts will work. It may not be the same, but even if it is, is this not an example of further administrative and organisational costs being imposed on the health service by a Tory Secretary of State?
My hon. Friend is completely right. The lack of clarity in all these negotiations is something that I will come on to later.
The truth is that if the Secretary of State wanted to persuade junior doctors that industrial action is not the answer, he has the power to do so; it is his political choice.
Junior doctors are the lifeblood of the NHS. Two weeks ago, I spent a morning shadowing a junior doctor at Lewisham hospital. It was the single most powerful thing I have done since taking on this role. I was blown away by the skills, knowledge, humanity and professionalism I saw. The junior doctor I shadowed was working a gruelling 11-hour night shift and regularly works 60-hour weeks. I left the hospital asking myself how it could possibly be right to say to that individual, “You might be paid less for the work that you do.”
I think we would all join the hon. Lady in her glowing tributes to our tireless junior doctors, working long hours across the NHS. Considering that not a penny is planned to be cut from the junior doctors’ pay bill, does she not agree that it is irresponsible for the BMA to suggest there will be pay cuts of 30% to 40% for some doctors?
As I have already said, there is absolutely no clarity. The hon. Gentleman might do well to read the article that appeared in The Guardian on 4 October, written by the former Health Minister, who quite clearly states that he has concerns about the fact that the new contract might be used as a lever to find some of the £22 billion of efficiency savings that the NHS needs to find over the next few years.
I will not give way, as I am going to make some progress.
Junior doctors are not just the first-year trainees fresh out of medical school. They are also the senior house officers and registrars with 12 or 15 years of experience. Junior doctors account for almost half of all doctors in hospitals and the vast majority already work nights and weekends. The responsibilities they carry are huge. Take the junior paediatric doctor working in accident and emergency who emailed me last week. Some of the things she does, I could never ever do. In her email, she said:
“I am in charge of teams resuscitating dying children regularly. I have had to make the decision to stop resuscitating a dying child. I have had to tell parents that their child is going to die. I have been the only doctor trying to stick a tiny breathing tube into a baby born 16 weeks early and weighing 600g at 3 in the morning.”
How is it right that she should face the prospect of being paid less? She is not asking to be paid more. She is just asking to be paid the same and to keep the safeguards that prevent her from being stretched even further.
I do not think that any of us dispute the fantastic work that doctors do day in, day out, but we need to debate the motion that the hon. Lady has proposed. She said there were three points that she wants to put to the Secretary of State, but she failed to mention the one in the last line of the motion, which is that she wants proposals to be put forward that are “safe for patients”. Given that there was an article just last month on 5 September in the BMJ, put together by seven experts, including three professionals, that said that there was a clear association between weekend admission and worse outcomes for patients—
The problem with how the Government have handled the negotiations is that they have provided absolutely no clarity to junior doctors about what the proposals would mean for them individually. Everyone thinks that they are going to lose out.
The Government say that they want to reduce the number of hours defined as “unsocial” and thereby decrease the number of hours that attract a higher rate of pay. They say that they will put the rate of pay for plain time up to compensate, but there is no guarantee that the amount by which basic pay goes up will offset the loss of pay associated with fewer hours being defined as unsocial. Does the Secretary of State understand that those who work the most unsociable hours, the junior doctors who sacrifice more of their weekends and nights, feel that they have the most to lose?
That is exactly the point, and I am glad that my hon. Friend is exposing the misleading comments of the Government, who are defending the indefensible. It is exactly those doctors—in maternity, in paediatrics, in emergency medicine—who will lose out the most and will see their pay cut by up to a third.
My hon. Friend is right. His concern is shared by the President of the Royal College of Emergency Medicine, along with 14 other leaders of medical royal colleges and faculties, who point out that as currently proposed, the new contract would
“act as a disincentive to recruitment in posts that involve substantial evening and weekend shifts, as well as diminishing the morale of those doctors already working in challenging conditions.”
It cannot possibly be right.
I am grateful to the hon. Lady for giving way and I join her in the praise that she issued in her opening remarks. What advice might she give the BMA, were she asked for it? Is it better for the BMA to get back around the table, so that the very important points that she is raising can be sorted out, or go straight to a ballot? Is it not better to talk first, then, if the BMA does not like it, by all means ballot? It is certainly doing it in the wrong way.
I was humbled, privileged and honoured, along with my hon. Friend the Member for Easington (Grahame M. Morris), to march with the junior doctors in Newcastle on Saturday—5,000 junior doctors, hardly militants or revolutionaries, who were fighting not just for the pay but in the best interests of their patients. If there are no problems, if everything in the garden is rosy, why on earth are they demonstrating?
My hon. Friend makes an important point. The junior doctors I have met are genuinely worried that the proposals make it more likely, not less, that they will be forced to work even more punishing hours. The removal of financial penalties for hospitals that force junior doctors to work beyond their rostered hours concerns them. They are right to be concerned.
A junior doctor in my constituency made precisely that point. She was an A&E doctor. My hon. Friend knows that there is an A&E crisis in London. The Health Secretary needs to understand that while there is indecision and no conclusion to the negotiations, junior doctors are making decisions about where they are going—and they are not staying in England. That is the point.
Tired doctors make mistakes. It is obvious but it is true. Nobody wants to return to the bad old days of junior doctors too exhausted to provide safe patient care. It is bad for doctors, it is bad for patients and it is bad for the NHS. So why are this Government hellbent on forcing through these unsafe changes?
The Secretary of State claims that the changes are about making it easier for hospitals to ensure that the staff needed to provide safe care at the weekends and on nights are available. Is he saying that there are not enough junior doctors on hospital wards and in A&E departments at these times currently? If so, how many more junior doctors would be present at these times as a percentage increase on current staffing levels if the new contract goes through? If the changes are about increasing the cover at weekends and nights, surely it means less cover at other times of the week unless he finds more money for more doctors.
I understand the arguments for increasing consultant cover at weekends and nights. I understand it is vital that patients who are admitted on a Sunday get to see a consultant as quickly as those admitted on a Tuesday, and I am pleased that the BMA’s consultants committee is negotiating with the Government on improving levels of consultant cover. Indeed, everyone in the NHS supports the principle of seven-day services. But this debate is about junior doctors. Junior doctors are already working evenings and weekends. So why has the Health Secretary tried to make this a row about seven-day services?
Let me quote some of the claims that the Secretary of State has made in recent weeks. In response to a question on the junior doctor contract from my hon. Friend the Member for Wirral South (Alison McGovern), he said:
“someone is 15% more likely to die if admitted on a Sunday than on a Wednesday because we do not have as many doctors in our hospitals at the weekends as we have mid-week.”
In response to a question that I asked him about junior doctors, the Secretary of State said that the overtime rates that are paid at weekends
“give hospitals a disincentive to roster as many doctors as they need at weekends, and that leads to those 11,000 excessive deaths.”
He went on to say:
“there are 11,000 excess deaths because we do not staff our hospitals properly at weekends.”—[Official Report, 13 October 2015; Vol. 600, c. 150-1.]
The authors of the research that the Secretary of State has been quoting said that it would be “rash and misleading” to claim that the deaths were all avoidable. Yet the Health Secretary has got dangerously close to doing just that. Indeed, he has gone so far down that route that some people do not think that our hospitals are properly staffed at the weekend. I know of elderly patients delaying their visit to hospital because they do not think that there will be enough doctors there. That leads to more complicated treatment, longer patient recovery time, people’s lives being put in danger and a bigger bill for the NHS to cap it all off. That is appalling. Don’t get me wrong: I am as committed as anyone to high-quality care, available 24/7, 365 days a year, but the Secretary of State needs to be careful with his words. He should look in the mirror and ask himself whether his soundbites are true to the conclusions of the study he references.
I am very grateful to the hon. Gentleman. Let me quote the editor of the British Medical Journal, who wrote to the Secretary of State on 20 October, saying that he had
“publicly misrepresented an academic article published in The BMJ”.
She asks him to clarify the statements that he has made in relation to the article to show that he fully understands the issues involves. She further says:
“Misusing data to mislead the public is not the way to achieve”
the very best health service for patients and the public. The Health Secretary needs to be clear on exactly how reforming the junior doctor contract will deliver a seven-day NHS. He should set out how he plans to pay for seven-day services, and precisely which services he is talking about.
Last week I met junior doctors in my constituency, many of whom told me that they cannot afford to live in London. One reported that she was sleeping on the sofas of friends and family members in order to cover her night shifts while working in London. The doctors also reported unfilled vacancies in departments in the hospital which serve and look after the sickest patients. Does my hon. Friend agree that the recruitment and retention of junior doctors is a bigger threat to patient safety than the issues to which the Secretary of State alludes?
I do agree. I was talking about a seven-day NHS. A truly 24/7 NHS does not just mean consultants being more readily available; it means 24/7 access to diagnostic tests, social care, occupational therapists—the list goes on. If the Secretary of State has a magic pot of money to pay for all that, bearing it in mind that the NHS can barely pay for the work that it is currently doing, I am all ears. If his plan is to deliver seven-day services by spreading existing services more thinly, he should come clean and say so.
My hon. Friend makes a very powerful speech. I bring her back to an earlier point which needs emphasising. At the moment trusts have to provide rosters that are not only fair but safe, so that junior doctors get time off. Now it seems that trusts will no longer have to pay attention to those rules and will no longer be fined if they do not follow them.
There are very serious concerns about the proposed new contract, and my hon. Friend is right to highlight them.
The sad thing is that it did not have to be this way. Instead of using the dispute with junior doctors to suit his own political ends, the Health Secretary should have listened. He should have understood the depth and strength of concern before it got to the point where junior doctors feel as though they are the first line of defence in a fight for the future of the NHS. Instead of telling junior doctors that the BMA was misleading them, he should have respected their intelligence and responded to their concerns. At the very least, he should have heeded the words of the present Prime Minister, who said this about junior doctors when addressing a rally in 2007:
“There’s a simple truth at the heart of this: you came into the NHS not because you wanted to get rich or famous, but because you have a vocation about curing the ill, about serving your community.”
The Prime Minister went on to say in his conference speech a few days later:
“I will never forget walking on the streets of London marching with 10,000 junior doctors who felt like they were being treated like cogs in a machine rather than professionals with a vocation to go out and save lives”.
It is time the Health Secretary started treating junior doctors like the intelligent professionals they are. When I spoke at the junior doctors rally in London 10 days ago, I delivered a message for the Health Secretary. He was not working that Saturday so I repeat it for him now: stop the high-handed demands, show you are prepared to compromise and put patients before politics.
I beg to move an amendment, to leave out from “House” to the end of the Question and add:
“welcomes the Government’s commitment to delivering seven-day hospital services and saving lives by combating the weekend effect; notes the British Medical Association’s (BMA) decision to walk away from negotiations to reform a contract which all sides acknowledge is not fit for purpose; further notes the Government’s proposed introduction of new contractual limits which protect staff from working unsafe hours and the commitment that average junior doctors’ pay will not fall; and calls on the BMA to put patient care first, to choose talks over strikes, and to return to negotiations.”.
I warmly welcome the hon. Member for Lewisham East (Heidi Alexander) to her post at her first Opposition day debate.
One Saturday in April 2006 a 20-year-old man called John Moore-Robinson was out mountain biking with his friends in Cannock Chase when he fell off his bike and the handlebars hit his stomach. His friends dialled 999 and he was rushed to hospital. Although the paramedic who took him to hospital thought he had life-threatening internal bleeding, instead of being treated he was left for 50 minutes, apart from a brief examination. Then he was told he had bruised ribs and sent home. In fact, he had a ruptured spleen and tragically died later that Saturday night.
Tragedies happen in any healthcare system, and despite such stories I am fiercely proud of our NHS and the brilliant care given by our doctors and nurses seven days a week. The hon. Lady was right to thank each and every one of them. Anyone who uses such stories to denigrate the NHS should remember that last year the Commonwealth fund rated us the best healthcare system of 11 major countries—better than France, Germany, Australia or the US—and rated our A and E departments —[Interruption.] It was the Opposition who called this debate, so they might want to listen to some of the arguments. This is a very important issue about the lives of NHS patients, and I am saying that the tragedies and the problems we have should not be used to denigrate the NHS or our A and E departments.
Part of being the best in the world is being honest about where we need to improve, and the fact remains that in our hospitals today we have around three times less medical cover at weekends. In our manifesto in May this Government committed to a truly seven-day NHS so that we prevent a repeat of the tragedy that happened to John Moore-Robinson.
The Secretary of State is absolutely right that we need to address the fact that there seems to be less cover at the weekends. He is trying to circle that square without expanding the number of doctors and the services. He is thinning the service on Monday to Friday to bring more cover to the weekends. That does not solve the problem.
I am happy to deal with that. We went into the election in May saying that on the back of a strong economy we were prepared to commit £10 billion extra to the NHS in real terms over the course of this Parliament. That was £5.5 billion more than the hon. Lady’s party was prepared to commit. In the last Parliament, when the increase in NHS spend was half that amount, we increased the number of doctors by 9,000, so we are increasing the number of doctors, but as we do so we need to ensure that we give the right care to patients.
I want to give a word of caution to the shadow Secretary of State. The tragedy of John Moore-Robinson, the gentleman I have mentioned, happened not only on a Saturday, but at Mid Staffs. The last time the House discussed the difference between excess and avoidable deaths was under a Labour Government, when they tried to brush the problems at Mid Staffs under the carpet, saying that we should not take the figures on excess deaths too seriously because they were a statistical construct and different from avoidable deaths. I would have hoped that the Labour party learned the lessons of Mid Staffs and would not make the same mistakes again. [Interruption.]
Order. The hon. Member for Islington South and Finsbury (Emily Thornberry) may shake her head, but I expect voices in the Chamber to be a little quieter. I want to hear the Secretary of State, and I think all our constituents do. I understand that you might not agree.
Let us look at some of the facts. What is the most important thing for people admitted to hospital at the weekend? It is that they are seen quickly by a consultant. Currently, across all key specialties, in only 10% of our hospitals are patients seen by a consultant within 14 hours of being admitted at the weekend. Only 10% of hospitals provide vital diagnostic services seven days a week. Clinical standards provide that patients should be reviewed twice a day by consultants in high-dependency areas but, at weekends, that happens in only one in 20 of our hospitals across all key services.
Is the Secretary of State shocked, as I am, that the shadow Health Secretary seemed to say that the NHS should continue as it is, and that she appears to deny the weekend effect, which means that people are dying unnecessarily?
Yes, I am shocked. I am really shocked about the suggestion that there is a difference between what is right for patients and what is right for doctors. The shadow Secretary of State spent a lot of time talking about morale. The worst possible thing for doctors’ morale is their being unable to give their patients the care they want to give.
Does the Secretary of State not see anything perverse in making the case for a seven-day NHS—he has repeatedly done so—while drawing up a junior doctor contract that financially penalises doctors who already work evenings and weekends? How can that make any sense?
The contract will not do that. The contract we are proposing will give more reward to people who work the most antisocial hours. I will explain the details of that later.
The shadow Secretary of State talked about academic studies, so let us look at what the academic studies on the weekend effect say. The Freemantle study, published in the British Medical Journal, which is owned, incidentally, by the British Medical Association, said in September that the mortality rate for those admitted to hospital on a Sunday is 15% higher than for those admitted on a Wednesday. It said the weekend effect equated to 11,000 excess deaths. Let us be clear about what that means. It does not mean that every one of those 11,000 deaths is avoidable or preventable—it would be wrong to suggest that. It means that there are 11,000 more deaths than we would expect if mortality rates were the same as they are on a Tuesday, Wednesday or Thursday. Professor Sir Bruce Keogh, the NHS England medical director, called it
“an avoidable ‘weekend effect’ which if addressed could save lives.”
It is not just one study. In the past five years, we have had six independent reviews. Another study in the British Medical Journal, by Ruiz et al, states:
“Emergency patients in the English, US and Dutch hospitals showed significant higher adjusted odds of deaths…on Saturdays and Sundays compared with a Monday admission.”
The Academy of Medical Royal Colleges—the body that represents all the royal colleges—said in 2012 that deficiencies in weekend care were most likely linked to the absence of skilled and empowered senior staff and the lack of seven-day diagnostic services.
During my travels across the country, I recently spoke with the chief executive and the chair of an acute trust. They said that they have no difficulty at all with junior doctors and ensuring that there is cover at weekends; their problem is with consultants—and the Secretary of State has just made that point. Has he not chosen the wrong target?
Chief executives of trusts and NHS employers have been very clear that this is about reform of contracts for both consultants and junior doctors, because the reduction in medical cover at weekends happens with both the consultant and the junior doctor workforces. Also, as I will go on to say, it puts huge pressure on junior doctors at the time when they do not have senior support and the ability to learn from it, and that is exactly what we want to sort out.
Junior doctors are not to blame for the weekend effect. The situation would actually be far worse without them, because they perform the lion’s share of medical evening, night and weekend work. In many ways, they are the backbone of our hospitals. However, the BMJ study this year showed that there is evidence that junior doctors felt clinically exposed at weekends, and nothing could be more demotivating for a doctor than not being able to give the standard of care they want for a patient.
The right hon. Gentleman has prayed in aid the weekend effect and quoted Sir Bruce Keogh, his own NHS medical director. Is he aware that Professor Keogh has also said that
“it is not possible to ascertain the extent to which these excess deaths may be preventable; to assume they are avoidable would be rash and misleading”?
Yes, and I agree with that, but it would be equally rash and misleading to say there are no avoidable deaths. Professor Keogh was saying that lives could be saved if we tackled this. All these studies are saying that 15% more people die than we would expect if we had the same level of cover at weekends as we have during the week. Therefore, as he says, the moral case for action is unanswerable.
The hospital to which my right hon. Friend referred earlier is in my constituency. The accident and emergency department has improved hugely over the past few years—well over 95% of patients are seen within four hours—and one reason for that is that it has consultant cover all the time. It is not open 24/7—we want it to be—but for the 14 hours a day that it is open, it has consultant cover all the time.
I am going to make some progress before taking any further interventions.
The question for a Government and for a Health Secretary is this: when we are faced with this overwhelming evidence—six studies in five years—should we take action or ignore it? We are taking action. That is why in July I announced that we will be changing the contracts for both consultants and junior doctors as part of a package of measures to eliminate the weekend effect. If we believe in the NHS, and if we want it to be there for everyone, whatever their background or circumstances, we must be able to offer every NHS patient the promise of the same high-quality care, whichever day of the week they need it.
Let me set out for the House what I have proposed. We announced ambitious plans to roll out seven-day services across the country, with better weekend staffing across medical, diagnostic and support services in hospitals, as well as better integration with social care and seven-day GP access. That will reach a quarter of the population by March 2017, and the whole country by 2020. For consultants, we proposed an end to the right to opt out of weekend working, replacing it with a maximum obligation to work one weekend in four. To its credit, the BMA’s consultants committee has agreed to negotiate on that.
For junior doctors, we proposed to reduce the high overtime and weekend rates, which prevent hospitals from rostering enough staff at weekend, and increase basic pay to compensate. We have made a commitment that the pay bill as a whole would not be reduced, and today I can confirm that not a single junior doctor working within the legal limits for hours will have their pay cut, because this is about patient care, not saving money. Incidentally, I made it clear to the BMA at the beginning of September that that was a possible outcome of negotiations, in an attempt to encourage it to return to the negotiating table. Rather than negotiating, it chose to wind up its own members and create a huge amount of unnecessary anger.
Is the right hon. Gentleman going to continue with his plan to change the rules so that trusts that insist on doctors working unsafe hours can no longer be fined for doing so? It will help if he can assure us that those rules will continue and trusts will be fined if they break them.
They are not fines; they are perverse incentives to doctors to work unsafe hours. We want to go one better than that. We propose to stop hospitals requiring doctors to work five nights in a row or six long days in a row, and to bring down the maximum number of hours that hospitals can ask a doctor to work in any one week. On top of that, we have imposed the toughest hospital regime of any country anywhere in the world that comes down very hard on hospitals that are not providing safe care.
I want to ensure that I fully understand the commitment that the Secretary of State gave about not a single doctor losing out. I think he said that that is “provided they are working within maximum legal hours”. Does that mean people working up to 48 hours, which is the maximum working week under the working time directive? What about doctors who have opted out of that and are working 60 or 70 hours? Could they lose out?
It applies to all doctors working within the legal limit. If they opted out of the working time directive, it would apply up to 56 hours. For people who are working more than the legal limits, even after opting out, the right answer is to stop them working those extra hours because it is not safe for patients. But yes, that is the commitment to people even if they have opted out.
I am going to make some progress, if I may.
As well as reducing the maximum hours a doctor can be asked to work from 91 to 72 in any week—a significant reduction—and banning hospitals from requiring doctors to work five nights in a row or six long days in a row, as hospitals can currently make them do, we propose to ban the routine use of fixed leave arrangements that mean that some doctors have to give up to three months’ notice before taking leave, meaning that they miss out on vital family or personal occasions.
We did not, and do not, seek to impose a new contract; rather, we invited the BMA to negotiate a new contract so that we could end up with a solution that was right for doctors and right for patients. However, because we had recently won an election in which a seven-day NHS was a manifesto commitment, we said that having tried to negotiate this unsuccessfully for two and a half years, we would ask trusts to introduce new contracts if we were unable to succeed in negotiations.
I have a specific point about Northern Ireland. Of course, health is devolved to the Northern Ireland Assembly, but I can assure the Health Secretary that junior doctors in Northern Ireland are absolutely furious about the proposed changes to their contracts. It would help if he could confirm that he is in regular direct dialogue with the Health Minister in the Stormont Assembly, Simon Hamilton MLA. I ask him not to reply that officials talk to each other regularly, because “Minister to Minister” is what I would like to hear.
We do have regular dialogue. I suggest that the reason doctors in Northern Ireland might be angry is that they have been listening to misinformation about what the Government in England are proposing, which has, very disappointingly, made doctors all over the UK very angry. I hope that the assurances I am giving, which I gave to the BMA last month and the month before, face to face and in letters, will encourage the hon. Lady to report to the doctors she mentions that the right thing for the BMA to do is to come and talk to the Government. Regrettably, the BMA’s junior doctors committee has refused to negotiate since last June. Instead, it put up a pay calculator on its website that scared many doctors by falsely suggesting that their pay could be cut by between 30% and 50%. It has now taken that pay calculator down, but the damage to morale as a result of it continues.
I will make some progress. Some people say that this is a battle between the interests of patients and those of doctors, but that is profoundly wrong. Doctors who are happy and supported in their jobs provide better care to patients, and the link between a motivated workforce and high-quality care is proven in many studies, as well as in hospitals such as that in Northumbria, where staff have become the greatest advocates for seven-day services since their introduction. Our proposed new system is intended to provide better support to doctors who work weekends, and make seven-day diagnostics more widely available across the NHS.
Given the clarity with which my right hon. Friend has addressed the principal concerns of junior doctors, does he expect the BMA’s junior doctors Committee to change its stance, come to the Department and restart negotiations, or will it continue to stall?
This debate is reminiscent of 12 months ago and the “Agenda for Change”, when the Government refusal to negotiate with 1 million NHS staff caused industrial action and a strike. The same thing seems to be happening again. Will the Secretary of State take the shackles off the negotiations and enable the professionals to put their case on the table? Will he listen to them and let them lead negotiations?
That is exactly what I would like to happen, but it can happen only if members of the BMA walk through my office door—it is open—and sit down and start negotiating, which they have refused to do since last June. Just as it is wrong to pit doctors against patients, it is also wrong for the Labour party to pit the Government against doctors. In the previous Parliament, Labour wanted to cut the NHS budget, but we protected it. In May’s election we promised £5.5 billion more for the NHS than Labour did, and in the last Parliament a Conservative-led Government delivered 9,000 more doctors to the NHS, 1 million more operations a year, and 600,000 more people were referred for urgent suspected cancer every year.
Because we are not stopping at that, and because we are passionate that the NHS should offer the highest standards of care available anywhere in the world, the Government have also been honest about the problems facing the NHS. Two hundred avoidable deaths every week is too many—it is the equivalent of a plane crash every week. Nor is it acceptable that twice a week we operate on the wrong part of someone’s body, or allow other “never events” to happen. In many of those areas the NHS is performing at or better than international norms, but that does not make such things any more acceptable. We want the NHS to be the first healthcare system in the world to adopt standards of safety that are considered normal in the airline, nuclear or oil industries.
The Secretary of State said that we are open to problems being highlighted. May I thank him for what he did by putting hospitals into special measures? Medway Maritime hospital had the seventh highest mortality rate in 2005, yet nothing was done. Support is now being given to that hospital to turn it around. We are highlighting problems, but we are also introducing measures to fix those problems.
I thank my hon. Friend for his consistent support for his local hospital. It has had many troubles, but it is beginning to show signs of turning a corner. If we want to turn things around, we must first be honest about the problem.
I welcome the shadow Health Secretary to her place. Her predecessor tried to minimise the care problems that took place under a previous Labour Government, and he described our attempts to put them right as trying to “run down the NHS”. I hope that she does not do the same. Labour used to be the party that stood up for ordinary men and women; it cared enough about them to set up the NHS, so that no one had to worry about getting good medical care, whatever their circumstances. People need to know that they can depend on our NHS seven days a week. Instead of making mischief about a flawed doctors contract that was introduced by a Labour Government in 2000, the hon. Lady should stand with us as we sort out this problem. Be the party not of the unions but of the patients who depend on high quality care, day in, day out. Professor Bruce Keogh talked about the moral and professional case for concerted action. Surely in that context, she might reconsider this rather ill-judged attempt to make party political capital out of a very real problem.
Everyone who cares about the NHS should want the same thing. The hon. Lady should tell the BMA to get around the negotiating table, something she conspicuously failed to do. In doing so she would stand alongside the many independent voices calling on the BMA to return to the table and discuss a solution with the Government—the Royal College of Surgeons, the Royal College of Physicians, NHS providers and the Academy of Medical Royal Colleges. If she does not do that, the British people will draw their own conclusion about which party is backing the NHS with the resources it needs, which party is supporting hospitals to become safer at the weekends, and which party is standing four-square behind doctors and nurses in their ambition to deliver high quality standards of care for patients. There is only one party that can be trusted, one true party of the NHS, and that is the Conservative party.
The hon. Member for Lewisham East (Heidi Alexander) described what a junior doctor is, and that is really important. Many people think that being a junior doctor is just for the first couple of years, and isn’t it character-forming to work a bit hard and not have a lot of money? However, in the NHS, which is quite a hierarchical beast, a junior doctor is a junior doctor all the way until they are not a junior doctor and they become a senior doctor: either a consultant, as I was for the past 19 years, or a GP. That means we are talking about people who might be in their 30s, with children, families and mortgages. They are not youngsters who are able to move around flexibly and have very few financial commitments. It is important that we remember that.
It is obviously quite some time since I started as a junior doctor. More than 30 years ago, in 1982, we had absolutely no limits on hours. My light week was 57 hours; my heavy week was 132 hours. You just had no idea what your name was by the end of a weekend. It took more than 10 years of my career before the first new deal started to come in, in the early 1990s, and trusts or hospitals had to pay an additional premium to junior staff if they worked excessive hours. The definition of excessive hours at that time was still pretty lax, but it was the first step. It was tightened up in 2003, when the European working time directive came in. The Secretary of State talks about taking away those safeguards, but that he will replace them with something else. But with what? They have served us well. When trusts are in financial difficulties, the pressure on them to save money is likely to outweigh completely any little safeguard. The 48-hour working time directive does not come with punitive safeguards, and the financial one was important.
It is important to remember that the basic pay is already for 7 o’clock in the morning to 7 o’clock at night, Monday to Friday. That is a pretty long day for most people. It is proposed that the time covered by basic pay should be extended to 7 o’clock in the morning to 10 o’clock at night and include Saturday. What many people do not know is that a junior doctor starts at under £23,000 a year—below the benefit cap we have been arguing about. The salary is made up largely of out-of-hours.
Does the hon. Lady not agree that in any other walk of life that would be intolerable, yet we put up with this situation in the national health service? Secondly, does she agree we still have not seen the £8 billion the Government promised, during the general election, to put into the NHS?
I totally agree with that.
As mentioned on both sides of the House, people do not work in an NHS hospital to make a lot of money. It is not high up the list of ways for the smartest people in our country to make money; it is a vocation, which means we have a responsibility not to exploit them. The Secretary of State says that no one will lose money, but what will happen to the people who start next August? After the first hours change, when I started my surgical career in Belfast, the “two in three” rota—every third evening off and no weekends off for a year—was no longer legal, and the hospital henceforth considered extra hours to be voluntary service. The NHS is a hierarchical organisation, bullying exists within it, and the junior doctor is in a weak position. These safeguards have worked well for a long time, and I would be reluctant to see them go.
Does the hon. Lady agree that across the piece—nurses, doctors, everybody—there is a huge loss of morale in the NHS? It is down to us to stand up for the workforce and put them at the heart of our thoughts, rather than concerns about how it might look politically.
I totally agree. I also agree with the Secretary of State about patient safety. There is no one in the profession who does not want a seven-day emergency service that is strong and responsive to the needs of unwell patients, but we keep moving from people who are ill to routine services. He has said we must not call them avoidable, yet he just referred to 200 avoidable deaths a week, which is exactly what Bruce Keogh described as “rash and misleading”, and people object to that. There are no excess deaths at the weekend; the issue is with people admitted at the weekend, usually for radiology or investigation. Scotland has been moving on this for the last decade, by working with the profession, not pulling out the pin and throwing a grenade.
For the sake of clarity, the 200 avoidable deaths are not about the weekend effect specifically, but come from the Hogan and Black analysis, which found that 3.6% of hospital deaths in England had at least a 50% greater chance of having been avoidable, which is separate from the weekend effect—the higher mortality rate among people admitted at weekends. None the less, where there are avoidable deaths—where death rates look higher than they should be—we have an obligation to do something.
I agree that it is important to investigate, but it is also important to understand the cause of the problem. A lot of the problem at Mid Staffs was the ratio of registered nurses to patients. That was echoed by Bray in his review of 103 stroke units, which showed that additional consultant ward rounds at weekends had no impact on death rates, while a better ratio of registered nurses reduced them by a third. We need to know the problem before spending billions trying to solve the wrong thing.
I am grateful to the hon. Lady for busting this myth about weekend death rates—these might be sick people admitted at weekends who die within the 30 days. In fact, fewer people die in hospitals on Saturdays and Sundays than on other days. The Secretary of State is not giving the right impression of the figures.
Since coming here, I have heard stories of people unable to access diagnostic imaging or to work up patients, but there is no argument about that from the profession. That is what we need to focus on, yet a lot of this seems to be about routine. There are fewer doctors at weekends because we do not do routine work. We have teams of people doing toenail and blood pressure clinics in the week. Professor Jane Dacre estimates that doing those at weekends would require 40% more doctors. We cannot do that. We need to make sure that hospitals at weekends have enough people and the right people to be secure, but junior doctors are already there—it is not they who are missing—and emergency services already have a consultant on call. We might need more discussion about their being physically in, but that is a discussion to have with the profession, whereas what we heard on 16 July, which gave the public the impression that senior doctors only worked 9 to 5, Monday to Friday, was very hurtful to the entire profession.
The hon. Lady is making some extremely powerful and relevant arguments. I wish to make a point about the importance of junior doctors in my region, having spoken to some of them at the demonstration on Saturday. They are essential to the functioning of the service. They have the option of going not only to the Antipodes but to Scotland, where these contracts do not apply. If we lose these valued staff, it could hurt my region more.
We will roll out a red carpet somewhere on the M74 and welcome them with open arms. The progression and migration in Scotland towards robust seven-day emergency care has been happening through a dialogue, not through a threat to impose a contract.
There are other things in this, such as the plan to change pay progression, which is currently on an annual basis, to recognise experience. That will be replaced with just six pay grades. Such a move will affect women in particular, because they tend to take a career break and they tend to work part-time, so they will get stuck at a frozen level for much longer. It may also be a disincentive to people to go into research, because they will be stuck on the same rung of the ladder for longer. We do not want that disincentive. We need to make sure that we are valuing how people develop and the experience they accrue along the way.
There is no doubt that we require dialogue, but it must involve sitting down at a table without preconditions. What we had in July and through the summer was a threat of imposing a contract, instead of proper negotiation. That is where we should be trying to get to: both sides negotiating in good faith across a blank sheet of paper. The threat of imposition is what has hurt the junior doctors.
There has also been talk of taking away the guaranteed income protection of GP trainees, there to try to keep them at the same level as they were, and replacing it with a discretionary payment. Such a payment can be taken away at any time—it can be cut and it can be changed. The Secretary of State aspires to have 5,000 extra GPs by 2020. We know from the BMA that one third of GPs—10,000 out of just over 30,000—are planning to leave, which means we need to find 15,000 extra GPs. Anything that is a disincentive for people to go into that profession is not serving the NHS.
I think that how this has been handled is a total disincentive, but that could change. We could simply take the decision to move to negotiations without preconditions—without the threat of imposition. We are talking about a threat to impose changes to the terms and conditions of people who, in the past, routinely worked more than 100 hours a week, as I did. That is a ghost that haunts the NHS and it really frightens junior doctors.
I have a huge amount of respect for the hon. Lady. She talks about her experience of working long hours. Does she think that what the Secretary of State has just said about introducing new limits on junior doctors’ working hours is the right way forward?
What the Secretary of State has not explained is how, within the same pay envelope, there will be more people at weekends, but not working extra hours—and not having fewer during the week. At the moment, we have a circle that cannot be squared. We need to see the detail of how that can be done. If the vision is to have more routine work at the weekend, that would result in a massive uplift in the number of doctors, which we simply cannot afford. We are already haemorrhaging doctors. Acute physicians describe 48% of junior places as unfilled, with the figure for obstetrics being 25%. They can go anywhere. We heard that over 1,500 of them registered for certification for overseas work just last week. We need to be careful that we are attracting them to stay. They are the brightest and best in our society; they have chosen a vocation. We need to bring them to the table, but by offering to start with a blank sheet of paper—not threatening them. As has been said, they are not radicals, but people who want to do the best for their patients.
I suggest that the Secretary of State and those working with him look at how they have spoken to both senior and junior doctors over this summer. Frankly, being new to this House, I found that to be quite shocking and quite disgraceful. We should draw a line under that and try to change the tone. We need to go forward and find a solution that is fair to junior doctors, fair to patients and safe—one that is not exploiting people and not threatening people.
I start by declaring a relevant personal interest in that my daughter is a junior doctor, and one of many hundreds who have moved to Australia to work. Because of that very clear conflict of personal interests, I shall abstain in this evening’s vote. I want to speak, however, because I have relevant personal experience, as before I came to this place I taught junior doctors and medical students for 11 years.
I can tell the House that this dispute is about far more than pay. It is about junior doctors feeling valued. The junior doctors I used to teach, including F2 foundation year doctors, felt that they were not being supported at the weekends, disliked the inability sometimes to work in the same county as their partner and disliked obstructive attitudes about rostering. That presents us with an opportunity to bring all those issues into the negotiations in this current dispute.
One thing I do know is that young people do not go into medicine because they are motivated by pay. I hope that the House sends a very clear message to junior doctors that we value what they do and are grateful for what they do on behalf of patients. What we must do is avoid a strike at all costs. A strike would be immensely damaging for patients. I would say to junior doctors that there is no meaningful industrial action that they can take that would not harm their patients. I urge them to step back from such a move. A strike would be damaging not only for patients, but for the professional reputation of doctors, and of course politically. That should not be the consideration. Our main consideration should be how we encourage junior doctors to walk back through the door of the Secretary of State’s office, as he has stated. The best way to do that would be to start again.
Many elements of the dispute feel similar to the one we had in 2007, when I was teaching junior doctors, over the medical training application service—or MTAS, as it was known. It was a very unloved, unlovely scheme that collapsed, after a much-needed apology, in 2007. The Government of the day went back to the drawing board and started again. I think it would be right to do so on this occasion. We need to remove the barricades that are preventing junior doctors from walking back through the door. It would be right to take away the preconditions, the red lines and the threat to impose—and start again, looking at all the issues in the round.
Junior doctors share many of the Government’s objectives. They want to improve care for patients; they recognise that shortage specialties in the NHS are a real issue and that if we are going to put patients first, we need to incentivise entry to specialties such as accident and emergency, general practice, psychiatry and so forth. We need mechanisms to make that happen. They recognise, too, the need to address variation across the NHS, including with respect to weekends, but we need to look at that in the round. It is not just about senior and junior doctors either; it is about nursing, access to diagnostics, being an outlier on a ward that someone should not be in because the hospital is over-full.
I am sure that my hon. Friend would agree that one thing about which junior doctors want certainty is no longer having whole weeks of nights or having to work beyond 72 hours. The Government need to be clear about how they will achieve that.
I thank my hon. Friend for his intervention. There is much to be welcomed in the new contract, but we need honesty about some of this. I am very pleased that the Secretary of State has given an assurance today that no junior doctor will be worse off, but I hope that when he sums up the debate, he will tell us what will happen to a junior doctor working 70 hours a week, perhaps in a specialty such as accident and emergency or anaesthetics. If the pay envelope is the same and some junior doctors will be better off, the maths indicates that some will be worse off and we need to clarify which ones. We need much more clarity, not just about whether an individual will be no worse off as a result of changing from one job to the next over the transition period, but about what will happen to the pay for that post over the coming years.
While I welcome many of the elements of the junior contract, I feel that, because the debate has become rather toxic, we should take the opportunity to begin again to examine all the issues in the round, and ask junior doctors themselves to work with the Secretary of State in establishing how we can achieve our common aims on behalf of patients. We should also take the opportunity once more to welcome junior doctors and value everything that they do.
It is a pleasure to follow two such thoughtful speeches, and, in particular, the powerful speech made by my hon. Friend the Member for Lewisham East (Heidi Alexander). I congratulate her on her appointment, and on the vigour with which she put the argument.
Three weeks ago, I went to a “keep in touch” meeting with doctors at the John Radcliffe hospital in Oxford. Two hundred and fifty doctors turned up, and their anger at the Government’s threatened imposition of this contract had to be seen to be believed. They were so alienated that I had a hard job trying to persuade them that it was just the Secretary of State’s incompetence which was to blame, and not a malevolent wish on his part to dismantle the NHS.
At a time when doctors, like other staff in the NHS, are working under such pressure, and when the Secretary of State knows that he needs to carry staff with him if further reform and efficiencies are to be delivered—including the better seven-day hospital services that we all want to see—it is beyond belief that he has simply stumbled into picking a fight with the core clinical work force in our hospitals, threatening to impose a contract that will leave some of them earning significantly less and many vulnerable to working significantly longer hours, thus risking a return to the dangers of the past.
No one, including doctors themselves, wants to see this degenerate into industrial action, but, as with other groups of workers whom we do not expect to strike, a particular responsibility is imposed on employers and the Government to listen, to be fair, and to negotiate in good faith. That is why it is so damaging that the Secretary of State gives such a strong impression of doing the opposite: threatening when he should be listening, and using weasel words when he should be showing how assurances can be delivered. As the public well understand, the success of the NHS is hugely dependent on the dedication, good will and trust of its staff. By mishandling the contract in this way, the Secretary of State is putting all those at risk, and, once lost, they could be hard to win back.
No one should be under any illusion about the damage that the contract—were it to be imposed in the way that the Government want—could do to patient care, and would certainly do to recruitment and retention in the English NHS, especially in high-cost areas such as Oxford. I already know of local GPs who have moved away, including one who found that he had a better quality of life as a locum than as member of a practice, and then found that it would be better still in Canada than in our NHS. At my meeting with doctors at the John Radcliffe, a show of hands was taken to find out how many of those who qualified would move to other parts of the UK or abroad if the contract were imposed. A sea of hands went up.
If the Government want to make good the damage that they have been inflicting and settle the issue of this contract, it should not be hard. In his letter to the chair of the BMA junior doctors committee, the Secretary of State said:
“I share exactly the same aims for the new contract as you do.”
If that is the case, the way forward is clear. First, the Secretary of State should reopen negotiations, without preconditions, lifting the imposition of the contract. Secondly, he should keep the financial penalties that protect staff from working excessive hours. Thirdly, he should show flexibility on the reimbursement for Saturday working. Fourthly, he should give a clear guarantee that no junior doctor’s pay will be cut as a result of the contract. That is what our motion calls for: it would deliver a new contract with safety for patients and fairness for doctors. It is what the Government would do if they had any sense, it is what the public wants, and I urge the House to vote for it.
I welcome this debate brought by the hon. Member for Lewisham East (Heidi Alexander) as a chance to offer some light, as opposed to the heat that has sadly dominated so much of this debate.
The House has often heard me quote the thinker and poet T. S. Eliot when he warns of the folly of trying to devise
systems so perfect that no one will need to be good.
This speaks extraordinarily to the NHS. The NHS is not a system; it is the people who work in it. That is why it is so important that we nurture and value our NHS staff in the ways so brilliantly expounded by my hon. Friend the Member for Totnes (Dr Wollaston)—those staff who work day in, day out, and, as the daughter of a surgeon I can vouch, at weekends and on Christmas days, too.
I was extremely concerned to hear the British Medical Association’s claims that this modernisation of the junior doctor contract would lead to dangerously long working hours and less pay for our junior doctors—cuts of 30%, it said. I began to look into this more closely. I noticed that the pay calculator had been taken down, but when I looked at the detail I became very surprised. In the proposals I could not see the kind of longer hours and the less pay scenario I had heard from the BMA with such certainty and to which many junior doctors, completely understandably, have been reacting with such worry and concern. I could not see anything approaching the authoritarian and draconian measures the BMA had led me to believe my own Government were imposing.
At most, I think there are areas where we need very careful negotiation and clarity with a doctor membership body so that we can work with doctors—that is incredibly important. I would have thought the BMA junior doctors committee would be very concerned for that to happen.
I cannot find evidence that the Government are imposing longer hours on doctors. What I did note was the new absolute limit on overtime worked, which is preventing dangerously long hours and those awful weeks of nights, and the current situation where doctors routinely work over the 48-hour working time directive often slightly off the record to get in the training that they need. I would have thought measures to tackle that would have been welcomed.
I know that huge numbers of people work during Saturday daytimes, but there needs to be further discussion on the agreement of what constitutes antisocial hours for doctors on a Saturday. Again, I would have thought the junior doctors committee would have valuably contributed towards that, and in fact the Government say the same.
To read the BMA submission we would think that less pay was a key aim of the whole exercise, but the plans make clear that there will not be an overall pay cut and that average earnings will remain the same. Yes, the distribution will be different to overcome the obvious unfairnesses in the system where a doctor working normal hours will get paid more than a doctor working antisocial hours, but I am not sure that is something to complain about. Yes, there will be a reward for progress as opposed to the time the doctor has been in training, but that is in line with many professions and I am just not sure that someone who takes longer in training to reach the same standard as a high-flyer should get paid more.
I support my hon. Friend on that point. It is uncomfortable but true that in almost any profession outside the NHS if someone takes time out for parental leave the clock stops on their career progression. They gain other skills; they do not just press on with their career, but they can go back to it afterwards.
My hon. Friend is absolutely right. In addition, I am just not sure it should be possible for supervisors with more responsibility to be paid less than those they are supervising. I am slightly confused about the BMA stance on this. When I spoke to it about the European working time directive, it assured me that it was not just time spent in training that mattered, but the quality of that training. Now in its submission it seems to have completely reversed that position and says that it is just time spent on the job that matters. That confuses me.
As the Government accept, there is a need for discussion on how doctors moving between different specialities can have their pay protected, but that is again something on which we must absolutely enter into discussion with junior doctors. I plead with the BMA to come to the table. The consultants committee in the BMA has done that and I applaud it for doing so. A part of the drive to get more consultants in at weekends is to improve the quality of junior doctor training which has suffered under the European working time directive.
I also note that one paragraph in the BMA’s submission states:
“Much of the subsequent detail that has been discussed in the news was never fully outlined as part of the previous negotiation process.”
That demonstrates that the Government are still completely open to talking about many things, yet the BMA almost seems to lament that fact. In the light of this, I simply do not understand why the BMA will not return to the table. I celebrated the BMA’s “No More Games” campaign. We do need to de-politicise the NHS, but I am really concerned that the junior doctors committee is bringing that laudable aim by the BMA, and the work on that which the BMA does, into disrepute.
Countless junior doctors have been in touch with me to say that they are worried and in despair about the Government’s threat to impose an unfair contract on them. They tell me that the dangerously long hours that the contract will introduce will be a threat to patient safety. Doctors tell me that rostered hours are not a realistic gauge of total working hours, and that reducing them will not prevent dangerous increases in working time.
Sofia, an anaesthetist in my constituency, says:
“A ‘normal’ rostered day starts at 7.45am and finishes at 5.45pm. In reality there is no such thing as a ‘normal’ day, because the clock strikes 5.45pm and it is impossible to walk out the door with an operation ongoing.”
Doctors like Sofia are content to work longer hours out of a sense of duty, but they are deeply concerned by plans to remove the financial penalties placed on hospitals to prevent dangerously long hours. She describes the Health Secretary’s assurances as follows:
“It’s a bit like trying to stop speeding on a busy road by lowering the speed limit, but at the same time getting rid of all the speed cameras, police and speeding fines.”
What does all this mean for patient safety? I was contacted by another doctor, Keir, a paediatrician in a neonatal intensive care unit in West Ham. He cannot see how his team could be spread more thinly during the week in order to provide more doctors on Saturdays. He is rightly concerned that doctors would be at risk of exhaustion. He says:
“High intensity specialties are particularly affected from a safety point of view. You don’t want any delay putting a three-month premature baby on life support. Putting in a breathing tube, getting a tiny line into tiny veins—all require skill and concentration. Any tiredness affects the swiftness and accuracy of these procedures.”
Doctors like Keir are aghast at what the Government are telling them.
Doctors are also deeply disheartened by the Government’s handling of the new contracts. One doctor, Simi, has told me:
“The mood is grim in hospital at the moment. We feel under-appreciated and undervalued. We are not being misled by the BMA. We can read the facts and analyse them for ourselves.”
Whatever the Health Secretary has said today, it is evident that some doctors will lose out financially. This uncertainty over pay is causing anxiety. Sofia says:
“Come August 2016, I have no idea how much I will be paid, whether I will be able to afford to pay my bills or even spend time with my children.”
I agree with Oliver, another West Ham doctor, who says:
“Not one doctor should be taking home less pay than they do now.”
This will have serious consequences for staff retention. Doctors are making plans to leave the NHS. Nick, a medical student in West Ham, says:
“I studied medicine to become not just a doctor but an NHS doctor. Under the proposed contract, I’ll be left in the sad situation of being forced elsewhere.”
That will be this Health Secretary’s legacy. Kirsty, a histopathologist, says:
“The health secretary has been nothing but belittling and demeaning. He has suggested we have lost our sense of vocation. Imposing a contract on us and treating us like children rather than professionals is so wearing.”
We trust these doctors with our lives and with our loved ones. Our NHS staff are truly phenomenal. They deserve nothing but the utmost respect, and they certainly do not deserve to have an unfair, unjust contract imposed upon them. The people in this country love the NHS. For their sake, the Government must put forward fair proposals, withdraw the threat of contract imposition and return to negotiations with the BMA.
Finchley and Golders Green is served by Barnet general hospital and the Royal Free hospital, which is just across the border in the constituency of the hon. Member for Hampstead and Kilburn (Tulip Siddiq). In particular, the Royal Free is the largest hospital serving my constituency, and it is one of the largest and safest acute hospitals in London. It has the high security infectious diseases unit, which has recently been in the news for treating Ebola, and it is a major centre for research into immunology and transplants. Not surprisingly, it is a major teaching hospital.
Many junior doctors who live in my constituency have contacted me and despite my best efforts, using the information provided by NHS employers and the Department of Health’s online pay model, they continue to be confused and believe that their pay will be cut. I have no doubt that the selective information from the BMA has not helped. I welcome the reforms in principle and the commitment to introduce a new absolute limit on the number of extra hours that junior doctors can work. Bringing an end to the week of nights and capping the extra hours are welcome, but most junior doctors in my constituency are simply not aware that that is what we propose.
In fact, most of the junior doctors that I have seen believe that the reforms will increase their working week, leading to more fatigue and therefore jeopardising, not improving, patient safety. They believe that this will hamper the Secretary of State’s quite-right drive to improve weekend mortality rates. I say to my colleagues in the Department of Health that something is going wrong in the communication of this welcome reform.
Let me turn now to a couple of issues that have been raised by junior doctors and that echo some of the concerns mentioned by the hon. Member for Central Ayrshire (Dr Whitford). On retention, the Royal Free is a major centre for research and yet Dr Renee Hoenkampf, who wrote to me, is concerned that those doctors who seek to go into research and to step away from the frontline will be penalised by being held back on their progression pay. Those doctors who choose to have a career break to raise a family will also be penalised. Both those concerns will impact on women more than on men.
My hon. Friend is right that just getting pay progression for time served is not the right thing to do, and most organisations have scrapped it. However, we must avoid accidental penalties acting as a disincentive for women joining the workforce. We should not encourage this idea that women, or any person, should be penalised for taking career breaks or for stepping away from the frontline by taking part in valuable research. I gently ask the Minister to look again at that matter.
When I met Dr Joseph Machta, a junior doctor in paediatrics, he said that, after consulting the Department of Health’s pay model, his pay would reduce by 15%. Like many junior doctors living in my patch—it is not a cheap part of London—he was concerned that he would no longer be able to pay his mortgage. Will the Minister look into that matter? I suspect that London’s junior doctors rely more than most on premium payments. While average pay across the UK may be neutral under the compensatory increase in basic pay, that may not be true in London. I would be interested to hear whether the Department of Health has done an impact assessment on London’s junior doctors and the amount of premium pay that takes up the wage bill in London hospitals. If many junior doctors in London are over reliant on premium payments to pay their bills—that may be a wrong thing to do because they are working too many hours, but that is a different issue—it is a matter that needs to be considered.
It is not unusual to want to have contract terms changed to meet current needs. On that basis, I support the reforms, but I ask the Minister to look into those two issues that I specifically raised.
I congratulate my hon. Friend the Member for Lewisham East (Heidi Alexander) on securing this important debate and on her powerful opening speech. As she will know, health services in my constituency have already suffered greatly at the hands of the Conservatives. Two years ago they downgraded Chase Farm hospital, axing both our accident and emergency and maternity services and breaking every promise they made to local people.
Now they are seeking to implement changes to contracts that I believe are unfair on doctors and pose significant risks to patients, both in Enfield and across the country. That view has been reinforced by the number of doctors from Enfield North who have contacted me to express their serious concerns. Dr Irene Gafson is one of my constituents and has been a junior doctor for eight years. She took part in the march in London earlier this month and carried a sign bearing Nye Bevan’s famous words that the NHS
“will last as long as there are folk left with the faith to fight for it.”
Many Members may have seen the thought-provoking and insightful article she wrote for The Daily Telegraph after the event. Two things in particular struck me when I read her piece. The first was the deep sense of privilege she and her colleagues feel about being doctors. It is not just a job, but a vocation. These are hard-working, dedicated professionals who care passionately about what they do.
I spent some time in a busy city hospital last week with doctors who told me that many junior doctors now feel so demoralised that there has been a flood of applications to receive the certification to go and work overseas, so much so that the department that deals with that process has had to take on extra staff just to deal with the number of applications. Does my right hon. Friend agree that that is very worrying indeed?
The second point Dr Gafson highlighted was the level of disillusionment in the medical profession with the Government’s plans. She said:
“Whilst the sense of solidarity and unity amongst junior doctors”
on the march
“was tangible to all, there was a much sadder force underpinning our mood...People who have invested years of passion into their work are feeling demoralised. This unique day that brought so many doctors together in one place really served to illustrate how dangerously low levels of morale amongst junior doctors have sunk.”
Dr Gafson voiced her strongest criticism for the way in which these contracts had not been negotiated with doctors and how the proposals threatened the safeguards on working hours. Significantly, she voted for the Conservatives at the last election:
“I trusted them with the NHS and I feel let down. I actually feel embarrassed”.
Dr Gafson is not the only one. Another local doctor who does not wish to be named contacted me to express her grave concerns at how the changes could impact on the NHS as a whole. She said that in a meeting last week a significant number of her colleagues were discussing alternative career plans and many were considering a move abroad to practise in another country. She said:
“If these reforms go through then the frontline specialties such as Accident and Emergency, General Practice and acute medicine will be hardest hit, and these areas are already undersubscribed”.
She went on to say:
“I am gravely concerned that if these changes go through they will signify the start of the dismantlement of the NHS.”
The Secretary of State should heed those words. They are an indictment of how the entire situation has been handled. If what is being offered is a “good and fair deal”, as he has described it previously, how does he account for the upset and concern the offer has caused? Is he willing to publish in full the financial models being used to calculate the proposed changes to contracts so that doctors can know exactly what they can expect to be paid? If he is not willing to do that, junior doctors working evenings and weekends have every right to be concerned that they face a possible pay cut.
Finally, is he willing to accept that removing the safeguards that penalise hospitals that force junior doctors to work in excess of their contract hours has the potential to overburden doctors and compromise patient safety?
I therefore urge the Secretary of State to stop his continued and unwarranted attacks on the BMA and to get back to the negotiating table and offer a deal that is fair to doctors and safe for patients in the context of talks without preconditions.
I declare my interest as a doctor, and a veteran of truly awful rotas of the 1980s, involving one in two very often—that is every other weekend, every other night on duty, as well as a normal working day, which I would not recommend to either patients or practitioners. Thankfully, they are a thing of the past.
I welcome very much the Health Secretary’s statement today and the guarantees that he has given. On that basis, I am more than happy to support the Government this evening. However, I would say that we need to insist on evidence-based policy making. It is important to understand the difference between a causal effect and an association. My worry is that perhaps the Front Bench has been more influenced by Euclidean theorem than a proper understanding of statistics. My reading of the Freemantle paper and Professor Sutton’s remarks lead me to conclude that no causal link has been established between doctors’ rostering and excess weekend deaths. If we are serious about reducing weekend deaths, and reducing the difference in health outcomes between this country and countries with which we could reasonably be compared, which I know that my colleagues on the Front Bench are, we need to properly understand what are the drivers of those differences, and I do not think that junior doctors’ hours are a principal driver in the problem that we are trying to address today.
I think it is also right to appreciate that we are heavily dependent on the good will of all doctors—consultant grades and junior doctors. Most doctors that I know work well beyond their contracted hours—I know I certainly used to when I was in hospital medicine—and in dealing with them and in communicating with them, we need to keep that in mind and not take that good will for granted.
I very much regret the BMA action, and I very much regret the ballot on 5 November on strike action. The last time such action was taken was in 2012 on, ironically, the subject of pensions. It ended ignominiously and the only outcome was a reduction in the esteem in which the public held the medical profession. I would urge the BMA, armed with the assurances we have had today, to think again. I say “ironically” because, of course, the proposals, as I understand them to be, would increase core hours, which are pensionable—out-of-hours are not—and I have yet to see the BMA make any comment on that, or indeed reflect it in its pay calculator. Maybe a belated understanding of that has meant that it has chosen to take it down.
In trying to reduce weekend deaths and in trying to reduce that gap between our health outcomes in this country and those in the rest of Europe, we need to be focused much more broadly than on junior doctors’ hours. I know the Health Secretary is trying to work out how we can best configure the health service of the future. It is a dynamic thing; it never is fixed in one place. In my opinion, part of that means looking at our NHS estate all the time to make sure that we are getting the best from our assets. In my opinion, it means concentrating our specialist services in larger, regional and sub-regional centres. Those centres find it much easier to roster junior doctors and to concentrate expertise in one place. I am talking about stroke, heart attack and upper gastrointestinal bleeding—all things where we do less well in this country than in countries with which we should be comparable.
I am grateful to my hon. Friend and parliamentary neighbour for giving way. Does he agree that in the rural communities in south Wiltshire that we both represent, there does need to be a certain minimum proximity in order for patients to be able to access their hospital with confidence?
I agree with that, which is where networks come into our national health service, and making sure that we have specialist centres that can deliver the right outcomes for people, and that there are protocols to ensure that ambulance services take people to the right place at the right time, so that they can receive the treatment they need. What we cannot do is continue with the current situation, in which our constituents can expect lower life expectancy and health in later life than, say, French or German patients. That is not sustainable and it is not right. It means looking again at how we configure our national health service. It may mean some difficult decisions in some parts of our NHS, but that should not be a barrier to making sure that we do it right.
What I would say to my right hon. and hon. Friends on the Front Bench is that this is not really about junior doctors; this is about consultant grades, who deliver the therapeutics and diagnostics in relation to upper GI bleeds, heart attacks and strokes. They are now, in our new NHS of the 21st century, at the coalface of delivery in a way that they previously were not. So, if I may say so, I would like a greater focus on consultant grades, perhaps at the expense of some of our junior doctors who are the principal subject of our debate today.
It is obvious that there are too many people who wish to speak and not enough time left. We have only 40 minutes of Back-Bench time remaining. There is no point in people looking disappointed; there are only 24 hours in a day and this is how it is. We can debate all sorts of things but there is only so much time. I have to reduce the time limit to three minutes, and I trust that colleagues will be decent and considerate to each other and not take too many interventions. If they do take interventions, could they not take the extra minute that is added on? I call Norman Lamb.
It is a pleasure to follow the hon. Member for South West Wiltshire (Dr Murrison), who made a thoughtful and valuable speech. As a principle, we must be willing to accept the importance of debating the reform of working arrangements if we believe that there is evidence that current arrangements are undermining the best possible patient care, and I know that junior doctors absolutely accept that view. But I have to say that I am not convinced by the Government’s arguments.
I mentioned earlier that I had talked to hospital leaders, who shared their view that junior doctors’ arrangements are not the problem. It was striking, listening to the Secretary of State, that he referred to a shortage of consultants at weekends. It was notable also that when I talked to hospital leaders, they spoke of a concern that some senior consultants in some specialties make outrageous demands for additional pay for weekend work. There is a problem there, and I would support reform of that situation, but I am not convinced by the case for reform of the sort that the Government are pursuing. The Secretary of State also rightly talked about juniors being clinically exposed at weekends. Again, the issue is a shortage of consultants at weekends, not issues relating to junior doctors.
I met some junior doctors yesterday and found them all to be very passionate and completely dedicated to the NHS. I found them to be not driven and motivated by pay. I have to say to the Secretary of State and the Under-Secretary of State for Health, the hon. Member for Ipswich (Ben Gummer), that junior doctors find it frankly insulting to be told that they have been misled by the British Medical Association. They are intelligent enough to make up their own minds, and they have done. The Secretary of State should choose very carefully the arguments that he puts to them. The Government must also recognise a basic reality—the contract will work only if it is attractive to junior doctors. If it is not, they will vote with their feet and do what the daughter of the hon. Member for Totnes (Dr Wollaston) has done and go to Australia—or Scotland or the United States—to work instead of in the NHS.
The reform and extension of plain time gives rise to real concerns about its impact on emergency medicine, on acute medicine, on intensive care and on maternity services—those areas where there is a particular need for substantial evening and weekend working.
I totally agree, and I am very grateful to the hon. Gentleman for raising that point.
Will the Minister clarify what the Secretary of State said with regard to no loss of pay for individual junior doctors because I fear that those may have been weasel words? He talked about working up to the legal maximum. Is he talking about working up to 48 hours or up to 56 hours? He has given no guarantee that those doctors who may still work 60 to 70 hours in a week will not end up losing their pay. It is very important that the Government are clear on that.
The Government seek to extract too much from a limited pot of money. We all know that £10 billion is not enough to keep the NHS going until 2020. We need to work together. I repeat the Liberal Democrat call for a non-partisan commission to ensure that we achieve a new settlement for the NHS and for care, and to engage with the public and the workforce to ensure that we get this right.
Three minutes is never enough, but here I go. First, we have heard a lot about seven-day working and a seven-day NHS. That does not occur only within the hospital. I would like to restate the point made by my hon. Friend the Member for Totnes (Dr Wollaston) in the Westminster Hall debate on the e-petition that, most important of all, we need to look at how we can reduce in the first place unplanned admissions to hospital from the community. Secondly, I echo what the hon. Member for Central Ayrshire (Dr Whitford) said. We here have a responsibility not to exploit junior doctors and their willingness, sense of vocation and commitment to the NHS.
It is worth looking at some of the deficiencies of the 2003 contract. As I understand it, a doctor working 47 hours can be paid the same as one working 41 hours. That cannot be right. A doctor working daytime can be paid exactly the same as a doctor working only nights and late shifts. A doctor progressing to a post of greater responsibility might not get any extra pay for that. There are multiple flaws in the existing contract that need to be addressed as part of the growing trajectory towards improving terms and conditions each time we reassess the contract.
I recognise that there is a desire on all sides to get back round the table, and I strongly urge all sides to do that. I hope it can be done, but there is no contract that I can see lurking in the Minister’s bottom drawer waiting to be unveiled. In the report from the Doctors and Dentists Review Body three scenarios were set out. There are a further six, I understand, in circulation and in preparation by the NHS Employers organisation. There is so much to discuss, so many alternative scenarios, that it would be a dereliction of duty for all sides not to get back round the table.
We should note that in what has been proposed, by reducing the maximum number of hours to 72, there would be no more of the four nights in a row that some junior doctors have had to work, and no more seven consecutive nights on particular rota shifts. There is much that is positive in the contract, yet I recognise why there are concerns. I urge Dr Malawana who wrote to the Secretary of State to look again at what my right hon. Friend is seeking to achieve. There is clearly a willingness to discuss how to redefine daytime work, how to judge what we pay for Saturdays, how we change flexible pay premiums. There is so much that can still be discussed that we are missing an historic opportunity here to set in stone for another decade a much better contract and a much better set of criteria for fairer working practices for our very, very hardworking junior doctors.
It is a pleasure to follow the hon. Member for Blackpool North and Cleveleys (Paul Maynard).
I welcome my hon. Friend the Member for Lewisham East (Heidi Alexander), the shadow Secretary of State for Health, to her new position.
I have three puncture marks on my left hand. They come from 2001 when I was admitted to accident and emergency suffering a life-threatening event, an ectopic pregnancy. It took four attempts before a junior doctor successfully inserted a line into my hand. He apologised to me and said, “I’m sorry, I’ve just worked for 24 hours without a break and I just can’t see straight.” I am grateful to that doctor, both for his compassion and for his honesty, and I will always be grateful to the junior doctor who wheeled me up to theatre at midnight and operated on me, saving my life.
Such overwork is what led the Labour Government to change the junior doctors contract. Under that contract, employers face financial penalties if junior doctors work longer than contracted. This Government want to remove these vital safeguards in the new contract and, instead, ask employers to follow the working time regulations. But in medicine, mistakes cost lives. The safeguards need to be much stronger than generic working time regulations, especially as junior doctors work a number of extra hours over and above what they are contracted to work, as we have already heard.
I have further concerns about the proposed changes. Currently, Mid Yorkshire Hospitals NHS Trust, which manages Pinderfields, Wakefield’s local hospital, carries vacancies in all specialties, like most other large trusts. Vacancies are particularly hard to fill in A&E, obstetrics, paediatrics and medicine.
Junior doctors provide all types of patient care—emergency care to mothers in labour, care for new born babies, specialist elderly medicine, cancer care and surgery. We have heard that almost 3,500 doctors applied for paperwork to leave the UK and work abroad in the first 10 days after the Government announced their threat to impose the new contract.
I have concerns that the contract will discourage junior doctors from gaining clinical experience and contributing to medical research. Currently, pay progression is an annual increment, irrespective of their stage of training. NHS employers want to change that. That will impact on doctors who work part time or who are taking maternity leave, because they will not get an annual increment at their stage of training, so will not get pay progression.
I will not give way.
The Prime Minister said this morning that he was a feminist, but women junior doctors know that his warm words hide the cold reality of direct discrimination. Will the Minister tell us whether an equality impact assessment has been done on the proposals?
Finally, we have discussed the weekend effect, but Fiona Godlee, the editor of the British Medical Journal, has written to the Secretary of State criticising him for misrepresenting the research. He must think again and both sides must negotiate.
I rise to support our Secretary of State for Health. Far from the Opposition’s claims, the reforms he proposes will improve patient care and protect junior doctors on their shifts by ensuring that there are higher staffing numbers out of hours.
I am disappointed that the British Medical Association, which should represent the views of junior doctors, has refused to meet the Secretary of State for Health to discuss the proposals. Instead, it has politicised the issue. One calculator on the BMA website—it has been taken down—led junior doctors to believe that their pay would be cut by 30%. That has never been the case and is not part of any proposal. As a trade representative, the BMA should be ashamed that it has been scaremongering on an issue that affects the heart of our NHS and patient care, instead of engaging with the process in a professional way.
Over the past few weeks, I have seen all sorts of rumours circulating about the number of hours that doctors will be asked to work under the new contract, but the maximum number of hours they will be allowed to work will decrease from 91 hours to 72 hours. No junior doctor working full time will be asked to work more than 48 hours a week on average. The proposal does not return doctors to the time before the working time directive, when they slept on hospital floors. That was very unsafe. On the whole, the premise is to ensure that patient care is the safest it can be.
Doctors working too many hours goes against the basic principles of what the NHS should provide: the best care in the world, free of charge. I support the proposal that Saturdays should become part of the working week. They are treated that way in many professions and attract no extra pay. The Government’s proposal is cost-neutral and there are no cuts. No one will lose out. Junior doctors will be better off, because they will have more support on all their shifts. Patients will be better off, because care out of hours will improve.
I urge the BMA to listen carefully to the debate and to reopen talks with my right hon. Friend the Secretary of State for Health. He is ready and waiting to discuss a package that works for all. Our NHS is fantastic, as are all our junior doctors who work in it. I urge the BMA to allow those young men and women to aspire to even greater heights, and to get around the table for a better NHS for all.
We have a very real problem in recruitment and retention in our national health service. Hospitals and general practices are forced to recruit doctors from overseas and highly expensive locum and agency staff. The British Medical Association has described the plans as unsafe and unfair. My postbag is full of letters from junior doctors in the past weeks. Many of them feel that they are already overworked and undervalued. The threat of the imposition of the new contract does nothing to make that feeling better and only compounds it.
One of my constituents, Elizabeth, was born in Whiston hospital, which is ranked the best hospital in the country—I am so proud of it. She has lived in St Helens her entire life and is now a junior doctor in the hospital where she was born, training to be a GP. Admirably, she wants to put something back in to her community, but she tells me her plans are at risk because the new proposals financially penalise those on maternity leave. She tells me that she will have an enforced pay cut of approximately 30%—I listened to what the Secretary of State said about that—which would leave her unable to pay her mortgage, which she carefully budgets for.
She would also be unable to pay for the compulsory exams needed to complete her training. Sadly, that means she would be forced to take her skills elsewhere. She went on to tell me that other countries, such as Australia, can offer a better quality of life compared with what the new proposals mean for her. Given the very real prospect that she might default on her mortgage, she would have no choice but to move abroad with her family. Applications for certification to practise abroad are soaring. These proposals will also impact unfairly on female junior doctors, 80% of whom are part-time trainers, as pay progression will be slower for them; we will lose even more doctors as a result.
I do not want to go back to the old days, when a junior doctor told me he fell asleep while with a patient—the patient had to wake him up. Another junior doctor was killed in a car crash on the way home after working for nearly 30 hours without a break. It cannot be proved that his working pattern was responsible, but nothing would convince his colleagues and family that that was not the case.
We cannot afford to lose the doctors we are training. Not one hospital in the north-west would be able to balance the books in the next financial year. The clinical commissioning groups are facing enormous financial challenges. Hospitals can only get the money from the tariff from the Government and the CCGs, and it is not there. We cannot pay consultants seven days a week if there is not the money in the CCGs.
As a doctor and BMA member, and having been a junior doctor until 2008, I have listened over recent weeks and months to medical colleagues who have articulated loud and clear their fears about what a new contract might bring. Of course, this is a contract for England and I am a Welsh MP, but some of my constituents work in the north-west of England, and we also know that the contract adopted in England is often reflected in the contracts adopted elsewhere in the UK.
I have been concerned by the breakdown in the relationship between junior doctors and the Government, particularly as there is widespread agreement that a new contract is necessary. I have met the Secretary of State and the chair of the BMA’s junior doctors committee, Johann Malawana, and I am grateful to them for conducting sensible and reasonable discussions.
Junior doctors and other NHS staff want to feel valued, because they work extremely hard, have large workloads and, like the rest of the public sector, have been subject to pay restraint. There have been multiple attacks from the media in recent years, and indeed from politicians, which frankly have been unreasonable. Some doctors and NHS staff have been voting with their feet and moving abroad. We cannot afford that.
The Government have a duty to improve safety for patients at weekends and ensure that the NHS is affordable in challenging financial circumstances. It is evident to me that there has been some misinformation and unfounded fears about what is proposed in the new contract. The real difficulty with the current situation is that unless and until talks resume, there are in some respects no precise proposals to discuss, so it is very much a fear of the unknown. I believe that the main issue of concern is the threat to impose a contract. I understand how that threat came about, because two and a half years of negotiations led nowhere. I believe that that threat is now impeding the opportunity to resolve the current impasse.
Let me look at the rationale behind a new contract. It includes: an attempt to increase rostering of doctors at weekend; pay scale flexibility, with premiums to support shortage specialties or geographical areas; a change from time served in annual increments to pay progression based on training grades; a reduction of the total number of hours worked by doctors each week; and better consultant cover at weekends.
Of course, concerns have also been raised by the BMA. They include: the removal of financial penalties for hospitals that allow doctors to work excessive hours; and recognition of unsocial hours as premium time. We now know that no junior doctors are at risk of a pay cut. The BMA acknowledges that, in reality, compromise through discussion is required, but some of its current demands would effectively limit the ability for any new contract to be formed along the lines originally envisaged.
I thank the Opposition for bringing this very topical issue to the Floor of the House for consideration.
Of course, we cannot be closed-minded about the need to reform large aspects of the state, but when reforms are blatantly of an ideological nature it is essential that the appropriate scrutiny is applied, and I welcome the opportunity to do so.
My party, the Democratic Unionist party, believes strongly that an imposed contract does not represent the best way forward. We remain optimistic that the widespread acknowledgement that the existing contract is not fit for purpose will provide sufficient incentive for all parties to ensure that UK-wide agreement can be achieved. I commend the hon. Members for Totnes (Dr Wollaston) and for Central Ayrshire (Dr Whitford) for their very cohesive contributions setting the scene for this sensible, pragmatic and rational route, and I hope that others can join in pushing the House in that direction.
We cannot play politics with the future of such an essential part of our health service, nor with hard-working, aspirational young people who have, in many cases, worked hard their whole lives just to enter the medical profession. Consequently, we must encourage constructive engagement between Government and junior doctors’ representatives with a view to achieving a positive outcome that underpins safe working practices as well as delivering the highest safety and quality of care for patients.
The current proposals seek to improve something by taking from it. They seek to make improvements that, frankly, cannot be made in a safe manner without increasing investment. It is not just the BMA making noises over these proposed contracts; a tidal wave of stakeholders has weighed in voicing concern. The only way forward is the sensible, rational and pragmatic cross-party debate that my party and others in this Chamber want to see. Such matters are simply beyond politics. Our young people’s futures are at stake, as is the safety of our citizens when treated by the NHS. We all need to come together, work out what is right, and make an agreement.
Although the Department of Health in London is responsible for these negotiations, Department of Health, Social Security and Public Safety officials from Northern Ireland have been engaged in ongoing discussions with local BMA junior doctor representatives to assist in identifying and understanding any issues particular to Northern Ireland. We need to find the middle ground so that, sensibly and positively, we can balance the concerns from the different parties involved and come up with a sustainable long-term solution to this issue. The DUP recognises the vital role played by junior doctors in our health service locally and trusts that an outcome can be achieved that appropriately recognises the important contribution that these dedicated professionals make to society in Northern Ireland and across the rest of the United Kingdom.
I am delighted to be able to take part in this most important of debates.
It is worth saying at the outset that the most important issue we face when talking about changing these contracts is patient safety. We do well to recognise that our No. 1 priority should always be patient safety, and about the service that the NHS delivers to the patients who require its health and assistance at the most important time of their life. In order to deliver the improvements, level of service and safety that we require, we need to have an engaged workforce who are willing and enthused about their work. It is important to recognise the challenges that NHS staff face and the long hours that they have delivered over a number of years, putting themselves at great risk, frankly, in working what would be regarded in any other industry as silly hours. We clearly need to change those working practices to make sure that patient safety is once again brought right to the top of the agenda.
It is important to recognise that these negotiations are not about cash. This is not about saving money or changing the system so that the Government can spread things thinner; it is about delivering an NHS service over seven days of the week to make sure that when someone has that moment when they need the NHS to step in to save their life or to help them, the service is there and able to deliver.
Junior doctors currently receive between four and five incremental pay rises, depending on the time they serve. In most other industries, increments in pay should be about qualifications and the way in which someone has worked through them, not simply about the amount of time they have served.
We must get to a point where we can deliver a seven-day NHS and eradicate the weekend effect. As hon. Members have mentioned, some patients are starting to change the way in which they engage with the NHS because they are concerned that, if they are admitted on a weekend, that will affect the care they receive. It is important to ensure that that does not happen. There will inevitably be changes to work patterns, and current contracts will have to change. At the same time the Government will ensure that there is extra pay for time that doctors work at weekends.
The Scottish Government have said that they will reject this new contract for doctors, and therefore doctors working in Scotland will not be affected by the reforms to pay and conditions. My constituency is in the far north of England, so this issue is of concern to me and my constituents. We already struggle to access decent healthcare in the county—particularly at our acute hospitals and Cumberland infirmary—due in large part to huge problems with the recruitment and retention of doctors.
Many people in my constituency already travel long distances to access the kind of treatment that they ought to be able to get much closer to home. If Scotland opens its doors to junior doctors from England who feel threatened by this new contract, that will have serious implications for my constituency and other constituencies on the Scottish borders. We already know—it has been discussed in this debate—that there is a problem with keeping doctors in the UK and stopping them moving to other countries such as Australia. If a doctor is working in Carlisle at the infirmary, and all they have to do is move to Dumfries, surely that is a lot more attractive and easier than emigrating to Australia.
As MPs we appreciate the sacrifices that come with working long hours, and the stresses of difficult decisions and the impact on our families. Surely, then, we should appreciate the highly skilled work that our doctors do, on top of the kind of work that we have to do, and we should respect and value their huge contribution. It disturbs me that the Government have lost the confidence of so many in the medical professions. While that lack of confidence continues, we will never resolve issues surrounding the recruitment and retention of professionals and junior doctors in our health service, and we will never resolve the problems experienced by my constituents in accessing the quality care to which they are entitled.
If this contract goes ahead, I have a genuine concern that not only will we fail to recruit the junior doctors we need, but we will lose those we have as they go over the border and into Scotland. I urge the Minister to consider that point. Has that impact been taken into account? Have the Government considered the potential loss of doctors to Scotland? I urge the Minister to look at the issue again.
At the election, the Conservative party promised to deliver a seven-day a week NHS, and my right hon. Friend the Health Secretary is working hard to deliver a package of reforms, including the contractual changes under debate. As a former NHS worker, I know that junior doctors, like all those who work in the NHS, are dedicated to the service of patients. We owe them a great debt, and it is only right that they are rewarded fairly—something that I believe this new contract seeks to achieve.
It is time to dispel some of the mistruths about the updated terms and conditions that have been peddled by the Labour party and its lobbyist allies outside the Chamber. On pay, the facts are now clear. I am delighted that the Secretary of State has made it clear today that no junior doctor will be worse off as a result of the new contracts.
In terms of pay progression, the move away from an automatic rise for years served and towards increases linked to career progression through training grades and levels of responsibility must be welcomed. This will help to bring doctors in line with the industry standards of almost all other professions and see pay increases awarded fairly and on merit, rather than simply on how long a person has been in post.
Some plain time working will increase because of the changes, but there will be a new maximum working week of 72 hours, down from the current maximum of 91 hours. In addition, no junior doctor working full time will be expected to work on average more than 48 hours a week, and new limits on the number of nights and long shifts worked will be introduced. Surely these measures will provide a better work-life balance for our junior doctors and allow them to plan their time off with some certainty.
It is deeply concerning that the BMA has refused to negotiate on contract reform and has instead turned to the threat of strike action. Strikes, especially in vital public services such as health, are never in the public interest and serve only to detract from the valid points made by trade union members. I therefore urge the BMA to suspend the imminent strike ballot, get back around the negotiating table and start making some real progress with the Heath Secretary to secure a fair deal for their members, while securing patient safety.
A Government who take the difficult decisions rather than what is politically popular are, by their very nature, a responsible Government. As a Conservative Government, we are taking those difficult decisions so we can build a stronger and more sustainable NHS for the future.
In order to save paper, I am going to read out an email that comes from a doctor in my constituency. It would be great if those responding to the debate dealt with the concerns that doctors have raised and told us whether they consider their concerns to be right or wrong.
In essence, the junior doctor says the proposed changes will mean that doctors who work shifts of up to 11 hours will be entitled to only a 20-minute break; an NHS trust will no longer face penalties for introducing unsafe working rotas; and there will be a change in description of what are called sociable working hours. For junior doctors, sociable working hours will now be from 7 am to 7 pm, Monday to Friday, and 7 am to 10 pm on Monday and Saturday. That means that 9 pm on Saturday will be considered to be the same as 9 am on a Tuesday morning. That cannot be right.
The proposals will lead to a decrease in doctors’ salaries. As my junior doctor says, “Contrary to popular belief, we do not earn a lot of money. We start at £22,600 a year after five to six years of hard training and we rack up a debt of £40,000. We work a lot of hours.” The £22,600 figure translates to £10.65 an hour. Junior doctors hold an incredibly responsible job for that amount of money. Changes to pay progression will mean that if they leave the NHS to take up either training or maternity leave, they will not receive the pay rises due to them. In addition, if they change specialism, they will start from the bottom of the pay scale again—all their experience will count for nothing. Patient safety will be compromised and to suggest that that will not happen is plainly wrong.
The junior doctor’s email goes on to state, “We have to move jobs every three to six months. We struggle to settle anywhere and put down roots. We love our jobs and that’s why we sacrifice so much to be doctors, but this new contract is bullying, undermining and undervalues the doctors in our country.” Many doctors may well leave the profession. He says that that is the last thing they want to do, as they love the NHS and they want to serve the NHS.
The suggestion has been made that the information presented by doctors is wrong, or that they are worrying unnecessarily. If that is the case, I would really like an answer to every one of the questions we have raised. We must also be mindful of the fact that many doctors are leaving the United Kingdom. They are going to Australia and to New Zealand, and, as my hon. Friend the Member for Workington (Sue Hayman) said, they may go to Scotland.
It is important to make the point that these reforms are categorically not about saving money—their impact on the pay bill for junior doctors will be cost-neutral—so any suggestion that they represent a pay cut for junior doctors, as The BMJ has claimed, is dishonest. Junior doctors’ basic pay will increase, as will their pension contributions, and they will be awarded pay rises for progression, rather than simply time served, which is in line with most other industries.
NHS employers, who are part of the NHS Confederation, the only body that speaks on behalf of the whole healthcare system, have said in a briefing note that the previous increases, linked to time served, were unfair and did not reflect real progression in terms of increased skills and greater responsibility. The world has changed. People are living longer and have busy lives, and our population is increasing, meaning there are pressures on our health service that were not there 10 years ago. NHS employers have also said that the current contracts are not fit for purpose.
Doctors provide a vital public service, but the NHS must adapt to the needs of the people they serve. This means we need more services available at weekends and in the evenings, and we need doctors to give people the peace of mind that comes from knowing they can get the help they need when they need it.
Opposition Members claim that the reforms will have a detrimental effect on patient safety, but what is safe about a young trainee medic working the maximum 91 hours per week? The reforms will drastically reduce this to 72 hours in seven consecutive days, meaning we will be working our new doctors less hard, while striving towards the seven-day NHS the Government were elected to deliver.
I would like to turn to some of the concerns raised in the BMA’s briefing document. On page 3, it claims that the reforms will not protect doctors from having to work “dangerously long hours”. As I have said, the reforms will reduce the number of hours junior doctors have to work and introduce new safeguards on work-life balance by ensuring that all work schedules are mutually agreed between doctors and employers. No junior doctor will be expected to work more than a 48-hour week or more than four consecutive night shifts, and thanks to the Government’s reforms to childcare all working parents with three to four-year-old children will have access to 30 hours a week of free childcare. The rise in childcare costs claimed by the BMA are therefore a fallacy.
In conclusion, these reforms will bring doctors’ contracts into line with modern lives and working practices. They are important and right. They will improve outcomes for patients, which is the most important thing, and improve conditions for junior doctors. I welcome the Government’s amendment to the motion, and I implore all colleagues from across the House to follow us into the Lobby this evening.
I would like to relay some comments made to me when I participated with other colleagues in a demonstration in Newcastle attended by about 5,000 junior doctors. I had the great honour to be in the company of Dr Rachel King, a dedicated professional from South Tyneside district general named “doctor of the year” for her outstanding contribution in the field of care of the elderly, and some of her colleagues. I was struck by their commitment. They love the service, they want to protect it and they want to see their profession valued, and to that end they asked me to make a few points today.
For them, this debate is not about money, although I take issue with the claim from some Members that the reforms are cost-neutral and that doctors will not lose out. That might be the case overall, but the hon. Member for Finchley and Golders Green (Mike Freer) made a really good point: some individuals might lose out. They pointed out that junior doctors, en masse, do not support the reforms. These are clever people—the cream of the crop—and we should listen to them. They know how the service works and how it should be reformed.
They also pointed out that the reforms could increase the danger to patient safety because they might well not solve the problem of junior doctors working longer hours. As colleagues have pointed out, including the hon. Member for Central Ayrshire (Dr Whitford), the protections currently in place are to be removed, yet we have not had an assurance that something else will be put in their place. As we all know, tired doctors make mistakes. We need to address this issue about discouraging career breaks. Many junior doctors are women who leave to have children. Having spent a great deal of money on training them—the Secretary of State may be able to tell us the figure, but I believe it is in the order of £200,000 or £250,000—we want to encourage them to come back into the profession. There are concerns about not having enough people going into specialist areas.
We need to address the issue about recruitment and retention. Members representing constituencies in the north of England have touched on the issue of how attractive it would be for people to go to Scotland where the new contract does not apply. Over a period of two or three days, about 1,300 GPs made an application for the certification to practise abroad. That should be a real concern when we are having difficulty recruiting and retaining GPs. There is also a knock-on effect in general practice, but I will leave it there, given the shortage of time.
My wife is a junior doctor, an F2 currently working in A&E in one of London’s busiest hospitals. I could therefore start by thanking the Secretary of State for livening up my evenings, some of my afternoons and some of my mornings. Instead, I wish to start by saying that however hard colleagues in this place may think we work, precious few of us, as politicians, will ever really understand what it is like to work 10 hours a day and longer, when there is no time to eat, drink or even use the toilet, all while making decisions that are vital for patients and where a single error is both life-threatening and career-ending. Too many doctors feel that the current health service works despite the existing outdated systems, rather than because of them. That is why I hope all parties agree that reform is vital.
The fact that people are working in such intense conditions goes some way to explaining the intense passion that has surrounded this debate. Doctors not only deserve better than the contract they are currently on, but they deserve better than the negotiating process that has turned serious attempts at reform into a debacle where a vacuum has been filled by knowing misinformation from the BMA. Although it is hugely frustrating that the BMA has told many people, wrongly, that they are in line for a 30% pay cut when many will get a 15% pay rise and that many now think the Government want to impose longer working hours when in fact they will be cut, it is understandable. I have seen precious little attempt at genuine honesty from the BMA, but nobody should forget that the union has stepped into a vacuum, and that is why I hope the BMA will come back to the table and negotiate.
We need as little politics in the NHS as possible. We surely need to accept that doctors, however angry and however misinformed, have a commitment to their patients that transcends their commitment to any one hospital, any union or any political party. The low morale that has persisted in the NHS since last winter has not been helped by a lack of negotiation, and it will not be helped by the exhausting anger of a strike. I would like to see a contract that entices people into specialties such as A&E and being a GP, in part because the latter will see fewer visiting the former, and which acknowledges that working on a Saturday morning is already the norm for thousands but says that working late on a Saturday night is distinctly antisocial. Above all, I would like to see the mature approach from the Labour party, the BMA and all those concerned that will put the NHS on a sustainable footing. We have acted in good faith and I hope that the Labour party will see that and not seek to undermine the health service to which we are all indebted.
My constituent Dr Amy Di Marco, specialist registrar in general surgery, says that the term “junior doctors” is pretty misleading. She says
“in fact it applies to all those who are not GPs or Consultants and therefore includes many doctors who, like me, are nearing 40 (or over), with several years of experience and with responsibilities for patients as well as their own families.”
These are not work experience kids making the tea; they are serious professionals. They are highly qualified individuals who need commensurate remuneration and conditions that recognise that fact. In the areas of general practice, nuclear medicine, chemical pathology, emergency medicine, psychiatry, learning disabilities— the list goes on—we have a recruitment and retention crisis in any case, so these changes to contracts are not going to make the situation any better and risk exacerbating it. Junior doctors face the removal of the obligation on hospital trusts to safeguard the hours worked and the hiking up of plain time from 60 to 90 hours a week.
On 5 November there will be the ballot to strike. The BMA states that this is not a decision taken lightly. Indeed, being forced to work at weekends tending to patients on the brink of death after staying up all night cannot be good for anyone. There are also serious concerns that this proposal would disadvantage those on maternity pay or sick leave, employees working reduced hours or those doing research, yet this work pays dividends for the future and pioneering research on incurable diseases might save the NHS. All those people would be disadvantaged because their safeguards are being removed at a stroke.
This summer, we all saw the “#I’m in work, Jeremy” campaign on the promise for a seven-day NHS. It is happening already. I know this; I was born in Queen Charlotte’s hospital on a Sunday in 1972. Bolstered weekend care is obviously a good thing, but not if it means already stretched personnel being spread even more thinly, and not if it is unilaterally steamrollered through without adequate staffing and resources.
My constituent, Dr William Stern, neurology registrar— he has been in the Public Gallery since 4 o’clock—told me that he was not optimistic because of
“the current funding crisis…increasing deficits in most hospitals…targets being missed”
and junior doctors “threatening to strike”—something he does not want to do. I urge the Government to think again and end this stalemate. I urge all MPs to back the motion.
We have had a comprehensive and powerful debate, with 23 speakers and many more Members who would have liked to contribute if we had had more time. I would particularly like to thank my right hon. Friend the Member for Oxford East (Mr Smith), my hon. Friend the Member for West Ham (Lyn Brown), my right hon. Friend the Member for Enfield North (Joan Ryan), my hon. Friends the Members for Wakefield (Mary Creagh), for St Helens South and Whiston (Marie Rimmer), for Workington (Sue Hayman), for Bolton South East (Yasmin Qureshi), for Easington (Grahame M. Morris) and for Ealing Central and Acton (Dr Huq); the hon. Member for Central Ayrshire (Dr Whitford), the right hon. Member for North Norfolk (Norman Lamb) and the hon. Member for Strangford (Jim Shannon); and the hon. Members for Totnes (Dr Wollaston), for Bristol North West (Charlotte Leslie), for Finchley and Golders Green (Mike Freer), for South West Wiltshire (Dr Murrison), for Blackpool North and Cleveleys (Paul Maynard), for Morecambe and Lunesdale (David Morris), for Vale of Clwyd (Dr Davies), for Sherwood (Mark Spencer), for Erewash (Maggie Throup), for Boston and Skegness (Matt Warman) and for Morley and Outwood (Andrea Jenkyns).
Members of all parties have spoken with great passion and praise for our junior doctors, who work tirelessly to deliver good quality services—despite the challenges they face in an NHS that is increasingly under pressure and under strain.
I do not have time to give way, I am afraid.
I echo those sentiments of sincere thanks, but we have heard of junior doctors who already work weekends, already work nights, already work holidays and give their all for their patients. Despite all this, the junior doctors now face a situation that has left them feeling deflated, demoralised and devalued.
Patient safety has been a key theme of today’s debate. Some Members have valiantly leapt to the Health Secretary’s defence, but those voices have been far outnumbered by Members who are deeply concerned that this contract is unsafe for doctors and unsafe for patients.
Members have argued that the removal of the financial penalties that apply to hospitals that force junior doctors to work unsafe hours risks taking us back to the bad old days of overworked doctors, too exhausted to deliver safe care. The BMA says this safeguard, which is built into the current contract, has played an important role in bringing dangerous working hours down. Removing this financial disincentive to overworked junior doctors is extremely alarming, especially at a time when junior doctors are already coming under an enormous amount of pressure and strain. If the Health Secretary would just listen, he would hear junior doctors shouting loudly and clearly that they cannot give any more.
Many Members highlighted the protests and marches that have taken place throughout the country in recent weeks. We had only to catch a glimpse of the placards that were waved as thousands of junior doctors marched against the contract to understand that those doctors now fear for their own health and well-being. I was struck by one banner which read, “I could be your doctor tomorrow, or I could be the patient”, and those doctors’ concerns have been echoed by many Members today. How can the Secretary of State possibly say that he is acting in the interests of patient safety if the very people who work in the NHS say he is putting safety at risk?
Another argument that has been advanced today is that the contract is necessary to ensure that our NHS works seven days a week. Not only does that argument do a huge disservice to our NHS staff who already provide care seven days a week and 24 hours a day, and reveal just how out of touch some Conservative Members are with the realities of working on the frontline in our NHS, but it is wholly inaccurate. If this junior doctor contract were imposed in its current form, it would have the opposite effect, as many independent clinical voices have warned.
It is a bitter irony that the problems that the new junior doctor contract was supposed to be trying to address when it was originally proposed back in 2012—the need to introduce better pay and work-life balance—are the very problems that will be made worse should the contract go ahead in its current form. In letters to the Secretary of State, the presidents of a number of royal colleges and faculties have made it very clear that they share those concerns, but he presumably thinks that they too have been misled.
The Secretary of State said that he did not intend to cut the pay of any junior doctor, but his sums simply do not add up, and everyone can see through the spin. No one with a GCSE in maths can believe that no doctor will be worse off as a result of the new contract. Let the right hon. Gentleman come to the Dispatch Box in the minute that I have left, and answer this question. To what percentage of junior doctors currently working within the legal limits will what the Secretary of State has said today apply? Is it 50%? Less than a quarter? What is it?
In that case, I ask the Secretary of State to explain this. If the pay envelope is not increasing, and if the pay is not being reduced, how can these sums add up? They just do not add up, and I suggest that he go back to night school and learn some basic arithmetic.
We know that the BMA has been conciliatory today: it has offered to speak to the Secretary of State again. I ask him, please, let us take this down a notch. Let us get him talking to junior doctors again. The simple fact is that these are the junior doctors who work in our A & E; these are the junior doctors who work in every department of every hospital on the frontline. They come in early and leave late, they already provide care for seven days a week, 24 hours a day, and they deserve a lot better than this Government.
Junior doctors form a critical work force in our national health service. They are critical in the truest sense of the word: they are indispensable to the care of NHS patients. They work around the clock, and they are crucial to the cure of millions of people every year. That was recognised in the powerful speeches that have been made today, not least the very personal speeches made by my hon. Friend the Member for Boston and Skegness (Matt Warman) and the hon. Member for Wakefield (Mary Creagh). It is clear that every Member appreciates the central importance of junior doctors, and the extent of their training was made plain by the hon. Member for Central Ayrshire (Dr Whitford).
The critical importance of junior doctors makes their career unique. Few professions are so rewarding, but few are so challenging. I know from my own experience in hospital and from listening to junior doctors how many strive to provide the very best care, how they devote themselves to advancing their knowledge and level of training, and how they frequently make sacrifices in their private lives that others in comparable professions are not asked to make. That is why I understand why there is such a sense of frustration and anger when junior doctors are told by a trusted source that they will soon be asked to work more hours for less money. I know it will be of small consolation to them, but we on this side of the House are as frustrated because we have always recognised in the contract negotiations that we have initiated with the BMA that no such situation would arise.
The assurances that my right hon. Friend has made in a series of letters over the past few weeks, and the assurance he has given today that no junior doctor working within the legal limits in their current contract will lose money as a result of these changes—
I cannot because I have to conclude.
They are precisely the offers that were made privately both by the Secretary of State and negotiators in their discussions with the BMA. Our frustration is compounded by the fact that right from the beginning of this process, we have sought in the new contract to eradicate the slew of injustices in the current contract which make life unfair, and in some cases unbearable, for junior doctors.
Let me give a few examples raised by hon. Members, including my hon. Friend the Member for Finchley and Golders Green (Mike Freer). It is unfair that doctors who take time out for valuable medical research receive precisely the same increments as colleagues who might take time out to do something completely unconnected with their training and with service to the NHS, and the same increments as those who take time out altogether from the health service, working only part-time perhaps to develop a career in business or another field. They retain the same increments and basic pay through their career as the doctor who works diligently five, six, sometimes seven days a week, progressing through their training, passing their exams—yet getting exactly the same level of pay as the doctors who do not.
The greatest injustice arises for doctors from the perverse incentives in this contract—for example, hospital management choosing to use the current contract to avoid difficult decisions in rostering staff, paying doctors to work unsafe hours rather than getting to grips with the roster they should be putting in place to ensure safe care for patients.
Let me make it clear to the hon. Member for Denton and Reddish (Andrew Gwynne), who spoke for the Labour party, that the reductions so far since the 2000 contract are a result not of the penalty payments put in place as part of that contract, but of the working time regulations which have made a significant impact on the working hours of doctors, and quite rightly so. Does he not see the logic of his own argument? There are still doctors in the national health service who are working dangerous hours despite the fact that there are penalties in place to stop them doing so. By extension, the only way we can ensure that we have a proper, safe working environment in the NHS is to ensure, once and for all, that in contract and through review, and by exposure to regulatory bodies, junior doctors are not permitted to work unsafe hours. When we are asked whether we back the mis-statements by some of the people involved in this debate, or whether we encourage people to—
claimed to move the closure (Standing Order No.36).
Question put forthwith, That the Question be now put.
Question agreed to.
Main Question put accordingly (Standing Order No. 31(2)), That the original words stand part of the Question.
Question put forthwith (Standing Order No. 32(2)), That the proposed words be there added.
Question agreed to.
The Speaker declared the main Question, as amended, to be agreed to (Standing Order No. 31(2)).
That this House welcomes the Government’s commitment to delivering seven-day hospital services and saving lives by combating the weekend effect; notes the British Medical Association’s (BMA) decision to walk away from negotiations to reform a contract which all sides acknowledge is not fit for purpose; further notes the Government’s proposed introduction of new contractual limits which protect staff from working unsafe hours and the commitment that average junior doctors’ pay will not fall; and calls on the BMA to put patient care first, to choose talks over strikes, and to return to negotiations.
On a point of order, Mr Speaker. You might recall that on Monday you granted me an urgent question about the arrests of a Chinese dissident, who is now a British citizen, and two Tibetan students following demonstrations against the Chinese President during his visit last week. Can you advise me whether there is any way in which I can record the fact that all charges have been dropped against the two students and the dissident Chinese British citizen?