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Junior Doctors Contracts

Volume 608: debated on Monday 18 April 2016

(Urgent Question): To ask the Secretary of State for Health if he will make a statement on the imposition of a new junior doctors contract.

This House has been updated regularly on all developments relating to the junior doctors contract, and there has been no change whatsoever in the Government’s position since my statement to the House in February. I refer Members to my statement in Hansard on 11 February, and to answers to parliamentary questions from my ministerial colleagues on 3 March, which set out the position clearly. Nevertheless, I am happy to reiterate those statements to the hon. Lady.

The Government have been concerned for some time about higher mortality rates at weekends in our hospitals, which is one reason why we pledged a seven-day NHS in our manifesto. We have been discussing how to achieve that through contract reform with the British Medical Association for more than three years without success. In January, I asked Sir David Dalton, the highly respected chief executive of Salford Royal, to lead the negotiating team for the Government as a final attempt to resolve outstanding issues. He had some success, with agreement reached in 90% of areas.

However, despite having agreed in writing in November to negotiate on Saturday pay, and despite many concessions from the Government on this issue, the BMA went back on that agreement to negotiate, leading Sir David to conclude that

“there was no realistic prospect of a negotiated outcome.”

He therefore asked me to end the uncertainty for the service by proceeding with the introduction of a new contract without further delay. That is what I agreed to, and what we will be doing. It will start with those in foundation year 1 from this August, and proceed with a phased implementation for other trainees as their current contracts expire through rotation to other NHS organisations.

Let me be very clear: it has never been the Government’s plan to insist on changes to existing contracts. The plan was only to offer new contracts as people changed employer and progressed through training. This is something that the Secretary of State, with NHS organisations as employers, is entitled to do according even to the BMA’s own legal advice. NHS foundation trusts are technically able to determine pay and conditions for the staff they employ, but the reality within the NHS is that we have a strong tradition of collective bargaining, so in practice trusts opt to use national contracts. Health Education England has made it clear that a single national approach is essential to safeguard the delivery of medical training and that implementation of the national contract will be a key criterion in deciding its financial investment in training posts. As the Secretary of State is entitled to do, I have approved the terms of the national contract.

The Government have a mandate from the electorate to introduce a seven-day NHS, and there will be no retreat from reforms that save lives and improve patient care. Modern contracts for trainee doctors are an essential part of that programme, and it is a matter of great regret that obstructive behaviour from the BMA has made it impossible to achieve that through a negotiated outcome.

Just when we thought this whole sorry saga could not get any worse, it now appears that Government policy is in complete disarray. Despite the Health Secretary giving us all the impression back in February that he was going to railroad through a new contract, it now appears that he is simply making a suggestion—or, as his lawyers would say, approving the terms of a model contract. Last night, the Health Secretary took to Twitter to claim that this was not a change of approach, and we have heard the same again today, so, on behalf of patients, I have to ask him: what on earth is going on?

We need a straightforward answer to a simple question: is the Health Secretary imposing a new contract—yes or no? If he is not, but merely suggesting a template, why did he not make it clearer beforehand, and why, in his oral statement on 11 February, did he lead Parliament, the media, the public and, crucially, 50,000 junior doctors to believe that he was announcing imposition? The junior doctors committee took the unprecedented step of escalating its industrial action on the back of his decision to force through a contract. How can he possibly justify a situation whereby his rhetoric, underpinned by nothing but misplaced bravado and bullishness, could lead to the first ever all-out strike of junior doctors in the history of the NHS? He must get back to the negotiating table, and quickly.

We also need answers to the following questions. Do all NHS employers have free rein to amend the terms of the Health Secretary’s so-called model contract? Does this include non-foundation trusts? Is it legal for Health Education England effectively to blackmail trusts on the part of the Health Secretary by withholding funding, if that is what Government policy now is? Finally, it seems there are two basic scenarios: either he has known all along that he does not have the power to impose a new contract, and so all this is part of a cynical attempt to take on a trade union, or he was oblivious to the fact that he did not have the power, in which case, what is going on in his Department? This is no way to run the NHS. Today’s revelations call into question the motives, judgment and competence of the Health Secretary, and the House, doctors and patients deserve some answers.

That is a truly desperate attempt to divert attention from the single biggest question that people in this House want answered: does the Labour party support or not support a strike that will see the care of thousands of people up and down the country suffer?

Let me answer the hon. Lady’s question very directly. Yes, we are imposing a new contract, and we are doing it with the greatest of regret, because over three years—with three independent processes, 75 meetings and 73 concessions that we made in a huge effort to try to come to a negotiated settlement—the BMA refused to talk. With respect, I think Sir David Dalton, the trusted chief executive of Salford Royal, understands these things better than the hon. Lady has shown she does today. After working very hard, he concluded that a negotiated settlement was not possible. That is why I announced on 11 February that I would introduce a new contract.

As for foundation trusts, if the hon. Lady had listened to my statement she would know that it is true that foundation trusts have the freedom to introduce new contracts on pay and conditions. They can choose to exercise that freedom, but none of them has done so. She asked about non-foundation trusts. They do not have that freedom, and that is why we will be introducing a new contract for everyone.

Let me say this to the hon. Lady. There has been a lot of talk about this, but none of it as specious as the story that she planted in The Guardian this morning about the Government changing their position, which was absolute nonsense. We have not changed our position. The fact of the matter is that the Government have bent over backwards to avoid this strike. Right now, the people refusing to talk, whether it be on rota design with hospital managers or training reform with the academy, are not the Government but the BMA. Had it negotiated on Saturday pay, as it said it would, we would have had an agreement by now. Instead, we have a strike—the first ever withdrawal of emergency care in NHS history. [Interruption.]

Order. Opposition Members should calm themselves. The Secretary of State is responding, and everybody will be heard.

Rather than try to fabricate some story about the Government changing their position, which the hon. Lady knows perfectly well they are not, she might think about the words that do need to be said in this Chamber this week—about whether or not it is appropriate for the BMA to be telling people to deny life-saving care to patients.

Some people in the NHS have shown great courage in speaking out, even against their own profession: Professor Sir Bruce Keogh, the NHS England medical director, Lord Darzi, the former Labour Minister, and Dame Sally Davies, the chief medical officer. But there is one person on the public stage who has not had the courage to condemn those emergency strikes, and that is the shadow Health Secretary. I hope that, for the sake of her constituents and the reputation of the Labour party, she will say at the earliest opportunity that withdrawing emergency care in pursuance of a pay dispute is wrong, disproportionate and inappropriate, and that the right thing to do now is to show courage to reform these contracts for the benefit of patients and a seven-day NHS.

The BMA has always been a very militant trade union. It has had bitter political battles with just about every Secretary of State that the national health service has had since it started. It has, however, never previously contemplated strike action, withdrawing urgent services in pursuit of what is essentially a pay claim. I do not believe that before this year the Labour party would ever have supported the BMA if it had done so. Does my right hon. Friend agree that as the pressures on the NHS are obviously mounting, with the ageing population and the rising level of demand, it is urgent to move towards a fuller seven-day service, and that it would be totally wrong for him to delay that in the face industrial action or nit-picking legalisms from a shadow Secretary of State who has just discovered what the legal status of foundation hospitals actually is?

My right hon. and learned Friend speaks with huge wisdom and experience. He makes a point about what happened under previous Labour Governments. He might also have said that those were the same Governments that gave us the current badly flawed contracts. Because those previous Labour Governments did not stand up to the BMA and because they ducked difficult decisions, we saw the pay bill balloon and some shocking failures of care. Leadership is not just about talking and negotiating; it is also about acting. That is what Ministers have to do, and in this situation we have a very simple decision to make after three years of talks: do we proceed with the measures necessary to deliver a seven-day NHS and better care for patients, or do we duck those decisions? This Government choose to act.

Yet again, I must pull up the Secretary of State. It is not a case of excess deaths at weekends; it is a case of people admitted at weekends dying within 30 days. He said the same thing again today, and it is being repeated over and over.

The Secretary of State has described, within the same pay envelope, having more doctors at weekends, not fewer during the week, and reducing a maximum of 91 hours to 72 hours. I do not see how the maths of that can possibly add up. We are not managing to cover the rotas that we have, and those rota gaps pose a danger to patients.

I was very disappointed that the equality impact assessment dismissed the impact on women and other people who train less than full-time as acceptable collateral damage. We are facing the first ever all-out strike next week, and I cannot believe that we are not in negotiations. We should be at the table trying to prevent that strike. May I ask the Secretary of State how he plans to get us out of this? He should come back to the table, because that is the only way in which an impasse can ever end.

Let me gently ask the hon. Lady how long she expects us to sit round the table. We have been trying to discuss this for three years. She asked how the maths added up. I will tell her how the maths adds up. It adds up because we are putting an extra £10 billion, in real terms, into the NHS over the course of this Parliament. Conservatives put money into the NHS. The Scottish National party, incidentally, takes money out of the NHS.

The hon. Lady referred to the equality impact assessment selectively. She normally pays very good attention to detail, but the paragraphs from which she quoted related to changes that were agreed to by the BMA. What she did not quote was paragraph 95, which says that the overall assessment of the new contract is that it is “fair and justified” and will promote “equality of opportunity”. Why is that? Because shorter hours, fewer consecutive nights and fewer consecutive weekends make this a pro-women contract that will help people who are juggling important home and work responsibilities.

Does my right hon. Friend agree that, notwithstanding the appalling nature of the decision that, for the first time during strike action, junior doctors may not provide life-saving care for young children and other vulnerable patients, that decision is also totally incomprehensible, given that the doctors’ own leader has said that it is indefensible to take such action?

It is totally incomprehensible, and I know that many doctors will be wrestling with their consciences. However, I think that, in the context of the House, this could be an occasion for us to put aside party differences. I think that there was a time when Members in all parts of the House would have condemned the withdrawal of life-saving care in a pay dispute, but that day has sadly passed, and it is the Conservatives who must now show leadership in this regard. As we heard from my right hon. and learned Friend the Member for Rushcliffe (Mr Clarke), the NHS faces huge challenges, but we will not tackle those challenges if we allow obstructive unions to hold a gun to the Government’s head and refuse to allow us to proceed with really important changes—modern contracts that will allow safer care for patients and better terms for doctors. We are determined to do the right thing for the NHS, and, indeed, to be the party of the NHS.

If the Secretary of State wanted to do a deal with anybody, does he not think it is a bit unwise to say to my hon. Friend the Member for Lewisham East (Heidi Alexander) that she planted a story in a newspaper? That is accusing her of reprehensible conduct. I think he ought to be looking at withdrawing that. I am an expert on this subject. Somebody said to me on the picket line, “Do you know what sums up this Government, Dennis? ‘When first they practise to deceive’”—I had better not finish it. [Interruption.] “Oh what a magic web they weave, when first they practise to deceive.” That is what they are.

Well, if planting a story in a newspaper is reprehensible, I do not think many Members of this House would survive the scrutiny of the hon. Gentleman’s very high code of moral conduct for long. Let me say this to him and to all Labour Members: we should be honest about the problems we face in the NHS, whatever those problems might be, and we should not sweep them under the carpet. One problem that we face—not the only one—is the excess mortality rates for people admitted at weekends. There was a time when Labour Members would have recognised that their own constituents were the people who depended most on services such as the NHS and who had the most to gain from a full seven-day NHS. Labour Members should be supporting us, not opposing us.

We are eight days away from an unprecedented full walkout of junior doctors, including the withdrawal of emergency care. Our constituents want to know whether they will be safe on the strike days. Will the Secretary of State and the shadow Secretary of State join me in calling on the BMA at least to exempt casualty departments and maternity units from this walkout? We know that, even with goodwill arrangements in place to bring people back in when hospitals are overwhelmed, the delays will cost lives.

As ever, my hon. Friend speaks very constructively on this issue. She is absolutely right to say that the departments at most risk are emergency departments, maternity departments and intensive care units. Those are the areas that we are most keen to ensure will maintain critical doctor cover over the two strike days that are planned. I really hope that the BMA will co-operate with NHS England as we identify where we think the gaps might be. We will share that information with the BMA and I hope very much that it will help us to plug those gaps with junior doctors, because in the end no one wants there to be any kind of tragedy. We all have a responsibility to work to ensure that that happens.

The Secretary of State will be aware that, when it comes to a medical diagnosis, words and clarity matter. The same applies to us as politicians. He has said today that he is imposing a contract, in contrast with what his legal team are saying to the doctors. For the avoidance of doubt, will he set out explicitly what legal powers he thinks he has to do that?

I am very happy to do so. We are introducing a new contract from this August, and it will be for all junior doctors. It will go progressively through the different ranks of junior doctors and, over the course of the next year, the vast majority of new doctors will move on to the new contracts. The reason that we did not use the word “impose” in the original statement was not a matter of semantics. We are proceeding with this new contract and everyone will move on to it, which is the gist of what most people mean by this. What we are not doing is changing existing contracts, so when people move trust or move to a new position, they will move on to a new contract. That is why we have used the term “introduction” of new contracts. However, it would have been much better if the introduction of the new contracts had been done through a negotiated process. That is why we took such trouble: we went to 75 meetings and made 73 different concessions in order to try to do this on a negotiated basis. Very regrettably, that proved not to be possible, which is why we took the difficult decision to proceed with these new contracts anyway.

Does the Secretary of State agree that it is totally unjustified for doctors to demand higher premium rates at weekends when almost all other NHS workers, and indeed most other working people across the economy, do not get them? It is completely disrespectful for the BMA to suggest that doctors’ lives are somehow uniquely disproportionately inconvenienced by Saturday shifts and that those of other people are not.

It is true that the BMA rejected Saturday premium pay that was more generous than the Saturday premium pay offered to nurses, healthcare assistants or paramedics working in the same hospitals and operating theatres as those doctors. Many people will ask whether that was a reasonable position to take, given that the doctors’ overall pay was protected. I think they will also ask whether, even if the doctors disagreed with the Government on that point, it was appropriate or proportionate for them to withdraw life-saving emergency care from patients in the pursuance of their disagreement. I wonder whether that is something that will shape many people’s confidence in what the NHS stands for.

I have been disappointed by the Secretary of State, and by his language and tone, during this urgent question. Looking at how he has responded here, we can understand why the discussions and talks have ended up as they have done. He asked how long we should do this for; I would say, “As long as it takes.” The problem with the negotiations so far has been the Government’s failure to respond to the BMA and to work with junior doctors, who do care about their patients and do want to provide a good quality of care.

I think that sums up the difference between the two parties. It is true that Labour would take “as long it as takes” to negotiate the changes, which is why we ended up with poor contracts in 1999, 2003 and 2004. After three years of trying to get reforms to contracts to make the NHS safer for patients and better for doctors, we need to proceed with a manifesto commitment. Ministers have to decide and act as well as talk. We did not choose this outcome and tried hard for a negotiated decision, but when the hon. Lady says that talks should go on for “as long as it takes”, she is actually saying that the other party has a veto over change. No one should have a veto over an elected Government’s manifesto commitments.

One thing that the whole House can agree on is that the postponement of treatment or operations is never cost-free for patients. Every hospital has an ethics committee, so does my right hon. Friend agree that all striking doctors should consult their hospital’s ethics committee? Does he agree that the removal of emergency cover by any doctor for industrial reasons would be unlikely to meet with the approval of any medical ethic committee? Finally, does he agree that it is unacceptable for any doctor to act unethically, and that that would place him or her in serious jeopardy?

My right hon. Friend speaks wisely. A whole chorus of senior doctors, from Professor Sir Bruce Keogh to Dame Sally Davies to Lord Darzi, have urged doctors to think hard about the ethics involved. My right hon. Friend is absolutely right to say that consulting the ethics committee in the trust is a wise thing to do. Doctors might also take note of what the General Medical Council said about it being increasingly difficult to justify the withdrawal of emergency care and about the ethics involved. In the end, this is a personal decision for doctors, and it is about whether it is right to withdraw emergency care from patients in an industrial dispute about pay. This is a bridge that the NHS has never crossed before. It is a very big decision, not only for the NHS, but for every single doctor inside it.

On the basis of the Secretary of State’s previous comments, and particularly his opening comments, is he absolutely confident that he has the legal power to impose the new contract?

No, it has not. If it had, I do not think that we would be having a strike. I think we would have a negotiated settlement, and the NHS would be able to proceed with the contracts, which have important benefits for doctors, such as reducing the number of consecutive nights or consecutive long days that they can be asked to work. The refusal to negotiate on the crucial issue of Saturday pay, which is not a reduction in take-home pay because the reduction in Saturday premiums was made up for with an increase in basic pay, was what led Sir David Dalton to say that a negotiated settlement was not possible. It is a matter of huge regret, but I am afraid that it leaves the Government with no option but to proceed in the way that we are doing.

A senior executive at Babcock once said to me that there are employers who could pick a fight with themselves. During 30 years in the world of work, I cannot remember a legitimate sense of grievance so grotesquely mishandled. Does the Secretary of State not recognise that he is poisoning relationships with a generation of junior doctors? Will he not get back to the negotiating table and stay there until the dispute is resolved?

Without going over the previous points about the three years we have been around the negotiating table, I just say this to the hon. Gentleman: I think there are legitimate grievances for junior doctors, and they extend well beyond the contract. There are some big issues with the way training has changed over the years, and there are some serious issues we need to address about the quality of life for junior doctors—sometimes they have a partner working in a different city and they are unable to get training posts nearby to each other. We want to address those issues, which is why we set up a review, led by Professor Dame Sue Bailey, the president of the Academy of Medical Royal Colleges. Who is refusing to talk to that review, and refusing to co-operate with it? It is the BMA. That is why it is so important that people get around the table and start to talk about how we resolve these problems, rather than remaining in entrenched positions.

Can my right hon. Friend confirm that the new contract provides a far better work-life balance than the current contract, which doctors tell me cannot even help them to provide and plan for important family events?

Absolutely. One of the key changes in the new contract that we hope to see is much more predictability about weekend working, and a sense for junior doctors that when they do go into work at the weekends they will get the same support around them as they would during the week; it can be incredibly stressful when junior doctors are called into work at the moment. All these things are improvements, and what has made it very difficult is that these improvements have been misrepresented by the BMA to its own members, so that people have become very suspicious about these changes. That is why we tried so hard to get a negotiated outcome, and why we have been so disappointed that that has not been possible.

Can the Secretary of State confirm that the studies of mortality rates within 30 days of weekend admissions have in no case said that the rostering of junior doctors is a problem? Instead of talking about others negotiating, why does he not take responsibility and get around the negotiating table himself?

With respect, not very far away from the hon. Lady’s constituency is the Salford Royal, whose very respected chief executive concluded that a negotiated outcome was not possible. That is why I reluctantly took the decision to proceed with the new contracts. As for the studies on mortality rates, we have had eight studies in the past six years, six of which have said that staffing levels at weekends are one of the things that need to be investigated. The clinical standards say that we need senior decision makers to check people who are admitted at the weekends, and junior doctors, when they are experienced, count as senior decision makers, which is why they have a very important role to play in delivering seven-day care.

I know that the BMA very properly balloted its members before embarking on a policy of industrial action, but has it yet balloted junior doctors on the specific question of withdrawing emergency cover?

No, it has not, and I think that is what is causing many junior members to pause for thought. Many people say that this escalation is something that the BMA should consults its members on, once again.

Does the Secretary of State accept that we need closure on the junior doctors’ strike, for patients and for doctors, to enable the NHS to concentrate on issues such as the projected £8 billion shortfall in the NHS; the GP out-of-hours services, which are under real pressure; the worst ever NHS performance in the first month of this year; and the long-term threat to the financial viability of our whole health and social care system?

We do face many challenges; the right hon. Gentleman is absolutely right to say that we need to focus on those, and so the sooner we resolve this dispute with the BMA, the better. I simply say to him that if we were to carry on negotiations that were clearly not going anywhere at all, this dispute would go on for even longer. We have been trying to resolve these issues for a very, very long time, and in the end one has to decide if one is going to do what it takes to move forward.

Mr Speaker, if every one of the 650 MPs came to you and said that one of their constituents was dying unnecessarily every five weeks—that is the lower estimated number of excess deaths; it would be once every two weeks at the higher estimated number—I would hope that you would grant this kind of debate every day until we had a system that was safer for patients and junior doctors, and until we brought into the open the nameless characters behind the BMA negotiators. They refuse to come out into the open and argue their case on its merits, and to say why they will not discuss Saturday pay.

My hon. Friend is absolutely right. Part of the hallmark of this Government’s approach to the NHS has to be honesty about where we have too many avoidable deaths, and where there is the weekend effect for people admitted to hospital at the weekends. We have a big responsibility in that regard. The reason why we discharge that responsibility is that we believe in the NHS. We want the NHS to be the safest, highest-quality system in the world. Just as this Government have pioneered reforms that have dramatically improved the quality of state education, so too we need equal reforms in the NHS. That is why it is absolutely right to say that we have to focus on these things and debate them in this House. We should not automatically say that there is someone who must be blamed when we are dealing with these difficult situations. Unfortunately, one of the things that has led to feelings running high in this dispute has been the sense of blame being tossed around, when what the Government want to do is try to solve the problem.

May I tell the Secretary of State about my admission to hospital in the early hours of a Saturday morning? I spent five and a half weeks in intensive care. I had many conversations with doctors during the time I was in St Mary’s hospital, Paddington. I ask him to look at the circumstances of those doctors today, as they do work weekends. We do have a weekend NHS. It is not true to say that the lives of people like me who are admitted at the weekend are not saved, because it is the doctors who make it possible for us to survive. Will he stop talking down the medical profession and start defending the doctors?

With respect, that precisely encapsulates the problem. The hon. Gentleman has interpreted the fact that I want to do something about excess mortality rates, which mean that a person admitted at the weekend has an 11% to 15% higher chance of death than if they were admitted in the week—that is proven in a very comprehensive study—as an attack on the medical profession. Nothing could be further from the truth. It was actually the medical profession—the royal colleges and Professor Sir Bruce Keogh—that first pointed out this problem of the weekend effect. We are simply doing something about it.

The Health Secretary rightly mentioned the excellent Salford Royal, which the BMA has used to suggest that the new contract is not necessary, because of the progress that it has made on seven-day working and on Sir Bruce Keogh’s clinical standards. However, is it not the case that what might be right in a large hospital in a densely urban centre might not be applicable right across our national health service? Is that not why the very radical changes to working practices that he is rightly prosecuting are necessary?

Yes, there are some hospitals that have managed to eliminate the difference between weekend and weekday mortality under the current contracts, but there are only a few. Having talked more widely with the medical profession, it is clear that we need a sustained national effort—contract reform is part of that effort—if we are to promise uniformly across the NHS that we will provide every patient with the same high-quality care, every day of the week. Part of that is having a modern contract for junior doctors that deals with the anomalies that they themselves recognise in the current contract; that is why this is the moment for wider reforms.

This is clearly a fight that the Secretary of State went looking for because he expected to put himself on the side of the patients. The trouble is that it has not worked out like that, because the patients, such as my hon. Friend the Member for Ilford South (Mike Gapes), use these services and know that junior doctors are in work at the weekend; it is some other procedures that are sometimes not available. Their feelings now will be fear and anxiety that they, their children or their elderly relatives will get sick, fall or need help on strike day. They will be seriously, seriously worried about that. Does the Secretary of State take any responsibility for the situation that he has caused?

On the contrary, I take full responsibility for delivering a safer NHS for patients. That is my job. If the hon. Lady wants to talk about patients, perhaps she might listen to the comments of one of the most famous patient safety campaigners in the country, James Titcombe, who tragically lost his son because of mistakes made at Morecambe Bay. He said that there has been

“much progress towards a safer NHS in recent years”,

but that there is

“much more to do to reverse the cover-up culture that flourished under Labour.”

Can my right hon. Friend confirm that on the last occasion that the BMA called on junior doctors to take strike action, that call was rejected by 47% of junior doctors? Now the BMA wants junior doctors to remove emergency cover. What does he think it will say about the BMA’s mandate for future action if fewer than half of junior doctors support its call for further strikes?

That is a very important point to make. On the BMA’s mandate for the current strike action, many hon. Members have said today that we should get round the negotiating table. They may not be aware that the BMA decided to ballot for strike action before even sitting down to talk to the Government about our plans. It decided to go straight to a ballot for industrial action on a false prospectus of the Government’s planned changes. That sowed many of the misunderstandings in the current dispute.

Like most hon. Members, I have had many doctors coming to my constituency surgery—not junior doctors, but registrars, on whom our hospitals rely. They have sometimes been in tears. They have asked me if the Secretary of State will define exactly what he means by a seven-day NHS, because clearly there is seven-day care. Is it just an ideological mantra?

I am not sure what the hon. Gentleman’s definition of “ideological” is. If “ideological” is giving safer care to patients, it is an ideology that we can all share, but I will tell him exactly the answer to his question, which he can relay to his constituents. What we want to do is reduce the difference between the mortality rates for people admitted in the week and at weekends. We have identified four key clinical standards that we believe are necessary to do that. It is by making sure that we can deliver those four clinical standards across the NHS that we will deliver this strategy.

Can my right hon. Friend imagine the distress and the anxiety felt by constituents who have come to see me over the past six years because they are concerned about the treatment of their relatives admitted at the weekend, when they see the BMA and the Labour party appearing to use them and other patients as hostages in a long-running dispute that must come to an end?

My hon. Friend is right. What patients want is a safe NHS where it does not matter on which day of the week they are admitted if something goes badly wrong. The big surprise here is that this is not something that the whole House can unite behind. It is something that people who believe in the NHS, as I think we all do, should strongly support. We are standing up for those patients, and I hope Labour, the party that founded the NHS, might do the same.

I would be grateful if the Secretary of State could update the House on any legal action against the Department, and on whether the Department will be defending it.

I, too, have been contacted by a number of junior doctors who are increasingly disillusioned by the way that the BMA is handling the dispute, and especially by the militant tendency, which has been hell-bent on strike action for many months. Will the Secretary of State meet other groups of junior doctors who want to resolve the dispute, recognise that a reformed contract is needed, and want to get back to looking after patients?

Of course I am delighted to engage with junior doctors, and I have been talking to a number of them over recent months. I agree with my hon. Friend. My observation from talking to junior doctors is that most of the time I am with them, they are not talking about things they do not like about the new contracts. They are concerned about things to do with their training and quality of life—things that I think we can sort out outside the current contractual negotiations. As my hon. Friend has correctly been passing on to them, there are many things in the new contract that will benefit junior doctors, and we should make sure that everyone knows about them.

How can the Secretary of State claim that he is motivated by a desire for a seven-day NHS when he and others in the coalition Government legislated to allow hospitals to make up to 49% of their money from private patients? If hospitals achieve that 49%, what impact will that have on mortality rates for NHS patients?

The difference between those of us on the Government side of the House and those on the Opposition side is that we do not have an ideological view about a trust wanting to offer some private treatment in order to benefit its NHS patients. That is what some trusts are doing, within very strict constraints. I think that most people know that all the scare stories that were put out about the Health and Social Care Bill in 2012 have not materialised. We are finding that trusts are being very sensible about making sure they get that balance right. Indeed, in certain circumstances it makes a big difference to improving NHS care.

The key thing is looking after patient safety, so will my right hon. Friend consider changing the law so that hospitals such as Derriford hospital can make use of dedicated military doctors to fulfil that service if it is needed?

My hon. Friend always makes important suggestions that can benefit his constituency, and rightly so. I do not think that there is a need to change the law for that to happen; if military help were needed, I think the military would stand ready to offer it. At the moment, we are making contingency plans by drawing on the consultant workforce, who are not involved in industrial action, and our hope is that A&E departments throughout the country will be covered by that extra support.

If the Health Secretary is unable to impose the original contract, how can people be expected to abide by a new contract that is not legally binding? Does he agree that maintaining a constant approach is absolutely vital, particularly in a fifth walkout, which could involve everyone? What actions is he taking to restore faith in the NHS among both the staff and the general public?

Just to be absolutely clear, the new contract is legally binding and it will apply to all junior doctors in the NHS. On restoring confidence, obviously morale is low at the height of an industrial relations dispute. I think the real way to restore confidence is to point out to the doctors who work incredibly hard inside the NHS that the Government are this year giving the NHS the sixth biggest funding increase in its history, that we are committed to making the NHS the safest and highest-quality system in the world, and that we believe that if that happens it will also be a better place for them to work. I believe that all those things will come together, but obviously there is a very difficult period that we have to get through first.

Against the background of Kettering general hospital being under huge pressure, there is a great deal of local sympathy for junior doctors, but increasingly people are bemused as to what the strike is about, given that the contract involves a reduction in hours from 91 to 72 and a 13.5% increase in basic pay. My constituents are opposed to strike action, and they are completely opposed to any strike action that involves the withdrawal of emergency cover.

My hon. Friend is absolutely right, and I am sure that that position is shared by many members of the public. I think people are very perplexed, because both sides in the January negotiations concluded that there was only one area of outstanding difference, which was Saturday pay. I adopted a compromise position on Saturday pay, which I thought was the fairest thing to do, but the BMA was not prepared to countenance any flexibility on that whatsoever. I therefore had to make the very difficult decision of whether we go forward, or whether we do not address the big issues that we need to address for a seven-day NHS. I share his concern about whether the strikes are really worth it, and I am concerned about the impact on the residents of Kettering.

If the Secretary of State is correct that he has the legal power to impose contracts, can he tell the House from where that power derives? Can he also explain why the Government’s legal team failed to argue that case?

I hope the hon. Lady understands that I am not going to go into the details of the legal cases that we are currently arguing. However, let me make it clear that the Secretary of State does have that power and that we are using it correctly, and we will argue that case very strongly in the High Court.

Many hundreds of operations were cancelled during the last strike. The next strike will see the unprecedented step of emergency cover being withdrawn, and many junior doctors are themselves worried about that. Does my right hon. Friend agree that it is time for the BMA’s leaders, who are calling for the strike, to heed the worries of those junior doctors and of patients, and to call it off?

I absolutely agree. It is entirely legitimate to disagree with the Government of the day about contract reform—we have tried to make the case as to why that reform is important—but it is wrong for patients to pay the price for that disagreement. While the NHS can cope with the withdrawal of labour for elective care, it is a much bigger deal when emergency care is withdrawn, and people throughout the NHS are extremely worried about the impact of that. Doctors should also worry about how the public will view their profession if they proceed with this wholly unnecessary step.

I am glad the Secretary of State has come to the Chamber to answer the urgent question—I witnessed for myself his eagerness to get here as he sprinted across Portcullis House.

There is a real lack of clarity in this debate. “Agenda for Change” staff get paid a premium rate for working unsocial hours. Foundation trusts’ freedom to set rates allows them only to improve conditions and pay, not to diminish them. May I add that 98% of those who voted in the BMA’s ballot supported industrial action, including the full withdrawal of labour? May I suggest that the Secretary of State arm himself with the facts and get back round the negotiating table?

The hon. Lady is right that I sprinted here—I was a little concerned that Defence questions might not last the full hour, although they did, and I am sure Mr Speaker is pleased about that. The point I would make about the ballot, which did receive the overwhelming support of junior doctors, is that it happened before they knew what the deal on the table was. On the heated issue of Saturday premium rates, we ended up with a proposal where the Government agreed to pay premium pay on Saturdays for any doctors who work one Saturday or more a month. At the moment, therefore, we have this extreme step—the withdrawal of emergency care—to boost the pay of doctors who work less than one Saturday a month. I think many members of the public will say that that is not proportionate.

Let us be clear: this is an old-fashioned wage dispute, run by one of the most militant long-standing trade unions. My constituents are asking why the highest-paid NHS workers should be paid extra for working Saturdays when some of the lowest-paid NHS workers are not.

My hon. Friend is right. Doctors who strike will need to explain that to paramedics, healthcare assistants and nurses working in their own operating theatres. In the end, that issue is why this strike is happening. The BMA said in writing in November that it would negotiate on Saturday pay; it went back on its word in February. As a result, this is the only outstanding issue, and we now have this extreme step—the withdrawal of emergency care. I find that very hard to justify.

At the beginning, the Secretary of State said he was publishing a model contract, which he believed trusts, including foundation trusts, would by convention implement, but he has subsequently said that there is a legal duty that he can impose. He needs to clarify that, and it would be helpful if he could publish the legal advice. That would not be a surprise in the judicial review cases, because his lawyers are presumably doing their skeleton arguments. We have a right to know the answers to these questions.

With respect, all the hon. Gentleman needs to do is look in Hansard at my response to the urgent question, which made it clear that we have the right to introduce a new contract. On the basis of the conventions that currently apply in the NHS, that contract will apply to all junior doctors. Foundation trusts do indeed have the right to set their own terms and conditions, but they choose not to do so.

This unprecedented withdrawal of emergency care seems to revolve principally around the issue of pay on Saturdays. Will the Secretary of State clarify whether pay uplifts will continue to be available to junior doctors who work regular Saturdays?

Absolutely. More to the point, any doctors who see an increase in their Saturday workload will see a significant increase in their pay, including their premium pay. The contract is designed to make sure that we reward people who work the longest and most antisocial hours, including women, but in a way that means that we can afford to deliver a seven-day NHS, which is why it is good for patients as well.

Many weekend admissions are for urgent cases such as heart attacks and strokes, while many weekday admissions are for elective surgery and other non-life-threatening conditions. Is not that the main reason for the myth of excess weekend deaths?

Why will the anxiety of this strike be felt only by patients in England, while the other nations have settled? Is it because of bad negotiation or because the health service is never really safe in Tory hands?

I wonder whether the hon. Gentleman would have the courage to say that in Wales, but let me answer his question directly. The 15% increase in mortality rates for people admitted at weekends falls to 11% when we take account of the more chronic conditions, so there is a small reduction, but the mortality rate is still significant.

May I take the Secretary of State back to the question he did not answer when it was asked by my hon. Friend the shadow Secretary of State? If the Government are now arguing that the Secretary of State does have the power to impose a contract, can he explain why Government solicitors did not argue that case in their letter of 15 April? Can he point to where it is proved that he actually has that power?

We do have that power by law. The letter we put out in defence against the legal action that has been taken against the Government explains very clearly why and how we have that power. It is all written there for the hon. Gentleman to see. I assure him that, on something as contentious and difficult as this, we take every care to make sure that we are acting within the law.

If I were Secretary of State for Health, I would feel personally responsible for this unprecedented action taking place on my watch, and I would do everything I could to build bridges to make sure it did not happen and that patients were not threatened in the way we all fear. What is the Secretary of State doing to build trust between himself and the NHS workforce?

I will tell the hon. Gentleman one of the things we are doing, which is turning around the hospital in his own constituency, which is no longer in special measures because the quality of care has improved dramatically. What else are we doing? Over three years, there have been 75 meetings, 73 concessions and three different independent processes. We have tried everything to get a negotiated outcome, but in the end we have to do the thing that is right for patients.

The Secretary of State needs to face reality: there is a recruitment and retention crisis of junior doctors in paediatrics, A&E, intensive therapy units and acute medicine. Those specialisms demand seven-day working and people working unsocial hours. The junior doctors know that these contracts will make the situation worse, so why is the Secretary of State not doing everything in his power to get people to sit around the table—even if that does not include him personally or David Dalton—to have negotiations to address the real issues concerning junior doctors?

That is exactly what we have been doing. Indeed, there are a number of changes in the contracts that will be beneficial for people working in A&E departments, as has been recognised by the president of the Royal College of Emergency Medicine, Cliff Mann. The difficulty we have had in terms of morale is that we have been faced with the BMA, which has consistently misrepresented the contents of the new contract to its own members. Nothing could be more damaging for morale than that. What we will need to do, I am afraid, is wait until people are on the new contracts, and then they will actually see that they are a big improvement on their current terms and conditions. That is the right thing for doctors and the right thing for patients.