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Junior Doctors: Industrial Action

Volume 614: debated on Monday 5 September 2016

I regret to inform the House that last week the British Medical Association announced that it was initiating further rounds of industrial action over the junior doctors contract. They involve a series of week-long all-out strikes between now and Christmas, which were scheduled to start next Monday, although this afternoon the BMA delayed the first strike until 5 October. That news is of course welcome, but we must not let it obscure the fact that the remaining planned industrial action is unprecedented in length and severity and will be damaging to patients, some of whose operations will have already been cancelled.

Many NHS organisations, including NHS England, NHS Providers, the NHS Confederation and NHS Improvement, have expressed concern about the potential impact on patient safety. Indeed, this morning the General Medical Council published its advice to doctors on the strike action. While recognising a doctor’s legal right to take industrial action, it urged all doctors in training to pause and consider the implications for patients, saying:

“Given the scale and repeated nature of what is proposed, we believe that, despite everyone’s best efforts, patients will suffer.”

Many others have also questioned whether escalating the strikes is a proportionate or reasonable response to a contract that the BMA junior doctors’ leader, Dr Ellen McCourt, personally negotiated and supported in May. She said then that the new contract was

“safer for our patients, safer for our junior doctors… and also fair.”

She said, with respect to junior doctors, that the contract

“really values their time, values them as part of the workforce, will really reduce the problem of recruitment and retention, emphasises that all doctors are equal, and has put together a really good package of things for equalities.”

We recognise that since those comments were made, the new contract has been rejected in a ballot of BMA members. However, it is deeply perplexing for patients, NHS leaders and, indeed, the Government that the reaction of the BMA leadership, which previously supported the contract, is now to initiate the most extreme strike action in NHS history, inflicting unprecedented misery on millions of patients up and down the country. We currently expect up to 100,000 elective operations to be cancelled and up to a million hospital appointments to be postponed, which will inevitably have an impact on our ability to hit the vital “18 weeks” performance standard.

Today I want to reassure the House that the Government and the NHS are working round the clock to make preparations for the strikes. All hospitals will be reviewing their rotas to ensure that critical services such as accident and emergency, critical care, neonatal services and maternity services are maintained. The priority of all NHS organisations is to ensure that patients have access to the healthcare they need and that the risks to patients are minimised, but the impact of such long strikes will severely test that. As with previous strikes, we cannot give an absolute guarantee that patients will be safe, but hospitals up and down the country will bust a gut to look after their patients in this unprecedented situation and communicate as soon as possible with people whose care is likely to be affected.

Turning to the long-term causes of the dispute, it is clear that for the BMA negotiators it has been largely about pay, but I recognise that for the majority of junior doctors there is a much broader range of concerns, including the way their training is structured, the ability to sustain family life during training periods, the gender pay gap and rota gaps. After the May agreement, we set up a structured process to look at all these concerns outside the contract and I intend that that work will continue.

Health Education England has been undertaking a range of work to allow couples to apply to train in the same area, to offer training placements for those with caring responsibilities close to their home, to introduce a new catch-up programme for doctors who take maternity leave or time off for other caring responsibilities, and to look at the particular concerns of doctors in their first year of foundation training. Today, HEE has set out further information for junior doctors about addressing these non-contractual concerns, and we are proceeding with the gender pay review that I mentioned in my last statement to the House on this issue.

We have also responded to specific concerns raised by the BMA. First, the BMA, NHS Employers and Health Education England have agreed changes to strengthen whistleblowing protections for junior doctors beyond the scope of existing legislation, so that junior doctors can take legal action against the HEE, in relation to whistleblowing, as if the HEE was their employer. Secondly, in direct response to the concerns raised by Dr McCourt over the role of the independent guardians of safe working hours, NHS Employers has written to all NHS chief executives to set out in considerable detail the expectations for the new guardian role. As of 2 September, 186 of 217 guardians had been appointed with the involvement of BMA representatives, with a further 15 interim arrangements in place, and it is expected that all will be appointed by the middle of this month.

Many junior doctors have expressed concern about rota gaps, and the new contract acknowledges and tackles this concern. The guardians of safe working hours will report to trust and foundation trust boards on the issue of rota gaps within junior doctor rotas. This will shine a light on the issue and it will be escalated, potentially to the Care Quality Commission and the General Medical Council, when serious issues are not addressed. I strongly urge all those considering taking industrial action to consider the progress being made in all these areas before making their final decision.

With respect to the broader debate about seven-day care, we recognise that many doctors have concerns about precisely what is meant by a seven-day NHS. As Sir David Dalton stated publicly last week, we offered to insert details of our seven-day plans in the May agreement, but this was rejected by the BMA, so it is very disappointing that it now says the need for more clarity over seven-day services is one of the reasons for the strike, but given that it has said that, I would like to repeat further reassurances on that front today.

First, while the changes to the junior doctors contract are cost-neutral—that is, the overall pay bill for the current cohort of junior doctors will not go up or down—our seven-day services policy is not cost-neutral, and will be funded out of the additional £10 billion provided to the NHS this Parliament. Secondly, while the pay bill for the current number of junior doctors will not increase, we do expect the overall pay bill to go up as we have committed to employing many more doctors to help to meet our commitment on seven-day services. That means that our plans are not predicated on simply stretching the existing workforce more thinly or diluting weekday cover.

Thirdly, we recognise that junior doctors already work very hard, including evenings and weekends, and while we do need to reduce weekend premium rates that make it difficult to deploy the correct levels of medical cover, we expect this policy to have greater implications for the working patterns of other workforce groups, including consultants and diagnostic staff. Finally, we have no policy to require all trusts to increase elective care at weekends. Our seven-day services policy is focused on meeting four clinical standards relating to urgent and emergency care, meaning that vulnerable patients on hospital wards at weekends will get checked more regularly in ward rounds by clinicians, and clinicians will be able to order important test results for their patients at weekends.

Despite these reassurances, there may remain honest differences of opinion on seven-day care, but the way to resolve them is through co-operation and dialogue, not confrontation and strikes which harm patients. To those who say these changes are demoralising the NHS workforce, I simply say that nothing is more demoralising or more polarising than a damaging strike. It is not too late to turn decisively away from the path of confrontation and to put patients first, and I urge everyone to consider how their own individual actions in the coming months will impact on people who desperately need the services of our NHS.

This Government will not waiver in our commitment to make the NHS the safest, highest-quality healthcare system in the world, and I commend this statement to the House.

The prospect of a rolling five-day strike by junior doctors was one of the utmost gravity. The junior doctors have suspended next week’s action, which is a step I believe the whole House welcomes, but the remaining programme of industrial action stays in place. If it eventually goes ahead, it will be the first such strike by junior doctors in the entire history of the national health service.

What the current situation shows is that there has been a complete breakdown in trust between junior doctors and the Government. The morale of junior doctors could not be lower, and that is not something for the Secretary of State to dismiss. But somehow the Secretary of State continues to take no responsibility for the current state of affairs—no responsibility for repeatedly arguing that the only problem was that doctors had “not read the contract”, no responsibility for the misleading use of statistics by claiming that thousands of patients were dying because of poor weekend care.

The president of the Royal College of Paediatrics and Child Health, Professor Neena Modi, said:

“despite concerns raised by senior officials, Jeremy Hunt persisted in using dubious evidence about the so-called ‘weekend effect’ to impose a damaging Junior Doctor contract under the bogus guise of patient safety”.

The Secretary of State still insists that the contract is about a seven-day NHS when we know now that his own officials were telling him that the NHS had too few staff and too little money to deliver what he was talking about.

The Secretary of State well knows that the public simply do not believe him in his attempt to demonise the junior doctors. Try as he might, he has failed to convince the public that somehow junior doctors are the “enemy within” or mere dupes of the BMA. Far from being manipulated, doctors voted emphatically against the new contract.

Everyone in this House will remember the 7/7 bombings and the No. 30 bus which exploded in Tavistock Square, a few yards from the headquarters of the British Medical Association. Everyone will remember the pictures of doctors, who had been in meetings and their offices, pouring out of the BMA building, heading for the 14 dead people and the 110 victims, without flinching or faltering, fulfilling their vocation of saving lives. These are the people that the Secretary of State seeks to vilify.

Today we know that the junior doctors—who, contrary to what the Secretary of State implied, have always made patient safety a top priority—have cancelled the action planned for next Monday, but if we are going to remove the threat of industrial action, there are questions that the Secretary of State has to answer. There are widespread reports of deficits and financial crises, so how can the NHS move to enhanced seven-day week working, even with the proposed £10 billion the Secretary of State mentioned in his statement, when there are not the resources to maintain the status quo?

I welcome the structural work going on outside the contract on issues such as work-life balance, the gender pay gap, the rota gaps, strengthening whistleblowing protections for junior doctors and, importantly, looking at the role of guardians of safe working hours, but the Secretary of State talked in his statement about confrontation: what could be more confrontational than seeking to impose a contract? Even at this late stage, I ask him to listen to the junior doctors’ leader, Dr Ellen McCourt, when she says:

“We have a simple ask of the Government: stop the imposition. If it agrees to do this, junior doctors will call off industrial action.”

The public are looking for the Secretary of State to try to meet the junior doctors: stop vilifying them, stop pretending they are the “enemy within”, and meet their reasonable demands.

I will respond to the hon. Lady’s comments, but she needs to be very clear to the House about the implications of Labour’s position on this. She has just said that she welcomes the suspension of next week’s industrial action, but that was not her position at the weekend. At the weekend, when the medical royal colleges, the General Medical Council and even The Observer criticised the proposed strike, what was she saying? She was saying that she would join them on the picket line—something her predecessor refused to do. The fact is that strikes cause harm, misery and despair for families up and down the country. When one of the most extreme members of the BMA junior doctors executive, Dr Yannis Gourtsoyannis, said that these strikes were

“the single most positive thing that has occurred within NHS politics in decades”,

what was Labour’s response? Did it condemn that? No. The shadow Chancellor actually invited him to advise Labour on policy. I just say this because—

Order. For clarification, I must emphasise that there is no concept of giving way in respect of a statement. Although this might resemble a debate to those who are attending our proceedings from beyond the confines of the Chamber, it is a statement with a response. There are no interventions.

We are always grateful to the hon. Member for Worthing West (Sir Peter Bottomley) for whatever counsel he might wish to proffer, even if it is done from a sedentary position.

Thank you, Mr Speaker.

The shadow Health Secretary needs to recognise that working people, the people her party claims to represent, need a seven-day NHS. The vulnerable people that Labour claims to represent get admitted to hospital at the weekends, and in industrial disputes patients should always matter more than politics. The next time she meets a constituent who has suffered because of not having a seven-day service or because their operation has been cancelled because of a strike, she and her colleagues should hang their heads in shame.

The hon. Lady has used some very strong words. She used words such as “vilifying” and “demonising” in relation to the junior doctor workforce, and that is a very serious thing to say. I challenge her to find a single piece of evidence that has come from me or anyone in the Government, and if she cannot do so, she needs to withdraw those comments and apologise to the House. The fact is that the single most demoralising thing for the NHS workforce is strikes, because they entrench and harden positions, which results in people getting very angry, and it becomes much harder to find consensus.

The hon. Lady also talked about the use of statistics. She does not have to listen to what I say—and I understand, given the sparring that goes on between us, that she might not want to—but we have had eight academic studies in the past five years that describe increased mortality rates for people admitted to hospitals at weekends. Her response to this, in a phrase she used in another context, was that there was “zero empirical evidence” for a weekend effect. I would caution her on this, because taking that approach to hard data is exactly what happened at Mid Staffs, where hard evidence was swept under the carpet year after year because it was politically inconvenient. This Government will not make that mistake.

Finally, the hon. Lady said that my civil servants had apparently advised me that this policy would not work. Not at all. What happens with every Government policy, as you would expect, is that smart civil servants kick the tyres of every aspect of the policy to enable us to understand the risks involved. She did not mention the fact that the same document to which she referred actually says that we are on track to deliver the four clinical seven-day standards to 20% of the country by next April. I think that her constituents will welcome that, even if she does not. These strikes are going to harm patients, damage the NHS and make it harder, not easier, to resolve the challenges facing junior doctors. Labour has chosen political opportunity today, but we will do the right thing for patients.

Does my right hon. Friend agree that it has been an indefensible anomaly for many years that the national health service so reduces its services at weekends when the patients it serves are vulnerable to urgent or emergency conditions and need the highest standards of care for chronic conditions on a seven-day basis? Will he continue to make what he has described as careful progress? Will he also make it clear that the seven-day service will not simply do routine work and that it will be introduced as resources and staffing allow in line with civilised conditions? Further, on the strange politics of the dispute that keeps coming back to haunt him, does he agree that while the BMA has always been one of our most militant trade unions and while the Labour party has been very left wing in its leadership before—most notably in the 1980s—it is almost inconceivable that at any time in the past such extreme militant action that threatens patients would have been supported by the BMA or the Labour party? They are now opposing a contract that union leaders praised as a sensible settlement, given the improvements that it offered, only two or three months ago.

As ever, my right hon. and learned Friend speaks incredibly wisely. Actually, his last comment goes to the nub of why this is totally extraordinary, unprecedented and completely unacceptable. It is true that the junior doctors have rejected the agreement that was reached in May in a ballot, and we have to accept that. There are all sorts of reasons why that might have happened, but the choice to escalate the industrial action and to call the worst strike in NHS history was made not by those junior doctors but by the BMA leaders. They made that decision about a contract that they themselves had described as being good and safer for doctors and patients only in May. How can they justify that? Is there not perhaps a desire to pick a very big fight?

We were making good progress over the summer in a whole series of dialogues in different areas to try to resolve some of the non-contractual issues that the junior doctors are worried about, but this action makes it virtually impossible to continue that progress, although we will try very hard to do so. My right hon. and learned Friend is absolutely right to say that this is completely unacceptable and damaging for patients. I am afraid that I am having to go through some of the very same battles that he had to go through when he was Health Secretary.

I know how difficult it will be for junior doctors to take part in the strikes that have been described, and I personally am really sad that we have come to this point. Does the Secretary of State recognise the anger and desperation among the junior doctors that have led us to this point? In my mailbag from junior doctors, two things stand out. One is that the threat of imposition was there right from the word go last summer, and it therefore felt like a threat rather than a negotiation. The other involves the misuse of numerical statistical data by translating it into a claim that it refers to avoidable deaths at weekends, even though there has been no evidence of avoidable deaths. The Secretary of State has not commissioned a review of cases that might show how many of those deaths were avoidable and whether a lack of junior doctors contributed to them. The real danger in the NHS at the moment is rota gaps. Doctors are being asked to do double shifts or to carry two pagers, which means that where there should be two doctors covering an area or a service, there is only one. That is a real, palpable danger right now.

The Secretary of State has said that he would employ extra junior doctors rather than spreading the same number more thinly, but where does he plan to get them from when we cannot even fill the existing posts? I welcome the focus on the four clinical standards that boil down to greater senior doctor review and access to diagnostics, but does he not think that we might have got further if we had started at that point last summer? He calls for a turn away from strikes and for getting around the table to co-operate and discuss these matters, so when is he going to meet the junior doctors to try to avert these strikes?

The hon. Lady is a doctor, and I would simply say to her, as I said to the shadow Health Secretary, that she needs to justify the claims that she constantly makes in this Chamber about a misuse of statistics. I have been very clear about when we can actually statistically say that a death is avoidable. The studies demonstrate clearly that a higher number of people are dying from weekend admissions than we would expect. What this Government will not do is sit and ignore those numbers, which are backed up in study after study. I think that we are doing the right thing, and as a doctor she should recognise that.

The hon. Lady has said time after time over the past year that the Government should lift the plans to impose the contract and get around the table and negotiate. She could today have given the Government credit for doing exactly that in May when we thought there was an opportunity to do a deal. We lifted the imposition of the contract and got around the table to negotiate a deal that turned out to be good for both sides. Having done that, the problem is that the same people with whom we negotiated the deal have decided to call the most extreme strike in NHS history, which is unacceptable.

Rota gaps are a real problem that we are trying to address by, first, ensuring that systems are in place for junior doctors to blow the whistle if they think that such gaps are unsafe for patients. That is why we have introduced guardians of safe working, and we are committed to that. Secondly, we want to ensure that there are people to fill those rota gaps by training more doctors. We are training 11,420 more doctors in this Parliament than in the previous and already have around 9,000 more doctors than in 2010. As a doctor, those are things that the hon. Lady should recognise.

As always, I am keen to accommodate everybody who wants to take part, but I think it not unreasonable, given the relatively small number, for me to hope that we might conclude these exchanges by 10 past 7—quarter-past at the latest. Brevity is of the essence. We do not need long narratives. We just need questions and short answers. We will be led in that mission by the Chair of the Health Committee.

I welcome the BMA’s suspension of next week’s damaging industrial action. It is clear from its statement that thousands of doctors had been in touch to say that they wanted to keep their patients safe. Doctors know that they cannot do so with full, rolling, five-day walkouts. Will the Secretary of State therefore join me in asking the BMA to ballot its members to hear their views before they proceed with the other proposed, damaging, five-day walkouts?

The BMA should talk to its members much more because, as far as I could tell, the consultation over the summer showed that only a minority actually wanted this extreme series of rolling one-week suspensions of labour that the BMA supported in the end. Most junior doctors are perplexed and worried about the situation and would love to find a solution. There was a bitter industrial dispute, but we actually started a process through which trust was being rebuilt on both sides. In a series of meetings, I met the junior doctors’ leader to talk through the areas of her greatest concern and we made progress in addressing two of those four outstanding areas. Building that trust means actually sitting around the table and talking, not having confrontational strikes. I think that that is what most junior doctors want.

I want to return to the critical issue of how we ensure safe cover during the week if we expect doctors to work more hours at weekends. The Secretary of State has repeated again today that he will employ more junior doctors, but what is the timescale? What will the net increase in doctors be this year, next year and in the rest of the Parliament?

I do not have figures to hand for exactly what the number will be this year—I will certainly let the right hon. Gentleman know—but around 11,500 extra doctors will be trained during the course of this Parliament.

As I said in the statement, it is important to recognise that the changes involve not only junior doctors. We need more weekend consultant cover—that is particularly important—and more people who are able to do the diagnostic tests. A whole range of people need to take part in the changes to improve standards of care at the weekends.

I congratulate my right hon. Friend on his reasonable yet resolute approach throughout the negotiations, which has been reflected in the fact that the leaders of so many royal colleges chose to criticise the decision to go on strike. The suspension of the strike action is therefore wholly welcome.

My right hon. Friend made the point that clinical standards will be improved as a direct result of the move towards a seven-day NHS. Will he enlighten the House about which particular types of patient in which circumstances will benefit as a result of his welcome drive to improve patient care?

I am happy to do that. Indeed, I am delighted to take a question from my right hon. Friend, because it is after someone has long departed an office that people actually appreciate that big, important changes were made, which was certainly the case from his tenure as Secretary of State for Education.

One of the clinical standards states that people admitted at weekends should be seen by a senior doctor—a consultant or an experienced junior doctor—within 14 hours. They will be seen by a doctor much sooner than that, but they should be seen within 14 hours by someone experienced enough to know whether there is something to worry about. That would happen in most places during the week, but it does not happen in many places over the weekend. Another standard relates to the most vulnerable patients who are at real risk of going downhill. This is not the clinical term, but doctors say that spotting people who are going downhill is one of the most important things. Such people should be checked at least twice a day by someone experienced enough.

Those are two of the four clinical standards that we want our constituents to be reassured are in place across the country. We think that that will make a big difference.

The Health Secretary will know that a worrying number of A&E and maternity departments were either closed or downgraded over the summer because they simply could not get the necessary number of junior doctors: Chorley, Ealing, Stafford—I could go on. If we are training more junior doctors, why do we still have that problem?

The pressures in the NHS mean that there is a need for more doctors for all sorts of reasons, and we do not have as many doctors as we need at the moment. That is why this Government are training more doctors and putting an extra £10 billion into the NHS. The manifesto that the hon. Lady stood on just over a year ago would not have put that sort of funding into the NHS and would have meant that we were unable to train that number of extra doctors. We are doing that, but it takes time and we need to ensure that services are safe while we are getting there.

I congratulate my right hon. Friend on his balanced and reasonable approach in the negotiations despite provocation from people who really should know better. Does he agree that there cannot have been a single occasion in the history of the NHS other than this in which the General Medical Council—the body responsible for professional standards—has effectively had to intervene to stop a strike? Will he also admit that we might have underscored the centrality of Sir Bruce Keogh’s four clinical standards a little more when introducing the notion of the seven-day NHS?

In response to my hon. Friend’s last point, we have been clear from the outset about what we mean by a seven-day NHS for hospital care, but a huge amount of misinformation has been put out. This time last year, for example, the BMA was telling many people that our plans were to cut pay by between 30% and 50%. That is why strikes are damaging. Positions get entrenched on both sides and misinformation sometimes gets out, as it has done, causing a lot of anxiety.

I agree with my hon. Friend about the GMC’s significant intervention. The medical regulator is completely independent of Government and has been clear that doctors have a responsibility not to take a decision under any circumstances that would lead to their patients being harmed.

As the Secretary of State knows, prior to taking up this office in June I was an emergency medicine junior doctor on the frontline of our NHS for the past 11 years. Today, doctors have listened and have halted strike action, putting patient safety first.

This is not the first time I have stood before the Secretary of State to say that I worry that the imposition of the contract does not put patient safety first. The Government can train all the extra doctors they want, but current junior doctors are leaving. The risk of having a contract imposed on them is causing them to move further afield to places such as Australia. I have always maintained that a safe seven-day NHS cannot be created with an overstretched five-day team and the rota gaps are proof of that. Doctors have listened today. Will the Secretary of State listen and please halt the imposition?

I thank the hon. Lady for what she did alongside many colleagues working in A&E departments over many years, but to call this an imposition is a mischaracterisation given what actually happened. The contract was not only agreed, but recommended and supported by the leaders of the BMA. Before she was elected, we had many discussions in the House about whether negotiations were possible and what I should do, and there were a range of different views. In the end, I listened—just as she has asked me to today—and sat down and negotiated a deal that was supported by the BMA’s leaders. That is why it is so incomprehensible that those same leaders—the people who represent her and her profession—have now called the most extreme strike in NHS history.

I put it to my right hon. Friend that the choice for junior doctors or doctors in training is whether they have the old contract or the agreed contract. I have not yet had a letter from any of my doctors saying that they think the old contract is better for them, for the health service or for patients. May I therefore recommend that they sign up willingly to the new contract, that they start discussions with the BMA, and through the royal colleges, on what should happen in a few years’ time when the contract itself comes up for review and that they work to improve the non-contractual situation, which my right hon. Friend has provided a good lead on?

My hon. Friend is absolutely right on that. In May, the BMA leadership, with whom we were having a very open discussion, had satisfied themselves that on the concerns many junior doctors have about their working conditions, many of which I accept are wholly legitimate, we had done pretty much everything we could inside a contract and the work that needed to be done was on the extra-contractual things. I am talking about the way the training system works when people are being rotated to a different hospital every six months, the fact that some people were being sent to a different city from their partner and how bad that was for family life, and all sorts of other things that need to be sorted out. Ironically, since the introduction of the working time directive, things have got a lot worse for many people, although we do not want to go back to the excessive hours of before. Those were the things we were patiently working through, and the way that is done is through dialogue, not confrontation, which is why this action is such a step backwards.

Is it not a weakness of the Secretary of State’s argument that it is just conceivable that he is wrong about imposing a settlement on a seven-day week for the NHS? It takes two to cause a strike, which is why he should look at this proposal again. He is very airy-fairy about training these doctors for the future. He is not being clinically correct at all. He has heard from people who have recently worked there, so why does he not reassess this seven-day week, get around the table, stop imposing a settlement and come to a negotiated agreement?

With great respect to the hon. Gentleman, if I am wrong about this, so are the leaders of the BMA, because they said the contract that he says I should not impose was a good contract, safer for patients and for doctors, and good for the NHS, for equalities and for a range of things. The contract we are proceeding with is one that doctors’ leaders said was a good deal for junior doctors, so if we are going to resolve this, that is the contract we should proceed with.

May I express my strong support for the Secretary of State, not only for the measured way in which he has handled today’s statement, but for the way in which he has conducted the negotiations, as shown by the 100-plus concessions that have been made to doctors’ negotiating positions over the past four years? Is not the inevitable logic of the BMA’s suspension of the strikes—I warmly welcome that—on the advice of other medical professionals that this should be applied in exactly the same way to the other strikes that have been called? The same logic would apply. Would it not be best for the BMA’s reputation to call off the rest of the strikes and to work with the Government on the other non-contractual areas that need to be dealt with, so that we can move forward from this, end this period of confrontation, get the health service that we all believe in and end some of this silly rhetoric coming from those who suggest that Conservative Members do not believe in the NHS?

I have a stunning new ministerial team, two of whom I am pleased to see here today, but I wish to take this moment to say how much I enjoyed working with my right hon. Friend last year. Then, as now, his advice and thoughts are very wise. The Government have made 107 concessions, and the BMA might like to think what signal it sends if that many concessions are made, an agreed deal is reached with the union leadership and the reaction then is for the most extreme strike in history to be called. What encouragement will that give to other Ministers to be moderate and reasonable in their negotiations with unions? The position being taken is preposterous and many other choices could have been made when dealing with losing the ballot, but he is right in what he says.

A lack of workforce planning and weak financial management have led to staff shortages, which have been a major contributor to this dispute. The Department of Health accounts and NHS England accounts, which came out on 21 July, underlined that weakness in financial planning, with the Comptroller and Auditor General saying clearly that he had real concerns about the future sustainability of NHS funding. We have, however, heard the Secretary of State say again today that the £10 billion available is to solve the issue about the seven-day NHS, but we have also heard that money promised for many other things by the head of NHS England. Does the Secretary of State really have a plan for the financial sustainability of the NHS? If so, what is it?

We do and we are implementing it. I know that the hon. Lady has looked at this in great detail, and I simply say, in broad terms, that following the tragedy of what happened at Mid Staffs the NHS was very honest about how some of the poor care there was happening in other places and NHS trusts decided that they needed to have more staff in their hospital wards. The poor workforce planning that she talked about, which goes back many decades in the NHS, meant that the result was an explosion in the use of agency staff, the cost of which rose to more than £3.5 billion in the last financial year, which has put huge pressure on finances. The lesson that we must take away, not just for the junior doctors’ strike, but for financial sustainability, is that we need to be better at workforce planning and training up the number of doctors and nurses that we need.

In other words, I am totally unqualified as a medical doctor. Therefore, may I ask a question about democratic mandates? I appreciate that, unlike a referendum, a general election does not give an entirely specific mandate on every proposal put forward, but will the Secretary of State take the opportunity to remind the House and the country of how central the proposal for a seven-day NHS was to the Conservative manifesto as far as his Department was concerned?

My right hon. Friend is right, as that was our only really substantive promise in terms of a commitment to the NHS at the last election. We are funding it and we have an absolute obligation to the British people to deliver on it. That is why in that short period after the last election I felt I had to be clear with the BMA that we were going to deliver on that manifesto promise. If the BMA had reflected on that, it might have perhaps behaved differently from how it did.

In the light of the ongoing dispute and concerns about patient safety, has the Secretary of State given any consideration to the idea of compulsory independent arbitration, binding on both sides, to settle disputes where patient safety and public safety is in dispute? Will he look at that?

I do not think that is the way forward, because the best way to solve these disputes is by an agreed solution. That is actually what we had, which is why it is so disappointing that the BMA has chosen not to work to try to implement it.

Last Thursday, I was at Queen’s hospital in Burton having a minor skin procedure—hence my black eye—where I met not just junior doctors and consultants, but patients. Let me tell my right hon. Friend how concerned they are about this series of strikes. They just do not understand it, as one junior doctor said to me—he may or may not have been in the minority. Dr Johann Malawana, the previous BMA representative for junior doctors, said that this was a “good deal” for junior doctors—I noted that down at the time. One point that was made to me was that this constant defence of BMA action by the Labour party and, in particular, by the Labour spokesman is regarded as being encouragement for these strikes, whether she means to do it or not. May I urge her to say, “Look, it is not good enough. It is not good enough for patients and it is not good enough for the NHS”?

My hon. Friend is absolutely right. All of us in this debate have one simple thing to consider: what is the right answer for the people we represent? They understand that there are financial constraints and that the NHS cannot do everything, but they do want us to strive to make it safer and better the whole time. It is a surprise and a disappointment that we do not hear more of that language from the Labour party.

My constituents who are patients do not want this strike, and I do not believe that my constituents who are doctors want this escalation in industrial action. If it is the case that only 4% of doctors support this escalation, should the BMA not again check its mandate?

It absolutely should. The BMA has been out of step with both the British public and its own members this week. My hon. Friend’s own hospital in Hereford—Hereford county hospital—is in special measures. It has a huge number of problems, which it is working really hard to sort out, and we are helping it to sort them out. Is that not what we should be focusing on in the NHS, rather than having to do contingency planning for these damaging strikes?

Does the Secretary of State agree that the actions of the BMA in warmly backing the contract in May only to condemn it in August and call for these extreme strikes have seriously damaged its credibility? On the issue of pay, which we know from the leaked WhatsApp messages is the only red line, can he confirm that no doctor working legal hours will be paid less?

Yes, I can absolutely confirm that. We have put in place pay protection to make that happen. My hon. Friend is right that this is very damaging for his constituents in Cheltenham. Given that there is so much pressure in the NHS, the junior doctors who are thinking of striking must ask themselves whether it is really going to help their organisation respond to those pressures if it has this enormous distraction—this incredible demoralisation that we get with these kinds of strikes.

Does my right hon. Friend share my disappointment that the BMA leader who co-authored the new contract and said that it was beneficial for our patients and for our junior doctors is now trying to whip up support for a series of strikes that every credible medical leader has said would be disproportionate and harmful to patients?

The fact that these strikes are occurring and being called off is very serious, especially against the backdrop of this contract. One of my constituents, who is a doctor, the chairman of Doctors in Unite and the deputy chairman of the BMA, stated in the Sunday Times that this issue could be used to beat the Tories and make the country great again. Does my right hon. Friend agree that it is appalling that patients across the country are being used as pawns in the political game of “Corbynista-ism”?

I completely agree. I am afraid that this is where I am very, very disappointed with the Labour party. Thrilled though it might be to have so many supporters of the leader in the more extreme ranks of the BMA, it helps no one to try to use the NHS as a political pawn and to weaponise the NHS as it tried so destructively to do before the last election.

Kettering general hospital is under pressure on a number of fronts. Even if the industrial action does not take place, the threat of it diverts key personnel from their normal difficult task of contingency planning, filling rotas and making sure that patients stay as safe as possible. Does my right hon. Friend agree that even the threat of industrial action does huge harm to our hospitals and the NHS?

I am more than happy to agree with my hon. Friend. The staff at Kettering general hospital work extremely hard. I have been there, as he knows. It is a very busy hospital. One shudders to think what the impact would be if we removed a third of the doctor workforce in a hospital such as that.

I was just reading an article from earlier in the year from The Guardian newspaper, which said that Saturday working is the major sticking point in the junior doctors’ dispute. Does the Secretary of State agree that any doctor who goes on strike over premium rates of pay on a Saturday, which most people in this country do not get when they work on a Saturday, should hang their heads in shame? Will he give a commitment that he will not make any further concessions, as he has already given far too many. Is it not time to look at whether we stop doctors from going on strike altogether in the NHS, as is the case with other emergency services?

It may be the first occasion upon which the hon. Member for Shipley (Philip Davies) has vouchsafed to the House that he is a Guardian reader.

I was nervous mentioning the fact that the Government have made 107 concessions when I saw that my hon. Friend might be in the Chamber because I knew that, for him, that would be 107 too many. His broader point is absolutely spot on. The working terms and conditions for Saturdays for junior doctors in this new contract are better than they are for nurses, police officers, fire officers and for those in many other parts of the economy. That is why I think it is a fair deal that everyone should recognise and welcome.

I know that the Secretary of State will agree that what sums up this dispute is that, under the existing contract unless the new one is brought in, we could be treated by a doctor working their 91st hour in a week. Does he agree that it is absolutely bizarre to see this level of strike action called when even the BMA’s own council was so divided over whether to support it?

That is absolutely right. What my hon. Friend is alluding to is the fact that, in the new contract, we are reducing the maximum hours that any doctor can be asked to work in any one week from 91 hours to 72 hours. There are all sorts of other safeguards that benefit safety. He is right. This should not be happening, and I urge the BMA to reconsider.

May I offer my support to my right hon. Friend. I have never heard him vilify the doctors, as he was accused of doing. That language was not appropriate in this debate. Is he aware—I have heard this from one chief executive—that hospitals have been told not to speak to the junior doctors to try to resolve the dispute within the hospitals and the foundation trusts themselves? If there has been such an instruction, does he agree that it will not help solve the dispute for the future?

I am very surprised to hear that. If my hon. Friend wants to pass me the details, I will happily look into it. On the ground, the management of hospitals are working very closely with not just junior doctors, but BMA representatives to try to do everything they can to keep patients safe if these strikes go ahead.

Order. I am most grateful to the Secretary of State and to colleagues.

Finance Bill (Programme) (No. 2)


That the following provisions shall apply to the Finance Bill for the purpose of supplementing the Order of 11 April 2016 in the last Session of Parliament (Finance (No. 2) Bill: Programme)):

1. Paragraphs (11) and (12) of the Order shall be omitted.

2. Proceedings on Consideration shall be taken on the days shown in the following Table and in the order so shown.

3. The proceedings shall (so far as not previously concluded) be brought to a conclusion at the times specified in the second column of the Table.



Time for conclusion of proceedings

First day

New clauses, new schedules and amendments to clauses and schedules relating to corporation tax.

Two hours after the commencement of proceedings on the motion for this Order.

New clauses, new schedules and amendments to clauses and schedules relating to tax avoidance and evasion.

Four hours after the commencement of proceedings on the motion for this Order.

New clauses, new schedules and amendments to clauses relating to VAT on women’s sanitary products.

Six hours after the commencement of proceedings on the motion for this Order.

Second day

New clauses, new schedules and amendments to clauses and schedules relating to capital gains tax.

4.30 pm

New clauses, new schedules and amendments to clauses relating to insurance premium tax; remaining new clauses, new schedules and amendments to clauses and schedules; remaining proceedings on consideration.

6 pm

4. Proceedings in Legislative Grand Committee and proceedings on Third Reading shall (so far as not previously concluded) be brought to a conclusion at 7 pm on the second day of proceedings on consideration.—(Jane Ellison.)