Junior Doctors’ Contract Offer Pay system changes For distribution to Boards, HRDs, medical directors, directors of medical education and medical staffing leads

The case for change - A doctor working 9am-6pm Mon – Fri can be paid the same as a doctor working shifts 24/7. The BMA has been saying since 2008 that the current contract and pay system needs to be modernised. In 2013, Heads of Terms were agreed between BMA and NHS Employers to negotiate a new contract. We need to move to a fairer system and reward those who work the most unsocial hours. Junior doctors are the clinical leaders of the future. We value the contribution they make to the NHS and want to reward them through a fair and transparent pay system. The government has prescribed that the current system where pay increases every year for time-served must end for NHS employees. The new contract and pay system will better protect junior doctors’ work life balance by making sure that there is a mutually agreed work schedule and review process with their employer. Some doctors continue to receive an incremental increase each year even though they are not progressing to an increased level of responsibility. Employers and the BMA agree the current banding system (introduced in 2000) is outdated, unfair and operates with unintentional consequences. For example: - Some doctors who work 41 hours could be paid the same as some who work 48 hours Additional information to support expected areas of discussion: Point 1: Timeline for junior doctor contract reform [http://www.nhsemployers.org/your-workforce/pay-and-reward/national-negotiations/timeline-for-junior-doctors-contract-negotiations] Point 2: Time Served pay progression - part of Government public sector pay policy reforms for public sector workforces; it is not within the gift of Secretary of State for Health to change. Point 3: Cannot continue with a system that sees junior doctors who are taking longer to complete training earning more than others at a higher level of training (and responsibility). In some cases this can mean trainees in specialty training with more responsibilities having lower basic pay than those in Foundation training. Point 4 & 6: Banding and unsocial hours : those working very different hours can be paid the same. For example, a junior that works 41 hours all of which fall between 7am and 7pm Mon-Fri, and one that works 47 hours including evenings, overnight shifts and weekends can get paid the same, both earning 40% over their basic pay. This does not feel fair. Point 7: The existing contract provides unethical incentives by making additional payments to those who work excessive and often unsafe hours. The new contract will prohibit working unsafe hours and will contain a work review system (with teeth) to ensure that junior doctors are not exploited and that addresses issues of overworking should they arise.

Underpinning principles of new contract Introduction of a robust work schedule review process to address concerns relating to hours worked and access to training opportunities. Training to be embedded into the work schedule that will be tailored for individual educational needs aligned to the curriculum. Improved quality of training for postgraduate doctors in training through scheduled time for training. Improved patient safety through limits on working hours. Hours are not being increased. Cost neutral – not looking to save money from new contract and pay system. A fairer pay system based on hours worked – with higher basic pay, payment for additional hours, enhancements for unsocial hours, flexible premia and on-call availability allowances. Ending the banding supplements and extension of plain time hours offset by increase to basic pay. More predictable pay and higher basic (pensionable) pay. GP trainees will not be worse off. Key principles Detail further in presentation on key individual aspects of the new system

Are the proposed changes fair for junior doctors? Overall pay bill will not be cut and average earnings will remain the same. There is no question of a 30-40% cut as the BMA has claimed. Safe working hours will be maintained and improved. No doctor will be required to work above new limits. A new system of ‘work scheduling’ with regular, routine reviews and reviews triggered by ‘exception reporting’ will be introduced. Work life balance will be better protected, with limits on additional hours. Junior doctors will get an improved training offer delivered through work scheduling. The unfairness in the pay system will be removed - pay will relate to actual work done. Progression will be linked to taking up a higher post, not time-in-post. Pay protection/transition arrangements put in place. Secretary of State for Health has provided cast – iron assurances in writing to Chair of the BMA Junior Doctors’ Committee (Dr Malawana) [https://www.gov.uk/government/publications/health-secretary-jeremy-hunt-writes-to-jdc-chair-johann-malawana] Not a cost cutting exercise No cut to the overall junior doctor pay bill, average earnings will remain the same. No question of a 30-40% pay cut, as has been claimed. New contract to improve patient safety by better supporting a 7 day NHS. Safe working hours will be maintained and no doctor will be required to work above new limits. The new contract will offer better protections and juniors will get an improved training offer with better support from senior and more experienced colleagues (as part of proposed consultant reforms working to ensure there is proper consultant cover at weekends so junior doctors are supported); working with other key stakeholders to look at how the training experience for junior doctors can be improved. No doctor will be worse off compared to what they get now.

What will the new pay system look like? Not to scale

Base pay old and new number of pay points & levels

Why six nodal points? Informed by clinical and educational input. However, for most training programmes, there was felt to be a significant change in responsibility between ST4 and ST5, and so the nodal changes were pegged at entry to ST3 and entry to ST5 (and similarly again to ST7 where this applies). Clear change in responsibility between F1 (provisionally registered) and F2 (fully registered). Clear change in responsibility when moving from the Foundation Programme to Specialty Training (core or run-through), following a competitive recruitment process before being appointed. Although this was not true for all programmes (there are, for example, some programmes with a third stage (CT3) of core training), neither NHSE nor the BMA wished to introduce different rates of basic pay for different specialties. The first two years of Specialty (ST)/Core Training (CT) are similar in the degree of responsibility required of the trainee, and are therefore grouped into one node. Accordingly, we opted for this option as being the one that best suited the majority of training programmes. The stage(s) at which responsibility increases between ST3/ST8 are less clear and are subject to differences between training programmes.

Rationale for basic pay values Parties agreed that there is a need to move a greater proportion of earnings into basic pay, with a reduction in the amount of variable pay. Graduate entry (F1) needs to be competitive, although almost every medical graduate is guaranteed an F1 place. Basic pay needs to remain competitive throughout a doctor-in-training’s career. Each step-change in responsibility is reflected in a change in basic pay. Point 1 – The BMA and DDRB have asked since 2008 for the balance of pay between basic and variable (i.e. banding payments for unsocial hours) to change with an increase in basic pay..

Replacing banding supplements Not to scale Additional information to support expected areas of discussion on replacement of banding supplements: In the current contract banding payments are complex and a ‘cottage industry’ has evolved around the design of rotas with requirement for several specialist software packages needing to be designed to support this. Need to replace these outdated payments with new clear and transparent payments for work being done that are fair to junior doctors and allow employers to reward in a fair an efficient way. For example: A junior that works 41 hours all of which fall between 7am and 7pm Mon-Fri, and one that works 47 hours including evenings, overnight shifts and weekends can get paid the same, both earning 40% over their basic pay. A junior that works 47 hours, 15 of which are ‘unsocial’ earns 40% over their basic salary. If a junior doctor works one more unsocial hour within that 47 hours, totalling 16 unsocial hours – they receive 50% over their basic salary for the lifetime of the rota. This will also apply to all junior doctors working on the same rota. These simple examples help to illustrate why the current banding system needs to be replaced, with a new fit for purpose set of payments.

Benefits for junior doctors Virtually guaranteed employment after graduation. Competitive graduate entry basic pay of £25,500, increased from £22,636. As responsibility increases then basic pay will rise. On full registration with the GMC, basic pay of £31,600, increased from £28,076. Specialty training basic pay will begin at £37,400, increased from £30,002. No one will earn less than they currently do. Trainees at ST4 and above will keep their current pay progression until their training is complete or until 2019, while moving to the new arrangements for terms and conditions.

Enhancements for unsocial hours Hours which attract enhancements: Saturday 7pm to 10pm and Sunday 7am to 10pm – 33% pay enhancement 10pm to 7am every day of the week – 50% pay enhancement Additional information to support expected areas of discussion on out of hours payments: Current position: plain time is defined as 7am until 7pm, Monday to Friday, with banding supplements used to recognise both work in addition to the standard 40 hour week and more intense working patterns. Key features of new system of payments: The DDRB recommended that plain time working should be extended into evenings and Saturdays in line with changes in the wider economy. New system does not remove unsocial hours; these will continue to be paid for at a higher rate to basic pay. New system designed to support activity across a seven day services model; fairer to junior doctors by paying for additional pay for those working the most unsocial hours. Changes in line with contractual position for other workforces where millions of staff are working long hours and at weekends for the same pay as they would during the week. These are fair proposals.

On-call availability allowance & additional rostered hours On-call availability allowance is a percentage of basic pay for being on call when not at work. Hours actually worked will be included in the work schedule and paid at the normal basic rate plus any enhancements applicable. Up to eight hours per week above the 40 hours full time. Paid at the same basic rate as normal 40 hours. Enhancements for any hours worked in unsocial hours.

Flexible pay premia Flexible pay premia will apply: Training programmes that FPP will apply to in 2016 are: Flexible pay premia will apply: for those on hard-to-fill training programmes, for the duration of the their training programme. to protect the pay of those choosing to retrain/switch specialty to an agreed hard-to-fill training programme. for those taking time out of the ‘standard’ training pathway, for example clinical academics and public health, or those doing work which benefits the NHS or patient care more broadly. General Practice (in the practice placement of vocational training). Emergency Medicine (at ST4 and above). Psychiatry (at ST1 and above). Additional information to support expected areas of discussion on flexible pay premia. Key points: The new structure based on basic pay, unsocial hours enhancements and availability allowances does not and cannot on its own address the recruitment requirements of all specialties, particularly given the cost-neutral pre-condition set for its implementation and when current shortage specialties do not always correspond with the specialties with the most onerous unsocial hours working. The use of flexible pay premia will enable the NHS to incentivise shortage specialties. GP Registrars: currently receive a supplement in addition to their basic pay; this covers two aims: to recognise out of hours working and so that the level of pay available to GP Registrars does not act as a disincentive to taking up a career in general practice as opposed to a career in the hospital sector where total earnings are typically higher. GP Registrars will not be disadvantaged by the proposed changes, this remains a priority area. Flexible Pay Premia will be subject to regular review through the pay review process, with parties submitting evidence to the DDRB who will make recommendations to Government.

Safeguards and work reviews Work schedule reviews Maximum shifts length 13 hours. No more than 72 hours over seven days. Max four consecutive nights. Max five long days. Work schedules. Exception reports. Work schedules review process. Regular discussion of work schedule and review with educational supervisor. Exception reporting – significant variation in hours or working pattern. Three-stage contractual work review process if work schedule no longer fit for purpose or frequent exception reporting. Informal stage, formal stage, and an appeal process to include the director of medical education. Annual report on outcomes of all reviews to HEE/Deanery, DDRB and CQC. Potential for employers to lose training recognition for repeat offenders. Additional information to support expected areas of discussion on safeguards and work reviews. Safeguards: The Secretary of State for Health has given an absolute guarantee to junior doctors that the new contract and pay system will not impose longer working hours. The new contract will prohibit working unsafe hours; there will be a new absolute limit of 72 hours in any 7 day period (lower than the current 91 hours possible under the current contract). The changes will better protect patients and doctors by putting a limit on the number of extra hours doctors can work and the patterns of hours. Medical Director should stress his/her commitment to this process in particular Work schedule reviews: The Secretary of State for Health has given as part of his public assurances statements, that he wants to see a work review system that ensures that junior doctors are not exploited and that addresses issues of overworking if they arise. New system and approach to ‘work scheduling’ required between junior doctors and their employers. This must have some teeth. Training experience for junior doctors needs to be improved; needs to recognise work life balance issues. Three-stage process, including director of medical education at final stage

Transitional arrangements All trainees will transfer onto the new terms and conditions on 3 August 2016. The old terms and condition will be closed. Those already in run-through or higher training at 2 August 2016 would be moved onto the terms of the new contract on 3 August 2016 but remain on the existing pay system. Existing trainees for whom the above doesn’t apply will be offered cash pay protection to ensure they do not lose out. Their current pay point and banding supplement (plus any uplift in April 2016) will form a cash floor which they cannot fall below. Pay under the new system will be compared with the cash floor, and the trainee will be paid the higher of the two until transitional arrangements end in 2019. Therefore trainees could earn more under the new system, but cannot earn less than their cash floor under transitional arrangements. The following trainees will be moved onto the new Terms and Conditions AND new pay system effective from 3 August 2016, where they move between posts and/or contracts of employment, and will be offered cash pay protection: All trainees remaining on F1 or remaining on F2 All trainees entering Foundation 2. All new entrants to core or run through specialty training (CT1 / ST1 points) All trainees moving into CT2 / ST2 existing points (and CT3 point where it exists) would be paid according to the new contract in August 2016. All trainees remaining in the CT1, ST1, CT2, ST2 or CT3 (where it exists) grades in August 2016 All new entrants to higher (non-run through) training (at ST3 point and in some specialties at ST4 point) Their pay protection will be calculated as follows on 3 August 2016 and this amount will apply as a baseline or “consistent cash floor” for each year until either the trainee exits training or until 31 July 2019, whichever is the sooner: Take the incremental pay point for eligible trainees as of 31 October 2015 and add any uplift that may be awarded in April 2016. Add the value of the banding supplement for the rota on which they are working on 31 October 2015, up to a maximum banding supplement of 50% (band 1A) or, for those trainees who have opted out of the Working Time Regulations, to a maximum of Band 2A (80%), which is also the highest level to which protection can be applied under the current contract. Trainees protected at 80% supplement would however have to accept a contract for up to 56 hours per week for this protection to apply; accepting a contract of only 48 hours would reduce the protected supplement to 50%. Trainees pay will be worked out on the new system, and if it is below the cash floor, pay protection will be paid. This means trainees could earn more under the new system but they can never be paid less than the cash floor. Those trainees already in run-through or higher training at 2 August 2016 would be moved onto the terms of the new contract on 3 August 2016 but remain on the existing pay system. The new terms and conditions would be used for the purposes of organising their work and all other matters but under transitional pay protection, they would continue to be paid using the old system of banding (subject to the maximum of band 2A - 80% - for those who have opted out of the Working Time Regulations, which is also the highest level to which protection can be applied under the current contract) and annual increments until they exit the programme or until 31 July 2019, whichever is the sooner. This preserves pay expectations, on the basis of the safe working patterns enshrined in the new contract, for those who could complete training during the transitional period.

Useful links – further information www.nhsemployers.org/juniordoctors Scoping report on the contract for doctors in training Heads of Terms for negotiations to achieve a new contract – June 2013 NHS Employers evidence to the DDRB DDRB report – Contract reform for consultants and doctors in training Summary of the DDRB report DDRB conclusions (pdf resource) DDRB report questions and answers Health Secretary assurances to BMA Juniors Chair Access all the latest information and resources on the junior doctors’ contract at www.nhsemployers.org/juniordoctors including: Pay calculator Video FAQs.