Junior Doctors’ Final Contract For distribution to boards, directors of medical education and medical staffing leads

Why do we need change? A new contract needs to be introduced that is safe, fair and effective for both doctors and employers. The current contract has significant weaknesses : safety: does not support safe working practices training: does not support the educational and training needs of doctors pay: has perverse incentives that do not recognise or effectively reward hours being worked or the intensity of work being done.

Key features of the new contract Safeguards Appointment of Guardian of Safe Working to oversee robust work schedule review process and address concerns relating to hours worked and access to training opportunities. Safe care for patients through protection and prevention measures to stop doctors working excessive hours New system of financial penalties to be applied where doctors are working excessive hours Training New terms to support training and education include: ensuring proper notice of deployment to rotational placements; exception reporting applying to missed educational opportunities; and a review of access to more flexible training Safety: The guardian will be appointed jointly with junior doctor representatives from the employing organisation Sensible shift rules that work with rather than against the WTR Tailored work schedules for doctors spelling out what work they are expected to do, and when Financial penalties will be levied when work is unsafe – but these will be spent on education and training, rather than paid out as salary to the doctor, removing the perverse incentives of the banding system. Training The offer includes commitments from HEE to resolving the issues preventing effective notice of deployment being given, allowing the code of practice to be implemented by trusts The contract makes explicit links to training through the work scheduling process Pay An end to time-served incremental pay progression A direct link between basic pay and the grade at which a doctor is working An extension of plain time into the evenings and Saturdays Proper pay enhancements for work done at premium time, weighted toward the most onerous times of the week A clear distinction in pay and reward between shift working and on-call working

Key features of the new contract Pay Cost neutral – not looking to save money from new contract reforms Pay for doctors and employers more stable and predictable; better financial management for employers Pay progression linked to responsibility and point of training – no longer time served Reward targeted at doctors working onerous rotas and unsocial hours; supports staff deployment to meet needs of patients on evenings and weekends (including those who work most Saturdays)

Safety: Restrictions on excessive hours Current contract: November offer: Final contract: Twice-yearly hours monitoring exercises Exception reports to replace hours monitoring Departmental rota Individual work scheduling Work schedules for GP trainees in practices to reflect COGPED guidance on work plans Work schedule reviews on request Work schedule reviews on request and when required by the guardian Rigid on-call rules with limited flexibility More flexible on-call arrangements linked to intensity or work Limits on on-call working: No more than three rostered on-calls in seven days except by agreement Guaranteed rest arrangements where overnight rest is disturbed Rigid paid rest break requirements Paid 30 minute rest breaks at intervals in line with working time regulations Paid rest breaks: 30 minutes if shift exceeds 5 hours, 2 x 30 minutes if shift exceeds 9 hours, taken flexibly across the shift Best practice guidance on rostering Financial penalty levied on employer for breaches of WTR 48-hour average working hours or contractual 72 hour weekly limit. While the current contract complies with the UK Working Time Regulations, it does not go far enough to promote and protect the safety of doctors. The new contract provides a comprehensive package to address concerns raised by junior doctors, and proposes additional safeguards and restrictions on the hours that doctors are required to work. These recognise the legitimate concerns raised by many doctors and so go even further than the safeguards originally proposed in the November offer.   The arrangements will be overseen in every Trust by the independent Guardian of Safe Working.

Safety: Restrictions on excessive hours Current contract: November offer: Final contract: Maximum average 56 hour working week Maximum average 48 hour working week Opt out capped at maximum average of 56 working hours per week Maximum 91 hours’ work in any seven day period Maximum 72 hours’ work in any seven day period Maximum shift length of 14 hours Maximum shift length of 13 hours Maximum of 7 consecutive long shifts Maximum of 5 consecutive long shifts Maximum of 7 consecutive night shifts Maximum of 4 consecutive night shifts Minimum 11 hours rest after final night shift Minimum 48 hours rest after a run of either 3 or 4 consecutive night shifts

Safety: Restrictions on excessive hours Current contract: November offer: Final contract: Maximum of 12 consecutive long, late evening (twilight into night) shifts Maximum of 5 consecutive long, late evening (twilight into night) shifts Maximum of 4 consecutive long, late evening (twilight into night) shifts Minimum 11 hours rest after final long, late evening (twilight into night) shift Minimum 48 hours rest after 4 consecutive long, late evening (twilight into night) shifts Maximum 12 consecutive shifts Maximum 8 consecutive shifts 48 hours’ rest after 12 consecutive shifts 48 hours’ rest after 8 consecutive shifts

Training: November offer: Final contract: Work schedule to be linked to the educational curriculum Training needs to be identified and included in the work schedule   HEE commitment to performance manage deaneries against code of practice on notice of deployment HEE to establish benchmark standards for educational facilities Contract will facilitate both “standard” and lead employer models HEE commitment to identify ways of reducing the costs of training through centralised provision and other means Improved access to less than full time training Enhanced continuity of service provisions to ensure that trainees returning from OOP are not unfairly  deprived of occupational maternity pay Fixed leave to be replaced by a mutual obligation for employers and doctors to appropriately manage leave arrangements The current contract is largely silent on the educational needs of training. The new contract offer includes both contractual terms and additional pledges from HEE that support the training needs of doctors.

Pay: Base pay - old and new

Pay: Why five nodal points? Proposed by BMA in negotiations. There are two further nodal points at ST3-7 and ST8, reflecting the sub-specialised nature of work at ST8. Informed by clinical and educational input. This allows for a flatter pay structure minimising the impact on those on academic pathways or taking a break from training. 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. Accordingly, we agreed with the BMA for this option as being the one that best suited the majority of training programmes. 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.

Pay: Unsocial hours enhancements 9pm to 7am every day of the week – 50 per cent pay enhancement Saturday 5pm to 9pm and Sunday 7am to 9pm – 30 per cent pay enhancement Trainees who work shifts beginning on Saturdays 1:4 weeks or more frequently will additionally receive a 30 per cent pay enhancements for any work done on Saturday 7am-5pm 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.

Pay: On-call availability allowance 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. Frequency required to be on-call Rate paid 1 in 4 or more frequently 10 per cent Less frequently than 1:4 5 per cent

Pay: FPP Indicative Values November offer Final contract Academia1 £3,125 Academia £4,000 Emergency medicine training programmes at ST4 and above £1,500 General practice2 £8,200 General practice   Oral and Maxillofacial Surgery Psychiatry training programmes at ST1 and above Notes:   1. Academic premia will be paid to those on recognised academic programmes upon successful completion of a higher degree, or to those completing higher degrees whilst holding a training number OOP approved by the postgraduate dean, upon successful completion of the higher degree and return to training. A similar premium will be paid to trainees taking time out of programme to undertake work deemed to be of wider benefit to the NHS, as defined in the contract schedules. 2. The general practice premia will only be paid to doctors undertaking general practice placements as part of a general practice training programme (replacing the GP supplement). It will not be paid to those trainees whilst they are in hospital or other community placements, or to trainees on other programmes (e.g. F2) undertaking placements in general practice.

Pay: Locums Junior Doctors who opt out of the working time regulations will be required to offer ‘first refusal’ to employer for any additional shifts they may wish to work. This work would be done via the host organisation’s / employer’s locum bank, rather than via an agency. This work is to be paid as per national terms and conditions, set out in the pay circular each year.

Implementation timetable Date Grade(s) Rotation(s) / Training programmes Aug-16   F1 All ST1/2/3 GP trainees undertaking practice placements Psychiatry; Public Health Sept ST1+ Paediatrics (Core, higher and all sub-specialties) ; dentists Oct CT 1-3 /ST3+ All surgical specialties (including orthodontics) Nov Dec Jan-17 Feb ST3+ Anaesthetics / ITU / Emergency Medicine / Obstetrics and Gynaecology ST1-2 Core Medical Training /remaining Core Surgical Training / ACCS / Anaesthetics Mar Any remaining Paediatrics trainees Apr Any remaining surgical and all higher medical specialties May Jun Aug-17 Any trainees not already included above The introduction of such a major contract reform will significantly change working patterns for doctors in training. Careful implementation will be crucial to ensure continued delivery of safe and effective care to patients.   A phased implementation plan has been developed that will enable employers to introduce the new working patterns enshrined in the new contract more safely. Doctors / dentists will therefore transfer onto the new contract on different dates over a 12-month period, commencing in August 2016 under the phased implementation plan. The proposed national timetable for this may be subject to some regional modifications. Doctors / dentists in training will retain their existing New Deal contract pay, terms and conditions until the date on which they transfer to the new contract and its associated terms and conditions, according to the national timetable. 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 March 2020, 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. Trainees already in run-through specialty training or higher specialty training at ST3 level or above before 3 August 2016, and moving to ST4 or above in August 2016 will 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 March 2020, 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. Note: Any trainee (e.g. F2; GP trainee in a hospital setting) sharing a rota with the above will move to the new contractual (and where applicable, pay protection) arrangements at the same time as those trainees.

Summary: Safer care for patients and a fair Summary: Safer care for patients and a fair deal for doctors and employers The new contract will: support the delivery of safer care to patients – achieved through the provision of a new and comprehensive package to address concerns raised by doctors, with additional safeguards and restrictions on the hours that doctors are required to work include new contractual terms and additional pledges from Health Education England that support the training needs and experience of doctors deliver a new model for pay that is fairer, more transparent and is financially sustainable, while ensuring that the average pay across the junior doctor workforce remains unchanged. It reflects agreements reached with the BMA in the discussions held in December 2015 and January 2016.

Finance The contract is cost neutral with small additional transitional cost, met from the global NHS pay budget. The cost neutrality has been modelled at a national level and there will be different implications depending on the deployment of junior doctors.  The phased implementation will allow for tracking of the additional cost or saving to your organisation. The government agreed an increase in predictable basic pay when negotiations were approved in 2012: this does increase pension contributions for both the employer and the doctor (an advantage to the latter in a career average scheme). NHS England and NHS Improvement are sighted of these implications over the three year transitional period, and these costs must also be tracked.