In the United Kingdom, junior doctors are qualified medical practitioners who are working whilst engaged in postgraduate training to become a consultant or a GP. The period of being a junior doctor starts when they qualify as a medical practitioner following graduation with Bachelor of Medicine, Bachelor of Surgery degrees, and culminates in a post as a Consultant, a General Practitioner (GP), or some other non-training post, such as a Staff grade or Associate Specialist post.
The term junior doctor now incorporates the grades of Foundation doctor, Specialty registrar; and prior to 2007 included the grades of Pre-registration house officer, Senior house officer and Specialist registrar. During this time junior doctors will do postgraduate examinations to become members of a Medical royal college relevant to the specialty they are practicing, for example Membership of the Royal College of Physicians for doctors specialising in Internal medicine, Membership of the Royal College of Surgeons for doctors specialising in surgery or Membership of the Royal College of General Practitioners for doctors specialising in family medicine. Doctors typically may be junior doctors for 5–15 years, and this may be extended by doing research towards a higher degree, for example towards a Doctor of Philosophy or Doctor of Medicine degree. In England there are around 53,000 junior doctors.
- 1 Working hours
- 2 Migration
- 3 Modernising medical careers
- 4 Pay and conditions
- 5 Patient mortality
- 6 See also
- 7 References
- 8 External links
In Europe and the US there has been some reduction of the working hours of doctors who are in postgraduate training, in line with recommendations and legislation aimed at improving patient safety and doctors’ working conditions. In 1991 the government, the NHS and the British Medical Association (BMA) agreed a package of measures on working hours, pay and conditions which was called the New Deal for Junior Doctors. The Doctors' duty hours, which were felt to be excessive, were reduced to a maximum average of 56 hours actual work and 72 hours on call duty per week, although the change was not enforced until 1 December 2000. The European Working Time Directive (EWTD) sets out minimum health and safety requirements for the organisation of working time. The EWTD required the average working week to fall to 48 hours or less by 2009.
The shortening of junior doctors' working hours had implications for how training programmes are organised, especially for specialties such as surgery where there was a tradition of maximising the hours of experience. Most studies that have looked at a reduction of junior doctors working hours have found either a beneficial or neutral impact in terms of measures of patient safety, clinical outcomes and postgraduate training.
The reduction in number of hours worked by junior doctors is one of the factors leading to blurring distinctions between them and other clinical professions such as nurse practitioners who also perform complex tasks.
An Organisation for Economic Co-operation and Development survey in December 2015 showed that 35.4% of NHS doctors, 34,000, were born abroad compared with 5% in Italy, 10.7% in Germany and 19.5% in France. The UK was the second highest exporter of doctors, second only to Germany, with 17,000 British doctors working in other OECD countries. These figures are for all doctors in the NHS, not just junior doctors.
Modernising medical careers
In 2005, Modernising Medical Careers saw significant changes to postgraduate medical training. A two-year Foundation Programme was introduced for newly qualified doctors, the number of years of postgraduate training changed in some specialties and it was doctors were needing to decide which specialty to follow sooner after graduation.
There have been recent initiatives to engage junior doctors in NHS leadership; junior doctors are seen as essential to the drives to achieve efficiency savings in the NHS.
|Year||Current (Modernising Medical Careers)||Previous|
|1||Foundation doctor (FY1 and FY2), 2 years||Pre-registration house officer (PRHO), 1 year|
|2||Senior house officer (SHO),
minimum 2 years; often more
general practice (GPST), 3 years
hospital speciality (SpR), minimum 6 years
|GP registrar, 1 year|
4 years total time in training
5 years total time in training
|9||Consultant, minimum 8 years total time in training||Consultant, minimum 7–9 years total time in training|
|Optional||Training is competency based, times shown are a minimum. Training may be extended by obtaining an Academic Clinical Fellowship for research or by dual certification in another speciality.||Training may be extended by pursuing medical research (usually 2–3 years), usually with clinical duties as well|
Pay and conditions
The NHS Careers web site states:
|“||As a doctor in training you’ll earn a basic salary plus bonus if you work more than 40 hours a week and/or work outside the hours of 7am – 7pm Monday to Friday.
In the most junior hospital trainee post of Foundation year 1 your basic starting salary is £22,636. This increases in Foundation year 2 to £28,076.
If you’re a doctor in specialist training your basic starting salary is £30,002. If you are asked in your contract to work more than 40 hours a week and/or to work outside 7am – 7pm Monday to Friday, you will receive an additional bonus which will normally be between 20% and 50% of the basic salary. This bonus is based on the extra hours that you work above a 40 hour normal working week.
The basic starting salary of a foundation doctor is £22,636 but having to work extra and unsociable hours attracts some additional payments. In 2015, NHS Employers reported the total annual earnings for foundation doctors in England averaged just over £36,000. While the basic starting salary for doctors in speciality training is £30,002 NHS Employers were reporting that average earnings in this group of doctors was nearly £53,000. Junior doctors can spend up to ten years working in the speciality training grade. Some specialties have long training programmes and after more than a decade it is possible for doctors to reach the top end of the pay scale where the combination of basic salary and additional payments can currently reach £70,000 (at this point although still junior doctors, they could be managing teams, performing surgery and making life-and-death decisions).
Research conducted in December 2014 showed that across a range of other jobs, almost a third of graduate programmes at Britain's best known and leading employers now pay starting salaries of more than £35,000 - however, 83% of these leading employers reported that they were recruiting for jobs in London where salaries are considerably higher than in the rest of the country, whereas NHS salaries are set on a nationwide basis, with doctors in London given an additional payment (£2,162 as of 2013) known as London weighting to compensate for increased cost of living.
Since 2007 junior doctors have been receiving below inflation salary rises. The independent Review Body on Doctors' and Dentists' Remuneration (DDRB) takes evidence from a range of sources and makes recommendations around pay; in 2015 they recommended a 1% pay increase. In 2005, the average starting earnings (salary plus bonuses) for a medical graduate was £32,086. In an inflationary environment all wage earners including doctors may find the buying power of their income becomes less, some describe this as a real terms cut in pay of 15% between 2007-2014, where the word cut does not actually indicate a wage reduction.
Since 2012 NHS Employers and the BMA had been in negotiation towards a new contract for junior doctors. These talks ran into serious problems when the Secretary of State for Health, Jeremy Hunt, appeared willing to impose items from the Conservative 2015 election manifesto upon junior doctors in England. In November 2015, the BMA balloted over 37,700 of their members in response to Hunt's contract proposals; 76% of eligible doctors voted with 99.6% of doctors voting for action short of strike and 98% voting for all out strike. After five days of talks between the government and BMA, conciliation service Acas confirmed that agreement had been reached to suspend the strike action that had been planned for December.
On the 12th of January 2016, Junior Doctor's in England took part in the first general strike across the NHS, the first such industrial action in 40 years. Emergency care was still provided. There have been claims that the Medical Director of NHS England, Professor Sir Bruce Keogh, has used performance target levels to justify and encourage NHS Trusts to declare an emergency situation, forcing Junior Doctors to work despite the strike, a move to which the BMA has condemned.
Doctors pay professional annual fees to maintain registration with the General Medical Council and medical indemnity cover. Junior doctors also incur costs associated with training courses, preparing for and sitting exams and college membership; training can be associated with £420-£3000 of professional fees annually depending on stage of training and level of income. English students embarking on a medical degree can now expect to pay £40,000 on university tuition fees alone - student loans are available to meet these costs, with repayment starting as soon as individuals begin working as a junior doctor. University tuition is free for Scottish domiciled students who choose to study in Scotland, and grants and loans are available to help with living costs.
Changes to working patterns of doctors meant there was no longer a requirement for first year junior doctors to be resident and from 2008 free accommodation was no longer provided by employers. The British Medical Association, claimed this amounted to a £4,800 annual pay cut for those who may have previously lived at the hospital rather than independently but the numbers of doctors involved is not yet clear. Ann Keen, Labour Parliamentary Under-Secretary for Health Services, stated "The provision of free accommodation for foundation year 1 doctors who are on call at night, is dependent on the contract of employment of the junior doctor, which is for agreement locally. The Junior Doctors Terms and Conditions of Service continue to provide that if a doctor is contractually required to live in hospital accommodation no charges should be made for the accommodation provided."
The NHS Careers web site states:
|“||Doctors in the specialty doctor grade earn a basic salary of between £37,176 and £69,325.
Consultants can earn a basic salary of between £75,249 and £101,451 per year, dependent on length of service. Local and national clinical excellence awards may be awarded subject to meeting the necessary criteria.
Many general practitioners (GPs) are self employed and hold contracts, either on their own or as part of a Clinical Commissioning Group (CCG). The profit of GPs varies according to the services they provide for their patients and the way they choose to provide these services.
Salaried GPs who are part of a CCG earn between £54,863 to £82,789 dependent on, among other factors, length of service and experience.
Junior doctors may pay into the NHS Pension Scheme which from April 2015 has been a Career Average Revalued Earnings (CARE) scheme. The 2015 scheme involves paying towards a pension which will be based on the average of a member's pensionable earnings throughout their whole career, with a revaluation of active members benefits in line with the Consumer price index plus 1.5 per cent per annum. The 1995/2008 scheme is closed to new entrants.
Proposed new contracts
In September 2015, Hunt proposed new contracts for junior doctors which would scrap overtime rates for work between 7am and 10pm on every day except Sunday while increasing their basic pay in a move that Hunt said would be cost neutral, a claim the BMA say NHS Employers have been unable to support with robust data. In response, the doctor's union, the BMA, called for a strike, the first since the 1970s. The union argued that the contract would include an increase in working hours with a relative pay cut of up 40%, and refused to re-enter negotiations unless Hunt dropped his threat to impose a new contract and extensive preconditions, which he had refused to do. The Department of Health responded, saying "We are not cutting the pay bill for junior doctors and want to see their basic pay go up just as average earnings are maintained." The strike vote started on 5 November. Many junior doctors have said they will leave the NHS if the contract is forced through.
He later tried to re-assure the BMA that no junior doctor would face a pay cut, before admitting those who worked longer than 56 hours a week would face a fall in pay. Hunt said that working these long hours was unsafe, claiming that existing pay arrangements were known colloquially in the NHS as "danger money", although a Facebook survey carried out by one doctor showed that 99.7% of 1,200 respondents had never heard of the term.
In November 2015 he said he would offer a basic pay increase of 11%, but still removing compensation for longer hours. In response, the BMA junior doctors committee chair, Johann Malawana said "Junior doctors need facts, not piecemeal announcements and we need to see the full detail of this latest, eleventh hour offer to understand what, in reality, it will mean for junior doctors. We have repeatedly asked for such detail in writing from the Secretary of State, but find, instead, that this has been released to media without sharing it with junior doctors’ representatives" and "The proposals on pay, not for the first time, appear to be misleading. The increase in basic pay would be offset by changes to pay for unsocial hours, devaluing the vital work junior doctors do at evenings and weekends."
Balloting of members
On 19 November 2015 the result of the BMA strike ballot was announced, with more than 99% in favour of industrial action short of a strike, and 98% voting for full strike action.
Appeal for arbitration
The BMA council chair appealed to the health secretary to resume negotiations. Hunt said the strike was "very disappointing", but declined the appeal for arbitration at this time. He was criticized for failing to answer MP's questions about the strike, with his deputy claiming he was too busy preparing for the strike.
He was also criticised by statisticians Prof David Spiegelhalter and David Craven, by Dr Mark Porter, BMA council chair, by an NHS England spokesperson, and by Heidi Alexander, the shadow health secretary, for, again, making misleading statements about weekend hospital treatment. The Department of Health confirmed his 10% figure actually related to the entire week, even though Hunt specifically said it was for weekend-admitted patients only.
Hunt eventually agreed to discussions overseen by Acas and withdrew his threat to impose a new contract without agreement, and the first day of strike action was called off hours before it was due to start (too late to avoid some disruption), with later days suspended.
Appeal for further Arbitration
On 24 December 2015, Dr Johann Malawana, leader of the BMA’s junior doctors committee (JDC), gave a 4 January deadline for the talks to result an acceptable outcome, or industrial action would be announced. An agreement was not reached by this deadline and so the BMA announced that a strike would go ahead, blaming "the government's continued failure to address junior doctors’ concerns about the need for robust contractual safeguards on safe working, and proper recognition for those working unsocial hours".
On 8 January, it was revealed that a supposedly independent response to the initial strike plans from Sir Bruce Keogh, Medical Director of NHS England, had been strengthened by Department of Health officials and approved by Hunt. Subsequently more than 1,000 doctors called on Sir Bruce to resign complaining that Hunt had exploited Keogh for political gain.
The first day of the strike went ahead on 12 January. Hunt claimed it was "unnecessary", that patients could be put at risk, and that many junior doctors had "ignored" the strike call and worked anyway, but the BMA responded that many junior doctors were in work maintaining emergency care as planned.
Junior doctors again withdrew their labour for routine care on 10 February 2016, leading to the cancellation of around 3,000 elective operations.
The period in August where there was a large changeover of hospital staff has sometimes been dubbed the "killing season" (due to a perception that there is an associated rise in the number of patient deaths). In 2009 research looking at emergency admissions to hospitals in England established that a small but statistically significant increase in patient mortality was occurring during August. The limited data was collected retrospectively over a 8-year period, comparing two week-long blocks (one week prior to commencement, one week post commencement). The methodology meant that drawing firm conclusions was unwise with correlation not implying causation. In the month when junior doctors start working - when other factors are adjusted for patients had a 6% increase in mortality. For patients admitted as an emergency who were not requiring surgery or suffering from cancer, the mortality rate increased by 7.86%.
Other concerns have been raised regarding mortality following admission to hospital at a weekend. A research paper published in 2012, looked retrospectively at data from 2009; the study observed an increase in 30 day mortality for people admitted to hospital on Saturday and Sunday, compared to mid-week days. The risk of dying in a hospital on Saturday or Sunday was actually less than on a weekday. The data in the study did not allow the authors to describe the cause of this so-called weekend effect. Subsequently there has been considerable speculation around whether the availability of consultants was a factor. The authors of the paper have also openly criticised the conclusions drawn by the government and popular media on the paper, saying that to draw such conclusions as to associated decreased weekend staffing levels to increased mortality at 30 days post-admission would be "rash and misleading" 
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