How to build a rota with new contract ‘principles’

7 days equal cover.

No more than 4 nights or 5 long days in a row

Not more than 56 hours a week over 8 weeks

Not more than 72 hours a week in any 1 week

Not more than 48 hours a week?

 

BBC Interview

They work 60 or 70 hours a week. Does that guarantee of them not being paid less, extend to a junior doctor working 60 or 70 hours?

Well, you are allowed to work 60 or 70 hours in any one week. But over the period of a rota the law is very clear. You shouldn’t be working an average of more than 56 hours a week. And it’s not safe for patients, frankly, if people are working those kinds of hours. So we want this new contract to actually just stop people working more than the legal maximum over an 8-week period. But the real point I am making is, yes of course, no doctors working within the legal limits will have a pay cut. But our plans are actually good for doctors. We want to put in place safeguards that stop hospitals requiring doctors to work 5 nights in a row or a week of nights which doctors find absolutely exhausting. We know that doctors who are looked after and motivated are likely to give better care for patients. And also we want to be able to promise to patients that whatever day of the week you are admitted to a hospital, an NHS hospital, you can be confident of the same high-quality standard of NHS care. 

It has become an issue about this issue to do with the legal number of hours. So if a doctor, and you know they do work over those hours, is working those 60 or 70 hours in a week, you are not guaranteeing that their wages will not drop. 

Well, that’s not right. At the moment, the legal maximum hours that a doctor can work in any one week is 91 hours. And we are bringing that down, proposing in this new contract to bring it down, to 72 hours. And we want to stop anyone working more than those 72 hours because it’s not safe for patients. 

The question is, between the 56 which you mentioned earlier on and the other figure you mentioned now, there’s quite a discrepancy. That’s where the issue is going to lie, isn’t it?

Sorry, this is quite complex for early in the morning. But the 56 is the average hours you work over a period of 2 or 3 months. And that’s what the law says mustn’t be more than 56. But in any 1 week, you could work more than 56, and we will pay for that. But it mustn’t average more than 56 over a period of 8 weeks. And that must be right. Because in the end, if people are working hours that are too long, that’s not good for patients. There’s a very small minority of doctors who will be working more than an average of 56 hours. And at the moment they get paid what’s colloquially called in the NHS ‘danger money’. We think that’s wrong. Actually we shouldn’t be allowing that to happen. It’s not safe for patients. And frankly I’m not sure it’s safe for doctors either. But what we are saying is that for the vast majority of doctors who are working within the legal limits there will be no pay cut. We’ll make sure that happens. Incidentally this is something that we have essentially offering for some time now. And the appropriate thing now, given that we have made this clear, I’ve said it in Parliament, is for the BMA to come and negotiate with the government to get the right contract for doctors. They’ve refused to talk to us since last June. And I think we will get a better contract for doctors if we had the BMA sitting around the table talking with us, helping us to work out what that contract should look like. 

Parliament debate 28/10/2015

Motion: That this House notes the stalled discussions between Government and the British Medical Association (BMA) about a new junior doctors’ contract; opposes the removal of financial penalties from hospitals which protect staff from working excessive hours; urges the Government to guarantee that no junior doctor will have their pay cut as a result of a new contract; and calls upon the Government to withdraw the threat of contract imposition, put forward proposals which are safe for patients and fair for junior doctors and return to negotiations with the BMA.

Amended: That this House welcomes the Government’s commitment to delivering seven-day hospital services and saving lives by combating the weekend effect; notes the British Medical Association’s (BMA) decision to walk away from negotiations to reform a contract which all sides acknowledge is not fit for purpose; further notes the Government’s proposed introduction of new contractual limits which protect staff from working unsafe hours and the commitment that average junior doctors’ pay will not fall; and calls on the BMA to put patient care first, to choose talks over strikes, and to return to negotiations.

I warmly welcome the hon. Member for Lewisham East (Heidi Alexander) to her post at her first Opposition day debate.

One Saturday in April 2006 a 20-year-old man called John Moore-Robinson was out mountain biking with his friends in Cannock Chase when he fell off his bike and the handlebars hit his stomach. His friends dialled 999 and he was rushed to hospital. Although the paramedic who took him to hospital thought he had life-threatening internal bleeding, instead of being treated he was left for 50 minutes, apart from a brief examination. Then he was told he had bruised ribs and sent home. In fact, he had a ruptured spleen and tragically died later that Saturday night.

Tragedies happen in any healthcare system, and despite such stories I am fiercely proud of our NHS and the brilliant care given by our doctors and nurses seven days a week. The hon. Lady was right to thank each and every one of them. Anyone who uses such stories to denigrate the NHS should remember that last year the Commonwealth fund rated us the best healthcare system of 11 major countries—better than France, Germany, Australia or the US—and rated our A and E departments —[Interruption.] It was the Opposition who called this debate, so they might want to listen to some of the arguments. This is a very important issue about the lives of NHS patients, and I am saying that the tragedies and the problems we have should not be used to denigrate the NHS or our A and E departments.

Part of being the best in the world is being honest about where we need to improve, and the fact remains that in our hospitals today we have around three times less medical cover at weekends. In our manifesto in May this Government committed to a truly seven-day NHS so that we prevent a repeat of the tragedy that happened to John Moore-Robinson.

Ms Gisela Stuart: The Secretary of State is absolutely right that we need to address the fact that there seems to be less cover at the weekends. He is trying to circle that square without expanding the number of doctors and the services. He is thinning the service on Monday to Friday to bring more cover to the weekends. That does not solve the problem.

Mr Hunt: I am happy to deal with that. We went into the election in May saying that on the back of a strong economy we were prepared to commit £10 billion extra to the NHS in real terms over the course of this Parliament. That was £5.5 billion more than the hon. Lady’s party was prepared to commit. In the last Parliament, when the increase in NHS spend was half that amount, we increased the number of doctors by 9,000, so we are increasing the number of doctors, but as we do so we need to ensure that we give the right care to patients.

I want to give a word of caution to the shadow Secretary of State. The tragedy of John Moore-Robinson, the gentleman I have mentioned, happened not only on a Saturday, but at Mid Staffs. The last time the House discussed the difference between excess and avoidable deaths was under a Labour Government, when they tried to brush the problems at Mid Staffs under the carpet, saying that we should not take the figures on excess deaths too seriously because they were a statistical construct and different from avoidable deaths. I would have hoped that the Labour party learned the lessons of Mid Staffs and would not make the same mistakes again. [Interruption.]

Mr Deputy Speaker (Mr Lindsay Hoyle): Order. The hon. Member for Islington South and Finsbury (Emily Thornberry) may shake her head, but I expect voices in the Chamber to be a little quieter. I want to hear the Secretary of State, and I think all our constituents do. I understand that you might not agree.

Mr Hunt: Let us look at some of the facts. What is the most important thing for people admitted to hospital at the weekend? It is that they are seen quickly by a consultant. Currently, across all key specialties, in only 10% of our hospitals are patients seen by a consultant within 14 hours of being admitted at the weekend. Only 10% of hospitals provide vital diagnostic services seven days a week. Clinical standards provide that patients should be reviewed twice a day by consultants in high-dependency areas but, at weekends, that happens in only one in 20 of our hospitals across all key services.

Helen Whately (Faversham and Mid Kent) (Con): Is the Secretary of State shocked, as I am, that the shadow Health Secretary seemed to say that the NHS should continue as it is, and that she appears to deny the weekend effect, which means that people are dying unnecessarily?

Mr Hunt: Yes, I am shocked. I am really shocked about the suggestion that there is a difference between what is right for patients and what is right for doctors. The shadow Secretary of State spent a lot of time talking about morale. The worst possible thing for doctors’ morale is their being unable to give their patients the care they want to give.

Jonathan Reynolds (Stalybridge and Hyde) (Lab/Co-op): Does the Secretary of State not see anything perverse in making the case for a seven-day NHS—he has repeatedly done so—while drawing up a junior doctor contract that financially penalises doctors who already work evenings and weekends? How can that make any sense?

Mr Hunt: The contract will not do that. The contract we are proposing will give more reward to people who work the most antisocial hours. I will explain the details of that later.

The shadow Secretary of State talked about academic studies, so let us look at what the academic studies on the weekend effect say. The Freemantle study, published in the British Medical Journal, which is owned, incidentally, by the British Medical Association, said in September that the mortality rate for those admitted to hospital on a Sunday is 15% higher than for those admitted on a Wednesday. It said the weekend effect equated to 11,000 excess deaths. Let us be clear about what that means. It does not mean that every one of those 11,000 deaths is avoidable or preventable—it would be wrong to suggest that. It means that there are 11,000 more deaths than we would expect if mortality rates were the same as they are on a Tuesday, Wednesday or Thursday. Professor Sir Bruce Keogh, the NHS England medical director, called it

“an avoidable ‘weekend effect’ which if addressed could save lives.”

It is not just one study. In the past five years, we have had six independent reviews. Another study in the British Medical Journal,by Ruiz et al, states:

“Emergency patients in the English, US and Dutch hospitals showed significant higher adjusted odds of deaths…on Saturdays and Sundays compared with a Monday admission.”

The Academy of Medical Royal Colleges—the body that represents all the royal colleges—said in 2012 that deficiencies in weekend care were most likely linked to the absence of skilled and empowered senior staff and the lack of seven-day diagnostic services.

Norman Lamb (North Norfolk) (LD) rose—

Mr Hunt: I am happy to give way to my former colleague.

Norman Lamb: During my travels across the country, I recently spoke with the chief executive and the chair of an acute trust. They said that they have no difficulty at all with junior doctors and ensuring that there is cover at weekends; their problem is with consultants—and the Secretary of State has just made that point. Has he not chosen the wrong target?

Mr Hunt: Chief executives of trusts and NHS employers have been very clear that this is about reform of contracts for both consultants and junior doctors, because the reduction in medical cover at weekends happens with both the consultant and the junior doctor workforces. Also, as I will go on to say, it puts huge pressure on junior doctors at the time when they do not have senior support and the ability to learn from it, and that is exactly what we want to sort out.

Junior doctors are not to blame for the weekend effect. The situation would actually be far worse without them, because they perform the lion’s share of medical evening, night and weekend work. In many ways, they are the backbone of our hospitals. However, the BMJ study this year showed that there is evidence that junior doctors felt clinically exposed at weekends, and nothing could be more demotivating for a doctor than not being able to give the standard of care they want for a patient.

Mary Creagh (Wakefield) (Lab): The right hon. Gentleman has prayed in aid the weekend effect and quoted Sir Bruce Keogh, his own NHS medical director. Is he aware that Professor Keogh has also said that

“it is not possible to ascertain the extent to which these excess deaths may be preventable; to assume they are avoidable would be rash and misleading”?

Mr Hunt: Yes, and I agree with that, but it would be equally rash and misleading to say there are no avoidable deaths. Professor Keogh was saying that lives could be saved if we tackled this. All these studies are saying that 15% more people die than we would expect if we had the same level of cover at weekends as we have during the week. Therefore, as he says, the moral case for action is unanswerable.

Jeremy Lefroy (Stafford) (Con): The hospital to which my right hon. Friend referred earlier is in my constituency. The accident and emergency department has improved hugely over the past few years—well over 95% of patients are seen within four hours—and one reason for that is that it has consultant cover all the time. It is not open 24/7—we want it to be—but for the 14 hours a day that it is open, it has consultant cover all the time.

Mr Hunt: My hon. Friend is absolutely right. The fact is that this is a package designed to ensure that we eliminate the weekend effect, and it involves both junior doctors and consultants, because they both have their part to play.

Emily Thornberry: Will the Secretary of State give way?

Mr Hunt: I am going to make some progress before taking any further interventions.

The question for a Government and for a Health Secretary is this: when we are faced with this overwhelming evidence—six studies in five years—should we take action or ignore it? We are taking action. That is why in July I announced that we will be changing the contracts for both consultants and junior doctors as part of a package of measures to eliminate the weekend effect. If we believe in the NHS, and if we want it to be there for everyone, whatever their background or circumstances, we must be able to offer every NHS patient the promise of the same high-quality care, whichever day of the week they need it.

Let me set out for the House what I have proposed. We announced ambitious plans to roll out seven-day services across the country, with better weekend staffing across medical, diagnostic and support services in hospitals, as well as better integration with social care and seven-day GP access. That will reach a quarter of the population by March 2017, and the whole country by 2020. For consultants, we proposed an end to the right to opt out of weekend working, replacing it with a maximum obligation to work one weekend in four. To its credit, the BMA’s consultants committee has agreed to negotiate on that.

For junior doctors, we proposed to reduce the high overtime and weekend rates, which prevent hospitals from rostering enough staff at weekend, and increase basic pay to compensate. We have made a commitment that the pay bill as a whole would not be reduced, and today I can confirm that not a single junior doctor working within the legal limits for hours will have their pay cut, because this is about patient care, not saving money. Incidentally, I made it clear to the BMA at the beginning of September that that was a possible outcome of negotiations, in an attempt to encourage it to return to the negotiating table. Rather than negotiating, it chose to wind up its own members and create a huge amount of unnecessary anger.

Mark Spencer (Sherwood) (Con): Given the Secretary of State’s assurance, is there any reason why the BMA should not come back to the table and negotiate with him to solve this problem so that patients are safer at weekends?

Mr Hunt: There is no reason whatsoever. What was strikingly absent from the shadow Health Secretary’s comments was an entreaty to the BMA asking it to come and negotiate. Labour Members can play a constructive role in this, but so far they have declined to do so.

Emily Thornberry: Is the right hon. Gentleman going to continue with his plan to change the rules so that trusts that insist on doctors working unsafe hours can no longer be fined for doing so? It will help if he can assure us that those rules will continue and trusts will be fined if they break them.

Mr Hunt: They are not fines; they are perverse incentives to doctors to work unsafe hours. We want to go one better than that. We propose to stop hospitals requiring doctors to work five nights in a row or six long days in a row, and to bring down the maximum number of hours that hospitals can ask a doctor to work in any one week. On top of that, we have imposed the toughest hospital regime of any country anywhere in the world that comes down very hard on hospitals that are not providing safe care.

Lady Hermon (North Down) (Ind) rose—

Norman Lamb rose—

Mr Hunt: I am going to make some progress before I give way again.

Norman Lamb rose—

Mr Hunt: As the right hon. Gentleman is my former colleague, I will give way once more.

Norman Lamb: I want to ensure that I fully understand the commitment that the Secretary of State gave about not a single doctor losing out. I think he said that that is “provided they are working within maximum legal hours”. Does that mean people working up to 48 hours, which is the maximum working week under the working time directive? What about doctors who have opted out of that and are working 60 or 70 hours? Could they lose out?

Mr Hunt: It applies to all doctors working within the legal limit. If they opted out of the working time directive, it would apply up to 56 hours. For people who are working more than the legal limits, even after opting out, the right answer is to stop them working those extra hours because it is not safe for patients. But yes, that is the commitment to people even if they have opted out.

Lady Hermon: Will the Secretary of State give way?

Mr Hunt: I am going to make some progress, if I may.

As well as reducing the maximum hours a doctor can be asked to work from 91 to 72 in any week—a significant reduction—and banning hospitals from requiring doctors to work five nights in a row or six long days in a row, as hospitals can currently make them do, we propose to ban the routine use of fixed leave arrangements that mean that some doctors have to give up to three months’ notice before taking leave, meaning that they miss out on vital family or personal occasions.

We did not, and do not, seek to impose a new contract; rather, we invited the BMA to negotiate a new contract so that we could end up with a solution that was right for doctors and right for patients. However, because we had recently won an election in which a seven-day NHS was a manifesto commitment, we said that having tried to negotiate this unsuccessfully for two and a half years, we would ask trusts to introduce new contracts if we were unable to succeed in negotiations.

Lady Hermon: I have a specific point about Northern Ireland. Of course, health is devolved to the Northern Ireland Assembly, but I can assure the Health Secretary that junior doctors in Northern Ireland are absolutely furious about the proposed changes to their contracts. It would help if he could confirm that he is in regular direct dialogue with the Health Minister in the Stormont Assembly, Simon Hamilton MLA. I ask him not to reply that officials talk to each other regularly, because “Minister to Minister” is what I would like to hear.

Mr Hunt: We do have regular dialogue. I suggest that the reason doctors in Northern Ireland might be angry is that they have been listening to misinformation about what the Government in England are proposing, which has, very disappointingly, made doctors all over the UK very angry. I hope that the assurances I am giving, which I gave to the BMA last month and the month before, face to face and in letters, will encourage the hon. Lady to report to the doctors she mentions that the right thing for the BMA to do is to come and talk to the Government. Regrettably, the BMA’s Junior Doctors Committee has refused to negotiate since last June. Instead, it put up a pay calculator on its website that scared many doctors by falsely suggesting that their pay could be cut by between 30% and 50%. It has now taken that pay calculator down, but the damage to morale as a result of it continues.

Rachael Maskell (York Central) (Lab/Co-op): Will the Secretary of State give way?

Mr Hunt: I will make some progress. Some people say that this is a battle between the interests of patients and those of doctors, but that is profoundly wrong. Doctors who are happy and supported in their jobs provide better care to patients, and the link between a motivated workforce and high-quality care is proven in many studies, as well as in hospitals such as that in Northumbria, where staff have become the greatest advocates for seven-day services since their introduction. Our proposed new system is intended to provide better support to doctors who work weekends, and make seven-day diagnostics more widely available across the NHS.

Simon Hoare: Given the clarity with which my right hon. Friend has addressed the principal concerns of junior doctors, does he expect the BMA’s Junior Doctors Committee to change its stance, come to the Department and restart negotiations, or will it continue to stall?

Mr Hunt: If the BMA is serious about wanting to do the right thing for doctors and patients, there is no reason for it not to negotiate with the Government to get the right solution. This is a test of how serious it is—my hon. Friend’s point is well made.

Rachael Maskell: This debate is reminiscent of 12 months ago and the “Agenda for Change”, when the Government refusal to negotiate with 1 million NHS staff, and caused industrial action and a strike. The same thing seems to be happening again. Will the Secretary of State take the shackles off the negotiations and enable the professionals to put their case on the table? Will he listen to them and let them lead negotiations?

Mr Hunt: That is exactly what I would like to happen, but it can happen only if members of the BMA walk through my office door—it is open—and sit down and start negotiating, which they have refused to do since last June. Just as it is wrong to pit doctors against patients, it is also wrong for the Labour party to pit the Government against doctors. In the previous Parliament, Labour wanted to cut the NHS budget, but we protected it. In May’s election we promised £5.5 billion more for the NHS than Labour did, and in the last Parliament a Conservative-led Government delivered 9,000 more doctors to the NHS, 1 million more operations a year, and 600,000 more people were referred for urgent suspected cancer every year.

Because we are not stopping at that, and because we are passionate that the NHS should offer the highest standards of care available anywhere in the world, the Government have also been honest about the problems facing the NHS. Two hundred avoidable deaths every week is too many—it is the equivalent of a plane crash every week. Nor is it acceptable that twice a week we operate on the wrong part of someone’s body, or allow other “never events” to happen. In many of those areas the NHS is performing at or better than international norms, but that does not make such things any more acceptable. We want the NHS to be the first healthcare system in the world to adopt standards of safety that are considered normal in the airline, nuclear or oil industries.

Rehman Chishti: The Secretary of State said that we are open to problems being highlighted. May I thank him for what he did by putting hospitals into special measures? Medway Maritime hospital had the seventh highest mortality rate in 2005, yet nothing was done. Support is now being given to that hospital to turn it around. We are highlighting problems, but we are also introducing measures to fix those problems.

Mr Hunt: I thank my hon. Friend for his consistent support for his local hospital. It has had many troubles, but it is beginning to show signs of turning a corner. If we want to turn things around, we must first be honest about the problem.

I welcome the shadow Health Secretary to her place. Her predecessor tried to minimise the care problems that took place under a previous Labour Government, and he described our attempts to put them right as trying to “run down the NHS”. I hope that she does not do the same. Labour used to be the party that stood up for ordinary men and women; it cared enough about them to set up the NHS, so that no one had to worry about getting good medical care, whatever their circumstances. People need to know that they can depend on our NHS seven days a week. Instead of making mischief about a flawed doctors contract that was introduced by a Labour Government in 2000, the hon. Lady should stand with us as we sort out this problem. Be the party not of the unions but of the patients who depend on high quality care, day in, day out. Professor Bruce Keogh talked about the moral and professional case for concerted action. Surely in that context, she might reconsider this rather ill-judged attempt to make party political capital out of a very real problem.

Everyone who cares about the NHS should want the same thing. The hon. Lady should tell the BMA to get around the negotiating table, something she conspicuously failed to do. In doing so she would stand alongside the many independent voices calling on the BMA to return to the table and discuss a solution with the Government—the Royal College of Surgeons, the Royal College of Physicians, NHS providers and the Academy of Medical Royal Colleges. If she does not do that, the British people will draw their own conclusion about which party is backing the NHS with the resources it needs, which party is supporting hospitals to become safer at the weekends, and which party is standing four-square behind doctors and nurses in their ambition to deliver high quality standards of care for patients. There is only one party that can be trusted, one true party of the NHS, and that is the Conservative party.

Letter to BMA (28/Oct/2015)

Dear Dr Malawana,

Today in the House of Commons I am giving a firm guarantee on behalf of the Government that no junior doctor will see their pay cut compared to their current contract.

When we met privately on 30 September I indicated that this could be the outcome of a negotiated settlement, and this builds on the commitments I made in my letter to you of 8 October, which of course remain.

As the Junior Doctors’ Committee moves towards a ballot of its members, I will be setting out the full details of the Government’s contractual offer to junior doctors in the coming days. However, I sincerely hope that on the basis of these assurances you will reconsider your refusal to enter negotiations.

It is deeply regrettable that so many of your members still believe that pay cuts in the order of 30 or 40 per cent are on the table. I am told that the pay calculator on the BMA website which implied this has now been withdrawn, but to date there has been no attempt to correct the misinformation and fear which quite understandably spread as a result.

I emphasise again that I want the new contract to improve patient safety including by better supporting a seven day NHS. Within this, nights and Sundays will continue to attract unsocial hours payments, and I would be pleased to discuss in negotiations how far plain time working extends on Saturdays.

I continue to believe that our ambition for the NHS to be the safest healthcare system in the world is underpinned by reducing, not increasing, the number of hours junior doctors work each week. The new contract will mean no junior is required to work more than an average of 48 hours per week, with tougher limits on unsafe hours including a new maximum working week of 72 hours, and a new maximum shift pattern of four consecutive night shifts and five long day shifts, compared with the current contract which permits more than 90 hours a week, 7 consecutive night shifts and 6 long day shifts.

So the idea that this contract would herald a return to the long hours of the past could not be further from the truth. In fact, it is the current contract which provides a perverse incentive for juniors to work unsafe hours by paying those who breach safe hours up to 100% of their basic pay.

As you know, my overriding aim in pursuing these contractual changes is to improve patient safety by dealing with the ‘weekend effect’ in our hospitals. I know that doctors share this aim of delivering the safest, most compassionate care possible.

I invite you once again to come back to the table to negotiate a contract that rewards doctors fairly and that has safe care at its heart. My door is always open.

Letter to BMA (08/Oct/2015)

Dear Dr Malawana,

Thank you for coming to see me to discuss the junior doctors’ contract. You stressed that the key issue for junior doctors is a contract which promotes both patient safety and fairness for juniors. I share exactly the same aims for the new contract as you do. As you know, I have put improving safety and quality at the heart of my time as Health Secretary and I agree with you that junior doctors play a vital role in the NHS and deserve to be treated with fairness and equity. They are tomorrow’s leaders and I want to support them to have long, productive NHS careers. Given we both fundamentally share the same objectives, I agreed to write to you with assurances for junior doctors about our approach to a new contract. Firstly, this is not a cost cutting exercise. I can give you a categorical assurance that I am not seeking to save any money from the junior doctors’ paybill. Whilst I want to see an end to automatic annual increments (with pay rises instead based on moving through the stages of training and taking on more responsibility), these changes would be cost neutral, rather than cost saving.  This will mean that junior doctors would still benefit from four or five progression pay rises as they move through training. Secondly, I want the new contract to improve patient safety by better supporting a seven day NHS. The Government was elected on a manifesto commitment to ensure that the quality of NHS care is the same across the week. So together with NHS staff, we must eradicate the ‘weekend effect’ of excess deaths in NHS hospitals. For junior doctors, this means some increase in plain time working (backed up with an increase in basic pay) and a replacement of the banding system, and a move to paying for hours worked, with additional pay for unsocial hours. Within this, I can give an assurance that nights and Sundays will continue to attract unsocial hours payments. I would be pleased to discuss in negotiations how far plain time working extends on Saturdays. Thirdly, I believe that our ambition for the NHS to be the safest health care system in the world is underpinned by reducing, not increasing, the number of hours junior doctors work each week. Junior doctors already work seven days and are the backbone of medical care in hospitals at weekends and at night. I can give an absolute guarantee to junior doctors that this contract will not impose longer hours. No junior doctor working full time will be expected to work on average more than 48 hours a week. I want to see a work review system with teeth that ensures that juniors are not exploited and that addresses issues of overworking if they arise. I recognise that there will be exceptional circumstances in which an individual doctor should be compensated for hours worked outside the work schedule. In such circumstances, employers will compensate the individual doctor for such hours, provided that the work has been undertaken for the needs of the service and is authorised by an appropriate person. Further, the employer will also have a duty to review the work schedule to ensure that such instances remain as exceptional circumstances. My ambition on safety is also underpinned by better training for junior doctors. I am working with the BMA consultant committee to make sure there is proper consultant cover at weekends so junior doctors are better supported. I also want HEE and the Royal Colleges to continue working with the BMA and NHS Employers to look at how the training experience can be improved more generally for juniors. This is not primarily a contractual issue but we do need to look at how we can better support work life balance including leave arrangements and recognising that juniors often have family responsibilities and choose to work part time. I would like your help to formulate that programme of work. Finally, I have asked NHS Employers to develop the details of the new contract to ensure that the great majority of junior doctors are at least as well paid as they would be now. In addition, although the current proposal does not provide protection for those whose pay reduces when they change jobs, under an agreed move to a new contract we would be willing to consider such protection for individual doctors who would otherwise lose out. In any scenario, I can give an absolute guarantee that average pay for juniors will not reduce. I have already given my assurances that GP trainees will not be disadvantaged compared with the current system. I can also say that it is our intention that flexible pay premia would be used to support recruitment into shortage specialties such as Accident and Emergency Medicine and General Practice. We would also include pay protection for doctors who change to shortage specialities and to support agreed academic work. I hope this letter makes clear what was discussed at the meeting – that we want to work with you, in good faith, to develop a new contract which is better for both patients and junior doctors. I am saddened by the distress being caused to junior doctors who were misled by the calculator on the BMA website into believing that their pay will be cut by 30% and that they will be asked to work many more hours each week. As you know, the Government has been saying privately to the BMA for many months that we have no such intention, so I hope that this letter, with a set of unequivocal assurances, now helps us to move the debate on and provides reassurance to junior doctors who have been on the receiving end of significant misinformation. The negotiations on the new contract began on the basis of a shared view between the BMA and employers that the current contract had served its purpose and needed reform. The best deal for junior doctors will be achieved by the BMA coming to the table to negotiate on their behalf and I urge you now to do this.