The government’s bid to change junior doctors contracts in the face of strong opposition has developed into the major political NHS story this year, and a major focus for officials and ministers alike. HSJ workforce correspondent Shaun Lintern examines the issues.

Where are we now?

After months of acrimonious exchanges, social media campaigns and protest marches junior doctors appear on the verge of taking strike action in response to the government’s plan to impose new terms and conditions on England’s 38,000 trainee medics.

There is little sign of the British Medical Association returning to the negotiating table, and the pressure of media attention and public concern is mounting on health secretary Jeremy Hunt.

The debate over the contract has largely been characterised by inaccurate claims and counter claims, with plenty of hyperbole about what is being proposed, and the original purpose of the reforms lost in the fog of war.

Ever since it walked out of contract negotiations, without pre-warning in October 2014, the BMA has been mischievously proactive – and has successfully dominated mainstream media coverage in recent months. In this way it has caught both NHS Employers and the Department of Health by surprise. Their failure to quickly rebut inaccurate claims - such as that doctors faced a 40 per cent pay cut, or that it would be reduced in more difficult specialties – was such that these misnomers became close to accepted facts for some.

For his part, Mr Hunt has conflated the government’s desire for seven day services with the need for a new trainee doctor contract – and unnecessarily added fuel to the fire by inaccurately linking it to claims of 11,000 excess deaths at weekends.

The current impasse is one of the most difficult for the DH to handle since the passage of the Health Act 2012.

How did we get here?

The BMA announced its surprise decision to walk out of talks in October last year at night on social media – catching both the government and NHS Employers off guard. Looking for a way forward, the government turned to the independent Review Body on Doctors’ and Dentists’ Remuneration.

Former health minister Dan Poulter, a medic himself who earlier this month added his voice to junior doctors’ criticisms, asked the review body to make recommendations on potential contractual change.

The DDRB report, published in July, largely accepted principles put forward by NHS Employers. These included that the current pay banding system should be scrapped; pay should be linked to responsibility not time served; and that plain time should be extended to evenings and weekends. This would release money to incentivise joining specialties such as accident and emergency, and those working more out of hours. However, the DDRB also recommended that some key points - particularly linked to pay and working hours – should be subject to further talks. It also suggested mandatory safeguards on working hours.

The BMA rightly identifies that the pay progression proposals could particularly hit women, and those working part time. It highlights fears that the loss of financial penalties inherent in the banding system mean trusts will be able to exploit doctors. Increasing plain time hours, regardless of a promised 15 per cent rise in basic pay, is unpalatable to many junior doctors who want weekend and evening work to be recognised with extra pay.

The BMA, refusing to re-enter talks, says it does not accept the DDRB’s principles as a starting point. The government doesn’t want to start from scratch after three years of debate, at the beginning of which both sides agreed the current contract was not fit for purpose.

What are the likely outcomes?

The original basis for reform of the junior doctor contract is now largely academic given the scale of protest over the government’s threat of an imposed settlement. The anger exhibited by many junior doctors is unlikely to end with anything short of industrial action. A background of grievances for doctors and the BMA – such as the Health Act, pension reforms and continued pay restraint – only add to this likelihood.

For the BMA, its course of action has successfully delayed implementation of changes for number of years, and united its members in opposition. However, the road may run out for the union. While the government wants to see a return to meaningful negotiation, its desire to implement a new contract by August 2016 seems as resolute as ever, and it is strengthened by its majority in the Commons.

Ministers are likely to make a full and final offer to junior doctors in coming weeks, with a final contract proposal drawn up by NHS Employers, which will be imposed. BMA members will almost certainly ballot for strike action – with a vote now scheduled for 5 November. The DH will seek to hold its nerve, as the previous administration did with battles over pension reform, and hope that it gradually wins back media and public support in the debate.

Should the DH impose a settlement but miscalculate the fallout, there’s a chance that Mr Hunt could suffer severe political damage, and lose the support of Downing Street.

In the longer term, the NHS will face an uphill struggle to repair the damaged relations, poor morale and manage the threatened exodus of trainees from the UK.

Snap survey: Hospital chiefs back bid to change junior doctor contract