Simon Stevens on junior doctors

When I started work for the NHS in the steel town of Consett, County Durham, just under 20 years ago, I shared a flat with a raucous group of junior doctors.

While NHS management trainees of a similar age were dispatched across the hospital to deal with outpatient clinics or manage the medical secretaries, my flatmate house officers and senior house officers were delivering babies and attending the dying - all on three or four hours' sleep a night.

Watching the huge emotional and intellectual drain on my friends, and their horrible sleep deprivation, gave me great respect for the baptism of fire that greets freshly minted junior doctors as they emerge from medical school into the harsh light of clinical practice. And it has served as a partial corrective to the sense shared by many frontline NHS staff that, at times, junior doctors can be the most solipsistic members of the 1.3 million NHS workforce (an accolade for which there are several contenders).

In many respects, therefore, we should share junior doctors' sense of dismay at the cack-handed implementation of the Medical Training Application Service appointments system. It has resulted in clear unfairness to young doctors and suboptimal staffing for hospitals. It is proof once again of the Department of Health's 'reverse Midas touch' when it comes to medical staffing.

Yet strip away the incompetence, and the fact remains that the previous method of allocating medical applicants to posts was far from perfect. For example, previous practice was racist - a consideration that does not seem to have been referenced in the headlines. Research, reported in the BMJ in 1993, showed that British-trained doctors with Asian names were less likely to be shortlisted for SHO jobs than those with English names. In two famous studies, matched pairs of applications were sent to advertised NHS posts in paediatrics, general medicine, geriatrics, psychiatry, obstetrics and gynaecology, general surgery, orthopaedics, and GP training schemes. Holding all else constant, only 36 per cent of candidates with Asian names were shortlisted compared with 52 per cent of candidates with English names.

The researchers - one of whom is now deputy chairman of the British Medical Association - concluded: 'Discrimination against ethnic minority candidates is still prevalent, despite numerous public commitments by the profession's leaders and employers to deal with it. The discrimination is being practised by consultants, who are responsible for shortlisting for junior posts.

'[We] suggest several mechanisms, including standard and anonymised application forms together with strict enforcement and publication of the results of equal opportunity monitoring. Sadly, little seems to have changed, and it is an indictment of our profession that we still seem to tolerate a situation in which people's careers and livelihoods are jeopardised simply because they have the wrong name and wrong colour of skin.'

So many of the features of MTAS that are now being railed against on grounds of 'political correctness' are precisely those new selection mechanisms that were identified as necessary a decade ago. None of which excuses incompetence, but it gives pause for thought.

And there is a more general problem with complaints by junior doctors about other aspects of their current working conditions. Namely: most of the things they are complaining about were self-inflicted by successive waves of junior doctor activists.

Take shift working. One of the main reasons we have this unpopular form of doctor rostering is because of the intransigence of the BMA junior doctors committee. When the European Court of Justice produced two rulings - SiMAP and Jaeger - that deemed doctors to be working even when asleep, the junior doctors committee refused to rule out bringing legal action against any hospital that did not implement to the letter the new rule. I know this, because I sat across the table from the BMA and medical royal colleges in a 'full and frank' session at Number 10 on precisely this topic. Hence shift working was born. And with it, the need for more junior doctors at the staffing 'base' than would secure coveted senior jobs at the 'apex' of the medical staffing pyramid.

Never mind that if the European Court interpretation (that is, extension) of the meaning of the original working-time directive had been known when the last Conservative government signed up to it, they probably would have decided not to, given the amount of disruption it would cause to the pattern of clinical services.

So this is an example where junior doctors have in some respects been their own worst enemy, with the activist class getting elected to the junior doctors committee on ever-shriller demands, seemingly unaware of the medium-term consequences for their successors. Let alone the impact on the rest of the NHS: junior doctors' staffing patterns have frequently been the tail wagging the dog of unpopular hospital closures and reconfigurations.

Twenty years ago my flatmates were quite right to demand cuts in their working hours. They placed junior doctors under ludicrous stress and were the cause of many avoidable medical errors.

Two decades on, doctors in training now work less - and earn more - than their counterparts in the US and parts of mainland Europe, despite having more generous tax funding of their medical education.

As the recent 55 per cent expansion in medical school places goes on to produce more doctors than at any time since the NHS was founded, it would be appropriate if there was some recognition that - with the exception of the MTAS debacle - juniors have in fact never had it so good.