BMA (Contract Negotiations)

Philippa Whitford Excerpts

Monday 21st March 2016 Westminster Hall

[Andrea Jenkyns]

I am going to finish. Can a policeman say that he does not want to cover a Friday night? Can a firefighter turn down a shift because it is a Sunday morning? No.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

I thank the hon. Lady for giving way. I want to point out that the opt-out clause for consultants is for routine work at the weekend. If they run an emergency service they are not allowed to opt out of emergency care.

[Andrea Jenkyns]

I thank my hon. Friend for that. We work together closely on many matters. At the end of the day, life has moved on from the time when the NHS was set up. Life has got to change.

Moving on to my next point, firefighters cannot turn down shifts. They are public servants, just like doctors. The new contract proposed by the Government is safe and fair. No doctor working legal hours will get a pay cut thanks to the 13.5% increase in basic pay and the unsociable hours pay for nights, Saturday evenings and Sundays. The NHS must adjust to the modern world if it is to survive. Seven-day working is vital to that, and the BMA needs to recognise that. The Government and the Secretary of State have gone out of their way to talk to the BMA and to accommodate its demands. A negotiation in which someone gets 90% of what they want would seem pretty successful to me, and it is a shame that the BMA does not see it that way.

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[Rachael Maskell (York Central) (Lab/Co-op)]

It is a pleasure to serve under your chairmanship, Sir David.

It is a privilege to be able to say that I worked in the NHS as a physiotherapist for 20 years—I remain on the professional register—and to bring that experience to the debate. The service that I worked on was changed to cover seven days. The complement of staff was the same, but spread over the whole week. To provide a full seven-day service with every specialism in place would require a massive investment of resources on a scale nothing like what the Government are talking about, given that they are set on making £22 billion of efficiency savings. Before being elected to Parliament I had a dual career, because I was also head of health at Unite, representing more than 100,000 health workers. I therefore have real experience of dealing with the Government and of how the Department of Health handles disputes.

On 5 December 2011, proposals were introduced to cut unsocial hours for all “Agenda for Change” staff. The proposals were discussed with NHS employers throughout the country and with the trade unions. We sat around tables and discussed the proposals, and they were turned away, but the fear is that they could be coming back on to the table. The NHS Pay Review Body report said that the Department of Health and NHS employers recognise that

“the cost of the unsocial hours premia makes the delivery of seven-day services prohibitive”.

That is why the whole NHS is worried: the real prize for the Government is the savings they will make from cutting unsocial hours throughout the NHS.

If the Government are planning to expand services to cover seven days, if only in name, they will need more people to work at weekends. The cost of having more people working at weekends cannot currently be met, so if the service is to be expanded, obviously the prize the Government are after is the NHS’s “Agenda for Change” staff, who are often very low paid. According to a survey I conducted of these professional NHS employees, they are giving eight hours of unpaid overtime to the NHS every week, doing the many things we have already heard that NHS staff do. Why? Because they care, because they are professional, and because that is what happens in the NHS.

I do not recognise at all the caricature painted by the hon. Member for Morley and Outwood (Andrea Jenkyns). What she described is not my experience of some of the most highly professional people in our land. They deserve our respect and awe, not to be degraded as she degraded them today and as the Secretary of State has previously. I am ashamed to have heard her comments. I had a meeting with junior doctors in my constituency on Friday and listened to their concerns. They are seriously concerned about recruitment and retention in the medical profession, particularly in accident and emergency, where there is a serious recruitment and retention problem in my local hospital.

They explained to me that as junior doctors are leaving they are being replaced by locums. That destabilises the multi-professional team. It destabilises the ability of clinicians to work in teams where clinicians know one another, which is the safest way to operate. All the tutoring, mentoring and other input that staff so value and need—learning on the job right through their professional careers—is lessened by that destabilisation. They are seriously concerned about recruitment and retention because they want to get the best professional development so that they can give the best service to patients. That is why we are seeing junior doctors applying to work overseas: they want to ensure that their careers are enriched so that they can give patients the best care.

We should be really concerned that there are such problems with recruitment and retention in many of the specialisms that require weekend working and are involved in emergency services. We are not discussing some of those services that, frankly, could operate according to clinical need during a Monday-to-Friday service because the demand is not there for such professionals to be there at the weekend. We should be very worried, as should the public, because the reality is that if doctors are not in A&E, who is going to care for us in our time of need? That is the reality of what is happening.

Psychiatry is another profession that is currently finding it difficult to recruit, as are other areas of emergency medicine and the intensive therapy unit at my local hospital. They face real challenges, and they have concerns about the new regime that is being introduced to try to deter hospitals from making doctors work long hours—the new guardian of safe working role. They are concerned because the new regime is like the trust marking its own homework. If doctors report that they are working excessive hours, the trust will be fined, but the fines will go into a training and development fund, so we will just see less money going into that fund in the first place. It is a case of playing with the accounts and shuffling the deckchairs on the Titanic as it is sinking under the proposal.The reality is that it will not be an effective measure for preventing people from working longer hours, and doctors have real concerns about it.

[Dr Whitford]

I, too, have concerns about the hours guardian, because it will require junior doctors to complain. The NHS is a hierarchical system, and those doctors, who are often on the lowest rung of the ladder, will have to step up and make a noise. Something that depends on their whistleblowing on their own hours will not provide strong protection.

[Rachael Maskell]

The hon. Lady is absolutely right. Although Government Members say that the NHS has a much more open culture, the reality on the ground is that it is difficult to raise concerns in the NHS. Shopping the boss if they are making someone work longer hours will be difficult. The hon. Lady makes an excellent point.

We want to maintain the best in our NHS; we do not necessarily want to give that gift to the world. That is why it is so important that we return to the negotiating process. There was pressure from the Opposition to ensure that there was a process of independent arbitration so the talks could be resumed. When Sir David Dalton became involved, the dynamic of the dialogue changed, so a deal could be brokered and progress could be made. All that we ask—hundreds of thousands of people who understand industrial relations have written to us about this—is for professional dialogue with professionals to ensure a proper negotiating process so we can find a solution to this dispute. That is how negotiations work. That is the process of industrial relations. It is about sitting around a table and working through the difficult issues before us. When great minds come together, solutions can always be found.

I urge the Minister not to impose the contract and to withdraw from that position. Of course it is possible to do that. Anything is possible if the will is there. Withdraw, calm down, stand back and let some dialogue continue. We need to find a solution that is good for NHS employers, for our doctors—do they not deserve a solution to this dispute?—for the rest of the NHS, for patients and for the public. Why not make that small concession and open talks immediately?

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[Dr Philippa Whitford (Central Ayrshire) (SNP)]

We seem to have been negotiating this topic relentlessly since last summer. The Secretary of State has cited multiple papers showing the “weekend effect”, as it is described. Twice in his statement on 11 February—the day he imposed the contract—he talked about increased deaths at weekends. That is clearly not the case—it is increased deaths among those admitted at weekends. Despite being pulled up on that in the Chamber, he used exactly the same phrase on “Newsnight” the same evening.

I am very uncomfortable about the conflation of what the problem is and what the cause is. The papers show a statistical excess of deaths among those admitted at weekends. We know that those people are sicker: any patient admitted electively on a Sunday is considerably sicker. Studies of elective patients only show that anyone admitted electively at the weekend has a 92% increased chance of death. Frankly, in the modern NHS we do not get to admit our patients the day before, so they have to have a lot wrong with them and a lot of morbidity.

What has not been done is to dig into that to discover what the issue is. Some of the papers that the Secretary of State cites discuss excess mortality and have no relationship to a weekend effect at all. Ozdemir’s paper clearly identifies—it is categorical—the fact that excess deaths do not relate statistically to the deployment of junior doctors, yet those doctors are described as a blockage to the achievement of seven-day services. We have not had a proper definition of what is meant, and we keep waxing and waning, going from one track to the other: do we mean to strengthen urgent and emergency care, which no doctor would argue against, or do we mean routine? That keeps slipping in.

Patients shop in Tesco seven days a week, and some shops are 24 hours—the NHS should be the same. As I have said in debates before, if someone goes to Tesco at 2 o’clock in the morning, the fresh bakery counter is not open, nor is the alcohol counter or the fish slab—it is not exactly the same. The NHS is comparable: the reason we have more doctors and more things happening Monday to Friday is that we do elective work. Quantitatively, that totally overwhelms the numbers on emergencies.

Some papers suggest that the biggest issue, as identified in the Francis report, is the ratio of trained nurses to patients. Other issues were also identified by our Scottish Audit of Surgical Mortality, which looked at every single surgical death in the ’90s and early noughties. It identified the fact that some patients were operated on by surgeons who were too junior. That was discussed with the profession, and it changed. A couple of years later, the audit showed that we had consultant surgeons in, but that the anaesthetist was too junior for certain very sick patients, so that changed. That is what can be achieved through dialogue and development.

In Scotland, we have a seven-day care taskforce, but we are not imposing a contract—we are doing it through dialogue. Two of our biggest hospitals, the Edinburgh Royal in Edinburgh and the new Queen Elizabeth in Glasgow, already have seven-day working. In my own hospital, we have consultant radiologists all day Saturday and all day Sunday, but not through shifts. It can be achieved without the all-out battle we seem to have had for the past nine months.

The standards produced for the Government identified increased consultant involvement—in assessment, review and, if necessary, consultant-led intervention. There should be more diagnostics and more radiology. Those things relate to senior medical staff and to support staff such as radiographers and laboratory technicians, not to junior doctors, who are already there. Another problem is the flow of patients through hospital and back out into the community. That is why A&E gets so backed up. The problem cannot be solved in A&E; people have to be moved out to the community. We need physio- therapists, rehabilitation and the ability to discharge. None of that is junior doctors’ work.

As we have touched on before, the term, “junior doctors”, describes people up to their mid-30s. Senior doctors and senior trainees may be committed to a place and may not move, but very junior doctors are not; they rotate every year, and they can easily go overseas, as mentioned—or if they want to come up the M74, we will welcome them with open arms, roll out the red carpet and bring them in. In 2011, 71% of foundationers—people at the end of their first two years—were applying for a post in the NHS to continue training. That figure has dropped every single year: last year it was 52%; and now, just after closure, 47%. Less than half of England’s junior trainees are applying to stay on in the NHS, which is a catastrophe.

Not recognising antisocial hours means that the very specialties that involve a large proportion of antisocial working time will become even more unattractive. Will the Minister tell us why consideration was not given to the BMA proposal? It was cost-neutral and had a lower basic rise, but it kept a stronger recognition of antisocial hours. It would allow antisocial jobs such as those in psychiatry, A&E, obstetrics and gynaecology, and general surgery to remain at least accommodated by salary.

We already have rota gaps. We are short of 4,500 doctors. I have read articles in the Health Service Journal that describe a rota in Basildon that should include 22 doctors, but has 13, so it has been decided that only one doctor will be on duty at night, instead of two. Social media is full of people who are carrying two pagers—the senior pager and the junior pager. What happens if they become busy?

For the Secretary of State, the biggest issue is the attack on junior doctors. He seems to be claiming that he is the only person in England who cares about patient safety. I am sorry, but I have been a doctor for 34 years, and every single doctor, nurse and member of the NHS is working to deliver care and to protect patient safety. It is insulting to imply that they are not.

How do we move on from where we are now? I agree that the imposition needs to be stopped. After Sir David Dalton had made so much progress in just a month, I was really shocked, the morning after the strike, having tweeted to say, “Great, let’s get back to the table”, to find a couple of minutes later on the BBC that the Secretary of State was imposing the contract. If Sir David Dalton got that close in four weeks, why could that process not continue? Why could consideration not be given to the junior doctors’ own cost-neutral solution?

We need research to understand the issue. Do we require more senior nurses, or better nursing ratios? Do we not need to ensure that it is consultants and, in particular, radiologists who are available? The problem is that with the rota gaps that we already have, we are endangering patients, because people are constantly being emailed or texted, “Can you do another shift?”, “Can you do a split shift?”, or “Can you stay on tonight?” Exhausted doctors are dangerous. I am asking Ministers to step back, to cool things down, to remove the imposition, and to allow both sides to come back to the table. That is important for patients and the NHS itself.

The situation is not unsolvable. A decision was made simply to raise the temperature, which has created a desperate attitude among junior doctors. To describe them as radicals or lefties—no insult to Labour Members —is flippant. Doctors are not generally known for being particularly radical, and this was the first junior doctors’ strike in four decades. I went through my entire career without ever seeing a junior doctors’ strike. It is not something that people have embarked on lightly. We need a change of direction and a massive change of tone. Do not insult the junior doctors. They are the people who already provide a lot of seven-day work; they are not the obstruction.

People cite Salford Royal and Sir David Dalton, but I was there this morning, and he is clear that what he means by seven-day work is urgent and emergency work—and he is managing it on the existing contract. Let us be a bit more imaginative and get a solution.

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[Ben Gummer]

I will, and by way of return I hope that the hon. Lady will consider what the Secretary of State has actually said on a number of occasions, which—I am sure completely unintentionally—she misrepresented at numerous points. The hon. Lady said that the existing contract had moments of imperfection—I cannot remember her exact words. However, it had rather more imperfections than that, which is why the BMA recognised many years ago there was a need for significant change, and why the coalition Government entered into negotiations with the BMA early in 2013. The heads of terms were agreed between early 2013 and July 2013. The negotiations began in October 2013 and broke down a year later, with no notice to the Government. The BMA just walked out, and it took some time to explain why. It claimed, generically, that it was to do with patient safety, which was an odd thing to say given that there were doctors negotiating on the management side who were also concerned about patient safety. The negotiations were not rejoined until we involved ACAS in November last year.

[Dr Whitford]

When we had a debate about the issue in October, the Secretary of State was reluctant to go to ACAS, yet only when the negotiations went to ACAS was some progress made. The BMA wanted the contract changed to include recognition of quality training. The junior doctors are future consultants and leaders, and at the moment, while they hold multiple pagers and cover rota gaps, they feel that they are getting no training at all.

[Ben Gummer]

I will come on to the hon. Lady’s sensible points about rota gaps, which have persisted for many years and need to be addressed as a separate issue, and about training. However, the negotiations have been going on for more than two years. There is an idea that the Secretary of State somehow ended them peremptorily, but throughout the period of the negotiations there was a serious attempt to engage with the BMA. Progress was very slow, and the BMA unilaterally broke off the negotiations in October 2014. It did not come back to the table until the offer was made to go to ACAS.

On why the Secretary of State took the stance that he did, I have a different interpretation from the hon. Lady, because I was with him through that whole process. We were very keen to return to negotiations via ACAS, but we needed to ensure that the BMA would give its representatives full negotiating powers.

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[Ben Gummer]

I will happily arrange for the hon. Lady to have a clinical explanation of the various studies that she has cited, because I think she will then understand why the part that she has quoted needs to be understood in context—[Interruption.] I am asking her a direct question: does she—and do other hon. Members, who are tittering about this on the Opposition Benches—really propose that there is no weekend effect? If they are saying that is the case, or if they are saying that there are 500 or 1,000 deaths and that somehow is acceptable and the Secretary of State should not address himself to it, that is a worrying statement of intent.

[Dr Whitford]

rose—

[Helen Jones]

rose—

[Ben Gummer]

I will not give way to the hon. Member for Warrington North. I give way to the hon. Member for Central Ayrshire.

[Dr Whitford]

The problem here is about exactly what it is the paper shows. What do any of these papers show? They show a statistical excess of deaths. We know that 25% more of the people are in the sickest category. We know that 15% more of them die on a Sunday. Maybe the NHS did an absolutely amazing job in saving the other 10%. We do not know the answer, so we do not know how many are avoidable. However, I would point out to the Minister, who referred to the standards, that the only mention of junior doctors in the 10 standards is with regard to review of outcome and focus on training. Not one of the 10 standards says there should be a change in how junior doctors work.

[Ben Gummer]

One of the studies that the hon. Lady cites does a control for acuity, which she has raised. I know that there is an understandable change in the acuity of patients and one of the studies allows for that.

As for the point about the 10 clinical standards—and here I will just move on from the points that the hon. Member for Warrington North was making—

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[Dr Whitford]

Will the Minister clarify whether the protection for GP registrars has been re-established? We obviously do not have access to the terms and conditions that have been agreed, because they have not been published. However, one of their concerns was that they had pay protection when they became GP registrars, and that was going to be taken away.

[Ben Gummer]

All trainees working within legal hours will have pay protection and that includes GP registrars. That was one of the bottom lines of our negotiations all the way through the process and precisely why we are so disappointed that the BMA consistently misrepresented our position.

I have addressed the point the hon. Member for Hornsey and Wood Green raised about the 20% fall in income. She asked me to say expressly whether that is right or wrong. It is wrong. No one will see a fall in their income if they are working the legal hours. Indeed, we think that 75% of doctors will see an increase through the course of this pay contract.

The hon. Lady raised the issue of maternity and cited a doctor who claimed that they were earning £22,600. I would be interested to know the detail of that because the foundation year one minimum pay rate is £23,768, which is slightly above the figure she quoted. She made an entirely valid point about the need to make sure that women especially, but I hope under shared parental arrangements, women and men in the service have the flexibility to be able to take time out of the service to bring up children. That is why the increased base rate of pay is particularly good because it will increase the parental pay, as we should now call maternity pay, under shared parental leave when people take time out to look after children.

The hon. Member for York Central (Rachael Maskell), who is no longer in her seat, talked about guardians, but was factually wrong to claim that there would be no payment to junior doctors. They will be able to get one and a half times their salary as part of the payment fines made to guardians. The guardians will not, as the hon. Lady suggested, just respond to complaints. They will have an overall duty to maintain the wellbeing of junior doctors. Theirs will be a critical position in trusts and I hope it will grow into being a substantial one, making sure juniors have the opportunities for training they wish for and the levels of welfare to which they are entitled.

The hon. Lady spoke about whistleblowing, and her comments concerned me because this is precisely an area where we should be asking juniors to speak up. If working longer hours is dangerous—we all agree with that—like any other patient safety issue, not only should they morally speak up to their guardian, but they are under a duty to do so under GMC guidelines.

[Dr Whitford]

Does the Minister recognise that if someone is the most junior person in a very hierarchical system, it is difficult and harder for them to complain about something they perceive is being done to them as opposed to something they see concerning a patient?

[Ben Gummer]

I recognise that speaking up is difficult in the current NHS culture. It is precisely what lies at the heart of Sir Robert Francis’s second report. That is why we need to change that culture. It is also the reason why we said that guardians, in receiving proactive complaints from juniors, should have an overall duty of care for the juniors in their trust and make sure they are treated properly. That is why this is an exciting role. It is a tutorial role in sense with a responsibility, especially for the youngest trainees, to make sure they are in the right place and supported in what can be difficult times.

[Dr Whitford]

May I ask the Minister again about not having the chance to see the details? One concern of junior doctors is that they would not have a voice or a role within the guardianship. They asked to have a representative as part of that function. Has that changed, or are they still excluded from that?

[Ben Gummer]

They are not excluded. It is important that that person does not become a BMA nominee, but we want the guardian to make sure they command the respect not only of the junior doctor workforce, but the trust itself. It is important to make sure that person gets that degree of buy-in from both sides, and I hope that the final solution we arrive at will satisfy that.

[Ben Gummer]

There has been a problem for decades with whistleblowers being listened to. That is what gave rise in part to the tragedy at Mid Staffs and the Secretary of State is trying desperately to do something about it. He cares passionately about it and his recent speech, which the hon. Member for Lewisham East (Heidi Alexander) welcomed, was about trying to create those safe spaces within trusts so that people feel they can speak openly. Indeed, recently at the social partnership forum, which I chair and where we hear contributions from trade unions, I heard of a very effective scheme recently developed in Somerset which showed a good way of getting people of all grades in a trust able to speak up.

I, too, am delighted that the hon. Member for Bristol West (Thangam Debbonaire) has been able to take her seat again. She has come back at an exciting time in politics—one that may be more exciting for her than the last six months. She asked about the funding for seven-day services. All I would say is that within the five-year forward view are two parts that are connected. The first is the commitment to have seven-day services in urgent and emergency care, which is reflected in our mandate for the service, our manifesto pledge at the last election and the request for £8 billion of cash funding connected with the £22 billion of efficiency savings in the service. That is the funding that is being provided to achieve not only that commitment, but everything else in the five-year forward view. Hon. Members have questioned whether that money is sufficient and I point them to the statement by NHS England today in which it was very clear that that is the amount that was asked for and that is the amount that they were glad to get.

The hon. Member for Central Ayrshire spoke about the opt-out, and I want to give clarification for the record to ensure that we are clear about it. In parts of the emergency care pathway, the opt-out has an effective impact and indeed affects part of the urgent care pathway. Ensuring the opt-out is removed is one of the areas we are keen to progress and was the origin of the Secretary of State’s statement, which related to that and not to junior doctors at the beginning of this process. It is important that we do that specifically around urgent and emergency care, and other hospital services, but we have never, ever wanted to extend by the process of our negotiations elective care at weekends. That is not part of our commitment, which has always been squarely about ensuring consistency of standards in urgent and emergency care.

[Dr Whitford]

I am afraid that I have sat in the House and listened to the Secretary of State talking about having elective services across seven days and how great that would be for patients. Of course it would be great, but we would need thousands more doctors whom we have absolutely no chance of finding. It has not been clear. In Salford Royal today, Sir David Dalton again said one crucial thing is for the Government to define exactly what they mean by seven days. Doctors have not objected to strengthening urgent and emergency care.

[Ben Gummer]

The hon. Lady, in repeating that, as have other hon. Members, makes it harder for us to state again—she knows I have done so on numerous occasions—that this is to do with urgent and emergency care. It is true that some hospitals—Salford Royal is one—do elective work at weekends. I have no doubt her hospital might do some elective work at weekends. That is part of the trust’s decision-making. It is for the hospital to make that decision. Our key in changing these contracts has been to concentrate on urgent and emergency care. That is the focus of the contract changes.

The hon. Lady also spoke about the tenor of the language that has been used and I know that she cares deeply about this, for understandable reasons. I, too, enormously regret the way this has been portrayed. Although to a lesser degree than the Secretary of State, I have been on the other end of language that one would hope professional doctors would not wish to use.

The whole debate has become intemperate in an extremely unfortunate way, but I have sat through every single speech that the Secretary of State has made on this matter and every single press utterance—I have also made a number myself—and never once has he attacked junior doctors as a body. He has only the utmost respect for them, not least because, like everyone else in this Chamber, he has been the beneficiary of their care. But it is true that they have been let down by their trade union.

I repeat—I know that the Opposition Front Benchers know this—that the BMA has let down its members, because first, it has allowed a series of statements to persist that it knows to be untrue, and secondly, the junior doctors committee has not engaged in meaningful negotiations in the way that it should have done and in the way that other parts of the BMA have been happy to do, and they have concluded better contracts as a result.

That brings me to the points that the shadow Minister, the hon. Member for Ellesmere Port and Neston, made. He asked quite a lot of questions, and I commit to giving a full answer later to the ones that I do not answer today.

The hon. Gentleman asks whether there will be any further steps to avoid industrial action. We will do whatever we can to ensure that junior doctors understand the nature of the contract, and we hope that they will therefore not feel the need to go on strike. We have contended all the way through that that is a needless endangering of patient safety. It is certainly a massive inconvenience to patients, many thousands of whom have now seen their operations cancelled as a result. The contract dispute does not have anything to do with safety, as the BMA itself has implicitly accepted. It is to do with Saturday pay rates. The BMA and its members really have to think about whether they wish to take the dispute about Saturday pay on to the street time and time again.

The hon. Gentleman asked whether there has been a risk assessment on patient safety. We have risk-assessed that at every single stage, and the way in which we have dealt with the industrial action has been concentrated solely on the effect that it has on patient safety, but the best way of ensuring patient safety is for the BMA to cease its unnecessary action.

In relation to an assessment of recruitment and retention, the whole contract has been framed to try to ensure that doctors have a better work-life balance. That is precisely why we have reduced the number of consecutive long days, consecutive long nights and consecutive weekends, and it is why the contract is better for junior doctors and why we hope that it will aid recruitment and retention in the long term. However, we are conscious of the fact that there are ongoing morale issues that go all the way back to 1999 and beyond. In fact, when the previous contract was negotiated, precisely the same points were made about morale as are being made now, so clearly the old contract did not fix those issues. That is why we have asked Professor Dame Sue Bailey to look at wider issues of training and morale in the service as they pertain to junior doctors, to see what else needs to be done to ensure that they are getting the training opportunities that they require, the welfare standards that they expect and the quality of work-life balance that they rightly wish to have.

The hon. Gentleman asked about the BMA’s proposal that it claimed was cost-neutral. Our judgment was that it was not cost-neutral, and given that the BMA was refusing to negotiate on the contract that was on the table and had been worked on for several years, it was rather odd—and, one might think, a political gesture—to throw an entirely new idea on to the table, knowing it not to be cost-neutral. I would say that that was more for effect than to actually try to further the aims with which everyone approached the contract renegotiation.

In short, I am afraid that I reject the premise of the petition, because the Secretary of State has attempted at every stage in the process, over a period of nearly three years, to have meaningful contract negotiations with the BMA. At every point at which contract negotiations have broken down, it has been the instigator of that breakdown, so the petition would better serve itself by being addressed to the junior doctors committee of the British Medical Association, which has broken off meaningful contract negotiations not just once but three times. It is with that committee that the responsibility lies for the failure to find a solution to the final 10% of the contract negotiation, as Sir David Dalton concluded.