Doctors who are parents are contemplating having to leave medicine after the government's own review of its new junior doctors contract said it could be particularly punishing for those with childcare responsibilities.
The new contract, which aims to make it easier for hospitals to schedule doctors to work across seven days, will see most working more evenings and weekends, when childcare is the most expensive and least accessible.
While most doctors already work during these times, they currently receive an elevated rate of pay for work undertaken during "antisocial" hours, but the number of hours eligible for premium pay will be reduced under the new contract. In addition, changes to pay progression will mean it will take longer for doctors working part-time to get pay rises.
More than half of junior doctors are women, and women make up an even greater proportion of those working part-time. The majority of female junior doctors working part-time do so because of childcare responsibilities, so many women will be facing a bigger childcare bill on a smaller pay cheque under the new contract.
The government is offering a 13.5% increase to basic pay to make up for this shortfall, but many doctors, especially those working part-time, are concerned that they will still see their pay reduced.
An equality impact assessment of the new contract conducted by the Department of Health acknowledged that women working part-time would be "advantaged less than other doctors under the new pay structure", a fact that would particularly "disadvantage lone parents (who are disproportionately female) due to the increased cost of paid childcare in the evenings and weekend".
The assessment concluded, however, that "any indirect adverse effect on women is a proportionate means of achieving a legitimate aim".
What do junior doctors who are parents think about all the changes? BuzzFeed News spoke to some to find out:
"I haven’t quite got my head around how I'm going to manage – I’m still considering my options," Dr Lauren Robson, a junior doctor and single mother based in Yorkshire told BuzzFeed News.
As a second-year trainee currently working part-time on a GP rotation, she is able to coordinate her shifts around school-based childcare for her 6-year-old daughter by working within daytime weekday hours at a cost of around £50 per week.
Working only within those hours means she does not get the premium "antisocial" hours pay, but she finds this arrangement "just about" viable.
"We're not destitute, but we only just manage – we don't have disposable money," Robson told us.
But the new contract will force her to work evenings and weekends, meaning she will need to find more flexible, more expensive childcare. "What am I going to do – have someone come to my house and put my daughter to bed?" she said. "And who is that person going to be? I just can't work it out."
A full-time doctor at Robson's level earns a basic salary around £28,000 per year under the current contract; even with the 13.5% increase promised by the government, it's unlikely she will be in the financial position to employ a nanny, typical salaries for whom range from £12,000 to £23,000.
Family support is not an easy option either. "My dad is 65 and he's still working six days a week – how's he going to help me with childcare too?"
Instead, she said, she was "desperately trying to think of ideas" of what else to do with her degree, considering perhaps going into medical law.
"I graduated in the top 20% of my year at university," she said, "and I've always been really ambitious and done really well, and now I'm faced with the prospect of perhaps not having enough money to cover my childcare in order to do my job."
Dr Sam Gujral, a plastic surgery trainee in Exeter and father of one, told us the new contract also presented problems for parents who live apart from their children.
Gujral's 22-month-old son lives with the child's mother in St Austell, Cornwall, while Gujral works as a plastic surgery trainee in Exeter, an hour and a half away. His specialty means he is often on call throughout the night and at weekends.
"If I get called in when my son is with me, which is every other weekend and, rota permitting, one day in the week, I need to someone to look after him," Gujral said. With no partner or family nearby, Gujral has to "pay for every second of childcare, and if I get paid less [for 'antisocial' hours] I won't be able to afford that kind of childcare".
He too was considering whether this would ultimately make leaving medicine a more viable option. "If I couldn't balance family life with work, I would choose family," he said.
Junior doctors with partners who are also junior doctors – a common occurrence in medicine – have said finding childcare as both parties work an increased number of out-of-hours shifts will be a struggle.
Dr Dagan Lonsdale, an intensive care registrar training at St George's hospital in London, told us he and his wife – also a junior doctor – are currently able to arrange their rotas so they can alternately care for their 3-year-old son.
"We just about manage it is because my wife works part-time, but it does mean we go through periods where we don't see each other," he said.
But Lonsdale said the inevitability of them both facing more evenings and weekend work under the new contract will create rota clashes. Coupled with changes to their pay, he felt the only viable option would be one of them leaving medicine.
"There is no easy childcare option for us after 6pm, other than to have a live-in nanny, but we can't afford that that kind of arrangement, and we aren't able to rely on family," he said.
Dr Robin Chung, a London-based cardiology registrar and father of two who is married to an NHS matron, had a similar story.
He and his wife pay around £1,400 per month for the care of their children, one of whom is disabled, and expect their bill to increase under the new contract, he told us.
"If my wife has to work 1 in 4 weekends or weekend night shifts, and I end up working nights on call, then either we only get one weekend together as a family or we have to find 24- to 48-hour childcare," he said. "How is that practical or affordable?"
Leaving the children with other family members was also not an option for Chung. "My mother lives abroad and my mother-in-law lives in the West Country, three hours away," he said. "They are both over 75 years old and even if they lived nearby, looking after two young children would be unfeasible."
Dr Robin Chung and family
The Department of Health has said the new contract will actually help promote a better work-life balance, because doctors will be asked to work fewer hours.
But without investment in expanding the workforce, many believe this aim will be impossible.
"The fact that they're going to move a five-day workforce into seven days with the same number of doctors means that people working five days will be under more pressure and will have less resource," Gujral said.
Lonsdale agreed. "The only way a seven-day NHS can be achieved quickly is to stretch the workforce and make the workforce cheaper," he said. "The current contract has no problem about servicing a seven-day NHS – it just doesn't have enough doctors to do it."
Both felt the solution to getting more shifts covered while also allowing doctors with children to manage their work around family commitments was simply to employ more doctors.
Instead the NHS faces a potential exodus of doctors unable to affordably juggle their work with childcare – and the majority of those facing a possible career change will be women.
"It won't be long before this profession becomes untenable for women with children," Robson told us.
"You'll find women going on maternity leave and simply not coming back, because it's not viable on the salary we have.
"What are we left with then?"
Laura Silver is a reporter for BuzzFeed News and is based in London.
Contact Laura Silver at firstname.lastname@example.org.
Got a confidential tip? Submit it here.