This week the death of Nigel Lawson was announced. Readers may be aware that Margaret Thatcher’s prominent Chancellor famously compared the NHS to a “national religion”. The second part of his observation is more rarely quoted – to the effect that those who work within the NHS system regard themselves as a kind of priesthood.
Lawson’s remarks were rarely so appropriate. The week following his death will see four days of consecutive strike action by junior doctors, accompanied by familiar incantations about how they are withdrawing their labour to save the NHS. The demand for a 35% pay rise is of course necessary to protect the system from the evil Tory Government and the privatisation agenda. Should readers wish to access any more of this propagandised pap, they are welcome to read the mainstream media. Here at the Daily Sceptic, we aim to provide more substantial analysis and to discuss the real issues behind the news – commentary which in polite society would certainly be characterised as ‘wrongthink’.
Many professional groups gripe about pay and conditions – disagreements between doctors and the state are by no means new. Doctors have taken industrial action of varying intensity on several occasions before, most recently in the junior doctors strike of 2016. The British Medical Association (the doctors trade union) has a longstanding tradition of opposing virtually every government policy, often in the interests of enhancing professional remuneration. So far, so normal.
On this occasion, however, I do think the current militancy represents something of a sea change in medical behaviour. This is a consequence of various structural changes in medical workforce matters over the past decade. It is important for readers to appreciate that the term ‘junior doctor’ covers a wide spectrum of practitioner, ranging from very recent medical graduates in their early twenties to senior trainees in their mid-thirties. In fact, the term itself is outdated and a better descriptor would probably be ‘doctors in training’ or similar. More senior trainees often have a different perspective than their younger colleagues. It is striking (excuse the pun) that the current junior doctor leadership seems to be drawn from the more inexperienced section of the junior doctor community.
The strike next week is the second round of the dispute. The first strike in March was unprecedented, in that junior doctors absented themselves from emergency cover for an entire 72-hour period. Readers may not appreciate what a big deal that is – to spell it out, the striking doctors refused to staff emergency rotas. This action left patients arriving to A&E departments with acute heart attacks, diabetic crises, strokes, car crash injuries and the like, with zero medical care. They also withdrew ward cover, so patients in hospital unfortunate enough to develop post-operative complications had no doctors to look after them. That’s apparently what it takes to save the NHS.
In actual fact, the first strike turned out to be a bit of a damp squib. Hospitals managed quite effectively to reallocate consultant level doctors to cover emergency and ward work. Paradoxically, emergency care pathways were more efficient than usual, as senior decision makers processed patients much faster than trainee doctors. This of course came at the cost of cancelling the vast majority of routine outpatient appointments and operative procedures – adding still further to the legacy of lockdown.
Managing the second round of strikes might not be so easy. The second round has been deliberately timed for after the Easter weekend, when a lot of consultants will be away on leave. In effect, the strike leadership is ensuring that there will be no routine work carried out in the NHS for a 10-day period. Major operations can’t be undertaken if there is doubt about the provision of 24/7 medical care, so no significant procedures can be done safely in the days leading up to the strike action. It is notable that senior hospital managers have been encouraging consultants to engage with the press emphasising the risk to patients – normally managers hate doctors talking to the press, but in this case there seems to be an intention to undermine the strike. It is unlikely that round two will be the end of this dispute and further escalation is quite possible. It is inconceivable that these young doctors are unaware of the effect their action will have on patient care. It is highly likely that some patients will be harmed as a result of this strike and some may well die as a direct consequence of industrial action – this is several orders of magnitude more significant than not being able to get on a train for a few days.
Readers may very well be wondering how it has come to this. Until recent times, a doctors strike would have been inconceivable. Of course, the charge is often levelled that older clinicians tediously harp on about how much better things were in the ‘olden days’. For clarity I should state that things were not better, but they were certainly different. As this dispute is ostensibly about money and conditions, readers may be interested in a comparison of junior doctors’ pay rates in the late 1980s with the modern-day equivalent.
Until a decade ago, hospital-level care was delivered by small teams of doctors, called ‘firms’. A typical firm comprised one or two consultants, a senior trainee and two or three other juniors. Being on a good firm was hard work but great fun. Patients got an excellent deal from the ‘firm’ structure, because it provided continuity of care – the same doctors looking after the patient throughout their time in hospital and afterwards in outpatients. Payment for medical time was split into four-hour blocks known as a UMT (unit of medical time) – so the standard 40 hour week comprised 10 UMT’s, paid at a basic rate. Junior doctors then had compulsory ‘on call’ UMTs – the standard for a one-in-three on call rota was 13 additional UMT’s. These were paid at 30% of the standard rate – please note, that is 30% of standard, not 130%. Junior doctors on call were the lowest paid workers in the hospital, with an hourly rate of pay less than that of the cleaners – far lower than the current remuneration. On the upside, the work was so intense and the hours so long that junior doctors were provided with hospital accommodation free of charge. Work life balance was perfect, because work and life were the same thing.
The reason I point this out is that low hourly pay rates for junior doctors is not news. Nor is it a secret. It cannot come as a surprise to any newly qualified doctor that the pay in the early years of medical practice is not great. About 15 years ago, the structure of junior doctor terms and conditions changed substantially. The ‘firm’ structure was abolished and on-call rotas were changed to shift patterns. The driving force behind this change was the assertion that long hours were dangerous for patients and damaging to doctors. There was some truth in this view – mistakes were made by tired junior doctors, myself included. Unfortunately, the cure turned out to be worse than the problem.
Loss of the firm structure demolished continuity of care and made the whole process of looking after patients very inefficient. The complicated shift systems proved unwieldy, inflexible and very unpopular with juniors. Not surprisingly, junior doctors remained unhappy with their pay and conditions – they were doing far fewer hours work than their predecessors and therefore lost free accommodation. Total pay reduced (because of a lower on-call commitment) and workforce surveys revealed far lower levels of job satisfaction than under the old regime. The numbers of doctors in training increased substantially, but their pay fell in real terms, because each individual was doing less work. Needless to say, this was entirely predictable and indeed was predicted at the time the changes were proposed.
Discontent with shift-working and its remuneration formed the basis of the 2016 strike, which ended in a comprehensive defeat for the doctors. A face-saving, window-dressing compromise was agreed which failed to address any of the real grievances. The current dispute in many ways is continuity 2016, driven by a more militant and explicitly Left-wing cadre of political activists.
It is often trumpeted by the BMA that as a consequence of poor remuneration, U.K.-trained doctors are leaving for jobs in Australia. Ironically, the doctors union fails to ask why Australian doctors have a much better deal than their British counterparts working in the socialist utopia of the NHS. Might it be because the Australians have a mixed health economy, where hospital systems are competing for a finite medical workforce and therefore provide better terms and conditions? Isn’t this the same mixed economy model that the BMA regards as unsuitable for the U.K.? There must be a fair amount of cognitive dissonance going on in BMA House – but then the doctors’ union is adept at that and the wilful blindness that goes with it.
I think the real cause of the juniors strike actually lies in disappointed aspirations. Indoctrinated medical graduates have been led to believe that possession of a medical degree guarantees membership of the NHS ‘nomenklatura’. The reality is that doctors are simply part of the lumpen proletariat, with little influence or bargaining power. The likely resolution of this dispute is hard to predict at the moment. A lot will depend on how cohesive the strike is as the dispute escalates. The BMA junior committee has started with a very intense and prolonged industrial action. The Government will not give in easily, so the expectation must be that the strike committee will raise the ante. As walkouts become more prolonged, it is quite possible that their members may return to work, concerned about loss of pay and the effect on patients. More senior trainee doctors may worry about the effect on their training and future career prospects. It is not inconceivable that the vanguard of the proletariat could yet end up marching on its own.
The author, the Daily Sceptic‘s in-house doctor, is a former NHS consultant now in private practice.