As seems to be the case with virtually everything these days – Covid, the cost of living, the Ukraine war – the junior doctors’ strike has given rise to a lot of discussion about the wrong things, in the wrong way.
To date, the focus has been on three big issues:
- The demand for a 35% pay rise
- A concurrent four-day strike period, directly after a bank holiday weekend
- The woke politics of the leaders of the junior doctors, in particular Dr. Rob Laurenson
All of this is understandable. A rise of 35% sounds like a lot (and it is); a four-day strike is hugely disruptive; and Laurenson seems almost a comic stereotype of a hard-left youngster with a very comfortable bourgeois upbringing and woke ideas. He also managed to arrange the strikes while he was away on holiday.
However, I think some context about how the NHS is managing its labour force will be helpful to many readers. This demands we address the tough conundrum of why the NHS is so bad at managing people.
The basic question that the people of the U.K. face in dealing with this issue is: How do we get better quality healthcare and better returns on our money? The structure of the NHS has much to do with answering this.
The envy of the world?
The NHS is the biggest employer in the U.K. In fact, it is practically a monopsonist. That is a fancy way of saying that it employs virtually all of the doctors in the country, in one way or another.
I am a chartered accountant by trade, but my parents and one of my brothers are doctors. I have been amazed by stories of just how wasteful the NHS is in the management of its workforce.
In my analysis, I will refer frequently to a recent piece by Kate Andrews in the Spectator, where she explores what junior doctors really earn. I build on this with my own data and arguments.
Let’s start with some basics. An F2 doctor (basically a doctor with one year’s post-graduation experience) can expect to earn roughly £40,000 gross per year, with uplifts for anti-social hours and London weighting. These uplifts can take that salary up to around £55,000 to £58,000 per annum.
However, an F2 has not decided on what specialism to pursue. In order to become a specialist, the doctor will need to join a training programme, which can take anywhere up to seven years to complete.
The NHS, in its wisdom, offers trainees a salary of £40,000 per annum for doing this. In other words, after a year or two earning around £55,000 a year, you have to take a pay cut in order to advance your career in the long run.
Once you are in that training scheme, your pay will begin to rise over time, but earning much more than £63,000 per annum as a senior registrar (the grade just below consultant) is unusual. That is, after many years of training, far more experience and steadily increasing responsibility, you might see your pay rise by about £8,000.
This goes some way to explaining why so many F2s now defer entering training – often by many years. The numbers doing so have risen from about 30% in 2010 to over 65% in 2019 (the latest year for which figures are available).
Then there is the locum issue. Locum rates vary hugely across the U.K. Locums working in the sticks (e.g. rural hospitals or the outer reaches of Northern Ireland) can earn £90,000 per annum putting in a normal working week, even in the most junior roles. Moreover, you are offered the best shifts. The nasty hours go to the full-time employees, at whatever grade.
Some locum roles offer as much as £80 per hour for an F2-equivalent role – that is £160,000 per annum.
On top of paying the locums these rates, the NHS also pays substantial fees to the locum agencies. Including agency fees for nurses (which will account for the bulk of this), these fees recently came to £3 billion per annum – just for finding the staff the NHS needs.
Andrews talks about the absence of a market rate for junior doctors, because the NHS is basically the sole employer in the U.K. However, this needs more analysis.
Firstly, NHS managers have created a much higher market rate within the U.K. by way of the locum roles. Secondly, they have created a higher market rate for F2+ roles (repeated taking up of F2 roles by doctors who theoretically have gone past that stage) than for specialist training roles. Thirdly, consider the mere existence of other countries – notably Australia – which pay better for less onerous roles. This means there is a higher market rate than the NHS is offering to doctors who would follow the conventional route of F2 followed immediately by specialist training. This is financially not a very smart move.
No one, as far as I can see, has addressed this. But junior doctors are human beings, and they will behave accordingly. As Charlie Munger, Warren Buffett’s less famous sidekick, says, “Show me the incentive and I’ll show you the outcome.” The mess the NHS has made of its medical labour force is living proof of this.
NHS or America?
In any discussion of the health service, the debate too often moves to a binary choice between the loving bosom of the NHS and the horrible capitalist mess which is America’s healthcare system.
Too rarely do we discuss how countries such as Australia, Germany, France and the Netherlands, to name a few, handle their healthcare. Those countries don’t seem to indulge in cringeworthy public worship of their socialised medical systems. Nevertheless their health outcomes on many important indicators are better than ours. Some of them spend a little bit more on healthcare as a percentage of GDP than we do; some of them spend a little bit less.
The American model really is bad. It is hugely expensive, terribly wasteful and has exceptionally poor outcomes in terms of population health and overall life expectancy. The U.K. seems to be heading in the same direction, but with a large public system.
Can we learn from other countries? One key thing to establish is whether successful systems distort the medical labour market as much as the NHS does.
Anecdotally, Australia is the Shangri-La for modern medics. Pay is better, conditions are vastly better (more respect, superior management, computer systems which work etc.), and many health outcomes are better than the U.K.
Interestingly, Australia currently spends much the same on healthcare as a percentage of GDP as the U.K. does. And even more interestingly, until they brought in this revised system a decade or so ago, their public medical system was hardly the world beater it is today.
Compared to what?
Andrews’ article refers to “average earnings”. But is being a doctor an average career?
Leaving aside the structural questions of the market for medical earnings, how do we benchmark a career in medicine against other careers? We’d have to start by accounting for things like the amount of education and training; academic demands; levels of responsibility; and nature of the hours demanded. Medicine is at the extreme high end of all of these. It also stands alone if we account for the need to perform some unpleasant and emotionally draining tasks.
This takes us back to incentives. A healthy market has a way of taking all of this into account. People choose careers based on things like aptitude, passion and work ethic. The price of their labour responds, and, in turn, so do their decisions.
By way of a very quick comparison, a newly qualified solicitor working in a commercial firm can expect to earn £100,000 a year, including bonus, even outside London. Doctors know this.
Instead of intelligently working with price signals, the NHS appears to be throwing money at the problem – with very little accountability.
Public sector spending: Wider context
It may come as a surprise to readers that the annual cost of the full 35% pay rise demanded by the doctors comes to £2.1 billion, according to the Government’s own figures. In the context, this sounds like a small number.
It seems strange that the Government has been so tough on this issue, given its gross irresponsibility with public funds elsewhere.
For example, the U.K. spent £2.3 billion on aid to Ukraine last year, and expects to do the same again this year. HS2 is due to cost far in excess of £100 billion for no discernible benefit. Indeed, the plans for platforms at Euston have cost roughly £2 billion already.
The taxpayer pours many billions of pounds into green subsidies of one form or another. Virtually all of this ends up in the pockets of the rich who have invested in the various recipient companies.
And as we know all too well, the country spent roughly £500 billion during the Covid crisis. This sum would cover the cost of the junior doctors’ pay rise for 250 years. Consider just the ‘track and trace’ debacle, which cost the taxpayer roughly £40 billion, or 20 years of the junior doctors’ pay rise.
To me, this raises an important question about what we do and don’t talk about. As we all remember, debate over pandemic spending was suppressed. Even now there is precious little discussion of it.
Our public discussion currently focuses on junior doctors as the enemies of the day. This after lionising them for a couple of years ago while they were on message and backing the ludicrous Covid restrictions.
But if we really want to save money and improve healthcare in the U.K., we should be talking about locum rates, locum agency fees, NHS management costs and economic incentives generally. We aren’t.
Lutatius is a pseudonym.
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‘As he is set to take Collins’s old job as NIH Director, there now is hope for the future. It falls on Jay’s shoulders to restore the integrity of medical and public health research so that it deserves to regain the trust of the public. He is one of the few scientists with both the track record and humility to do that.’
Spot on. If anyone knows of a better summary of the covid debacle, I’d like to see it:
‘It is an epidemic that’s hitting the United States and everyone’s worried about what the death rate is from it. I did some research on the spread of the disease, but I’d been reading the literature on how deadly it was. So the first reports for H1N1 were really high, 4%, 5% mortality. And I noticed in the literature, there were a whole series of serial prevalence studies, studies, essentially, of antibodies and what they was that for every case of H1N1, there were 50, 100 people that had it that they didn’t identify, the public health hadn’t identified.
When I saw the World Health Organization in 2020 say that we have a 3% mortality rate. They were very cagey about what they meant, but I knew what they meant. They meant that three out of 100 people that had been identified with COVID died from it. And they were looking at Chinese data, they were looking at Italian data. And the first thought I had was, well, maybe this is like H1… It’s a respiratory disease, respiratory virus. It spreads very, very easily, obviously. It seems likely that many more people have had it than had been identified. Our testing resources weren’t all that good at the time. So that was what motivated me in that piece was we don’t know the mortality rate ’cause we don’t know how many people actually had been infected. I wanted to know the denominator.
We did one in Los Angeles County and we did one in Santa Clara County, which is where Stanford is. We learned that in both LA County and Santa Clara County, there were 40 or 50 infections per case identified. 40 or 50 per case identified.
The problem is that if you have a situation in mid April, 2020, where 3, 4% of large Metro centers had evidence of the disease already, you know the disease is very, very infectious, that’s a strategy that cannot work. At that point what folks should have realized, including folks like Fauci and the CDC should have realized, is that a strategy to stop the disease from spreading down to zero was not possible.
The typical finding in these seroprevalence studies is that for people that are under the age of 70, there’s a 0.05% mortality risk. So 99.95% survival after infection for people under 70. For people over 70 it’s 5% mortality. So 95% mortality, 95% survival, a huge difference. It essentially changes smoothly with age. So roughly speaking, I’m 53, my infection fatality rate from these studies is something like 0.2%, 99.8% survival if I get infected.
So herd immunity is not a synonym for zero COVID. I think Hancock, I think, that’s the mistake he made there. The other thing about herd immunity with these disease is, it was clear in October of that year of 2020, and even more clear now that if you are infected, you actually gain substantial protection against re-infection. So there was a study that was just released actually recently, but verifies a whole long line of studies. At one year… This is out of Italy. At one year after infection, 0.3% are reinfected.
we sent people in the early days of the epidemic that were infected with COVID back into nursing homes who then infected a large number of vulnerable people, instead of realizing who the vulnerable were and seeking to protect them, that was the scarce resource. We thought hospital beds were a scarce resource. Most parts of the country in March, April 2020 were empty hospital beds.’
Jay Bhattacharya 21 Oct 2021
The indictment is that various experts around the world had correctly identified covid as a novel common cold coronavirus from February 2020 onwards.
But no-one listened to the real experts……and Lady Hallett is not listening now.
Why not?
And another thing…….
Why has it taken U.S. democracy to get us to the point where someone who really knows what they are talking about is appointed to clear up the public health shambles, corruption, when all that the supposedly exemplary British democratic system can do is saddle the taxpayer with a £208m inquiry wandering slowly and expensively down an illusory yellow brick road…..with a bunch of total nincompoops in charge?
Systemic reform is indeed required…….
Interesting question
Americans just seem more right wing than people in other rich world countries
More religious people
Maybe because it’s a younger nation founded on the idea of freedom from tyranny
Also the presidential system allows for an outsider to barge in unlike our parliamentary system
I am not sure about “systemic reform” (whatever that is). We had the chance to reject the Uniparty and most voters didn’t take it. People with views like mine seem to be in a tiny minority here
I don’t think it’s the Americans (in the US), it’s that Europe has been suffocated by the EU infrastructure, along with Establishment Smugness. In the UK, it is shown by the lack of STEM (and Business) expertise in Westminster and Whitehall:
https://conservativehome.com/2020/11/18/luke-tryl-were-failing-to-turn-pure-research-into-new-industries-a-challenge-which-the-government-must-help-to-meet/#comments
And:
How the Deep State Fails Britain:
https://youtu.be/5EK3diXgqbI
Well in the US there was a majority vote against the Establishment
Not in the U.K. or France or Germany- not yet anyway
It is possible that many of those taking part in the Inquiry are behaving in a defensive way, or if you are a real cynic, some might be opportunistic. As many were, selling junk of one kind or another. But despite the negative commentary here yesterday about Jay B’s appointment by Trump, it does seem like a wise move; we’ll see.
If you can keep your head when all about you are loosing theirs and blaming it on you….
Jay Bhattacharya is that man.
…and there you have almost the entire Covid fiasco in a few short paragraphs…. I say almost, because Kulldorff doesn’t touch upon the dreadful amount of politicking, power play, and corruption that also drove the fiasco, almost undoubtedly in every country
Never forget that the contribution to the Covid fiasco of the noble, learned and historic Mother of Parliaments included the immortal wisdom that “a Scotch egg is a proper meal”
That, and a debt of say £400Bn, plus £200m for the utterly pointless whitewash Hallett inquiry
Yet further proof that Trump is racist.
Interesting that almost all of the Indian Subcontinentals chosen by Drumpf worship VISHNU in some form or other, because the AntiChrist is also associated with Vishnu (who is also associated with Metatron).
Such Indians pretend that they worship the Great God Brahma, but shove him into the background while really worshipping the Evil Vishnu and his Evil ally Shiva=Satan, who are both protected by the Hideous Moon Spider “Goddess of All India” called Kali-Allah, the Goddess of Death. Here she is riding a white horse across a Lake of Blood, while seated on a saddle-blanket made from the skin of her own son. Here she is called “Palden Llamo KALI-deva” by the Tibetan Buddhists. Different name, same bug.
Sounds daft, I know, but you will eventually see.
She is the one the Tibetan Buddhist monks ask to choose the next Dalai Lama, believe it or not. Truth is stranger than fiction.
Note the Crescent Moon above her head, and the head of her skinned son dangling below her foot, with his skin spread out beneath her. You can also see his hands on either side, where his skin is tied around the horse as a horse blanket. This is “The Mother Goddess of All India”, who is especially fond of human sacrifices.
Then the Muslims, Hindus, Sikhs, & Buddhists say to the Gullible Christians of the West, “Oh, don’t worry, we worship the same God as you!”
And yet another professional, who really ought to know better, maintaining there was an actual pandemic. These people will go to their graves clinging on to the fallacy there was a chuffing ”pandemic”! Hey, maybe if we obsessively test for flu using the exact same approach as we did with ‘Covid’, we can enjoy pandemics every single year…
Anyway, great work by Martin Victor Sewell here;
”To say that this is a comprehensive review of the COVID literature is an understatement. I commend Martin’s work to you.
A seasonal influenza-like illness became a pandemic of governmental overreach and collective hysteria. Lockdowns turned out to be the greatest health economics mistake in modern history, face masks served no useful purpose in the community, in schools or in healthcare, whilst vaccinations were effective against severe COVID-19 in the elderly in 2021, but ultimately likely did more harm than good.”
https://metatron.substack.com/p/the-effectiveness-of-lockdowns-face
He calls it an epidemic, which it was….in the same sense as, in Britain, we get Influenza Like Illness epidemics on a regular basis.
You could argue that a ‘pandemic’ is an epidemic accompanied by panic.
There certainly was a great deal of unnecessary panic in 2020.
Mr Bhattacharya did a great deal more than almost anyone else to allay that panic.
At least in my humble estimation, he is a living legend.
P.S. Unnecessary fact: Epidemic was a 1991 heavy metal album released by the prescient band ‘Panic’. It included the tracks ‘Blackfeather Snake”, “High Strung”, and “Hypochondriac”.
Why do you keep saying that? You do know the article was written by Kulldorff, and you did see the bit where he says “The only major country which took an evidence-based approach to the pandemic was Sweden”? There is a huge difference between a pandemic and an epidemic, which I’d expect somebody in Kulldorff’s position, and his colleagues, to know. Language is key and you most certainly cannot get away with using these two words interchangeably and expect to maintain any sort of credibility.
There was a ‘casedemic’. Without those fraudulent tests none of it would’ve been possible. Deaths due to government policies and at the hands ( and neglect ) of doctors are what killed people in any greater number than any other flu season.
Also, anybody pro-death jab, such as Ioannidis, most certainly have lost any respect and credibility, as far as I’m concerned. Profs Fenton and Neil have debunked this particular topic many times now. To say these injections saved any lives is pure bunkum.
I made the mistake of assuming that your comment would have been directed at Bhattacharya and the article above.
My apologies.
Hear, hear!
No.
The just ‘reward’ for Fauci would be to have his reputation comprehensively dismantled such that he lives out his meagre few years left in complete disgrace.
And preferably behind bars. He and Bill Gates of Hell could share a cell
I wish I had your confidence that science will prevail in the £200 million UK enquiry.
Delighted to see this appointment as I was to see RFK Jr. Trump is appointing all the right people to roll back the authoritarianism of the last few years. No wonder they tried to kill him
The medical profession will be bereft of integrity for the foreseeable future. Heinous crimes have been committed.
Measures must be put in place that ensure the corruption of Big Pharma, Regulators, Journals, Health organisations, is never allowed to destroy our established ethics and morality again.
Assisted dying bills are extremely dangerous in our broken society.