It’s been a busy couple of weeks on the healthcare news front. Industrial action continues apace, with junior doctors declaring a further five-day strike in mid-July and hospital consultants voting for strike action shortly thereafter. In the Guardian on Thursday, Professor Philip Banfield of the BMA exults that all English doctors could be taking strike action before the next election. Banfield states this is precisely the BMA’s intention.
That the BMA is inciting politically motivated strikes is no surprise – the union has been run by Left-wing agitators for many years. The main bone of contention is ostensibly financial – the BMA demand a 35% increase in basic pay across the board for all grades of hospital doctor. The cost to the taxpayer of such a demand is hotly debated. Estimates for full settlement of the junior doctors’ pay claim range from between £1 billion per year (BMA) to double that amount (HMG). The cost of the consultant pay demand would be substantially more expensive. Assuming a reasonable mid-point estimate, the BMA is probably demanding an extra £4 billion per year in taxpayer’s money.
Closer inspection suggests all may not quite be what it seems on the barricades. For example, the nursing union failed to secure a mandate for further strikes, and the junior doctors’ action may also be wavering. During the last juniors strike, some hospitals reported 70% of their trainees turned up for work. It is important to remind readers that the term ‘junior doctor’ covers a wide spectrum of medical practitioner – from the newly minted F1 houseman fresh out of medical school in his or her early 20s, to the senior registrar in his or her mid- to early 30s, with 10 or more years of hard work invested in their careers. Many older trainees with family commitments can’t afford to strike, nor have their valuable training time reduced by industrial action.
My understanding of the current situation is that more experienced medical trainees are either reporting for work as normal on strike days or making money by doing extra shifts to cover absences of their younger colleagues – at pay rates of up to £269 per hour.
The strike is still disruptive as a lot of routine work has to be cancelled. On the other hand, it is a manageable situation as the die-hard militants are mostly drawn from the younger group of juniors – the equivalent of medical toddlers. This cohort are easily replaceable by more mature practitioners for short periods of time.
A consultant strike could be a different beast. Consultants are fully trained and accredited specialists – in short, no clinical work can happen without a consultant assigned to supervise it. Yet again, there is more to this action than meets the eye.
The union publicly exhorted members to vote for strike action, even if the individual had no intention of striking, in order to ‘send a message to the Government’. The proposed consultants action involves providing ‘Christmas day’ cover – in other words a full emergency service but no elective work. This is a strike deliberately intended to disrupt efforts to reduce waiting times for patients. It remains to be seen how many consultants will actually turn up for work as usual, despite the strike vote. That said, even if a surgeon arrives for a planned operating list on a strike day, the list still can’t proceed if the anaesthetist is on strike.
I think it helpful at this point to explain just how consultant specialists are paid. There has been a good deal of argument in the deadwood press as to the precise amount consultants earn, with every claim and counterclaim subject to traditional accusations of ‘misinformation’ and subject to contentious ‘fact checks’ by BMA agitators. Having spent 20 years as a consultant, I can shed light on this byzantine system for readers with the stamina to stick with the detail – you certainly won’t read this information anywhere in the mainstream media. The remuneration system goes some way to explaining the productivity conundrum – why NHS productivity continues to fall, and the system continues to underperform despite more money being spent and more doctors recruited.
Consultant time is remunerated per ‘programmed activity’ of four hours – abbreviated to PA. Hence a 40-hour working week constitutes a 10 PA job plan. The basic salary rates quoted by the BMA are on a sliding scale from £88,000 for a newly qualified consultant to £128,000 at the top of the scale. There are several important points to note when interpreting what the BMA says. The first is that not all new consultants start on the lowest salary point – those with post-fellowship qualifications may start several points up the scale. The second point is that this is an upwards-only increment – in other words, progression up the scale is related purely to time in the job. There is no requirement to achieve certain milestones, or hit productivity targets – simply keeping breathing and not getting fired is sufficient to get a pensionable salary increment, before any nationally agreed pay increase is added. Given that it is virtually impossible to be fired as a doctor, pay progression is assured.
The figures quoted do not include various add-on supplements. For example, there is an extra pay award for intensity of on-call, for London weighting and for extra duties such as managerial roles. Consultants can also apply for ‘clinical excellence points’ which accumulate and can make a substantial contribution to take-home pay. Doctors taking on extra work can be awarded extra PAs – in my time working for the NHS it was not unusual for some colleagues to be on 13 PAs, effectively enhancing their base salary by 30%.
The definition of a programmed activity is open to negotiation in the yearly job planning process. About 25% of a doctor’s time is allotted to ‘supporting activities’ – teaching, audit, participation in mandatory training and various other administrative tasks. Even PAs for direct clinical care of patients can be modified to include time taken on writing letters, travelling between hospital sites and a multitude of other tasks not involving patient contact time.
Annual leave allowances are generous. The BMA states that consultants are entitled to six weeks paid annual leave per year. Again, in fact the allowance is more than stated. Once bank holidays and various other entitlements are considered, most hospital consultants get between seven and eight paid weeks of holiday per year. In addition there are 10 days per year of paid study leave or professional leave to attend courses and conferences. Doctors involved in national bodies such as the many Royal Colleges, professional associations or in academic practice can negotiate much more paid leave than this. It is not uncommon for some NHS consultants to be absent on paid leave for nine or 10 weeks of the year.
Contrast this system with remuneration in private practice. In the private sector a doctor is only paid for directly relevant clinical services. Doctors are not paid for all the necessary administrative tasks involved in running a practice. There is no paid leave of any kind – no holiday pay, no sick pay and no study leave. Nor are there any pension entitlements. Financial incentives in private practice are aligned to encourage direct clinical contact. In the NHS it is the other way around.
NHS consultants can also be remunerated (in addition to their base salaries) by taking on extracurricular activities for NHS England or other national bodies. Consulting work for the pharmaceutical industry or medical device companies is commonplace. Some consultants earn significant extra money by writing medical reports for the legal system.
And then there is private practice. It is important to state that a minority of NHS consultants do a large amount of private work. Nevertheless, the nature of job planning usually leaves at least a whole day a week free for private practice, plus evenings and weekends. A moderately industrious doctor in a reasonably affluent part of the country should be able to clear £80,000-£100,000 per year net of expenses from private practice without too much extra effort.
The NHS itself also provides opportunities for additional income by laying on extra clinical sessions outside agreed job plans to reduce waiting lists – simply put, if patients cannot be treated during normal paid working hours, the NHS will pay consultants extra to treat them in the evenings and at weekends to meet political targets. Several enterprising companies have started highly lucrative ‘insourcing’ ventures – where NHS staff use NHS facilities outside normal working hours to treat NHS long waiters. NHS managers look kindly on these companies, because the ‘optics’ are preferable to passing over large numbers of long waiting patients to private hospitals for treatment – if patients are being treated in NHS facilities, it looks like the NHS is managing the process by itself, even if a private company is actually involved.
And then there is the pension. It is certainly the case that NHS pension entitlements reduced when the 1995 final salary scheme was changed to the 2015 career average scheme, but benefits are far better than anything available in the private sector. For example, higher earning consultants pay 13.5% of their pay into a pension (with tax relief), but the employer pays in an additional 20.5%. This is the reason why there was such squealing about the pension lifetime allowance and reduction in tax relief on contributions. But pensions are just a mechanism for deferred payment and need to be considered when assessing overall remuneration levels.
Many consultants approaching retirement have substantial benefits in the 1995 scheme – inflation linked to final salary with a normal pension age of 60. Such schemes are no longer available in private industry, for a very good reason – they are too expensive to run. But, if one’s employer is the British taxpayer, no scheme is too expensive for the BMA.
Finally, consider this. A high proportion of NHS consultants are married to other NHS consultants or to GPs. I can’t find any statistics on this point, but in my own social network I estimate that over 50% of my peers are married to other medical professionals. That’s two sets of taxpayer funded salaries and pensions per household. I’m not claiming such couples don’t deserve their financial compensation – medicine is a highly demanding and stressful occupation which carries a significant personal cost for many practitioners and doctors work hard for their money. Even allowing for my obvious bias, I doubt many people would push back too strongly on that point. However, a demand for a 35% increase in salary by the BMA is surely unjustifiable when taxes are already at a 70-year high and many working people are struggling to make ends meet. I entirely agree with Banfield that many senior doctors are highly stressed and angry. My perception, however, is that discontent about pay is secondary to dissatisfaction with the coercive NHS system, intimidatory professional regulation and intense organisational friction. I may examine those points in more detail in future.
The British Medical Association would do the nation a service if it focused its effort on enhancing NHS productivity. Unfortunately, the union prefers politically-motivated industrial action intended to facilitate the election of a malleable socialist Government. Prepare for more boondoggles masquerading as patient care in our wonderful NHS, which remains of course, the envy of the world.
The author, the Daily Sceptic’s in-house doctor, is a former NHS consultant now in private practice.