It might be a new year, but on the healthcare beat it is very much back to business as usual. Which, to be clear actually means lack of business as usual, due to an upcoming six-day junior doctors strike, following on from the three-day strike in Christmas week.
In an odd way I have to admire the cynicism of the Junior Doctor leadership. Pulling emergency cover from the NHS during the traditional winter permacrisis was bound to attract criticism, but scheduling the walkout over the festive period will probably increase strike cohesion. I had suspected that support for the BMA might have been waning, but the prospect of taking an extended Christmas break, perhaps getting a few days of Yuletide skiing while someone else attends to the sick and injured is probably quite hard to resist for many junior colleagues.
Cue choreographed squawking from various quarters. On the one hand tedious talking heads from NHS high command predicting imminent catastrophe, on the other the disingenuous BMA claiming noble doctors are striking to save our beloved NHS from decades of underinvestment by the evil Tory government. Yawn – déjà vu all over again.
And there in fact is the point. A couple of years ago, the concept of a group of doctors refusing to staff on call rotas for the sole national provider of emergency healthcare would have been unthinkable. Now it is commonplace. The Rubicon has been crossed on so many occasions that it is quite possible we have a ‘new normal’ and that our current cohort of young doctors will regard these tactics as legitimate methods of extracting more money from the taxpayer – to use contemporary parlance, we are witnessing the ‘weaponisation of patient harm’. It is important to appreciate that not all ‘junior doctors’ are acting like militant train drivers. The term ‘junior doctor’ covers a wide spectrum of medical professional from a recently qualified graduate to a trainee with 10 years of more of sustained effort and experience. It is hard to say precisely how many junior trainees are participating in the strike, because the figures are not readily available, but anecdotal reports suggest up to 50% are refusing to turn up for duty.
Regular readers will know my inbuilt scepticism about shroud-waving by NHS senior leadership, but on this occasion, I fear the shrouds are real – there is mounting evidence that significant harm is occurring to patients, over and above the legacy of lockdown.
How has it come to this? The arguments on either side have been rehearsed at length in the mainstream media, with customary distortions on either side. From reading and listening to various opinions a few points emerge.
It’s inconceivable the BMA Junior Doctors committee are unaware of the consequences of this strike for patients and their senior colleagues. The inescapable implication is that the JDC believe behaving in a manner known to cause harm to the sick is a reasonable way for doctors to conduct themselves. This is a radical departure from previous generations of medical professionals. If that is the case, there is little to prevent the current crop of young medical graduates from employing the same methods in the future, even when they have completed postgraduate training and become consultants or GPs.
Their rationale for such action is that short term harm to some patients is justifiable to prevent greater long-term harm to many more, and that giving doctors a 35% pay rise will prevent harms in the future. Further, that the refusal of the Government to accede to their demands in full ‘forces’ the doctors to go on strike. They have no alternative; they didn’t want to hurt the public, but the evil Tories forced them to.
That line is a tough sell, particularly when one considers the latest available data about medical working practices.
For example, the General Medical Council has produced a recent report on the matter.
It will come as no surprise to regular readers to discover that the U.K. medical workforce trends continue to feature more female doctors, more international medical graduates and more part-time working by doctors. Readers will be pleased to read that the chair of the GMC celebrates the fact that the medical workforce continues to be “more diverse” and that is “undeniably a positive thing”. Well, that may be her opinion, but from my perspective I would prefer a workforce that put in a full shift, irrespective of gender and ethnicity balance. The fixed costs of training a doctor are the same whether the graduate works full- or part- time – more part-timers mean a proportionate loss of training costs and associated reduction in productivity.
In 2022, the GMC calculates that 61% of the workforce were home grown medical graduates with 8% from the EEA and 31% from other countries. Interestingly, the proportion of European graduates was 9% in 2015, so it is hard to spot a significant ‘Brexit effect’ at this time. Furthermore, even with the putative increase in U.K. medical school places, the GMC estimates that the percentage of foreign medical graduates required will increase to 42% by 2027.
The NHS-oriented think tank The Kings Fund conducted its own survey of working intentions of junior doctors training to become GPs. In this survey 41% of respondents indicated that they intended to work five or six sessions per week (20 to 24 hrs) once they had been fully trained. Perhaps that’s why they want a 35% pay rise – almost the same money for half the workload.
Of even more interest is a report from the Institute for Fiscal Studies about part time working by Hospital Consultants in the NHS.
In 2012, 15.6% of consultants worked less than full-time in the NHS, but by 2021 this had risen to 21.6%.
These headline figures conceal important differences between female and male consultants. In summary, one in three female consultants aged under 60 work “less than full-time” compared to one in 10 males. Unsurprisingly, this is because female consultants tend to work full-time until they have children, then go back to work part-time (Lachish et al. ‘Human Resources for Health’ (2016) 14:62).
Extraordinary finding. Who knew?
There is a lot in this report, and I encourage readers to explore it for themselves. One missing point is a comment about the gender demographics of consultants by age cohort. Simply put, the older cohorts of consultants have a male preponderance. My conclusion is that as older males retire from the NHS, the overall proportion of part-time consultants will rise. I should stress to readers that these findings relate to the hospital specialist workforce – the part-time issue in general practice has been documented on multiple occasions and is a well-known issue dating back many years.
It is not immediately clear to me how paying junior doctors 35% more fixes any of these problems. Nor is it obvious how this dispute will end. Even the Guardian appears to be running out of patience with the juniors, describing their action as “an unapologetic V sign” to the Government; contrasting it unfavourably with the consultant cohort’s pragmatism in agreeing a deal which, subject to an upcoming ballot should resolve their dispute.
For once, I find it difficult to argue with a Guardian columnist. Strange times indeed. Happy New Year.
The author, the Daily Sceptic’s in-house doctor, is a former NHS consultant now in private practice.
Stop Press: The Mail reports that the NHS bosses running the 11 trusts with the longest referral waiting times – where the average delay for treatment is more than a year – all earn more than the Prime Minister (who’s on around £160,000), some up to £300,000 a year.
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