13 April 2023

The doctors’ strike is about so much more than pay – a lasting solution needs to reflect that


The current junior doctors’ strike is part of a broader drama playing out within the NHS.

It is not just the well-publicised arguments over headline salaries, but the unsociable hours, abuse, night shifts, and a pay system that’s as flexible as a steel girder. Then there is the bureaucracy, support (or lack of it) and inflexibility of career paths. 

First of all the term ‘junior doctor’ is a misnomer. You don’t usually become a ‘senior’ doctor until your early 30s and, for some, closer to 40. And despite their misleading title, junior doctors are often the most senior medical professionals on duty, particularly during night shifts at district general hospitals making life and death decisions. Despite that, they are often paid less than the designers and coders I’ve recruited in my life sciences work.

Nonetheless, medicine remains oversubscribed, even though the applicants presumably know about the pay levels (although many of the current juniors would have applied pre-2010 and the austerity erosion). The strike is, in essence, the doctors’ attempt to harness the power of market forces for their life-saving skills. As the NHS is a monopsony, the only employer in town, there are limited options for doctors to protest. They must either flee the country, abandon their medical aspirations altogether, or strike.

So what is the Government to do? Pay is clearly part of the answer, but there’s a great deal more it could do to make working life more tolerable for doctors and improve outcomes for patients.

Negotiation point 1 – skew the pay rises

One of the things about the NHS is that assuming the same grade (constrained by years of service) and rota, the pay is identical for every job, everywhere. Except for London, where pay is higher, even though the capital is by far the most popular place to work. A post in Dumpsville in the least desirable specialism gets exactly the same pay as the plum job in the plum place.

This offers the first negotiation angle, to offer the biggest pay rises to jobs that juniors rank the lowest in their applications. After all, if market forces were working, you wouldn’t need to pay as much for those places and jobs that are oversubscribed lower pay could be offset by other perks, be they training opportunities, unique experiences or extra-curricular advantages.

Negotiation point 2 – focus on the flexibility of training

As it stands pay does go up with years worked, which largely correlates with experience and responsibility, but that does mean superstars are no longer able to whizz through, and there is significant variation of talent within any one pay band. The formulaic approach to training is designed to assure core standards, but brings with it restrictions and frustrations.

Negotiation point 3 – discuss total package, including pensions

Pay ramps up much more as a consultant, and pensions remain generous, although much less so than previously – the recent pension rule change to discourage consultants from retiring largely applies to those over 55 on the old more generous schemes. Nevertheless, a clearer optic on the total pay package rather than headline salary would be sensible. Most juniors I know don’t know the value of their pension. 

Negotiation point 4 – bring back the firm

This isn’t all about money, it’s also about feeling valued and supported. When I was a junior in the 90s, the hours and conditions were really tough, but a saving grace was that we were part of ‘firms’ – albeit involving more death than the gangster variety. The same group of us, including the consultants, stuck together through thick and thin. The consultants had a sense of ownership, of a duty to mentor their foot soldiers. Then the European Working Time Directive came along, and to make rotas work, the juniors ended up as cogs in a complex machine, themselves fragmented, and like Humpty Dumpty, nobody has yet managed to put things back together again. We had the senior registrar supporting the registrar supporting the senior house office supporting the house officer.

A hierarchical apprenticeship, with progression when your competency secured you the next job at a competitive interview could be one option. That’s not to say that getting more senior always makes you more competent. There are some procedures that are delegated to juniors, which means consultants become bad at them. The anaesthetists are particularly busy during the strike as they’re one of the consultant groups who have maintained their skills in sticking tubes into people.

Negotiation point 5 sort out the IT

One of the biggest barriers staff face is the ability to navigate through hospital systems. It would have been much easier if this doctors’ strike had occurred 15 years ago. Everything was written down and ordered on paper. Now it is so much harder. Unless you know the system, the little tweaks to make things work, you can be stuck in technological purgatory.

In my day hours were longer, but the juniors are correct in saying the pressures are now relentless. The phone always hot with constant calls, to see, sort, discharge. Heart attacks are not managed with a bit of morphine from matron and bedrest anymore. Night shifts and weekends are no longer limited to keeping patients safe and dealing with emergencies, rather the emphasis is now on keeping up forward momentum towards safe discharge. This is a worthwhile aspiration but means safe rotas are tougher to organise when those same junior doctors running the wards and staffing clinics during the normal working day are also dealing with a greater load of routine business out of hours.

As a GP or consultant, one can go part-time or retire early. One of the reasons for the staffing pressures in the NHS is that so many are taking up that opportunity. Four days per week used to be the norm for a GP, but these days it’s three. And that is not just for women returning from maternity leave, but also their male counterparts. Some of this is their sanity limit, some pure work-life balance. There’s also an element of social copying, and a broader problem in health at the minute is that a negative narrative has taken hold, which is self-amplifying, when the realities on the ground haven’t changed that much.

Negotiation point 6 – bear down on box-ticking

Another change has been the enormous amount of bureaucracy that has been brought into junior doctors’ lives. The logging of cases seen and documentation of reflections. It is designed to raise the standards, particularly of the weakest, and weed out those that don’t make the cut. It has indeed helped to raise standards, but at considerable cost, both in terms of productivity and box-ticking psychological burden.

We do, of course, need quality assurance. But the best way is if the system has quality by design. With better data flows and analytics one could do some of this on the fly, to relieve some of the bureaucracy burden. Also drive through useful national standards, like having a passport system for mandatory training and CRB checks. Are fires in hospitals really so different north and south of the Thames that fire safety training needs to be repeated if you work in both places?

Negotiation point 7 – address doctors’ accommodation

In the good old days, on-site accommodation provided a backdrop for team building, despite living conditions that would make Charles Dickens weep. I must admit I didn’t last long as a junior in 1995 in the Hammersmith hospital’s juniors’ residence, which shared a wall with Wormwood Scrubs Prison. We might as well have been on call in the hospital being disturbed by constant crises, as being disturbed by booty being passed from cell to cell via the windows and the searchlights scanning across your curtains.

That job was really tough, but it also had a sense of camaraderie, with us juniors dreaming up what illnesses would be easiest to fake if we ever ended up on the wrong side of the wall. If we could recreate that sense of unity, perhaps we could heal the wounds inflicted by bureaucracy and disconnection. One way to address it, which I’m working on, is creating NHS campuses with purpose-built accommodation.

So, if we’re asking how to resolve these strikes and get the health service on a more sustainable footing, we need to get beyond arguments that focus solely on pay. Like a good doctor, we need to think about things holistically – and the points I’ve set out are a good place to start.

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Dr Paul Goldsmith is a consultant neurologist, a non-executive director of the Medical Defence Union and a research fellow at the Centre for Policy Studies.

Columns are the author's own opinion and do not necessarily reflect the views of CapX.