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Should junior doctors be paid more? Low pay isn't the problem

The NHS needs a lot more than cash (JUSTIN TALLIS/AFP via Getty Images)

The NHS needs a lot more than cash (JUSTIN TALLIS/AFP via Getty Images)


January 8, 2024   7 mins

Only two years after the NHS was founded in 1948, GPs first demanded an increase to their salaries — and threatened to withdraw their labour from the service entirely if those demands weren’t met. Many of the doctors involved in the proposed industrial action had, they complained, “suffered financial hardship”; all felt that their status in society had rapidly deteriorated since the establishment of the NHS. They had ceased to be elite practitioners of an ancient craft, becoming instead mere salaried members of the welfare state.

In the end, no withdrawal of labour came to pass in 1950; but today, more than 75 years on, their arguments are being echoed by the junior doctors who have been on strike since last Wednesday. Their central demand is a restoration of pay to pre-austerity levels. But the question of how much doctors ought to be paid has hung over our National Health Service since its inception. Every couple of years or so, in the second half of the 20th century, the pages of the British Medical Journal were filled with new complaints about remuneration. In 1956, for example, Dr A. E. Loden of Tunbridge Wells threw up his hands, suggesting that all junior doctors should resign from the NHS and offer their services directly to patients in exchange for ÂŁ5 per annum. Will this fraught question ever be answered?

Various governments have, over the years, made attempts. In 1957, a Royal Commission was established; it concluded that increased salaries would not attract more young people to medicine, or dissuade existing NHS staff from emigrating — whereas today, the BMA insists that pay rises are essential to retain doctors. However, it did concede that doctors’ pay was too low in comparison with other professional salaries, suggesting an increase of 22%. Harold Wilson’s government actually improved on this, increasing doctors’ and dentists’ salaries by up to 30%. This infuriated unions representing blue-collar workers.

The Commission also recommended the establishment of a permanent, impartial Review Body that would advise the government on NHS staff pay. This was set up in 1962 — and its goals were lofty. It would prevent pay disputes from disrupting the work of the NHS through even-handed analysis of data. It would assure the taxpayer that doctors weren’t earning too much, particularly at times of national economic hardship. It would guarantee that salaries wouldn’t become a manifesto talking point. Its very existence was supposed to thwart the politicisation of NHS pay.

Needless to say, these goals weren’t entirely realised. During the Sixties, the British Medical Association repeatedly campaigned to increase doctors’ salaries, arguing that low pay was eroding staff morale; in 1966 the Guardian reported that up to 500 doctors were leaving the UK and Ireland every year in search of better remunerated posts elsewhere, a narrative that has persisted to this day. And in the Seventies, both junior doctors and consultants engaged in industrial action for the first time. Between January and April of 1975, consultants suspended all “goodwill activities” — that is, non-emergency care — in response to the Labour government’s pledge to abolish “pay beds” (the practice of providing private care in NHS hospitals, and a way for consultants to supplement their income). Their action was called off when then health secretary Barbara Castle backtracked. To this day, NHS consultants being permitted to carry out private practice remains an “essential part of the flexibility and freedom built into national contracts”, according to the BMA.

While the majority of NHS doctors support the current industrial action, the strikes of the Seventies — with junior doctors walking out in November 1975 — were more controversial. Many doctors found the idea of withdrawing their labour troubling, forcing them to confront the fundamental question of what, if anything, makes medicine different from other jobs — and whether it is ethical for those in the business of saving lives to take industrial action.

Patient safety has always been the most contentious sticking point. In 2016, the then health secretary Jeremy Hunt proposed new contracts for junior doctors, scrapping overtime rates while increasing their basic pay. Hunt insisted this would be cost neutral; the BMA argued that it would mean a relative pay cut of up to 40%. Hunt eventually admitted that those who worked longer than 56 hours a week would face an overall fall in pay, but the Conservative government refused to back down, so in April 2016, junior doctors, for the first time ever, withdrew their labour from emergency care as well as routine. NHS England’s medical director Bruce Keogh warned in The Observer that junior doctors might “irreparably damage” the reputation of the profession. Ultimately, industrial action was called in the September after some junior doctors expressed concern about patient safety. It took until 2018 for the government and the BMA to agree on a new contract.

But it seems that neither establishment can make history of this seemingly endless dispute. Now, as a six-day strike approaches its end, the BMA is arguing that between 2008 and 2022, junior doctors’ salaries fell by 26%, once rising costs are taken into account. Comparisons between doctors’ pay and that of other workers have also been a major feature of this latest bout of strike action — but unlike in the Fifties and Sixties, when medicine was being compared to fields that required similar levels of training, like law, doctors’ pay is now being juxtaposed with that of baristas. Back in March 2023, the BMA launched an advertising campaign that stated:

“Pret a Manger has announced it will pay up to £14.10 per hour. A junior doctor makes just £14.09. Thanks to this Government you can make more serving coffee than saving patients. This week junior doctors will take strike action so they are paid what they are worth.”

Most of us can understand why doctors might expect to earn more than baristas, but nevertheless, the language of this campaign is off-putting. It has been criticised by both doctors themselves and other trade unionists as elitist and simplistic: it fails to recognise the vastly different earning potential and social status of the two professions.

Comparing doctors’ pay with that of other professions is a tactic that has, over the years, been used by critics of strikes as well as their supporters. In 1965, economist Brian Abel-Smith felt squeamish about pay rises for doctors, claiming that young GPs were already paid “much more than their contemporaries in other occupations”. He was right: mid-century, doctors were very well paid. In the Seventies, the full-time salary of a consultant was between £7,500 and £10,700; a full-time manual worker earned around £2500. Some senior hospital doctors were taxed at the top rate, which applied only to incomes over £20,000.

It might seem strange that this period of affluence was also the first time NHS doctors participated in industrial action. But something else was happening in the Seventies, too: the public was starting to fall in love with the NHS and doctors were starting to reinvent themselves, capitalising on the new affection for their employer. Today, there are echoes, with some striking doctors holding up signs saying “claps won’t pay my bills” — referencing the outpouring of love for the NHS during the pandemic. But doctors have a much stronger argument now. It’s difficult to deny that their pay has been eroded in real terms.

But doctors aren’t a monolith. There have always been some who are sceptical that pay rises are useful or even moral — especially when other members of the NHS workforce earn so much less. “I need my nursing colleagues,” a consultant in the mid-Eighties said. “Such disparity in salary scales makes me ashamed.” In the mid-Seventies, at a time of widespread poverty and unemployment, Dr W. J. Abel suggested it was “surely fairly evident to any intelligent being that we are facing major problems in our world. Is it not reasonable to suggest that we should all live more simply?” In the early Eighties, a pair of doctors wrote to the BMJ to argue that their colleagues should forgo any pay rises, “while there is so much hardship among the unemployed”.

The same argument that is sometimes used to justify doctors being paid more than baristas — they save lives — is also used to justify why they should forgo high wages: they are supposed to be self-sacrificing, driven by a sense of vocation. If it is easy for some to sympathise with doctors, as public servants, it is harder for others, who might see medics as generally privileged, wealthy and vaunted professionals. This dichotomy exists partly because both views of their profession can benefit doctors; it isn’t in their interests to let go of either entirely.

For now, public support for doctors, even striking ones, remains remarkably high — but public opinion is fickle, and it is possible that a focus on pay during industrial action makes medics vulnerable to media and political critique. During the 2016 junior doctors’ strike, the Daily Mail repeatedly ran such headlines as “Luxury holidays of the junior doctors leading this week’s NHS strike”. They continued this tactic last year, running the story of the “striking junior doctor” who “owns a £500,000 flat with no mortgage and is a director at his family’s investment firm”. But if anything, the BMA seems to be focusing more on pay this time around than they did in 2016 — when the trade union framed their demands more in terms of patient safety.

Of course, trade unions know that campaigning around salaries is legible to the public: everyone can relate to the feeling of being undervalued, and it makes the success of their industrial efforts measurable. A pay rise means they’ve won. But whether it will actually improve the working lives of doctors — or the functioning of the NHS — is far less certain. Money, or lack thereof, does not get to the heart of what makes being a doctor difficult in today’s NHS. Bigger salaries won’t substantially improve their health, happiness, or wellbeing. It won’t make it easier for them to book annual leave for their own weddings; it won’t address rampant bullying and harassment; it won’t bring back the spaces where they could once rest and socialise, which have been slowly stripped from UK hospitals.

Like the Royal Commission in the Fifties, I’m sceptical that it will meaningfully improve recruitment and retention. It won’t do anything for decrepit infrastructure or woefully outdated IT. It won’t repair collapsed social care. It also won’t address inequity in patient care or outcomes. It won’t correct damaging power imbalances between doctors and patients, or eradicate medical gaslighting.

None of this is to say that the current strike action being undertaken by doctors is unnecessary or inappropriate, or that healthcare professionals don’t deserve to be paid more than they are now. But it’s safe to say that, as history has suggested, even if they do get the money they’re after, a pay rise is unlikely to satisfy them. Their plight is the same as their employer’s: extra funding alone won’t fix it. The NHS, and the people that work in it, need things that are harder to give, and harder to measure, than cash: attention, good leadership, a vision for the future, hope. Otherwise this cycle of grievance will continue, an inevitable, recurring part of our health service’s history.


Agnes Arnold-Forster is a historian of healthcare and Chancellor’s Fellow at the University of Edinburgh.

agnesjuliet

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Steve Murray
Steve Murray
6 months ago

So here’s the pay scales for junior doctors:
Pay scales for junior doctors in England (bma.org.uk)
I’ll leave others to deduce whether their pay is equivalent (or less) to a barista, but what is clear is that there’s a gradient which a junior doctor starts out on – knowingly – that each year of progression will take them further and further away from anything resembling “barista pay” which presumably doesn’t accrue annual increments, or at least not on anything like the same scale.
Does this mean that junior doctors should fall behind due to inflationary pressures? No. Does this mean that in their first year as a junior doctor they’re “saving lives”? No. Does this mean that most of the hot air being blasted out by the media (and this article gives some historical analysis but doesn’t help that much with the present, simply quoting the trite barista comparison) is in many respects bordering on disingenuous? Yes.
Disclosure: One of my children is a Registrar (i.e. a “senior” junior doctor). Badly recompensed she absolutely is not, nor has ever been.

J Bryant
J Bryant
6 months ago
Reply to  Steve Murray

In your opinion, are junior doctors really striking over money (even if many people would not consider them underpaid), or, as the author suggests, are they unhappy with their general working conditions? Is it over-work and too big a caseload?

Steve Murray
Steve Murray
6 months ago
Reply to  J Bryant

When i started out in the NHS, it wasn’t uncommon for junior doctors to work 60+ hours in a week, which was clearly too onerous if not downright dangerous. Their maximum hours per week is now limited to 48, although in exceptional circumstances this can be exceeded.

Again, in the 80s and 90s they were often subject to open bullying by their seniors. This is now much less apparent, though doesn’t mean it doesn’t still happen.

The point is: their conditions have improved in many important respects from a generation ago. There are few instances where they enter the workspace without prior knowledge of their professional conditions and responsibilities. There is some other factor at play here, and it’s highly likely to be symptomatic of the general feeling amongst 20-35 year olds that the world has dealt them a poor hand.

J Bryant
J Bryant
6 months ago
Reply to  Steve Murray

Thanks. From my perspective (way over here across the Atlantic), this strike is simply an attempt to secure a pay raise when doctors feel they have a strong bargaining position with the Tory government facing an election and not wanting to be blamed for further disruption to the health service. It seems that in the UK many public sector unions have successfully struck for more money over the past year.

j watson
j watson
6 months ago
Reply to  Steve Murray

Agree with much of this SM. I’m sure the ability to get on the housing ladder, not of course a unique problem for doctors, plays a big part in the sense of frustration for younger doctors.
What’s less clear is why the Govt not made a slightly better offer than 5%. Wages nationally grew by 7%+ last year. Private sector pay growth has been appreciably better than public sector since 21 – (albeit doesn’t translate into much economic growth but a separate debate). The Consultants got a better deal too. I suspect with inflation having dropped there is a sensible medium here both sides could get to. I fear though the problem is the Nurses got 5% so they may take action again if they see all doctors doing appreciably better. Proper muddle and perhaps the failure was to separate the pay negotiations and offers.
Fundamentally of course we are poorer as a nation and that means the value of real wages has to reflect that. The issue perhaps is that feeling equitable. If your only echo chamber is the fellow aggrieved the sense you might be doing as well as most in these stormy times gets lost.

Alison Wren
Alison Wren
6 months ago
Reply to  j watson

I actually really hate % pay rises. When food and fuel prices rise there’s a definite amount extra that people need to feed themselves and get to work, but % rises favour the higher paid eg 5% on £50k=£2,500 extra per annum 5% on £10k £500 extra per annum. I think we need flat rate pay rises!

David Morley
David Morley
6 months ago
Reply to  Steve Murray

There is some other factor at play here, and it’s highly likely to be symptomatic of 20-35 year olds feeling that the world has dealt them a poor hand.

And perhaps the greater intensity of status competition – it’s everywhere you look now, unashamed where it used to be muted. And increased by social media based comparison.

Charles Hedges
Charles Hedges
6 months ago
Reply to  Steve Murray

In many engineering jobs young graduate has to work long hours in arduous, difficult , dirty and dangerous situations construction/infrastructure repair, mining,oil , etc. In some construction jobs where large concrete pours are involved an engineer may work 36 hours non stop. Forestry, trawling and mining have high fatality rates.
Census of Fatal Occupational Injuries – Wikipedia
Construction of bridges across roads/ railways often involve working non- stop over bank holiday weekends. Repairing electrical cables damaged by falling trees often occurs at night, during storms and often around Christms and other repairs to infrastructure often taken place at nigth and in bd weather.
The first six or so years of a professionals life is training. Once they become Chartered or MRCGPs/MRCS salaries increase especially when they become partners.

MJ Reid
MJ Reid
6 months ago
Reply to  J Bryant

Some of them might have too large a caseload and be overworked, but the majority seem to have tiime on their hands. I visited my partner most days over the festive oeriod when he was in hospital. I spoke to two junior doctors about his care and treatment and would have been better speaking to the cleaner who at least knew he walks with a zimmer and is waiting a hip replacement unlike the two doctors who couldnt give me any info re his bladder and kidneys which is why he was on the ward and who had told him to needed more walking exercise! They get paid enough… And in some cases, far too much.

Billy Bob
Billy Bob
6 months ago
Reply to  Steve Murray

Those wages don’t seem to be anything special, not for the amount of stress and responsibility they face, not to mention the colossal debt they have to take on to become qualified.
At the end of the day Britain has a shortage of doctors, which implies the wages aren’t high enough for the working conditions. Therefore you have to improve either the pay or the workload or you won’t have the staff you need

Steve Murray
Steve Murray
6 months ago
Reply to  Billy Bob

BB, places in the UK’s medical schools are limited and controlled by government:
The cap on medical and dental student numbers in the UK – House of Commons Library (parliament.uk)
Might i suggest the merest of googles before commenting?

Michael K
Michael K
6 months ago
Reply to  Steve Murray

Places are capped because the NHS system can only cope with so many students at a time. There should, however be a policy that UK students get first priority for places and foreign students get allocated whatever remains. That would help to limit the number of people being trained here and immediately leaving our shores.
This problem is particularly acute in Scotland where the SNP administration doesn’t give universities anything like the cost for training so foreign students are needed to subsidise Scottish students.

Dougie Undersub
Dougie Undersub
6 months ago
Reply to  Steve Murray

In 2008 the BMA – yes, them – opposed an increase in med school places.
https://www.bmj.com/content/337/bmj.a748

Alison Wren
Alison Wren
6 months ago
Reply to  Billy Bob

We need to insist that those training in U.K. largely at taxpayers expense should work for a minimum time here before being able to run after higher wages elsewhere

UnHerd Reader
UnHerd Reader
4 months ago
Reply to  Alison Wren

Maybe I am wrong but I understood that people training in the medical profession in the UK were already expected to work for a given number of years in the NHS before leaving to work abroad? If they arent, then there should be.

Andrew Dalton
Andrew Dalton
6 months ago
Reply to  Steve Murray

My issue with these figures is always how they compare by region – the important figure for anyone is not gross earnings, but rather the purchasing power of their net disposable income.
Frankly, I’d be astonished if baristas earned that money where I live.
So, looking at median salaries: https://www.statista.com/statistics/416139/full-time-annual-salary-in-the-uk-by-region/* (no surprises that London and the South East are dragging everything up).
In my part of the country, for a single year’s experience, 32K looks pretty good considering how quickly that amount will rise. Particularly considering housing is probably 20% that of London.
And one final point, where exactly is the money coming from? As far as I can see, the UK is essentially insolvent. The government can increase taxes and extinguish the economy, or go the austerity route and finish off the public sector.
*Title says median, graph says mean, so may not be the best source

Ross Jolliffe
Ross Jolliffe
6 months ago
Reply to  Steve Murray

Thank you.

Chipoko
Chipoko
6 months ago
Reply to  Steve Murray

Thanks, Steve. This is very interesting, especially as you have a child working as an NHS registrar. Both of my children are medicals – one a senior consultant in emergency medicine; the other a dentist/oral surgeon. Both now work in Australia, where my son has been since leaving the NHS in his F2 year. The terms and conditions of employment in Australia are so much better. Not only are the salaries significantly higher, but the work environment (e.g. doctor/nurse/patient ratios, beds per head of population, equipment, etc.) are incomparable with the NHS. If my son works one minute of overtime, he is automatically paid one hour of OT remuneration. In the UK, if he or our daughter worked (say) six hours of overtime, they did not receive a penny. It was expected of them, and often they had no choice but to help out to cover absenteeism, etc. Their Australian managers provide excellent support, whereas in the UK they were shabbily treated by the system. Moreover, both my children left university with huge student loan debts and faced enforced repayments at massively over the prevailing interest rates – scandalous
I do not support a 35% increase in pay for British ‘junior’ doctors. I wonder if the BMA is populated with committed socialists who are hell bent on getting rid of a Tory government, as so much of their rhetoric seems politicised as much as self-seeking? But I do have considerable sympathy for NHS ‘junior’ doctors who work in dreadful conditions, serving significantly increasing populations with no additional resources (while Fat Cat managers enhance their huge salaries each year), receiving poor levels of support from management and administration and having to spend inordinate amounts of time wallowing in bureaucratic ‘goo’, dealing with graduate nurses who won’t make beds, empty pans or feed patients and being constantly hit with Woke rulings and requirements in relation to their everyday work. No wonder they are mightily hacked off and creating such a stink. I have some sympathy for them, though do not respect the 35% ‘give me’ attitude.

Emma Davies
Emma Davies
6 months ago
Reply to  Chipoko

I resonate with your comment. I have sympathy for Junior doctors situation too. However comparison with an Australian situation is not entirely fair on the NHS. Australia has a bismarck healthcare model – where there is a significant private funded sector. Therefore salaries will reflect this uplift. I work for the NHS and left Australia about 20 years ago – I would certainly be better off paywise back home. Although the cost of living is significantly higher in Australia – so wages must reflect this.
I think the question we all should be asking ourselves is how long we can continue with the Beveridge model of healthcare where it is free at the point of use? The UK has an aging population and has had to cope with a significant influx of immigration over the last 10-15 years. We are constantly asked to do more with less money. There are some benefits to this – we are forced to innovate and I don’t know how beneficial it is to throw everything and the kitchen sink at healthcare problems – see the American insurance model where some individuals receive far too much ‘healthcare’, but the pressure of increasingly complex health problems and high demand for trained staff is one I don’t think the NHS can continue to cope with over the longer term.

Chipoko
Chipoko
6 months ago
Reply to  Emma Davies

Thanks for your valid observations, Emma. With your background you have an interesting perspective on the relativities of UK NHS vs the Australian model. I actually think this is an excellent model in which high income-earners are required to subsidies their healthcare via private insurance (not the hugely expensive National Insurance model in the UK), whereas low-income earners access free healthcare, with iterations in between these extremes. My half-brother has had major surgery under this system and had nothing but praise for its efficiency, effectiveness and costs – and he is in the middle-income bracket so contributes towards healthcare expenses. He was shocked when I told him that there is a 5-year waiting list for hip replacement surgery on the UK NHS – and most of us cannot afford the ÂŁ15-20K for having this done privately.
I take your point about the higher cost of living in Australia. But in reality the remuneration of doctors there far outstrips this differential. They are very well paid and, unlike their counterparts in the UK (unless they have wealthy parents to help them financially), most of them own their homes (when my daughter aged 35 worked as an oral surgeon in the UK, she still rented a room on a floor of a multi-story townhouse converted into flat, sharing living-room, kitchen and bathroom facilities with two others as she could not safe enough even for a deposit to secure a mortgage. The way these young professionals are treated is disgusting. The level of investment in facilities, equipment and personnel makes the British NHS appear very shabby and Third World. Moreover, investment in UK public services generally has not kept pace with the huge increase in the UK population over the past 40 years – c.50 million people in 1980; now closer to 80 million (accounting for levels of illegal immigration), most of this increase resulting from foreigner immigration, legal and illegal. Couple this with the massive slashing of public service budgets as an end in itself by the Cameron government from 2010 and it is no wonder that the NHS and other public services are in such dire straits. On top of this dismal scenario is the cost (financially and psychologically) of the mind-numbing consequences of woke policies and practices that now infest these services at every level, vertically and horizontally. Yes, this is a feature ot the Australian system too, but not to the same, deep penetration as in the UK and much less ruthlessly imposed or nurtured.

T Bone
T Bone
6 months ago

I’m not saying the American Health Care system is cost efficient right now. It’s filled with administrative bloat and unnecessary bureacracy due to the massive list of compliance requirements. But it’s not a system full of government doctors.

US Doctors are generally paid according to free market principles. The market for doctor salaries is set high by specialty surgeons. From there the pay goes down for every less specialized physician service but a GP is still very well off relative to the population. Few have a problem with high doctor pay in America because we want doctors to be compensated well. They’re very important!

If people in the UK like a more collectivized health care with public sector doctors, I respect the choice. You may know something that I don’t but it seems the more the State controls health care, the more it implements price controls; which in my view, should only be applied in rare circumstances. In a system that implements price controls you have no choice but try to balance an inflationary question like raising public sector wages. Higher public sector wages without price controls mean service costs have to rise. So when you have public sector workers demanding pay increases during an inflationary period, the government is put in an impossible situation. Dig yourself into greater debt or raise service costs of health care.

I’m still not saying America has a “better system.” It’s probably worse in sum total because the cost and quality of care varies more by locale and America has truly crumbling economic centers right now. Most of the health systems in crumbling cities are heavily subsidized by payments from the Federal Government and have so many bureacratic compliance requirements that they operate like a DMV. But in places where doctors are allowed to practice with relative autonomy and can continually earn more due to service demand, the quality of care seems to be very high.

Maybe 10-15 years ago I noticed that nobody in America used the term “Austerity” but every time I read the Economist or a European journal, the word was everywhere. Europeans seemed to demand a far more “robust” Central State than Americans.

j watson
j watson
6 months ago
Reply to  T Bone

The main difference TB is US health system works on ‘fee for service’ for doctors as opposed to salary. One of the drivers of much higher health expenditure in US (almost double) is believed to be the supplier induced demand this generates, whereas in the UK there is no incentive for a doctor to book more tests etc for financial reasons.
Nonetheless the HMOs in the US have increasingly sought ‘managed care’ solutions where the doctor has to follow a set pathway protocol and if they step outside that they have to seek approval – and this because of the concern at rampant cost inflation. For the public who have to purchase insurance it’s a trade off – the managed care systems tend to have lower premiums.
At a macro level Health policy makers the world over see many ‘cost containment’ benefits to the NHS – salaried, primary care (although that’s weakened), drug price controls and even NICE. Hence UK system, despite aging population controls total costs better than most. But on quality of care it can struggle if the total investment doesn’t keep pace with some of the changing demographic.
On a micro level there is much the UK can learn from US, but it has to be selective in those lessons. 25-40m don’t have cover in the US at all.

T Bone
T Bone
6 months ago
Reply to  j watson

That’s a fascinating point about testing. I can tell you from personal experience that in the US, doctors order a test every time there is a potential problem. I actually stopped going to the doctor for 20 years because every time I went, they would find some abnormality requiring months of testing and it wore me out emotionally. Many people seem not to care about this but others will avoid treating.

So your position is that the fee for service incentivizes the ordering of unnecessary tests?

j watson
j watson
6 months ago
Reply to  T Bone

Not so much my position but the position of many health economists that ‘fee for service’ does generate some over-testing. I just happen to think it also makes intuitive sense. You incentivise someone to book more tests then that’s almost inevitable.
What I’d call ‘diagnostic creep’ an issue to varying degrees in all health systems though even if the method of payment different. As more tests become available the doctor can feel pressurised to request because if they don’t and then miss something…so it increases costs because of ‘defensive medicine’. In the UK we better control this but it’s still a factor. In the US the ‘fee for service’ just drives it even more which is why the HMOs have tried to control it more.

Emmanuel MARTIN
Emmanuel MARTIN
6 months ago
Reply to  T Bone

Not sure what your point is. The US system has huge flaws, especially in terms of costs. No wonder doctor pay is good, the sytem is flush with cash.
Do you really want US healthcasre system in the UK ?

T Bone
T Bone
6 months ago

I am American. I’m comparing the two systems while openly acknowledging that I don’t fully understand the UK system.

Anna
Anna
6 months ago
Reply to  T Bone

The US health system isn’t really a system at all; it’s largely run by private for-profit and nonprofit institutions, with the government negotiating lower rates for the two large public health care programs, Medicare (elderly) and Medicaid (poor). It is very expensive. On the other hand, like everything in the US, you can get what you need when you need it if you or your insurance will pay.

I broke my ankle hiking a couple days after Christmas. A French nurse assisted me back down the trail. She was amazed I was able to arrange an Xray that same day and a visit to the orthopedist the day after. I ended up needing surgery, all done by New Year’s.

Charles Stanhope
Charles Stanhope
6 months ago

Apparently it costs about £250,000 to ‘train’ a junior doctor, of which they contribute a measly £50,00 at best.

Once qualified, should they decide to flee to the US or elsewhere they are entitled to do so completely ‘free of charge’!

This situation is quite ridiculous and the legislation must be changed to force them to repay the long suffering British taxpayer for their medical education.

We can NO longer afford
such absurd largesse.

Andrew Dalton
Andrew Dalton
6 months ago

This also applies to the way we cherry pick clinicians, and other medical staff, from other countries, too.

Amanda Elliott
Amanda Elliott
6 months ago
Reply to  Andrew Dalton

Australia,the US etc don’t seem to have any qualms over taking our doctors



Peter B
Peter B
6 months ago

That’s another flaw of the absurd implementation of student loans – go and work abroad and you’re probably free of the loan. Not that most of them will get repaid anyway. At least half the student loan debt will never be repaid.
The asset stripping of doctors and nurses from poor African and Asian countries is appalling. It’s actually a designed in feature of the NHS. Quite immoral. Certainly if we are not compensating those countries for their training costs and loss of skilled medics (and we are not and never have done so). Rather gives the lie to the idea of the NHS as some sort of righteous moral crusade and therefore beyonf criticism. Certainly not as implemented today.

Chipoko
Chipoko
6 months ago
Reply to  Peter B

Both of our children graduated with medical degrees in the UK, both now work in Australia; and both continue to repay their student loans – in my daughter’s case, c.ÂŁ90,000 (for which she is charged monstrously high interest rates far above the prevailing rate of inflation). With this financial noose (thank you Tony Blair and David ‘Call-Me-Dave’ Cameron) she was unable to earn sufficient to save for a deposit on a mortgage, even at the age of 35 after 8 years of work – which is a principal she accepted a job offer in Australia where she will be paid far better, with excellent working conditions and the distinct prospect of investing her own home within the next few years.

Richard Calhoun
Richard Calhoun
6 months ago

With respect Charles, an absurd solution on your part.

Charles Stanhope
Charles Stanhope
6 months ago

Perhaps, but no more far fetched than your admirable idea of actually slaying the ‘Golden Calf’ itself?

Andy Moore
Andy Moore
6 months ago

The British military have similar rules to what Charles proposed. If the military can do it, then so can the NHS. In fact, even if you do leave the military early, you can still be put on the reserve list for a few years.

Alan Tonkyn
Alan Tonkyn
6 months ago

But, with some modification, Charles’s solution becomes perfectly sensible. In Singapore, newly trained doctors are ‘bonded’ to work in government hospitals/clinics for several years. If they decide to decamp for other countries during the period of bonding, they have to pay back whatever proportion of the cost of training them has not been worked off in service. It is ridiculous for the taxpayer to pay huge sums of money to train UK doctors to go and work in Australia and the USA just after being trained. And it is equally ridiculous and immoral to plug the doctor shortage gap thus created with foreign doctors.

Charles Hedges
Charles Hedges
6 months ago

Return to O levels/ A level / S level/ Oxbridge / University Scholarship exams so people can go to university at seventeen years of age and complete a five year degree by the age of twenty three. William Penney, Rector of Imperial obtained a doctorate at the age of twenty two. Have all Engineers, lawyers, surveyors, accountants train via Institution Exams, ( Civil, Law Society ). etc) at night school. Reduce number of A levels to languages , STEM, History , Geography, Economics – pre 1960 choice. Someone with Grade Bs in French, Latin and History of pre 1960 standard A Level was quite capable of entering management training. Thereality was that someone five good O levels of pre 1960 standard in say English, Maths, French, Chemistry and History was quite competent for administrative jobs. By having night school provide masters, people can always upgrade academic ability through evening study.
Birkbeck, University of London – Wikipedia
Provide every large town/city with a college for evening study which combines best of Birkbeck, Fraunhofer ( German) and pre WW2 Poly’s and one could probably reduce fees to ÂŁ5K per year. Some degrees such as medicine require attendance at a research university but as far fewer people will be attending, fees could be reduced. Some people will benefit from attending Imperial. Historically many people undertook a science /engineering degree at poly and the attended Imperial/Cambridge or other from the second year. As so few would be attending full universities, fees can be kept low and perhaps offer scholarships. The old S – Scholarship Paper was used to award county scholarships but this was phased out, perhaps in the 1960s. Historically if one won a scholarship to read Maths at Cambridge one could miss out on first year. This meant able students could obtain a Part III in Maths in three years.
The reducing of standards has resulted in pupils spending longer in education, spending more money and delaying earning a salary but has benefitted teachers, academics and universities by increasing the numbers employed and income earned.

Peter B
Peter B
6 months ago

When you listen to the junior doctors leaders, you hear distinct echoes of 1970s disputes about pay relative to other groups and “demarcation” (a word we rarely hear these days). In some ways this feels like it is about status as much as pay.
But regardless of this, I take the general view that professionals do not (or should not) strike. I believe that doctors have made a fundamental error in doing so and have permanently undermined their status. Which ironically is part of what they seem to be so keen to protect.
It’s also interesting that in most professional jobs – certainly for all my career in engineering – above a certain level and overtime is unpaid. I’ve never been paid overtime, but frequently worked it. But have no compliants.
So why is it that the NHS continues to run a system which requires large amounts of overtime from doctors ? Why, over the course of 75 years, has it never been able to adequately resource sufficient doctors to eliminate overtime ? Also bearing in mind that overtime increases costs.
I have said it many times here – a huge part of the problem is the restricted supply of doctors. For which the BMA is one of the main culprits. Yes, it’s great to have high entry standards to the medical profession, but these are arguably academically far higher than actually needed. And do not apply to the many doctors we import from overseas.

David Morley
David Morley
6 months ago
Reply to  Peter B

I have said it many times here – a huge part of the problem is the restricted supply of doctors. For which the BMA is one of the main culprits. Yes, it’s great to have high entry standards to the medical profession, but these are arguably academically far higher than actually needed.

There is a strong argument from economists that what we are seeing is rent seeking behaviour. The supply of doctors is deliberately restricted in order to maintain salaries at a high level. A sure sign of this a profession which is highly concerned with the quality of entrants, thus restricting supply, but resistant to monitoring of the quality of the work they do once they get there.

David Hewett
David Hewett
6 months ago
Reply to  Peter B

a huge part of the problem is the restricted supply of doctors. For which the BMA is one of the main culprits.
This is uninformed nonsense.
The BMA has zero influence on the supply of doctors as evidenced by successive governments failure to undertake manpower planning in the NHS. The government by way of NHS England sets the number of 1st year Foundation doctors entering the NHS. The first two years of foundation Training after graduation are required to achieve full registration. Not only that, then Health Education (England) issues a fixed number of training numbers for each specialism which controls the number in higher training to become consultants or GPs at any given time. Numbers are therefore centrally controlled by the NHS itself.
Taken with the import of foreign trained doctors the numbers actually employed in posts other than those holding training numbers or as consultants in the hospital service are growing rapidly. These doctors are locally employed in purely service roles with little prospect of career progression. Their dispute has received little by way of publicity or interest in the media.
It is the stranglehold that leads many doctors in training to feel trapped in a rigid inflexible training program which requires long working hours, a lot of commuting due to the rotation of working places, coupled with arbitrary rotas riddled with gaps, and restricted protected study time that causes huge resentment. It lies at heart of the present dispute.

Peter B
Peter B
6 months ago
Reply to  David Hewett

Not correct.
Historically, the BMA has acted to restrict the supply of doctors (hardly surprising from a poweful professional trade union):
“Delegates at the annual BMA conference voted by a narrow majority to restrict the number of places at medical schools to avoid “overproduction of doctors with limited career opportunities.” They also agreed on a complete ban on opening new medical schools.9 Jul 2008”
They may have changed their position in the last few years. But historically, they were part of the problem (and allowed the problem to build up over decades) and not part of the solution.
They are also a body which whilst claiming to represent all doctors (and like airline pilots in the past and some railway workers today to be doing it primarily to “protect public safety”) allowed junior doctors to routinely work 60 hour weeks. Something which so obviously puts patient safety at risk.

Billy Bob
Billy Bob
6 months ago
Reply to  Peter B

I refuse to work overtime unless I’m paid for it, if a company wants my time then they have to reimburse me for it. I won’t even answer the phone if it’s outside my work hours. I owe the company nothing, I’ve earned them money for the hours they’ve paid me to work so they shouldn’t expect me to work extra for free

A D Kent
A D Kent
6 months ago

 Whether any workers “should” be paid more is an interesting question, but only so far as it’s a sub-component of something like “What conditions are sufficient to entice people to work in a given role?”. Since Brexit we’ve had similar questions beyond the NHS for the likes of lorry drivers, fruit pickers, our military and many others. We’re told these are recruitment crises, but they’re actually almost always wages and training crises.

Training is poor to non-existent or expensive when it exists. All jobs are now much more ‘flexible’ and conditions ‘moderniseda’ and pay has been surpressed for too long (which is the main reason why I voted Leave). Our nation is wealthy enough to afford rises across the board – when we joined the EEC the proportion of GDP that went to employees (through wages) was just shy of 60%, now it’s much closer to 50%. Most of the benefits of increased productivity have been syphoned off.

As for whether juniors doctors should be paid more – the answer is yes – there’s a demand for their services, the nation as a whole is better off with a fit and healthy population and we most definitely can afford to pay.

Richard Calhoun
Richard Calhoun
6 months ago

Junior Doctor’s are clearly underpaid and work in atrocious conditions in many instances.
The NHS is never going to work whilst it is a nationalised state entity, we have seen both Labour & Conservative’s simply using it as a political tool for decades.
It’s time to free the NHS to operate in the ‘market’ which will benefit staff and patients alike.
Market forces will drive competition, quality and bring much needed investment.
Anything else is simply tinkering at the edges.

A D Kent
A D Kent
6 months ago

The bulk of that decline has occurred in the years since such market based mechanisms have been applied to the NHS. Those markets encourage the wrong kind of efficiency – no spare capacity, insufficient long-term planning (you know how long it takes to train staff don’t you?) and rents extracted across the board. There’s simply no evidence that competition is more effective than cooperation in such provision – no incentive to share good practice with competing entities in your market based approach.

Steve Murray
Steve Murray
6 months ago
Reply to  A D Kent

I can vouch for that.
Many commenters (not just on Unherd) rail against the NHS being used as “a political football” then go on to apply their own political opinions to the question of how it should be modelled.

Richard Calhoun
Richard Calhoun
6 months ago
Reply to  Steve Murray

I have not railed against it being a political football, but it is indisputable surely that both parties have and are using it as such.

JR Stoker
JR Stoker
6 months ago
Reply to  A D Kent

One of the lessons of the last 80 years is that part private, part state monopoly, is the worst solution to any given problem. Cf the railways. The government cannot run anything, even usually, itself. So get all health services run by private suppliers, and the government can ensure that all citizens can pay for a good level of care, preferably by insurance. It works elsewhere!

Richard Calhoun
Richard Calhoun
6 months ago
Reply to  A D Kent

There is no commercial market, as a nationalised entity with no pricing, it simply is not a market led business.
Until that changes nothing else will, the NHS will be condemned to continue declining as it has, certainly for the last 25 years.

William Edward Henry Appleby
William Edward Henry Appleby
6 months ago

The ones in hospitals I agree. The GPs are not deserved of a pay-rise IMO and I hope they aren’t part of this round of pay negotiations.

Mike Downing
Mike Downing
6 months ago

None of this type of argument would apply in a privatised health service and many of the problems would be sorted out.

Of course, we’d end up with a different set of problems.

Andrew Wise
Andrew Wise
6 months ago
Reply to  Mike Downing

It’s no so much “in a private health service” as “in a health service with a plurality of providers”
if doctors could shop around for the best terms and conditions & the patients could shop around for the best service and price point
. Then there would be no need for strikes.
simply privatising the NHS in its entirety won’t fix it, just as privatising the railways failed

Jon Morrow
Jon Morrow
6 months ago

Only the free market can tell you what doctors should be paid. Incidentally it’s also a free market which can best allocate the limited resources we are obliged to manage.

David Morley
David Morley
6 months ago
Reply to  Jon Morrow

Only the free market can tell you what doctors should be paid.

Only if you open the door to allow more people to enter the profession. If you restrict supply (through excessively high entrance qualifications, for example) the market will not be free and will not operate optimally.

William Edward Henry Appleby
William Edward Henry Appleby
6 months ago
Reply to  David Morley

Would you bargain for a discount to be treated by someone lower qualified?

Allison Barrows
Allison Barrows
6 months ago

Genuine question: can junior doctors go into private practice or are they required to work through the NHS?

Andrew Wise
Andrew Wise
6 months ago

”Doctors” at any level can practice privately, but you need to be a consultant to be taken seriously
 for GPs to refer patients to you and for the insurance companies to pay your fees.
it’s not uncommon for a consultant with a private patient to delegate some work to “junior” doctors and to pay them part fees,
effectively you do need to be a consultant to work privately, and you need consulting rooms and secretaries etc. Lots of overheads 
 most surgeons have a mixed portfolio of NHS and private

Patrick Raleigh
Patrick Raleigh
6 months ago

Interesting article

edward coyle
edward coyle
6 months ago

The medical profession, as with teachers and others, once had considerable influence over their state run employers. Over the years that has declined and the medics are no longer on top, but as can be seen from the strikes, not on tap as ministers and their supporting managerial class might wish.
Doctors are now closer to the proletariat than a privileged elite than they ever have been and are now behaving to role.(It is ironic that medical professionals have one of the strongest trade unions (not TUC affiliated) at a time of very low unionisation of the British working class.)
The junior doctors, as an entity remain bitter about the enforced contract by Hunt in 2016 and I get a sense of payback time.
just a small detail on the accuracy of the article, GPs are not employees and not salaried by the NHS. They are independent contractors. The Socialist Health Association and the Medical Practitioners Union,affiliated to the TUC and now within Unite have campaigned since 1948 for an nhs salaried option for gps, with limited success. The way the salaried employees get treated I suspect provides no incentive.

David Morley
David Morley
6 months ago
Reply to  edward coyle

It is ironic that medical professionals have one of the strongest trade unions (not TUC affiliated) at a time of very low unionisation of the British working class.

There’s no irony here – it’s a sign of the times. Those at the bottom have been rendered almost powerless. Those further up the tree have the clout to improve their position even further.

edward coyle
edward coyle
6 months ago
Reply to  David Morley

Indeed, Arise ye starve lines from your slumbers

edward coyle
edward coyle
6 months ago
Reply to  edward coyle

Starvelings

David Morley
David Morley
6 months ago
Reply to  edward coyle

Doctors are now closer to the proletariat than a privileged elite than they ever have been and are now behaving to role.

Oh come on!

P Hine
P Hine
6 months ago
Reply to  David Morley

The salary comparison is completely flawed, NHS employees have inflation proofed final salary pensions which are worth 30% of salary . Baristas don’t.
Yes they should be paid more. But only solution is to blow up NHS and start again. Recruitment, training, retention of doctors and nurses is woeful. There is no control or debate over the scope of what they do, can removal of tattoos, for example, be justified compared to its original purpose? And it is now well behind the clinical excellence of many countries which one would expect to be, at best, as good as UK.

0 0
0 0
6 months ago
Reply to  David Morley

No mention in article that junior doctors in Scotland accepted a deal from Scottish Government Junior doctors in Scotland accept new pay offer – BBC News

edward coyle
edward coyle
6 months ago
Reply to  David Morley

With the majority of the younger generation going to have a higher education qualification, we must adapt our former notions of the proletariat. If there is a lesson from the doctors, it’s get organised. My guess is the Ai robots will work that one pretty quickly.

George Venning
George Venning
6 months ago

WTF is this article? In the 50s were paid very well compared to manual workers. In the seventies, they were paid three times as much as manual workers and now they are paid a little less than twice as much – in exchange for longer hours and upon reciept of years of tough training.
So comparisons between what people thought about pay disputes over that period are misleading.
And to argue that, although doctors don’t get paid vastly more than baristas, they do get more status than baristas, is also nonsense. See also “claps don’t pay my bills”.
What else? Oh yes, the Daily Mail has criticised doctors with family money from striking in support of colleagues who don’t have the benefit of family money. Does that make them greedy hypocrites? Or does it make them decent human beings capable of empathising with the plight of their more numerous colleagues who don’t have the benefit of that support – just like the doctor concerned about the wages of nurses – quoted elsewhere in the article.

Alan Kaufman
Alan Kaufman
6 months ago
Reply to  George Venning

Doctors deserve much much more than what they are paid. A brain surgeon saves thousands of lives over a career and makes less than a very mediocre footballer.

William Edward Henry Appleby
William Edward Henry Appleby
6 months ago
Reply to  Alan Kaufman

No-one in the UK ever studied medicine for the financial rewards. It was just a nice middle-class profession with a reliable income and (undeserved) respect and social status. Nowadays it’s a nice middle-class profession for the offspring of aspiring middle-class South Asian parents.

Chris Hume
Chris Hume
6 months ago
Reply to  Alan Kaufman

A sewerage worker saves many more lives than a brain surgeon, should they earn even more? Is this to be the metric for deciding pay?
Putting aside the fact that professional footballers who earn big money are pretty far from mediocre, the reason why the earn so much is that millions of people are more than happy to pay to watch them play. Their product generates billions of pounds, so I would argue they should receive a large chunk of it.
It’s easy to use outliers like footballers to point out seemingly obvious absurdities, but it would be a lot trickier to work out the relative pay of a doctor and a structural engineer, for example. Once you start drilling down into the vast array of important jobs it would be literally impossible to figure out who “deserves” what.

UnHerd Reader
UnHerd Reader
6 months ago

I had heard that some of the strikers are moonlighting n other hospitals as locums for quite a lot of money.
Anyone know if it’s true?

Alan Kaufman
Alan Kaufman
6 months ago

Medicine is extremely demanding. More than a decade of costly study, long hours once in the profession, enormous profession to never make a mistake, difficult patients in difficult situations. So yes, I like our American system that allows doctors to make good money. And even then, they are underpaid for what they do.

Edward De Beukelaer
Edward De Beukelaer
6 months ago

The biggest issue with medicine is that what we learn and how we need to practice has often little to do with reality: medicine has become a mechanical scientific money business. This even though that much of the philosophy of medicine points to the fact that medicine is an art that should treat the living, and not see them as machines that need to be fixed. But we are caught is a system in which it is money that drives medicine and this will not change soon.. unless medicine becomes really integrated and whole person oriented… https://www.who.int/publications/m/item/who-traditional-medicine-summit-2023-meeting-report–gujarat-declaration

David 0
David 0
6 months ago

A common perspective is that crises and waiting lists are signs of system failure. An opposite perspective is that all living systems develop mechanisms for balancing supply and demand; think predators and prey, production of goods and services, etc, etc.
In the NHS, supply is increased by crises which are transmitted via the media to the politicians with control over medical incomes and health infrastructure. Demand is suppressed by queues and waiting lists.
If a better system for balancing supply and demand is not built in, then expect more crises and queues; that’s how the system works.

Dougie Undersub
Dougie Undersub
6 months ago

Yes, doctors’ pay has fallen in real terms over the past 20 years but then so has everyone else’s (except, perhaps, Instagram influencers). The country has become poorer as we’ve been awarding ourselves a standard of living our labours haven’t earned. For as long as health care remains part of the public sector, and the BMA seems very keen it should, its workers can’t expect to do better than taxpayers in general.

R Wright
R Wright
6 months ago

You stop being part of a profession when you strike and become a mere ‘worker’. I have little sympathy for those that wish to have to both the status and the pay.

Al Hicks
Al Hicks
6 months ago

The question is not should junior doctors be paid more but should we actually reform the health provision in this country and ensure we meet the same standards as our European neighbours who pay only a fraction more for a service that does not rank 28th out of 33 in cancer outcomes.
The only way to achieve this is to slay the socialist cow and give the management and funding to a social insurance company model and ensure that those who can pay, do, and those that can’t get a minimum standard. Like the Germans, French Dutch etc do. It is only the unions and the labour party that can deliver this as the Tories are unable to slay any demons. Wes whatshisface has been making sensible noises but I expect the BMA to cut his hamstrings with a blunt scalpel as soon as he’s in post.
All of us should enjoy an insurance funded well run health provision based on our income. then Junior doctors can be paid the same as their German or Dutch compadres. Which might be less who knows!