On today's junior doctor strike

Doctors are quite possibly the worst group of people the government can get into a dispute with. At an Institute for Government event last year, the Former Labour Health Secretary Alan Milburn, a man who knows a thing or two about NHS reform, addressed a question on how to politicians can best deal with doctors. Jeremy Hunt, who was also speaking at the event, had left by this point but he can take some encouragement from what was said.

It is patients, not politicians, who are best placed to challenge doctors, said Milburn. It is they who will bear the brunt of industrial action on Tuesday that will inconvenience and endanger patients.

As one would expect in a dispute between a trade union and a government, most of the public announcements are heavily spun, and all too often sober analyses are lacking. The BMA, like the Royal College of General Practitioners and the Royal College of Nursing, is more trusted than other trade unions due to its grandiose name and the staff they represent. However, their approach to “negotiations” and media operation is barely distinguishable from the tactics of, say, the RMT. Just because some of their spokespeople have medical degrees, that doesn’t make them any less intransigent than the late Bob Crow.

Doctors enjoy exceptionally high levels of public trust that politicians never will. In most cases, this is no doubt warranted. Put a doctor next to a politician on a television programme to debate almost anything and the doctor will usually win the debate in the eyes of the public regardless of the veracity of the points they make.

The government’s claim that they are offering an 11 per cent pay rise is only part of the story, as junior doctors’ earnings are made up of basic pay – which is being increased by 11 per cent – and a banding supplement which is being replaced.

This system of banding supplements is a continuing source of confusion and dispute between employers and junior doctors, after 15 years in operation. There’s a good reason other NHS staff are paid differently.

The system is complicated, but essentially it compensates for hours worked in addition to the standard 40, as well as intense working patters. It is worth between 20 and 100 per cent of basic pay with hours worked placed into three broad bands of 40, 48 and 56 per week. Because of the breadth of the bands, it’s possible for those working 47 hours to be paid the same as those working 41 hours.

What’s more, the extremely sharp jumps between pay multipliers in the bands can trigger very significant cost increases for employers if a doctor works for, say, 48 hours instead of 47. One trust reported an extra £250,000 cost for eight junior doctors when just one exceeded the banding limit on one occasions in six months. This has led to trusts adopting rigid shift systems that are not conducive to quality training or patient care. Junior doctors have also complained that employers pressurise them into underreporting hours, so as not to trigger large cost increases. In their initial submission to the pay review body, the BMA argued in favour of retaining this system, albeit with some added flexibility.

The proposed window of unsocial working hours for which junior doctors will receive pay premia is narrower than that for other NHS staff and it’s not entirely clear why. But they will be significantly more generous than those on offer elsewhere in the public sector. Police officers receive time plus 10 per cent for working nights, whereas junior doctors will receive a 33 or 50 per cent enhancement. Additionally, Police and fire and rescue service workers do not receive pay enhancements for weekend work. There are obviously considerations around industrial relations and recruitment to bear in mind, but considering the overall fairness of the offer, it’s not clear why doctors should receive much more generous unsocial hours supplements that those working in other essential 24 hours public services, many of whom are not allowed to strike.  

The archaic incremental salary scale, whereby junior doctors progress up the pay scale annually, is also for the chop. Under this system, a doctor could take three years out of the NHS and return on a salary 3 notches up the scale. The BMA says this discriminates against women who take maternity leave, but the proposed changes that would link progression to levels of training and seems more sensible and in line with the overwhelming majority of other professions.

The overall number of hours a doctor can work will be reduced from 90 to 72. Average hours will remain the same and other rules will limit the length of shifts and the number of long shifts that can be worked in a given time period.

Very little of this has been discussed properly, as insults have been traded and misinformation peddled. But with patients set to be dragged into the dispute, something has to give.