No 68: Junior Doctors' Pay, Strikes and Morality

Disclaimer:

Firstly, I am not a BMA member.

Secondly, I am not sure this post is finished. I was trying to tie together threads in my mind and I think they are coherent but perhaps not polished. I am hoping that by publishing them, some kind souls will help me improve the idea. Please feel free to leave a comment.

TL:DR

My three points in this post are:

Firstly, junior doctors are working harder than ever, in a system that is more stressful than ever.

Secondly, that Christian Social Democratic morales presume that it is the duty of the rich and the strong to altruistically look after the needy, and therefore, junior doctors such sacrifice their own health, wealth and happiness for the greater good of society and the NHS.

And lastly, that this situation is unsustainable. A strike is not the answer. It will not prevent a whole cohort of our best and brightest being burnt out. It will not prevent the brain drain to other professions and other countries. The only thing that will work is a radical overhaul of the entire UK healthcare system.

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"We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.

That to secure these rights, Governments are instituted among Men, deriving their just powers from the consent of the governed,

That whenever any Form of Government becomes destructive of these ends, it is the Right of the People to alter or to abolish it, and to institute new Government…”

The Declaration of Independence, July 4th 1776

2400 

This is what junior doctors were paid per month in the early 2000’s. At the time it was a very good salary. 

20 years later… and 2400 is still roughly the average monthly salary of a junior doctor, in the first few years after medical school. 

Over the last 20 years, inflation has devalued this pay check by roughly 30%. That is the equivalent of someone’s rent or mortgage per month less than a doctor used to be paid.

So, a junior doctor today is paid roughly 30% less than a junior doctor 20 years ago. 

In addition, to that 30% pay cut, current junior doctors are probably working harder than previous cohorts for a number of reason. Firstly, there are more drugs and treatments now, so there is more to learn, more to memorise and more to prescribe. There are new treatments for stroke and heart attacks that require very urgent treatment, whereas 20 years ago these patients would have just needed clerking and putting in a bed. So modern doctors may not work as many hours as previous generations, but the hours we do work are far more intense.

There are many, many new guidelines which require learning, memorising and following. The patients are on the whole older, larger, on more medications and more unwell than they were 20 years ago.

In short, medicine is more complicated, more urgent, more intense and as a result a lot more stressful than it was 20 years ago.

On top of that you are more likely to be sued and referred to the GMC now than you were 20 years ago. 

In conclusion, as a new junior doctor, you are paid a lot less, for a job that is more much stressful than previous generations. 

Now, lets zoom out a little bit. 

Everyone knows that the UK healthcare system has been “running on good will” since the NHS nationalised healthcare in 1948. The monopoly system deliberately controlled wages and expenses for the “common good”. 

Yet, healthcare staff and doctors were still expected to provide the best service they could for their patients, and so, doctors have always been expected to go above and beyond what they are paid. Even when what they are paid has been below the “market rate”. 

Examples of going above and beyond include: 

1. Staying late to treat a patient, or arrange a test or follow up

2. Staying late to update the list 

3. Staying late to prepare for the next day 

4. Staying late to prepare the morbidity and mortality results and slides 

5. Teaching juniors and students 

6. Doing audits, QI and research in your spare time and not being paid for it or receiving any sort of formal qualification or recognition 

7. Doing QI to actually improve the service and then having to deal with the paperwork and business cases to make it viable 

8. Doing most of the admin work to make a service or unit, actually viable 

9. Seeing extra patients 

10. Reviewing all of the test results that couldn’t be done during “clinical time” 

11. Helping out colleagues 

12. The list is almost endless 

These additional tasks, or free work or altruistic duties, have been expected of almost all doctors since 1948. The vast majority of doctors are still doing all of these things in addition to their paid work and doing their best for their patients. 

Modern junior doctors also have to pass extensive exams which are very expensive, they also need to jump through admin hoops and keep huge portfolios up to date. All of this is in addition to all of the above and must be done in your “free time”. 

So, the conclusion from all of this is that modern junior doctors are working for less money and having to use up almost all of their free time just so that they can continue to keep their registration and keep their jobs. They are underpaid and overworked. 

Is this moral? 

Western society is mostly based on “Christian morality”. In the last 150 years there has been the evolution of “Christian Social Democracy”. 

The principles of our society and morality can be summarised as follows: 

1. The strong have a duty to help the weak and needy. 

2. If you are in need, then this should be provided by “society” or the state. 

3. We all have “human rights” and therefore, your right “must” be met. 

4. If you need food, you must be given food by someone. 

5. If you need water, you must have a drink. 

6. If you need education then the state must provide a school and a teacher. 

7. If you have a healthcare problem, then society must provide you with a clinician and a treatment. 

Most people would not find this controversial, or even really question these principles. In theory, they are good. They are nice. They are right. 

They should not be questioned. 

However, they have been questioned by some individuals, such as Nietzsche and Ayn Rand. And I would suggest reading the following works by Ayn Rand: 

1. The Fountainhead By Ayn Rand

2. Atlas Shrugged by Ayn Rand

3. Free Market Revolution: How Ayn Rand’s Ideas Can End Big Government By

   Yaron Brook, Tom Weiner, Don Watkins

These books are worth reading for the pleasure of their plot and purely as an intellectual exercise. Some times, it is worth taking a critical look at our underlying assumptions and testing them to see if they stand up to analysis. 

Rand’s morality can probably be summarised as follows: 

• No one has a right to demand the wealth or services of another individual. 

• Everyone should strive to be independent, resilient and strong individuals. 

• People should look to trade and barter as equals without coercion. 

The state, and society, should be limited and only use coercion and force in as few instances as possible. To protect the life and property of those within the state. The principles stated above in the Declaration of Independence.

The strong do not have a duty to donate to the needy, however, they could choose to do so. The needy should not expect help, just because they are in need, but instead should look to exchange for what they need. 

Why is any of this relevant? 

Junior doctors are being paid 2400 a month to work in a creaking system that expects them to go above and beyond. They are at breaking point. 

Either they will strike, they will leave medicine, they will stop caring or they will leave the country and go somewhere with better pay and a less stressful job. 

This combines to mean a brain drain. 

A brain drain from the NHS would be fatal. Not just for patients, but also for the system and the country. You can not simply replace an entire generation of doctors.

If the current trajectory continues, then the NHS will collapse, people will be left with potentially no access to healthcare and the politicians will panic and probably lose their seats. 

Junior doctors are expected to be strong, resilient and altruistic. They are expected to provide for all those within need. They are expected to sacrifice their free time, their health, their happiness and their potential earnings, all for the good of their patients, the NHS and society. 

This moral code is breaking a cohort of good young people. 

My question to you as junior doctors is: is it right for you to sacrifice your life for the good of the current NHS? 

My question to you as patients is: do you think it is safe to have a burnt out doctor looking after you or would you prefer a system where your clinician is excited to be at work and is fresh and healthy and focussed? 

My question to the government is: are you prepared for your junior doctors to give up caring? Give up working or leave? Are you prepare for the system to be put under even more pressure by people working to rule and not doing all of the extra work? 

My final point for you junior doctors is this: you should look after yourself first. If you do not look after your own health, wealth and happiness, then no one else will.

If you are not healthy and focussed then you won’t be able to do the job as well as you want to do. And if you continue to sacrifice yourself for your job, once you are burnt out and on sick leave at home, will the system really care about you? 

We are cogs in the machine and if we burn out, the machine will replace us without caring. No one will honour you as a fallen martyr. That’s not how our system works, but it is what the system expects of us. 

Should junior doctors go on strike? 

What would Ayn Rand say? 

I expect she would argue that a formal strike would not help because after the strike is over, will the system change? Or will you just have slightly more money? Will you risk the lives of your patients for no change in the system?

I think she would say that if you care about yourself, your self worth, and your own desires in life, then you should voluntarily withdraw your labour from a system that expects you to sacrifice all of these. 

Be that working to rule, leaving medicine, leaving the NHS or working abroad. 

This would have a much greater effect on the system and hopefully, improve your own quality of life far more than a formal strike would. 

There are two alternatives, firstly, that you except the system will grind you down and you carry on regardless. The second, is that you commit yourself to overhauling the system radically.

Accept, Leave or Improve - the three options facing our generation.

Thank you for reading these ramblings.