Winner of the New Statesman SPERI Prize in Political Economy 2016

Tuesday, 26 April 2016

Junior doctors: asking the right question

A government source (anonymous of course) has told the BBC that junior doctors, in their long running dispute, are really trying to topple the government. It appears some in this government really think that this dispute is their version of the 1984 miners’ strike. A compromise to trial the new contract, which would have almost certainly led to the strike being called off, was rejected by Jeremy Hunt as ‘political opportunism’.

It is natural when this kind of standoff happens to choose sides. The government is trying to introduce a 7 day week culture into the NHS: are they trying to do this ‘on the cheap’ by suppressing pay (and safeguards against excessive hours), or are the doctors being unreasonable and putting lives at risk?

I think that is the wrong question. A much better question is to ask how this dispute came about in the first place. The mine workers had a long history of strike action, but this strike by doctors is unprecedented. Unlike coal miners, doctors are not in a declining industry, and they are not led by the likes of Arthur Scargill. Instead they are a key part of a sector where demand continues to rise, and technology (for the moment at least) tends to add rather than reduce costs.

In this context, this government and its predecessor have tried to do something pretty radical, which is to reduce the share of NHS spending in GDP (for a chart from the Kings Fund, see here, and for details of the NHS squeeze see here). It is part of their attempts to reduce public spending, initially under the pretext of deficit reduction but in reality to allow tax cuts. In their typically Orwellian way, they call this ‘protecting the NHS’. Their hope is that this squeeze on resources will reveal and end inefficiencies which until now vested interests, lethargy and bad management have maintained.

An alternative way of achieving the same goal is to embark on a top down reorganisation that you believe will make the system more efficient.

The 2010 coalition government tried to do both at the same time. You do not need to be an expert on the health service to guess that trying both at once would be a disaster. Any kind of successful wholesale reorganisation of a large organisation costs resources in the short term, even if it brings benefits in the longer term. Predictably, according to the experts, this reorganisation was “distracting and damaging”.

Did the new (2015) government learn the lesson? Silly question. Introducing a 7 day week culture into the NHS may well be a good idea in principle, although the evidence is not nearly as clear as Hunt suggests (which is why trials are a good idea). Using dodgy statistics to suggest to the public that going into hospital at weekends rather than a weekday was dangerous was an extremely irresponsible thing to do. To the extent that there is a problem it is unclear whether doctors are critical to it. But even if the reform itself is justified, it is another reorganisation that requires resources in the short term.

Aneurin Bevan, who set up the NHS, said that to persuade reluctant doctors to accept the idea he had “stuffed their mouths with gold”. Reorganising doctors’ contracts was bound to create winners and losers, and in a profession with considerable solidarity that would not be agreed to without extra money to compensate the losers. To try and do it while starving the system of resources was just crazy, and allows doctors to tell themselves that they are striking to save the NHS rather than to protect their pay.

The only similarity with the miners strike is that the doctors also cannot force the government’s hand. The more they escalate the dispute, the more their solidarity and public support will fragment. Jeremy Hunt has already got away with putting party interest above public probity once in a previous job, with Cameron’s active assistance, and he may profit this time as well. If he does demoralised UK doctors will leave in increasing numbers for more congenial working conditions overseas, and gaps will be filled by doctors trained overseas (if the home secretary lets them in).

The question to ask is not which side is right, or whether the strike is justified. The critical question is how did we get to this situation, and what that tells you about this government’s competence. The NHS works on relatively meagre resources because of the goodwill of those that work within it. Do we really think that facing down UK doctors is the way to get a better NHS? If the government does not compromise, the only losers in this dispute will be you and me.

Postscript (29/4/16) This by Ben Dean in the Telegraph makes similar points, and even questions whether the new contracts are better than the old in achieving a true 7 day week goal. 


  1. Yes- And of course another large part of why 'ring-fencing' of the NHS has been a spurious claim has been the large cuts to social care than impinge so heavily on NHS resources. It's not just tax cuts the Government is after, it is out to discredit the NHS to reduce resistance to further privatisation so that this huge 'cash cow' can be a source of profit.

  2. When high earners say that they will move abroad if taxes are increased, it is rightly met with a lot of scepticism. Why do people think it's different for junior doctors? It looks like bluff to me, and apparently to the government too.

    1. Junior Doctors are NOT striking because they want lower taxes or more pay. Despite the insinuation here and what I've heard elsewhere, this is not analagous to bankers' bonuses.

      The issue here is that Junior Doctors will be forced to work longer hours despite already being overworked and often covering unsociable hours. Many fear making mistakes from lack of sleep and exhaustion. Many consider leaving the country or the profession altogether. Wouldn't you if you were in a stressful job but had options elsewhere that offered a better work-life balance? They are only human.

      Now, I agree with the government's overarching goal of having a 7 day NHS that provides full elective and emergency care on weekends. But that requires retaining and recruiting more doctors. Sadly, the government's actions are likely to have the opposite effect. The response will probably be to import more doctors from countries that can't afford to lose them.


    2. "I agree with the government's overarching goal of having a 7 day NHS that provides full elective and emergency care on weekends"

      The Department of Health have "clarified" that the "7 day NHS" doesn't refer to elective care, only to emergency and urgent care.

      Given that we already have urgent and emergency care 24/365 in the form of the ambulance service, A&E, acute medical and surgical wards, emergency operating theatres, 24 hour radiology services, emergency cover on the ward for sick patients, etc. etc. one can only assume that they're seeking to improve these services. If they were serious about this, they would know that of all the staff groups within the NHS, the junior doctors (along with the nursing and midwifery staff) are the most likely to be working to provide that 24/7 care already. Other staff - porters, radiographers, physio, OTs, lab technicians etc. etc. - often work similar hours but there is, in general, lower provision of diagnostic services and some therapy services at weekends. If they were serious, they would start by providing extra resources so that these services could run more consistently around the country at weekends.

      Finally, the evidence is that the public in general don't really want elective care at the weekend. Lots of GP surgeries who made appointments available on Saturdays and Sundays found that they weren't being filled, probably because the public would rather spend that time with their families or otherwise enjoying themselves rather than sitting in a waiting room.

    3. S -

      I think it's exactly analogous to banker's bonuses in so far as people don't make huge decisions about where they live and the job they do on the basis of even quite significant changes to their pay.

      And I'm afraid I don't buy most of the bleeding stumps arguments put forward by junior doctors any more than I buy Hunt's BS about weekend mortality. This is largely just a standard industrial dispute about pay and conditions.

      This is not to say that I don't support junior doctors: I do. They work bloody hard and are not particularly well-paid as it is. Why should they accept the unnecessary imposition of a worse contract just because of the stupid policies of an economically illiterate government? All power to them, I say.

  3. Krugman blog June 5, 2011 'Canadian Health Care in Perspective' has the Commonwealth Fund ranking of the NHS in 2010. It was in an excellent position when the Labour Party was voted out of office.

    The upcoming 2016 EU referendum, which unlike the previous European referendum in 1975 that seemed largely to be about the split in British socialism, this time appears to reflect the deep problems in contemporary English conservatism.

    I have found Matthew Bennett's blog posts at the LRB about the motivations behind government changes to English education to provide further evidence of the Conservative's dishonest politics.

    And so it is not much of a surprise to find paranoia starting to grip a government with a wafer-thin majority in a country with an increasingly unsuitable electoral system.

  4. As an American I'm pleased that the British are finally making some sense and working towards rebuilding their seriously flawed medical system to more resemble the wonderful, highly efficient one we have here in the States.

  5. Simon, I do hope that this article will not be construed as criticising the government because, if it had appeared after 1st May (and you being financed by a government grant) you could lose your grant money as the rules about anti-government lobbying by government-funded bodies come in.
    Please be careful about writing anti-government stuff in future. If they do get heavy with you I suppose you could claim that your human right to free speech was being infringed. But you had better do that quickly because Mr Cameron is thinking of pulling the UK out of the European Convention on Human Rights. Mrs May certainly wants us out of it.

  6. This puts into context the real agenda behind the governments strategy, they firstly pick their fight, those they think they can win, the junior doctors being the first in line, all the others would follow on after the government has so say won, but finally unlike in the miners strike, the rest in the NHS understand they will be next inline and are themselves preparing to ballot for a strike, the sooner the better.
    This document comes from the governments own think tank headed by Nicholas Ridley in 1977, and shows in detail how they planned the denationalisation of the state and the methods essential to achieve it.

    There is nothing like evidence written in their own hand to destroy the myth that they are doing this for the good of the nation.

    This is the ongoing agenda to dismantle the state and subjugate it's people into debt and reliance on a monopolistic private sector.


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