The NHS has recently revisited the challenging issue of strikes by clinical staff – and not for the first time in the last 50 years. Why do we need to repeat this, generation after generation? And why do we in the UK struggle to learn sound employee management and implement good practice from previous experiences?
Lessons from historical strike action
In 1975 while Barbara Castle was health minister in the Labour government, junior doctors were pushed to the point of strike action. Then, as now, it was the overwhelming disregard by the government of the day for recognition of long hours and low pay that led to the strike. It is a relationship that sours professionals’ thinking. Their view is that over many years they have trained and developed trustworthy skills, and their delivery, yet the outcome is that their hourly pay is less than that of a Pret a Manger worker at around £14.00 per hour.
It was not that different in 1975; the hours were significantly longer then, yet the pay was very poor. The hospital cleaner responsible for cleaning the doctors’ residences earned more per hour than the junior doctors. These cleaners witnessed the long hours worked by their ‘young doctors’ and found it difficult to believe they were paid less than themselves – a real-terms hourly rate of just £1.10. Similar incredulity from the junior doctors was met with standard responses such as, “don’t worry… you have prospects”.
At that time, the junior doctor on-call rota for emergencies, and covering care for all the inpatients across a general hospital, varied. An on-call weekend would start on Friday morning at around 8.30am and finish on Monday evening at around 5pm. This was just short of 80 hours continuous working unless it was ‘a quiet night’ with no emergencies and no ward calls, which was unlikely in a city with a population of 300,000.
The most onerous rota was a 1:2 where a junior doctor was on-call either 132 hours or 84 hours out of 168 hours in a week. To be clear, this meant you might get some 10 hours of sleep across three nights of managing acute urgent admissions and being on-call in the wards with patients.
Managing lack of sleep and returning to bed at 4am having struggled to deal with an elderly patient with heart failure, or a young father bleeding pints from a ruptured ulcer, was very tricky. Practicing safe clinical care with sleep deprivation and round-the-clock callouts was at times torturous.
Never ask junior doctors to share about their inner and worst thoughts at 4am after a very long period with no access to food, drink, or rest. Sleep deprivation, worries about being safely competent with patients and the ability to take multiple decisions whilst exhausted, often means they see themselves as not 100% fit to take safe action.
Fair pay is essential
Medics are dedicated to their vocation and the majority now, as then, love what they do and deeply value working in a team. The situation with remuneration back then was unfair, leading to understandable bitterness and culminating in the strike of 1975.
The positive change in the decades that followed included moving to a kinder shift rota, a reduction in hours on call, and less sleep deprivation – so safer practice in line with the European working time directive. But over the past decade, the Covid-19 pandemic and long-term erosion of employer support to junior doctors and all clinicians, has seriously impacted morale.
Where are we going as a country if we ascribe less and less value to those working in public services? Can we not pay junior doctors a fair salary to ensure they are not earning over a quarter less than they were in 2008 for the irreplaceable work they do for our common good and health.
The commitment of clinicians during the pandemic was a superb example of effective team working during a time of intense crisis and change; pulling together, covering each other’s shifts, doing double shifts as staff fell sick with Covid, being relocated to other wards or services and needing to consult patients using technology. Contracting Covid two or three times as an NHS health worker since January 2022 has not been uncommon.
Many clinicians were subject to the trauma of witnessing or treating distressingly ill and dying colleagues. Every UK hospital would have such an example. Many clinicians, including junior doctors faced an uncertain journey as Covid started and progressed, not knowing if they would emerge alive. The clinicians who died took with them decades of irreplaceable healthcare experience, like the head of renal transplants UK, Professor Donal O’Donoghue. Yet they took on the workload challenge and today some are left with long Covid, reduced capacity to work long term and less lifetime income.
The lesson of constructive engagement
The compassion the current health minister has for the plight of NHS clinicians is more than lacking. There is a marked reluctance to take action and follow the 1975 health secretary’s example and engage in negotiating constructively with the junior doctors – a rich and missed opportunity.
Castle negotiated with the junior doctors’ leaders through the night of 11 December 1975. At one point she is reputed to have said something like “This is exhausting, I need some sleep”. The junior doctors realised they had made their point, as this was just the start of the night for them. Negotiations lasted until early hours of the morning with a valued outcome – deemed fair and kind for those willing to dedicate their lives to saving our lives and who meet their duties with integrity and compassion.
Not to be taken for granted
How do we retain the doctors we have nurtured and trained in our NHS and education system and not lose them to higher-paid and less-demanding roles elsewhere? Are we not prepared to pay more fairly from our public budget, for work done for such commitment?
Over 6,000 medical practitioners leave each year for fairer pay and conditions overseas, mainly to English-speaking countries. Why waste their talents and skills and our public money in letting them go? What have we done to allow this to happen yet again to our healthcare system? We seem blind and ignorant and lacking in care for our own common good.
The junior doctor on qualifying has an income of £28,000 per year, yet faces repaying a debt of around £90,000 for the six years of medical training, on top of purchasing accommodation and covering everyday living expenses. No wonder recruitment to Australia and Canada is brisk for UK junior doctors, as the pay, work conditions and rewards on offer are extremely attractive.
Following the 1975 strike and subsequent agreement on a basic working week time of 44 hours and paid overtime, the loss of doctors overseas was reduced, with the biggest growth in general practitioner numbers from 1984 onwards. In those days you might have 100 applications of newly qualified GPs to attractive posts in towns like Kendal in Cumbria. Cities like Bradford, West Yorkshire acquired top-quality GPs to work in such challenging areas like the celebrated Dr Maggie Eisner in Shipley. Today much fewer applicants are seen in GP practices across the UK.
Simple solutions for these times
A proposed remedy would be to cancel the medical school debt to £30,000 or less and increase junior doctor income fairly and with agreement that they will then work in the NHS for five years post qualification. Extrapolated from an idea suggested by the late Dr Sarah Burnett-Moore, radiologist and admissions tutor at Imperial College medical school, this would make a beneficial starting point. The brain and workforce drain would immediately reduce and then for each five years working in the NHS frontline an incentive recognition of skills value payment can be offered.
Likewise, the seniority payments for GPs based on number of seven-year periods in practice was a useful incentive to retain experienced practitioners in the 1980s and 1990s. Solutions are available, all that is required is the will, and good faith, to implement them. In the meantime, if you would like to support the junior doctors, the BMA has set up a strike fund – all donations welcome.