How much should a doctor earn?

The British Medical Association has called the recent pay rise awarded to some NHS staff a ‘brutal cut’ that will come as a ‘bitter blow to doctors’. Some doctors will now receive a 4.5 per cent salary increase, a cut in real terms. The pay award does not include doctors in training, who are still subject to a pre-existing deal that gives them a raise of only 2 per cent. The junior doctors committee of the BMA is preparing to ballot for future industrial action.

Doctors’ pay has been a fraught and contentious issue since the foundation of the NHS. Never quite enough, but always well above the national average. Consultants have been seen both as affluent, golf-playing members of polite professional society and as under-resourced, overstretched civil servants. Junior doctors are supposed to be motivated by duty and vocation, but have regularly engaged in trenchant negotiations and industrial action to increase their pay.

In 1950, two years after the NHS was launched, GPs threatened to withdraw from the service entirely if their demand for increased remuneration was not met. In 1956, Dr A.E. Loden of Tunbridge Wells suggested that all GPs should resign from the NHS and offer the same services for an annual premium of £5 per patient, paid directly to the doctors.

In 1957, the government appointed a Royal Commission on Doctors’ Pay, which acknowledged that the ‘current earnings of doctors … were too low’. During the 1960s and 1970s there were repeated campaigns on behalf of the BMA to increase doctors’ salaries. In 1966, the Guardian reported that staff morale in the NHS was so low that up to five hundred doctors were leaving the UK and Ireland every year.

Junior doctors and consultants engaged in industrial action for the first time in the 1970s, framing their demands for higher pay in terms of their poor working conditions. In 1986, doctors were offered a 6.2 per cent pay rise but in 1990, the BMA told the pay review bodies for doctors, dentists and nurses that since the early 1980s, doctors’ pay had slipped far behind that of the other professions with which they were traditionally compared.

These periodic campaigns for better pay met with some pushback. Throughout the 20th century, there was disagreement over whether doctors were workers or a special set of elite, bourgeois professionals. This debate didn’t only get to the heart of the question of what if anything makes medicine special or different from other pursuits or practices, it also tapped into broader questions about the ethics and viability of industrial action by doctors and the place of the NHS in British national identity.

In 1965, Brian Abel-Smith cautioned against pay rises for doctors because young GPs were already paid ‘much more than their contemporaries in other occupations’. In 1975, the full-time salary of a consultant was between £7500 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.

Doctors themselves were often uneasy about their collective efforts to increase their pay when other members of the NHS workforce earned so much less. In the mid 1980s, a ward sister at a London teaching hospital took home £104 per month. ‘I need my nursing colleagues and value their help,’ a consultant said. ‘Such disparity in salary scales makes me ashamed.’

The discomfort was especially acute against a backdrop of widespread poverty and unemployment. In 1974, 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?’ Eight years later, a pair of doctors wrote to the BMJ to argue that their colleagues should be prepared to forgo any pay rise ‘while there is so much hardship among the unemployed’.

The idea that doctors’ pay was already much higher than that of other British workers dogged demands for salary increases. Hostile politicians and newspapers weren’t slow to point it out. During the 2016 junior doctors’ strike over pay and working conditions, the Daily Mail ran such headlines as ‘Luxury holidays of the junior doctors leading this week’s NHS strike.’ Last year, too, the Mail drew repeated attention to the salaries of GPs (they make £100,000 a year, on average) in its coverage of doctors’ pay debates.

For some people, though, there was something unbecoming to the profession, or even unethical, about doctors seeking higher pay. A surgeon wrote to the Royal Commission on the NHS in 1976 with high-minded concerns: ‘Doctors have to decide whether medicine is to remain a profession with ethics or to become an industry with strictly regulated hours of work.’ He criticised the industrial action doctors had been taking part in by arguing that the withdrawal of services would ‘make nonsense eventually of any idea of vocation’, which was ‘over and above job satisfaction and one of the chief prerogatives of the profession’. The ‘element of vocation’ is difficult to ‘define or evaluate’, he wrote, but described doctors as having a ‘calling’ – it was ‘something personal’. The same year, Philip Hugh-Jones of King’s College Hospital wrote to the government to argue against industrial action, which had ‘immediately put the doctors on a par with the trade unions and other workers’.

These ideas are still around. In 2016, the Telegraph argued against industrial action by junior doctors because their ‘vocation in life’ is ‘to care’. There has been a slow but perceptible shift, however. While older notions of a medical ‘calling’ and exceptionalism still exist, the identity of the NHS doctor has changed.

For one thing, deference has declined. This has had a paradoxically positive effect on doctors’ ability to advocate for themselves in the same way as any other public sector workers. Second, the strategies of doctors campaigning for better pay have changed. If, in the 1960s and 1970s, they were content to argue for salary increases on the basis of their own working conditions and entitlement, they have more recently placed themselves in the broader context of the health service and its workforce. They ally their working conditions to the funding conditions of the NHS, and tie their pay to the quality of care they are able to provide their patients. Third, the politics of medical workplace wellbeing have become more salient, particularly in the context of the pandemic. And fourth, despite the crises in ambulance provision, waiting lists and general practice, public commitment to the NHS remains high.

The next time doctors go on strike – in the face of real-terms pay cuts and worsening work conditions – they’ll do so with the support of over half the British public. What they might have lost in deference and exceptional social status, they have gained in solidarity.