How much should a doctor earn?
Agnes Arnold-Forster
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.
Comments
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17 August 2022
at
6:21pm
XopherO
says:
When Bevan tried to found the NHS he was faced with the hostility of doctors to it. To get them on board he had to agree that they would be allowed to have private patients (today at one of the highest fees in Europe, as then.) The BMA has always supported doctors rather than the NHS, and was responsible for the hospital doctor overtime deal that was supposed to pay doctors to watch tele at home, but backfired due to the shortage of doctors and consultants created by the desire of the BMA to restrict the number of doctors to give a strong hand in pay negotiations!! So some on-demand doctors were out working for just 10% of overtime pay, and it led to the horrendous hours junior doctors worked while consultants enjoyed weekends on the golf course or wherever. That in turn led to the rumble over weekend working with the now 'holy' Jeremy Hunt - who is left in the 'one-nation' Tory establishment - even though he is and was as bad as the rest. The British public has no notion of the history and so will support pay rises for some of the best paid doctors in Europe. All in the false name of the 'best in the world' health service, and this national (on its knees) 'treasure'. There is no hope. People will die unnecessarily, some 100,000 a year or more, as they have been for years now.
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17 August 2022
at
7:36pm
David Gordon
says:
Well, three things please:
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18 August 2022
at
9:49am
XopherO
says:
@
David Gordon
'Golf' is just a metaphor for the absence of consultants from hospitals at weekends leaving junior doctors in charge. Health care is political, like most services, but politicians have chosen to rearrange the deckchairs rather than create a system of sustainable funding that doesn't let in rapacious American companies as at present. There are too few doctors (one of the poorest ratios in W Europe) and not enough modernisation of provision to make for bearable working conditions, which helps retention. The UK has never trained enough doctors or nurses, partly because the GMC and BMA have impeded it with the tacit approval of governments who wanted to restrict spending. The mix of private practice that Bevan was forced to accept has played its part in undermining the NHS, as has the silly mantra 'best in the world' which if it was ever true was certainly not by the early 1960s - if you are the 'best' so easy to not try to be better. But the mantra still plays, particularly with Tory politicians who know it is a lie, but also with the general public who do not know any better because they know nothing of provision in other countries
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20 August 2022
at
12:55pm
Robert
says:
@
XopherO
1.Some years ago the Audit Commission found that hospital consultants worked on average 10% more hours than they were paid to do. Do we have non-anecdotal evidence to the contrary?
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17 August 2022
at
7:37pm
David Gordon
says:
Plaid?.... played
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18 August 2022
at
2:02pm
Patrick Cotter
says:
How can a country that spends billions a year - since 1945 on fighter jets, jet bombers, aircraft carriers, nuclear submarines, tank squadrons, etc., as if it were still a superpower, expect to have the money to pay a nurse a living wage? You can't have both. Until you British address that quandary, all the industrial action, agitation for tax reform, changes of government, etc. will be just like replacing the colour of the paint on the bars of the cage you have made for yourself. The Russians, in their invasion of Ukraine, have proved, even with all their military investment how futile military ambitions and expectations can be. They've proved they are unable to reach Western Europe with conventional arms. Against who exactly are you British wasting all your taxes?
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18 August 2022
at
3:03pm
XopherO
says:
@
Patrick Cotter
This a common argument, but the UK spends about 2.3% of GDP on defence and around 8% on health. Even 10.3% would not solve the problem because of the backlog of underspending. France spends around 11.5%. In government cash terms, defence is about £32 bn, while health is over £150bn. The NHS probably needs at least £40bn a year more in real terms - though probably not all at once given the wastefulness of Blair's billions in 2000 after the WHO report exposed the UK NHS as only 19th in the world, France first. There needs to be a proper plan to get out of the current black hole, with consistent and annually increasing expenditure, starting perhaps with an extra £15bn to shore it up. But certainly it could start with trimming the defence budget substantially. It won't happen! Not under this government or a Starmer-led one.
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18 August 2022
at
5:07pm
bentoth
says:
A few points to add, one already made I think. All are details but all make a silent contribution to the salaries of GP partners and consultants.
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21 August 2022
at
3:03pm
Fred McElwaine
says:
@
bentoth
‘Consultants used to have full time salaries for part time work’? Where did this come from? It certainly isn’t the case now and hasn’t been for decades, if it ever was. The basic consultant contract is for 10 programmed activities, each is a 4 hour block of work, 40 hours, not remotely part time. There are no perks to being an NHS consultant and most do extra hours which aren’t paid for at all. If the Tories keep on undervaluing NHS workers, they’ll find out just how much unpaid work is done by NHS staff.
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21 August 2022
at
2:54pm
Fred McElwaine
says:
We’re not asking for a pay rise, we’re asking that our pay isn’t cut again after real terms cuts of over 30% since 2010. It’s all well and good saying ‘oh but it’s a vocation’ but that doesn’t change the fact that inflation marches on. Comparing doctors’ pay with other workers is difficult, which other professionals put up with such sustained hostility from the right wing press, while working under ever worsening conditions, with ever rising responsibilities? Either the U.K. government starts valuing U.K. doctors adequately or they’ll leave and go to a country that does, which is already happening. George crosses and applause count for absolutely nothing if our pay keeps falling. The Tories say they want a high wage economy, no better place to start than people payed by the state. Oh and the idea that consultants spend all their time on the golf course is a tired and obsolete cliché, very few of my colleagues play golf and I’ve worked weekends my entire career, not just on call, in work and very much on the front line, contrary to Hunt’s nonsense.
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22 August 2022
at
9:49am
XopherO
says:
Is it still the case that consultants can opt-out of non-emergency weekend and evening work (just do 10 4 hour units in normal hours), and if they do attend for emergencies they are paid overtime at an hourly rate, which can be as high as £200/hour? And of course there is the old bugbear of them doing private work in private hospitals although they are trained at government expense in the NHS to work in the NHS. And if a patient in a private hospital needs intensive care they have to be transferred to an NHS hospital as a priority.
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27 August 2022
at
9:18pm
nlowhim
says:
Nice article. Im mainly thinking about the US. As these comments can attest to, if a society’s bonds and trust fray, that distrust gets thrown at the most visible targets nearby. So distrust at the healthcare system (a massive eco system with many players, not all with the same goals) gets pointed at the easiest target, doctors and nurses. Insurance companies? Hospitals? Don’t see them targeted much,
Read more1. Can we please stop using "doctor" and "golf" in the same article? I have been a doctor for 52 years and the number of doctors I have known who also plaid golf is fewer than the fingers on one hand.
2. The biggest problem by far for doctors here or in most other countries is
political nonsense surrounding the health care system. There are votes in health care, but near-zero understanding by politicians of the real issues.
3. If you do not pay doctors enough they will leave. Doctors are a near-perfectly fungible commodity. The "modernising medical careers" fiasco of 2005 did wonders for the staffing of medical practice in rural Australia.
2. Hospitals run by junior doctors, in as much as they ever existed, are a thing of the past. Some specialities such as paediatrics and obstetrics have consultants resident in the hospital 24/7. Even in psychiatry, new admissions are reviewed by a senior doctor in person over the weekend.
3. I could go on. The strength of feeling people have about doctors and the NHS seems to prevent open-eyed accurate appraisal of the issues.
4. This problem affects both Left and Right.
5. Declaration of interest. I'm a hospital consultant. I think consultants are overpaid. But then I don't think anybody should earn over £100K.
Consultants used to have full time salaries for part time work (this may not be the case now but for many years it was a nice perk which allowed them to move wealthy patients seamlessly to their private practices)
GPs have always enjoyed various practice benefits which topped up their income .
The merit award scheme was a very handy top up which used to be awarded locally between colleagues. It has been reformed but remains a silent salary boost costing the NHS over £100m a year
I’ve been wondering why that is. In the 90s HMOs we’re a regular target, no more. Corporate consolidation of the media certainly plays a part of that, combined with the successful class warfare the big players have used to, as their ilk have said, “get half of the working class to fight the other half.”
I’m sounding conspiratorial, and that at least parallels the amount of conspiracies that many Americans feel or sense or make up about the big players in their society (or corporations etc). Most that I hear are “doctors in cahoots with big pharma” in terms of the actual conspiracy theory of COVID being either oversold or made up or the same about vaccines. And what they use as example is how some doctors did seem to buy bs papers to oversell opiates which led to the previous epidemic.
Of course the funny thing is none of these (made up) conspiracy theories actually tackle real corporate powers where it hurts them. People seem to sense when they are outmatched.
Kind of a ramble here without much to say except, of course, when one sees another health care system with clear austerity and how what follows isn’t concerted United fronts against the powers that be but rather just focusing on the nearest face of it, no matter how relatively blameless.