Tuesday, 16 February 2016

Maybe The Government Wanted Me To Write This?

Next week junior doctors will be taking their nuclear option and starting a series of complete strikes. While their previous walkouts have left emergency and critical care cover in place, this time they won’t. I wonder how many, when voting on the strike ballot back in November realised how far this would go, and how many would change their minds now, considering risks to patient safety and  to their own public support.
The BMA is probably the most powerful union in the country. Its members are well educated, respected by the public, photogenic and middle class, and crucially people don’t think of it as a trade union. Trade unions are full of burly working class men covered in coal dust. When doctors start agitating, social media is filled with middle class solidarity, petitions and opinion pieces shared by people who would never dream of doing the same for striking tube workers. Indeed, a popular graphic directly compared hard-working junior doctors to those feckless and overpaid tube workers.

Current pay distribution for doctors. Left three peaks are for juniors.

Doctors therefore start with from an extraordinary position of strength compared to other unions, and as such the BMA has had great success in the past at achieving its goals through soft power, making public statements and quietly lobbying without the need for a real strike. The union has therefore managed to preserve the relatively privileged position of doctors rather well. In spite of often understaffed hospitals, they have successfully limited places at UK medical schools. There is no shortage of capable people willing to be doctors, thousands more bright teenagers apply for medical school than are accepted, but if the supply increased, wages would fall. This is a completely reasonable thing for the BMA to do, all unions protect their members’ interests, that’s their job, but we shouldn’t see it as any different or more high minded just because it’s for middle class professionals. Equally, it is the job of the government to get the best deal for the taxpayer, and spending more money on wages for doctors isn’t necessarily the ideal use of scarce NHS funding.

With regards the actual substance of the deal, the gulf between the BMA and the government is actually rather small. The final sticking point was over how many Saturdays junior doctors would have to work before they were paid extra. The government offered extra money if it were more than one saturday a month, the BMA wanted all Saturdays to be paid a premium. Had the government conceded here, they would have called off all industrial action.

Since then, however, junior doctors on social media have been whipped up into a frenzy. As a medical student, I’ve watched this first hand both in person and on social media. Anyone not fully on board is subject to tirades of abuse by an army of medics utterly convinced of their own righteousness. For the first time in their lives, the class swots are getting to be rebellious, and they’re enjoying it rather too much. Facebook is filled with posts from doctors and medical students warning each other not to believe the mainstream media lies, retreating into a conspiratorial mindset more often associated with Communists, Scottish Nationalists and Donald Trump fans. Once this happens, it’s only a matter of time before they lose public respect, and I worry that they’re too far gone to back down now. There is even some suggestion that their leader, Johann Malwana, realises things have gone too far. He tried to exempt children’s healthcare from the strikes, but was overruled. Has he unleashed something he can no longer control?

Most statements around the strikes are wrapped up in very high minded rhetoric about protecting the NHS from private companies, often including a conspiracy theory where the government deliberately tries to crash the NHS so they can sell it off to private sector cronies. This seems very unconvincing to me. While many doctors moaned about the NHS reforms of 2012, they did not strike then. Instead, that same year, they went on strike over changes to their pensions. The last time before that, in the 1970s, it was over the right to private work for consultants. Again, these are all totally reasonable things to be concerned about, but they are matters of industrial relations and pay, not a crusade to save the NHS.

The doctors have also talked a lot about patient safety. This is a sensible decision to get the public onside. People are far more sympathetic to saving lives than increasing the pay of someone earning well over the median wage. Many previous studies, however have looked into doctors working hours. Ironically, these were responding to concerns at the time that limiting doctors hours were dangerous. Old school consultants who had to work 90 hour weeks as juniors felt that limitations imposed on working hours would mean understaffing, as well as a lack of experience by the time the juniors became consultants themselves, which would harm patient care. The evidence does not back this up, with both published meta analyses finding that there is not enough evidence to say patient safety is made either worse or better by any changes in working hours.

In the last few weeks I have seen several doctors and medical students on facebook approvingly sharing this. It argues, correctly, that there is nothing to stop individual NHS trusts from negotiating their own contract settlements with the doctors who work there. This would be very appealing to the strikers, who presumably think their own trusts would offer them better pay and conditions than the Department of Health, or at least stick with the old contracts. I'm not aware of the BMA making a statement on this yet, but they have been very wary of it in the past. For a union to have negotiating power, it needs to have a monopoly on the supply of labour. Allowing each NHS trust to negotiate separately would fundamentally undermine this.

Individual pay negotiation and the breakup of large public sector unions combines well with the government's agenda of breaking up the centralised NHS. NHS trusts would be able to experiment with different pay structures on a local basis, and maybe even compete against each other to attract the best junior doctors onto their staff. The Department of Health would no longer have to negotiate with the BMA, in fact the BMA would essentially have ceased to exist for the purposes of pay negotiation. This may be a good thing for the country, but it would hardly fit the aims of the strikers, they’d be cutting off their nose to spite their face.

None of this is to say that doctors shouldn’t try to improve their working conditions or pay. They should, however, be careful with how they proceed. This is a simple contract negotiation, albeit one that has become very hostile. Though the BMA have a lot of power, this power is vulnerable. Doctors are one of the few professions left with the respect of the public. Once a profession loses this respect, it doesn’t come back. Spending all their public sympathy on endless strikes over what is in the grand scheme of things a small issue is dangerous in the long run, and could jeopardise the future of the profession.

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