The Doctor is Out

As the BMA ballots its members on strike action, the workings of the government’s spin machine need to come in for an examination

When you think of selfish, over-privileged scumbags being paid far too much for a job that adds no value whatsoever to society, what springs to mind? Is it bankers, corporate lawyers, politicians; or is it NHS doctors?

Doctor, My head is spinning 

As the Tory government squares up for a confrontation with the BMA over changes to the contracts of all doctors below consultant grade, the spin machine is in overdrive trying to persuade us that the NHS is staffed with grasping, entitled and overpaid good-for-nothings milking the public purse.

The row has been rumbling now for the better part of a year, with the government shifting its position on a regular basis as each of its arguments have been knocked down or shown to have little traction with the public. The claims made to win headlines and then dropped as soon as they’ve been proven false or otherwise lost their utility include:

  • That this is not a pay cut. It is merely a change that requires NHS doctors to work more hours on the same salaries.
  • That this is a pay cut, but only for a minority of doctors.
  • That they have no idea whether or not this is a pay cut.
  • That 10pm on a Saturday does not constitute anti-social hours, to which Private Eye responded with this gem

NHS Number Crunching

In addition, the government has been running a parallel campaign that claims to be pushing for a “truly 7 day NHS” and conflating the issue with that of doctors’ pay. This has lead to people putting their lives at risk by not in to hospital for emergency treatment on weekends because the government’s line has made them think there will be no staff there. So pronounced is this phenomenon that doctors have dubbed it #thehunteffect.

The idealised form of the government’s argument can be found in this remarkable piece of propaganda in Rupert Murdoch’s Sun Newspaper.

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Now, painting the government as reasonable and doctors as unionised fat cats looking to keep their cream is a hard sell so it is worth looking at the Sun article in detail because it brings together all the techniques used by the government’s (publicly funded) spin merchants in one neat package. It is also very likely, based on my experience in the ugly world of spin, that it was directly briefed to the journalist by a Special Advisor in Jeremy Hunt’s Office.

The first technique is decontextualisation: the 11 per cent pay offer the article was referred to was not made at the negotiating table it was made through the media on the day that ballot papers went out from the BMA. As the doctors’ representative Johann Malawana observed, it was “megaphone diplomacy” not intended as an actual offer but designed to undermine the doctors position as a pure public relations exercise. The same goes for the claim that doctors have “shut the door” on negotiations. It is true that they have refused to negotiate given that the government is willing to discuss only one of the 22 points they have issues with, but putting forward an unacceptable offer and demanding that 90 per cent of it is acceded to without question before “negotiations” begin is not negotiation at all it is a cynical manipulation of public perception.

The second technique is the conflation of issues: The claim is made that keeping doctors’ pay at present levels stops the NHS from providing adequate staffing over the weekend. This just isn’t true. It is the case that non-urgent surgeries only take place on weekdays, but emergency care is available 24/7. While this particular article stops just shy of making the claim that there is no 7-day NHS, the claim has been given currency by articles in other newspapers and it taps into that latent understanding.

The third technique is comparing two different things as if they were alike: “Junior Doctors… are well paid compared to other public sector workers.” Yes, they are, compared to cleaners, traffic wardens and even nurses. This is because they are more highly trained and skilled. The idea that someone who is more skilled should be paid more is one that should be relatively easy to fathom.

The fourth is an appeal to prejudice and envy: By accusing the doctors of acting in “typical trade union style” they have been placed in a discourse that harks back to the winter of discontent, rubbish piling up on the streets and general strikes. The bad old days, in other words. The appeal to envy is straightforward enough to dissect – doctors have an overtime gravy train. The typical Sun reader does not. That is unfair and so the gravy train must be taken away.

And the final, most pernicious technique is dereliction of duty: This  is summed up in the last line condemning the BMA because “it puts its members financial interests ahead of the public’s needs.”

It is worth bearing in mind that the row is not about new contracts for people just qualifying as doctors, but existing agreements.  If your boss came to you one day and told you that your contract was being unilaterally altered to make you work longer and less sociable hours for less money, you would feel entitled to withdraw your labour because that was not what you signed up for. If your boss then said “you can’t strike because your skills are too important” you would wonder why they weren’t paying you what those skills are worth in the first place.

What is disgusting about this is that every NHS doctor is already taking a hit because they are working for the NHS at much less than the market rate for their skills, generally because they feel a sense of duty towards their fellow human beings. Hunt appears happy to use doctors’ consciences against them while appearing blissfully unencumbered by the Department for Health’s own duty of care towards its employees, leaving both the government and the Sun in the incongruous position of supporting the anti-capitalist stance of paying people less than the market rate for their wages.

[Addendum: It has been pointed out to me since this article went live that junior doctors can’t choose their overtime as the Sun article asserts so we can add “bare-faced lies” to the techniques listed.]

Politician, Heal Thyself

Ginuwine Remedys for ailments rehumatic, pneumatic and phlegtastic

Ginuwine Remedys for ailments rehumatic, pneumatic and phlegtastic

The interesting thing about the whole row is quite apart from the government’s position being cynical and constantly shifting, it is terrible politics and terrible economics. It also cuts to the heart of wider debates on how our society judges value.

Now it might be the case that doctors are on a publically funded gravy train and are destroying the NHS with their greed (it isn’t) but even if it were, I personally would rather than the person reattaching my arm after it has been severed by falling machinery or saving my child from meningitis wasn’t simultaneously worried about their mortgage or how they will pay for their daughter’s school uniform.

After all, the same government that claims to be on your side against grasping, greedy doctors has cut the 50p tax rate, wants to sell the public stake in RBS at a discount, is giving a free ride to millionaires through changes to inheritance tax and put forward a bill to cut tax credits that was so egregious that even the House of Lords – hardly a bastion of left-wing agitation- could not stomach it.

The people who have benefitted from these policies are sometimes called “wealth creators” in the hope this will distract from the fact that so much of the wealth they create either ends up in their own pockets or in political donations. Doctors, by contrast, do not create wealth, they merely help our workforce to be healthier and happier (not to mention more productive) for longer. A form of value those in power seem unable to process. In fact, for a government that prides itself on being stuffed full of business-minded, results-oriented people the Tory stance also betrays a lack of understanding of the basic rules of labour flow and the relationship between pay and conditions and the retention of skilled workers.

Unlike tube drivers or steel workers, Doctors do not fit easily into the bracket of bolshie militants. Many of them will be Tory voters or the children of Tory voters and all of them are articulate professionals both able to make their case and to access the media to ensure that their arguments are heard by the public. Moreover, most unionised workers have very limited options if things don’t go their way. A London tube driver can’t just up sticks and go to work for the New York Subway, a Redcar steel worker can’t just head off to China if the local works is shut down, but a medical professional with the best training in the world who is already working at 1/3 of the market rate can and will move to other countries if the combination of horrible hours, low pay and unrelenting insults to their value and professionalism continue.

But then, Hunt has already stated that his long term aim  is to privatise the NHS so maybe running it down by making conditions untenable for the junior doctors who are its backbone is exactly what he’s trying to achieve.

Doctors have yet to make the decision on whether they will strike. But their considerations should not include the ridiculous notion that the removal of their labour is unethical because the job they do is so important. If their work is so vital, they should be paid a fair amount for it. Unlike bankers who continue to get bonuses when the institutions they work for are part owned by the public, doctors add value and make daily sacrifices to look after the health of the nation. The government’s attempt to paint them as selfish for doing so is deeply destructive and morally bankrupt.

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23 responses to “The Doctor is Out

  1. Well put in the main. The only other point to pick up on from the Sun article is that we can’t actually choose how much out of hours we work. We are contractually obliged to do it as part of our training.

  2. Doctors and other Health Service workers have always been extremely reluctant to take action because they care about the patients.
    For them to consider withdrawing their labour must tell the rest of the population that something is wrong with the proposed new contract and we must all tell our M.P’s to stop this is process now.

  3. I disagree that doctors are not wealth creators. Any member of society who spends, rather than personally investing their money, is creating wealth. This is the same basic argument that exposes the fallacy of austerity and deficit reduction in the present context.

    Massive wage inflation is clearly counterproductive, but cuts are madness.

  4. Excellent arguments well expressed. I would only add that you could replace ‘doctors’ with ‘teachers’ and ‘Tory’ government with ‘any government’ over the last forty years and all that you say would be equally apropos.

  5. Another consideration is that doctors are clever and hard working enough to secure a job in banking should they wish to leave healthcare. They do not need to leave the country, but the NHS will still face a labour shortage. Ironically, if the NHS were to be privatised, Doctors would financially benefit (look at the US system of healthcare as an example and compare pay scales for the respective doctors) so if this were just about money then they would be happy with the concept of Jeremy Hunt in charge of the NHS. However, doctors are campaigning to save the NHS in its current state. The Government is spinning it so that it looks like a simple pay dispute, when in fact that is just one of many issues in a complex dispute including pay, conditions and staff and patient safety.

  6. The big shame of this is that Johann Malawana failed to make any of these points on the Today programme the other morning, up against a barely-hostile Jim Naughtie. The BMA, like many unions is crying out for a more impressive, media-trained spokesperson to play the press’ and broadcasters’ games and avoid falling into their traps.

    • He’s done his best to fight a good fight. But the BMA aren’t like your average union. They aren’t equipped for labour relations work because they never expected to have to do it. I think my next post will be on making the positive case for doctors and on strike tactics.

    • The question you should be asking is why have teachers and doctors have pay cuts when the bankers that caused the economic crisis are untouched and politicians have given themselves a healthy raise as well. Playing public sector workers off against each other is a classic tactic see the paragraph in my post about prejudice and envy

      • I’m a teacher. I’m so ashamed by Caroline’s comment, I had to speak out. The vast majority of the teachers (every single one that I know) support the doctors 100%! Good luck to you all. Stick together, to beat this grasping, ideologically bankrupt government. If there was more I could do to help, I would not hesitate to do it!

  7. Hunt’s point about need for 24/7 cover seven days a week or present lack-of is based on false interpretations of the facts — Hunt presents one item of skewed
    statistics to prove his point — there are several other ethical reports suggestions that emergency cover is available seven days a week.
    This is just another example of a politician or his backroom boys coming up with a “pro-active” idea to justify their worth or just for the sake of doing something — and this time it has backfired in their faces

  8. The article is good in the whole. It mentions ‘market rate’ a lot a then claims junior doctors are paid ‘1/3 market rate’.
    Since the nhs are the almost monopoly employer, on what basis is this below market rate idea derived? Seems a bit like the spin complained about in the article?

      • That doesn’t make a lot of sense does it? It implies doctors could go and work for 3 times pay doing a job in the private sector when these jobs don’t exist.

      • Of course if every single doctor were to go looking for private work at once, there wouldn’t be enough jobs to accommodate them, but there is private healthcare in the UK and those in the private sector earn about 3 times as much if you calculate it as an hourly rate. They can also earn at least at much in New Zealand, Australia, Canada or the US.

  9. Maybe so, although I understood all junior doctors had to work in the nhs to achieve full qualification in their speciality.
    The nhs is the market, they set the rate.

    • If the NHS is a market, it does not get to set the rate. The whole point of a market is that the rate sets itself as a negotiation between service user and service provider. That is exactly what is happening here and refusing to work under the conditions your employer is offering is a perfectly legitimate tactic as well as the thing that separates employment from indentured labour.

      I’m not a doctor, but my understanding is that it is about 7 years from when they are licensed to practice medicine that they are still classed as junior doctors. During that time they could find work as doctors at higher salaries in the UK private sector or a dozen of different countries.

      That they do not routinely do so is because they are, by and large, the kind of people who see both social and capital value. They derive immense satisfaction and purpose from working for a free universal healthcare service.

      The really unpleasant aspect of what the government is doing is that it is stiffing them on capital value, then using arguments from social value to both vilify them in the press and guilt trip them into accepting an unsustainable officer.

      The guilt trip would not work if doctors were the kind of people who only did it for the money and the vilification would not work if what they do did not have enormous social value. So the only reason the government is able to pursue this strategy is that doctors are precisely not grasping capitalists who do nothing of any value.

      Is pretty much my point.

      • ‘That they do not routinely do so is because they are, by and large, the kind of people who see both social and capital value. They derive immense satisfaction and purpose from working for a free universal healthcare service.

        The really unpleasant aspect of what the government is doing is that it is stiffing them on capital value, then using arguments from social value to both vilify them in the press and guilt trip them into accepting an unsustainable officer.

        The guilt trip would not work if doctors were the kind of people who only did it for the money and the vilification would not work if what they do did not have enormous social value. So the only reason the government is able to pursue this strategy is that doctors are precisely not grasping capitalists who do nothing of any value.’

        Well said. Although I would argue that as much as bankers and lawyers can be perceived as money grabbing capitalists, they do actually do work of value and for our society to function we do require them as much as doctors. However, much like many mid level pro football players earn a lot more than world class badminton players, greater financial value is placed on the work they do. Much like football, there is more money in the banking ‘game’ hence salaries are larger. Once again, we are talking market forces and actually (and I have accidentally come back to the point I made above) doctors would financially be better off if the NHS was privatised, which is also what you were saying about their current salaries being about a third of a doctor in the private sector. This then brings us back to your point above about how the government is unfairly spinning their argument using a mixture of social and capital values.

  10. Maybe forcing doctors to leave the NHS for other countries or private work is part of the government strategy to privatise the NHS

  11. I have to agree with Seb here. Your suggestion doctors are working for less than the market rate is just the kind of poor economics you accredit to the Health Secretary.

    The market rate is the price paid by employers for an employee of equivalent skill to perform a role. That price implicitly includes the conditions of the role. For example it would be unfair to state the market rate for an unskilled deep level miner is the same as the rate for an unskilled administrator – simply because the same unskilled worker when considering both roles would put a value on working in an office compared to a mine, and as a result accept less to work in the office.

    The NHS comparison here is the private hospitals or locum work that form the alternative lines of employment for a junior doctor in the UK health economy. Those alternative roles involve limited supervision, poorer pension and terms, and crucially – no accredited training. As such, to compare those roles to training posts in cash terms is always going to look worse for training jobs because doctors are factoring in the intrinsic benefits to establish the rates.

    Concluding what the exact market rate is for a junior doctor in the UK is extremely complicated because of the market moving effects of an organisation as large as the NHS.

    I would suggest, for simplicity, it’s fair to assume that so long as the NHS is continuing to have new F1s joining the profession, and no dramatic increase in the number of junior doctors leaving the UK/profession compared to historical norms – the market rate is what the NHS is offering.

    Clearly, there is a point when pay and terms are sufficiently poor that it will put people off the profession and provide a sufficient push factor for those existing doctors to move overseas or change profession, however it’s nigh on impossible to quantify what level that pay would be.

    If that point were reached, and the NHS were to be losing doctors in droves, the market rate would then need to incorporate the rates being offered to those doctors leaving, however, at present, that only represents a fringe case and as such can be rolled into the margin of error for the market rate.

    The Health Secretary is effectively gambling that he can impose his terms and still not cause sufficient harm to create the push factor for the critical mass needed to break the health service’s monopoly on UK doctors. The junior doctors are proclaiming that his terms will cause at least that amount of damage. Sadly, neither know the objective truth – as the old saying goes – the proof is in the pudding. We will find out only if the terms are made real.

    As for the morality of Mr Hunt abusing the good faith of doctors, there are a few things to be said in his favor.

    Firstly, doctors don’t just act in the interests of their patients. They also act for themselves. They get financial gains from their job and they also get immense job satisfaction from helping people. I wouldn’t claim to know the exact derivation of motivation each doctor has, but it’s reasonably to assume more is selfish (pay and satisfaction) rather than altruistic (simple good of patient).

    Many people work in journalism despite poor pay for their skill for the love of the job. Doctors are the same. We always have been. Doctors have analytical ability, science grounding and communication skills – the holy trinity of modern market skills. If they wanted pure cash gain, they’d be working in the financial markets, but they don’t. The immense job satisfaction is factored in and given a value that makes the equation balance in favour of medicine.

    For a hypothetical example to illustrate my point, being a junior doctor (age 27) pays £40k a year. Working in banking at that age pays £60k a year. For a rational actor to take the role of a doctor here there must be a factor missing from the equation. Doctors are very rational, therefore, they are assigning a value of at least £20k a year on the satisfaction and security derived from being employed as a doctor. Equally, working in Australia as a doctor pays £60k/year, therefore the NHS doctor is, by remaining in the NHS, acknowledging a £20k+ benefit of remaining in England.

    Mr Hunt here is implicitly gambling that the £20k may actually be £30k and as such doctors will remain in the profession/uk even after a pay cut, as the equation will continue to balance. There is nothing immoral about the Health Secretary attempting to optimise the pay of NHS staff to reduce costs to the taxpayer.

    Secondly, Mr Hunt was elected (not by me I should be clear) on a manifesto to reduce public sector costs. A sufficient minority of the UK electorate believe he should be doing all he can to achieve this and as such he has an obligation to deliver on his promises, even if doctors suffer as a consequence, his morality in the matter is unaffected.

    I want doctors to be well paid, I am a doctor. If juniors go on strike, I support them 100%. But I’m sick of the one-sided, cherry picked arguments doctors are making to support their claim.

    • I don’t have the time to reply in full; that would take another blog post. But there are three points I’d like to make, one on market rate, one on morality and one on the tactics being used by the doctors.

      In terms of market rate, the term was used as shorthand for “a lower rate than the pure capital value of their services based on a rough estimate that compares equivalent private sector and locum work as well as anecdotal evidence on the pay and conditions of doctors in other countries with roughly equivalent healthcare systems.” For the purposes of a 1500 word blog, I think it stands up. For the purposes of a PhD in economics, it may not. But there is no attempt to spin or be disingenuous, merely to put an argument in the simplest terms that are still factually accurate.

      On the question of morality, I have to disagree with you. Yes, Hunt was elected on a mandate that includes cutting the cost of public services, but he has stated explicitly that this is not a cost-saving measure. Further, I think that the tactics he has employed, regardless of the rightness or the wrongness of his cause are unconscionable.

      And the mandate itself is problematic. It is a very narrow one achieved through a campaign that included pitting the English against the Scots, fetishising the deficit when it is only one of several key economic indicators and promises that were immediately reneged on, like tax credits.

      Now it may be the case that every politician in history has made promises to get elected that they have later not kept and never had any intention of keeping, but if we’re looking at it in purely ethical terms, he is still entirely culpable for:

      1. Being part of an election campaign that made promises it did not keep and possibly had no intention of ever keeping.
      2. Once elected not speaking out against the fact that his party was not keeping its promises or resigning because it was not fulfilling the mandate it was elected on.
      3. Running a media campaign against doctors that uses the tactics outlined in my post as part of strategy that only stands a chance of working because doctors are not the kind of people they are being painted as (see my last reply to Seb).

      The final point is on the tactics used by the doctors themselves. You may find them distasteful, but it was the government that put them in the position of having to fight on these terms. Doctors have been dragged, very much against their will, into a universe of spin and if they do not adapt to match the tactics used by their opponents, they will lose for reasons that have nothing to do with the rights and wrongs of their case and everything to do with the fact the government can shout louder and is willing to mislead the public to get its way. All I’ve tried to do in this post is highlight some of the tricks being used to achieve this to level the playing field a bit.

      • Thanks for the reply, I understand the lack of complete reply given the length of my response.

        I’ll not quelle on the detail of the market rate point any further. I appreciate your need for simplification in the original post, however, I feel the use of the term at all only covering “pure capital value” is inherently misleading and enters the realm of spin. If an economic argument is to be mounted, it should be done so in a reasoned manner, and not simplified in such a manner that it becomes misleading (however unintended).

        Personally, for the reasons I detailed in my comment, I think the BMA should stay well away from economic arguments, as they play right into the hands of the DoH (i.e. economically, it’s a reasonable thing to reduce doctors pay, on the basis the risk is low [though not non-existent] it will cause harm to the health service).

        You raise several valid points with regard to the mandate issue. It’s messy not least because the Tories as you say have reneged on several manifesto promises already which does weaken that argument enormously. However, it doesn’t entirely weaken the argument. While it’s stated it’s not a cost cutting exercise, it is intended as a measure to improve efficiency and reduce costs indirectly (e.g. lots more staff on weekends). I personally disagree that these will improve efficiency or reduce costs, but the Health Secretary seems to believe it, and as such it fits his mandate to pursue it.

        As for the tactics used by JH, I agree it’s distasteful. I’m not sure stooping to their level is a good plan though. I can find examples of social media posts by doctors to meet almost every one of the tactics you neatly summise having been used by the DoH. Now juniors have started to get down and dirty things get really difficult. Doctors now need to play the politicians preferred game (spin) on their turf (the media) – I don’t fancy their chances.

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