Head to head: resident doctors on strike
Research Manager and Head of Health
It is easy to lose track of the detail in the resident doctors debate. While the strikes themselves may elicit a strong reaction from people – either to oppose or to support – this debate is in fact not at all straightforward. It hinges upon incredibly complex questions about the market value of a resident doctor, whether we can afford it, and whether six months of strikes is a justifiable response.
Imagine stripping away the noise and sitting two people down – one critical of the strikes, one defending them – to talk it through. What would they actually say to each other about pay, value and priorities? Maybe something like this:
Critic: You have just been given a pay rise equivalent to 28.9 per cent, the highest pay rise of anyone in the public sector. And now you’ve gone on strike again. This is exactly what some commentators warned the government about when they set out their public sector pay deals.
Supporter: First, yes – it was a big pay rise. But it also started from the biggest real-terms decrease in the public sector. And even if it wasn’t, it’s still not full pay restoration – a return to the real-terms pay we had previously.
Critic: But your definition of 'full pay restoration’ is questionable, isn’t it? Why are you using Retail Price Inflation when it was officially discredited by the Office for National Statistics over a decade ago? Your critics would say it’s because it inflates the number dramatically. Is that fair?
Supporter: No. RPI is the rate at which student loans grow (and most resident doctors will have student loans from post 2012), it reflects living costs more closely than CPI because it includes housing costs, and there are other parts of the government that use RPI (like index linked gilts) so why can’t we?
Critic: Because the evidence consistently demonstrates that Consumer Prices Index with Housing (CPIH) is a fairer representation of cost of living than RPI. Other parts of government use RPI as part of legacy agreements, anything that has been decided since it was discredited as national statistic hasn’t used it, and it’s being phased out by 2030 even though it’s costing some industries billions. Private companies are also widely discouraged from using it when calculating pay rises. Details like this – that look like straightforward political sleight of hand – undermine the credibility of your argument.
Supporter: Fine. But even if you use CPI, our pay is still below 2008 real terms pay.
Critic: Any trend analysis on pay is highly sensitive to which year you choose, which inflation measure you choose, and what pay data is used. Doctors rarely earn their base pay due to weekend and night shifts which pay more.
Supporter: So let’s compare our average pay (which does take into account overtime and weekends) with 2010 CPI. Even accounting for the latest uplifts, using average pay and CPI, first year doctors are paid 6.2 per cent less than in 2010, for second year doctors it’s 10.8 per cent less than in 2010. Following a pandemic and hospitals that are literally caving in, I think the question becomes: ‘is the work of a doctor today worth 10.8 per cent less than it was then?’
Critic: We’ve been living in an austerity or inflationary economy for some years now. Hasn’t everyone in the public sector had real terms pay cuts? Isn't everyone in the public sector 'worth less' today than in 2010?
Supporter: No. This is a huge vibes-based generalisation. Just because the economy has been bad since 2007 that does not mean everyone’s pay has fallen like ours. Mean public sector pay dropped by 0.9 per cent in real terms in 2010-2023, while doctors dropped by 14.7 per cent. The scale of our loss is in a different league.
In fact, compared with 2007, the real earnings of a public sector worker at the 75th percentile (earning more than 75 per cent of public sector workers) had fallen by 8 per cent in 2023, while for the lower paid in the 25th percentile, real earnings rose by 16 per cent.
And even for the higher paid end of the public sector, we fared particularly badly. Over the 2019-2023 period, nurses’ average pay kept pace with inflation since 2019 (even despite large falls in 2022), while teachers’ pay increased by more than 5 per cent between 2019 and 2023 after large falls between 2010 and 2019. All the while, our pay fell by 6 per cent in real terms between 2019 and 2023, compared with no change for the public sector as a whole.
Critic: But unfortunately that’s the reality of redistribution. The richer take on more of the burden because they can tolerate it more. Someone earning below £24,000 and experiencing a pay freeze during high inflation would be in much worse shape than you. If you go straight into core training, you could be earning £67,400 a year by your third year out of university, when most resident doctors are around 27 years old. You have high long-run earnings, and will be in the top two earning percentiles for most of your working life. This isn’t the case for teachers and nurses. If anyone can handle the pay cut, it’s you, right?
Supporter: You are right we will earn more in the long-term. But not everyone goes straight into core training (which is also 4.1 per cent below 2010). And maybe more people would be earning the core training salary if the government expanded the number of places available, but instead the number of new doctors has increased while training places have stayed flat, which has left many of us not earning that salary.
If you compare us to the wider economy, first year resident doctors earn slightly above the median – so a bit more than half of all workers, but still less than the other half. Is that the real market value of what we do? We shouldn’t have to wait eight years of intense training, while helping to make life and death decisions, to be paid a fair labour market value for our work.
Critic: Ok this brings us back to full pay restoration. What do you mean by fair labour market value? Medicine does have a labour market, but it’s a very unusual one. The NHS is almost the sole buyer of doctors’ labour, so there isn’t the same competition on wages you see in other sectors. The private sector is small and largely sets its rate off what the NHS pays. Right now medical schools and training places are massively oversubscribed. That tells me there’s no shortage of people who still want these jobs on the current pay and conditions. If someone’s idea of a ‘fair market value’ is much higher than the government’s they can leave, and some do, but there are plenty more who will take their place – that’s the reality of a taxpayer funded public service.
Supporter: There are so many unintended consequences of that view. Flooding medical schools doesn’t fix the problem. Recruiting more 18-year-olds to burn them out by 26 is a waste of time and money. Treating doctors as disposable just means the UK spends £175,000 per student for their training, loses them to Australia – creating constant churn and expensive agency cover – and plugs the gap by poaching doctors from countries with far worse shortages. Oversubscribed medical schools is not the same as an oversupply of doctors, which can be seen by the fact the vacancy rate remains high (even with the number of doctors overall increasing).
You talk of moral and economic fairness but there is nothing fair about hiring doctors from countries that need them much more than us – like India, Nigeria and Pakistan – just because you don’t want to pay a fair wage to your junior doctors.
Critic: Ok yes, when pay is seriously misjudged, you don’t see it in the number of people applying to medical school, you see it years later, in burnout, in doctors going abroad, in shortages, which is already starting to happen. But pay isn’t the only reason for that. Long hours, rigid training bottlenecks and poor work-life balance matter just as much. Flooding the system with pay rises alone won’t fix those structural issues.
Supporter: I agree with that and our poor working conditions are part of our rationale for the strikes. We’re expected to work nights but cannot even get hot food out of hours, pay obscene hospital prices for parking, have little control over our rotas, and after eight years of training, struggle to get places for specialist training.
Critic: But this brings us back to pay again, because how can you improve working conditions if you’re not at the negotiating table with government – because you’re striking over pay. The BMA’s militancy undermines its effectiveness. You know that working conditions won’t be settled via a pay negotiation and requires policy collaboration with government. So that can’t be settled until the strike is.
Didn’t the Review Body on Doctors' and Dentists' Remuneration (DDRB) – an independent board, not the government – outline what the ‘fair labour market value’ should be? What’s wrong with that assessment?
Supporter: The DDRB are told in their terms of reference to take into account fiscal prudence and government affordability, which would make sense if they were the government. But they’re not, they’re supposed to be a fully independent, evidence-based pay reviewer.
Critic: Ok let’s theoretically accept your argument that rejects the DDRB recommendations but leaves the exact value of fair pay undefined. From the government’s perspective, the moral and economic trade-offs government face are enormous.
Anything in the billions has to be funded by higher spending (and in turn higher taxes), higher borrowing or taking money from something else. The fiscal rules mean borrowing can’t be used. Taxes are deeply unpalatable. So higher pay for you means money taken from something or someone else, in an economy where 3.2 million children are in relative poverty, prisons are almost full and elderly people can barely access social care. The contagion risk is also significant – if you get full pay restoration then everyone else will want it too.
Supporter: That wasn’t our decision and it’s not our fault. We didn’t make 15 years of policy choices that eroded our pay or deprioritised prisons or social care or poverty – the government did. None of that means we should shoulder the cost of the decline of the public sector since 2010. We’ve already been paying that price.
Critic: My point is about affordability. The constraining factors on the government’s side are so significant that they’re not just going to agree with you because you go on strike. You may deserve a fairer pay settlement but you know full pay restoration would come at great cost not just to the taxpayer, but other public services too. You may need better working conditions, but you know these aren’t solved by pay disputes. Despite this reality, you’re striking rather than negotiating. It often looks like you will only accept one thing, RPI based full pay restoration immediately, or nothing. That’s not happening, those aren’t the only options, and there are plausible and fair alternatives.