In this issue
Consultant strikes · Theatre time · GP training · Board Round · Second Opinion · Take‑Home

Plus all about the 35-hour week that’s a 14% pay rise

Industrial action is back in the headlines, and this time it’s consultants. They will strike for two days, on 25 and 26 November, over pay and working conditions.

There’s no doubt consultant pay has failed to keep up with inflation since 2008/09. The difficulty is agreeing on how much it has been eroded, an economic question we visited during the resident doctor strikes.

Use the retail price index (RPI) and a new consultant’s starting pay is 20.5% lower in real terms than in 2008/09. The UK Statistics Authority has called RPI a poor measure of inflation, for economic reasons you probably don’t care about as a medic. It lost its National Statistic status in 2013 and will be brought into line with CPIH from February 2030. But we aren’t in 2030, and the government still uses it for rail fares and student loan interest as the BMA are very keen to remind us.

Use the consumer price index (CPI) instead and it’s down 7.6%. Opt for CPIH (CPI including owner occupiers’ housing costs) and the figure falls again, to 5.8%.

So pay has been eroded whichever measure you use, but the numbers vary massively.

At 2026/27 prices so far, restoring starting pay to its 2008/09 value would take a rise of about 26% on RPI, 8% on CPI or 6% on CPIH.

The BMA’s “Demanding better” page throws out another idea: cap programmed activities (PAs) at 3.5 hours. A standard 10-PA contract would then be 35 hours a week, not 40, for the same pay.

Same salary, five fewer hours. Some simple maths: 40 ÷ 35 = 1.143, so each hour is worth 14.3% more.

How much this costs depends almost entirely on what consultants do with those five hours:

The BMA goes further on PAs.

A typical 10-PA job plan splits into 7.5 PAs of direct clinical care (DCC) and 2.5 PAs of supporting professional activities (SPAs): time for teaching, audit and continuing professional development.

The BMA wants a minimum of 3 SPAs, which leaves 7 PAs for direct clinical work.

More quick maths:

Today: 7.5 PAs × 4 hours = 30 hours of direct clinical care. Under the BMA proposal: 7 PAs × 3.5 hours = 24.5 hours.

That’s 18% less patient-facing time a week.

We know that Wales already runs a 37.5-hour consultant week fairly successfully and crucially, standard hours aren’t an output measure. They are just a unit baked into contracts. How much a trust “gets out” of a consultant per hour depends on job plans and hospital efficiency.

So (and this is where we get to inject some opinion) we see no inherent problem with reducing consultants’ contracted hours. We emphasise that a good consultant is worth their weight in gold, and we aren’t just saying that because 26% of the doctors who read On-Call are consultants. They should know the inherent value of their labour.

But if we’re going to cut their hours, we need a plan for productivity-gaining reforms to go with them. Some will argue shorter hours prevent burnout and boost productivity in themselves, but we won’t be the only ones asking for firmer guarantees if every consultant is going to end up with fewer clinical hours.

We promised you that this is a place where you will interact with arguments that you sympathise with, and also arguments you disagree with. This next section embodies that principle:

“Consultants earn an average £152,000 a year”

Whilst this average figure is true, around £28k of that is on top of basic pay, and only around £16k of it is clearly extra sessions (e.g. extra PAs and waiting list initiative sessions).

A full-time consultant’s basic pay averages £133,375, and new consultants start on £113,565. Additional work should not be bundled into the basic pay discussion without providing the context.

They are additional hours that consultants have traded for additional pay (that they may not have had to do if frozen thresholds and tax traps weren’t a part of our tax code… too harsh?)

“Consultants are in the top 2% of earners”

The average consultant does find themselves in the top-2% cut-off (about £145k). Once again true, but it answers whether consultants are well paid compared with the public, not whether the NHS can recruit them and crucially, keep them working in the NHS.

Being in the top 2% is relevant to public sympathy however, which politicians greatly care about before announcing fiscal policy.

Surgeons want to do one thing: operate. They’re happiest on the other side of the anaesthetic room.

But how much are they actually doing? Luckily, workforce censuses and Royal College figures can help.

The Royal College of Surgeons’ 2025 UK workforce census found many surgeons struggle to get on lists: 68% of core and 60% of higher surgical trainees reported limited access to elective lists, and 53% of surgeons overall named theatre access as a barrier.

But here’s the key finding from the British Journal of Surgery:

Surgeons spend over a decade acquiring these skills, only for the system to stop them using them once they finish training.

All of the respondents said they would prefer to spend at least three days per week performing elective surgery. Of course they would: which surgeon wants to be on a ward or in clinic?

The RCGP called for longer GP training in 2012. Why is it still three years?

In 2012, the Royal College of General Practitioners published a statement on ‘enhanced and extended specialty training’. In it they wrote:

That was 2012, and GP training is still three years long. As an undergraduate, I remember these rumours circulating our lecture theatres in every year of medical school. Yet here we are.

In a 2018 survey, 50% of GPs said their training should last four to five years. But opinion among GPs is divided. Some say their hospital rotations in ST1 and ST2 added little beyond making them a glorified FY2. Others found rotations in, say, paediatrics or ENT invaluable. No doubt our IMT readers have something to add here.

The debate comes down to two questions:

General practice is an incredibly difficult and varied job. In one shift you’ll see the whole breadth of medicine. It also needs particular skills: decision-making under uncertainty, probability-based reasoning and handling undifferentiated presentations. These take experience to learn.

The RCGP seems to agree, but knows that an extra year without redesign risks adding a year of service provision rather than a year of meaningful development.

Then there’s the consequentialist argument. We need GPs, and the short training pathway is no doubt part of the appeal. Remove it and do we risk fewer GP applicants? Can we afford that when the health service is stretched more than ever?

“The 2025 RCS workforce census makes for bleak reading. 56% of core and 40% of higher surgical trainees have considered leaving training in the past 12 months.”

“Solidarity with the consultants. After years of pay erosion, their indispensable contribution to this country deserves far greater remuneration. Frozen tax thresholds, punitive 60% marginal tax rates, the loss of tax-free childcare, and the burden of unfair Plan 2 student loans for newer consultants only makes their financial picture look worse as well.”

“What got me into neurology as a med student was being able to localise a lesion and build a reasonable differential. But here, I feel like I am just an MRI and EEG ordering service.”

“The only aspect of the “work from home” setup I envy is the lack of a commute. Beyond that, there’s little appeal to me in spending the entire twenty-four hours of my day within the confines of my home, especially when my wife is at work too (and I don’t have a dog to keep me company either).”

What’s on your mind? Email us!

The Prime Minister plans to scrap the pensions triple lock from 2030 and put the savings into a National Care Service to reform social care. We already have an NHS-style funding system for those with the most serious care needs (NHS continuing healthcare), yet it seems to have failed many with strict eligibility criteria and opaque bureaucracy.

The Times reported the case of 81-year-old Robert Jackman, who was diagnosed with Lewy Body Dementia and Parkinsonism in 2019. His condition has since deteriorated to the point where he requires a wheelchair, cannot move his arms or legs, is incontinent and can no longer speak.

Yet when his wife, Mariam, applied for NHS healthcare funding in October 2024, he was deemed insufficiently ill to qualify. The couple now pay £240 a day for 12 hours of private care, covering an annual bill of more than £85,000 from their savings.

Last week’s poll:

If you had to lean one way, which is closer to your view?

…and whilst you’re here, can we please take a quick history from you?

Something you’d like to know in our next poll? Let us know!

Anyone reading this who isn’t a radiologist is probably wondering who on earth Prometheus Lionhart is. Some may have Googled him, only to find a collection of books that look like Dungeons & Dragons instruction manuals.

Prometheus Lionhart is a pseudonym. The actual author is a US radiology attending who wrote the Crack the Core series, widely considered the bible of radiology training.

Every radiology registrar picks up the book, opens the first chapter and sees the title: Preparing for War. They rub their eyes, check the blurb to make sure it’s actually a radiology textbook, then read on. Before even reaching traction bronchiectasis or closed-loop bowel obstructions, Lionhart wants to psychologically prepare you for what are often considered the hardest exams in medicine.

Perhaps the strangest part (and likely why he chose a pseudonym) is his emphasis on hatred, anger, vengeance and aggression. He isn’t literally telling readers to become angry people (I think). Rather, he advocates channelling these raw emotions into motivation.

He considers advice like finding the “joy in studying” or “inner peace” useless to a tired anaesthetist preparing for their FRCA exams. Instead, he urges you to channel your resentment at having to study while battling on-calls and nights into something productive. Use that spite to power through another textbook chapter or 50 more questions.

We’re keen to know whether Lionhart’s brand of “spite-driven motivation” has helped any of our readers. Have you used thoughts like “winning against the odds” (the odds being a run of nights before your exam) or silencing a critic (the consultant who said you’d never pass) to motivate yourself and get that much-needed dopamine hit?