The Lesson Every High-Earning Doctor Should Pass Down Beyond Inheritance

Why wealth doesn’t make it past three generations

Somewhere across the country right now, a consultant is sitting across from their financial advisor, discussing NHS pensions, discretionary trusts and the seven-year gifting rule, whilst half-thinking about the clinic letter they forgot to sign before leaving the hospital.

Their local wealth manager’s office is the last place our consultant wants to find themselves after a 12-hour NHS shift running the show on the gastro ward, but she knows arriving home late for dinner is trivial compared to the important task of preserving as much of her wealth as possible for the next generation.

For most doctors, wealth doesn’t come from old family money. It is hard-earned money that is accumulated after years of training, exams and delayed earnings, and doctors often feel personally responsible for “setting up” their children for later life.

Forget Kumar and Clark’s, Enter Clark and Cummins

Enter the economists Gregory Clark and Neil Cummins, who decided to examine the effect of original wealth on the grandchildren’s generation. What they found was that by the grandchildren’s generation, the effect of the original wealth had become insignificant, and by the fourth generation or great-grandchildren, it had almost vanished entirely.

This idea of riches disappearing by the third generation can actually be traced back to an old Chinese proverb that termed it the ‘third generation curse’. Today, we have concrete data confirming the truth of this trend from people like Clark and Cummins.

Clark and Cummins concluded that: “In the long run, wealth mainly derives from sources other than inheritance itself.”

This isn’t exactly what our Consultant expected to hear, but we can stop to ask: if inherited wealth doesn’t seem to make it past three generations, why is it that we hear of some families staying wealthy for generations?

For the answer, we can turn back to Clark. He followed 422,374 English people between the years 1600 and 2022 and found the biggest influence is what he calls the “family’s financial DNA” - attitudes to risk, the instinct for wealth accumulation, and habits of financial discipline. These features were present in the families that kept wealth for centuries. They also realised something quite interesting. Children born into larger families (who therefore inherited less each) who were taught these crucial financial skills didn’t end up poorer than we would expect, as those who inherited less tended to compensate for it.

A More Important Inheritance

Luckily, our Consultant reads On-Call news, and she decides to wrap up her financial meeting and make the journey back home.

That evening, she realises that the real inheritance doesn’t cost a penny. It is the act of building good financial habits in her children, teaching them how to make financial decisions calmly, how to ride out market falls without panicking, and creating an environment where money can be freely discussed and questions addressed. Our Consultant begins to involve her children more in financial decisions, and yes, that means even the boring ones about pensions or about the considerations of remortgaging.

She realises that many of those traits that got her through a medical career (consistency, tolerating discomfort and long-term thinking) can also be applied to preserving wealth across generations.

This is how our On-Call community of doctors with children can beat the third-generation curse.

International PLAB Centres Closing, But Is This the GMC’s Kindest Option?

The medical landscape continues to be reshaped by the Medical Prioritisation Bill as emails from the GMC regarding the PLAB exam hit inboxes. For those unfamiliar, the PLAB is a two-part exam required for international doctors to begin practising in the UK.

From 2027, many international centres that offered the February PLAB part 1 exam will be closing down, such as in Alexandria, Chennai and Dhaka, whilst the exam will still be available in the UK and the EU. The GMC says it is making this change to ensure it is meeting demand and operating effectively following a 40% reduction in bookings between 2023 and 2025.

The first question that arises is one concerning GMC funding. The PLAB exam was a major source of the GMC’s revenue, making £25 million from the exam in 2024. So, what will plug these gaps in the future?

But is this, dare we say, realistic and benevolent from the GMC? Discouraging thousands of IMGs from sitting the PLAB and throwing themselves into an already saturated system that heavily prioritises home graduates has to be the kindest option? Or would it be better for doctors to invest their time, money, and expectations, to be trapped in a system with little sign of progression out of non-training posts?

Cynics would argue that there is nothing compassionate about it. Rather, it is a cold economic calculation by the GMC that says: with the number of exam candidates declining, maintaining its international centres is simply no longer considered financially worthwhile.

The Illusion of Unity in the NHS

Why conflict is a part of everyday practice

The health arena of the NHS is a prime place for conflict to unfold. Should we strive to eliminate conflict? Of course not, the illusion of unity is often not worth having. Conflict is often how we air our disagreements and keep our opinions in check.

The issue arises when we fail to ‘do’ conflict properly and end up with our conflicts remaining unresolved. This is when you sit in traffic on your way home from the hospital, thinking of all the possible rebuttals you could have mentioned to Andy, the bed manager. Conflict can be a destructive force in the NHS and is the reason why every hospital has those two consultants who haven’t spoken in 13 years over a disagreement about whose patient deserved the final slot on the MRI list.

So, how do we learn to disagree better without giving up one of our valuable weekends to attend a conflict resolution course?

The Illusion of Unity

Let’s start by asking where conflict arises. Differences between people surface because of conflicting values, communication skills and priorities. Then, if we put these people in the NHS pressure cooker that includes an endless list of patients to see, defensive medicine and declining working standards, conflict is always waiting to surface.

Now we know that meaning is not found entirely in the literal spoken word. At work, we also communicate using our tone, politeness strategy and facial expressions. Doctors who are shipped across the country and those who come from abroad are quickly reminded that NHS hospitals are run on local idioms, expressions and colloquialisms.

When you tell the patient from Teesside in bed 12 that he will go down for his scan tomorrow morning rather than this evening, as initially planned, and he replies saying: “Owayy, our lasses’ mam is goosed coming ere every day.” you may have no option but to ask for clarification, which can frequently be misinterpreted as slowness or obstruction.

Meaning is socially situated and moulded by culture. Look around you at the interactions you see in the workplace on a daily basis, and begin to notice how, sometimes, incompetence is often just unfamiliarity with the unwritten linguistic codes and cultural practices.

Expectation is Your Friend

To handle conflict in our jobs before they consume our happiness and satisfaction, we first need to realise that conflict is a part of everyday life. You will run into an argument with a patient or colleague, even if you refine every aspect of your speech and actions. Patients will be in a bad mood, colleagues will be frustrated, and this will influence their proclivity to engage in disagreement.

Some people have internalised a culture of equating disagreement with hostility, so that any challenge to their opinion puts them in a defensive state of fight or flight.

Sometimes doctors challenge us because of a genuine interest to learn and understand. “I see. Why did you opt for a seven-day prednisolone course for your Bell’s palsy patient rather than a ten-day tapering course?” How one delivers such a question is vital, and good communication skills cannot be downplayed, but first, we need to be comfortable in accepting disagreement and realising that being asked to provide our reasoning is not an unreasonable request.

But interestingly, when we take the above point and overlay the dynamics of hierarchy, we get a different picture. In an ideal world, asking a Consultant to justify their reasoning as the new foundation doctor on the ward should be seen as an opportunity for learning. Power dynamics can easily turn a simple clinical query into a perceived threat.

“My 15-second attention span meant that really there was Emergency medicine and nothing else.”

“When that UCAS medical school acceptance email came through, my eighteen-year-old self was not dreaming of dictating endless clinic letters or a constant stream of arguments with bed managers. I had an intellectual desire to study medicine and to apply that knowledge to heal. I couldn’t even estimate what percentage of our daily work is taken up by bureaucracy and excessive admin.”

“Do you think hospitals and the NHS would benefit from Consultants offering more on-site out-of-hours cover?”

“Anecdotally, I find that there is something about the prevention of skin cancer that doesn’t hit home and register to patients in the same way as other cancers do. We know annual Melanoma cases in the UK have risen above 20,000 for the first time ever. Simple preventative measures, such as using sun cream, simply don’t interest many people in the same way as preventing other cancers do.”

What’s on your mind? Email us!

Some things to review when you’re off the ward…

The On-Call team found this piece from The King’s Fund showing how the demographics of British society have changed since the inception of the NHS, incredibly interesting. 11% of British society was over 65 in 1948, compared to 19% in 2026, rising to an estimated 23% by 2047.

Read this great breakdown of the NHS pension by former doctor and financial adviser Diarmaid McMenamin. Understanding your NHS pension and how to base your financial decisions around it is perhaps one of the most important things you can do as a doctor.

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The Consultant Cash-in: Martin’s £100k Trap Door

If we are to have public spending, we must also have taxation. Who doesn’t know this?

But in the words of our most reputable independent financial institution, the Institute for Fiscal Studies: “Most taxes influence people’s behaviour in unhelpful ways and all reduce the welfare of those who bear their economic burden.”

So, the challenge for our tax system is to achieve the government’s social and economic objectives whilst reducing its welfare-reducing side effects. If only it were that simple…

Martin is a newly qualified Acute Medicine Consultant diligently offering his services to the health system that trained him to a position of seniority. He is currently earning £113,500 for his services.

A pay rise for Martin would mean that for every pound he earns, he will only see 24p. For a £10,000 pay rise, £2,400 would reach his bank account.

This is what happens when the tapering of your Personal Allowance between £100,000 and £125,140 results in an effective marginal income tax rate of 60%. On top of that, 12.5% is deducted for Martin's pension contribution, 2% for National Insurance, and, as a newly qualified Consultant with a Plan 2 student loan, 9% is deducted for Martin's student loan repayments.

As Martin sits there wondering whether to give up more of his time to his job and less to his wife and children, he asks himself: Is this really worth it? Have we sleepwalked into a system where our most senior doctors, with an abundance of knowledge and experience, are not incentivised to work within our healthcare system, and the treasury receives fewer tax receipts as a result?

Will any government have the courage to address the £100k tax trap? Until then, expect more turned-down promotions and refused extra shifts.