The Public Disapproves of Strikes - But Who Will Get the Blame?

Why the government will likely take the fall for the resident doctor strikes…

When a football team is underperforming and the fans hound the players down the tunnel at the full-time whistle, who usually takes the blame?

Part of the poor performance can be explained by the players, but it’s nearly always the manager who faces the pressure. For one, unlike the squad, they are seen as strategically responsible and the decision maker with a role to stabilise and fix things. On the surface, a quick change of the manager seems to be a much easier fix than an entire upheaval of the squad. The fans demand the one person with authority over outcomes be replaced.

The same principle applies in politics. Ultimately, governments are perceived as the one’s responsible for the functioning of the state. For the average citizen, life in the UK is based on a simple social contract: authority and taxes are handed over to the government in exchange for the delivery of services and stability. When that contract is broken (whether it be due to strikes or any other externality), the public quickly jumps to call it a failure of governance.

Slipping Sympathy

During the 2016 junior doctor pay dispute, public sympathy was strong, with 66% of the general public supporting the doctors. This remained high in 2023, when a YouGov poll found that 57% of the public backed the striking doctors. Sentiment has since shifted with only 36% of the public supporting continued industrial action by doctors. That is a significant decline, but it is crucial to understand that it does not mean that the public now sides with the government. In the 2023 dispute, YouGov polling showed that 44% of respondents blamed the government for the ongoing strikes, whilst only 17% blamed the unions.

So even when the public becomes frustrated with disruption, they continue to expect the government to end it. Now this doesn’t say much about the method the government employs to do this, whether by appeasing the strikers or cracking down hard on them, they just simply expect it to be resolved.

Personality Invites Scrutiny

What does history tell us? The famous Winter of Discontent in 1978 saw a wave of public sector strikes, from grave-diggers to nurses, and led James Callaghan’s Labour government to be heavily punished at the ballot box. The 1978 strikes involved numerous trade unions, with no single individual recognised as a universal leader.

Compare this to the tensions in 1984, when the miner’s union, spearheaded by Arthur Scargill, went on strike against pit closures and poor pay. At the time, there were around 49,000 miners, mostly in Nottinghamshire, who opposed the strike without a national ballot, a stance that was condemned by Scargill. A report in The Guardian suggests that it was Scargill’s uncompromising approach that alienated broader support and ensured Thatcher’s victory.

It may be argued that when strikes are associated with a strong leadership figures such as Arthur Scargill in the miners’ strikes or Mick Lynch with the RMT union, public anger and media scrutiny can be directed somewhere. But when strikes are led by an autonomous body like the BMA, the blame vacuum gets occupied by the government. The public have no say in the actions of the BMA, they don’t elect its leaders and often wouldn’t be able to tell you who they are.

The New Statesman recently covered this issue and observed that whilst many doctors may long for a more visible and charismatic BMA spokesperson to articulate their case, a faceless approach may be strategically wiser. The implications of this could mean that even as support for strikes wanes, the government could be seen as the focal point of frustration as the public tire of the disruption.

“Bed 23 Is Difficult”: How Labels Hijack Your Clinical Judgement

As you prepare to clerk in the next patient, the sister stops you to say: “Be careful with Bed 23, he can be a dodgy character”. You’ve heard versions of these comments before - towards patients, staff and doctors. Sometimes, it’s casual and feels innocent, but regardless of the intent, we can never escape the power and influence of human psychology.

Pre-emptive descriptions shape how we think. Our minds anchor to the first impressions we see or hear, even when we try to stay objective. You may think you are above this and have such an objective outlook on the world that your clinical judgement is immune to the comments of others, but none of us are.

As always, the more illuminating examples are found in the grey areas. Say a colleague tells you that a patient is aggressive… you enter the room and he throws the chair at the wall. Fair enough, the warning was correct. But what about if we take the same pre-emptive description for a patient who jumps to question a plan after a negative healthcare experience in the past. Maybe he notes: “Last time you doctors gave me the wrong Insulin and I crashed, why should I trust this dose?”

Now without the negative priming, this could be seen as a reasonable act of self-advocacy given the serious health complication he faced in the past. But the ‘aggressive’ or ‘difficult’ label shifts how you approach the patient, how you speak to him or even, how you treat him.

Time to start thinking about your portfolio?

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Buy Now Pay Later: Is the Government After Our Pensions in Exchange for Better Pay?

Streeting asks doctors to pick between pay today or pensions tomorrow

In recent times, the government have trialled policy ideas to the media to test public opinion before deciding on their implementation. A good example is the recent commotion surrounding the potential slashing of Cash ISA allowances which didn’t materialise. This time it is the health secretaries turn to test the waters.

Last week on LBC, a resident doctor proclaimed to the health secretary that the pension he will receive in 50 years time will not help his real costs today. In response, Wes hinted that the generous defined benefit pensions could be cut to end the strikes and fund a pay deal.

But anyone who thinks this will give the chancellor some breathing room today is misguided. The NHS pension scheme works in a unique way where current contributions paid today fund the current retirees. Reducing future pension promises doesn’t generate spendable cash, it lowers future liabilities, not current costs. It might improve Rachel Reeves’ long-term balance sheet, but offers no fiscal breathing room today.

Just Show Me An Example

Imagine you are an F1 doctor, contributing 9.8% of your salary to the NHS pension. Unlike in other professions with private pensions, that money does not go into a personal saving pot or investment account. Instead it is used immediately to pay the pensions of doctors who have already retired.

At the same time, the NHS, as your employer, contributes an additional 20.6% of your pensionable salary into the NHS pension scheme, with an additional 3.1% paid by the treasury totalling 23.7%. Comparing to the private sector, an employee earning between £50,000 and £70,000 saving into a workplace pension can expect an average total (employee + employer) contribution rate of 11% as per the IFS.

Then the employer and doctor contributions are combined and used to pay the existing pension obligations of doctors retired today. If there's a surplus after pension payments are made, it is returned to the Treasury.

The government may decide to play around with the 23.7% figure. This will effectively lower what is being ‘accounted for’ against your future pension. To balance for this the government may:

1. Ask doctors to contribute more of their salary towards their pension

2. Cut the benefits of the pension entirely, making it a less generous scheme. For example, today doctors are told that the accrual rate for their pension is 1/54th. So each year you will accrue 1/54th of your pensionable earnings. The government may decide to reduce this to 1/60th - reducing the final salary you could expect in retirement.

3. Find alternate revenue streams through raising taxes or greater borrowing. This would seem to be an unlikely option, however, as the main argument against the pay deal request is the state of poor public finances and the huge existing borrowing costs.

A Young Man’s Trap

It’s understandable that many younger doctors might see some appeal in this trade-off. The cost of living crisis, high student debt and the goal of homeownership, makes long-term pension benefits feel distant.

Our On-Call message is this: one of the most important decisions you will ever make is how you plan for retirement. The state pension alone will not provide sufficient income in retirement and its generosity may shrink further by the time some resident doctors get there.

The NHS pension, by contrast, is a rare defined benefit scheme with inflation protection and long term security. Weakening it now may feel painless, but for your future self, it will be a costly gamble. We don’t live in a profession where we can easily work into old age. Our careers ask us to remain sharp between the ears and for some, remain physically dexterous. Doctors should live in a society where they can draw their career to a close on their own terms.

“In response to the ‘you will earn a fortune as a consultant’ crowd - The arduous and uncertain path aside, fair pay should reward today’s efforts, not rely on a hypothetical high-earning future.”

“All I was thinking about mid-way through that MRCP exam was all the other ways I could have spent my £500. Spare a thought for me guys”

“I was on a consultant interview course recently with a neurosurgeon. This guy had starting prepping his portfolio in the first year of med school. He had two extra degrees including a PhD. The fact I’m paid the same as him is, to be honest, quite hilarious”

“Never worry about where you "should be". There will always be people ahead and behind you in your career. Just make what you can out of this career of yours.”

What’s on your mind? Email us!

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

Knowing how the NHS pension works is essential for retirement planning. If you are still uncertain here is a good guide from the BMA.

It can be argued that the effectiveness of vaccines has led to complacency. Personal choice advocates will have to answer for the rise of measles in the UK. Here’s a breakdown from The Guardian.

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The Case of Prof. Leng’s Loophole

The Leng review is complete. The big news that has gone down well amongst doctors is a recommendation to rename Physician Associates to Physician “Assistants”. This change also seems to have gone beyond suggestion with Wes Streeting already voicing his support on Sky News, hinting at swift implementation.

Yet the team at On-Call is more interested in another recommendation. The headlines will say that the Leng review clearly recommends a ban on Physician Assistants seeing ‘undifferentiated’ or ‘un-triaged’ patients, but the report seems to contain a critical loophole. The full recommendation reads: “PAs should not see undifferentiated patients - except those with minor ailments.” But what exactly is a minor ailment?

The idea of a case being "simple" or “minor” is only ever obvious after the fact. Medicine isn’t like accountancy or engineering. It’s an interpretive science, full of uncertainty. 9/10 the chest pain in the waiting room is musculoskeletal in nature or related to stress; but that one time, it’s an evolving MI or aortic dissection. The ever-present irony is that it takes expertise to rule out the need for expertise or the labelling of a condition as ‘minor’.