Wes Streeting’s Wager: A Deal Meant to Fail?

The BMA rejects latest offer in just 4 hours, but was it designed to be accepted or just to set the narrative?

A great deal has transpired since we last covered the recent pay dispute between the BMA, its members and the government. This latest round of industrial action has fallen at a politically and economically significant time for the government, with the budget approaching at the end of the month.

Streeting’s last-ditch attempt to avert another round of strikes was dismissed in just hours last week, setting the stage for a full resident doctor walkout.

In this On-Call piece, we cover this proposal, the limited options remaining for both sides, and the broader political and economic context that will shape what happens next.

Wes’ Wager

Streeting reached out to the BMA’s Resident Doctors’ Committee with a proposal aimed at addressing the BMA’s two central grievances: the training bottleneck crisis and pay erosion. The deal included a commitment to create 2000 additional training posts over the next three years, with half of them to be opened in this application window, alongside funding of mandatory Royal College examination and membership fees, and a pledge to increase the less than full-time allowance by 50% amongst other measures.

Some were sceptical of the logistics behind creating another 1000 training posts for this year’s application cycle. Given that we know how long it takes to just about do anything in this country, some found it hard to believe such a proposal was possible. But it wasn’t to matter anyway; just four hours after Streeting published his deal, the rejection email from the BMA had already hit inboxes.

Through his meetings with the BMA, it is possible Streeting knew the offer would not be accepted. Call us cynical, but with the way that the game of politics is played, it is possible that the inclusion of additional posts and financial sweeteners may just have been tactical, designed less to win over the BMA but more to frame the government’s narrative. If so, the offer allows ministers to claim that they attempted to compromise and that doctors are primarily motivated by pay rather than reform.

It’s speculative, but credible: a pre-emptive move from Streeting to control the optics of a failed deal, whilst showing the public that they aren’t the same old Labour that is held captive to the unions.

The Limits of Leverage

The belief that unity alone can force a government to yield rests on an assumption that the government can yield. But this current dispute now sits in the context of a more dire economic landscape than previous eras of industrial action. Streeting may sympathise, and Reeves may even agree in principle, but both are locked in fiscal shackles, partly of their own making.

When the BMA locked horns with the last Conservative government, they were very much dealing with a hostile government that often wouldn’t even agree to sit in the same room as them. This government is not a hostile one, but it can be described as a financially immobile one.

Rachel Reeves is on the cusp of becoming the first chancellor to raise income tax in nearly fifty years as she battles to gain control of our country’s public finances and poor economic growth. Labour fought and won the last election on the mantra that there would be “no tax rises for working people.” To breach that promise now is not a marginal policy shift like her last budget, where she raised employee national insurance and was able to escape mostly unscathed; it is a demolition of political credibility.

Just dwell on the political significance of this for a second. The government has been backed into such a corner where it believes the only way to plug the holes we need to is to break the party’s own manifesto promises, potentially at huge political cost.

This is why Andrew Marr asked the chancellor this week: ‘If you believe raising income tax in such a fashion is the best thing for the country’s finances, will you stand by that and later resign after its implementation for breaking your pre-election promises?’

Within this context, it seems highly unlikely that Streeting will be knocking on number 11’s door asking for a larger slice of the chancellor’s fiscal pie. In comparison to the previous governments, it may be unfair on the man to suggest that he does not at least sympathise with doctors, but sympathy doesn’t expand the size of the fiscal budget.

Labour’s Ideological Problem

Labour has an ideological problem. It came into office promising to rebuild public services after many years of conservative austerity, without raising taxes. In promising so, they have an impossible equation: Prioritise public services the way Blair did, on budgets more akin to the Brown years.

For Better or For Worse, Technology Has Killed Off Clinical Skills

The Urgent Treatment Centre is the scene, and you have just listened to a patient’s chest and heard a heart sound so abnormal that you won’t get away with the classic “S1+S2+0” in the documentation. But what is this murmur? You have no clue where to start.

You turn to your consultant for guidance and explain the situation. Before you can finish, she launches into an anecdote about her early days clerking a neurology patient. Struggling to localise the deficits, she tried to go straight to imaging, completely sidestepping clinical reasoning. In those days, however, imaging was scarce, and it often meant a tense debate with the radiologist about the urgency of the scan.

An echocardiogram can certainly diagnose a murmur more accurately than a stethoscope, but at what cost to our diagnostic skills? Some people will throw their hands up and proclaim that this is a sign of the times, and that technology has led to better patient outcomes.

Certainly, this argument deserves respect, as medicine is designed to serve patients, but there is something emotionally troubling about a medical workforce that is slowly becoming worse at the bedside when identifying clinical signs.

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Is Rachel Reeves Going After GP Partners?

Potential tax reforms could be a major blow to GPs

If you weren’t aware, November 26th is a big day for the finances of the UK, including UK doctors. That’s the day the Chancellor, Rachel Reeves, releases her new budget and it may also be the day that GP practices get a major shock.

Reeves has made clear she’s not going to break her own fiscal rules, which state that responsible governments must match day-to-day spending with their income and only borrow for investment. In plain English, if she wants to spend more, she has to find the money from somewhere, either by cutting spending or raising taxes.

This has led to months of frankly, boring speculation about what could be on the table for her, from ISA amendments to mansion taxes, and more. But the latest rumour hits a target much closer to home. Reeves has hinted she may be looking at those working in Limited Liability Partnerships (LLPs), a structure popular amongst many GP practices. So let’s see what they are…

A GP-What?

GP partnerships can sound quite confusing, even among doctors. In the UK, most GP surgeries aren’t owned by the NHS. Instead, they are independent contractors who provide NHS services. The individuals who own and run these practices are GP partners. So, as well as all the clinical work, they are also business owners who employ staff, manage premises, and handle finances.

Rather than receiving a fixed wage like salaried GPs, the partners share the profits the practice makes after expenses are deducted. This can sometimes mean higher or lower incomes than salaried GPs, who have more stability in their expected pay. A partner’s pay depends on patient numbers and practice outgoings. In short, GP partners become partners because of the prospect of greater ownership, autonomy, and the potential for financial upside.

Traditional Partnerships vs LLPs

Okay, so we understand what GP partners are, but why was there such a shift from traditional partnerships to LLPs? Under a traditional partnership, each partner was personally liable for the debts and obligations of the business. If things started going pear-shaped and the practice went into debt (think of a big lawsuit for negligence against one of the partners), every partner would be personally responsible for repaying it.

An LLP changed that. It’s a separate legal entity, meaning the partnership itself, and not the individuals, can own property, sign leases, and be sued. If something goes wrong, it’s the LLP in trouble, not the partners’ personal assets.

The biggest upside, however, lies in the tax implications. An LLP does not pay corporation tax as a company would. Instead, each partner is taxed individually on their share of the profits. Their tax becomes very similar to what most people pay on their PAYE slip (income tax plus employee NI). If that same GP practice were a limited company rather than an LLP, it would first pay corporation tax on profits, and then partners would pay income tax again on any money they take out as a salary, creating a “double taxation” system that LLPs avoid.

The main point of contention that Reeves is eyeing up, however, is the fact that the LLP itself does not pay employer National Insurance contributions, which sit at 15%, on what its members earn. Each member instead pays their own employee National Insurance rate, which is much lower than the combined employee and employer National Insurance burden most businesses in the UK face.

Rachel Reeves has called this “unfair,” given that the individuals who work in these LLPs are often wealthy. For us at On-Call, it seems no one knows how to define the word “fair” anymore, and it is often used to justify any tax rise. One thing is certain in this budget: whichever lever Mrs Reeves decides to pull, it will almost certainly continue to squeeze the middle class, which means doctors will suffer the brunt.

Just Speculation, Mrs Reeves?

Reeves has been accused of allowing rumours to seep into the media as a way of gauging public opinion before going ahead with a policy, just take the “Cutting of the Cash ISA” circus that has dominated headlines for the best part of six months.

But if this isn’t speculation, and she does decide to go ahead with it, practices could face a significant rise in staffing costs and perhaps even discourage new GPs from becoming partners.

“Rads Law: One will always sound grumpier over the phone than in person.”

“The radiology registrar perhaps receives more phone calls than any individual in the hospital. This can become incredibly frustrating when reporting complex scans, as these constant calls serve to divide attention. I never understood why it wasn’t possible to have one dedicated on-call radiologist to answer queries and VET scans, whilst another reports. Interruptions are the enemy of clear thinking.”

“The patients we fear are often not the ones we have seen, but the ones we didn’t see and we hope we never hear about again.”

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

In 2021, there were 706 cases where a procedure began in a private hospital and the patient had to be sent by ambulance to an NHS trust for emergency care.

With more tax rises potentially around the corner in this month’s budget, the government is perhaps setting the stage to go after GP partners. An article in The Times this week decided to put their earnings on show to the public by stating that one third of GP partners make more than £175,000, meaning they earn more than Keir Starmer. One in six earn more than £225,000, and the top 10% earn over £256,400.

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The Moral Obligation Argument For Staying In The UK

You are autonomous. You are free. Your ancestors fought for these rights, and in the West, thinkers like Bentham, Mill, and Kant built entire worldviews around liberty. So why shouldn’t you pack your bags after F2 and head for the States? Or take your CCT to Melbourne?

In this climate of training bottlenecks, it’s a tempting idea and a perfectly reasonable one. But some doctors see this decision through a different moral lens. They aren’t living under a rock; they recognise the attractions of moving abroad, yet one main factor keeps them in the UK: obligation.

Before you fire back with arguments about freedom, it’s worth at least hearing them out. These doctors believe that everything they have become through their education, their training, and their ability to practise medicine was made possible by this country, often at a subsidised cost. To leave now, they say, feels like taking what the system offered and walking away before giving something back.

Some people, no matter how you frame it, view values such as obligation and reciprocity as antiquated, and that’s perfectly fine. We aren’t here to call one moral lens preferable to another. We know there are fair counterarguments. Personal freedom matters. A doctor exhausted by understaffing or feeling undervalued might reasonably conclude that staying isn’t a moral obligation but rather self-sacrifice.

Still, obligation isn’t erased just because other values exist beside it. To be a doctor is to reflect. The decision to stay or go isn’t only about where life might be easier; it’s about what we owe and to whom. And for some, that quiet voice of duty is enough reason to stay.