Last week I stood on a picket line outside the hospital where I work. I didn’t feel excited or energised or even proud to be there. I felt sad.
I do, however, feel proud to have worked at that hospital as a consultant in intensive care and anaesthesia for 18 years. So to stand outside it striking while patients were waiting for operations was uncomfortable.
I love the NHS, both emotionally and practically. To paraphrase Nigel Lawson’s famous line, it is the closest thing this English person has to a religion. I believe in the founding principles of a universal, equitable, comprehensive, high-quality health service that is free at the point of delivery, and I believe that funding it through general taxation offers good value for money.
The problem is not the model, it is the amount we are prepared to invest. Healthcare becomes more expensive every year as technology advances and our population ages, so we need to work out what we want the NHS to do and then apportion sufficient funds to do it. That amounts to an extra £40billion per year to keep up with comparable northern European countries.
We could reform the service (yet again) at vast expense and even change the funding system, but we’d only exchange our current set of problems for different ones. Waiting times might reduce, but the variation in quality would increase. Safety would be sacrificed for productivity.
Patients asked to contribute directly to the cost of their healthcare might give up dangerous hobbies like hang gliding and smoking, but they’d also stop getting their blood pressure, cholesterol and diabetes checked. Doctors paid per intervention might undertake more interventions, but only on good payers and the free-market model so beloved of successive governments doesn’t work.
If we started paying doctors per procedure, they’d perform more procedures, but that might not be in the patients’ best interests. When I’m trying to decide whether to have my varicose veins operated on, I want my surgeon to be as impartial as possible. (They’re keen enough on their scalpels as it is, without attaching pound notes to them).
Successive governments have searched for the answer in competition and free
market economics, but to be successful, a free market must meet four criteria. There must be large numbers of consumers and providers, there must be homogenous, standardised products, there must be easy entry and exit from the market by consumers and there must be perfect information for both providers and consumers. Healthcare doesn’t get close.
There is no perfect healthcare model, but ours is as good as any. The problem is that we expect the NHS to do everything on a shoestring. We either need to scale down our expectations and deal with the impact on society, or hand over the £40billion it needs. I’d advocate the latter, not only because it is the right thing to do, but also because it makes economic sense. A healthy population is a productive population.
And the first place to invest is in the staff – all the staff. We have to attract workers to the NHS, and then crucially to retain them. It is all well and good to publish a comprehensive 15-year NHS workforce plan that includes doubling the number of places at medical schools and increasing nurse training by 80%, but if you just turn the taps full on without first putting the plug in, it amounts to little more than a huge waste of taxpayers’ money.
That is why I was on the picket line last week. I am comfortably off. I know that many will have found the idea of a consultant, who earns in excess of £100 000 per year, (I am very old and that includes out-of-hours on-call work and extra shifts) striking unacceptable. I found it difficult myself.
For weeks I wrestled with whether I should vote to strike and then whether I should follow through and actually strike. I secretly hoped that I’d be on call for the ICU and so derogated and able to avoid the issue. But I wasn’t, so I had to make a decision and with a heavy heart, I joined the strike. If it had been just about me, I wouldn’t have, but when I spoke to younger consultant colleagues and junior doctors I realized that this was about the future of the NHS.
Consultants earned 35-40% more in real terms in 2008 than we do today and the current pay rise offered by the government is below inflation, so the downward trend is set to continue. But we are not doing 35% less work or facing 35% less stress or taking 35% less responsibility. If anything the opposite is true. The amount of work to be done is at an all-time high, burnout is becoming more common and the expectations of patients increase every year.
I do not believe in medical exceptionalism. In the end, being a doctor is a job like any other, but to become a consultant requires decades of training, and there is a price to pay for taking responsibility for people’s lives on a daily basis. At the end of the Covid pandemic that responsibility became too much for me and I had to stop. I became anxious, I lost my confidence and I even considered leaving medicine.
I was lucky. With fantastic support, I recovered, but many don’t and if we don’t value and appreciate our senior doctors, they won’t be there for us when we need them. New consultants can move to Australia, New Zealand, the Middle East and Ireland and earn twice as much under far more favourable conditions, and many of them are. Even before the pandemic, in 2020 nearly 40% of consultants reported a vacancy within their department. And every time one leaves of course, their work has to be picked up by those left behind.
The NHS is the people who work in it and all the staff deserve proper remuneration, but the buck stops with consultants. They take on the difficult and dangerous operations, they lead the heartbreaking conversations, they make the impossible decisions and they carry ultimate responsibility for their patients.
Judging by the reaction at the picket line, the majority of the public understand this. They appreciate that comparing consultants’ wages to the national average is not helpful and they accept the arguments for pay restoration.
Let’s hope that the government catch up with them and get back around the negotiation table before the waiting times get even longer due to further industrial action next month. It was the government’s pledge and is their responsibility to reduce NHS waiting times, after all.
Jim Down is a consultant in intensive care and anaesthesia. He is the author of Life in the Balance. A Doctor’s Stories of Intensive Care.