Doctoring the NHS’ Agenda for Change

I’ve just been going over some of my notes and found something that I’d planned to write and then forgotten about.  On the one hand, it’s probably not as topical as it was at the time when I wrote the notes, but then on the other, this is an issue that is likely to come up again.  Hopefully the distance from what was an emotionally charged time will help people to read this in a positive frame of mind: given one of my other posts, my aim is not to be deliberately provocative.  Well, I guess it is in some ways, but in a manner that I hope is generally positive!

At about the time that the Chancellor and the government were trying to deal with junior doctors pay, there was another pay-related news story: CEOs in the US will have to declare their annual pay.  In part this is being touted as a measure to try and improve equality between the average worker and top management.  When asked, most employees estimate that the big boss earns ~30 times more than the average employee’s salary (for their company).  In reality, most CEOs earn 300 times more than the average.

Closer to home, and admittedly not on the same scale of disparity, is the inequality, between doctors and the rest of the NHS.  All employees of the UK’s biggest employer signed up to something called Agenda for Change, the purpose of which is to improve pay and conditions for employees across the whole of the NHS.  Everyone signed up, except that is for the doctors.  There are over 150,000 doctors in the NHS and they have sufficient clout, as a body en masse, that they are still outside “Agenda for Change” and negotiate their own deals.

Where is the inequality?  Surely these guys are much more qualified than everyone else and deserve to be paid more?

It’s difficult to make exact comparisons because the promotions structure is slightly different, but let’s start with ‘Agenda for Change’.  This has a nine band scale, with the usual divisions:  the most basic work is done by those on Band 1 and the most senior staff (except those outside the structure) are at Band 9.  Meanwhile, doctors are on more traditional descriptive grades.  As I say, direct comparison is not possible, but a brave attempt would say that a newly qualified doctor jumps straight in at band 5 and a consultant is equivalent to – well actually they earn considerably more than a band 9.

So what?  Well, one of the arguments is that doctors make is that their higher salary is due to their higher level of training, and the time and hard work spent as a student.  This though is something of a nonsense.  There are many within the NHS who have spent an equally long time studying, who have studied to doctorate level* who are subsumed into Agenda for Change because they are not ‘medical practitioners’ with MB BS (or equivalent) after their name.  This includes physiotherapists, psychologists, radiologists, dieticians and so on: the people who have to win the peace after the war of surgery has been completed.  We should also not forget that there are numerous nurses who have significantly more on the job experience than newly minted doctors and yet earn less, or at best not much more.

*I’ll skip the earned vs courtesy ‘Dr’ – oh wait…

It should also be noted that:

  1. Consultants are only employed for 9 sessions (i.e. 4 and ½ days per week), and
  2. We are not getting consistently higher levels of professionalism as a result of higher pay.

Coming to the point, I think that we can all agree that doctors in the NHS carry a lot of responsibility and work long hours.  But this is not true of all doctors and is true of a lot of other people working in the NHS and in the sector more broadly.  It could be argued (and there is evidence for this) that shift work is damaging to long term physical and mental health, therefore, perhaps those working shift patterns should be compensated appropriately?

There is also some evidence to suggest that there is a spike in mortality rates that corresponds with junior doctors starting out on rotations.  Further, problems seem to continue for up to four months after rotations begin.   But we still have started talking numbers so:

  • There are ~37,750 consultants and 39,410 GPs in the NHS
  • 20% of GPS (i.e. ~7800) are salaried – this ranges between £55,412 and £83,617. The other 80% are paid according to a formula relating to the number of patients on their books and the number of treatments (for example flu jabs) given throughout the year.
  • The average remuneration that a non-salaried GP receives is £102,000: 1/10 earn more than £142,500 i.e. MORE THAN THE PRIME MINISTER. (This is not a suggestion that the PM deserves a pay rise, by the way).
  • Doctors in training, i.e. those that have graduated from their degree and started working are paid £22,636 for the first year, and £28,076 in year two.
  • When during specialist training, they’ll earn between £30,000 and £47,000 pounds.
  • Strangely, consultant tend to earn less than GPs: between £75,000 and £101,000. But then and again, they get more opportunities to earn other income through private practice.
  • And finally, lets recall that Income tax thresholds are
    • Personal Allowance = £10,600
    • Basic Rate = 20% on £10,600 to £31,865
    • Higher rate = 40 % on £31,866 and above.

So, as a starting point, we can say that there are some doctors in the NHS, mainly GPs, who pay more in income tax in a year than people who are on the national average salary earn in the same period.  I suppose you could argue that this is good for the Exchequer.

We could be really punitive and decimate (in the true meaning of the word) doctors salary, but actually we don’t have to, to make a difference.  Doctors are demanding a payrise (and will get it) at a time when everyone else in the NHS is suffering from a pay freeze.  I’d like to suggest that all we ask is that doctors think in a more collegiate manner for a change and think about those around them.  We won’t include the junior doctors in this, because they have their own problems, but if everyone else took a 1% pay _cut_ then:

  • 7800 salaried GPs, earning a ‘straight’ average (((83617+55412)/2) = 69514.5) would return £5,422,131 to the NHS budget.
  • 3160 ‘self-employed’ GPs earning more than the PM: it’s very difficult to find out how much GPS can potentially earn, although a Daily Mail article – I know, I know – suggest there are some extremes up in the £380,000 territory. Let’s be conservative and suggest that this 10 % are earning a mere £180,000, on average, so that would give us £5,688,000 for the NHS budget.
  • The remaining 28,449 GPs are now earning an average of £93,346 so would return £26,553,180.
  • 37,750 Consultants earning a straight average of £88,350 would return £33,353,892

This would give us a grand total of £71,017,203: we’ve left the registrars and junior doctors completely alone and made a modest 1% cut to the most senior doctors.  When you compare it to the National Deficit or the NHS budget as a whole, it’s pretty insignificant, it really is chicken feed.  But when you consider that you could use this to pay for another 2000 or so doctors or nearly 3000 nurses, it starts to become an interesting proposition.  Of course it’s more complicated than this: medical staff are expensive to train and need to be recruited in the first place but the NHS has become a two-tier employer and this needs to be addressed.

Doctors, the medical ones that is, get paid a lot.  They get paid a lot compared to people who have similar qualifications in their own organisation.  They get paid a lot compared to similarly qualified public sector workers in other areas.  They get paid a lot compared to some private sector works.  This is all doctors, not just those that have been in practice for a long time, but a small minority of those get paid amounts that are obscene when taken in the context of an organisation that has stretched budgets and in the context of a country where there are people who are living in poverty.

In closing, I would just like to say that I have met some truly brilliant practitioners who have helped stitch me back together on more than one occasion.  I’ve met some fabulously humble people who just want to get you back on your feet and at match fitness: they are certainly ‘worthy of their hire’.  I’ve also met some arrogant know-it-alls that I wouldn’t trust to put a plaster on a child’s teddy-bear, who at best have managed to keep the first part of the Hippocratic oath: first, do no harm.  These are the people that need to be weeded out early or supervised more closely.  I believe that both the training, financial renumeration and oversight models for the medical profession need rethinking not to mention the structure of the NHS – but that’s a problem for another day.


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