The Week 5 January 2024

It is the first week of an election year, and the inevitable cycle of will-they-won’t-they has formally commenced. While Parliament is still in recess, speeches from party leaders across the spectrum continue to fuel commentary on how parties will position themselves.

The most significant event of the week for citizens, however, is the longest strike in NHS history, and the ninth since March 2023. As we enter another year punctuated by strikes, it is worth unpacking some of the fundamental questions and policy considerations they involve.

As analysis by the FT at the start of last year showed, doctors have fared much worse in the austerity era than any other occupation. It is completely rational to want to see pay keep track with inflation – anything less means a real-terms pay cut – and junior doctors do work that is not only vital for society, but high-skilled and high pressure, which their salaries should reflect.

However, this is inevitably complicated when inflation is several times the standard 2% Bank of England target as a result of uncontrollable geopolitical events. It’s even more complicated when it’s funded by general taxation, unlike our international comparators, meaning savings are unfortunately found at the expense of other public service investment or pay rises.

The trade off of striking is most severe when the people that benefit the most from a fully functioning, free health service – both in terms of physical wellbeing and its redistributive impact – are low earners and deprived communities. Even with the view that a pay rise is a reasonable expectation, anything that creates more dysfunction in the health service limits its accessibility to those who need it most and cannot afford an alternative .

However, there is no question that commensurate pay is important – regardless of questions of fairness, there are clearly issues of retention. If doctors can get better pay working in the private sector or abroad, then this contributes to workforce shortages.

Yet, if more money is to be allocated, should it not be prioritised for the lower paid end of the health and care labour market? This includes the earlier years of junior doctor training, but also nurses and, most notably, social workers.

Adult social care is fundamental to dealing with our demographic challenges in healthcare. And yet, despite pay increases as a result of increases to the National Living Wage, low pay remains the norm. Indeed, pay in social care is now lower than in many other low paid sectors, such as retail. Unsurprisingly then, despite significant growth in demand for adult social care, the workforce has only increased by 12 per cent since 2012-13, and the vacancy rate is higher than in the NHS. The erosion of this workforce is detrimental to the NHS’s own commitment to shift to community based, preventative health care.

It is also worth noting that, in the NHS, it’s more complicated than a simple ‘pay more, get more’ assumption. Incentives to stay in the workforce are also about culture.

A survey by the General Medical Council found that doctors were two times as likely to point to workforce culture, burnout and stress over financial reasons for leaving. Even with an eventual pay settlement for junior doctors, qualitative factors continue to dominate reasons for discontent. This has to be resolved within the NHS, and at a Trust level, not by government.

The NHS is often thought to be in a state of polycrisis but each of its individual problems do not happen in a vacuum. This seemingly binary debate about pay should be situated within a broader policy context.