Executive summary

Junior doctors in England have just started balloting for strike action in pursuit of a 30 per cent pay rise. The ballot is due partly, of course, to the general inflationary squeeze on living standards; and to wide, long-felt and genuine staff dissatisfaction in the medical profession, the NHS and the broader public sector. That discontent is rising, reflected in staff survey results and a significant increase in the number of doctors seeking to work abroad.

But there is another factor – which may also help explain the unusually high pay claim, and might mean that finding a solution to the dispute is harder. As this report reveals, substantial parts of the doctors’ union, the British Medical Association, have been taken over by young, self-declared “entryists”¹ in a planned campaign similar to that in the Labour Party at the time of Jeremy Corbyn’s leadership. Corbyn is, indeed, explicitly cited by some of those involved, and key people are former activists in his supporters’ club, Momentum. As the activists say, “never in the history of the BMA has such a large-scale, coordinated effort been made.”²

Their methods – an inner core of hard-left figures (“Broad Left”) within a larger insurgent group (“DoctorsVote”) – will be familiar to students of caucus politics. Benefiting from tiny turnouts in internal BMA elections, they now between them control the BMA’s junior doctors’ committee, which decides on strike action; 26 of the 55 voting members on the whole union’s ruling council; and the deputy leadership of the BMA.³ “The BMA is no longer the BMA of old. With DoctorsVote comes new management,” the activists promise.⁴ This report is based largely on a cache of internal documents and online discussions in which they outline their views, tactics and plans.

The activists are secretive, refusing to identify all their leaders for fear of “government reprisal.”⁵ But some who we can identify have extreme views, or a record of serious misjudgment. One new Broad Left BMA council member, Becky Acres, has attacked the Labour Party as “proto-fascist”⁶ and the Conservatives as “almost genocidal.”⁷ Emma Runswick, the BMA’s new Broad Left and ex-Momentum deputy chair (deputy leader), was on the national steering committee of the UK campaign for “zero covid” – quite possibly, as China is proving, the worst idea in recent medical history.

The workforce grievances on which the activists have built support are real. But their 30 per cent pay demand is far greater than for any other group – even they admit it is “steep”⁸ – and its evidential basis is weak. Pay for most junior doctors has fallen in real terms, but by nothing like that much. Even the activists were only asking for 15 per cent until recently; it is not clear why the demand has now doubled. There is also evidence that working conditions, as much as or more than pay, are at the heart of junior doctors’ concerns.⁹

The BMA said last week that the government’s intransigence had meant there was “no other option left” but to strike.¹⁰ However, the material we have seen shows that strike action and confrontation with the government has been some of the activists’ objective for almost two years, since well before the inflation spike. It also shows that they are planning much longer, continuous and more comprehensive strikes than any other major workforce as part of a “radical industrial strategy.”¹¹

Other NHS staff, such as nurses and ambulance crews, are typically striking for a day at a time, and still providing emergency cover. But the BMA activists believe action of that sort makes “little impact. The answer must be consecutive days of real impact”¹² involving “potentially a full walk-out of all non-consultant grades for a week”¹³ and explicitly including the withdrawal of emergency care. Last week, the union announced that it would start, subject to approval in the ballot, with a “72-hour full walkout” in which “junior doctors will not provide emergency care.”¹⁴

The announcement claimed trusts could arrange alternative cover, meaning that emergency care would be “no different to any other day.”¹⁵ In the material seen by Policy Exchange, however, the activists admit that “patient safety could be compromised to varying degrees,”¹⁶ stating that “unfortunately a strike has to be disruptive in order to work.”¹⁷ As Jo Sutton-Klein, another new Broad Left member and BMA council member, earlier put it, “The ability for a trade union to win, comes from one thing – which is their ability and readiness to withdraw their labour for as long as it takes to win.. Things like ‘professionalism’ [and] ‘looking respectable’… are not relevant for trade unions.”¹⁸ Research in a publication of the BMA itself shows that the last junior doctors’ strike, which mostly didn’t withdraw emergency cover, saw 71 extra hospital deaths.¹⁹

The activists admit, too, that only a “tiny minority”²⁰ of junior doctors are in real hardship, that doctors are “not poor compared with the average worker”²¹ and that one aim is to “make an extra £1.5-2 million” over a career²² or to be able to “go less than full time.”²³ For at least some in the organising group, the real agenda – in Sutton-Klein’s words – “isn’t just about our pay… this is a hugely important ideological political moment.”²⁴ She says the BMA’s “public-facing strategy should situate ourselves in a broader workers’ struggle.”²⁵ Runswick has described organising doctors as an “opening for socialist politics.”²⁶

As the hard left has grown its control over the BMA, the union’s public statements have become more partisan and strident. Its strike ballot announcement said ministers “treat the public as fools”²⁷ and it described a government invitation to talks and plans for “minimum safety levels” as “laughable.”²⁸ The health secretary, Steve Barclay, is caricatured as “Wally” from the “Where’s Wally” cartoons. Earlier this month the BMA’s leader, Phil Banfield, accused the government of making a “political choice” which caused patients to “die unnecessarily.”²⁹ The BMA’s official magazine, The Doctor, devoted much of its December issue to an attack on austerity, which it said, inaccurately, had caused a jump of 735,000 in the number of working-age people with multiple serious health conditions over the last two years.”³⁰

Older members of the BMA, and former junior doctors’ leaders, including those who led the 2016 strikes, are worried that the new crowd are riding for a fall – as one put it, trying to “eat an elephant in one go”³¹ – with a wider membership that, while clearly angrier and more radical than it was, may not yet be fully ready for mass confrontation with patients’ lives in play. At a time when even the Labour Party has accused the BMA of “living on a different planet” in some of its demands³², it remains unclear whether the junior doctor profession, only about two-thirds of which is even in the union, will want to become footsoldiers in the broader workers’ struggle.

A note on quotations

Where individuals’ statements were made in an official capacity as BMA officeholders, this is stated in the text. In other cases they were made in an individual capacity, sometimes before they were elected to BMA representative positions, sometimes whilst in post.

A note on sources

Where sources are posts on social media such as Reddit or Twitter, links to the posts are provided. Screenshots of each post are also published in an Appendix to this report in case the original posts are removed, edited or made private. Individuals and groups named in this report have the following Reddit usernames:

Emma Runswick u/RedRunswick

Becky Acres u/AcutelyMedic

Jo Sutton-Klein u/thatsycamoretree

Rob Laurenson & Vivek Trivedi u/BMA_JDC_Chairs

(co-chairs of BMA junior doctors’ committee; joint account)

DoctorsVote u/DoctorsVoteuk

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Chapter 1: “A strange union”

The BMA benefits from the fact that many people do not think of it as a trade union. Certainly, that is not all it is. It holds regular symposia and lectures on clinical and professional matters. It publishes the British Medical Journal, one of the profession’s oldest and most influential, and around 65 other specialist journals. It owns a specialist law firm. Founded (as the Provincial Medical and Surgical Association) in 1832, it is older than any other surviving union. Its imposing, Lutyens-designed headquarters in Tavistock Square, with its members-only restaurant and lounge, courtyard garden, library and grand meeting rooms, feels more like a cross between an academic institution and a private club.

In practice, however, the BMA has long been mainly a trade union – well before it was formally recognised as such in 1971. Most famously, it opposed the creation of the NHS as totalitarian and harmful to its members’ wealth – drawing an equally strident riposte from the then Minister of Health, Aneurin Bevan, who called the BMA a “small body of politically poisoned people” engaged in a “squalid political conspiracy.”³³

It says it represents 173,000 doctors³⁴, about half the UK total.³⁵ Of these “over 45,000” are junior doctors³⁶, about two-thirds of the UK total.³⁷ Its junior doctors’ committee has significant autonomy, including the ability to decide strike action, though it can be overruled by the BMA council.

What is a junior doctor?

Junior doctor training normally lasts between five and ten years after graduating from medical school. All junior doctors start with a two-year foundation programme – the first year of which is spent under provisional registration. After the two foundation years, doctors continue training in either general practice (a further three years) or another medical specialism (up to eight years, depending on the specialty chosen.)

The BMA has taken major industrial action four times: in 1975, when consultants worked-to-rule against plans to reduce their earnings from private practice and end private beds in NHS hospitals; again the same year, when junior doctors reduced work in a pay dispute; in 2012, when consultants went on strike over changes to their pensions; and in 2016, when junior doctors held six days of strikes, grouped in ones and twos over three and a half months. The 2016 strikes were the only time that emergency cover was withdrawn, on two of the six days.

Doctors’ pay has been “a fraught and contentious issue since the foundation of the NHS. Never quite enough, but always well above the national average.”³⁸ In the mid 1960s, roughly five hundred doctors were leaving the UK and Ireland every year due to low morale. Last year, almost seven thousand doctors reportedly applied for a certificate to work abroad (up from 5,576 in 2021), with pay and working conditions cited as key reasons for their desire to depart.³⁹

The 2016 dispute resulted, eventually, in a new contract and the current junior doctor pay deal, which ends in March 2023. In a referendum, the deal (which provides a total pay uplift of 3% this year) was approved by 82 per cent of the BMA’s junior doctor membership who voted.⁴⁰

For the new generation of activists, the 2016 deal was a sellout and the BMA’s non-political image is part of its problem. The Broad Left organiser Emma Runswick, now the BMA Council’s deputy chair, effectively the union’s deputy leader, called it “quite a strange union” which “represents a professional group who do not see themselves as workers… there is a strong history of the BMA being very small ‘c’ conservative. It sees itself as a lobby group, a professional association…you have a historical weirdness going on. Many members are very reluctant to be seen as political.”⁴¹

Another Broad Left member of BMA Council, Jo Sutton-Klein, says that the BMA does “not campaign properly – because it might make them look unrespectable.”⁴² Sutton-Klein said in her council manifesto that the BMA must be turned into a “fighting trade union that takes industrial action.”⁴³ (She was also “quite taken aback by how fancy [the BMA offices] were….there was a huge sense of detachment to the actual working conditions of junior doctors.”⁴⁴)

The activists may have a point about the BMA’s conservatism, if perhaps not in quite the way they meant. According to the NHS’s official historian, Charles Webster, while the union arguably “possesses an unenviable record for assaults against the government of the day on matters great and small,” it has a habit of fighting for whatever the status quo is at the time. “Paradoxically over the life of the NHS… [the BMA] turned full circle to the point where, in the 1990s, it has vigorously defended the system that it had decisively rejected some fifty years earlier, just as in the 1940s it defended the National Health Insurance system that it had rejected in 1911.”⁴⁵

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Chapter 2: “A small group of like-minded people”

In autumn 2021, a group calling itself DoctorsVote (DV) first appeared on Reddit, an online discussion forum heavily used by junior doctors. It describes itself as “a small group of like-minded people… committed to achieving full pay restoration [FPR; that is, returning pay to 2008 levels in real terms, a pay claim of 30%].

“Having seen other grassroots organisations fail to effect change, we knew the only way to change the focus of the BMA was to do it from the inside, and our work to date has centred around getting as many FPR candidates into voting seats as possible… Never in the history of the BMA has such a large-scale, coordinated effort been made, and we cannot let it fail now.”⁴⁶

In a “campaigning strategy” for the BMA council elections of April 2022 (reproduced as an annexe to this report), DV planned to use the fact that “BMA elections have painfully low turn-out” and was clear that “persuading current voters… shouldn’t be a big focus.”⁴⁷

Instead, the strategy set out plans for what it called “entryism,” the dictionary definition of which is the infiltration of an organisation, such as a trade union or political party, with the intention of subverting its policies or objectives. It continued: “We should encourage people to join the BMA for the purpose of voting in this election. This is particularly worth asking first year medical students to do as they have free/low cost BMA membership.”⁴⁸

It went on: “This is the chance to get BMA council accountable, transparent and support a proactive and radical industrial strategy to win full pay restoration… Winning the election is the start, we will then need you to come out on strike.”⁴⁹ Online, supportive doctors advised that “you can join for 1 month just to vote and then end your membership” and others announced that they had done so.⁵⁰

To choose its candidates, DV carried out a “vetting process [which] took place over several weeks… We hand-picked well-rounded individuals who will push hard for pay restoration above all else whilst carrying out their elected duties… We must elect representatives who will not sell out, who will not falter under media and government pressure.” ⁵¹

Within less than a year, DoctorsVote and Broad Left controlled the BMA junior doctors’ committee; 59 of the 60 regional junior doctor representatives; and 26 of the 55 voting members of BMA council, its national executive committee. They then went on to elect Emma Runswick as the Broad Left and DoctorsVote deputy chair, or deputy leader, of the whole union. At the BMA’s annual conference in July 2022 DoctorsVote, as it boasts, “pushed through… by far the most significant change in BMA industrial strategy for a decade,” ⁵² the emphasis on a big pay claim and strikes.

DV won its council seats on the votes of only 1600 people,⁵³ about 3 per cent of the BMA’s junior doctor membership and 2 per cent of all junior doctors. In practice, however, the proportion will be lower, since some of those who voted for DV candidates were medical students or other non-junior doctors.

How is BMA policy made?

BMA policy today is set at its ARM (annual representative meeting), with motions submitted by divisions, regional councils, branch of practice conferences, and national councils from across the devolved nations. A RB (representative body) consisting of 600 members who attend the ARM vote on motions, which if passed, becomes BMA policy.⁵⁴ For junior doctors, the annual junior doctors conference (which takes place once a year) acts as the primary policy setting body for junior doctors across the UK, with motions submitted by regional junior doctors committees (RJDC).⁵⁵

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Chapter 3: “Named and unnamed members”

Many in the BMA have asked who actually runs DV. The answer remains partly secret. DV says it is a “collective with no single leader” controlled by a “steering group” with both “named and unnamed members… The option of anonymity within DoctorsVote protects the people who are doing a lot of the heavy lifting towards FPR from being distracted or targeted via media… Others among us have concerns about government reprisal.”⁵⁶ Its advocates describe it as “non partisan”, with members including those “across the political spectrum”.⁵⁷ But, as Emma Runswick says, there is an overlapping “Venn diagram of people” on the BMA Council between Broad Left and DoctorsVote.⁵⁸ Not all DoctorsVote members of the council are members of Broad Left – but almost all the council’s Broad Left members are part of DoctorsVote.

Six DoctorsVote steering group members were named by DV in August 2022 – Stuart Maitland, Jo Sutton-Klein, Ellen Newberry, Sid Parashar, Poh Wang, and Emma Runswick.⁵⁹ However, the steering group has numbered “about 20,” according to Maitland, who said that “initially there was a plan for transparency of who was involved, but after we listed the first three doctors (incl myself) the one who was already involved in the BMA received vexatious and now dismissed complaints, which made all of us worried… So there was then a hybrid structure with some named people with specific experience, and some people who did not want to be publicly named.”⁶⁰

In essence, the group appears to be self-selected, or in DV’s words comprised of “those whose initiative, focus and effort have acted as proof of their value towards our goal achieving FPR.”⁶¹ It describes itself as “mainly” comprised of full-time doctors and “entirely funded by anonymous donations from doctors. No money is received by [sic] political or lobbying groups or otherwise.”⁶²

The DoctorsVote members of BMA council are Shohaib Ali, Becky Bates, Corey Briffa, Ollie Burton, Hannah Cagney, Cristina Costache, Vassili Crispi, Adam Daneshmend, Louis Downland, Preethi George Pandeth, Shan Hussain, Nyree Jackson, Anil Jain, Zain Khan, Sumi Manirajan, Anvarjon Mukhammadaminov, Kayode Oki, Serge Omanyondo, Sid Parashar, Emma Runswick, Selvaseelan Selvarjah, Arjan Singh Nagra, Tom Stocks, Jo Sutton-Klein and Poh Wang.⁶³

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Chapter 4: “Trying to eat an elephant in one go”

Part of the answer as to who runs DoctorsVote lies in a smaller and slightly older grouping within DV and the BMA known as Broad Left. Set up in about 2020, this describes itself as “a group of active BMA reps on the left of politics who engage in rank and file organisation”⁶⁴ and which campaigns for a “radical and accountable” BMA.⁶⁵ Its logo is a stethoscope arranged to look like a hammer and sickle. Most of the active members of DoctorsVote, as measured by speeches at BMA conferences, online presence and organising activity, are part of Broad Left.

The two key Broad Left organisers appear to be Jo Sutton-Klein and Emma Runswick, who as well as being the BMA’s deputy leader is emerging as one of its chief media spokespeople. Runswick says there are eight Broad Left members of BMA council⁶⁶ of whom she names seven – herself, Sutton-Klein, Becky Acres, Becky Bates, Kayode Oki, Vassili Crispi and Shohaib Ali.⁶⁷

All these, apart from Acres, are also part of the council’s 25-strong DoctorsVote group. Sutton-Klein has stated that she is “really proud of how we have supported DoctorsVote and helped [it] navigate the BMA’s bureaucracy.”⁶⁸

Broad Left has been trying to commit the BMA to strike action for almost two years, long before the inflation spike, and to becoming a more politically partisan body directly attacking the Conservative Party. But before DoctorsVote appeared, its record of success in these objectives was patchy.

At the 2021 junior doctors’ conference in May of that year, Broad Left put a motion demanding that the BMA campaign against “the declining health of the UK public due to government policy since 2010 [when the Tories took office],” that it “inform and educate the membership about the true scale of the real-terms pay erosion in doctor wages since the Conservative Party gained power,” and that it “lay the groundwork for industrial action over pay” – at that stage, with a 15 per cent claim.⁶⁹ Sutton-Klein said: “Our wages are being siphoned into the pockets of billionaires and it’s not fair… If we want our pay restored, we must join other NHS workers in making big demands.”⁷⁰

These elements of the motion were all defeated. A former chair of the junior doctors’ committee, Jeeves Wijesuriya, said: “We are currently a non-partisan union. When I was JDC chair in 2016-19 we got £120m in additional [pay] funding and an 8.4% uplift over four years, not by trying to eat an elephant in one go, but by going above employers to a secretary of state that, God forbid, was a Conservative. We have done a pay survey of our membership that tells us over 50% are not in favour of strike action… the only concrete polling we have tells us this is not their ask.”⁷¹

Another speaker, a member of the Labour Party, warned that explicitly party-political attacks would “alienate a significant proportion of our membership.” (A 2021 poll found that 42 per cent of healthcare workers had voted Conservative in that year’s local elections, though support for the party has declined since.)⁷²

Broad Left has clearly learned from the experience; since 2021 its public language and policy demands have become less party-political. DoctorsVote broadly avoids political rhetoric altogether in its public language, presenting itself as a simple pay campaign. This has brought dividends in the form of support from BMA members who may not be aware of the broader agenda. (It also appears that support for industrial action has risen since 2021; a later BMA survey, last September, claimed 72 per cent support.⁷³) Away from their doctor-facing statements, however, the leaders of both groups remain intensely partisan.

As Rob Laurenson, the DV co-chair of the junior doctors’ committee, put it in October, “doctors are being coerced into the managed decline of our healthcare system by this government. We will not participate in their failed plans and we will be voting to withdraw our labour on 9th January.”⁷⁴ Becky Acres, a new Broad Left member of BMA council, recently attacked Labour as “proto-fascist Red Tories;”⁷⁵ tweeted that the Tories and austerity were “almost genocidal;”⁷⁶ and warned that “the extremists (and fascists) are trying to wrest control of our institutions from the artists, liberals and leftists; they must be resisted.”⁷⁷

Runswick, 27, whose Reddit username is “RedRunswick,” is more disciplined but has a long record of hard-left activism. She was active in the Jeremy Corbyn supporters’ group, Momentum⁷⁸ and signed an open letter against the “purge” of non-Labour Party members from the group’s youth wing. Naming her as a “young Momentum member,” it called for “the whole left to unite to fight to make Jeremy Corbyn prime minister and win socialist policies.”⁷⁹

Her time as a medical student was a trial run for some of the tactics now being pursued in the BMA. In 2016, Runswick and two other hard-left activists described how, under the banner of “Labour Left Students for Corbyn,” they “made a successful intervention into Manchester Labour Students, a notoriously Blairite grouping [and]…hotbed of party careerists” which favoured a “narrow electoralism” rather than “organising alongside workers.” These efforts led to charges of bullying – “disingenuous” according to Runswick – but she did admit that she and the others “organise[d] caucuses and recruit[ed] heavily… we used our left caucus as a battering ram to open up an insular Labour club.”⁸⁰

In 2019, she said that “doctors’ ideas have changed; they’ve realised that they are workers as well as professionals… I think that’s where the opening for socialist politics is — the realisation that we are workers and that we can be open and proud about organising in a trade union, not just an apolitical professional association.”⁸¹

Runswick was on the national steering committee⁸² of the UK Zero Covid Campaign, which demanded “a full UK-wide lockdown until new cases in the community have been reduced close to zero.”⁸³ (If this demand had been met, the UK might still be on lockdown today.) She said the campaign “makes my heart sing”⁸⁴ and spoke at its launch event and 2021 national conference. At an online campaign rally in November 2020, only three weeks before the first UK patient received their covid vaccine, Runswick continued to insist that “the primary measure against this virus is isolation” and criticised how workplaces and schools had reopened “to maintain profits for the ruling class.”⁸⁵

As late as August 2021, she attacked a government decision to end isolation for Covid-19 patients’ close contacts who had been double jabbed as “tantamount to murder.”⁸⁶ As China has shown, a zero Covid policy would have been disastrous, imprisoning tens of millions for months longer than necessary, causing greater economic harm and resulting in a surge of deaths when the policy inevitably became untenable.

Runswick has also defended prostitution for medical students as “flexible, well- paying work with limited hours,”⁸⁷ adding: “Support your members at ARM [BMA conference], folks – at least some of them will be sex workers.”⁸⁸

Runswick graduated from medical school in 2019 but seems to have practiced relatively little. In May 2022, she said she had “taken time out of [junior doctor] training to locum, so I can do a PGCert [a medical teaching qualification], BSL [British Sign Language] qualification and still have money to enjoy life a little.”⁸⁹

Sutton-Klein, 28, an A&E junior doctor from Sheffield, believes that the forthcoming strike “isn’t just about our pay (as much as it would be nice and simple if it was) – this is a hugely important ideological political moment.”⁹⁰

Earlier, when organising for a 15% rise, she said: “Nationally coordinated, disruptive, wide-scale industrial action with extremely ambitious demands would seriously disrupt government… it will mark a significant step in the reversal of the defeats that trade unions have faced since the 1980s.”⁹¹

She warned that “we should therefore anticipate inordinate and aggressive resistance to this from capital and its representatives i.e. the government and political class, the media… Anyone is at risk of being enticed to sell out due to the lure of careerism and the pressure from the media…. We should anticipate that those in the BMA bureaucracy who choose to support the campaign will be subjected to media vitriol similar to that faced by Jeremy Corbyn.”⁹²

She says: “There is definitely a sense that by being well-dressed and well-spoken and not asking for too much or by making too much of a fuss the BMA thinks it can achieve more. Not only is it classist, it’s also proven ineffective and wrong.”⁹³

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Chapter 5: “Professionalism is not relevant”

Having taken control of the junior doctors’ committee, the activists’ mood is upbeat. Rob Laurenson, the new DoctorsVote co-chair of the committee, said that “the government has been pursuing a starve-the-beast strategy in healthcare. I think we’re about to see what starving beasts do. Fight back or we risk losing everything!”⁹⁴ He celebrated how “a profession on its knees [has been] given the opportunity to stand. No longer do we beg. United we bargain!”⁹⁵

Jo Sutton-Klein said: “The ability for a trade union to win, comes from one thing – which is their ability and readiness to withdraw their labour for as long as it takes to win….things like ‘professionalism’, ‘looking respectable’, and tactical secrecy are not relevant for trade unions – but a lot of people in the BMA are trying to say that they are… Whatever our demand is, we should be prepared to go on strike until we get it. If we demand 30% then I would not be happy with any leader who calls off the strikes at 10%.”⁹⁶

Accordingly, the activists are planning a long strike by the standards of other recent ones. Almost all other current strikes, from rail to nurses and ambulance workers, involve walkouts of one or two days at a time, the model also used by junior doctors in 2016. In a Reddit question-and-answer session in November, Laurenson and his DV co-chair Vivek Trivedi said that the 2016 dispute failed because “days of [strike] action were staggered and made little impact. The answer must be consecutive days of real impact.”⁹⁷ DoctorsVote states that “the campaign this time would potentially include a full walk out of all non-consultant grades for a week.”⁹⁸ They announced an initial 72-hour strike last week with the “possibility of escalation.”

Laurenson and Trivedi are clear that this must include the withdrawal of emergency cover. Asked in the same Reddit exchange whether they supported “a FULL strike? (i.e. including the withdrawal of emergency care?)” they replied: “Yes….It is our (Rob + Vivek) preference that we announce our strategy in the form of action before the ballot opens. Our preference is giving employers the legally required notice of days of action and nothing more. Our preference is a full walkout.”⁹⁹

Emma Runswick, Becky Acres and Jo Sutton-Klein were asked the same question in another Reddit Q&A. All replied that they would support the withdrawal of emergency care, though said they would do it with no great enthusiasm.¹⁰⁰,¹⁰¹,¹⁰²

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Chapter 6: “Of course patient safety could be compromised”

In its strike ballot announcement, the BMA claimed that even though junior doctors would withdraw emergency care, trusts could arrange alternative cover, meaning that emergency care would be “no different to any other day.”¹⁰³ But the discussions by the activists tell a different story. Asked on Reddit how much patient safety could be compromised during industrial action, Broad Left council members admitted that it could.

Becky Acres replied: “The answer to this is of course that patient safety could be compromised to varying degrees by any industrial action… Personally my preference is for strike coordination to ensure maximum irritation value for least harm. Unfortunately a strike has to be disruptive in order to work.”¹⁰⁴

Jo Sutton-Klein said: “Patients are missing out urgent and emergency care as it is, and the situation is only getting worse. So I still believe that a full walk out [would] be less harmful for patients in the long term than letting the status quo continue.”¹⁰⁵

In the 2016 strikes, when emergency care was withdrawn on two of the six strike days, consultants covered for striking juniors. This time, however, NHS Employers has noted there could be difficulties in repeating the arrangement because “there is considerable push back from some groups of consultants regarding the rates at which additional hours are remunerated and this could have a significant impact on an employer’s ability to plan effectively if faced with industrial action by junior doctors.”¹⁰⁶

The weeks of the 2016 junior doctors’ strikes – which mostly didn’t stop emergency care – saw 71 more deaths than in normal weeks, according to an unnoticed publication of the BMA itself. Furnivall at al, in the British Medical Journal, compared hospital deaths in the weeks of each of the strikes with the weeks immediately before and after (Mon-Fri).¹⁰⁷ The article has never received mainstream media coverage.

It finds there was a 9.75% increase in accident and emergency deaths (31 more deaths) in the strike weeks versus the comparator weeks. These are patients who died in the A&E unit. This was despite a 6.8% fall in A&E attendances in the strike weeks versus the comparator weeks. If we take account of this, which the article doesn’t, A&E deaths were 17.9% higher in strike weeks than in the comparator weeks, equivalent to 54 extra deaths.

There was a 1.3% increase in “emergency admission” deaths (40 more deaths). These are emergency inpatients who went on to die in another part of the hospital, such as an intensive care ward. This was despite a 3.7% fall in emergency admissions in the strike weeks versus the comparator weeks. If we take account of this, which the article doesn’t, emergency admission deaths were 7.8% higher in strike weeks than in the comparator weeks, equivalent to 197 extra deaths.

The article only deals with deaths in hospitals during the strike weeks. There may have been others caused by the strike, for instance people who got bad care but died later than the study weeks, or who died outside hospital after discharge, or who were put off seeking treatment in the first place because of the strikes.

The article states there was “a significant impact on outpatient appointments, admitted patient care and accident and emergency visits” but that “mortality did not measurably increase on strike days.” This appears to be because the authors have defined any increase below 5% as not a “measurable increase” and decided that the 9.75% increase in A&E mortality was on too low a base.

Section 240 of the Trade Union and Labour Relations (Consolidation) Act 1992 criminalises breach of contract (which all strike action involves) that has the “probable consequence” of “endangering human life or causing serious bodily injury.” The maximum penalty is three months’ imprisonment.¹⁰⁸

NHS Employers recently advised hospital trusts to “raise awareness of Section 240 TULRCA 1992 obligations with their employees” and recommended that “employees are directed to seek further information from their unions about whether their preference to take strike action could be viewed as refusal to co-operate with derogations [for emergency care] where safe and essential care cannot be provided by use of other staffing methods.” It notes, however, that “to our knowledge, no such proceedings [under s240] have been taken in the past.”¹⁰⁹

The BMA has responded angrily to this advice, saying claims that it could be used to penalise doctors failing to provide emergency care are “simply not true.”¹¹⁰ It commissioned advice from the Labour peer Lord Hendy KC, which said that for criminal liability to be upheld, any potential claimant must prove “the doctor’s withdrawal of his or her labour is significantly more likely than not to be the cause of death or serious injury to a patient.”¹¹¹

Under the 2016 Trade Union Act, industrial action in “important public services,” including health, needs the support of 40% or more of a union’s total workplace membership in the ballot to be lawful. The junior doctors do not appear to believe that this threshold applies to them; certainly, the BMA’s get-out-the-vote material for the current strike ballot does not mention it.¹¹² This may be because the relevant secondary legislation defines what are “important public services” in health quite narrowly, essentially only A&E, intensive care, emergency ambulance, and lifesaving psychiatric, obstetric and midwifery services.¹¹³

Where the majority of a workforce being balloted does not work in the specified areas, government guidance is that none of the workforce is subject to the 40 per cent rule. The guidance states: “If the union reasonably believes that the majority of members who are entitled to vote in the ballot are not carrying out an important public service, then it will have a defence to legal challenge, even if that later turns out to be an erroneous belief.”¹¹⁴

The BMA may therefore have decided that the junior doctor workforce is mostly employed outside the specified areas, allowing even doctors in clearly life-saving jobs such as A&E to be withdrawn on strike without meeting the 40% support threshold. The narrowness of the role definitions in health is anomalous: the secondary legislation for transport and education covers many more roles. There is a case for revisiting the role definitions in health, as well as the guidance which gives unions significant discretion.

In an official BMA statement last week, Runswick described plans for new legislation to enforce “minimum safety levels” as “laughable,” saying: “This Government has failed to ensure anything like minimum standards of patient care or service delivery in the NHS for many months, if not years.”¹¹⁵

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Chapter 7: “We don’t want the public getting doctor strike fatigue”

In preparation for a strike vote, DoctorsVote and Broad Left have “begun to train over 300 junior doctors in industrial organising and campaigning (the Jane McAlevey principles).”¹¹⁶ McAlevey is an American union organiser closely followed by the activists. The principles are:

leader identification, or: understanding who can move people (it’s often not who you first think);
semantics, or: the words we use matter – they have to centre each worker’s active participation as key to winning;
structured organizing conversations, or: what it takes to recruit the hardest-to-recruit leaders;
charting, or: a simple method to understand human social relationships, and to prioritize and systematize outreach;
structure tests, or: mini campaigns to build solidarity and site structure, and to know when you are ready to win.
Runswick and Acres say that the “’inoculation’ of members against the response of [the] public, bosses, media and government is vital.”¹¹⁷ The BMA have issued an “activists’ guide” which tells doctors to draw up a “power map” of relationships in each NHS trust and sets out a “messaging triangle” that strikers can say.¹¹⁸ The phrases they are told to repeat include “junior doctor pay has been cut by 26% since 2008…the Government is ignoring the views of grassroots junior doctors. Only by standing together as a profession can we make ourselves heard. Refuses to meet with the BMA. Has billions to pay for test & trace and private providers – but nothing for NHS workers. More members than ever before. United profession. Different to ‘last time’.”¹¹⁹

The BMA has hired a former RMT rail union official, Matt Waddup, to organise the pay restoration campaign.¹²⁰ He did 14 years at the RMT before joining what became the Universities and Colleges Union, ending up as head of campaigns there.¹²¹

The union claims that 4,000 junior doctors have volunteered (via online signups) as pay campaigners.¹²² Large numbers of “pizza and pay” meetings have been organised at hospitals to encourage doctors to vote in the ballot and campaign WhatsApp groups have been established. These allow “almost real time dialogue between grassroots and us. We can now be very agile in our reactive approaches. What we need to improve though is turning mobilised doctors into activist doctors who will get us that supermajority…Our work needs to be done face to face first, and then we will spread into the public arena. We don’t want the public getting Doctor strike fatigue and acclimatising.”¹²³

Runswick has said that the strike in 2016 failed because “a lot of decisions that we made, and a lot of the opinions that were formed, and not just on the JDC but among the broader membership, was based on what they saw in social media and in the press. So when the press turned against us, they found that very difficult to maintain.”¹²⁴

In the other main NHS disputes – involving nurses, ambulance workers and ancillary workers – each workforce was balloted employer-by-employer. Any strike ballot must secure at least a 50% turnout of union members to be valid. Strikes where the majority of the workforce is providing an “important public service” must also secure the support of at least 40% of the union’s membership at that employer to be lawful. Among ancillary workers, strike votes at the vast majority of NHS employers did not meet the legal thresholds for action. Among nurses, strike ballots met the thresholds at only 57% of NHS employers.

The BMA, however, has chosen to hold a single national ballot of all junior doctors across England – as it is legally entitled to – which is likely to make it easier to meet the 50% turnout threshold and to deliver a strike mandate across the country. As we have seen, the union appears to have decided it need not worry about the 40% support threshold at all. There is a case for requiring employer-by-employer balloting and not leaving it to the discretion of the union.

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Chapter 8: “I’m talking to people who are lying to me”

Junior doctors make up only about a quarter of the BMA’s overall membership; the majority are consultants or GPs. But the rise of the activists appears to have heightened the rhetorical tone in other parts of the organisation too. The BMA’s new chair, or leader, Professor Phil Banfield, this month accused the government of making a “political choice” to let patients “die unnecessarily.”¹²⁵

Summoned to a DoctorsVote hustings (chaired by Emma Runswick) for the Council Chair candidates in June, Banfield, a consultant obstetrician and BMA lifer with 11 years on the union’s council, was at pains to show his alignment with the new realities, stressing his support for the 30% pay claim, his belief in the “power of coordinated action” and adding: “One of the things I’ve always done is stand up against injustice and that’s always led me into trouble… My mother still has a press cutting of me setting fire to a prime minister one bonfire night, many moons ago.”

Describing his interactions with politicians, he said: “I discovered that half the time I’m talking to people who are lying to me. If their lips are moving, then they must be not telling the truth… What’s missing from the BMA at the moment is a reputation of being a trade union, and we have to re-establish that.”¹²⁶

The BMA’s official magazine, The Doctor, has become increasingly politicised. It devoted much of its December issue to an attack on austerity, speaking to “the charities and organisations trying to hold together what remains of the UK’s disintegrating social safety net. Everywhere the stories have similar themes – services have been pared back to the bone… The tales of tragedy are everywhere you look.”¹²⁷

The article claimed that a 735,000 rise in the number of working-age people with multiple serious health conditions over the last two years was “driven by austerity policies.” The rise was in fact a consequence of Covid-19; the number was falling before that.¹²⁸ It attacked the “doubling” of street homelessness “between 2013 and 2018,” but neglected to mention that street homelessness has almost halved again since.¹²⁹ It ended with the story of a man who “tries to pick people up when they are down. After more than a decade of austerity, communities in Nottingham are asking when, if ever, the government will be minded to do the same.”¹³⁰

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Chapter 9: “Doctors are not poor”

A recent BMA survey, based on responses from 3,800 junior doctors, claimed that 79% “often think about leaving the NHS” and 40% “will” leave as soon as they can find another job. Some 85% said they were doing so because of inadequate pay. ¹³¹

These figures are likely to be significant exaggerations. According to the NHS’s latest staff survey, published in March 2022, which used a sample three times the size, 23.8% of junior doctors and dentists often think about leaving the organisation they’re currently working for (not the NHS as a whole) and 16.8% say they will leave it as soon as they can find another job.¹³² Only 10.8% of those considering leaving said they wanted to leave the NHS.

The truth about pay is also more nuanced. In the same NHS survey, only a minority – albeit a large one, 39.1% – of junior doctors and dentists were dissatisfied with their pay. This was lower than most other NHS clinical staff, including adult and general nurses (48.2%), paramedics (47.8%), nursing auxiliaries and healthcare assistants (59.9%) and ambulance technicians (66.1%).¹³³

According to the General Medical Council’s 2022 national training survey – with an even larger sample size, 49,000 junior doctors (about three-quarters of the total), 79% of junior doctors agreed that their working environment was a fully supportive one. Minorities – although again large ones – felt burnt out to a high or very high degree (39%) or rated their work intensity as heavy or very heavy (45%). There were significant variations between specialties, with only 18% of junior doctor anaesthetists saying their workload was heavy or very heavy compared with 77% of emergency medics.¹³⁴

This is not to deny two important things. Firstly, that junior doctor dissatisfaction is clearly growing – dissatisfaction with pay was 29% in the NHS staff survey of 2019, and only 19% were thinking about leaving their current workplace.¹³⁵ And secondly, with the increase in inflation and workload, that dissatisfaction has almost certainly grown further since the latest NHS survey was conducted at the end of 2021.

However, average earnings per junior doctor are better than or comparable to those of other professionals at similar stages of their careers. Median salaries for “high skilled graduates” in their first year out of university were between £25-£27,000, according to the Higher Education Statistics Authority.¹³⁶ These are 2019/20 figures, the latest available; adjusted for inflation the March 2022 equivalent would be £27-29,000. A member of a graduate trainee scheme will typically earn £23,743 in their first year, according to the recruitment site Graduate Jobs.¹³⁷ The “Times Top 100 No1” graduate training scheme, the civil service fast stream, pays £27-28,000.¹³⁸

Including both basic and non-basic pay, junior doctors in their first “foundation training” year, the first year out of medical school, earned an average of £36,364 in 2021/22. Those in their second year averaged £42,910. Junior doctors in their “core training” years, typically years 3-5 or 3-7 after medical school and most still in their twenties, averaged £55,141. Specialty registrars – the majority of junior doctors, about 55 per cent of the total – had average pay of £61,553 in 2021/22.¹³⁹

The average pay of all English junior doctors across all grades in 2021/2 was £55,436.¹⁴⁰ Each of these sums will be about 3 per cent higher now with the 2022/3 pay award, making average junior doctor pay this year about £57,100.

DoctorsVote advises those preparing to strike to “start saving today – £20 per day for 100 days – save money to sustain the strike.” It was pointed out in a Reddit discussion that if you can save £600 per month you aren’t all that impoverished. DV replied to this criticism: “There are almost certainly doctors living hand to mouth, but I doubt anyone will argue when I say they’re (fortunately) a tiny minority.”¹⁴¹

Beth Newberry, the DoctorsVote deputy chair of the junior doctors’ committee, was interviewed recently in The Doctor, the official BMA magazine. As the article put it, “Dr Newberry’s point is not that doctors are poor compared with the average worker, but that they went into their careers thinking they would have well-paid jobs in return for their hard work and dedication.” Newberry was quoted as saying: “It’s a difficult topic to broach, but many doctors now struggle to get on the property ladder whereas public perceptions are that that’s something doctors can afford. It used to be something that an F1 [someone in their first year out of medical school, typically aged 23-24] might be able to contemplate. Now, I don’t know a single F1 anywhere near that position.”¹⁴²

Part of the real aim in the dispute may be that a significant pay rise will allow more junior doctors to go part-time, as many GPs already have. As Emma Runswick has said: “Pay restoration… will enable some to go less than full time instead of leaving altogether.”¹⁴³ In Stuart Maitland’s words: “With adequate pay, you can choose better hours.”¹⁴⁴

DoctorsVote has also stated: “It looks like you’ll make an extra £1.5-2 million over the course of your career if we achieve [our demand for full pay restoration] and link it to inflation (which is a must), depending on seniority, hours/week etc.”¹⁴⁵ Their italics.

Junior doctors do face some significant costs for professional advancement, including compulsory enrolment fees for higher specialty training of up to £880 a year and exam fees of more than £3,500.¹⁴⁶ There is a case for these fees being subsidised or met by the NHS.

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Chapter 10: “£50 billion isn’t that much money”

Until last year the activists were arguing for a junior doctor pay rise of 15%. They now want 30%, which they say is necessary to achieve “full pay restoration,” FPR, restoring pay in real terms to 2008 levels. Thirty per cent is significantly greater than the claims of any other workforce in dispute. Runswick said last year that paying for it will cost “in the order of 10s of billions per year”¹⁴⁷ but claimed that “£50bn isn’t that much money.”¹⁴⁸

This month, the union issued a new calculation claiming that full pay restoration will cost only a tiny fraction of this amount – £1.03bn per year, net of extra taxes returned to the Treasury.¹⁴⁹ Based on annual NHS earnings statistics¹⁵⁰ the junior doctor paybill, including employer pension and national insurance contributions and the 3% uplift delivered in 2022/3, is around £5 billion this year. Theoretically, a 30 per cent rise for junior doctors would therefore cost about £1.5bn a year. But given the pay spiral it would certainly trigger, with other NHS and public sector workers demanding similar settlements, the actual cost is likely to be closer to Runswick’s original figure of tens of billions.

The 30% demand is also higher than pay claims by other parts of the BMA. The union demanded RPI+2% (9.5% at the time) in its 2022/3 pay submission to the Doctors’ and Dentists’ Review Body in January 2022.¹⁵¹ Junior doctors did not submit to the review body, citing a lack of confidence in it. As the review states, “the BMA written evidence submission…did not have specific sections covering consultants and doctors and dentists in training in England, and representatives of these groups did not attend their oral evidence session with us. This weakened the evidence that we received about these groups and made it more challenging for us to make comments, observations and consider the case for making recommendations for these groups”.¹⁵² Junior doctors were not included in the DDRB recommendations as because they are in year 4 of a four-year pay deal agreed in 2019 – and approved by the BMA junior doctor membership in a referendum that year by a margin of 82% to 18%.¹⁵³ As mentioned, this awards a total average pay uplift of 3 per cent in 2022/3 (2% on basic pay and the rest by more generous allowances or pay banding.)¹⁵⁴

The DDRB noted that they would not be reporting on prospective uplifts for those on multi-year deals (including junior doctors), “regretting no action” was taken in this regard.¹⁵⁵

The BMA’s junior doctors committee in Wales (where pay is negotiated separately from England) recommended acceptance of 4.8% in September 2022.¹⁵⁶ This was rejected by the membership in a referendum. A rise of 4.5% has been imposed. However, Welsh junior doctors are not yet balloting for strike action.

The English junior doctors’ committee co-chair, Rob Laurenson, tweeted last month: “If our demands are steep then it goes to show that the cuts to our wages have been too.”¹⁵⁷ But it is not quite clear why the 30 per cent figure has been chosen. As recently as May 2022, Runswick said the real-terms pay cut suffered by doctors since 2008 was 22.4%.¹⁵⁸ The union now claims basic junior doctors’ pay fell in real terms by 26.1% between 2008 and April 2022.

But the methodology by which the BMA calculates this¹⁵⁹ is problematic. It uses RPI inflation, which lost its status as a national statistic in 2013 because of its unreliability. The then National Statistician, John Pullinger, said: “Our position on the RPI is clear: we do not think it is a good measure of inflation and discourage its use. There are other, better measures available and any use of RPI over these far superior alternatives should be closely scrutinised.”¹⁶⁰

It also uses the RPI figure to the end of April each year, the wrong month – it should be March, because junior doctor pay deals run April to March. In 2021/2 alone this means it used an RPI figure more than 2% higher than it should have. And the calculation is based on basic pay only, other than for post-2019 figures. Non-basic pay, such as extra allowances for on-call and weekend working, typically makes up 20 to 30% of junior doctor pay.

NHS figures do not support the BMA’s claims on basic junior doctor pay. They show that between 2009/10, the furthest back the numbers are readily available, and March 2022, basic pay for most junior doctors did fall in real terms, but by much less than the union says. ¹⁶¹ And for junior doctors in the “core training” stage between three and seven [chk] years out of medical school, average basic pay rose slightly in real terms over that time. The calculations below use CPI, the more statistically accurate measure, rather than RPI.

	Average basic pay per FTE JD (year to March 2022)	vs 2009/10	*what it would have been if had risen by CPI (and by how much it falls short)**
FY1 doctors	£28653	£22387	£29314 (-2.3%)
FY2 doctors	£33089	£27848	£36465 (-9.3%)
Core training	£42283	£32078	£42004 (+0.7%)
Specialty registrar	£47291	£38044	£49816 (-5.1%)

* CPI figures 2010 vs March 2022 on Bank of England calculator. Source for earnings figures is NHS data tables.¹⁶²

Clearly, however, all junior doctors will have seen their pay falling in real terms since March 2022, because the 3 per cent pay rise they received for 2022/3 is well below inflation.

It is also unclear whether the junior doctors want 30% all at once or over three years. The FPR motion at the BMA’s 2022 junior doctors’ conference called for “full restoration of junior doctors’ pay to 2008 RPI-adjusted equivalence, either immediately or by incremental increases over a maximum period of three further annual pay review rounds” but then went on to say the BMA should be “balloting by Q1 2023 at the latest for industrial action including withdrawal of labour, on the demand for immediate and full restoration of pay to 2008 RPI-adjusted equivalence.”¹⁶³ (Our italics). Runswick said in May: “We want pay restoration ASAP, but a plan to restore in 3 pay rounds would do.”¹⁶⁴

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Chapter 11: “Poor working conditions are the primary concern”

Whilst the focus in recent statements and the justification for industrial action from the BMA has been predicated upon pay alone, it appears that working conditions are an as significant, or or more significant, cause of junior doctor dissatisfaction overall.

This dissatisfaction is real, as shown in independent opinion polls and the BMA’s own surveys. In 2011, when preliminary career-destination surveys were first conducted, 71.3% of Foundation Year Two doctors progressed to specialty training. By 2016, this figure had dropped to 50.4%. By 2019, to just 37.7%, meaning there is a significant issue with retention which must be addressed. As a recent journal article puts it, “changes to junior doctors’ salaries, hours worked, a reduced investment in training, inflexible schedules, lack of consistent teamwork, and an understaffed service” are all contributory factors. ¹⁶⁵

A recent issue of The Doctor, focused on the junior doctors’ dispute, largely though not entirely (and without acknowledgment) used activists from Broad Left and DoctorsVote.¹⁶⁶ Only one of those interviewed spoke of pay as their main issue.

Interviewing one doctor, Vanya Gurr, the magazine put it thus: “While junior doctors are set to ballot over industrial action in a dispute over pay this January, Dr Gurr speaks for many doctors when she says poor working conditions are the primary cause for concern.”

Gurr was quoted as saying: “The issue is the sacrifice we put in and how rubbish our lives are comparative to the pay. Family and friends were questioning why my knees were bruised. It was because I knelt in front of a computer all day to work. The next four months I regularly sat on a bin lid because there wasn’t space for enough chairs. And the last four months I often sat on a step ladder maintenance happened to leave in the office because it had a little back support.”¹⁶⁷

Priyesh Parekh, a DoctorsVote regional junior doctors’ committee representative, said: “Being a doctor is great when you can do the doctoring – but when you’re constantly focusing on other stuff, like writing consultants’ notes, you’re basically a secretary. In one day of work you’ve written the equivalent of a novel. But they haven’t got anyone else to do it.”¹⁶⁸

The Broad Left and DoctorsVote BMA council member Vassili Crispi was quoted as saying: “Junior doctors can’t take proper breaks. We sit in front of our computer to work, eating a sandwich, sometimes holding a bleep.”¹⁶⁹

Roshan Rupra, another DoctorsVote regional rep, said: “I’ve yet to have an uninterrupted break during my four years as a junior doctor. In an ideal world there would be enough staff available to cover. Then uninterrupted breaks would be feasible. In one trust with hundreds of junior doctors there’s a mess the size of a bedroom with a collapsed sofa and another sofa propped against the wall because it’s unfit for purpose, a toilet with a flush that doesn’t work, leaking showers and one without a lock.

“If you’re lucky enough to get some sleep on a night shift there are usually two solutions. One is to put chairs together and the other is to lie on the floor. Sometimes people end up using pillows taken from somewhere on the ward. Some facilities are better than others, but that’s quite common. It’s not the glorious profession many of us envisioned, let alone what the public think.”¹⁷⁰

Similar sentiments are visible in the junior doctor threads on Reddit and in the NHS staff survey, where concerns about conditions are often greater than concerns about pay. In the survey, as we have seen, 39.1% of junior doctors and dentists were dissatisfied with their pay – but 51.8% believed there were not enough staff to do their jobs properly; 40.5% said they often or always had to work under unrealistic time pressure, and a further 41.7% said they sometimes had to; 56.1% said they often or always felt worn out at the end of their shift; and 50.4% said they had felt unwell in the previous year from work-related stress.¹⁷¹

The medical journal, The Lancet, had this to say in October 2022: “Ministers should also understand that this dispute is only partly about money. It is also, and more importantly, about valuing the contribution that trainees make to patient care. There is no other profession today where new graduates are treated as badly as doctors. Trainees are seen as mere cogs in the machine of the NHS. Their feelings of disillusionment, even despair, are real… The NHS cannot thrive when trainees are burnt out, demotivated, and taken for granted. The threat of industrial action should be seen as a signal of a health service under intolerable stress.”¹⁷²

This report takes no position on what an acceptable pay settlement would be, though one of 30% is unlikely to be affordable. But whatever is agreed on pay, it should be beyond dispute that there must be a greater focus from the Government, NHS England and providers (among others) on improving working conditions. In the first instance, it is important that the Government supports the work of Health Education England in accelerating the implementation of recommendations and strategic direction set out in the latest Enhancing Juniors Doctors’ Working Lives progress report to enable the introduction of further flexibility in training models and to enhance educational experience.¹⁷³ It is clear that structured supervision, appraisal and pastoral support is all too often lacking.

There is also a case to consider how the Foundation Programme might be reformed to address issues set out in the recent ‘F3 Phenomenon’ report from the Royal College of Physicians and Health Education England.¹⁷⁴ Greater representation for junior doctors in rota design and management and in service improvement functions will be required to improve understanding of these issues and to effectively implement solutions.¹⁷⁵

Whilst working patterns will vary significantly across different specialties and workplaces, rostering can often be a subject of frustration for junior doctors. Rostering ensures the effective deployment of personnel, but as a principle, there is a need for a greater focus on flexibility in rota design to account for educational and personal circumstances for junior doctors. For instance, ensuring sufficient flexibility to plan shifts around postgraduate examinations or around significant personal or family events.

There is also a strong case for the Government to improve its support to junior doctors with postgraduate training costs. The introduction of a new scheme should be considered with the aim of covering postgraduate examination fees (but only a candidate’s first attempt) and with their e-rostering costs. We have calculated that the scheme would cost roughly £60 million each year (based upon the current size of workforce and costs incurred).

All of these changes however, need also to be coupled with setting a vision for longer-term change. The introduction of an ‘NHS Staff Charter’ would signal the intent to make significant improvements at a national level. The Government should work with NHS England, Health Education England, NHS Employers, the BMA and providers to establish principles in the coming months, which would include making sure that providers ensure “the basics” are in place for all NHS employees, including the provision of hot and cold food and drinks during every shift and the establishment of dedicated and improved staff rest and relaxation spaces.¹⁷⁶ There should also be renewed emphasis on ensuring employees are aware of the ‘Freedom to Speak Up’ Guardians operating in every NHS trust, to build confidence among junior doctors to highlight issues and to whistleblow.¹⁷⁷ The provisions of the Charter should be included in future amendments to the NHS Constitution.

As part of these developments, it is clear that capital investment is required to urgently improve workplace infrastructure (which would in turn enable greater workforce productivity and satisfaction). A focus will be needed upon overhauling cumbersome IT equipment to improve support for everyday clinical service and to assist staff as well as patient communication. As part of the improvements to rostering that have just been outlined, transparent e-rostering systems across all trusts should be ensured.

As David Oliver has stated in a recent BMJ piece, “persistent understaffing begets further disengagement”.¹⁷⁸ A recent staff survey by the Royal College of Physicians meanwhile finds staff shortages to be the biggest challenge facing the NHS. 57% of respondents stated they were being asked to fill rota gaps at short notice. More staff and less clinical work would – respondents reflected – make the biggest difference to members’ wellbeing, with reduced staff vacancies in their team (42%) and reduced clinical workload (36%) cited as the top two factors.¹⁷⁹

A consequence is the curtailment of working hours junior doctors choose to undertake, which has in turn, increased workload intensity, risks of burnout and has encouraged a greater number of junior doctors to seek work abroad. A fifteen-year workforce strategy being prepared by NHS England will be an important contribution in setting out how staffing numbers across the health service can be planned more sustainably in the years ahead. Part of this plan should include a significant expansion in medical school places. A recent report from Policy Exchange, entitled Double Vision sets out seven ‘pathways’ to achieve this, which also considers the concomitant expansion in clinical placements and educators that would be required to deliver it.¹⁸⁰

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Conclusion

This report has explored the individuals, organisations and emergent strategy which has led the BMA to ballot junior doctors for industrial action in March 2023. It finds that through the ‘entryism’ of a number of recently-elected representatives to JDCs and the UK Council from the Broad Left and DoctorsVote, the character of the BMA as a campaigning organisation has shifted in recent years, necessitating a revised approach from the Government in turn. Whilst its demands are now more strident, its approach has also become increasingly adversarial. Whilst its representatives claim that its “demands are simple and modest”, the findings of this report show them to be factually incorrect or inflated, when set in both their historical precedent and compared with other unions engaged in industrial disputes at present.¹⁸¹

Ask any junior doctor about their experience of working in the NHS today and they will highlight significant challenges: workforce shortages; ageing equipment and buildings; frustrations with rotas; increasing costs of further training and examinations. These are all legitimate grievances – and they have been exacerbated by inflationary pressures. Junior doctors do deserve better and progress needs to be made to enhance working conditions overall if the NHS is to sustain a workforce which is satisfied and motivated in the long-term. As a recent article in the New England Journal of Medicine reflects, “though it is tempting to say that we also need to pay health care workers more and improve their working conditions, and we do, such actions will have little long-term impact if health care systems remain neglected”.¹⁸² That is, therefore, where substantial effort and focus ought to be directed. The aim now must be to bring more light to a debate which has become increasingly characterised by heat alone.

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Appendix

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“Professionalism is not relevant”

The activists taking over the British Medical Association

Related Publications

Disconnect

Authors

Andrew Gilligan

Content

Executive summary

A note on quotations

A note on sources

Chapter 1: “A strange union”

Chapter 2: “A small group of like-minded people”

Chapter 3: “Named and unnamed members”

Chapter 4: “Trying to eat an elephant in one go”

Chapter 5: “Professionalism is not relevant”

Chapter 6: “Of course patient safety could be compromised”

Chapter 7: “We don’t want the public getting doctor strike fatigue”

Chapter 8: “I’m talking to people who are lying to me”

Chapter 9: “Doctors are not poor”

Chapter 10: “£50 billion isn’t that much money”

Chapter 11: “Poor working conditions are the primary concern”

Conclusion

Appendix

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Policy Projects

Policy Areas

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“Professionalism is not relevant”

The activists taking over the British Medical Association

Related Publications

Just About Managing

Mission Critical

Disconnect

Authors

Andrew Gilligan

Content

Executive summary

A note on quotations

A note on sources

Chapter 1: “A strange union”

Chapter 2: “A small group of like-minded people”

Chapter 3: “Named and unnamed members”

Chapter 4: “Trying to eat an elephant in one go”

Chapter 5: “Professionalism is not relevant”

Chapter 6: “Of course patient safety could be compromised”

Chapter 7: “We don’t want the public getting doctor strike fatigue”

Chapter 8: “I’m talking to people who are lying to me”

Chapter 9: “Doctors are not poor”

Chapter 10: “£50 billion isn’t that much money”

Chapter 11: “Poor working conditions are the primary concern”

Conclusion

Appendix

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