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Junior doctors are striking. Should we increase their wages by a third?

Their union says that demands on doctors keep rising while their pay keeps shrinking.

Their union says that demands on doctors keep rising while their pay keeps shrinking.

2024 started off on a rather dour note, with tens of thousands of junior doctors in England downing stethoscopes to take part in the longest NHS strike in history (for a total of six days). ‘Junior doctor’ is a job title that is carried by qualified medics with up to nine years of hospital experience. Their demand is for a 35 percent increase in their wages, which are currently paid out in seniority-based bands that range from £32,398 to £63,152.

The British Medical Association (BMA), the doctor’s union, says that this is not so much an ask for a pay rise as it is an ask for pay parity, because in real terms junior doctors wages are just three-quarters of the amount they were twelve years ago. ‘Real terms’ means that inflation (price rises) is being taken into account. This is important because if your wages don’t increase at the same rate as the cost of the stuff you need to buy - housing, food, leisure activities etc. - then you are getting poorer even if on paper the amount you are being paid is going up. Basically, the BMA are demanding an income for junior doctors that will give them roughly the same purchasing power that they had decades ago, so that they can afford the same standard of living.

The UK government's response is that it can’t afford to pay for these wage increase. There is some debate about how big the bill will be: the BMA says it will cost the government £1 billion a year, the government says it will be double that. According to FullFact, a fact-checking website, both figures are basically right. The difference comes about because the BMA has deducted from its estimate the money that will wind its way straight back to the government via the extra amount of income tax and national insurance that higher-paid doctors would hand over to the state.

£1 billion is still a heck of a lot of money, of course. Although for the government of a rich country like the UK, it’s not quite as out there a sum as it would be for regular folks. It would add 0.6 percent to what the UK is predicted to spend on healthcare in the next financial year (£176.2bn), and 0.01 percent to what the UK is expected to spend overall (£1,058bn).

However, things could quickly get pricer if this wasn’t the end to wage raise demands from NHS workers. Plenty of other medical professionals are feeling as undervalued and underpaid as junior doctors. When strikes work, it encourages others to reach for the same tool. That’s a good thing in terms of increasing worker power: the NHS is the largest employer in the UK. But it’s not such a good thing from a budgeting perspective. With almost half the NHS annual budget going to staff salaries, giving everyone a 35 percent wage increase for 2024 would cost the government closer to £30 billion. And with demands on the NHS and inflation still rising, it seems reasonable to assume that NHS staff might want another pay rise on top of this one in the not-so-distant future.

Thing is, though, even sums as big as this wouldn’t actually be “unaffordable” for the UK, because nothing is ever really unaffordable for a state in the same way it is for individuals. Governments who want to spend more money can raise more money, usually via tax increases, and they can also take out more debt without ever facing the same consequences that would befall you if you started maxing out multiple credit cards. That’s why the UK government was able to find the extra £300-£400 billion it spent on Covid-19 measures during the pandemic, for example.

However, what is true is that there are negative sides to any policy choice that shifts around government spending. Taxes take money out of some people’s pockets. Government debt incurs interest. And any money spent on NHS salaries is money that isn’t being spent on something else voters might want more resources to be diverted to: pensions, say, or tax cuts or foreign aid or energy subsidies. Public support for junior doctor strikes has declined over the last six months, falling from 50 percent in August 2023 to 43 percent in January 2024. The use of walkouts as a leverage tool has angered some people who feel like the price is paid mostly by ordinary, unwell people, who have been asked to put up with later diagnoses and delayed treatments.

Concerns about fairness may also flavour the debate around doctors’ pay. The BMA’s assertion that people shouldn’t be being paid less than they were 12 years ago is perfectly reasonable. But it is also the reality that most workers in Britain face. In 2023, the average UK wage was still 2.7 percent lower in real terms than it was in 2008. That translates to a personal loss for each employee of £3,600 a year, on average. With a cost of living crisis raging, millions of Britons are now really struggling to make ends meet. Plenty of them earn a great deal less than junior doctors (the average full-time UK wage is about £35k). They also have much less earning potential for their future: once junior doctors graduate on to become specialists, consultants or GPs, their salaries push up to around the £70-100k mark.

Wages do not have to be a a zero-sum game: one profession getting a pay rise does not mean another profession can't get one too. (Although some economists think that across-the-board pay rises drive inflation, a phenomenon known as the wage-price spiral.) But some people would like to see much more of our society's energy and attention focused on wage increase campaigns for the most disadvantaged.

As many economists would be quick to point out, however, such concerns around fairness are somewhat irrelevant, because wages under our current economic structure are generally not set by concepts of what is fair but by supply and demand. (Of course whether they should be set that way is another question, one many would answer no to.) The higher the demand for a job role is above the supply of qualified candidates, the more valuable that job is and the more power those qualified candidates have to demand higher remuneration for their labour. The UK’s demand for NHS doctors is sky-high, but the supply is plummeting as burnout and inadequate pay causes more and more of them to throw in the towel.

Decreasing the UK's demand for NHS doctors would require either a significantly healthier, younger population (difficult in the long-term and impossible in the short-term) or a switch away from a free-at-the-point-of-delivery national health service model (an idea that would be absolutely rejected by the vast majority of Brits).

Increasing supply is a better bet, but not much easier to accomplish. One way to do it is by training many new doctors, but that is a plan that would take a long time to achieve even it wasn’t restricted by training capacity and minimum standards of ability. The UK could also facilitate the immigration of lots more doctors. English hospitals seem to pay some such staff less than their British peers, so this option could help them balance the books, albeit in a way that is morally unpalatable. But even if this particular exploitative practice was avoided, there are other ethnical quandaries associated with relying on immigration to plug labour gaps, such as the consequence of contributing to brain drains in lower-income countries. Plus, since there is nothing to stop newly-trained and foreign doctors from also deciding to strike and demand higher pay, there's no guarantee that these supply-increasing paths wouldn't result in the exact same situation unfolding.

A more sustainable plan would be to persuade existing NHS doctors not to quit, and to return to the job if they have already quit. This could be achieved by making the job more desirable, which junior doctors are saying required increasing their wages by 35 percent. It is an expensive option that comes with some downsides. But compared to the expense and downsides of all the other options on the table, it looks like the best route forward.

On balance, the UK, its residents and its government need junior doctors to keep working more than junior doctors need to remain in their current line of work. For that reason, it would probably be better for everyone if their strike demands were at least partially met.
One debate that voters might want to have is where the money for such a pay rise should come from. Higher taxes just for the richest is often something that is held up as a fairer way to meet extra spending demands on the government, for instance.

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