Why doctors are angry about their 4.5 per cent "pay rise"

To BMA Scotland, the award demonstrated exactly the opposite and was condemned as "hugely disappointing".

The 4.5% rate meets the recommendations of the Doctors and Dentists Pay Review Body, which advises the UK and devolved governments, and is more generous than it might have been.

The Department of Health had proposed a two per cent uplift for doctors and dentists in England, while the Scottish Government's sums would have equated to a basic salary increase of £700 for a junior doctor or £500 for a consultant.

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Instead, the basic pay for a first-year junior doctor on NHS Scotland will increase by £1,191 to £27,653, while the starting salary for a consultant will increase by £3,939 to £91,473. Overall, it adds £77 million to the annual NHS pay bill in Scotland.

The UK Government had warned that unaffordable pay awards would "lead to a reduced ability to expand clinical capacity and tackle the elective care backlog", but the DDPRB cautioned: "pay awards that are too low have the potential to have significant budgetary downsides, including increased use of temporary staffing, understaffing and worse motivation, which can affect the quality of patient care and efficiency of services and undermine any budgetary benefit that lower pay awards might bring".

Tuesday's pay award is far from the end of the story, however; if anything it fired the starting gun on an increasingly bitter battle between health trade unions and ministers across the UK.

For medics, the bottom line is that a "pay rise" of 4.5% will be wiped out by inflation running at 9.1 to 11.1% (depending which measure you use); in this sense then, it represents a substantial pay cut.

What's more, it comes on the back of a decade of successive real-terms pay cuts. A previous analysis by think tank, Nuffield Health, found that - based on consumer price index (CPI) inflation - average earnings for doctors in the UK actually fell by 9.1% between 2010 and 2019.

Source: Nuffield Health

Having endured the pandemic, they emerge only to face record-breaking elective care backlogs, staff shortages, and a year-round winter crisis in A&E, with their incomes eroded further by rampant inflation at a time when senior clinicians also continue to be hit with punitive pension tax bills.

To paraphrase anchorman Howard Beale, doctors are "mad as hell and they're not going to take this anymore".

In England, BMA members have voted for "full pay restoration" - equivalent to a 30% increase in pay for consultants over the next five years that would bring salaries back into line with 2008 levels, based on retail price index (RPI) inflation.

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The BMA, including BMA Scotland, had urged the DDPRB to recommend uplifts of RPI plus 2% in the current year: a 13.1% increase that would have taken the salary of a first-year junior doctor in Scotland to just under £30,000 and the starting salary of a consultant to £99,000.

Speaking last week, Professor Philip Banfield, the newly appointed chair of the BMA, said industrial action by medics in England is "almost inevitable", with strikes by junior doctors most likely in the Spring.

The experience of the pandemic has been blamed for contributing to 'burnout' among doctors, with problems exacerbated by current backlogs

North of the border, BMA Scotland has begun consulting members on "how we should respond" to the pay award. 

"It will be entirely up to the membership across the profession about what level of action they might consider taking in response," Dr Lewis Morrison, chair of the BMA in Scotland, told the Herald.

“Regardless of the question on industrial action, what we know for sure is that burnt out staff are already taking their own individual decisions to leave the NHS in Scotland.

"This is the last thing we need right now, with rising waiting times, delays across the whole system and an NHS that is beyond breakpoint."

It comes against a backdrop of a wider threat of industrial action by nurses, midwives and other healthcare workers, such as physiotherapists, over their 5% pay offer.

For its part, the DDPRB acknowledged the effects of inflation but noted that "employers across the economy are not matching current high levels of inflation with their pay awards", adding: "We do not believe that doctors and dentists should necessarily be exceptionally shielded from these increases to the cost of living faced by the wider population this year."

Its report shows that in 2010/11, the average total annual earnings of consultants put them within the 98-99th income percentile when compared against all full-time employees across the wider economy.

Source: DDPRB *NB: data relates to doctors' pay for England, but salaries broadly similar in Scotland

By 2020/21, this position was unchanged - they remained among the 98/99 percentile of top earners.

Of course, all that really tells us is that real-terms pay cuts have been hitting workers across the board.

Set against comparator professions, however, a first-year junior doctor earns more than a vet a the same grade, while consultants’ median earnings in 2021 exceeded the highest-paid vets and university academics, but lagged "substantially" behind equivalent senior professionals in finance, accounting or legal careers, for example.

And while down, half (49.8%) of the 47,000 medical and dental staff surveyed in 2021 reported being 'satisfied' or 'very satisfied' with their pay - ranging from 34.5% among trainees to 59.6% of consultants.

It is difficult to gauge, then, what the appetite for industrial action might be, or what form it might take.

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Walkouts by doctors in Scotland are almost unheard of; in the UK as a whole, the only recent example was junior doctors striking in England in 2016 in protest over contracts. 

Research by Imperial College London found that the action had a "significant impact on care", including over 100,000 outpatient appointment cancellations and more than 25,000 fewer planned admissions than expected - though "no obvious change in the death rate".

Bizarrely, there is some evidence that strikes by doctors can actually correlate with a reduction mortality.

An analysis of five walkouts lasting nine days to 17 weeks by doctors around the world, from 1976 to 2003, found no associated increase in deaths; population mortality either stayed the same, or fell.

The findings, published in the journal 'Social Science and Medicine' in 2008, seem counterintuitive until you delve deeper.

For example, in a Los Angeles strike over medical malpractice insurance premiums in 1976, only 50% of physicians took part, while Israeli medics striking over pay in 1983 set up their own temporary aid stations outside hospitals to provide emergency care for a fee.

In most cases, only elective treatment stopped and since all surgery comes with a mortality risk, it was these deaths which ceased when doctors withdrew their labour.

Total population mortality in Los Angeles fell from 21 deaths per 100,000 in week one of the doctors' strike to 14 per 100,000 by week seven - lower than the five-year average.

This is cold comfort at a time when elective waiting lists have already ballooned, however.

Governments and NHS workers look set on a collision course with no easy answers.