Junior doctors versus Scottish Govt: who will blink first?

The deal will see the starting salary of a newly-qualified nurse in Scotland - a Band 5 NHS employee - rise to £30,229 from April, an increase of 15.8 per cent compared to £26,104 in 2021/22.

Nurses in England, Wales and Northern Ireland had already staged two 24-hour walkouts by Christmas while their counterparts in Scotland remained locked in pay negotiations.

READ MORE: Why doctors are angry about their 4.5 per cent 'pay rise'

Additional walkouts in England during January and February were the largest ever staged by the profession.

A consultation on the UK Government’s revised pay offer to nurses in England opens on Tuesday, but for all the disruption to patients and lost earnings for staff on the picket lines it would still leave a Band 5 nurse in England on starting salary from April of only £28,407 - roughly £1,800 less than their colleagues north of the border.

Pay bands for NHS staff on Agenda for Change contracts, Scotland and England, from 2023/24 (Image: RCN/Scottish Government)

That said, Agenda for Change NHS staff in England will receive more generous one-off lump sums of between £1,655 to £3,789, compared to a maximum of £939 in Scotland.

But amid all the turmoil engulfing the health service, the Scottish Government can at least be credited with avoiding strikes and agreeing a settlements that mean NHS staff here are better off.

But as one crisis ends, another looms.

On Wednesday, the BMA will begin balloting junior doctors in Scotland on strike action over pay.

If approved, mass walkouts could begin as early as mid- to late-May in what would be the first national strike over pay ever staged by medics in Scotland.

This would have major ramifications for services, particularly in relation to elective care, given that junior doctors account for 44 per cent of NHS Scotland’s total medical workforce.

READ MORE: Nurses urged to accept 'record breaking' NHS pay deal

This cohort spans everything from someone in their first year out of medical school to a qualified specialist one rung away from becoming a consultant.

The row has already resulted in a three-day strike by junior doctors in England earlier this month, which was said to have resulted in around 175,000 appointments and procedures being cancelled. A 96-hour walkout is now scheduled for April 11-15.

Either side of the border, the call is for “pay restoration”: not a rise, they insist, but a “correction”.

In Scotland junior doctors were awarded uplifts of 4.5% this year versus 2% in England, where a separate contract applies.

Pay bands for junior doctors in Scotland and England in 2022/23, by training level (Image: BMA)

Nonetheless, both groups argue that the effects of spiralling inflation and stagnant wages mean that a junior doctor today is earning 23.5% less in real-terms than they were in 2008, with salaries in Scotland ranging from a low of £29,036 in year one to £57,349 for a fully-qualified specialist.

No one could argue that the workload or responsibility shouldered by a junior doctor has diminished by nearly 25% in 15 years, but the conundrum for policymakers is how to balance the cost to the public purse of meeting such pay demands versus the consequences of failing to do so in terms of staff retention, and working out which would do more harm in the long-run?: cutting other services to boost salaries, or being unable to provide care in future because there medics simply aren’t there.

READ MORE: Pension tax changes 'potentially transformative' for NHS

Earlier this month, Chancellor Jeremy Hunt announced sweeping changes to annual and lifetime pensions allowances in a bid to stem an exodus at the top, among senior consultants and GPs, who in some cases had been retiring early just to avoid massive tax bills.

The gamble there is that the loss in revenue for the Treasury (roughly £800 million a year from all top earners, not just medics) is considered worth it if it means more senior clinicians staying longer and working more hours in the NHS at a time when record waiting list backlogs need cleared.

At the opposite end of the spectrum, however, are the juniors - especially those in the early stages of their career - who are increasingly seeking an exit from the NHS.

Among NHS staff, doctors-in-training (also known as junior doctors) and consultants have seen the steepest fall in real terms pay compared to 2010/11, according to analysis by think tank Nuffield Trust (Image: Nuffield Trust)

The problems go beyond pay.

Huge tuition fee debts mean some (exempting Scottish graduates who studied in Scotland) can be paying off £2000 a year only to earn £4000 in interest.

Then there is the cost of the exams required for career progression, which run into thousands of pounds.

Some will be stuck because they simply cannot afford to sit, and potentially re-sit, these exams.

Others pass but end up in limbo anyway because there are too few specialist posts available for the numbers of applicants.

According to a BMA Scotland survey, 44% of junior doctors are actively looking to leave the NHS and 80% are considering taking second jobs to manage rent, food and heating bills.

Of course, the findings are self-selective (those who are motivated to respond tend to be the most aggrieved), but it cannot be taken for granted that these young doctors will stick around to prop up a health service where they feel overworked and under-appreciated.

According to the GMC, of the 6,085 junior doctors who obtained a certificate of completion of training (CCT) in 2017 (signifying they are eligible to join the GP or specialist register), 368 were no longer working in medicine the UK by 2021.

This could mean they are working overseas instead, or in other careers, but the key will be to track whether that attrition rate increases.

READ MORE: GP practices 'collapsing' as doctors flee overseas and junior medics 'quit for jobs in finance'

The GMC reported that the number of doctors applying for its Certificate of Good Standing - a document required to work abroad - had increased from 150 in 2021 to 439 in 2022, though this could simply reflect the fact that Australia and New Zealand reopened their borders.

There is plenty of anecdotal evidence that young medics are quitting the UK or the NHS - for example, some are opting for private practice doing aesthetic medicine, such as Botox - but concrete data is still patchy.

For now, ministers - in Westminster and Holyrood - are calling the doctors’ bluff.

Not because they don’t expect medics to strike, but because they are betting that warnings of a doctor exodus unless pay conditions are met are overblown. 

They might be right. But if they're not, it is a gamble that will cost us all dear in the long-run.