Junior doctors’ fight to save our NHS betrayed

Proletarian writers

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Proletarian writers

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We’ve given up the junior doctors’ strike. The government have agreed to nothing. At best, we’re delaying the inevitable, but we are also losing the initiative.

Hunt’s pledge not to impose a contract is “time-limited”. So he’ll do it later, when a more opportune moment presents itself.

Our BMA leadership seems to have no positive programme. We should not accept pay cuts, but where is our positive list of our demands?

We must make the connection between the sustained attack on NHS funding, relentless cuts to staff pay and conditions (all staff, not just medics), and the bid to privatise the NHS.

Brushing this aside (for now) also leaves the way clear for the government to push for the bombing of Syria on Wednesday – supported by ‘Corbyn’s’ Labour, because my local MP Chukka Umuna, for example, is a veritable Blairite hawk, and these are the people who still dominate Labour.

Was it my imagination, or did we already decide that this was a bad idea? Two years of a sustained media campaign and our rulers think the time is right to push the war button once again? Does no-one remember what our government has just done to Iraq, Afghanistan, Libya and already visited upon Syria?

The absence of junior doctors putting the health of the nation firmly on the agenda, will allow ‘our’ MPs to talk earnestly of the need to combat IS (their own creation – and, in reality, British intervention in Syria has targeted the democratic government, not the jihadist factions set loose by Saudi and Turkey, on the instructions of the US and British governments), without the obvious questions being asked:

Why can hundreds of millions be found to rain missiles on other countries, while billions are cut from providing for the health needs of workers at home?

What’s the common theme? You tell me. Who do these policies serve?

Despite the ill-considered withdrawal of the industrial action that junior doctors in England had overwhelmingly voted to support, the issues remain unresolved and festering, threatening the very survival of the National Health Service.

The following article, submitted by the same London-based junior doctor who wrote the above lines, explains what is going on, and why determined action to protect pay and conditions is desperately needed – as part of a wider campaign to defend and renationalise our rapidly disappearing National Health Service.

On 19 November 2015, the British Medical Association (BMA) announced the result of its ballot of junior doctors on the question of whether we should take industrial action over the government’s threatened imposition of a ‘contract’ that would slash our take-home pay by as much as a third. No one could argue that we have not spoken with one voice.

England’s 53,000 junior doctors have voted overwhelmingly for action. (No doubt the action would have been truly nationwide, but with recent reorganisations, NHS England, Scotland, and Wales are considered separate entities – a victory for division and parochialism.) More than 76 percent of BMA members cast their (postal) vote with an overwhelming 99.4 percent voting for action short of a full walkout, and 98 percent voting for action up to and including full withdrawal of our labour – an actual strike as any other worker would understand it.

I have not yet heard health secretary Jeremy Hunt denounce the result as “a rigged ballot of Stalinist dimensions”, but it would no longer come as a shock if he did! The ballot result is a gauge of the strength of feeling amongst the medical profession – and junior doctors in particular – who have already seen a steady erosion of their pay and conditions over the last decade.

What does it mean?

Proposed dates of action were released by the BMA before the ballot, on 12 November, in order to allow trusts to put contingency plans in place. These dates are:

• Emergency care only over 24 hours from 8.00am on Tuesday 1 December. This would see junior doctors provide the same level of service that happens in their given speciality, hospital or GP practice on Christmas Day.

• A full walk-out from 8.00am-5.00pm, Tuesday 8 December.

• A full walk-out from 8.00am-5.00pm, Wednesday 16 December.

NHS trusts are stating that there will be minimal disruption to services, but it will be wise to avoid the NHS on those days unless your need is an absolute emergency.

Interestingly, strikes of the medical workforce are not associated with a higher mortality risk among the population – if anything the reverse seems to be true. This may be due to their generally short duration and successful outcome, which tend to improve provision long term. (See Doctors’ strikes and mortality: a review, Social Science and Medicine, December 2008)

Fed up with the continual attacks upon the profession and the NHS

Doctors are dedicated and committed – as individuals and as a group – to patient care, welfare and safe service provision. It is our common mantra. So we do not take this action lightly.

The government also knows this and has long realised that, while dedicated service gives us a special relationship with the working population of Britain, it also ties our hands behind our back. For where is our dedication to the people if we go on strike and effectively – even if momentarily – take that service away, refusing to treat them? This is the catch-22 situation with which successive governments have been happy to beat doctors, nurses, and all NHS workers into submission.

Cutting pay puts the NHS under threat

I have no doubt that, come the day of action, our government and the ‘objective’ press will be out scouring the streets for negative anecdotes with which to regale us by mass media, but the fact of the matter is that if the conditions of the medical workforce are forced down far enough, it poses a very real threat to the actual existence of the NHS itself. You cannot separate the idea of medical provision from the real people who provide it.

Our nurses are already facing a critical situation where their earnings barely meet their costs of living – and yet plans are being made to make them shoulder the additional costs of their training. We must oppose this idea wholeheartedly, for it will be the death knell of their profession, the straw that breaks the camel’s back. And who will care for us then? (See Nurses could be forced to pay tuition fees under new Treasury proposals by Laura Donnelly, The Telegraph, 2 October 2015)

While doctors do not yet pay their entire training bill (which approaches £270,000 for every Foundation Year 1 (FY1) doctor on the postgraduate medical training programme, and reaches £380,000 for senior registrars and staff-grade doctors – all of whom are considered ‘juniors’), the fact is that tuition-fee hikes, course duration and living expenses mean that today’s medical students will incur around £100,000 of debt before they ever receive a single pay cheque.

Medical training is sufficiently intense to make earning while studying very difficult. Unemployment for doctors is a growing reality, and low earnings in the early years of work make paying back this debt onerous. Add to this the cost of living – and of buying a house – and it is clear to see why we are at a tipping point.

Inevitably, they started with the weakest (those least able to defend themselves, owing to their smaller numbers, and lower ‘status’ – the hospital cleaners, porters, groundskeepers, etc. Since the 1980s, our governments have been steadily degrading the conditions and privatising the services of these essential health workers. And, sure enough, as we (as a profession) largely stood aside as our colleagues were picked off, they are now coming for the junior doctors. Rest assured that, if this attack is successful, our consultant colleagues will be next.

It used to be standard practice to praise doctors and nurses at election time – particularly while ‘peripheral’ NHS services were being privatised and colossal NHS giveaway financial contracts (PFI rebuilds) were being forced through. But now that the privatisation of the NHS has stepped up a gear, with every part of it being made to act as a business (‘trust’) and preparing itself to become independent of central government control, the time has come for the privateers to show that the NHS isn’t working.

This is the same tactic as was used in the privatisation of the railways and the post office, and so it has become routine to hear Jeremy Hunt lambast the medical profession. He claims that he’s offering an enormous 11 percent pay rise, but that greedy doctors want more; that we don’t provide out-of-hours care (weekends and evenings) and that we should be forced into 24 hour working … and so on.

24-hour working

The reality – which NHS doctors have highlighted during our recent campaign – is that we do provide a 24/7 NHS service already. Of course, we don’t run routine operating theatres at 3.00am on a Saturday. It would not only be unsafe, but who’d want to come? We can’t altogether ignore facts as glaring as the difference between night and day!

But if anyone turns up at A&E with appendicitis, a ruptured aneurysm, major trauma, a heart attack, a stroke, difficulty in breathing, chest pain, or a host of other emergency conditions at 3.00am of any day of the week, that person will receive excellent and usually life-saving care, free at the point of use, irrespective of income or social status.

That remains – despite all the funding shortfalls that challenge our day-to-day practice – a remarkable achievement, and it needs an incredible amount of organisation of skilled and expert staff of the most varied kinds, with the necessary tools to do the job.

Why this contract? Why the cuts? Why privatisation?

Since the 2008 financial crisis – a crisis of the banking system resulting from a classic capitalist crisis of overproduction – this country’s governments have been searching for ways to cut spending by intensifying attacks upon social provision.

More than £850bn of private bankers’ debt was paid off from taxes. This has put the government into a huge amount (now approaching £1.5tn) of debt. In order to remain solvent – that is, to be considered ‘financially viable’ by the very failed banks that only yesterday came cap in hand to the treasury for a bailout – the government is slashing essential services across the board – from housing to youth work, to disabled and unemployment benefits, and, of course, health care – while asking workers to work harder for less.

Everyone’s wages are under attack. State pensions have already been raided, and the medical pension was also slashed, with just a little mumbling from the BMA. No wonder they think we’re easy pickings!

While banks are considered ‘too big to fail’, you and I (and doctors are now realising this includes them also), the workers who produce all value, are not! The Keynesian consensus, it seems, is over.

It is in this context that, before the 2010 general election, all parties talked increasingly openly of the necessity for imposing massive spending cuts. £20bn of NHS cuts were to be spread over three years initially, but since then these cuts have been perpetuated and increased. The government’s stated intention is to reduce Britain’s spending on health from around 8 percent to 6 percent percent of GDP in perpetuity.

Apparently bucking this trend, Chancellor George Osborne recently announced an increase in NHS funding, but the reality – admitted by all – is that with a population that is both growing and, more significantly, ageing, the funding is falling well short of the costs of provision. This has led to a situation where 100 percent of trusts – every single NHS health provider in the country – has entered a state of financial deficit.

NHS providers are currently running a net deficit of £930m annually, which is expected to rise to an annual shortfall of £2bn by the end of the year. Barts and the London NHS Trust, following a PFI rebuild, are by themselves running up £100m a year of debt, while the total debt of St George’s Hospital in south London is approaching £50m. And the list goes on.

Service closures, ward closures, staffing reductions, hospital closures, ‘consolidation’ of services … all these have flowed one after another in rapid succession, without a hint of serious opposition from senior doctors and the medical colleges, who have appeared to be perfectly happy, for the most part, to secure ‘honours’ and financial gain through their spineless servility to the political representatives of the capitalist class, pushing their agenda of dismantling the NHS. They not only foresaw it, they have been happy to brainstorm the best ways to implement it. (See 20 billion to be cut from the NHS budget, politicians tell senior doctors, Lalkar, May 2010)

Let us not forget, either, that it was a Labour government that most aggressively pushed through PFI schemes whose costs will continue to soar for another five years and which will end up costing taxpayers more than £300bn in total. The 717 PFI contracts currently under way across the UK are funding new schools, hospitals and other public facilities with a total capital value of £54.7bn, but the ultimate repayment cost will reach £301bn over the coming decades.

It is a first, and again a reflection of the impact of cuts on the NHS, and of the widespread discontent amongst health workers, that “several medical royal college presidents who met [health secretary] Hunt two weeks ago at his invitation rejected his suggestion that they individually or collectively publicly warn that strike action could harm patients”. (See Junior doctors overwhelmingly vote for NHS strikes by Denis Campbell, The Guardian, 19 November 2015)

Sadly, as ever, the conservative Royal College of Surgeons of England has spoken up against its members taking strike action, piously taking the position that withdrawal of junior doctors’ labour “would be damaging to all those concerned, both doctors and patients”. Perhaps this was to be expected, but it is nonetheless disappointing. The college has demonstrated once again that it is incapable of showing political leadership.

So what about the new pay contract for junior doctors?

It should be noted that a ‘junior’ doctor is everyone who is not a consultant. That is a very large number of doctors throughout all stages of training, upon whom the NHS relies for much of its day-to-day and emergency medical care.

In recent years, substantial pay cuts have already been effected, not only by numerically ‘increasing’ the basic salary of doctors and nurses by less than the rate of inflation (ie, making pay cuts in real terms), but also by systematically reducing our pay-banding supplements – the amounts paid for excessive and unsociable hours over and above our ‘basic’ hours.

Nurses have been subject to other unannounced cuts – for example, when they were ‘invited’, en masse, to reapply for their own jobs and justify their salary levels, leading (surprise, surprise) to a mass downgrading of salaries for people performing the same work.

EU working-time directive

The perception is that, in line with the European Working Time Directive (EWTD), doctors’ hours have been reduced. And, to an extent, they have. Working a three-and-a-half day (Friday morning to Monday evening) 80-hour shift over the weekend is no longer routine practice (although 48-hour weekends plus a normal working day Monday continues in some pockets of the profession, by various sleights of hand).

When the current pay scale was introduced, in recognition of the greater than 100-hour weeks routinely worked by many doctors, the ‘banding supplement’ (overtime) was set at 100 percent – ie, take-home pay was twice the ‘basic’ salary. Even this meant that the hourly rate of pay for working anti-social hours was often less than the hourly rate for the basic hours.

The EWTD specifies that doctors should work, on average, no more than 48 hours each week. In reality, doctors continue to work well in excess of these hours. Personally, most weeks, I work twice these basic hours or more.

Much of the extra time worked by doctors is ‘unscheduled’, in order to finish jobs, deal with sick patients, or perform emergency procedures, which we do out of (an entirely laudable and appropriate) sense of duty to our patients. Much of it is, on the other hand, built into official rotas as the only way service provision can be met with present staffing levels. Moreover, many doctors – particularly those who must master surgical and other interventional procedures of various kinds – work a huge number of entirely voluntary hours in pursuit of ‘training opportunities’. This is actively encouraged.

Hospitals and trusts are supposed to hold diary-card exercises to monitor juniors’ hours every six months in order to ensure that staff rotas are ‘compliant’ – which they are not. It is routine practice, in my experience, for trusts to ‘interpret’ this as monitoring half way through your employment period – junior doctors rotate continually during their training and it is normal to be employed for only one year at any particular trust.

This monitoring period is carefully picked to ensure the result is void (less than 75 percent of the staff affected are present to take part), but the trust considers its obligations to the law to have been met. Junior doctors are often taken aside and told that if they fill in the card appropriately (ie, by putting down the real information), their shift patterns and training opportunities will suffer. As apparently savvy professionals, it is amazing how we can be gulled and cajoled – by the prospect of future consultancy and private practice, or, conversely, by the threat of damaged career prospects – into harming our own immediate and the NHS’ long-term interests.

Thus, as paid hours are legally required to be reduced – although the hours we work in reality continue to be far longer than those legally recognised and paid for – the banding supplement for many doctors has fallen steadily from 100 percent towards unbanded salaries for many. Clearly, this means that the rate of pay for some roles has actually halved.

Many hospital doctors are still banded around the 40-50 percent mark, however. If the banding is done away with, then it is clear that a small increase in the ‘basic pay’ will still mean a hefty pay cut. That is why, when reporting on the latest episode of ‘negotiation’, Hunt has emphasised his generous offer of increasing basic pay by 11 percent, while the BMA has warned junior doctors that take-home pay will drop by as much as one third.

First doctors’ strike in forty years

The last serious industrial action undertaken by doctors was in 1976, before many of us were born, by our colleagues who have either retired, or are now in very senior positions throughout the NHS.

Doctors are not the most militant workers. As a profession, we tend to be relentlessly career focused, and driven to excel as individuals. All to the good, when it comes to advancing the barriers of medical research or improving patient care; but when it comes to professional solidarity, our CV focus and mutual competition for jobs has not made standing up for these rights of all – doctors, nurses, other hospital workers, or the wider working class – our strong point, historically.

But now I have never seen the solidarity and spirit of junior doctors so high. They are attending meetings and considering how to act. What is more, we have the backing of the rest of the hospital workers, and the broad sympathy of the working people.

There can be no doubt that the time is ripe to act – but the path to victory is not straightforward, and, for all our specialist knowledge, doctors’ overall lack of class consciousness is our undoubted tendo-achilles. While junior doctors genuinely believe they are fighting to save the NHS, as well as their own pay (and this is indeed the case), few realise the strength of the conspiracy that is being enacted against them and against the entire National Health Service.

Stay ‘professional’ – not political?

I went to a meeting of junior doctors on the eve of the ballot result, and, while feelings ran high, a Labour trade unionist addressed the assembled doctors as ‘comrades’ (to visible shudders from the assembly), while a Workers’ Revolutionary Party (WRP) Trotskyist, selling their paper Newsline, stood and ground out her time-worn call to arms: for ‘a general strike’ to ‘bring down this Tory government’. A consultant later responded to this tirade by saying: “this isn’t a race war, or a class war – we need to stay professional, not political”.

That Trotskyists behave in a stereotyped fashion, unable to gauge their audience and win their support is not surprising. That better-paid workers – including medical consultants – are so ill-equipped to defend their own interests and those of the wider working class is a lamentable consequence of a century of domination of the working-class movement by social democracy.

Many of the junior doctors’ leaders feel they can solve all the problems of the NHS by getting rid of Jeremy Hunt. Others feel they can achieve the same by getting rid of the Tory government. Both ideas are terrible underestimates of the power and determination of the capitalist class that truly owns and runs Britain – and of the lengths to which that class is prepared to go to save its own skin.

The capitalists’ economic crisis is deep, and their need to push the financial burden onto workers is real. NHS cuts are in some respects tame compared to the treatment of other sections of the British working class, the cuts to other services, and certainly compared to the treatment meted out to workers in Libya, Syria, Iraq and Afghanistan, in the imperialists’ attempts to rinse ever-more profit from the oppressed nations. But there is no doubt that the campaign against the NHS is deeply ‘political’.

The power to harness the sympathy and support of the working people is our greatest weapon. But without an understanding that the capitalist class is seriously intent on destroying the NHS, and that organised and united resistance by the British working class will be necessary to frustrate this aim, we can win at best only temporary and partial victories.

Save our NHS!

To truly save the NHS, a more radical approach must be taken. Our party has an adopted policy on the NHS, which our readers are now invited to revisit. The following points should be brought out in all our campaigning, and in the discussions that are going on around this current action of the junior doctors – which is to be applauded by all who cherish the NHS.

1. Oppose all privatisation of services – ‘core’ or ‘peripheral’ – and campaign for the renationalisation of all privatised aspects of NHS provision, working towards a health service that provides nationally-funded, universal and comprehensive care, free at the point of use, that fulfils its original charter.

2. Oppose private provision of health care, and the internal market in health care within the NHS.

3. Campaign for the scrapping of all PFI debt.

4. Oppose the forced conversion of the NHS into Foundation Trusts, which will act as businesses first, and health providers second.

5. Oppose pay freezes and ‘restraint’, and the movement of Foundation Trusts to disband national employment contracts and frameworks.

6. Demand the nationalisation of drug and medical technology companies. It has long been the case that while public debt is social, profitable enterprises are private. This is one source of inequality under capitalism, and the source of much of the NHS debt also.

7. Join fully in the campaign to defend the NHS.

8. Encourage broad participation of workers, patients and healthcare professionals within a single, vibrant movement to defend the interests of the NHS – learning from examples such as the Save Lewisham Hospital Campaign how to involve the local community in the fight for their NHS services.

9. Point out within this campaign, and to British workers generally, that NHS cuts and privatisation are being smuggled in under the banners of ‘choice’, ‘efficiency’ and ‘excellence’.

10. Refuse to accept the legitimacy or necessity of cuts to the NHS and social provision. If these cuts are due to the direction of the state by the capitalist class, and the economic and financial crisis that is of their making, then they prove themselves bankrupt and unable to rule in the interests of the vast majority.

11. Campaign for the reintroduction of integrated health planning, commissioning and provision on a national and regional level, by the NHS itself.

12. Oppose the proposed GP commissioning groups, which are too small to plan adequately, and are simply the vehicles of distributing taxpayers’ money to private health corporations, or of ‘purchasing services’ – increasingly from private rather than NHS providers.

13. Point out to British workers that Labour governments, as much as Tory and ConDem administrations, have sought to privatise and destroy the NHS. Our party must use this fact to demonstrate that capitalism seeks nothing more than maximum profit – which means privatisation of health care, and decreased provision to the mass of the working class. And, in the last analysis, we must show that the welfare of workers cannot be achieved and maintained without putting in place a socialist system of economy, controlled and administered by the working people themselves. (Public healthcare – a vanishing commodity?, Motion passed by CPGB-ML congress, November 2014)