The ethics (and economics) of paying doctors

If you have friends who are doctors (or keep a close eye on the national news) you will have heard of the recent bust up over a contract for junior doctors. The very short summary is the Department of health wanted to reform existing contracts for doctors, and started negotiations with the BMA. These broke down, but the government threatened to impose the contract anyway, junior doctors, in turn have threatened to strike. 1

I am much more ambivalent about the contract than most of my peers, who are varying shades of outraged. I’m not sure why.

Safety

One of the better reasons to be against the contract is the removal of safeguards for overwork. Rhetoric about the contract demanding ’90 hour weeks’ is false (the envelope of what is no longer overtime may extend to this, but this doesn’t entail a usual medical job will oblige working all this time), but a complaint about removal of ‘re-banding’ remedies is fairer.

Doctors currently get paid for working nights and weekends via a ‘banding’ system. Work more weekends, nights, and there are corresponding supplements to your salary (20%, 40%, 50%). If you work more than 48 hours (or 56 hours), there are higher bands (up to 100%). Thanks to European regulations, these higher bands shouldn’t exist, as no one should work more than 48 hours.

Yet many do. One (not very rigorous) survey gives junior doctors working an average of 7.7 hours unrecognized overtime every week. One remedy doctors have against being overworked is to monitor their own hours – when it turns out they are working much more than their official banding, they can agitate (via the BMA) to get paid the difference. Further, as 2X or 3X banding shouldn’t exist, this is a further impetus for those in charge to change working conditions.

Although good for doctors, this is probably also good for patients. The 48 hour resident on calls or 90+ hour weeks senior doctors reminisce about ‘back in the day’ were also pretty dangerous. The proposed contract would get rid of banding and not offer such assurances about overwork. 2

Intra-professional inequity

The removal of automatic pay progression will likely disadvantage women – currently there is automatic pay progression which ‘ticks over’ even if one is working part time or on parental leave, which partway compensates the delayed career progression of (for example) having children. This might be uneconomical, but one may be happy with this given it corrects another inequality – and prefer it not be removed if something else cannot be put in its place.

Further, the redistribution of pay between medical specialties looks fairly inequitable. The proposed changes to pay involve a basic rate of pay increase, but a smaller added bonus for working antisocial hours, and the hours considered antisocial are being further restricted (most notably, Saturday is now ‘plain time’). What this means is that doctors working fairly normal hours (Public Health, Histopathology, etc.) might stand to benefit, whilst doctors who work a large balance of antisocial hours (Accident and Emergency, Obs and Gynae, etc.) stand to lose a lot of money. (For one example for Anaesthetics, see this analysis).

This seems to be redistributing pay in the wrong directions. I don’t think, important though Public Health is, I morally deserve a 15% pay hike whilst colleagues slaving away in A&E lose money. Plausibly colleagues in these specialties are undercompensated for their efforts even now. It also seems bad economic sense in terms of retention and recruitment: Public Health generally has an 8:1 applicant to place ratio – it doesn’t need more pay to attract even more willing applicants. Contrast with the ongoing A&E recruitment crisis.

It’s not about ‘saving the NHS’

So those are the two good reasons I can see to be against the contract. 3 Yet many doctors opposed to the contract see their opposition as trying to save the NHS from the nasty Conservative party trying to break it up for private healthcare firms, inter alia.

I don’t think we can pretend our motives in striking will be out of some altruistic zeal to ‘protect our NHS’. Grant that the Government really is on a malicious campaign to destroy the NHS. Why are doctors choosing now as the time to get angry about it? As a whole, the medical profession was much quieter about the healthcare reforms during their passage through parliament than they are now about the junior doctor contracts. There was a strike by doctors during 2012, the year of the reforms, but it wasn’t about the reforms, but rather their pensions. Doctors have been on strike before, in 1975. The issues then? Private work for consultants, and pay for juniors.

One doesn’t need to be much of a cynic to suggest that what doctors are really upset about is the threat to their pay and conditions, rather than any existential threat to the NHS the new junior doctor contracts allegedly imply. Even if the government promised UN peacekeepers to monitor our hours, or it was a Labour government who were concurrently trying to roll back the Lansley reforms, we’d still be threatening to strike.

Do doctors deserve better?

I’m not sure junior doctors ‘deserve better’ than the current contract offer. Not because medicine is easy, but it shouldn’t be too hard to us to find a lot of people who have it even worse.

Consider a healthcare assistant. These are probably the lowest paid clinical workers in the NHS, and their job is broadly to assist the nursing team in less-skilled tasks (washing patients, providing food, taking observations, etc. etc.) Their job can involve similarly long and anti-social hours and, if anything, is much less pleasant, less interesting, and involves a lot more bodily effusions than what I did as a freshly minted junior doctor.

If people were compensated according to how unpleasant their job is, there’s a strong case for paying healthcare assistants more than most junior doctors. 4 In fact, of course, they get paid a lot less – often around half a junior doctor, and about a quarter of a consultant. 5

One may say ‘let’s not have this crabs-in-buckets mentality where we race to the bottom – we’re not saying we have it worse than everyone, but that we do have it bad – what about comparing us to politicians and bankers?’ Comparisons to people who notoriously have it pretty good (like bankers) 6 look favourable to us, whilst comparisons to those who have it tough (like HCAs) will look less so.

Yet if we compare ourselves to most professions who work in health, I think doctors generally look pretty good, if only because they get paid generally significantly more than nurses, support staff, physios (for further circumstantial evidence, I know many of my collegues who moved from being physiotherapists or nurses or HCAs to enter medicine – I’m unaware of any people moving in the opposite direction.) If we compare ourselves to the entire working population of the UK ranked in terms of how good our pay and conditions are, I think pretty much all of us are in the top, not bottom half. Even if you ignore (and you shouldn’t) the fact that most juniors will progress to become GPs or consultants with much better pay, if you offered the average person in retail or office work on the median salary: “You’ll have to work 50ish ours thanks to unpaid overtime, and you’ll have some nights and weekends – on the plus side, you’ll get about 10k more a year”, I think most would take it. The revealed preferences of doctors leaving medicine suggest the same: doctors very seldom leave medicine and become a cleaner, a postman (or a nurse) – instead they exit to even more lucrative things like management consulting and the pharmaceutical industry. Yet if medicine was as rubbish as is sometimes claimed, medics should think these less lucrative jobs are worth leaving medicine for.

An egalitarian excursion

One may say this is the wrong comparison class. Even if medics do pretty well compared to the UK, the fact is medics were also people who worked very hard at school, got 3 As at A level, and were generally high achieving. If we compare ourselves to similarly highly achieving people (those who go into law, management consultancy, work in finance, etc.), things do not look so good. Doctors generally could have earned more outside medicine if they wanted to, and they are willing to sacrifice some of their expected earnings to do something worthwhile. Their good will should not be taken advantage of by further worsening their conditions.

I’m not sure this counts for much on reflection. Even if we think we are paying doctors ‘below market rate’ (on which more later). The market forces that set salaries are uncorrelated with the reasons that justify inequality.

There were no moral auditors that set healthcare professionals salaries based on the difficulty of their work. The reason why I can expect around double the salary of the healthcare assistant would go something like this: the health services wants pretty academically able people doing medicine, but lots of other fields also want these sorts of people, and thus competition for their services drives up the price of their labour. In contrast, folks who aren’t so academically able are not in such high demand, so jobs which they can do (such as healthcare assistants) do not get paid so much.

If academic performance was solely a matter of personal merit, then perhaps this is equitable. Yet, of course, it is not. You can take little credit for being born into a good family or being able to attend a good school (I’m pretty confident I wouldn’t be a doctor were I raised in less propitious circumstances). I aver you can take similarly little credit for winning the genetic lottery for being intelligent, which strongly correlates with academic performance. If I had a twin in identical circumstances but with a significantly lower IQ, who tried to become a doctor but struggled with school, and was only able to get a job as a healthcare assistant, it seems hard to say I deserve double his income – if anything he should be paid more in compensation for what he has missed out on.

Thinking more widely makes this acuter. Maybe I’m wrong and you can take credit for being clever, but it is incontrovertible that one cannot claim moral credit for where one is born. Yet this factor explains more than half the variance of individual income of people on earth. Not just more important than anything else, but more important than everything else put together.

The factors which conspire to give pre-medics their very appealing suite of options before medical school are primarily outside their personal merit. One does not get a halo for picking a slightly less lucrative option out of the very lucrative options available. Exceptions aside, junior doctors have it considerably better than most in the UK (and miles better than nearly everyone globally), and can expect to have even better conditions as they progress through training. This will remain the case even if the fears of a 10-20% pay cut are realized. 7 For us treat these new conditions with moral indignation betrays a misplaced sense of entitlement (“If this contract goes through, I’ll only be in the top 30% of UK earners at the moment, and in the top 6% of the world! I’m far better than that!“), as well as a naivete about what most others have to labour under. 8

Markets, monopolies, and medicine

Enough high falutin’ philosophy. Whatever doctors may morally deserve, fact is the government is trying to use its monopoly power to pay junior doctors below their true value on the market. The strikes can be seen as an economic warning that worsening pay and conditions will reduce supply of doctors, when they are already in desperate need.

Maybe. There’s a fairly common renegade view that maybe doctors are being paid over the odds. It goes something like this: thanks to licensing laws, doctors are a monopoly supplier of medical care. Pace extended role staff, you need a doctor to authorize a prescription, order an X-ray, do medical procedures. Doctors can exploit this monopoly by deliberately training fewer doctors than required, and so the artificial under-supply acts to drive up their prices.

The evidence on this is equivocal. On the one hand, the UK has one of the lower physicians-per-capita rates in the developed world, despite being recognized shortages of medical staff. Medical school in the UK is greatly oversubscribed, implying you could make conditions less appealing and still have sufficiently qualified applicants (the applicant pool may be not as strong, and so we have slightly less capable medical students, but I don’t think the cohort of ‘people who just missed out on medical school’ is dramatically worse than the people who just got in).

However, if doctors were exploiting their monopoly, you would expect them to extract salaries significantly greater than would be expected given their academic performance or intelligence. Yet these things broadly line up: the average salary of a doctor is in the top few percent of the UK 9, as are their IQ and A level results 10 Further, when compared to other western countries, UK doctors do fractionally worse than par in terms of how much more than the average salary they get paid. I’ve also been trying to work out the marginal impact of a doctor, if this was wildly higher than NICE’s cut off for spending on health technology, this would also imply under-supply (it would imply the health service could get a lot more bang for its buck by having more medics, but something is stopping it from doing so). Again, these things line up too. 11

There could still be a rent-seeking story here. Doctors not only benefit from their salary, but also in the high status of their profession and the fact they usually enjoy high levels of satisfaction. So maybe in an (market-) ideal world they would get paid a bit less than other comparable jobs because, in effect, they are also getting paid with status and satisfaction. It seems a lot less persuasive, though. Maybe two monopolies just about make a market.

De facto demand

Distorted or not, medicine is currently a seller’s market. I doubt I’m an exceptional case, but the following has happened to me over the last few months:

  1. I have two different locum agencies call me daily about doing work.
  2. I got approached by a firm specializing in training medics to be management consultants.
  3. I get occasional offers for attending seminars and lectures about working in Australia and New Zealand.
  4. After working a night for a consultant, I had an email the next day by them wondering whether I’d be interested in doing clinical work alongside public health training (and, if so, to give her a call).

These were all absent me making any efforts to get other opportunities. I’m pretty sure if I made some effort I could find something even better paid than I currently do. 12

So perhaps what doctors should be saying is something like this: “Look, we objectively have it pretty good, but we see we could do even better if wanted. We don’t want you to make our pay and conditions worse, and, ultimately, if you do, we can leave and do something else. And that will hurt you a lot more than it hurts us.” 13

Perhaps threats like these are what makes the labour markets turn efficiently, and medics are only human: making their conditions worse whilst they have other good options has predictable consequences. But let’s not arrogate some air of affronted noble morality whilst we are at it.

Notes:

  1. For much, much more detail, consider reading NHS Employers, the BMA, and the DDRB (renumeration board) proposals.
  2. This may be particularly troubling as the new contract will pare back protections to the EWTD, but there are rumblings the government is simultaneously negotiating to be given an opt out over EWTD as well.
  3. You might think, however, they would be amenable to negotiation, rather than walking out. The BMA asserts that the government demanded the vast bulk of the contract – regressive and worrying features above included – was not up for negotiation. If so, walking out seems reasonable.
  4. One of my abiding experiences in medical school was offering to help out a friend who was an HCA on her shift so I have a better appreciation of ‘what it’s like’. 4 and a bit hours later I was confident that you would have to pay me a lot more to do this job full time than being an FY1.
  5. Granted, they don’t have 5-6 years of medical school and the costs of lost salaries and tuition fees.Yet it doesn’t take all that many years of earning double someone else’s salary to catch up in terms of net worth, even ignoring that student life is heavily subsidized.
  6. I’m actually not so sure MPs have it that good compared to medics. Even after their 10% pay rise, they earn less than the average consultant, with generally less job security, and junior roles in politics are generally poorly paid.
  7. It is unclear whether there really will be a 10% pay cut. The government assures that it will be cost-neutral, but this seems to imply a lot of flexible top up payments to most doctors, as most stand to lose money on net from the changes in basic and premium pay which have been declared so far.
  8. Saturday being ‘normal time’ is standard in most other jobs. Obviously one may dislike turning Saturdays to plain time, but the proposed changes to extend normal time only brings medicine into line with other careers. It is paring back previously very generous arrangements, rather than perpetuating some great injustice to doctors.
  9. Compare Table 14.7a (Average doctor salary = £70 648) to the income percentiles here (95 percentile = £67 900)
  10. IQ data is old, but this paper has doctor and medical student IQ at around 125-130 on average – around the 95th percentile. The most recent A level results for medical students puts the average score at 536 points, just above A*A*AA. This FoI gives the proportion of students getting A*A*A or higher at 4.9% – given A levels select for the more academically able, the true percentile here will be even higher.
  11. NICE’s cut off for financing a new technology is 20-30 thousand per year of healthy life. My estimates give the impact of an additional doctor as a few QALYs. Divide this through by the average income, then the ‘yield’ of adding medical staff is around 20-30 thousand per year of healthy life, albeit with very large error bars.
  12. That said, many of these options hurt my lifetime earnings. The main factor in lifetime earnings is end-point salary of being a consultant or GP, so delaying training to take locum opportunities displaces years at the end of your final post, and the locum opportunities, lucrative as they are, as not as well paid as this.
  13. So, again, barring issues surrounding childcare, I don’t buy remarks of doctors being ‘forced’ to go to Malta or Australia or ‘forced’ to leave medicine or having ‘their backs against the wall’. They are choosing significantly more favourable pay and conditions, but if they really wanted to they could forego these out of loyalty to the NHS and slum it with their meager top 20 percent salary. Despite student loans, the vast majority of the six-figure fees to train a doctor is borne by the government. This plausibly incurs some moral obligation to stay, even if the grass is greener in the antipodes. (q. v.)

    The feared exodus of doctors due to these contracts will not happen by magic, but rather by doctors collectively choosing to leave. The consequences of us doing so would be partly our corporate responsibility.

4 thoughts on “The ethics (and economics) of paying doctors

  1. As a junior doctor who has worked as a healthcare assustant and is married to a nurse, I must disagree with the point that being paied more compared to both professions is unfair as they may ‘work harder’ then us. Physically yes, but important things not to forget are the length of training doctors have to have, the fact that we have paid far more for it and acruued far more debt (personally £80,000 on graduation) along with the responsibility. At present, HCAs have no accountability at all. Nurses do of course but compared to the responsibilities and expectations of a 23yr old doctor and even the most experienced nurse, the doctor holds far more. Doctors must so pay privately for their continued training, exams, memberships and indemnity which costs easily over £1,000 a year.

  2. Not sure what to make of this on the whole, but a few thoughts

    1) Your points regarding safety and intra-professional inequity are well made, though I feel some context would be helpful. The effect of changes on removing disincentives for overwork are likely to be significant, particularly, as you mention in the foot note as the government wants to remove EWTD restriction. With regards to intra-professional inequity, I feel it is important to note that one of the reasons given for this new contract is to facilitate a 7 day NHS, and it is bizarre that we should do this by disincentivising people from out of hours work. The top-up payments that supposedly compensate for this appear to be discretionary, and no indication has been given as to how they will be dispensed.

    2) Your “Do doctors deserve more pay” section could easily be replicated for almost any job, as the argument you make is essentially “No one is special, it’s all luck, so be content with what you get” Society, however, does appear to care about academic ability, and certainly one does get a halo for picking a less lucrative option, because as you mentioned, there is high status of the profession as a result of this.

    3) “Look, we objectively have it pretty good, but we see we could do even better if wanted. We don’t want you to make our pay and conditions worse, and, ultimately, if you do, we can leave and do something else. And that will hurt you a lot more than it hurts us.” – is a pretty accurate description of why doctors are saying this is to save the NHS. The other question is whether you conflate the wider public with the government.

    4) I’m not so certain about your figures re: pay. I would be amazed if the average junior doctor earned 70k.

  3. I agree that doctors in the UK are towards the top of the global tree in terms of income. I would however like to respond to a two of your points

    1) ‘It’s not about the NHS’ – the fact that a pay cut is likely is obviously a motivating factor for the less politically minded. But I could just as easily argue that it is much clearer to the average doctor that cutting pay is harmful to the NHS because it will drive away doctors, whereas structural reforms like the Health and Social Care Act are far removed from the frontline reality of most juniors, so they are protesting simply because they understand it. I also think it is fair to say that this protest comes at the end of a long series of reforms that have generally worsened pay and working conditions for UK doctors throughout their careers, while simultaneously changing the structure of the NHS in England and increasing private sector involvement. The politics of the ‘7 day NHS’ are just as controversial as the proposed contract changes (see #iminworkjeremy). Our frustrations have been simmering for a long time but are now boiling over.

    2) ‘Misplaced sense of entitlement’ – I agree with the general sentiment but I think it is not pay per se that is the problem. Generation Y/Millenials are more concerned with work-life balance (according to media reports), as are the increasing number of people who wish to raise a child while having a career in medicine. Other health care professionals may be paid less, but they do not have to work for a new employer every year, migrate around the country to towns they don’t particularly want to live in far from family and friends, repeat all of their induction and training programmes annually, find out their rotas at the last minute, haggle endlessly for leave to be able to organise and attend their own wedding, do 12 long days in a row, work unpaid overtime, keep their families guessing about whether they can be home for Christmas, or any of the other routine things junior doctors generally put up with. I love my profession but have never felt valued by my employer and I know many of my peers feel the same. These are the issues that the JDC had been working on prior to the contract row and the proposed changes do little to address the issues and may make them worse.

  4. What a detailed and nuanced discussion amid all the shrieking trolls.

    I feel I recognise, with a broad grin, many of my rants about the value, value ascribed to, and grim discrimination against, healthcare assistants. Only more eloquent. Thank you, thank you for highlighting this, and many other important-but-nuanced aspects of health – land and this issue. It takes real courage and humility to present the experiences of (“rival”) healthcare professionals to aggrieved doctors.

    Also, I’m vividly reminded of dragging you round a night shift on rehab. You poor lamb. (Unironically!)

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