LAST week I received an email from the Regional Coordinator and Industrial Relations Officer (West Midlands) for the British Medical Association (BMA) inviting me to join a picket line outside Queen Elizabeth Hospital, Birmingham, tomorrow and Friday, the days of the BMA-led consultant strike.
This invitation is surprising for a number of reasons, not least that I retired as a consultant more than eight years ago. More pertinent is that I have never been a BMA member. I remember well that in 1975 the BMA, in collusion with the then health secretary Barbara Castle, tried to foist an appalling contract on junior doctors. They were working on average about 86 hours a week with many working way beyond that (including myself). The new contract allowed for a standard 44-hour week at basic rate, the next four hours to be worked for nothing, and any time over that at 30 per cent of the basic rate for those first on call, and 10 per cent for the second on call. The inevitable result would be that it would be cheaper for hospitals to employ fewer doctors for longer, and some doctors being paid less.
I never forgave the BMA for that, and they continued to have form with the juniors. In 2016 there was the spectacle of the BMA siding with the then health secretary Jeremy Hunt in the High Court over the implementation of another new contract. The judge ruled against the juniors and the contract was imposed against their wishes, resulting in much of the unhappiness we see among the juniors today.
Another disaster strongly supported by the BMA was the implementation of the European Working Time Directive. Although it seemed beneficial to limit by law the working hours of junior doctors, the consequences included the destruction of the supportive ‘firm’ system which placed doctors in teams, reduced training opportunities and the breakdown of continuity of patient care.
Finally I am surprised at the concept of NHS consultants as pickets. I find it difficult to imagine consultants, in general a fairly conservative breed, standing round a brazier outside the hospital gate, shouting ‘scab’ at fellow consultants who cross the line and trying to persuade Joe Public as s/he hobbles past that they are badly done by, especially since they will be far better off financially than most of their would-be patients.
So what do consultants earn, and do they deserve our sympathy and support?
The typical consultant job plan is based on ten four-hour sessions per week, termed programmed activities (PAs). These may be direct clinical contact (DCCs, usually seven) and supporting professional activities (SPAs) for admin, teaching, research, management etc. At current rates the starting salary is £88,364, although many will begin on a higher increment based on previous training and experience.
The salary rises year on year to £99,425 after four years, to £105,996 after nine years, to £112,569 after 14 years, and to £119,133 after 19 years. It should be noted that these increments are not dependent on productivity or outcomes, but merely on the consultant continuing to be alive and turning up for work each day, an arrangement which those working in the private sector would give their eye teeth for! (The government has just accepted the Pay Review Body’s recommendations and the doctors are to get a 6 per cent rise on these figures, although this has not been agreed by the BMA.)
For a workload in the more demanding specialities, for example those with a higher incidence of emergencies, the consultant may be awarded additional PAs per week which will significantly boost the salary. Similarly those who take on management or teaching roles in addition to their clinical duties, such as clinical or medical director, will get additional PAs.
Consultants are entitled to six weeks holiday per year, plus the six bank holidays or days off in lieu. There is a further allowance of up to two weeks for study leave for which course fees and reasonable expenses may be claimed. International medical conferences can be great fun, especially since the stringent UK governance rules are more relaxed and corporate entertainment allowed. I have enjoyed fine dinners in some of the great cities of the world, compliments of the companies. If all leave is taken the consultant provides clinical care for 43 weeks of the year.
In addition, consultants may be eligible for clinical excellence awards (CEAs). This is a complex subject and the process has recently been changed. Awards are given for activities over and above the normal contractual requirements such as introducing innovations, research excellence, publications, service development and such like. There are 12 levels, eight of these local and four national. Level one starts at an additional £3,016, and level eight is worth £30,160. The national awards range from £36,192 to £77,320 and these will be awarded to the small number working at the highest level, such as presidents of Royal Colleges.
The next issue is waiting list initiatives (WLI). I always hated these and I refused to do them since they introduce perverse incentives and merely rescued the service for inadequate provision. Individual consultants could contract with their trust to take on additional clinics, operating lists, or radiology reporting at an agreed price, generally on a cost per case basis. This was a real cash cow, especially for specialities such as surgery or orthopaedics, and many thousands of pounds could be earned. However changes to the tax system undermined such initiatives in the last few years since, rather than having a nice little earner, the consultant could end up with a huge tax liability. The recent decision by the chancellor to abolish the lifetime pension allowance was clearly aimed to address this, although I am not expert enough to know whether this has been achieved. Nevertheless if the government want to make any impression on the millions waiting for treatment, they will need to find a way to circumvent this problem and WLIs are the only solution.
Then there is the elephant in the room – private practice. The NHS contract allows consultants to do private practice, though there are strict rules governing this, and full-time consultants must ensure that there is no detriment to their NHS work. However many consultants opt for a part-time contract where they drop an agreed number of weekly sessions, and there is no limit on how much they may earn.
Estimates on the numbers of consultants doing private work vary (20 to 40 per cent depending on locality). The big players earn very substantial amounts indeed, but the average consultant spending one or two half days a week in the private sector could probably rake in £50,000 to £100,000 a year with little difficulty.
The NHS pension is another bonus. The consultant will contribute 13.5 per cent, and the employer (that is the taxpayer) 20.6 per cent. The final pension is based on a career average with a 25 per cent tax-free bonus. Obviously with the lifetime allowance abolished there is no reason why a consultant should not also invest in a private scheme to boost the pension.
Finally there is the simple fact that professionals tend to marry other professionals. Many consultants are married to other consultants, GPs or senior nurses (true in my department but not me – I married a humble psychologist). Their double take-home income places them among the highest-paid families in the country.
Last weekend’s Sunday Telegraph included an interview with Dr Vishal Sharma, the chair of the BMA consultants’ committee. He disputes the figure of £128,000 for an average salary as too high and states that ‘going on strike is a last resort, but we have been left with no option’. But as I have tried to point out, consultants are not exactly on their uppers, and they have opportunities significantly to increase their income should they choose to do so. Sharma bleats that, due to underfunding and inflation, the real value of the consultant salary has fallen, and ‘unless things change, I am not sure how long the NHS can go on’. Well, I have news for you, Dr Sharma: the value of incomes and pensions for the poorest in Britain has also fallen, and they have no ability to hold the country to ransom.
The invitation from the BMA to join the picket line ends with the statement that the BMA is ‘a leading voice advocating for outstanding health care and a healthy population’. Going on strike is a funny way to go about it. The reality is that with the juniors demanding 35 per cent, the consultants need to preserve the pay differential. In addition, with waiting lists at a record high the BMA believe they have the government over a barrel. My suspicion is the government will hold out until the next election and leave the mess to an incoming Labour government to sort out.
A medical career can be rewarding in many ways other than financial. Those unhappy with their lot should resign and stack shelves in Tesco.