News from Nowhere 68 August 1st 2018

Peoples’ Front of Judea saves the NHS!

Recent exchanges about a possible 10 Minute Rule Bill show that, following the time-honoured tradition set by the Peoples’ Front of Judea, the left has already split into factions over what to do about our NHS.  They have some agreement about what is wrong (like too many private providers) but almost zero agreement on how to put things right.

At one end of the spectrum are the most vocally aggressive faction; the conspiracy theorists.  They believe that everything that has happened in the NHS since the 1970’s has been bad – but more importantly part of a plot to break up the NHS.  The more modern version is that everything being done now is so that the NHS can be Americanised. This faction have never explained why such a long standing and pernicious plot continues to fail.  Nor do they have any actual evidence such as a whistle-blower, leaked documents, an undercover report after infiltration. They do have numerous anecdotes and argue from these rather than actual evidence. Their solution is presumably a revolution.

A milder version of this position is held by those who don’t necessarily believe in an actual plot but are entirely hostile to private providers and private sector management approaches in the NHS – the restore the public NHS faction; aka The Nationalisers.  Their strategy for reform is more money and only public provision of services – and that’s it. We can then return to the NHS of the 1970s as a national edifice with regional and local outposts.

In the NHS in England today such a plan would involve the biggest ever top down reorganisation; much bigger than the Lansley disaster of 2012 and much more far reaching that the last truly major reforms in 1990.  Nobody within the NHS actually believes it could work or that reorganisation ever solves anything.

One further problem with the make-our-NHS-public-again narrative is that it is a fiction.  The NHS has always had services provided by organisations outside the NHS (GPs, Dentists, Pharmacists etc) and has always had to buy goods and services from the private sector.  But that aside the belief is that removing the 8% of private provision (if you just quietly ignore the 14% from GPs etc) solves everything. Sadly this rather large ‘heart-the-NHS’ faction has little interest in making the NHS better or looking for ways to improve related and interdependent services like social care or housing.  Their wish is for a public NHS that remains an isolated island separated from the rest of public services.

A more pragmatic version of this is held by many of the less vocal and less likely to march, the faction of the Stevensites; after their spiritual leader.  They believe more money is essential and that the superstructure of markets and competition must be removed. Private provision remains but is limited in scope and scale and properly regulated and procured; but most provision is public and everyone cooperates with everyone else. This faction believe all other care related services, like social care, should step up and ensure the NHS is untroubled.  Or else they accept some need for some kind of integration and are happy to let some experiments on new models take place provided the NHS retains its control. Above all the NHS retains its unique position outside the rest of public services and devoid of proper accountability.

The final faction believes in the Third Era; something better can emerge from the present crisis.  They go along with wanting more money but only if it is within a broader settlement for a far better care system.  More for the NHS and less for social care or even for Public Health is wrong. They agree markets and competition should be removed as the strategic force from all public services, but not everywhere on Day One.  They agree that over time private provision at scale should be reversed as public and third sector capacity is built up and that can be done with leadership and investment. They reject the monolithic NHS and believe that while much about WHAT services must be provided and WHAT we are entitled to expect (maybe even as a right) should be determined nationally there can be a lot of flexibility over HOW services are delivered or provided.  Not hundreds of options for local organisation but several possibilities which meet defined standards; small and workable is more beautiful than large and domineering. This is to allow local determination of how the many care services that those in need rely on over a long period can be made to work together to deliver wellbeing for a defined population. It far more about wellbeing and prevention, more about families and communities, and less about the individualistic consumer medical model – and the NHS bit sits somewhere in the mix.

The big factional split is not between those who support the private sector and those that do not – that is a fiction.  The big splits are about whether the NHS remains as a separate service only loosely linked to other care services and about whether we allow local flexibilities through new forms of ownership, devolution and delegation. Sadly the discussions the left ought to be having are not the ones it ever actually has.


Medical salaries – another ding-dong coming?

The new Secretary of State has got off to a pugnacious start, offering a pay rise to NHS consultants below the 2% level recommended by the Doctors & Dentist Review Body.  From 1 October 2018 consultants will get a 1.5 per cent increase this year, whilst the value of both national and local Clinical Excellence (‘merit’) awards will be frozen.  The Department of Health will seek “multi-year deals” in return for contract reforms for consultant and GPs, and 0.5 per cent of the pay bill would be linked to a new system of performance-related pay.

Junior doctors will get a two per cent increase in income, and GPs get a 2 per cent pay uplift backdated to April 2018, which will also apply to practice staff expenses that are paid for as part of the GP contract. 

NHS managers are concerned that salary increases will have to come out of existing budget allocations, at least for a couple of years, which will worsen the financial position of many Trusts.

The British Medical Association is not happy. Its representative body chair, Dr Anthea Mowat, said: “It is truly astonishing that the UK Government has chosen to ignore the already insufficient recommendations of its own independent pay review body and to then compound the misery that this will cause for thousands of our hard-working members and their families by refusing to backdate what will be an inadequate pay uplift. Just last week the new Secretary of State for Health and Social Care talked about how ‘heart-breaking’ it was to see how ‘under-valued’ NHS staff feel. Considering those words, doctors in England will rightly feel both anger and disappointment that sentiment has not been matched with action.

“…… it is unacceptable that the policy of inflicting a real-terms pay cut on the majority of doctors will continue. Since 2008, doctors have experienced the largest drop in earnings of all professions subject to pay review bodies, with consultants seeing a 19 per cent fall in pay, junior doctors 21 per cent and GPs 20 per cent. The effective pay uplift this year for some doctors will be as little as 0.75 per cent, which will be widely seen as derisory.

“At a time when the NHS faces severe shortages of doctors across all specialties, it beggars belief that the ministers have failed to recognise the contribution declining pay has had on the ability to recruit and retain doctors and the significant damage to morale. Today’s announcement, coming at a time when understaffed and under-resourced hospitals and primary care services are having to manage unprecedented levels of patient demand, will only make a bad situation much worse and the BMA will be considering its next steps in response.”

Should we be concerned with the “misery” of consultants and the seemingly huge drops in their income’s purchasing power during the period of austerity? The Medscape report of April 2018 may help us answer such questions. Medscape is an international educational organisation for medical learning, to which doctors can subscribe. It carried out an on-line survey of members in the UK, Germany, France, the USA and Spain, in October to December 2017, asking doctors to respond to questions about their income in 2015 and 2016 (

In the UK the average income for a full time doctor in the Medscape sample was £114,600. Full time women doctors earned about half the income of their male peers, and specialists earned more than generalists.  The table below shows earnings across five countries, in 2016.


                                                                          Mean FT income
UK France Germany Spain USA
Total £114,600 £84,000 £110,600 £46,900 £218,000
GPs/Family physicians £104,300 £81,400 £117,300 £45,100 £161,700
Specialists £116,100 £85,000 £111,600 £47,880 £235,400

€ converted to £ at £1 = €0.885; USD converted to £ at $1=74.5p

UK doctors in this sample earned nearly 2.5 times as much as their Spanish counterparts, and a third more than French peers. About a half of UK clinicians saw no change in their 2016 income, compared with 2015. Of the other half, 19% reported at least a 10% increase in income whilst 25% reported a decrease in income. In this sample of UK doctors, 85% reported living at or below their means.

Medical salaries are a tricky problem for the NHS, because doctors insist that they are dedicated to their work, sometimes to their own detriment (the Knightly response) whilst also asserting that such selflessness cannot go unrewarded (the Knavish response). The Medscape sample may well not be representative of doctors in the NHS, but if its suggestions that NHS consultants are amongst the highest paid in Europe and that the majority are living within their means are anywhere near true, then the Department of Health’s approach to increasing clinical salaries makes sense.

General practitioners are rewarded for carrying on when pressures on them are high, and their income does not come from Trust budgets. Junior doctors are rewarded, perhaps to encourage uptake of posts, or maybe to avoid another politically damaging conflict. And consultants – as the best off – are asked to bear almost stagnant earnings for a while longer, to minimise the impact of their pay rises on NHS Trusts. So, will they comply, like good Knights, or campaign for more money, like Knaves?


Wholly Owned Subsidiaries

Dr Linda Patterson explains the current urge to makes WOS. Here’s a summary, from:

Some Trusts are creating Wholly Owned Subsidiaries –limited companies 100% owned by the Trust – for NHS support services like portering, estates management, cleaning etc. Staff who were formerly employed directly by the Trust are transferred out under TUPE arrangements. The advantages to the Trust are a VAT refund, and employment of staff on new conditions of service, not national terms and conditions. Trusts argue that staff are still working for the NHS but they are employed by an arms- length body. Some companies have applied to use the NHS logo, but this is not always possible.

Some of these staff are the lowest paid in the NHS. Taking them off national terms and conditions (the Agenda for Change agreement) and out of the NHS Pension scheme will ultimately reduce the pay bill.   Usually, new terms and conditions will be applied to new starters, those changing role or getting a promotion. Some WOS will pay the national living wage, which is an increase, but with fewer holidays and less scope for overtime payments. In some WOS, after campaigns by Trades Unions and staff, there has been an agreement to keep Agenda for Change for all staff, including new starters, but this is not widespread.

Does any of this matter? It does! Penalising the lowest paid to help with NHS financial problems caused by under-funding is wrong. WOS take staff off nationally agreed terms and conditions and out of the NHS pension scheme, which will be to their detriment. The VAT loophole could be closed in the near future. And people want to work for the NHS, so commitment to public services is in danger of being lost. There are also risks of loose governance, with inadequate oversight by Trust Boards. Despite these drawbacks trades unions have failed to obtain ballot support for industrial action.

Nevertheless the arguments about WOS have prompted the Department of Health & Social Care and NHS Improvement to act, according to the HSJ (Nick Carding 23rd July 2018). A consultation about wholly owned subsidiary companies in the NHS will soon be launched, as part of a drive to gain stronger “central oversight” of how and why Trusts establish and run such companies.

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