Going on strikeBMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7218.2 (Published 30 October 1999) Cite this as: BMJ 1999;319:S2-7218
Consultant Mark Pugh took industrial action as a junior doctor in Ireland and reflects on the lessons for doctors today
For two weeks in the autumn of 1987 there were virtually no junior doctors present in the Republic of Ireland's hospitals. As a junior doctor at the time, I took part in the strike and even had a small part in organising it. The aim of the strike was to increase overtime payments in the belief that this would decrease the amount of overtime we would be expected to work.
Going on strike is not something any doctor will find easy. We want to help patients; using them as pawns runs counter to the reasons why we do medicine. There is the alarming possibility that patients may be harmed because of one's actions. Junior doctors also have the concern that going on strike may potentially damage their future careers. Thinking about strikes and money seems to change the nature of what we do from a medical vocation into an ordinary job. The change could detrimentally alter our commitment to medicine. How will the public view us afterwards? If all these concerns were realised, no doctor would strike. However, the experiences of previous medical strikes, including my own, do provide some answers.
Harm to patients?
I do not believe any patients suffered seriously because of the strike. Patients would have been inconvenienced by having routine work postponed for two weeks, but substantial morbidity or mortality did not occur. The media and the government would have been on the lookout for such problems, but I do not remember any cause for concern coming to light during or after the strike. More objectively, there are published studies that reassuringly show that hospital mortality did not increase during the course of hospital doctor's strikes in Israel1 and Sweden.2 It could be argued that during a strike mortality is just pushed into the community. However, during a junior doctors” strike, health care is provided by the most experienced doctors—the consultants—rather than the least experienced, so it is not unreasonable to think that hospital standards at least would not fall. This is, after all, the accepted argument for why hospital health care should be consultant led. The beneficial effect would presumably be increased by hospitals being less busy during the course of the strike owing to the cancellation of routine work.
Harm to careers?
We all worried about the possible effect of the strike on our future careers. Importantly, the strike was supported almost completely across the country, making it impossible to be victimised collectively. Before the strike some people felt under pressure from consultants not to walk out. However, their having done so did not result in ruined careers after the strike. Junior doctors, I think, overestimate the importance of a reference. Failure to be appointed to a post is usually because of poor performance in the pre-interview or appointment interview and not because of poor references. It is important to remember that it is only after a candidate has been selected for a job that the references are checked. References are always multiple, allowing one to bypass or at least dilute those from unhelpful seniors.
Consultants work hard, and it is naive to think that they are going to be pleased to have to change plans like holidays to accommodate a strike. However, the IMO (the Irish equivalent of the BMA) offered support to the striking doctors and made it clear that it would pursue vigorously any senior doctor threatening junior doctors. Blackmail and excessive pressure could be construed as professional misconduct and dealt with accordingly by the GMC. In my own case the consultant I worked for cancelled the end of rotation dinner as he was upset at having to cancel a trip to a scientific meeting that he had been working towards for many years. However, the same consultant helped me to get my first post in the United Kingdom, and we stayed amicably in touch for many years after my arrival. I should add that my eventual consultant post in the United Kingdom does not represent a form of political exile: at the time I qualified, the Irish republic produced three times as many doctors as it required. Under these circumstances, training abroad was routine and, as a job without general medical on call work was not possible, it was inevitable I would end up not working there.
Harm to vocation?
Being on strike has not affected the way I view medicine. I feel as committed to my profession as my UK colleagues. We went on strike for our benefit, but I believe patients also stood to gain—overworked doctors are not good for patients. Although our being on strike may have inconvenienced patients, in the long term they should have benefited as directly as we did. Our conditions were unbearable, and our requests were modest. It takes two sides to cause a strike, and there was every opportunity for the government to have negotiated and avoided the action. I do not think that the strike altered how Irish patients felt about doctors. There was then, as there is now, a huge pool of good will towards doctors. Patients at that time were appalled to find out about junior doctors” working conditions: shortly after the strike, my neighbour offered to maintain my half of our shared front garden because she had just found out how hard junior doctors worked.
Background to the strike
In the mid-1980s several hospitals had started to look at junior doctors” overtime payments and work patterns as a way of saving money. At our hospital it was suggested that overtime payments might be stopped when junior doctors were having a meal or sleeping. In one particular hospital, contracts were unilaterally withdrawn and salaries threatened. This incident, more than any other, strengthened the resolve of the junior doctors to try and settle the overtime issue at a national level.
During the build up to the strike, a meeting was held to discuss how the campaign should progress. This was the first time I had attended such a large meeting, and it felt extraordinary to be in the headquarters of the militant Irish trade union movement. The vocabulary was of “strike action” and “solidarity”: it felt odd and uncomfortable, yet by the end of the meeting it was clear that we would go on strike.
Much of the meeting centred on what sort of action to take. Complete withdrawal of labour was overwhelmingly considered the most feasible option. It required a more radical approach, especially on the first day of the strike, but would be probably be easier to manage and would hopefully bring about a more rapid result. We believed a particular problem with a partial strike was that junior doctors would find themselves daily having to agree to do some tasks and not others. Part of the agreed strike plan entailed providing a backup core of junior doctors who could go back into the hospitals in the event of exceptional problems such as a major disaster. It was also felt that a complete withdrawal of labour would be easier for consultants to plan around. We correctly assumed that routine work would be cancelled while the consultants covered the work normally done by the junior doctors. A partial action, we thought, would be more onerous for consultants as it would be more difficult to predict how the action would affect the day to day running of the hospital service.
As the proposed start day of the strike approached, everyone became increasingly tense. Would the overtime payment issue be settled and so prevent the need for the strike? Would people actually not turn up for work as planned, and after that how was it all going to end? No last minute deal was done, and for a couple hours on the first day of the strike we waited uncomfortably for the news that we were not the only ones to have backed the strike call. It was with relief that I heard that the junior doctors had supported the action across the whole country. I felt sure that the government would move quickly to resolve the strike once we had shown our resolve. Instead, a very long week followed with no sign of useful negotiation. It was not like being at home on holiday; I felt anxious about not working and the effect that this was having on patients. In the second week of the strike, however, negotiations moved in a more useful direction, and we went back to work after 14 days. I was pleased it was over, though returning to work was something of an anticlimax. Although we had “won,” there were no changes in our working conditions, and it was many years before things started to improve. Indeed, the Irish junior doctors are now again threatening industrial action in an attempt to improve working conditions. Like most junior doctors, I felt absolutely essential to the working of my hospital, so it was disappointing to find everyone had managed without me. There were no recriminations, and after a short time it was as if we had never been on strike.It is now 12 years since the strike in Ireland, and I do not regret what I did. I did not enjoy being on strike but felt it was the only way forward in what had become an impossible situation. It was one of the most difficult decisions I have ever faced, and I hope that today”s junior doctors will not feel forced to go down the same path.
Pros and cons of going on strike
Reasons not to strike
It is not possible to guarantee that no patient will suffer during the strike
The public may think less of the profession for having walked out
Being labelled as a striker may jeopardise your career
Losing will weaken the bargaining position
Winning may divert money from other areas, causing additional problems
Reasons to strike
Doctors are employees and entitled to strike to improve their working conditions
Published evidence suggests patients do not suffer during medical strikes
Enhanced media attention on working conditions may encourage public support
Widespread support makes it difficult to victimise individual strikers
Successful negotiations for one part of the profession may help the negotiations of others