Intended for healthcare professionals


Junior doctors: waving or drowning?

BMJ 1999; 318 doi: (Published 19 June 1999) Cite this as: BMJ 1999;318:1639

The real solutions to juniors' conditions lie beyond pay

  1. Fiona Moss, Associate postgraduate dean
  1. Thames Postgraduate Medical and Dental Education, London WC1N 3EJ

    Last week junior doctors' representatives in the United Kingdom voted unanimously to ballot on industrial action.1 Such action may be some way off, but this is a serious preliminary step. The last industrial action by junior doctors was 25 years ago. Since then juniors have been paid for their overtime working; limits have been set to their hours ofwork—although they are not fully implemented; and specialist training is better organised. Yet, as before, morale for some is in a critical state, and pay and conditions are the stated problems.

    Junior doctors as a group are hard working and dedicated, and this move towards industrial action is a clear signal that things are not right. But in seeking to respond effectively to their problems we should not be blinded to the crucial issue of “conditions” by the smokescreen of concernsabout pay. The secretary of state for health has offered to consider changes to the structure of juniors' pay “if that is what they want.”1 Junior doctors need to consider that challenge carefully. Is changing the pay structure really what is needed? A vast body of evidence shows that pay is not the most important aspect of job satisfaction. That is not to diminish the problems of juniors' pay: overtime is paid at half the standard rate, so house officers may receive only £4.02 an hour—little over the national minimum—for demanding work requiring significant qualifications often done in difficult conditions at antisocial hours. Such absurdities hardly need negotiation—they simply need to be sorted.

    Understanding and improving difficult “conditions” should, however, move the discussion beyond problems experienced by doctors. In a system where professionals do not work in isolation, if one group experiences difficulties others will too. Stress is high in all groups in the NHS.2 Many nurses work under huge pressure, and for some first year nurseswork is as bleak as it is for some preregistration house officers. Real changes to working conditions are likely to be found by looking at how the workforce as a whole works together. But to do this means a clean break with past habits and patterns of reaction for each of the health service's professions.

    The many changes in the delivery of health care over the past 25 years have largely been absorbed within existing systems instead of the systems being changed to suit the new demands. Increasesin ambulatory, day case, and outpatient care and reductions in beds and average lengths of stay have changed the pace of both hospital and community care. The pressures to see more patients affecteveryone in the health service. Unfortunately, the common response to these increasing demands is simply to work harder (and to shout loudly when the pressures become too great) though the solutions are likely to lie in doing things differently—and that includes finding new ways of working together.

    Even those who agree theoretically that changing the way we work together through adopting a “systems” approach to resolving the problems of junior doctors is a better bet than simply reacting to superficial demands feel there is no time to work out how to do things differently. Yet there is a danger of making false economies with time. Some of the actions that mitigate stress in house officers include regular appraisal, support, and feedback by consultants.3 Time spent doing such things, although spent away from direct patient care, may result in better motivated team members, better able to deliver good patient care. Similarly, time spent sorting out the organisational aspects of work is likely to benefit patients. And time for reflection is a crucial for thinking coherently about the way we work.

    Although in practice the healthcare professions work interdependently, education, training, andprofessional representation and negotiation remain steadfastly separate. Directives to reduce junior doctors' hours and the number of menial tasks they do should be welcomed. But because implementation affects the work of nurses and others, achieving these aims might be more likely if some of the discussions were multiprofessional. This, however, means challenging many assumptions about professionalism within health care, and the old barriers of tradition and trust get in the way.4

    Nevertheless, the professions do have important separate identities and some particular problems face the medical profession today. There have been a series of widely publicised serious lapses in medical care. Doctors feel that patients trust them less than they used to. It may be easier towork hard in difficult conditions when people think you are a saint for doing so. Moreover, the wider availability of information and patients' desire for a different relationship with their doctors mean that doctors are having to come to terms with a new role. Junior doctors may be articulating a more general sense of professional unease. The solution to that lies in the hands of the medical profession itself, which needs to adjust its professionalism to meet the needs of today's society.5

    Consideration of changes to ways of working together should concentrate on patients' needs and on improving the quality of care. That way we may end up with a system capable of delivering good care that suits everyone. Patients certainly do not want to be cared for by tired, unhappy professionals. Improvement implies change to systems.6 Although this can be difficult and may appear time consuming to clinicians used to expecting quick results, there is a literature on organisational change,7 and there are examples within the NHS where radical changes have occurred. Many junior doctors do work in good conditions within well functioning teams.8

    Responding to the juniors by seeing only their superficial concerns—and, in the traditionof pay disputes to “settle” with a millennial pay out—would be to fail to take the needs of these doctors, their colleagues in other professions, and their patients seriously. The real question is whether any policymakers or groups within the NHS have the courage to move beyond the traditional tribal constraints that govern the way we work.


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