Intended for healthcare professionals


Wider political context underlying the NHS junior doctors’ dispute

BMJ 2015; 351 doi: (Published 24 November 2015) Cite this as: BMJ 2015;351:h6317
  1. David J Hunter, professor of health policy and management
  1. 1Centre for Public Policy and Health, School of Medicine, Pharmacy and Health, Durham University, Stockton on Tees TS17 6BH, UK
  1. d.j.hunter{at}

Unhappy doctors are back centre stage with a vengeance

Whatever the rights and wrongs of the dispute over the junior doctor contract, the ramifications will be felt throughout the NHS for some time to come. These have their roots in a wider political context that may prove decisive in settling the longer term fate of the NHS.

This dispute has striking echoes of the deep malaise among doctors in the late 1990s and early 2000s, also a time when the NHS was under severe financial pressure and undergoing reorganisation. The then prime minister, Tony Blair, spoke of bearing “the scars on my back” from attempts to reshape public services. An editorial in The BMJ in 2001 asked why doctors were unhappy.1 It suggested the causes were multiple but highlighted one in particular: the mismatch between what doctors were trained for and what they are required to do. Trained in a particular medical specialty, doctors found themselves spending more time thinking about issues like management, improvement, finance, law, ethics, and communication.

Subsequent analysis suggested that the cause of doctors’ unhappiness was “a breakdown in the implicit compact between doctors and society: the individual orientation that doctors were trained for does not fit with the demands of current healthcare systems.”2 The old compact that underpinned the NHS and was no longer regarded as fit for purpose had two aspects: what doctors gave and what they got in return. Doctors sacrificed early evenings, studied hard, saw patients, and provided “good” care. In return for these sacrifices doctors got reasonable remuneration; reasonable work-life balance later; autonomy; job security; deference; and respect.

The mismatch between the gives and gets was the cause of growing dissonance over what doctors might have reasonably expected the job to be and how it was.3 Silversin’s contribution to the debate was significant because he worked on the physician compact at Virginia Mason Medical Center (VMCC) in Seattle. There is a nice irony here because the health secretary, Jeremy Hunt, earlier this year publicly sang the praises of the VMMC, holding it up as an exemplar for the NHS.4

Among the new imperatives identified for a revised compact for the NHS aimed at helping to create a happier workforce and improve care for patients were greater accountability (for example, guidelines); patient centred care; being more available to patients and providing a personalised service; working collectively with other doctors and staff to improve quality; evaluation by non-technical criteria and patients’ perceptions; and action to counter the growing blame culture.

Notwithstanding important gains in some of these areas, especially during the years of new investment which ended in 2008, the current dispute has led to the “unhappy doctors” syndrome resurfacing and for not dissimilar reasons in regard to pressures on staff, the need for a better work-life balance, and concerns over patient safety.5

But there are two further underlying pressures that have a bearing on the dispute. Firstly, the coalition government foisted deeply unpopular changes on the NHS that were widely opposed by NHS staff.6 Since the implementation of the Health and Social Care Act 2012, staff have been living with the consequences of a dysfunctional and fragmented health system not of their making. The erosion of trust between NHS staff and politicians was therefore well entrenched before the junior doctors’ dispute gained traction.

Secondly, this government is not trusted with the NHS. The health secretary may assiduously wear his NHS lapel badge whenever he appears in public or on television. However, it is unclear whether this is to show his reverence for the institution he presides over or to remind him to transform the NHS into something more aligned to his government’s neoliberal ideology. The unprecedented financial pressures on the NHS seem linked with a perception that the government’s real agenda is to dismantle the NHS as part of a wider redesign of the public realm.7

Institutions like the NHS and BBC stand out as aberrations in the government’s vision of a smaller state in which public services are largely privatised or outsourced.8 The deep seated anger felt by junior doctors is to some degree a manifestation of a deeper frustration with the government’s stewardship of the NHS.

The issues that came to the fore some 15 years ago have not disappeared. Unhappy doctors are back centre stage with a vengeance, and resolving their concerns remains as big a challenge now as then, regardless of the immediate outcome of the present dispute.


Cite this as: BMJ 2015;351:h6317


  • Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Commissioned; not externally peer reviewed.


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