Intended for healthcare professionals

Opinion Dissecting Health

Scarlett McNally: We need to talk money to retain our NHS

BMJ 2024; 384 doi: (Published 07 February 2024) Cite this as: BMJ 2024;384:q277
  1. Scarlett McNally, professor
  1. Eastbourne
  1. scarlettmcnally{at}
    Follow Scarlett on X/Twitter @scarlettmcnally

It used to be considered impolite to talk about money, but times are tough. Poverty causes ill health,1 and six million people in the UK—10% of the population—are in “very deep poverty,” with one million children in “destitution.”2 Living in the most deprived 10% of areas means having 26.4 years of ill health, which compares with 15.6 years in the least deprived.3

A third of working age adults in employment have at least one long term medical condition,4 and 2.6 million people are unable to work because of long term sickness—up by 500 000 since the covid pandemic started.5 This is a double whammy for the economy: every person who is too sick to work no longer pays income tax, but they still need their healthcare, social care, benefits, and living costs covered. Keeping the NHS free at the point of delivery, and accessible to those without the means to pay, is essential to a healthy society and economy.

Healthcare isn’t just about delivering services. Prevention needs investment to reduce the disease burden, comorbidity, and complications. Healthcare requires a whole team working together to deliver clear health messages. Continuity of care from a GP gives better outcomes and is more cost effective than isolated appointments.6 We need more GPs, consultants, and specialists—all with scientific knowledge, experience of dealing with multimorbidity and complexity, and sound judgment for balancing risks. But the process for developing experienced doctors is flawed and underfunded. They work for several compulsory years as postgraduate doctors in tough training programmes, and this cohort remains locked in industrial dispute.

Doctors are typically graduating with £100 000 of student debt from five years at medical school, with an interest rate of 7%.7 Compound interest means that the debt doubles to £200 000 in 10 years if little is repaid. GP training programmes take a minimum of five years to complete after graduation. Progressing through postgraduate educational posts for as much as a decade is still the standard route to becoming a consultant.

Most doctors now graduating in the UK are women, and many extend their postgraduate training years with parental leave or less than full time working. But student loan repayments, tax, subscriptions, exam fees, childcare, commuting, and living costs all come from basic salary earnings and by my calculations amount to £212 000-£500 000 over their whole postgraduate training of up to a decade.8

Unintended consequences

Investment in doctors is needed to increase their salaries, provide them with administrative support, and boost the numbers of training posts.9 When I was director of medical education in East Sussex we bid to convert locally employed doctor posts to training posts, requiring a little additional funding to existing salaries—so, increasing training posts isn’t as expensive as it seems. These measures would help incentivise excellent doctors to stay in the NHS, providing decades of care for our ageing population with its increasing complexity.

Paradoxically, the sudden announcement of an increase in the minimum wage, by £1 an hour from April,10 is likely to have unintended consequences for the NHS. Social care costs will increase: for example, providing 24 hour care will rise by £168 a week, with additional employer expenses. Social care staff are poorly paid, so the increase is needed, but the knock-on effects for the NHS need to be mitigated.

NHS hospital beds are already too full, with one in seven in use by people medically fit for discharge.11 Rising costs and understaffing in social care will make it harder to discharge patients back into the community.12 Childcare providers will struggle to remain viable, so more women working in healthcare will struggle to return to work after parental leave, and children will lose early education opportunities.

In the longer term, pay scales where people with astronomical student loans have less spending power than others without debts may generate unrest. Perhaps debts from medical school should be written off after seven years of NHS service, or salaries for doctors in postgraduate training programmes should be increased significantly.

We can’t afford to let the NHS fail. We must fix the leaky pipeline so that doctors can afford to get through their postgraduate years and keep the nation healthy.


  • Scarlett McNally is a consultant orthopaedic surgeon, deputy director of the Centre for Perioperative Care, and president of the Medical Women’s Federation.

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