Striking

With both the 2016 strikes and more recent 2023 strikes, this is a topic which is likely to crop up in your interviews. Although learning facts and figures isn’t necessary (but impressive), having an idea of the damage caused by a day of strikes is useful. At the bottom of this page, we have included ethical arguments for and against striking, a key interview topic but one that may also come up in a BMAT essay. Once again, this is much more comprehensive than other resources and by learning some of these additional facts, you will immediately be placed into the top interview candidates.

Definitions

Whistleblowing: An employee who reports unlawful or unsafe activity within a public or private organisation.

Altruism: Putting others concerns before your own - selflessness.

BMA Junior Doctor Contract 2016

In 2016 there were 4 junior doctor strikes due to a new Conservative contract. This contract helped the Conservatives strive towards the 7 day NHS initiative following a British Medical Journal (BMJ) study which found:

  • 10% increase in death rate on Saturday

  • 15% increase in death rate on Sunday

Although the proposed contract increased the junior doctor’s basic rate (+13.5%), Saturday shift were no longer paid at a premium, and Sunday's were paid at a reduced premium (the basic rate +33%), compared to the original basic bonus which could be anything up to basic rate +100%. Although this seemed like it would increase pay for junior doctors, instead it enabled doctors to work more nights and weekends for a similar pay overall.

On top of this the BMA highlighted the inequalities brought about by the new contract:

  • Impacted women disproportionately as maternity leave pay was reduced.

  • Impacted junior doctors disproportionately as the contract was only applicable to them. This meant that:

    • Junior doctors would have to work more antisocial hours compared to senior doctors.

    • Junior doctors in certain specialities, who have a longer period as a junior doctor, are more greatly affected.

  • Reduced pay for doctors who change speciality.

  • Reduced pay for research.

  • Overworking doctors would result in worse patient care.

Instead, the BMA proposed a contract where the basic rate was increased by 4-7% and the premium was always basic rate +50% (weekends and nights).

Both the “British Medical Association” and “Just Health” arranged strikes which the Department of Health and Social Care called “expensive and totally unwarranted”.

Effects of the Strike

There was a total of 4 strikes, with the first 3 withdrawing just elective care, and the final strike including emergency care as well. In total:

  • Over 100,000 outpatient appointments were cancelled.

  • A total 10% decrease in hospital admissions (15% during the final strike).

  • 7% decrease in emergency attendants.

Although its difficult to determine how many deaths were caused by these strikes, the decreased admissions and attendants indicate that it resulted in patient harm.

Outcome of Strike

In 2019 a contract was decided on:

  • 8.2% increase of the basic rate (2% increase annually until 8.2% in 2023).

  • Limits on the amount of weekend work and number of successive 13 hour shifts.

  • Increased protection of whistleblowing employees.

  • Implementation of Guardians of Safe Working: Each hospital must have a designated guardian who ensures junior doctors have safe and practical rotas.

2023 Strikes

July 2022 Pay Offer:

  • Doctors and dentists will receive a 4.5% pay increase.

  • All NHS staff which are not dentists, doctors or senior managers received a £1,400 permanent increase in their full-time equivalent salary.

Disagreements with the 2022 Pay Offer

After a BMA ballot at the start of 2023, out of the 77.5% (36,955) junior doctors who returned their ballot, 98% voted to strike, compared to a mere 2% who didn’t support striking. This led to a 72 hour strike for junior doctors beginning on the 13th of March across all departments (including cancer wards, A&E, intensive care etc.) the most disruptive in the history of all strikes.

The health secretary, Steve Barclay, was “deeply disappointed” with the ballot results and fears the harm this will cause. However, doctors argue that it is the only way to ensure change.

Strikes that occurred in England and Wales in 2023:

  • Further Junior doctor strikes: 11-15th April, 14-17th June, 13-18th July

  • Nurse strikes: 18-19th January, 6-7th February, 30th April-1st May

  • Ambulance strikes: 6th + 17th February, 6th + 20th March

  • Consultants - first strike in their history: 20th + 21st July

So far, over half a million appointments have been cancelled due to strike action from December 2022 to date.

Outcome of the March Strikes

  • A one time payment worth 2% of their salary.

  • A tiered ‘backlog bonus’, worth an average of 4% (dependant on the tier of the staff).

  • A 5% pay rise in 2023/2024 for most staff, and a 10.4% pay rise for the lowest paid staff.

  • Measures to support the recruitment and retention of NHS staff.

The majority of the unions which struck accepted this offer.

The Ethics of Striking

The Four Pillars of Medical ethics

Agreements

  • Not Applicable.

  • Strikes improve the working conditions of the staff and, therefore, the quality of care given to the patient. A strike will maximise the overall good that NHS staff can do.

  • Sleep deprivation, poor working conditions, and overworking affects the physical and mental health of NHS staff. Striking may prevent as much future harm.

  • Doctors/NHS staff are legally able to strike.

Conflicts

  • Not Applicable.

  • On the day of the strike, the patient’s best interests are not prioritised.

  • Patients are inadvertently harmed due to a strike. In the 2016 strikes, over 100,000 outpatient appointments were cancelled.

  • Doctor’s are legally able to strike, therefore there is no “justice argument” against strikes.

Other Arguments

FOR:

  • Striking places some power back in the hands of the NHS staff. By having the option to strike, NHS staff are able to negotiate. Therefore, even without using it, enabling doctors to strike may better working conditions.

  • Without the opportunity to strike, some compare working in the NHS to slavery; the employers can exploit and abuse their workers without consequence.

  • Doctors strike altruistically - they strike in order to improve their working conditions so that they can improve patient care.

AGAINST:

  • By striking, doctors are prioritising themselves over their duty of care. This contradicts the NHS Constitution of ‘improving lives’ and a ‘patient centred approach’ (see: NHS Constitution: Principles and Values).

  • The public trust in the NHS may be affected by strikes. This may discourage patients to use the NHS.

  • Previous strikes have resulted in patient harm and death for not only the days of the strike, but the days of ‘catching up’ afterwards.

The Theories of Ethics

  • Ethical Altruism: Doctors must not consider themselves when making decisions. By striking, the net consequence is harming patients (therefore morally wrong) even if they are protecting themselves. Ethical altruism forbids striking.

  • Deontology: Doctors should always act altruistically. Therefore, striking to benefit themselves would be going against the deontological argument.

  • Virtue Ethics: Compassion and Conscientiousness. When overworked, a doctor is unable to provide the expected level of healthcare. Decision making is impaired. Clinical and diagnostic errors increase. Therefore, striking could be argued to increase the ‘compassion’ and ‘conscientiousness’ of doctors (by improving working conditions) and therefore morally valid on the grounds of virtue ethics.

Values of the NHS Constitution

  • Improving Lives

    • For: By striking, doctors encourage employers to improve working conditions and, therefore, the patients experience of healthcare.

    • Against: On the day of a strike, critically ill patients are at much greater risk.

  • Working Together for the Patient

    • For: Doctors are striking against the employer for the benefit of the patient.

    • Against: By striking, doctors are prioritising themself above the patient.

Good Medical Practice Quotes

  • “You must put patient safety first”