Medical school is widely regarded as one of the most difficult paths for a young person. Applicants require exceptional academic qualifications and, even then, medical school acceptance rates are extremely low. Public perception has always been that once you have got into medical school, life would get easier. The medical profession is, after all, a well-paid and prestigious one. But such has been the scale of the decimation of the NHS in recent years that this is no longer the case. In fact, many junior doctors now experience working conditions that would be seen as unacceptable anywhere in the modern economy.

Emma Runswick, deputy chair of the British Medical Association (BMA), grew up on a council estate in Wirral. As a junior doctor in the North West, she sees first-hand the challenges they face. ‘It’s a job where you’re not treated like a professional,’ she explains. ‘You’re moved around a lot. They expect you to have nothing else in your life: no family, no responsibilities, no hobbies.’ Impossible workloads aren’t confined to junior doctors in today’s NHS, with everyone from nurses to cleaners and porters reporting increased levels of stress.

This is having predictable consequences for patients. Over 7 million people were waiting to start routine treatment at the end of October 2022, a record-high hospital waiting list totalling more than Denmark’s entire population. In 2022, just 68.9 percent of patients in England were seen within four hours at A&E. For context, in 2009, just 4 percent of patients waited over four hours. The decline is extraordinary by any standards. A beds crisis, a recruitment and retention crisis, and an A&E crisis are just some of the many consequences of an underfunded healthcare system that is now reaching breaking point.

Deteriorating Conditions

Ibrahim, a junior doctor working in general surgery, has been aiming for medicine from a very young age. He begins his shift at 8 AM by reviewing patients on ward rounds. No two days are the same and Ibrahim finds himself dealing with all sorts of emergencies during his day. ‘I’m supposed to finish at five but I usually leave an hour later every day,’ he tells Tribune. Ibrahim doesn’t get paid for those extra hours; but, in the interests of patient safety, he stays on to ensure patients get the care they need.

Last week a patient collapsed. I couldn’t leave without doing a heart trace on that patient and I was solely responsible. It wouldn’t be safe to hand over.

Ibrahim ended up leaving at half past six on that particular shift; and, he says, with experienced staff leaving the profession in droves, this is becoming increasingly normal for junior doctors.

Our rotas are chronically understaffed. Seniors are burnt out. Many patients are essentially having catastrophic medical events happening on our watch. When you’re so understaffed and you have one individual managing thirty patients, you’ll inevitably miss things. As a result, people are dying.

Emma works in psychiatry and sees the impact of the beds crisis every day. She spends her time visiting patients in the older age group with complex psychiatric problems, such as dementia, depression, schizophrenia, and bipolar disorder. She carries out home visits, consults with their carers and family, and assesses patients. ‘We’re talking about people who are very sick. It’s not a pleasant experience for anybody and we haven’t got any beds to put them in.’

Mental health services, like NHS services in general, have been chronically underfunded. The number of beds in NHS mental health hospitals has fallen by a quarter since 2010.

Inpatient services have been hammered. It’s really hard to staff them and we haven’t got enough beds in inpatient care. They end up in a random hospital ward, which is quite dangerous, with nursing staff who don’t really know how to look after them and in an environment that isn’t going to be therapeutic. We simply don’t have a safe place to put them.

The crisis in the NHS is directly tied to the broader crisis of Britain’s public services, something Emma sees every day in her job. The cuts to adult social care have been particularly damaging, leading to far greater demand for hospital beds. Ibrahim is on his feet for twelve hours almost every day. There’s no protected lunch break, and he often finds himself skipping meals. On a night shift, he says, there’s not a moment of rest, and he’s feeling the consequences.

I am always in pain. Particularly my knees these days. I’m quite tall and I have to crouch down or go on my knees to do things for patients. And my body is always in pain. My hips, my heels, and my joints.

Cost-of-living Squeeze

The government has played on public impressions of doctors as well-paid professionals to whip up opposition to the BMA. But the reality is sobering. Real pay for a junior doctor has declined by an astonishing 26 percent since 2008. With successive real-terms pay cuts and now a cost-of-living crisis to contend with, the struggles of junior doctors have seldom been more difficult.

Yet, like in many jobs across the economy where wages have fallen, the daily work remains the same. Says Ibrahim,

We are the ones that have to do the crappy jobs. We are the ones putting tubes into someone’s genitals to allow them to pee from their bladder. We’re the ones putting a tube through someone’s nose into their belly so that can get rid of all the blockage in their bowels. The vomit and mucus goes all over you. We’re the ones hearing the cries of patients in pain and agony waiting to be seen by us. We’re the ones getting abuse for things beyond our control.

Nearly half of junior doctors are struggling with basic costs like rent, heating, and commuting. For Emma, childcare is one of the biggest sources of financial difficulty. With junior doctors forced to move to other parts of the country, they often find themselves isolated, away from family, and raising children on their own. ‘You need childcare not just during the day but also nights and weekends, and that makes childcare much more expensive than the hours that you are working,’ she explains.

One of Emma’s colleagues has cut back on her hours simply because she can’t afford to pay those costs. In fact, it works out cheaper for her to look after her children than to go into work. Long commutes don’t just take up considerable time; they can be costly as well, and many junior doctors are resorting to car sharing to cut down on petrol costs. ‘It means you’re standing around waiting for somebody else to finish their shift and very often junior doctors are forced to stay beyond their contracted hours anyway because we’re so understaffed.’

On top of the day-to-day job, junior doctors are expected to do research and audits, and study for exams. This additional work takes place in their own time and means junior doctors are often working over sixty hours a week. The exams themselves can cost thousands of pounds; and what with long commutes, parking charges, and General Medical Council fees, junior doctors are losing a substantial amount of their income just doing their jobs. ‘All of these are coming out of your pay cheque,’ says Dan Zahedi, a junior doctor in the East of England. ‘If you factor all of that in alongside tax, national insurance, pension — there’s not much to take home when you’re earning just £14 an hour.’

Real-Terms Pay Cut

Like so many workers across the economy whose wages have been stagnant even as corporate profits have risen, junior doctors are expected to take a real-terms pay cut this year. It’s an added insult when you consider the experiences of healthcare professionals during the pandemic, which saw government ministers clapping in appreciation.

Lara McNeill has been a junior doctor for nearly three years. She was one of many medical students to graduate in 2020, finishing earlier in April instead of August in order to join the frontline of the fight against Covid-19.

It was really horrible sweating in PPE and not being able to go to the toilet for hours. Watching people pass away. It was a surreal experience. I didn’t really know my colleagues and there wasn’t much support.

Hospitals during the pandemic were like a war zone, Dan says, with rooms being repurposed for PPE and demand at an all-time high. ‘Morale was a little better because there was so much public support; you felt like you were doing your part to keep the country going. Businesses were sending free food to hospitals,’ he remembers.

But it was tiring at the same time. We were dealing with a highly contagious and deadly virus. Everyone was isolated. While many people had family at home, we were usually living by ourselves to avoid mixing with family or friends.

The NHS, battered and bruised by years of neglect and underfunding, was woefully underprepared to deal with a catastrophe of this nature. Those on the frontline felt the consequences the most.

We often didn’t have the right equipment, or we had expired equipment, or broken equipment. And it was putting people’s lives at risk. Putting healthcare workers lives at risk. And I saw that first-hand.

Britain had been sleepwalking into an NHS crisis and Covid should have been the wake-up call. But, two years on from the height of the pandemic, it appears few lessons have been learned. Today, around 10 percent of patients can be waiting for more than ten hours in A&E departments, with vulnerable patients left in ambulances or trolleys for hours on end.

‘We have adapted to this corridor medicine, which shouldn’t even exist,’ explains Lara. ‘We’re having to go past people in pain, moving trolleys out the way to try and access people who are having a cardiac arrest. It’s horrible.’ In a BMA survey published in December 2022, 79 percent of junior doctors said they often thought about leaving the NHS, while 40 percent said they were planning to leave as soon as they found another job. Ibrahim estimates that around 20 percent of his cohort has already left the profession; and Dan fears, without pay restoration, more will leave.

The Fightback

Junior doctors like Dan and Emma are actively involved with the BMA and see strike action as the only way to get the government to listen. The last time junior doctors went on strike was in 2016. Then, it was over a new contract imposed by former Health Secretary Jeremy Hunt. It was a complex dispute and one that didn’t end in substantial success.

According to Emma,

We had slow and unclear communication between central BMA and members. We often cancelled action last minute for no clear reason. But we have learnt a lot from 2016. This time, we are sharing strategy ahead of time, telling members about what’s happening internally.

The current dispute is much simpler: a demand for pay restoration.

We’re organising at work, we’ve run training for activists, we’re doing ward walks when we’re mapping and charting. We have the strike WhatsApp groups. We’re so much better organised.

The wider context is different too. In the NHS, nurses, paramedics, and other healthcare workers are also embarking on strike action, often for similar reasons: successive real-terms pay cuts and concerns about patient safety amid a retention and recruitment crisis. More widely, railway workers, teachers, posties, and workers across the country are engaged in industrial action. Numerous opinion polls demonstrate strong support for strike action, particularly in the NHS; and a government that is already incredibly unpopular is facing growing political pressure.

‘Everybody is coming to the same conclusion,’ says Emma.

The ‘enough is enough’ phrase is spreading across so many groups. And we are getting more organised to fight back. I get a lot of my hope from my colleagues.

Conservatives like Sajid Javid and even Labour politicians such as Wes Streeting have pushed back against pay demands, talking instead in vague terms about reform.

When Sajid Javid says we should charge people to use the NHS, it’s clear that reform for them is just privatisation. That doesn’t work. We’ve tried PFI, we’ve tried outsourcing — that’s gone badly for patients and it’s a waste of money. All of that can go; that’d be a reform.It would be a reform to treat staff drastically better, so that we didn’t spend and waste so much on locums. It would be a reform to have a functioning IT system that works across every hospital and GP practice in the country.

But these reforms, unlike privatisation, would require proper public funding. And in the end, Emma argues, that is the only way to secure the NHS’ future.

In the aftermath of the 2016 strike, many junior doctors felt a sense of disillusionment as new contracts were imposed. Today, as the government refuses to negotiate on pay and seeks to impose anti-strike laws, how does the BMA seek to turn anger into action? ‘The best way is to show results,’ Dan says. ‘We’ve seen plenty of union wins in recent months and we’re working with those unions too. We’ll fight together and we’ll win together.’

Every single doctor Lara has spoken to supports strike action. ‘People do feel demoralised but I think of the Bob Crow line: “If you fight, you won’t always win; but if you don’t fight, you will always lose.” For junior doctors, after so many years of cutbacks, we don’t really have a choice.’ She’s been on picket lines in support of paramedics and nurses, and believes they will return the solidarity.

Strike action can be quite isolating but 2023 is different. Doctors are not alone. Nurses and paramedics are fighting for the same thing. Everyone is fighting back.