Junior doctors in the United Kingdom have spoken: of a total of 47,700 junior doctors working in the UK, 37,000 cast their vote in a ballot on prospective industrial action, with 98.06% voting in favour of strikes. According to the British Medical Association (BMA), this represents the highest-ever turnout in a union vote by doctors in the history of the National Health Service (NHS). The current set of strikes (at the time of publication) in March, April and June 2023, which have lasted for 72, 96 and 72 hours respectively, affected both elective and emergency care. The strike in March only represented the sixth such action ever taken by junior doctors in the NHS, with the previous walkout occurring in 2016 following a dispute over contract reform. Further strikes are expected in the coming months as there has been no agreement with the government as of June 2023.
Recently, the Swiss Newspaper “Neue Zürcher Zeitung” published the results of a survey on the working conditions of junior doctors in Switzerland, highlighting issues including excessive working hours, institutionalised violation of labour laws, lack of training opportunities, and increasing administrative requirements. As doctors who are completing their training in Switzerland but have gained years of experience working in the NHS, we aim, through this paper, to draw attention to the various factors that led to these strikes. As such, we will explore why the developments in the NHS are a warning signal to all healthcare systems across Europe that are facing similar pressures.
Training structure and prospects
After passing their university medical exams, junior doctors in the NHS are initially required to complete four-month rotations in various medical specialties as part of the two-year UK Foundation Programme (FY1-2). It is only upon successful completion of their first Foundation Year (FY1) that they receive full registration with the General Medical Council (GMC), which enables independent medical practice. Following the Foundation Programme, a three-year training programme to become a general practitioner can be undertaken without recognition as a specialist, which means that one cannot work independently in a hospital setting. Alternatively, after completing the Foundation Programme, junior doctors can either embark on the surgical (Core Surgical Training, 2 years) or the internal medicine (Internal Medicine Training, 2–3 years) common trunk pathways, where further rotations are carried out in 3-, 4- or 6-month blocks. Depending on the specialty, following the common trunk, a further 4–5 years of work as a "Specialist Registrar" in a single specialty will follow, interspersed with duties in general medicine or surgery.
At each stage of training, junior doctors face selection through standardised, national selection processes, which take into account performance at interviews, situational judgement tests, detailed statements and a ranking based on experience and achievements. Becoming a specialist (consultant) in cardiology, for example, requires at least 10 years of clinical experience as a junior doctor with at least three competitive selection stages. Each selection stage largely determines the location and format of a junior doctor’s training. Settling in one location or within a single team for an extended period during medical training is extremely challenging, as rotations not only mean a regular change in discipline but often also a change in hospitals and cities. Within this extended training programme of more than 10 years, opportunities to take breaks within a training stage, without leaving the programme entirely, are few. There are integrated training programmes offered by some universities, but these are highly selective and limited in number.
After the first two years in the Foundation Programme, only around one-third of junior doctors continue their training in this framework. Ten years ago, this figure was more than 75%. Most doctors usually leave training for at least one year after the Foundation Programme to gain clinical experience abroad or in a field of interest, complete research or master’s degree programmes, earn additional money as locum doctors or leave the medical profession altogether. Unlike in Switzerland, where research or other clinical experience can count towards training, a majority of these alternatives cannot be counted towards medical training in the NHS. Furthermore, it is almost impossible to find a consultant position in key specialties in large population centres such as London or Birmingham without a PhD and/or fellowship, which implies another 2–3 years of academic training beyond that already described.
Moreover, private practice can only be established in the private insurance sector and not within the NHS, where there is insufficient integration between the two systems. Currently, only an estimated 10% of the population is privately insured or self-paying, with the effect that the market is dominated by a small number of specialists who have well-established reputations and prestige, rendering entry for young consultant doctors extremely difficult.
Continuity of care within the NHS is often sacrificed to the frequent rotations associated with the training pathway. This can mean that superiors rarely form training relationships with their juniors, thus demotivating their teaching efforts. In addition, in the absence of continuity, clinical details of treatment plans in patient care are often lost in handover. Extreme duty rotas, unlike those in the Swiss training system, are often seen in the NHS and have already been extensively documented by the British media. For example, new graduates are regularly assigned to night or weekend shifts in their first week of work, and rotating doctors, without any prior induction, are deployed directly to on-call duties when moving to a new department or hospital. In this context, the national rotation day for junior doctors (the first Wednesday in August) was dubbed "Black Wednesday" by the British media, and the first week of August was nicknamed "Killing Season" following a 2009 retrospective study, which showed a 6–8% higher mortality rate in UK hospitals in comparison with the preceding weeks.
As the density of doctors in the UK is significantly lower than in Switzerland (28.1 versus 43.0 per 10,000 inhabitants), junior doctors in the NHS are usually responsible for more inpatients at any given time, an issue compounded by gaps in working cover. This can also impact the flow of information between different medical teams and general practitioners, as discharge reports are often brief and do not contain the same level of detail as those in Switzerland due to time constraints. In addition, the size of the healthcare system and the fragmented structure of clinical information systems present challenges in the organisation and coordination of follow-up appointments between different specialties and hospitals in the NHS.
General practitioners are under exceptional pressure and cannot be held responsible for coordinating all such correspondence, as only an average of 11.9 minutes per patient is allotted for routine appointments (in comparison with 21.3 minutes in Switzerland). Furthermore, the number of patients waiting for elective treatment is higher than ever before, at over 7 million, and the prescribed limit on average waiting time of 18 weeks has not been met since 2016. This is evident in the comparative satisfaction of doctors in primary care. In international rankings of general practitioner satisfaction, Switzerland is at the top, while the United Kingdom is at the bottom. While it should be noted that job satisfaction within primary care deteriorated in all countries during the Covid-19 pandemic, the contrast between the UK and Switzerland remains stark.
Interdisciplinary collaboration and salary structures
Particularly in their first 3 to 5 years of practice, junior doctors in the NHS often have to deal with organisational tasks that do not further their education and are routinely performed by ancillary staff in Switzerland. One reason for this is the deteriorating working conditions for nursing staff, who also have to cope with staff shortages, inadequate pay and unsocial working hours. Strikes by nursing staff took place in December 2022, January 2023, and February 2023, and further action is planned.
On the other hand, one positive aspect of inpatient work in the NHS can be found in the regular presence of pharmacists on wards and daily rounds. They ensure that admission and discharge medications, as well as the medications prescribed during the inpatient stay, are in accordance with each patient’s medical needs. This practice has been shown to be beneficial to patient care in numerous studies from both Switzerland and the United Kingdom. Additionally, the availability of physiotherapy in the inpatient setting of the NHS is in no way inferior to that in Switzerland. However, rehabilitative, psychiatric or nursing discharge solutions following an inpatient stay in the NHS have significantly longer waiting times than in Switzerland.
A further key issue for junior doctors in the NHS is remuneration, which is significantly below that of Switzerland or other European countries such as Germany or Austria. Although the cost of living in the United Kingdom is generally not as high as in Switzerland, it has increased sharply since late 2021 due to rising inflation and has taken its toll on affordability, with prices in major cities, particularly London, already barely affordable for normal earners. In addition, from 2008/09 to 2021/22, there has been a real, inflation-adjusted salary cut of 26.1% for junior doctors in the NHS. The current starting salary for junior doctors is £29,384 p.a. (gross) in the Foundation Programme, with progression to £58,398 p.a. as a speciality registrar in the last three years of training. Allowances are granted for duty at night and on weekends as well as bank holidays. In a recent BMA survey (n >4500), approximately half of the doctors surveyed reported difficulties in paying their rent/mortgage (45%) and monthly energy costs (51%). The majority also had to reduce spending on food (78%) and heating their homes (81%). Half of all doctors surveyed had to borrow money from family or friends and/or work overtime or extra shifts beyond the contracted 42-hour working week to cover their living expenses. To compensate for the real, inflation-adjusted salary cuts, a 35% salary increase is necessary; that is why the BMA and its doctors voted to strike.
Although a reduction in pay is officially cited as the main reason for the 2023 doctors’ strikes in the United Kingdom, it is evident that the root cause is a multifactorial deterioration in working conditions for junior doctors. A lack of leadership, which could address shortcomings in patient care as well as the structure and length of medical training, and act in the interest of doctors, is central to this problem. Current surveys by the BMA illustrate the precarious mood of junior doctors in the UK: 79% of those surveyed have considered leaving the NHS in the previous year, while a third of all junior doctors in the NHS reported they were actively seeking jobs overseas in the next 12 months, in Australia and New Zealand in particular, but also Canada, Europe, the Middle East and the USA. In addition to pay cuts, 83% of surveyed doctors cite deteriorating working conditions in the NHS as one of the main causes of their dissatisfaction.
In some Swiss cantons, salary scales have already been adjusted in line with rising living costs, and at least more than one-third of junior doctors in Switzerland report being satisfied or rather satisfied with their work. Nevertheless, a survey by the Swiss newspaper “Neue Zürcher Zeitung”, outlines the concerns of Swiss junior doctors, the results of which are worrying: some parallels can be drawn with the systemic deficiencies regarding working conditions of young doctors in the UK. As such, it is imperative that close attention be paid to developments in the UK.
Studying medicine, becoming a doctor, and a continuing career in medicine must remain desirable for those who are bright, motivated, and ambitious. In the NHS, junior doctors feel grossly underpaid compared to colleagues with similar educational backgrounds in other industries. In Switzerland, while pay is more generous, junior doctors appear to be struggling with the workload and the stressful nature of the work itself. Annual surveys by the Swiss Institute for Postgraduate & Further Education in Medicine (SIWF/ISFM), with a response rate of up to 70% of all training doctors in Switzerland, lend credibility to the statistics presented by the Swiss newspaper “Neue Zürcher Zeitung”, which highlighted that across key specialties, junior doctors average more than 50 working hours per week. In a society where the corporate sector offers the flexibility of remote work and where trials of four-day working weeks have shown promising results, it remains to be seen whether those with the potential to succeed will opt to study and work in medicine rather than join the corporate world.
Compared to the nationalised structure of the NHS, the Swiss healthcare system offers advantages that may help prevent the issues discussed in this paper. Chief physicians in Switzerland typically have a good overview of events and employees within their departments and are usually able to implement changes effectively and efficiently. In addition, increasing numbers of junior doctors are able to choose to work part-time which improves job satisfaction. However, the dangers for Switzerland arise when junior doctors are faced with excessive work in the context of outdated computer systems, institutional cost savings, bureaucracy, lack of nursing staff and high weekly working hours without sufficient training and resources to tackle such issues. Junior doctors require structural support to balance their professional and personal lives. Leaders must be bold and break age-old dogmas of self-sacrificing culture, resilience, and deference in clinical settings. Thus, it is important that we learn from the developments and mistakes of comparable healthcare systems and always work to improve the conditions for all members of this highly complex healthcare system, ensuring workforce retention, as well as safe and high-quality patient care.
Christian Eichhorn, Division of Acute Medicine, University Hospital Basel, Basel, Switzerland, christian.eichhorn[at]usb.ch
Shan Mian, Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois (CHUV), Neurosurgery Service and Gamma Knife Center, Lausanne, Switzerland
Anna Rom, Division of Acute Medicine, University Hospital Basel, Basel, Switzerland, and West London Renal and Transplant Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom