Scotland’s NHS is facing a retention crisis

Junior doctors in Scotland want change. They want better pay, kinder working conditions and for the Scottish government to take their demands for full pay restoration of just under 35 per cent seriously. Otherwise, they say, they’ll simply up and leave to greener pastures – or hotter beaches, as the exodus to Australia continues.

It was revealed last week that 97 per cent of those medics who had voted in the BMA strike ballot cast their votes in favour of industrial action. The turnout was high at 71 per cent but could have been higher still, as it is understood that Civica, the external organisation in charge of posting ballot papers, ran into problems meaning an as yet unquantified number of medics never received their voting cards.

While the BMA has been criticised for choosing to focus entirely on pay as the sole negotiating ground in these disputes, the bigger picture should not be overlooked: the toll that poor working conditions is having on NHS workers is significant. Just under 75,000 NHS staff have taken time off work in the last five years due to mental health-related illnesses, as revealed by a freedom of information request made by the Scottish Conservatives. Burnout is increasing amongst doctors UK-wide: in 2022, 39 per cent of junior doctors said they had experienced burnout to a high or very high degree due to the work – an increase of six per cent on the previous year.

In Scotland, 44 per cent of junior doctors surveyed by the BMA have actively researched leaving the NHS in the last 12 months. A trend is emerging: once doctors have finished their foundation programme – the initial two years of training medics have to complete in the UK after graduating – many turn their attention to sourcing locum work or long-term specialty training jobs overseas.

‘Australia offers more favourable working conditions,’ one foundation year medic planning to move abroad told me. ‘Junior doctors in the NHS are made to feel as if they can only begin to plug gaps in an underfunded system, whereas Australia offers junior doctors a chance to professionally develop themselves in a system where they are valued. The fact that well over half of the doctors I know are moving across the world tells its own story.’

And healthcare providers in Australia have no qualms about capitalising on the dissatisfaction of medics here: using emails and adverts to entice junior doctors over. Dr Sophie Nicholls, a UK-based sexual health doctor, said online: ‘I have daily emails from Australia with tempting offers. Our doctors will move with their feet if they are not recognised for the work they do and paid appropriately.’

Doctor-turned-comedian Dr Adam Kay recently shared a picture of an advert placed in the British Medical Journal by Blugibbon Medical Recruitment. ‘Got that Dr Adam K feeling? Come to Australia!’ the jolly bubble font cried. ‘Work 10 x shifts per month & travel, swim and surf in the sun for 20 x days! $240,000 annual salary package. Accommodation provided. $5,000 sign-on bonus for 12 months of commitment.’

You can’t say it’s not tempting. Dr Kay hinted at the ‘big question’ facing both the UK and Scottish governments: ‘If you don’t address doctors’ very reasonable pay concerns, alongside their conditions and wellbeing, guess where they’re going?’

Scotland has so far avoided healthcare worker strikes, which First Minister Humza Yousaf points to as one of his few successes as health secretary. The impression amongst junior doctors north of the border is that the Scottish government is more serious than Westminster about their demands. Scotland’s health secretary Michael Matheson has already met with the doctors’ union last Thursday, though it’s currently unclear how the negotiations are proceeding. How much will the Scottish government be prepared to offer junior doctors? Matheson refused to commit to a figure, saying only that ‘negotiations to agree a pay uplift are already underway’.

Dodging strike action is only a short-term goal, of course; long term, the real problem remains: how to make sure more doctors are trained in the UK – and that they stay here. During his leadership campaign, Yousaf described the Scottish government’s ‘three pronged strategy’: to increase medical graduates by 100 per year, to recruit domestically and to recruit internationally. But Scotland sees approximately 700 doctors leave the country to work elsewhere each year and in 2016, a fifth of doctors finishing their foundation programme in Scotland left to find better jobs elsewhere – some for England, and some for much further afield. 

‘We’ve got to make sure we’re not filling up a leaky bucket,’ Yousaf admitted to me outside a Dundee GP practice during the leadership contest. While the former health secretary said he wouldn’t give medics the full pay restoration they were looking for, he accepted that the system for junior doctor allocation to hospitals post-graduation could be examined ‘so we don’t spend years and years training somebody up only to lose them because we’re being inflexible’.

So how to stop the exodus? Scottish Labour’s deputy leader and health spokesperson, Jackie Baillie, said that she was ‘not adverse’ to considering options that would see Scotland-trained medics obliged to work in the country’s NHS for a certain number of years after qualifying. ‘Do I think if we’ve spent hundreds of thousands of pounds training a junior doctor – which we have – that we should expect some longevity of service to the NHS? I think that’s perfectly reasonable.’ But Baillie makes clear that this wouldn’t be a policy introduced without movement on pay: ‘You can only apply the golden handcuffs if you are fair about the pay that you give people. I would want to talk to the BMA, and to junior doctors, about how we land this in the best possible way. I don’t want anything we do to accelerate people leaving.’

A common thread unites the Scottish political parties across the divide on the junior doctor issue: firstly, that some sort of pay rise is needed (though no one wants to be the first to name their price), and secondly, that the workforce crisis cannot be solved by wage increases alone. Baillie discussed rota complaints, missed breaks and unpaid – and often unplanned – overtime as being key areas to sort out, while Dr Sandesh Ghulane, the health spokesperson for the Scottish Conservatives, pointed to ‘the little things’ that need changed, like food provision for those working night shifts and better rota organisation. Free accommodation offered by hospitals – an incentive offered in the above advert from Australia – is another concession that could help relieve pressures from medics, Ghulane suggested.

Another problem is managing the expectations of BMA members: while some medics in Scotland have admitted that they would accept a pay rise of less than 35 per cent (with others admitting that it was their work-life balance rather than their pay checks that most concerned them) there are groups of members within the doctors’ union who remain vocal in their demands to accept nothing short of full pay restoration (FPR). 

‘As unrealistic as it may seem, I really hope the BMA remains strong for genuine FPR,’ one junior doctor wrote. ‘It’s honestly the bare minimum needed to keep us going in the NHS. It’s just not a viable career anymore in the UK.’ Agreeing, another medic responded: ‘Frankly, if we were to get an offer close to but not quite FPR and the BMA asked us to vote on it, I would personally vote no. It’s unaffordable to be a doctor in the UK and we have the ability to work for better pay and less hours elsewhere.’

Health secretary Michael Matheson says he has been frank in negotiations so far and remains firm that ‘the recruitment issues are not all about pay’. Perhaps aware that this line of discussion may not fly with the BMA, Matheson has also revealed that he’s already asked NHS boards to start preparing contingency plans should the strikes go ahead.

The workforce crisis is at the heart of the dispute over wages and working conditions in the NHS. There are over 133,000 vacancies in the health service and both junior and senior doctors are feeling the strain. In fact, the BMA announced today that consultants in England are now being ballotted on strike action. While it’s all very well looking for international recruits to plug gaps, there is a real tragedy here: Scotland is home to some of the best medical schools in the world. Something has gone very wrong when it is only Australia’s patients who feel the advantages of that.