Charging migrants more for NHS care isn’t just bad for migrants. It’s bad for all of us.

Opinion, Pay

The government has made a new pay offer for public sector workers. Prime Minister Rishi Sunak says he accepts the recommendations of the public sector pay review bodies in full. Great! Except that a Conservative backbencher already admitted what every public sector worker has known for years: the pay review bodies are rigged. But the thing I want to talk about in this article is where Sunak says the money will come from. Sunak says the government will fund pay increases by charging migrants more for healthcare.

Pitting migrants against workers already resident in this country is not a new tactic. Nor is using the NHS as a national icon around which to wrap your divisive rhetoric. We all remember the Brexit bus, but Dominic Cummings didn’t invent racism. In 1952, Nye Bevan railed against the potential concern that foreign people might avail of free healthcare in the UK. He wrote:

The whole agitation has a nasty taste. Instead of rejoicing at the opportunity to practice a civilised principle, Conservatives have tried to exploit the most disreputable emotions in this among many other attempts to discredit socialised medicine.

While we certainly ought to valorise Bevan’s arguments, we must also recognise the imbrication of colonialism in the origins of the welfare state. How did the UK come to have enough wealth to be able to fund a welfare state? Who has worked in the NHS over the course of it’s 75 year history? Who works in the NHS now? Which governments pay for the training of NHS staff? Who pays taxes to those governments? Who provides healthcare for those taxpayers in India, Jamaica, Nigeria?

Fine. But what do we do now? Claps won’t pay the bills. Nor will recalling the historical origins of the current political conjuncture. Understanding that the NHS was built on the backs of migrants is necessary, but not sufficient. The BMA – and others – have already pointed out that it is not ethical to pay for (still way below inflation) pay increases for UK workers by punishing migrants (including migrant workers who work in the UK public sector). Good on the BMA. But I want to add one more point. It is not just migrants who lose out when a Conservative government attempts to divide and rule working people. We all lose out.

The cost-benefit calculations of the migrant cost recovery programme[1] have always been suspect. (See here, here and here for critiques of earlier iterations of the programme). Looking at it now, it still makes little sense. If you charge migrants even more to come to the UK then you reduce the amount of migrants who want to come and the amount of migrants who want to stay (since working people may want or need to bring family members over to help with care, particularly in a country where childcare often costs more than a middle-class salary). One of the key motivations underlying the strikes is to improve pay in order to address the recruitment and retention crises in the healthcare workforce. A very high proportion of recruitment of clinicians is from abroad. For nurses, those trained overseas accounted for nine tenths of growth in nursing numbers in the past year. So encouraging current migrant workers to leave and disincentivising future migrants from coming may not be the best idea. That is, if this government really gives a fuck about the NHS and the care it provides.[2]

So what have been the real effects of the migrant cost recovery programme? Apart from consolidating anti-migrant arguments in public discourse, the key material change brought forth by the migrant cost recovery programme has been the creation of an administrative bureaucracy within the NHS – within most NHS trusts – whose purpose is to recoup costs from people. They are called overseas visitors managers (OVMs). This is a bureaucracy that we all pay for.[3] These are administrators and managers whose express purpose is to track people down who they think are meant to pay for NHS care, and then to make them cough up.

The people who they think are meant to pay for NHS care are “overseas visitors”. The Windrush scandal has already demonstrated that, in practice, OVMs can come for any UK residents, including UK citizens. But even if the overseas visitors managers (OVMs) managed to do what they were theoretically meant to do, do you really think that the institutional mechanisms used to extract funds from “foreigners” will stop at charging them? Once this bureaucracy exists, a future portends in which we are all in its crosshairs. It’s only a matter of time before the bureaucracy widens its remit. You are next. That is why the only way to view the migrant cost recovery programme is through the frame of solidarity with our fellow workers, wherever they are from: “an injury to one is an injury to all”.

When Rishi Sunak comes for migrants, it’s not just migrants who lose out. It’s everyone. Let’s fight to keep the NHS universal, free and comprehensive. Let’s fight together for better pay and better healthcare for all of us.


[1] There are two main components to the programme. The first is the health surcharge added on to the cost of a UK visa. The second is the requirement for NHS trusts to identify people who are not eligible for free NHS care and to charge them.

[2] There is also a separate argument regarding whether increasing pay by increasing government funding would actually incur the kinds of costs Sunak implies. The government would recoup a significant amount of the pay in the form of tax anyway: not just income tax but all the other taxes that working people pay as well, such as VAT. Healthcare workers would also be able to use that money to buy things that they are currently unable to afford, thus stimulating a lagging economy. Would that be inflationary? Well, the NHS isn’t going to increase its customer costs to cover the pay increase, is it? It’s free at the point of use. Oh wait, that is exactly what Sunak is proposing, for the one group who does pay for NHS care. His hypocrisy is galling.

[3] To charge people for something, you have to create a system. Until the creation of the migrant cost recovery programme under New Labour (for a decent account, read this), and its advance under David Cameron’s Conservative governments, the NHS did not have a system for charging people. Why would it? The NHS is meant to be free at the point of use. A cost recovery mechanism takes time and money to devise. And then more time and more money to continue to administer. People have to be trained. Administrators have to be employed. They need offices and equipment. And then you realise it would have been cheaper never to have created the system in the first place.

Pay restoration in Scotland: A Munro to climb

Conferences, Opinion, Pay

At the BMA’s Junior Doctors Conference this month (7th May 2022) members from all 4 UK nations voted overwhelmingly to demand full real-terms pay restoration to 2008 levels by supporting the motion COMP 1 (pictured). In real terms junior doctors working in England are paid around 25% less than their equivalent colleagues were 14 years ago. In nations such as Scotland where devolved governments set public sector pay policy, despite pay awards often being higher percentages than those given in England, pay erosion is actually even worse.

The reasons for pay parity with 2008 have been laid out before but, put simply, we all know in our gut that we are not worth only three quarters of what our colleagues were during the financial crash of the 2000s. If anything the job has got more technical and responsibilities have increased, even if what we take home at the end of the month hasn’t.

Demands for full pay restoration have not materialised overnight and come off the back of work that the Broad Left- and more recently and visibly the Doctors Vote campaign- have been doing. In May 2021 we achieved BMA policy of demanding a 15% pay rise to take us halfway there. But, in Scotland, we never even made it this far.

As pay is set by the government in Edinburgh, so is BMA policy for pay and negotiations in Scotland. The Scottish Junior Doctors Committee of 2020/21 voted not to adopt the 15% goal and instead decided to stick to the status quo that has already led to more than a decade of stagnant or swindled income. 

Traditionally, BMA Scotland presents evidence to the Doctors’ and Dentists’ Remuneration Body (DDRB) in a united, pan-Scotland way with a single pay demand. For the 2022 pay round this was “inflation plus 2%”. There are some positives to this: linking pay to inflation was a significant policy position made at this conference for UKJDC and, if permanently linked to RPI, would stop our pay being eroded by political choices that lead to high rates of inflation. 

However a pay rise of 2% in real terms is shamefully inadequate given the years of erosion already imposed. Our pay has dropped around 30% in 14 years and, with BMA Scotland’s current goal, it would take us 14 years again before our pay approached the 2008 baseline. This is longer than an entire training pathway for many juniors!

So, what do we do about it? There is something we can all do immediately, but more of the work needs to be done over the medium to long-term so we can build a movement capable of winning an ambitious- but ultimately achievable- demand. 

Bluntly, we are at least a year behind our colleagues south of the border in terms of securing our worth.  We have not invested the time or resources into educating our members about pay erosion that both UKJDC and grassroots online groups have done. We need regular and useful comms output to help bring Scottish doctors with us; this includes social media, physical media in workplaces, a pay loss calculator hosted on BMA sites.

A first step towards this is an online pay Q&A on June 8th (sign up here Online Event Registration Form). A high turnout will be noticed by elected reps and will be further proof that we want more radical action on pay and are willing to turn out and spend our time to make our voices heard. The new Email your MSPs template has space to customise the message, which we can use to wake up our Holyrood representatives to the fact they have been degrading our pay- and the health service as a result- for years. The analysis lined up for these two tools looks thorough and useful so engagement with them, viewing them as a launchpad for more, is worthwhile.

But beyond this we need to keep telling SJDC that pay is our priority. Email your reps, find them in your workplace and make it clear that our members support the conference position of seeking full pay restoration; it will help current reps deflect criticism that a focus on pay is unhelpful and not representative of our members, some of the critiques levelled at pro-restoration reps in Scotland.

Over the next year, we must re-examine our relationship with the DDRB. English junior doctors have not engaged with it for years as it is broken and in desperate need of reform. This year English consultants took this position too, striking another blow to the DDRB’s legitimacy in its current form. Scottish doctors still present evidence to the DDRB and turn up to talks with them. This undermines our English colleagues and wins absolutely nothing for us; the Scottish government has ignored even the paltry increases they’ve recommended in the past and probably will again. By walking away and eventually negotiating directly with the Scottish government until it is reformed, we reclaim power from the bureaucrats and send a message that our union is alive and kicking.

We do not act in a vacuum and SJDC need to be taking note of the mandate given by conference for planning radical action in England. We need to immediately commence a campaign to prepare, educate and organise rank and file junior doctors in Scotland so that we are adequately prepared to support our colleagues in the event of English industrial action. Besides being the right thing to do, winning in England will pile the pressure on the Scottish government to keep up, else they face an exodus of junior doctors southwards. Solidarity with any ballot and subsequent industrial action will give us a blueprint and help to inform any action Scottish doctors may need to take in the future, when nothing should be off the table.

But finally and imminently, you have the power to change all this. Across Scotland, regional BMA committees for juniors- LNCJDSs- are chronically underfilled as engagement is rock bottom. But who’s really surprised given the stresses of the pandemic and the seeming inertia in some crucial areas?

Stand for these committees and then stand for a seat on SJDC, or stand for one of the two seats in the upcoming national SJDC elections. Information about election timetables should be made available soon- they will open at the end of July, so follow your Broad Left reps and BMA Scotland accounts on Twitter.

Now is the time to take an active role in our union, or even to re-join it. If you’re excited by the progress being made in England, help us harness that momentum north of the border and make meaningful steps towards proper pay restoration. We are not worth less than our peers in England, so make sure we are not complicit in demanding any less than them- any less than we deserve.

Slowly Winning the Arguments on Pay

Pay, Reports, reflections and accountability

It has been almost a year since we won the NHS Pay 15 demand at Junior Doctors Conference last year (watch from 1.54 here). This was in the context of repeated below-inflation pay awards, minimal pay requests from the BMA, a growing NHS Pay 15 campaign across multiple unions, and heavy opposition within the BMA.

This year, our arguments about Pay Restoration have become more widely accepted on the Junior Doctors Committee, and our efforts with Medics4PayRestoration and then Doctors Vote have borne some fruit in terms of doctor-created graphics. We will be proposing a motion for full pay restoration at this year’s conference.

So why has the BMA been so slow to put this demand out on social media? Why have they not written to the government with this demand? What has the Broad Left been doing since it passed?

The BMA centrally is now doing some campaigning work, with a webpage, some graphics, a letter-to-MPs tool. Whilst we remain critical of the inadequacy of this work, it is a significant change. It is worth examining what had to happen to get here.

Sorry – this is a long read!

March 2021 Council Meeting

BMA Council has not withdrawn from the DDRB as ARM demanded in 2020, due to concerns about the impact on Devolved Nations and smaller Branches of Practice. Other elements of that motion have not had action taken on them. 

The Broad Left and some allies on Council submitted a motion and paper to March 2021 Council

Only parts ii) and iii-i) pass.

Junior Doctors Conference May 2021

The North West motion from Emma Runswick is composited (merged/compromised into one motion) with a Yorkshire motion to produce this (31 in the agenda here):

You can watch the debate from 1.54 here. It was proposed by David Smith from Yorkshire. Multiple Broad Left members spoke in favour. Part vi) fell due to a requirement to have a two-thirds majority on issues of significant financial cost.

June 2021 JDC Meeting

Broad Left members of JDC gathered the assent of one-third of JDC members to request an additional meeting of JDC to discuss pay strategy, as required in the Standing Orders. Without evidence or warning, we were publicly accused of including members’ names without consent. and a “Lessons Learnt” review was conducted. Despite requests, no evidence and no report from the “Lessons Learnt” review has been offered to members of the Broad Left. Over half of JDC members subsequently voted to have an additional meeting to discuss pay strategy when offered by the Chair of JDC. Two JDC meetings occurred in June, one wholly devoted to pay strategy discussion.

Usually the first meeting of JDC after the Junior Doctors Conference adopts the policies passed at conference. At this meeting, a motion to reject the pay motion was heard. Devolved Nations representatives made clear they would not uphold the policy regardless of whether it was adopted or not. We won the argument and the policy was adopted.

We voted on a series of options and agreed to survey the membership on industrial action if the DDRB and government gave us nothing additional in the 2021 pay round. 

October 2021 JDC Meeting

In October, we received the results of that survey. Turnout was ~6,000, and while 96% said the pay offer was unacceptable, that turnout didn’t show that we were yet ready for industrial action of the scale needed to win a 15% pay uplift for doctors in England. JDC outlined a good plan of what was required to build a pay campaign and readiness amongst our members, including education on the key issues, and training for reps and activists. This would draw comparisons to costs of living e.g. fuel and food costs to demonstrate losses against inflation. We agreed to discuss balloting again before the end of the session. We also agreed to withdraw from the DDRB process in England. 

December 2021 JDC Meeting

In December, despite the good work JDC and JDC executive had done in outlining what we wanted, the work completed was minimal. We received a short document from the communications team, an outline of a communication and industrial strategy. Key messages included the effect of the pandemic, the lack of award in 2021, and then the pay depreciation we have seen. It planned an activist training session in January, with heavy emphasis on lobbying; member webinars in late Feb/early March, including wider content on financial issues such as coping with higher cost of living and creation of a “strong visual look”; then a campaign for a specific pay ask to the DDRB, which we have withdrawn from.

We were asked whether we should ask the Government not to seek “comments and observations” from the DDRB, and what JDC’s £% ask was for 2022-2023.

We believe the questions were unnecessary and the outline plan misguided: we have withdrawn from DDRB and we knew our ask was 15%. We deserve pay restoration regardless of the pandemic, and many find this focus inappropriate given the widespread trauma. We want to win pay restoration, not just cope with a depreciated income. We know the DDRB will follow the government remit, which is why we have withdrawn from it and are choosing to focus campaigning on the government. Constantly having the same discussions is exhausting.

There were no materials drafted, no KPIs for comms, and no industrial strategy. The discussions at JDC and exec might as well not have occurred for how little there was of them. We did not want a public facing campaign, but assistance to engage our colleagues with a campaign for partial pay restoration. Members of the Broad Left criticised the ongoing “frontline” branding, the lack of materials and the plan for corporate branding. We requested that member-made materials could be checked and circulated by BMA, including infographics and memes which addressed our issues. We wanted shareable versions of our briefing papers which outline the numbers so members could read and make their own contributions on new/social media. We wanted an FAQ which could develop iteratively with activist feedback.

We needed to talk about the plan to win – the industrial action plan: what we are asking for; what the risks are and how we will mitigate them as a union; what taking action could deliver. We highlighted the complete lack of structure testing – i.e. there was no plan to check how ready we were before deciding whether or not to ballot.

We were told this was taken on board and that we would be closely involved with further development. JDC has seen nothing further.

In late January, Emma Runswick was asked if she was free on 15/2/22 for a planned pay activism webinar. She got more information about this the week prior, with suggestions that we discuss successful local organising in the round. 

The Webinar: mid-February

We promoted the webinar best we could – including on twitter, facebook, reddit, discord, whatsapp cohort groups. We believe the promotion was insufficient. Approximately 80 attended. Questions were understandably hostile given the lack of progress in the campaign, rising inflation and pay depreciation over the last 15 years. Staff worked to pass questions through that were upvoted, regardless of the hostility, which we believe was correct. We have not seen all the questions or comments, but JDC have since been informed that some were abusive. We have asked to see these.

Emma presented a brief upskilling session on Structured Organising Conversations, but the webinar was one-way in the context of mostly information giving. The website landing page has been created and an activism network set up, with materials for sharing with colleagues and educating promised soon. 

The website links to a good briefing and has clear infographics. Do have a look:

Fair pay for junior doctors in England

March 2022 JDC Meeting

In March, JDC was due to have an update on pay campaign activity, see feedback from the webinar event, and discuss what resources were needed. Survey data, requested by other branches of practice, was presented about the public’s view of doctors’ pay campaigning. Communications teams asked JDC some strategy questions about timing, separation from the broader BMA campaigning, straplines and similar.

There were still no materials, no KPIs, no plan for member-led resources, and so on. Industrial strategy is mostly absent from discussion, except to say that industrial action is a tool to get to negotiation. Criticism was heavy.

Now

We are getting progress – graphics with the graph have been released, posters, the webpage and the write-to-MPs tool. Broad Left members of JDC are happy that we are making slow progress and critical of shortcomings of the BMA output. This is now being received well. 

However, we continue to do our own work, which does not rely on the slow internal mechanics of the BMA. That work is primarily in our workplaces. We also continue work with Medics4PayRestoration and Doctors Vote, who have wonderful volunteer graphics-creators.

What Now?

Educating Colleagues Ourselves

  • Medics4PayRestoration has set up some social media and created infographics for sharing, discussing and building on. @Medics4PayRestoration | Linktree
  • Follow Doctors Vote on social media for good graphics to share

Changing policy

  • Junior Doctors Conference is coming up this Saturday! 
  • Please consider lobbying your JDC representatives to vote in favour of “Comp 1” and tell your colleagues about it in work. Having discussions and arguments about this, and convincing colleagues of the need for action on pay is crucial

Elections

  • JDC elections will happen at ARM in June and in regions and devolved nations in the summer

Completing our own Structure Test

Pay When Rotation Has Been Cancelled

News, Organising, Pay

Author: Emma Runswick

For many doctors, the cancellation of April rotations did not just mean loss of training, it also represented significant loss of expected pay. Those doing jobs without out-of-hours work in March would lose thousands by not moving into high-intensity jobs, through no fault of their own.

Colleagues who made financial decisions on the basis of expected pay, or reliant on this for childcare, stood to be particularly badly affected.

Several Broad Left supporters who are Local Negotiating Committee representatives* have won pay increases for trainees at multiple hospitals and we are involved in helping other reps secure this.

In these trusts, doctors are being paid the highest salary from:

  • The rota they are working
  • The rota they were expected to be working from April and had a work schedule for
  • The emergency Covid rota

For some trainees, this is worth £3700. Many more have gained over £2000.

We have argued for this on the basis of Schedule 2 of our contract.

71. Where changes to the work schedule are required by the employer and total pay would be decreased as a result, the doctor’s total pay will be protected and so remain unchanged until the end of the particular placement covered by that work schedule. This protection will not extend to any subsequent placement, including a placement where the doctor returns at a later date to the same post.

2016 Junior Doctor Contact in England, Version 8

Or 21h in the 2002 Contract, which says similar.

If you had a work schedule for April-August rotation before they announced rotation was cancelled, then you have experienced “changes to the work schedule” “required by the employer” “and total pay would be decreased as a result”. As such, you are entitled to the pay “until the end of the particular placement covered by that work schedule” (April-August).

If some trainees in your trust had a work schedule and some did not – i.e. a department didn’t get their work schedule out in line with the guidelines – then you have an argument that the department’s failure to send out work schedules should not disadvantage those trainees.

We gained support by emphasising our contractual rights, sharing the stories of doctors who were badly affected, building alliances with supportive members of management, and later by using examples of other trusts who had agreed this.

If you would like support to negotiate with your workplace or want to know more about becoming an effective BMA representative, contact us!

*Local Negotiating Committees (LNCs) are your local BMA representation. We encourage all Broad Left supporters who are hospital doctors to become LNC reps.

Pay and BMA Surveys

News, Pay, Terms and Conditions
The BMA does not have the best track record with surveys, or their response to them. We have been accused in the past of subjecting our members to death-by-survey, and of hiding results, or ignoring them where they are not convenient. It is difficult to know what is true without being on the inside.

Now, however, we have great need for a survey. At the Annual Representative Meeting, the BMA was instructed to ‘identify actions to reflect the feeling of the profession’ on pay.

When the government made the pay ‘award’ last week, the need to survey our members and their willingness to take action became even more apparent.

In order to do this well, we need to explain the effects of prolonged pay restraint and the current offer, then suggest actions and ask if members would be willing to take that action.

We also need to show some leadership – by educating our members, who have had a slow-acting pay cut of around 20% over recent years. To add insult to injury, the latest pay cut offer is less than half of its apparent value. All doctors will lose out due to inflation, and the lack of backdating makes us suffer more. This year’s NHS staff survey has laid bare the realities of working life for doctors in the NHS, as detailed in the latest report of the Review Body of Doctors and Dentists Remuneration (DDRB):
• 80% of medical staff report regularly working unpaid extra hours
• 60% of doctors don’t feel they have enough time to do their job properly
• 30% of medics report their work is making them sick

We should say that we were disappointed by the DDRB recommended rises of 2% to doctors’ pay, which was wholly insufficient to address pay erosion across all doctor groups. Our confidence in the DDRB’s continued independence and utility has been shattered. We are further dismayed that the government has – in bad faith – gone further and halved the DDRBs miserable recommendation. The situation is untenable. We need to officially assess what our members are willing to do about it.

The survey sent via email to members this evening to has failed to do that. Only asking questions that are already asked via the NHS Staff Survey and we already know the answers to. It is embarrassing that the BMA feels the need to ask members if they are angry. As this survey was not run past elected Council representatives before it was sent, we have been left out of the strategic planning of the BMA’s response to another real terms pay cut.

 

We are demanding better, perhaps with a further survey, but definitely with a clear call for genuine action in response to the DDRB and Government failings.

Here are the kind of questions we would like to be asking you now:

 Would you:
  • write to your MP asking them to support the DDRB recommendation?

  • want the BMA to disengage from the DDRB and negotiate directly with government?

  • take action short of a strike – working to contract, refusing overtime and refusing to fill rota gaps? For how long?

  • take action short of a strike – refusing to collaborate with coding practices to damage the financial flow of the hospital without affecting patient care? For how long?

  • take half-day or late-start strike action? For how long?

  • take strike action to end elective treatment? For how long?

  • take strike action to bank holiday cover? For how long?

  • take all-out strike action for just your Branch of Practice (allowing other BoPs to cover)? For how long?

  • take ‘rolling’ strike action where your branch of practice takes strike action one day, and another branch of practice does the next day, and another the next day and so on? For how long?

  • take all-out strike action alongside other branches of practice? For how long?

We recommend members fill out the survey and use the free text comment box to tell the BMA what action you would be willing to take. Lobby Council members and branch of practice reps for a determined response to the pay offer.

Email us at broadleft[at]doctorsbroadsheet.org  if you’d like to get more involved in our campaign.