The bleep woke me from deep sleep. I struggled to focus on the red LED as it flashed up each digit in turn. By that stage of my career, the number was ingrained: casualty. I dialled it on my bedside phone, then sank back on the pillows and closed my eyes, listening to it ringing.
It was answered eventually by Moira, one of the sisters in A&E. “You’ve got a patient, 14-year-old boy, query appendicitis.”
“OK, I’ll be down in a few minutes.” I let out a despairing sigh.
“No, don’t worry,” she told me. “Mr Kipping said you’ve been working so hard. He’s coming in from home to clerk him for you.”
This was unheard of. An often-irascible surgeon, Mr Kipping hadn’t been the easiest consultant to work for and we’d had more than one run-in during my time as his house officer. Yet here he was, doing something utterly benevolent, turning out of his own bed at 3am so that I could remain in mine. I had a few seconds of stupefied amazement at the kindness this implied, and how I could have been so wrong about the man, before slipping gratefully back to oblivion.
The bleep, casualty again. I woke to find the telephone receiver still in my hand, laid on my chest. Forty minutes had elapsed in what felt like a second. Moira answered: “Are you coming to see this lad or what?” My horrified brain abruptly shrugged off the muffled cloak of make-believe. “Sorry, yes! I’ll be right down.”
This was summer 1991, towards the end of my first year as a junior doctor. I had been averaging 80-hour weeks for months on end. The weekends were the worst, continuous duty periods from Friday morning to Monday evening. A few broken hours’ kip here and there if I was lucky, with a full working week to follow and at least one more night on call before I would finally get to rest. I had lost weight and had a cough I’d been unable to shake. The hallucination amazed me; Moira’s voice had sounded so convincing. I trudged down to casualty, marvelling at the artifice of my exhausted brain, able to dupe itself completely if fantastically in the vain hope of respite.
Today, junior doctors are known as resident doctors, and while they work extremely hard, none experience the kind of conditions former generations endured. Hours are capped at sustainable levels, shifts can’t last longer than 24 hours, and minimum rest periods are mandated contractually. Through a protracted series of strikes under the last government, junior doctors persuaded the incoming Health Secretary, Wes Streeting, to award a 22.3 per cent two-year pay deal for 2022-24, with a further 5.4 per cent this year. The news, then, that they have voted to embark on a renewed campaign of strikes commencing on 25 July in pursuit of a further staged 29 per cent award will leave many onlookers puzzled and dismayed. Yet were I to be given the choice between undertaking my resident years now rather than in the early 1990s, I would stick with what I had, unquestionably.
Adjusted for inflation, my starting salary of £12,000 was less than the £36,000 a first-year resident doctor now earns, but that conceals important differences. The hospitals where I did my early placements were obliged to provide me with free accommodation on site. These days resident doctors must rent privately, and with even rooms in shared houses costing £600-£1,000 depending on location, this represents a significant pull on income.
I was able to get a mortgage on a two-bed Victorian terrace in Oxford during my second year as a resident. With house-price growth far outstripping general inflation over the past three decades, home ownership is unattainable for many young doctors today. Then there are professional expenses. Doctors will be barely a year out of medical school before they must sit the first in a succession of postgraduate exams to progress their careers. These have multiplied in number and cost since I began in practice. Many are self-funded and charges are typically well in excess of £1,000, to say nothing of the purchase of preparatory materials such as question banks. Additionally, I finished my five years at university with nothing more than the modest overdraft my friendly NatWest bank manager had granted me. A medical graduate today begins their career around £100,000 in student debt, a figure that will rise even as they begin paying it off out of their salary, thanks to exorbitant interest rates.
Although this fresh industrial action by resident doctors is ostensibly about achieving a standard of living comparable to previous generations, pay has become a lightning rod for the shambles that has been made of their careers. When I qualified, jobs were well matched to the numbers of new graduates, and one rarely had to move to a different part of the country unless by choice. Residents today enter a lottery system in which they can be randomly posted hundreds of miles away from friends and family. There are often too few jobs available, so an unlucky minority are held in suspended animation, often waiting till just a fortnight before their start date to learn if something has been cobbled together somewhere in the country to enable them to commence their career.
Once past the two-year foundation programme, further jeopardy awaits. Numbers of specialty training programmes have failed to keep pace, so competition has become intense. For some branches of practice, fewer than one in six applicants will secure a training place. The rest are left languishing in “holding” jobs, if they are lucky enough to find them, or obliged to tread water undertaking insecure locum work until the next batch of training programmes is released and they can try again. In specialties like anaesthetics, a further bottleneck awaits those completing the first phase, when they must reapply against stiff competition to continue to progress. Medical unemployment simply didn’t exist during most of my career, but over the past few years it has become a grim reality. In general practice it is now endemic, the funding squeeze of the past 15 years leaving many surgeries unable to afford to recruit new doctors, even as patients’ top priority for the NHS has become the ability to access care from a GP.
The previous Tory government injected toxicity into this already demoralising environment through its promulgation of a new type of practitioner in the NHS: medical associate professionals, or Maps (sometimes referred to as physician associates and anaesthesia associates). Maps have a fraction of the training and experience of resident doctors, yet start on salaries substantially higher and without the same debt burden. They have rapidly displaced doctors from medical jobs and rotas over the past few years.
A series of patient deaths highlighted the scandal of scantly trained practitioners being substituted for medically qualified personnel. Streeting has commissioned Gillian Leng to lead a review into the way Maps have been deployed in the NHS, which is due to report this month. The impact that their mishandled introduction has had on the current generation of resident doctors must be among the issues it examines. It is hard to imagine a more brutal way for a government to have communicated its indifference to the skills and dedication of those undertaking medical training.
The Map debacle is but one symptom of a long-standing trend among politicians and NHS leaders to devalue doctors. A large part of the NHS budget goes on salaries, and behind senior managers, doctors are the highest-paid personnel. A seductive line of reasoning holds that one way to control the ever-escalating healthcare budget would be to restrain the medical wage bill, both in terms of absolute staff numbers and pay levels. This economic argument has been fuelled by the rise over the past 20 years of protocolised care. To a politician or leader with no clinical background, it must seem that much of medicine can now be conducted simply by following a flowchart. What is the point of doctors when so much “healthcare” can be dished out by lesser qualified and cheaper personnel?
The problem with this approach is that it is based on a false prospectus. Far from being reducible to protocols, medicine is inherently uncertain and complex – and individual patients even more so. Judgement and flexibility, and the ability to cope with risk and uncertainty, are prerequisites for cost-effective and holistic care. Replacing highly skilled automatous decision-makers with lower-grade staff degrades quality of care for patients and hugely amplifies system costs. One example: 20 years ago, out-of-hours cover in the community was almost exclusively delivered by local GPs. Today, doctors are increasingly rare participants in the sprawling and disjointed services that have replaced that model, yet costs have spiralled unmanageably along with the volume of work referred unnecessarily into the expensive hospital sector.
GPs in particular have borne the brunt of ministerial ground-softening as governments sought to create the conditions for this doctor-lite NHS. The right-wing press conducted an unrelenting campaign of denigration against GPs that can only have been with the tacit approval or encouragement of successive Conservative health secretaries. Streeting is attempting to repair the damage with rhetoric about “bringing back the family doctor” and his insistence that the recently published NHS ten-year plan is “GP-centric”, but the respected branch of the profession I joined 30 years ago is brow-beaten and demoralised by the sustained battering it has been subject to. The latest resident doctors’ vote for industrial action indicates to me they are feeling the same.
After more than three decades of service in the NHS, I moved to Canada earlier this year, to practise as a family physician in British Columbia. The change has been every bit as refreshing as hoped, and instructive, too. The self-respect among the profession here is palpably strong; doctors know their worth and are confident in making the case for commensurate compensation. Government collaborates constructively and respectfully with doctors’ representatives, and the conflict and contract impositions that have become standard in the NHS would be anathema here. Public appreciation for the profession is every bit as high as it was in the UK 30 years ago.
I am once more practising proper medicine. I have adequate time to discuss with my patients and arrive at shared decisions suited to them as unique individuals. There is room to think through complexity, and to research unusual or puzzling presentations. And that magic ingredient, continuity of care, is inbuilt: I once more have a list of patients for whom I am “their doctor”, who return to me to follow up and develop our understanding of their situation. Where I need to involve specialists, I coordinate their care and guide them through events as they unfold.
I am far from the only British doctor to seek new pastures. Last year, the General Medical Council issued more than 10,000 certificates of good standing – which medics interested in emigrating must supply to regulators in their prospective new country – more than double the number in 2020. Meanwhile, the UK continues to take in far more doctors from developing countries than it trains, to plug the shortfalls. There is no hard data on how many incomers move abroad again, but anecdotally the churn is high.
I don’t envy Streeting. He has somehow to reverse 15 years of calamitous NHS mismanagement against a backdrop of fiscal constraint and with a British Medical Association (BMA) determined to counter the degradation of the medical profession – for its members’ sake, for the continued viability of the NHS, and for the good of the patients they serve. In opposition, Streeting was stridently critical of the Conservatives’ refusal to sit down with doctors’ leaders and thrash out solutions during the last series of strikes. While he is an extremely intelligent and able politician, he has a hot-headed side that at times leads him to react to the BMA purely as a union to be opposed, rather than as a professional association concerned with ensuring an excellent and sustainable NHS. The notable failure to involve the BMA in the development of the NHS ten-year plan is another facet of the same problem. Sooner or later, someone in government is going to have to listen to what the medical profession has to say about how the health service should be staffed and run. I hope it will prove to be Streeting, and I hope it will happen before the damage inflicted by the Tories can no longer be undone.
“What Is a Doctor?” by Phil Whitaker is published by Canongate
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This article appears in the 16 Jul 2025 issue of the New Statesman, A Question of Intent