What if the doctors never come back?

As a description of the effect of the 2016 pension tax changes on the NHS it fits well. 

The issue blipped onto the NHS’s radar about a year ago, though many individuals had been aware of it for much longer. 

What few predicted was quite how serious the situation would become when combined with the other pressures on the service. The withdrawal of discretionary medical labour has led to cancelled operations and delayed diagnostics, thrown winter planning into disarray and heaped more work and worry onto tens of thousands of NHS staff. It will take a few years to determine the impact on outcomes, but patient anxiety is – no doubt – already on the way up. 

This entirely avoidable catastrophe is the NHS’ most pressing and immediate problem – bar none. It also appears to have no simple or quick solution.

Various schemes ranging from the innovative to the desperate have been developed to try and entice doctors to return to do the extra work on which the NHS has relied for years. 

There is no evidence that any of the schemes are working in a way which makes a significant difference. 

That is unsurprising. Once you have had an unexpected £100,000 tax bill drop through your letterbox – or have heard about somebody in a very similar situation to you who has – you are going to be very wary of any proposed solution. 

So, why not as many affected argue, simply not just scrap the taper?

“Ay, there’s the rub”, or to misquote another poet, “let us count the ways” in which such a move would be far from simple. 

The most obvious one is that of logistics. A government needs a “fiscal event” such as a budget to make any change. The chance of it happening during a general election campaign is vanishingly small – and may be just as problematic should we get another hung parliament. 

Even if such an “event” did happen, the parliamentary arithmetic might not support it.

Labour has pledged to “urgently” review NHS pensions, but non-medical unions have made it clear they are not prepared to accept doctors getting special treatment.

It is also the case that many of the doctors affected belong to the top 5 per cent of earners who Labour wants to tax more heavily to support its public spending plans.

Matt Hancock has said he is discussing ending the taper for NHS staff with the chancellor. However, that means little while an election campaign is going on and discounts the alternative advice Sajid Javid is getting from other interested parties – not least the senior Treasury civil servants who oversaw the creation of the taper in the first place. 

But as this crisis has deepened, a profound and worrying truth has begun to emerge. Many doctors are concluding that – whatever the offer – they are not prepared to return to old ways of working. 

There are myriad of reasons for that. Many doctors have found climbing out of the hamster wheel a refreshing experience. They conclude something along the lines of: “Yes the extra money was nice, but I didn’t really need it and spending time with the kids is better for them and me.”

The pensions snafu has effectively introduced them to the wonders of work/life balance and, since most of their colleagues are in the same boat, the idea that professional respect is earned through working all hours is rapidly diminishing.

This is, perhaps, no bad thing. But the NHS was not prepared for this switch in mind-set from so many medics and has been caught off guard. 

That doctors no longer feel so beholden to the NHS as a source of personal fulfilment has a dark side too. 

The changing attitudes towards the medical profession, the inevitable reduction in medical autonomy brought about by technology, and the impact of years of austerity are among the long and short term trends that have all led to what one trust chief executive described to HSJ as a breaking of “the psychological contract” with the NHS. 

Now while HSJ does blame the government for much of this, we would also note that the medical establishment is also far from innocent, particularly in its failure to prepare younger medics for the realities of serving in the modern NHS.

The pensions crisis is not just a technical screw up with some unfortunate results, it has also turned out to be the spark which has lit the blue touch paper for the destruction of many of the certainties which have governed the NHS’ relationship with and reliance on the medical profession.

There is very little that is meaningful the NHS can do about the situation it finds itself in this winter. Patients will be harmed – and some will die. 

How can the NHS, government and the medical profession make amends?

Answers on a postcard please – but at the very least it would be good to see the forthcoming “NHS people plan” address this issue head on.

This would mean acknowledging that the withdrawal of much discretionary labour provided by doctors is a permanent change. And that, therefore, in the short term it will mean a very significant increase in the number of overseas medics trained working in the NHS; and in the more distant future – as well as training more doctors – services must be re-engineered in a way which makes them and those they care for less vulnerable to changes in one profession.

It is hard to see a “black swan” coming, it is unforgivable not to try and learn the lessons it brings.