What should a GP's income be? It's a question that's been bothering me recently for three reasons. First, by reading Polly Toynbee's excellent book, Hard Work, which explores the lives of those on the minimum wage, I have been forced to confront and question my own income and lifestyle. Second, post new contract, our practice is negotiating with the PCT over out-of-hours cover, from which, being an island practice, there is no escape. The local LMC has suggested that we should cost our time at some more or less arbitrary figure — let's say £50/hour — and multiply this by the number of hours to be covered, charging extra for bank holidays. The sum arrived at is in the region of £230 000 — to be shared between two doctors in the four winter months and three for the rest of the year. Not bad as a bonus to the day job. Finally, I have just received an email from an ex-trainee of mine who has taken up a post in New Zealand. He works a 12-hour day, earns about £40 000 gross and pays tax at 40%, and believes that the cost of living is only slightly lower than in the UK.
It is part of the contemporary zeitgeist to celebrate one's ‘worth’, whatever that may be. There are those TV cosmetic ads that flatter their viewers with the claim, ‘because you're worth it’. I am reminded of this when I discuss the issue of my out-of-hours commitment with colleagues: ‘Don't undervalue yourself,’ they say, with an earnestness that seems to defy contradiction.
Should it matter that I do a job that I enjoy? That I have security, a generous and guaranteed pension, a degree of autonomy, a comfortable and safe working environment, social status, lengthy holidays and protected study leave? That these are all things that every employee would love to have, but is less likely to have the lower their income?
I am no economist, but I would say that there are three things that, by and large, determine the going rate for a job. One is an evaluation of the intrinsic features of the work involved: certain dangerous jobs, or those that demand exceptional levels of training, commitment and responsibility are generally recognised as being worth more than safer or less demanding jobs. Second, is the play of market forces: competent plumbers are rare, so they can demand high rates; competent actors are common, so they can't. And third, there are the more nebulous accidents of history and politics: doctors and lawyers have long been members of the ruling elite in this country; social workers and teachers have not.
Of course, these factors are inter-related in all sorts of ways and have different weightings in each case. But can I justify my income by the first two alone? Yes, the job is intrinsically challenging and demanding. But to the extent that it is worth more than twice that of a head teacher or a university professor; three times that of a senior social worker or paramedic; eight times that of a care worker? (These figures are hard to come by: I am approximating from a table in Polly Toynbee's book). I don't think so.
What about market forces then? True, there are few GP registrars out there who would want to work a 1 in 2 or 1 in 3, whatever the pay, and there are other disadvantages to living on a rather small and remote island. In the current climate it might well be difficult to replace one of the doctors over here without a hefty pay rise. Similarly, it still seems to be a sellers' market over there on the mainland, with practices crying out for new recruits, and the government prepared to offer all sorts of incentives to sugar the pill. But will this situation last, or will managers look towards cutting costs through skill-mix and other innovative approaches to providing health care? The truth is that the labour market in medicine is not a true market at all — although in a private health system it might be — but is heavily influenced by politics and social consensus.
I wonder if we are pushing our luck. The new contract offers a substantial increase in our pay, in return for a centralised stranglehold on our clinical practice and ways of working. It also prepares the way for a possible weakening of our bargaining position if we fail to satisfy the expectations of a public who know that the government has invested huge extra sums in the NHS. Are we really worth it?
- © British Journal of General Practice, 2004.