This dispute is about patient safety, not just pay, argues Dr Rathi Guhadasan, writing on behalf of the Socialist Health Association.
The headlines tell one version of this
story: disruption, cancelled appointments, patients stuck in the middle.
It’s understandable that the government’s position resonates with many
people. But headlines don’t tell the whole story.
If we’re serious about what’s good for
patients in the long run, we can’t stay silent. We support the BMA’s
resident doctors in their dispute with the government — and here’s why.
Fifteen Years of a Shrinking Pay Packet
This dispute didn’t start in 2025. The
roots go back to 2008, when pay policy began quietly — but steadily —
chipping away at what resident doctors actually earn in real terms.
Measured against the Retail Price Index —
which includes housing costs and student loan interest, two of the
biggest financial pressures on junior doctors — pay has fallen by roughly 22% in real value since 2008/09. Even Full Fact,
the independent fact-checking organisation that questioned the BMA’s
preferred measure, still agrees that pay has fallen in real terms.
Whichever way you count it, doctors’ spending power has been steadily
eroded over more than a decade.
The low point came in 2022/23, when the
BMA estimated the real-terms loss had reached around 29%. Strike action
in 2023 forced movement. The deal struck with the newly elected Labour
government in September 2024 included a combined pay uplift of 22.3% across 2023/24 and 2024/25 — though it’s worth noting that part of this had already been awarded under the previous Conservative government.
Despite those rises, resident doctors’ pay in England remained around 20.8% below where it was in 2008. The 2024 deal was progress — but it wasn’t the finish line.
Then came Labour’s offer for 2025/26: a
5.4% rise recommended by the independent pay review body. The BMA argues
this still represents a real-terms pay cut when set against actual
inflation. Their position is that a 26% uplift on 2024/25 basic rates is needed to fully restore pay.
This pay gap wasn’t created by doctors. It
was created by successive governments — Conservative and Labour —
repeatedly choosing to let doctors’ pay fall behind the cost of living.
Asking doctors to simply accept that as permanent isn’t fairness. It’s
making them foot the bill for political decisions they had no part in.
The Career Bottleneck: Too Many Doctors, Too Few Opportunities
Pay is only part of what’s at stake here.
There’s a second issue — one with even deeper implications for the care
patients receive.
After their initial training, junior
doctors must compete for specialty training posts — the pathway to
becoming a consultant, a GP, or a surgeon. In 2019, there were roughly
1.4 applicants for every available training post. By 2025, that ratio
had surged to more than 5 to 1. In some specialties, the figures are
startling. Over 10,000 doctors applied for psychiatry training posts in
2025 — fewer than 500 places were available, amidst a national crisis in mental health care.
Five doctors applied for every GP training post, at a time when
millions of patients across England are struggling to get a GP
appointment at all.
How did this happen? The
previous Conservative government expanded medical school places without
creating a matching expansion in specialty training posts. At the
same time, overseas recruitment was increased — without addressing the
underlying shortage of training posts. The predictable result: thousands
of doctors unable to move forward in their careers, or unable to find
posts at all.
This isn’t just a career problem for individual doctors. It has direct consequences for patients. The Lancet has warned that the consultant bottleneck alone could leave up to 11,000 posts unfilled by 2048.
The NHS is training doctors it cannot then absorb into the senior roles
they were trained for — while using less-qualified staff to plug the
gaps those doctors could fill, if only the training posts existed.
The government’s response was to pass the
Medical Training (Prioritisation) Act in early 2026, giving UK medics
priority in competing for these posts. But overseas-trained doctors have
been a vital lifeline for the NHS, filling critical gaps that the
domestic system failed to plug. The answer is not fewer doctors but a
dramatic expansion of the training posts needed to develop the service
we need, one that is fully resourced and fit for the 21st century.
And legislation about who gets to compete for too few positions doesn’t solve the problem – for doctors or patients. As one surgeon put it in parliamentary debate:
“If we increase the number of trainees, we will also need to increase
the number of consultants and GPs. If we do not do that, we will simply
push the bottleneck down the road.”
The Substitution Problem: Who Is Actually Treating You?
Here’s the part of this crisis that gets the least attention — but as patients, should scare us most of all.
Across the NHS, physician associates (PAs)
and anaesthesia associates (AAs) are increasingly being used to fill
roles that have traditionally been carried out by doctors.
PAs typically hold a two-year postgraduate
qualification. They cannot prescribe medication independently and they
cannot make admission or discharge decisions on their own. They are not
doctors. Yet in too many NHS trusts, they have been placed in clinical
roles that require a doctor’s training, a doctor’s legal accountability,
and a doctor’s level of skill — at a lower cost to the employer. The previous government planned for 10,000 PAs in the NHS by 2036/37 and Labour so far has stuck to this plan.
This isn’t a fringe concern. A BMA survey of more than 18,000 doctors found that 87% believed the way PAs currently work poses a risk to patient safety.
The case of Emily Chesterton — a 30-year-old woman who died after being
misdiagnosed by a PA she believed to be her GP — brought these concerns
into sharp public focus.
In response, the Royal College of General
Practitioners withdrew its support for PAs in primary care in September
2024. The government commissioned an independent review (the Leng
Review), which reported in July 2025, and the GMC began formally
regulating PAs and AAs from December 2024. The Socialist Health Association argued two years ago for an immediate recruitment freeze and eventual phase-out of existing roles.
But none of that changes the basic
financial logic driving the problem: PAs cost less. In an NHS under
constant financial pressure, the incentive to fill a rota gap with a PA
rather than a fully trained doctor doesn’t go away just because a policy
document says it should. It won’t change until the underlying
structural conditions change.
This Is a Patient Safety Issue, Not Just a Pay Row
All of this connects. A doctor who is
financially worse off year on year, who can’t see a clear path to the
specialty they trained for, who watches less-qualified staff fill roles
that should support their own development, and who routinely works hours
that exceed safe limits — that doctor is not at their best. And that
matters for the patients they treat.
Burnout, moral injury and emigration are
not abstract risks. The NHS is already losing trained doctors to
Australia, Canada and New Zealand in significant numbers — partly
because those systems offer better pay, clearer career prospects, and a
greater sense of professional respect.
When we allow the conditions driving that
exodus to persist — when we systematically underpay, under-employ, and
structurally sideline the doctors we’ve spent public money training —
we’re not saving money. We’re deferring the cost onto future patients,
future NHS budgets, and future governments left with a consultant
workforce too small to meet the needs of an ageing population.
Where Things Stand
The BMA’s resident doctors committee
rejected the government’s most recent offer at the end of March 2026.
The government says it was a generous deal — pay rises over three years,
up to 4,500 additional specialty training posts, and reimbursement of
Royal College exam fees. The BMA says the pay trajectory still embeds a
real-terms cut, and that 4,500 posts over three years falls far short of
addressing a deficit measured in tens of thousands.
A settlement that doesn’t genuinely
reverse fifteen years of real-terms pay erosion — and that doesn’t
commit meaningfully to expanding specialty training at a scale that
matches the problem — isn’t a solution. It’s another chapter in managed
decline, dressed up as responsible government.
An Honest Reckoning
Strike action causes real disruption.
Patients have appointments cancelled. Procedures are delayed. Those are
genuine harms, and they fall on people who are already unwell.
But let’s apply the same honesty to what
happens if this dispute isn’t resolved. What is the cost of letting a
generation of medical graduates be lost to other countries or to career
stagnation? What is the cost of systematically replacing clinical
expertise with associate roles that don’t carry equivalent training or
legal responsibility? What is the cost of a consultant workforce that,
by the 2040s, is too thin to serve an ageing population?
The disruption of a strike is visible and
immediate. The harm of getting this wrong is invisible and slow — until
it isn’t. When the Prime Minister and the Health Secretary threaten to
withdraw training places, it is the patients of the future who are most
at risk.
Our Position
We want this dispute resolved — with an
agreement that honestly reflects what has happened to medical pay and
medical careers over the past fifteen years. That agreement must include
a credible commitment to expanding specialty training at a scale that
actually matches the pipeline of doctors the NHS has already trained.
Until that agreement exists, we stand with the doctors who are asking for it.
Dr Rathi Guhadasan is Chair of the Socialist Health Association.
