Junior doctors’ accommodation—more than just the money
BMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b3570 (Published 16 September 2009) Cite this as: BMJ 2009;339:b3570
- gajendragadkar{at}gmail.com
Abstract
One year on from the withdrawal of free accommodation for junior doctors, Parag Gajendragadkar and Saleem Khoyratty assess the impact of this measure
The removal of free accommodation for foundation year 1 (FY1) doctors has been covered extensively in the medical media. Aside from the obvious financial implications for new doctors, little is known about how new junior doctors themselves feel about this measure and whether there are other issues surrounding loss of free accommodation that were not directly apparent.
Background
In July 2007 the requirement for preregistration FY1 doctors to be resident in the hospital was removed from the Medical Act 1983. This meant that employers were no longer required to provide free hospital accommodation to FY1 doctors.
Various arguments were advanced for this change. The Department of Health took the view that because of the European Working Time Directive, FY1s did not work resident on-call rotas and so did not need on-site accommodation. The department argued that the decision not to compensate doctors for this was entirely the responsibility of the Doctors and Dentists Review Body (DDRB). However, the DDRB relies heavily on evidence from the Department of Health and NHS Employers in making their pay recommendations.
Indeed, the Department of Health in their evidence in 2007 to the DDRB stated, “We believe that the removal of the residency requirement for FY1 trainees is an improvement in their conditions of service and reflects the improvements in their working hours. As salaries are already competitive even without free accommodation and taking into account the virtual guarantee of a post on graduation, there is no case for increasing salaries to reflect this change.”
This is a marked change in policy, as in 2005 the government in their evidence to the DDRB said, “When the value of the free accommodation provided in the first year of training is taken into consideration, the position of medical graduates is rather better than graduates in other professions. Even after taking into account the longer university course and the consequent potential for higher levels of student debt, the savings on accommodation and travel to work (because most pre-registration house officers are housed in or close to their base hospital) . . . still leaves medicine as a most attractive career choice.”
The BMA issued a rebuttal to many of these claims and wrote directly to the health minister, but further meetings to discuss the issues were declined. A strong grassroots movement and a petition gathered 7730 signatures, but despite protests outside the Houses of Parliament and questions raised by opposition MPs within the House of Commons, the government does not intend to revisit the loss of accommodation issue. However, it held out the possibility of some review of junior doctors’ pay by saying, “We will be reviewing the future structure of junior doctors’ pay as the achievement of the European Working Time Directive becomes reality . . . It is too early to say what outcome will result from these considerations, but we note [the] DDRB’s suggestion that it would be reasonable to expect discussions to begin by August 2009.”
Current views of junior doctors
At the time, the BMA as well as many doctors and medical students felt that these changes had been introduced unilaterally by the government without due consultation. We therefore designed an online questionnaire and asked all deaneries in Scotland, England, Wales, and Northern Ireland to distribute it to FY1s and FY2s. We wanted to compare attitudes to the loss of free accommodation between current FY1s, who are subject to the new regulations, and previous FY1s (now FY2s). We received 518 completed responses, of which 366 were from FY1s (70.7%) and 152 from FY2s (29.3%).
For FY1s, the modal age was 24 or 25 (57.7%), 71% were single, and 46.2% lived in privately rented accommodation. Only 35.8% lived in hospital accommodation. Of the FY1s, 74.3% were not made aware of the cost of hospital accommodation before applying for jobs, and 81.4% would have lived on site in hospital accommodation if a free room were provided.
The lack of free accommodation had a major impact on income for 78.7% of respondents. Three quarters felt that social interaction between junior doctors had decreased considerably as a result of withdrawal of free accommodation. The modal cost of accommodation for FY1s was more than £500 a month including bills (32.2%), although clearly there are issues with regional weighting in the survey that have not been adjusted for. Nevertheless, 88.5% of FY1s paid more than £200 a month for accommodation including bills. More than two thirds of FY1s (69.7%) felt that the withdrawal of free accommodation was not justified based purely on the “European Working Time Directive argument,” whereas a substantial minority were not sure why the regulations were changed in the first place (18.6%).
For FY2s, the modal age was 24 or 25 (38.8%), 68.4% were single, and 63.8% had lived in hospital accommodation during their FY1 posts. Free accommodation had been available to 78.3% of FY2s as an FY1 doctor. Interestingly, nearly all of those who did not have access to free accommodation had access to subsidised accommodation. Just over half of FY2s (52%) felt that the withdrawal of free accommodation had considerably decreased social interaction between junior doctors, and 55.9% felt that these changes were not justified despite changes in regulations. For 67.1% of FY2s, accommodation had cost less than £200 a month during FY1.
As might be expected, there were marked regional variations particularly regarding cost of living, for which we did not control. Survey data showed that a few isolated trusts continued to provide free accommodation to FY1s (West Suffolk Hospital, East Anglia; Borders General Hospital, Scotland; Cumberland Infirmary, Carlisle; and the West Cumberland Hospital, Whitehaven). However, of note is the fact that the Welsh health minister agreed to extend the offer of free accommodation for FY1s in Wales until July 2010. The same did not apply to Scotland, England, or Northern Ireland.⇓
Reaction
The survey had a “free text” area for respondents to voice any other opinions on the subject. A total of 163 comments were received, many of which were extensive. There were several major recurring themes.
Financial
Most respondents felt that after free accommodation had been withdrawn, the lack of financial recompense for this represented a major burden on top of student debt. A selection of the many responses is presented below.
“Many of us move hospitals every 4 months making it very difficult to have private accommodation—that is, pushing us to have hospital accommodation as it is a bit cheaper . . . Having a mortgage to cover on a house elsewhere, which cannot be sold due to negative equity, means I’m paying twice and have been forced to enter into IVAs [individual voluntary arrangements] with creditors.”
“I don’t think we need on site accommodation, but I am amazed they have been able to stop it without some financial compensation, as it represents a significant pay cut.”
“With the de-banding of many jobs, in addition to the increasing debts that medical graduates have, the retraction of free accommodation adds to the financial difficulties new doctors have to face.”
“The inclusion of free accommodation in the pre-registration year was a long-standing arrangement that we had assumed would still be in place by the time we graduated. I took on a personal loan on the assumption that since in my first year of work I would not be paying rent I would be able to pay it off quickly. Since this has not been the case I now have a burden of debt that is going to take me years to erase.”
Social support
A considerable number of respondents also commented on how they felt there had been erosion of support networks.
“I really feel the biggest shame is the loss of camaraderie between FY1s, not living together, and the nightmare of having to commute almost an hour each end of the day when doing a 14 hour day on-call. Having on site accommodation would have been both easier and safer.”
“I think that the removal of the free accommodation hugely detracted from the community spirit . . . As the [hospital] accommodation was not only not free, but actually quite expensive, most people decided to live out (and those living in have largely been given poor accommodation). This has meant that social interaction between all of the FY1s has been quite limited which I think is a detriment to all of us.”
“I think that the removal of accommodation combined with shift work means that FY1s are feeling more isolated/are able to support each other less during stressful jobs.”
“I am glad I had the opportunity to live in for free. Despite not having a good, lively mess on site, there was a good crowd of around 18 junior doctors living in, and it was a great way of meeting new people, sharing lifts to work, relaxing, and socialising, as well as being wonderfully low maintenance particularly when doing long days/on-calls. The flat was very basic, and hadn’t been updated (or didn’t look like it) since the 60s. No one cared, because it was free. However, I have heard that they were going to charge the FY1s a small fortune for it this year, which is ridiculous when you can get a much nicer property cheaper.”
“More importantly, FY1s living together is most important for their pastoral care. They are the most empathetic to the strains of starting as an FY1 and give the best support. I believe that losing this would have a major negative impact on the junior doctor body as a whole. In particular: its sense of community, confidence and happiness.”
Miscellaneous
What was clear reading through the comments was the level of cynicism and discontent that respondents had with the way the changes had been introduced.
“Although justified due to changes in regulations, this change has not only impacted on morale and camaraderie between junior doctors . . . It has been carried out in a typically underhand way and shows the disregard the government has for the morale of doctors. In the long run I and many of my colleagues feel this will be proved a very poor decision.”
“Disgraceful and underhanded way of docking junior doctors’ pay just when they need it most.”
“It has become, not entirely subversively, a means for trusts to produce more income. In doing so they frankly devalue doctors in the trust.”
“Another example of cost cutting that has led to a further decrease in team working and the morale of junior doctors . . . it is absolutely appalling.”
“I feel that the way in which accommodation was removed without proper consultation and against massive opposition created a great deal of bad feeling towards individual trusts before we had even started jobs.”
“Junior doctors are demoralised and disempowered. It is easy to take advantage of this group now while they feel they have no right to complain or dictate the terms of their work. The problem will come in the future when this feeling filters down to the general public. The incentives to be a doctor are fast diminishing. We will have academically weaker applicants, public confidence will falter and a vicious circle will develop with less and less able applicants, a dissatisfied public and politicians destroying a successful system for short term popularity. Loss of accommodation for juniors is just another nail in the coffin of the medical profession.”
“The removal may have been ‘justifiable,’ but wasn’t ‘justified’. . . It seems to have been interpreted in whichever way was financially beneficial to the government.”
External bodies
We invited the BMA, Junior Doctors Association, the Health Secretary’s office, and Remedy UK to comment on the results of our survey. The BMA declined to comment as we were not members and referred us to the Junior Doctors Association, who did not respond any further. The Health Secretary’s office promised a response within 20 days but sadly none was forthcoming.
In the end only Remedy UK offered us a response. Matt Jameson Evans, a spokesman for Remedy UK said: “Transition from medical student to doctor can be as intense and stressful as it gets. It’s baffling how doctors are logistically able to secure three four-month private rental agreements in three different towns in a single year. PRHO [preregistration house officer]/FY1 hospital accommodation, which was always low-cost and spartan, provided on-tap peer support of immense value in doctors’ crucial first months. Removing it is a stellar example of a false economy. And the fact that Ann Keen, the minister in charge of this myopic and retrograde step, has accommodation expenses bordering on the surreal lends an almost poetic poignancy to the situation. We look to her successor to reverse the damage she has inflicted on doctors and, in turn, patients.”
Implications
As one can see from our survey, there has been a considerable change in accommodation demographics among junior doctors since the removal of free accommodation, with considerably fewer living in hospital accommodation.
Although this change, of course, has financial implications, probably more important than anything else is the effect it has on morale among junior doctors, who now struggle to gain support from other junior doctors, have to undertake unreasonably long commutes, and struggle to socialise because of finance and transport issues, especially late at night.
A recently published study conducted anonymously among doctors showed that nearly half of them would self medicate or seek informal medical advice from colleagues regarding health problems rather than visit their general practitioner.1 With a much higher prevalence of past mental health illness noted in the same study, this adds further weight to the importance of social networks in maintaining a healthy and productive medical workforce.
We hope that the results of this survey will prompt an association such as the BMA, which is meant to look after doctors’ needs, to pursue the issue further. After the recent press furore over MP’s expenses, the somewhat cynical way in which the “perk” of living free in hospital accommodation has been removed leaves a bitter taste in the mouth of junior doctors across the country.
Footnotes
Competing interests: None declared.