NHS strikes: what happens when politics clashes with patient care?

Qualified doctors of all grades represented by the British Medical Association (BMA) are on strike again. This time it’s a ‘double strike’: consultants and their junior doctor colleagues are staging their first joint strike in the history of the NHS. Consultants are already out and will now be joined by junior doctors, until Thursday. Such is the disruption, only an emergency ‘Christmas Day’ level of service will be provided.

In response, the government is considering invoking minimum service level rules that would require some doctors and nurses to work during strikes in order to protect patient safety. Legislation giving ministers this power, which also covers other public services such as the railways, came into force in July and this would be its first application.

What do the doctors want?

Their demand is for pay to be restored in real terms to the levels prevailing in 2010 – around a 35 per cent rise. Because nurses and others have now settled their disputes, the government is now in a position to impose pay rises on the doctors, even though they have yet to accept an offer. Health secretary Steve Barclay said this year’s pay offer was a “final and fair” settlement and met the independent pay review body’s recommendations; consultants are being given 6 per cent, junior doctors an average of 8.8 per cent, depending on their grade.

Isn’t 35 per cent unrealistic and unaffordable?

Yes, though doctors would settle for a plan to restore some of the shortfall, as happened after the Blair government was elected in 1997. But fiscal conditions were far easier then.

Are extremists running the BMA?

Some claim militant elements are egging the strikers on, but the ballot result and visible solidarity so far suggests the majority of doctors are still solidly behind the campaign – even at the risk of losing more pay by being away from work than they’d likely gain with a higher award.

Why aren’t the two sides talking?

There are negotiations between NHS managers and the BMA, but in reality nothing can be agreed without ministerial approval and there seems to be no sign of that, even though it is 181 days since the BMA sat down with government representatives.

Will it harm patients?

Doctors insist cover will be sufficient to protect the most vulnerable. However, it is also impossible to believe that there won’t be some detriment to patient welfare as a result of, for example, postponing tests and treatments. As is so often the case in medicine, early diagnosis and attention is the key to more successful outcomes. If real ‘horror stories’ of pain and bereavement start to emerge from this unprecedented situation, the public mood that has been thus far generous to the doctors might darken. Matthew Taylor, of the NHS Confederation, said he feared ministers were underestimating the risks of the strikes, describing the situation as dangerous. That may be true also of the doctors.

Could doctors be sacked for not working?

In extremis, if local trust management and BMA committees can’t agree on staffing and there are no informal fixes. But the government will be wary of creating martyrs out of skilled, dedicated professionals forced out of their vocation by a heartless government. Who wants to chuck an eye surgeon on the dole?

The human right to withdraw one’s labour would then be pitted against the human rights of sick or even dying patients. It’s not the kind of emotional trauma Britain needs right now, with the potential to drag on until Christmas and beyond.

Why is the government so stubborn?

Fear. Recent coverage of the short-lived Truss government should remind us what those in the Treasury and the Bank of England already know only too well: that the precarious state of the public finances means there’s very little room for manoeuvre. Hence also the prospective cancellation of further stages in the HS2 project, and the persistence of relatively high levels of personal taxation.

If the economy slows so much, while public spending on debt interest and services rises so much that it forces further government borrowing, there could be even more interest rate hikes by the Bank of England to contain inflation. It would be a bit of a death cycle for a nation with huge public debts. The effect on the housing market, pensions and economic confidence more widely could prove calamitous. Hence the determination of Barclay, Jeremy Hunt and Rishi Sunak to say no to higher pay claims.

Even if there is no cataclysm, the latest OECD forecasts on the UK economy are a sign that stagflation – slow growth, unemployment edging higher, stubborn inflation – might last for much of 2024. That is a miserable backdrop for an incumbent trying to win a general election.

What about waiting lists?

These will inevitably grow further; indeed, the prime minister has already admitted his ‘five people’s priorities’ pledge to get NHS waiting lists down this year will most likely be missed. With some justification, Sunak has blamed this on the strikes, but it’s also likely he would have found reducing the lists a stretch even without the BMA action.

Whose side is the public on?

Most recent polls, dating back to the summer, suggest substantial public support and sympathy for the doctors, just as there had been for nurses and ambulance drivers (who have now settled). But if patient harm or death can be linked to the industrial action, there might be a backlash that strengthens ministers’ resolve to see things through.

Who will win?

Neither side. If the industrial action drags into next year, it will probably outlast the Sunak administration and doctors will have to face Wes Streeting and Rachel Reeves after the general election. For all their passion about Labour’s proudest achievement, and tacit support of the strikes, Labour have made it explicitly clear that they are not going to agree to what the doctors want. Given Labour’s lead on the NHS issue, Streeting and Reeves will actually be in a stronger bargaining position because voters cannot yet blame them for the mess. By this time next year, doctors may have settled for more or less what the government is giving them now. They’re not likely to get much special treatment; after all, the BMA isn’t even affiliated to the Labour Party.