Trust between the BMA and politicians has never been particularly strong. In the middle of the longest strike in NHS history, we are now seeing a breakdown in trust between the doctors’ union and leaders in the health service. Last night the union issued what was, even by its own standards, a bit of a stinker of a letter in which it accused NHS trust leaders of bowing to political pressure to undermine the junior doctors’ strike.
Addressed to NHS England chief executive Amanda Pritchard, the letter says ‘derogations’ – the ‘last resort’ call for striking medics to return to work as a result of safety concerns – are being misused and that trusts aren’t providing the evidence that patients really are at risk. The BMA says:
It is, therefore, astonishing that during this current round of industrial action, NHS England and some Trusts have refused to evidence any efforts to source alternative staffing or demonstrate rearrangements or cancellation of less urgent work. This refusal to provide the information necessary to take well informed decisions is fundamentally undermining the derogation process as we are being asked to take decisions about our members’ right to strike without the requisite information. NHS England, it feels, is wilfully placing the BMA in an impossible situation.
It lists the ways in which derogation is being misused, then adds the killer lines: ‘We are increasingly drawing the conclusion that NHS England’s change in attitude towards the process is not due to concerns around patient safety but due to political pressure to maintain a higher level of service, undermine our strike action and push the BMA into refusing an increasing number of requests; requests, we believe, would not have been put to us during previous rounds of strike action. The change in approach also appears to be politicisation and weaponisation of a safety critical process to justify the Minimum Service Level regulations. It is an operational matter for the NHS if hospitals choose to prioritise less urgent cases over life and limb care.’
In fairness to the BMA (a phrase that is not often justified), there is good reason for some doctors to be suspicious of the way trusts are using derogations. During a previous wave of strike action in April 2023, the Weston General Hospital and the BMA had a fundamental breakdown in relations when seven doctors were recalled from the picket line to work in A&E and acute medical departments after the hospital said staffing levels were dangerously low. The BMA then claimed the trust did in fact have enough staff and that either the management were ‘unaware they had sufficient senior cover, or they deliberately misled us’.
So there is already suspicion from this particular pay dispute, but it actually reaches back even further than that. As I revealed in my new book, Fighting for Life, during the last junior doctors’ strikes in 2015, there was a particularly ugly scrap behind the scenes over whether staff would return from the picket lines in the event of a terror attack. The then chief medical officer Sir Bruce Keogh horrified junior doctors by writing a letter to the BMA’s chair Dr Mark Porter in which he referenced the recent terror attacks in Paris and asked for clarification that doctors would return to work. What wasn’t known at the time was that the reason Keogh wrote that letter in the first place was that the BMA had suggested he do so.
Here’s what happened:
Keogh says he was initially instructed in a meeting with senior government ministers and members of the security forces – who were jumpy about the prospect of a copycat terror attack on London – to confirm his assurances with the BMA that junior doctors would be prepared to call off their strike in a civil contingency. He thought this would go without saying, but phoned Porter to discuss it:
I said, “Look, I’ve got to write you a letter to ask whether the junior doctors would call off their strike.” I said: “So there are two ways I can phrase the letter.” The first option was that I was going to say, “I have absolutely no doubt that in the event of a civil contingency or an emergency or something, that junior doctors would call off their strike.” I said: “The other way is just to ask you, quite bluntly, that if something happened…” and he said: “I think you should ask specifically, if there’s an emergency, would the junior doctors call off their strike? Because I think there are some very rabid people in the junior doctors’ committee who would not call off the strike.”
Dr Porter remembers the meeting a little differently. He says: ‘I do not recall saying and indeed did not say that there were very rabid people in the junior doctors’ committee who would not call off the strike. I knew from my regular attendance at the JDC, my many meetings with the committee officers and indeed from their presence at the meeting, that the junior doctor representatives in the BMA were responsive to the potential patient safety issues raised by industrial action and would respond appropriately in relation to their responsibilities as registered medical practitioners.’ It is Porter’s view – and that of many other doctors to this day – that ‘it was the actions of the government that had needlessly provoked, insulted, attacked and angered junior doctors’.
Porter isn’t wrong, either: ministers repeatedly make clumsy comments that only a fool wouldn’t notice are guaranteed to offend and enrage doctors. The latest is the comment from Health Secretary Victoria Atkins that junior doctors are ‘doctors in training’. While very technically correct in that these doctors are, until the very last stage of their registrar years, still going through examinations for royal college membership and continuous assessment within their trusts so that they can progress to consultant level, they are also very much not the work experience kids just making tea. Even from their first few weeks they are working as real doctors. The ‘doctors in training’ comment taps into a particular insecurity that some medics have about ‘not being real doctors’ because that is a comment sometimes thrown at them by patients who think they look too young or who question their authority to make decisions or stick large needles into them. Atkins is sharp and will have picked that up. Perhaps as a politician who has been called far worse, she thinks that doctors should get over themselves. But is a lesson in humility really best taught during industrial action when a union can quite easily tell exhausted doctors that they are being dissed by politicians who just don’t understand them? Probably not.
As for NHS leaders, they will of course be sensitive to the accusation that they are bending to political pressure. They are also privately concerned that while Rishi Sunak currently seems to be content to use the industrial action as the key excuse for his failure to meet his five priorities pledge on waiting lists falling by the next election, he might switch his fire onto the health service itself. There was, for a while, a level of paranoia that the Prime Minister could make overhauling the NHS a continuation of his theme about attacking the political consensus which he launched at the Tory party conference in the autumn. The main victim of that attack was HS2, a project without the levels of support, cultural adoration and emotional bonds that the health service has, and the PM has since realised that attacking the consensus wasn’t what voters wanted from him anyway. So the risk has somewhat receded. The lack of trust between all camps, though, remains acute.
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