The thing that happened

The 48 hour walk out of junior doctors on March 9th and 10th 2016 did not gain as much mainstream media coverage as the previous one day stoppages. Nor did it trigger government concessions on the new junior doctor contract. So on March 18th the British Medical Association (BMA) announced plans for an “escalation” of strike action over the Government’s decision to impose a new contract on junior doctors. 

The chairman of the BMA’s junior doctor committee (JDC), Dr Johann Malawana, said the “exact nature” of the action would be confirmed shortly. A few days later the BMA announced a full walkout by junior doctors, including those working in emergency services at the end of April. In each of the junior doctor strikes so far, emergency staff have remained in post. 

A&E doctors are among those most concerned about the new contract and pressure for a full walkout has been growing among BMA members frustrated that the union has so far proved powerless to prevent the Government imposing a new contract. This is scheduled to come into effect in August 2016, cutting pay for Saturday working in exchange for an uplift in basic pay. 

Dr Malawana added: “We have shown solidarity, stated our case clearly and passionately to the public, and done everything possible to avert what could be the worst of all worlds for junior doctors – the refusal of the Government to get back around the table forces us down this road.”

Public opinion polls show high levels of support for the junior doctors and social media carry testimonials from individuals expressing no anger, sometimes even gratitude, about their postponed hospital appointments. Yet there is also a sense that the dispute has gone on too long. Writing for the Guardian on March 13th, Sonia Sodha said: So what’s the link between Saturday pay and patient safety? A BMA spokesperson told me the Saturday pay dispute will further damage junior doctor morale, with knock-on impacts for patient safety.

Let’s call a spade a spade. This is a workplace dispute about terms and conditions, not a campaign to save the NHS. There are bigger and more immediate risks to patient safety: hospital trusts under great financial strain struggling to meet safe nursing levels; cuts to social care budgets putting immense pressure on hospital beds.

This echoes a ‘plague on both your houses’ piece in The Economist on February 12th which sympathised with the junior doctors and criticised the Health Secretary Jeremy Hunt (whilst deeming him well intentioned). Unable to decide which side it favoured, The Economist blamed the British public for being an electorate that notionally adores the NHS, propels a mushy song by health workers to the top of the Christmas charts, happily accepts the left’s bogus insinuations that the only alternative is an American-style private health-care model, equally happily votes for Tory politicians promising to expand services to weekends and yet, despite all this, shows remarkably little willingness to pay more in tax towards what remains a relatively cheap system”. 

Whilst not taking The Economist too literally, we might learn something useful from two particular economists, Roland Benabou and Jean Tirole, whose 2009 essay “Over My Dead Body: bargaining and the price of dignity” casts some light on the current dispute. They say: “Concerns of pride, dignity, and the desire to “keep hope” about future options often lead individuals and groups to walk away from reasonable offers, try to shift blame for failure onto others or take refuge in political utopias. Costly impasses and conflicts result”.

Both sides blame the other, and the junior doctors – many of whom genuinely believe they are saving the NHS – have found a political dystopia. As the junior doctors’ leader puts it, failure to achieve the BMAs objectives will bring about “the worst of all possible worlds”, which seems an odd conclusion after months of argument and negotiation had apparently brought both parties closer to a resolution. Exactly how will an uplift in basic pay but a reduction in Saturday overtime pay constitute the worst of all possible worlds?

The thing that didn’t

On Friday March 11th the Private Member’s Bill – called the National Health Service Bill but publicised as the NHS Reinstatement Bill by its proponents – went to Parliament for a second reading. It was an ambitious piece of legislation that aimed to abolish the purchaser-provider split in the NHS, end contracting and re-establish public bodies and public services accountable to local communities. In other words, it was intended to roll back the marketization of the NHS. More specifically it sought to re-establish the Secretary of State’s (SoS) legal duty as to the National Health Service in England, and to repeal section 1 of the National Health Service (Private Finance) Act 1997 and sections 38 and 39 of the Immigration Act 2014, amongst other changes.
Before the debate there was a lively handover ceremony for the 60,000 strong petition supporting the Bill outside the Department of Health, with Caroline Lucas MP (the sponsoring MP), NHS campaigners and junior doctors. Action then shifted to a rally outside the House of Commons. Labour MPs Rachael Maskell and Grahame Morris came to show their support, and speakers from Unite, Doctors for the NHS, Keep our NHS Public and many local NHS campaign groups and junior doctors addressed the spirited crowd.

Inside the House of Commons the opportunity for the Bill getting sensible debating time rapidly disappeared (as happens in most Private Members’ Bills) because Conservative MPs filibustered, leaving the NHS Bill with precisely 17 minutes. As Peter Roderick, lawyer and co-author of the NHS Bill said “17 lousy minutes. A contemptuous Parliament unworthy of the people.

He went on to say “If enough Labour MPs had turned up, it might have been possible to stop the Tory MPs talking by putting a closure motion. When this was pointed out by Caroline Lucas, the shared smirks on the faces of silent Heidi Alexander, Labour shadow health minister, and the junior health minister Ben Gummer, gave the game way. The Tories didn’t want a proper NHS debate, neither did Labour’s health team and together they made sure it didn’t happen. Body language speaks louder than words. Filibustering, empty benches, silence, smirks and front bench deals are contemptuous responses to tens of thousands of people. They are also counter-productive.  This second NHS Reinstatement Bill will fall. But the spirit is high and the commitment to bring a third, and a fourth, and a fifth – until a proper public NHS is restored – is stronger than ever”.

The NHS Bill’s supporters were very annoyed, understandably so given this was their second failure to get the Bill debated in Parliament. They remain defiant, planning another attempt at getting the Bill back to the House of Commons, and are angry at Labour’s growing disinterest.

The Labour Opposition said it supported the overall objectives of the Bill, in particular the principles restoring accountability to the Secretary of State for the delivery of health services and the requirement that a comprehensive health service continues to be provided free of charge. However, the Bill was seen as poorly constructed and in need of a great deal more thought and effort to get it into a workable state. Even worse, there were concerns in the Labour Party that some of the other parts of the Bill would require another wholesale reorganisation of the health service. The top-down reorganisation of the NHS, brought about by the Coalition’s Health and Social Care Act 2012, threw the NHS into turmoil, cost over £3bn and eroded staff morale. Labour understandably wants to avoid a repetition of such shock therapy.

Let’s call a spade a spade. Why should the Parliamentary Labour Party invest time and energy in a Bill to turn back the clock on NHS marketization – some of which Labour had initiated – which has no prospect of being passed? Particularly at a time when it is writing its election manifesto and contemplating an election before the end of the present parliamentary term – referendum results being an unknown quantity at this stage. By the time Labour in whatever form regains government office the needs of the NHS may be different. Anyway, is turning back the political clock really possible, or is it just a nostalgic dream? Why is it preferable to look backwards to a proper public NHS (whatever that might mean) than to face forwards and solve the problems of the NHS as they evolve? Are we being encouraged to take refuge in political utopias?

Steve Iliffe 28/3/16