The BMA has marched its junior doctors up to the top of the hill, and marched them down again. The manoeuvre appears to have scared the Secretary of State for Health enough to make him back down on imposing a new contract for doctors in training. It has emboldened the BMA enough for it to resume the negotiations that it had broken off in October 2014. Jeremy Hunt looked tired and worn, which probably serves him right for intervening in an industrial dispute and making it worse.

On Saturday 28th November the BMA announced that, after two days of talks with the Advisory, Conciliation and Arbitration Service (ACAS), it seemed “increasingly unlikely that we will be able to avert Tuesday’s (1 December) industrial action”.  Before the planned strike Dr Yannis Gourtsoyannis, of the BMA Junior Doctors Committee, described in a message to “our fellow NHS workers, trade unionists and campaigners” how the junior doctors were resisting the “imposition of a contract that we feel would jeopardize the profession, patient care and the NHS for a generation”. He signed off with the very doctorish phrase “Kind Regards”, but added the unusual (for medicine) flourish “and Solidarity”.

By Monday November 30th the BMA was able to announce that it had agreed to temporarily suspend its proposed strike action and the Department of Health had similarly agreed to temporarily suspend implementation of a contract without agreement. Time runs out for negotiations on January 13th 2016, but the negotiating period may be extended.

Calling off the strike at short notice did not necessarily avoid disruption of NHS services; thousands of outpatient appointments and planned operations had been rescheduled, but at least military doctors were not deployed.

So what was at stake in all this conflict? Three things stand out from the joint memorandum of understanding published on November 30th.

The first is that there is no more money on the table. The cost-neutral offer made by the employers in November 2015 remains the basis for further negotiation. Pay protection – a strong demand amongst Junior Doctors – will need to come from within the current budget for medical staffing, so there must be losers as well as winners amongst doctors in training. This probably means that overtime payments will decline.

The second is that part of the government’s aim was to secure safe and effective medical staffing in hospitals every day of the week. All parties in the arbitration supported the idea that the quality of care and patient outcomes (including death rates) would be the same every day of the week. Admission of ill people to hospital peaks around 4pm, and these people take four to five hours to diagnose, stabilise and transfer to wards (or operating theatres). The current contract treats work after 7pm as unsocial hours, qualifying for overtime payments. The proposed new contract aims to move the boundary for unsocial hours (on weekdays) to 10pm, so reducing the salary bill during periods of peak activity. Redesignation of Saturday between 7am and 7pm as normal working time will also reduce salary costs for those working at weekends, without reducing their working time.

The third is that the dispute is presented in very different ways to different audiences. Junior Doctor organisers, reporting on the opening rounds of negotiation to colleagues, have focussed on establishing pay protection, pay for all work done and some form of protection for academics.

These details are important to Junior Doctors but not necessarily to the rest of us. We are given the message that the Junior Doctors are saving the NHS – a clear message on demonstrators’ placards – and that the government’s desire for a new contract puts the whole NHS in jeopardy.

Here is how one BMA Divisional secretary informed his members about the reopening of negotiations.

“”….the future of the NHS is not a minor subject, and that’s what is really at stake. Doctors’ and nurses’ working conditions are central to the provision of a high standard of health care. The agenda is to further down grade us all: our Junior colleagues were only the first. We hear that changes in the Consultant’s contract are imminent. Nurses will surely follow. GPs are slightly different but are also under great pressure. All in the name of making the NHS more attractive to private bidders”.

He went on to remind readers of Edmund Burke’s saying: “The only way for Evil to flourish is for good people to do nothing”

So the conflict is not only about the potential exploitation of medical labour, but also about resisting privatisation of the health service – an evil that could flourish if this conflict over unsocial working hours is resolved in favour of the government.

This might strike some as odd. How will an argument about overtime payments (amongst other job-related concerns) lead to privatisation of an industry? Even if the connection was obvious, why does the public display of concern about privatisation appear now, deployed in support of a conflict over a contract? Why did it not appear before, say around the Health & Social Care Act, which openly proposed marketization of NHS services?

It might be tempting to see the use of a political slogan in a contract dispute as cynical opportunism. Although understandable, this would obscure what is happening even further. There is a sense that protecting doctors is protecting the NHS. The BMA has always conflated the interests of the profession with the interests of the public; what is good for the doctor is good for the patient. It has been able to do this because the logic is partially correct – try operating without a surgeon, or an anaesthetist. All other disciplines and roles – nursing, management, physiotherapy, portering, cleaning, radiography, catering and so on – are necessary to run a hospital but not sufficient to run a health service. Given what hospitals do (save lives), doctors are their lynchpins. And when we say “NHS” what we usually mean is hospitals.

The problem is that doctors want hospitals run on their terms, which are not necessarily shared by others, including NHS management. Hospital managers need to roster medical staff to meet patients’ needs, but junior doctors would like to work as few unsocial hours as possible, preferably at advantageous pay rates. It is difficult to see how this conflict of desires can be resolved within the budget currently available for medical staffing. More funding may be needed to give each side what it wants, and that will require a political fight within government.

So another round of Saving the NHS seems likely, when the quiet but difficult debates around the negotiating table give way to catastrophizing rhetoric before the TV cameras. This will be a relief to political campaigners who have been struggling to get much attention for their efforts to prevent privatisation. Labour’s attempt to play the saviour of the NHS in May 2015 was an electoral flop, and independent campaigns desperately need a shot of energy. By an irony of history this may come from the BMA, which once opposed the idea of a national health service.

Steve Iliffe 6/12/15