We agree about nearly everything

I have blogged about the English junior doctors’ dispute more than once before. Right back in January, I said

“There is a great deal at stake in this dispute. A strike is always a two-edged sword, and I have misgivings about where this strike will take us. Nevertheless, sometimes you just have to decide whose side you are on” 

Nothing has happened to change my mind about any of that.

Strikes in industrial settings are contests that test both sides’ ability to bear economic pressure. Strikes in the health service are different. They are battles that are fought in the arena of public opinion. Government and employees try to persuade the public that the discomfort they experience as users of the service is being caused by the other side. In the first half of this year, the junior doctors were unequivocally winning the battle, with a well-reasoned and articulate campaign, assisted by Mr Hunt’s apparent inability to use evidence convincingly.

This time around it is more difficult. Mr Hunt has gained some propaganda assets, including the British Medical Association (BMA)’s initial recommendation to accept the contract, and the revelation that the Department of Health previously conceded that a “seven-day NHS” only meant emergency cover with extra resources. I understand the caveats to be attached to these points, but they have had a detrimental impact on the BMA’s case in the public arena.

Hitherto, the medical profession has been amazingly solid in its support of the junior doctors. Over the past week, the medical establishment has started to equivocate in the face of escalation of strike action. Equivocation is not the same as betrayal, but it can feel like that.

The Academy of Medical Royal Colleges (AMRC) issued a short statement on Thursday, opposing the planned extended strike action by junior doctors on the basis of likely harm to patients. It was followed by an important, but largely ignored, follow up paper on Friday. On Monday the General Medical Council (GMC) reiterated its warning, originally issued in May, that if individual patients suffered harm that could be attributed to individual doctors’ failure to go to work, the doctor might be subject to disciplinary action by the regulator.

Not surprisingly, some reaction to these statements has been very angry, which raises a fear of persistent schisms within the profession. The Colleges and the GMC stand accused of operating a double standard, insofar as they are said to have been less forthright in condemning the actions of medical managers in implementing Government policies that may have been equally, or more, damaging to patient safety.

Meanwhile, Theresa May has deliberately heightened tension through fulsome praise of Jeremy Hunt. Very few doctors would agree with her that he has been an excellent Secretary of State for Health. Since becoming premier, Mrs May has adopted an uncompromising stance that is no doubt intended to evoke the spirit of Margaret Thatcher. This winter will see the crunch point for NHS finances in England. It will be a disaster if Mr Hunt manages to deflect blame from his stewardship of the health service onto the junior doctors.

Parallels with the miner’s strike are potentially misleading, but it seems clear that the Government sees the junior doctors’ contract as a dispute that they can ‘win’, just as that dispute was ‘won’. In the background, backbench Tory MPs are calling for emergency legislation to make it illegal for doctors to strike. I was a supporter of the miners throughout their strikes of the 70s and 80s. I am starting to get a sinking feeling that I remember from 1984.

Luckily, the junior doctors’ leaders are proving more tactically agile than Arthur Scargill and his colleagues were. The BMA has called off next week’s action as a response to concerns that there has been insufficient time for hospitals to prepare. There is a range of alternative tactics that could be deployed, and no doubt these are under consideration. For example, it is not essential to escalate the severity of strike action over time. Wars of attrition can be won.

I think that the narrative of betrayal by the medical establishment is seriously unhelpful. The GMC’s attitude is not new, and a restatement of their position was to be expected. Similarly, the attitude of the Academy of Medical Royal Colleges was not a surprise. Although the Royal College of Paediatrics and Child Health dissented, I thought that the AMRC position was inevitable. It seems to me that both the AMRC and GMC were bound to take the positions that they did, determined by their particular roles in guarding patient safety.

A number of leaders of Royal Colleges have issued statements that make it clear that they still want to support the junior doctors. Sir Simon Wessely’s Royal College of Psychiatrists blog on the subject can be read here. Many comments about it are extremely critical. In my opinion, it is a courageous and truthful statement that clearly conveys the discomfort created by feeling that there is a conflict between loyalty to psychiatric trainees and commitment to patient safety. Many junior doctors will be struggling with the same discomfort in trying to decide whether to participate in the next round of strikes or not.

I am sure that the junior doctors’ leaders weighed up all of these factors prior to seeking approval for further strike action from the BMA Council last week. If we get to the first day of the planned strike without any movement from Mr Hunt, individual junior doctors will do what they think is right. In that event, I hope that there will not be recrimination in either direction between those who strike and those who work. I hope that the junior doctors will not conclude that medical establishment have acquiesced to the destruction of the NHS and allow internecine conflict to flourish.

Whatever happens, this dispute is just one part of a bigger story. Junior doctors face more difficulties than can be resolved through their contract. In my opinion, the entire way that training is organised has been seriously and persistently flawed ever since the Modernising Medical Careers debacle. The current dispute is an important episode in the fight to preserve the health service, but it is not the whole battle. That will continue throughout the life of this Government, and quite possibly beyond.

No matter what the outcome of the junior doctors’ dispute, there is a long haul ahead. Our profession’s strengths in the battle are evidence, rationality and trust. We must be able to disagree about tactics whilst travelling together as allies. We all agree about protecting services for vulnerable patients. In fact, we agree about nearly everything.