Strikes did not stop Sunak hitting his pledge to cut NHS waiting lists, but they are the nail in its coffin | Conservative Home

This morning’s headlines about the looming strike by junior doctors focus on a grim figure: that the number of appointments and operations cancelled as a result of industrial action is set to pass one million.

In fact, if the reported numbers are accurate – 200,000 expected cancellations from the latest six-day walkout, on top of over 940,000 over the previous 24 days of strikes – it will be well over that number.

All that is on top of fears that some people, especially the elderly, will be put off seeking care, potentially building up a further backlog of cases that doesn’t immediately show up on the Health Service’s books.

An unpropitious set of headlines with which to kick off what Rishi Sunak has said will be the year of a general election. For starters, if such action continues it puts paid to any hopes of fulfilling the Prime Minister’s pledge to cut NHS waiting lists.

The Government’s failure on this front is not entirely down to industrial action. As the Institute for Government notes in its most recent assessment of the five pledges, other factors are also biting, including the corrosive effect of inflation on budgets and woeful public sector productivity:

“Covid certainly worsened the picture, but it mostly exacerbated pre-existing issues, namely underinvestment in capital, worsening staff morale and a lack of management capacity. This means that despite more than 15 per cent more doctors and nurses in hospitals compared to February 2020, elective activity in 2022/23 was 2.7 per cent lower than in 2019/20 and more than 10 per cent lower than it would have been if pre-pandemic trend increases had continued.”

So whilst the strikes are certainly making things worse, even if Victoria Atkins could wave a magic wand and end them tomorrow, it would still take some extraordinary performance to get the Government back on track to deliver on Sunak’s pledge.

Of course, in theory the Government could bring the strikes to a close by settling with the British Medical Association. But although it has been able to come to terms with other Health Service workers, such as nurses, ministers are standing firm against the junior doctors’ demand for a 35 per cent rise. This morning the Sun reported Victoria Atkins’ attack on the BMA for walking out of the talks.

Ministers’ reticence in the face of the junior doctors’ pay claim is quite understandable, for several reasons. First, accepting anything like a 35 per cent increase might risk re-opening the disputes it already settled. According to the Nuffield Trust, the permanent pay increase accepted by the other unions is about ten per cent, with the rest of the settlement made up with a one-off payment.

A much larger settlement with the BMA would thus set an extremely unhelpful precedent to other public sector workers when the next round of pay disputes comes around.

Second, it would lock in a much higher ongoing salary cost to the NHS, at a time when inflation is corroding the real buying power of budgets and taxation is already at historic highs – to say nothing of the Government’s efforts to find the fiscal headroom for pre-election tax cuts.

The problem is that there isn’t any obvious way to end the standoff. Whilst some Tories have sought echoes of the big showdowns with the unions in the 1980s, the parallel is inapt.

In those cases, be it Margaret Thatcher versus the miners or Rupert Murdoch versus the printworkers, management was pushing for a big structural change which would permanently break the power of their opponents, be that by shuttering uneconomic mines or moving to much more efficient methods of producing newspapers.

Absent some vast and as yet entirely-imaginary revolution in how the NHS operates, there is no comparable victory condition for the Government in the case of the NHS.

Moreover, in what is now a familiar tale, the Conservatives have squandered 13 years in which they might have at least changed the structures of the Health Service to make the battlefield more favourable.

For example, if they had followed through on decentralisation and devolved pay to NHS trusts, whilst making trusts the legal employers of their doctors and nurses, existing strike legislation would have meant there could be no more sector-wide strikes. Instead there would be trust-by-trust negotiation between management and unions, which might have been more productive and discouraged the idea that there is an inexhaustible pot of public money from which to settle claims.

Alas. Instead, the Government has maintained a formula in which pay disputes are ultimately a confrontation between it and the medical unions – and as of the autumn, the unions are winning the public relations battle on that one.

Which leaves what? This morning’s Daily Telegraph editorial suggests introducing curbs on NHS workers’ right to strike, in line with those imposed on soldiers, police officers, and prison wardens.

Assessed narrowly, that might work in its own terms, at least in the short term. But it would be no mean feat politically: according to YouGov, public opinion has drifted against such a ban both for doctors and nurses over the past year. It would also likely provoke another round of strikes, in an election year.

Beyond that, it would do nothing for staff morale and retention – bad news if the Government is serious about trying to wean the NHS off imported workers via its long-term workforce plan.

All of which means there isn’t an obvious way out. We know this because if there were one, Labour would be shouting about it.

But whilst the Opposition have said they’re prepared to negotiate (as is the Government), Wes Streeting has refused to say that a Starmer government would meet the 35 per cent demand, and branded last year’s 19 per cent demand from the nurses “obviously unaffordable”. The unions are already warning that strikes will continue under Labour.

Perhaps, Nixon-to-China style, Labour will have the political cover to introduce some structural changes to healthcare that change the playing field. If not, the vicious combination of a low-wage country, a health system funded exclusively by taxation, and rationing by waiting list will continue to play out – whoever’s in charge at Westminster.