A 1970s-style walkout by doctors - could it happen this year?
The junior doctors saga rumbles on. There have been protest marches, claims and counter-claims and now more detail of the government's offer.
Hugh PymHealth editor@bbcHughPymon Twitter What's clear is that in two weeks' time, we will know whether junior doctors in England are prepared to strike in what would be the first such walkout over pay since the 1970s. The reaction from those doctors who have spoken out on Wednesday has been largely hostile to Jeremy Hunt's letter. They claim the extra detail contains no significant concessions and that it will not influence their decision in the ballot. The health secretary is hoping that the letter, sent to all 50,000 junior doctors in England and bypassing the British Medical Association, will attract the attention of an undecided majority (if it exists). Pay rise? Early headlines highlighted Mr Hunt's offer of an 11% pay rise. But that proposed increase in basic pay is in effect matched by a cut in unsocial hours payments as the definition of what is unsocial and outside a normal working day is changed. Weekday evenings and much of a Saturday will be treated the same way as office hours from Monday to Friday. The argument will focus on who will be the winners and losers under the proposed contract. Whitehall sources say that over the next four years the policy is cost-neutral - and will cost no more and no less than what would have been the case if the existing deal had continued. Mr Hunt argues that 75% of junior doctors will be better off over that period than they otherwise would have been. Within NHS management there is a feeling that that might be an optimistic assumption, but there is a consensus that at least the vast majority will not see any pay reduction. The 1% of doctors who currently work up to 91 hours a week will see a reduction in what they earn now. Mr Hunt argues that they should not be working those hours anyway and will benefit from more safeguarding of their roster. But the loss of any earnings, however excessive the hours worked, will hardly be welcomed by those doctors affected. Beyond the four-year timespan envisaged in the government's proposals there is a lack of clarity. Some doctors believe that in the long term they will lose out as the automatic pay progression currently in place is replaced by a more selective merit-based policy. NHS leaders counter by saying there is no hidden agenda and no reason to pursue a course that might lead to an exodus of doctors from England. Weekend battleground The question of weekend working remains as contentious as ever. Jeremy Hunt argues that the current contract has a disincentive for hospitals to employ more junior doctors on Saturdays and Sundays. The BMA counters with the view that the new proposals remove a financial sanction that deters employers from making staff work even longer hours. Battle lines have been drawn. An uneasy calm may descend during the ballot process, which ends on 18 November. It seems likely that only when the BMA reveals what sort of mandate it has will there be a renewed focus on areas of disagreement and pressure for negotiations to restart. Senior government sources anticipate that there may well be a majority for strike action. Their hope is that public sympathy with the doctors will wear thin if there is the prospect of disruption within hospitals. The BMA, in contrast, believes that a large majority for industrial action will concentrate minds in Whitehall and lead to intense political pressure on the Department of Health to find a solution. Winter is always difficult for the NHS. The possibility of industrial action among an important swathe of the workforce, covering the most junior doctors through to registrars with a decade or more of experience, is adding to the uncertainty this time.