Health in Focus: Resident doctors & devolved elections

For the 15th time since March 2023, the resident doctors went on strike following the Easter break, bringing the cumulative cost of the dispute, according to Health Secretary Wes Streeting, to an estimated £3bn. The strikes have developed following a breakdown in talks between the Government and the BMA. The passing of the Medical Training (Prioritisation) Act earlier this year, which was originally intended to be conditional on positive BMA talks, briefly hinted at a thaw in hostilities. Streeting has also spoken positively about talks, saying that he believed the Government and the BMA had ‘collectively constructed a serious, good-faith attempt to resolve this dispute’. The deal presented by the Government included a minimum pay rise of 3.5%; higher pay rises on average for the lowest paid foundation year 1 (FY1) and foundation year 2 (FY2) doctors, at 6.2% and 7.1% respectively; reform of the pay structure leading to more frequent pay rises; at least 4,000, and up to 4,500, additional specialty training posts over the next three years, with at least 1,000 of these beginning this year; reimbursement of mandatory royal college exam fees; and substantial contract reforms to locally employed doctors.

Despite these ‘constructive talks’, the BMA has accused the Government of moving the ‘goalposts’ at the last minute, moving from a two-year pay uplift to a staggered increase distributed across three years. From the Government’s perspective, the BMA’s expectations are ‘unreasonable and unrealistic’, triggering a regression into the bitter hostilities seen previously with public appearances laced with high criticism and dismay at the actions of the opposing parties, rather than the ‘collective’ reasoning and negotiation. On the picket line, Chair of the BMA Dr Jack Fletcher said that the Government is now refusing to talk with the BMA and offer a ‘credible deal’ that does not have real-term pay cuts baked in. The Government chose, through the Prime Minister, to publish an article in The Times, saying the rejection of the deal was reckless and benefited no one. At the time, Starmer issued a 48-hour ‘take it or leave it’ ultimatum which went unheeded. This ‘strongman’ approach seems to show the Government reverting to type on this issue, having responded to calls for a more collaborative and respectful approach to dealing with the BMA in the past. Since the conclusion of the strikes, Streeting has also been unequivocally sharp in his frustration and criticism with the BMA’s actions, asking them to ‘stop pretending that this government can sort out everything for everyone everywhere all at once’ and calling their claims ‘categorically untrue’ and ‘nonsensical’.

A key aspect of the Government’s ultimatum was that if the strikes went ahead, the Government would have to pull the 1,000 specialty training places put on the table for the current training round. The Government has said this was being pulled to cover the costs of the strikes, taking place in a period to cause the most ‘havoc’ to the NHS. For them, this was not a punishment nor a threat, but a logistical choice the BMA has made. This move has been criticised, including by Jeremy Corbyn MP who called the move a ‘disgrace’ that will cause patients to suffer and push doctors to leave the UK and work overseas. Once again, this highlights the irregularity of negotiations between the Government and trade unions more widely. To seek an end to a dispute there must be negotiations between the two parties involved, and where an agreement can’t be reached compromise is sought from the parties. If a compromise can’t be reached then the Government must opt to either exit negotiations or leverage themselves in the negotiation to reach a compromise. The issue arises where leverage over public sector workers, such as pulling training places, ultimately always harms the public and the Government’s objectives as well as those on strike.

This creates a paradox where the Government is forced to leverage against its own ambitions while the trade union stays, as it seems, in an uncompromising stance able to criticise this leverage as harming the public. Of course, the Government could do more and spend more to appease the concerns of the BMA, drawing money away from other key areas in the healthcare sector, or the wider public purse as a whole. But as noted by Streeting, this could cost over £30bn a year once all public sector employees are considered. Importantly, when we look at the BMA itself, its own employees have chosen to strike having been offered a 2.75% pay rise, notably below the 3.5% Government offer to doctors which the BMA has described as a ‘crushing blow’. This possible irony encompasses the complex nature of this situation and the frustration that stems from the Government. Nevertheless, the Government must square this circle to alleviate further criticisms, whether those are calls for more financial generosity and ‘backing’ of the NHS, or for an outright ban of doctors strikes. The latter, which according to the FT is reportedly under review by senior health officials, could represent a seismic shift in industrial relations.

The upcoming local and devolved national elections will prove hugely consequential for the Government with polls placing its popularity at record lows. For the Labour party, the bar for success is probably the lowest it has ever been, with no control over Scotland nor Wales being deemed a probability rather than a disaster as it once was. Reform, Plaid Cymru and the SNP, the strongest cohort of the non-traditional parties in the upcoming elections, look set to dominate both in Scotland and Wales, bolstering a wide array of proposals in the health space. It is useful to examine the likely winners and understand, specifically in the case of a probable coalition Government in Wales, what policies are the sticking points for parties. The SNP is polling strongly in Scotland, relative to what could have been a difficult election. According to a MRP poll conducted on behalf of the National Newspaper, the SNP is predicted to win a small majority, taking home above 30% of the vote. The party’s manifesto is yet to be published but will highlight the steps ahead for the health sector.

In Wales, current polling suggests a Plaid Cymru win, with Reform taking second spot, and the incumbent Welsh Labour Government falling to less than 25% of the seats, a huge drop for a long-lasting administration. Polling also suggests a possible coalition bridged between Plaid Cymru with Labour and/or the Greens. For Plaid Cymru this presents a decision to either form an alliance with the experienced Government-ready Labour Party or the fresher and arguably more ideologically-aligned Green Party to form a workable Government.

In its manifesto, Plaid Cymru sets out two key pledges to recruit 100 additional salaried GPs and establish 10 new surgical hubs to tackle regional ‘postcode lotteries’. The vision presents a decentralised governance model, seeking to remove political influence by transferring responsibility for placing boards into special measures to a reformed NHS Executive specifically tasked with managing operations set out by the Government. In its plan for the First 100 Days set out in February, Plaid Cymru said that it would also commission an independent review on the performance of the NHS in Wales and establish a health finance efficiency team to drive fiscal performance. This focus on efficiency is a key pillar throughout all manifestos, highlighting the cross-party consensus on the plethora of waste in the current slow-acting, overly bureaucratic NHS system. Plaid Cymru also pledges a Real Living Wage for social care workers and the implementation of a ‘no wrong door’ approach to mental health that bridges the gap between child and adult services. A core part of Plaid Cymru’s plan for Wales is a shift to prevention, centred around a new dedicated Minister for Public Health. Other initiatives outlined by the manifesto include greater emphasis on social prescribing and nature-based interventions, 28-day guarantees for Carer’s Needs Assessments, and a ‘young cancer travel fund’ to assist patients with the hidden costs of seeking treatment far from home.

Reform UK’s plan for Wales focuses closely on structural accountability, performance-driven management, and a return to standardised care. The proposal is a comprehensive emergency action plan to scale up planned care and eliminate corridor care through national patient flow standards. A key theme is professional rigor: an intention to tie health board leadership pay and contracts directly to performance while amending the NHS Wales Act to allow for direct ministerial intervention in cases of persistent failure. Reform also seeks a reversal of the NHS’s approach to identity and language, pledging to end the use of the term ‘birthing persons’ and strictly maintaining single-sex wards. The plan also includes modernising the NHS Wales App, standardising IT systems, and introducing targeted recruitment incentives for dentists in rural areas. It also emphasises ‘lawful resident status’ as a requirement for NHS eligibility, framing healthcare as a benefit reserved for those with legal standing.

The Green Party’s vision for Wales centres on transforming the nation into a ‘Marmot nation’ where health equity is a national mission, moving away from fragmented, disease-led models toward a system built on prevention and long-term wellbeing. This vision begins at the first 1,000 days of life, with the manifesto focusing on strong access to perinatal care and youth mental health, while enshrining the right to healthy food and regulating harmful food environments to treat obesity as a public health challenge. The manifesto also calls for a 20–30 year workforce plan, improved gender-affirming care, and a gendered approach to mental health. Through the expansion of Nature for Health programs and the retention of 20mph speed limits, the policy seeks to integrate environmental health with medical care.

Welsh Labour’s manifesto proposes a £4bn Hospitals of the Future Fund, which aims to drive new hospital builds and major developments across the country. The primary care strategy hinges on a guaranteed appointment for medical needs and a significant expansion of dental services, including a new dental school and a revised dental contract. Labour also places a heavy emphasis on specialised health plans, specifically targeting women’s health with dedicated actions for endometriosis and incontinence, alongside maternal mental health support. Their preventative agenda is notably interventionist in line with national Government proposals, seeking a ban on energy drink sales to under-16s and exploring new planning restrictions to keep takeaways away from school grounds. To ensure delivery, Welsh Labour plans to regulate NHS managers and set a strict 26-week target for all NHS appointments.

With the May elections less than a month away, polling suggests that Labour will fall short in both Wales and Scotland. The current projected winners, Plaid Cymru and SNP, will likely represent a greater push for the devolution of powers and authority in the health space, further decentralising control. Greater devolution, while reaping the benefits of care managed closer to home, could also lead to weaker cross-border healthcare and policy synchronisation across the UK, potentially exacerbating health inequalities. This is a vital consideration the aforementioned parties must take when deciding to take steps asymmetrical to the UK Government. Meanwhile, the UK Government is still attempting to wade through the miry depths of as low as 16% in polls. There is wide speculation that a catastrophic round of May elections, however that will be defined, could see the likes of Angela Rayner or Streeting come into play. The latter of whom the BMA could will be happy to see the back of as Health Secretary…