Junior Doctors. Brinkmanship. Virtual Strikes.

Here we go again. As August tipped into September, the British Medical Association announced the seventh walkout by junior doctors this year over new contracts. Taking place from the 12th to the 16th of this month, all departments will be closed from 08:00 to 17:00, including Accident and Emergency. Health Secretary Jeremy Hunt has already warned that up to 100,000 operations and 1 million appointments would be cancelled. It can also get a lot worse as the BMA has planned monthly week-long walkouts until the end of the year if no agreement is reached. With no end in sight, is there at least a way of making the process as painless as possible for patients?

The stakes are a lot higher when doctors go on strike compared to when, let’s say, rail workers do so. Instead of interrupted commutes, human lives are possibly at risk. Theoretically, this means that an agreement between the unions and the management ought to be reached relatively quickly. This is because both parties understand the risk of adding an extra day of strikes. Brinkmanship describes a situation where parties increase bilateral risk in an attempt to see who crumbles first. If junior doctors go on strike, brinkmanship could result in deaths, irreversible and incredibly destructive to both the government and the NHS. With such risk, someone tends to blink sooner rather than later.

So why has this conflict lasted so long? It is partly because up until recently the strikes have not been serious enough to significantly endanger lives and therefore incentivise action. The first four strikes of 2016 did not affect the emergency departments but in April, two further strikes saw junior doctors walk out of A&E for the first time in the entire history of the NHS. It was no surprise that a compromise was seemingly reached less than a month afterwards; it was just unfortunate that the new contract was voted down 52-48. This leads on to another reason why no resolution has been made. Strike action only occurs when neither side is willing to give in to the other and when both parties are convinced that the other will fold before they do. It is highly likely that the Health Secretary sees the division within the BMA as a sign that the contract would be eventually accepted. On the other hand, junior doctors believe that its public support will force the government to concede before its voter base starts eroding. Both sides, in their belief of success, can prolong the issue until a shock jolts the stalemate.

Until then, the negative externalities of the strike could very well result in serious and possibly fatal consequences. So is there a way of removing the externalities whilst maintaining the strike? In theory, yes. Over fifty years ago, the ‘virtual strike’ was invented. Everybody goes to work and does their job before going home in the evening; from the point of view of a consumer (or patient) everything is business as usual. Except it isn’t; during a virtual strike nobody gets paid and the management surrenders its revenue to charity or to the state while it is going on. The costs of the strike are isolated to the conflicting parties and consumers don’t suffer; they can even benefit if instead of donating revenue, the firm temporarily offers its goods and services for free. There is also no long term damage to the business such as customers switching to rival firms out of distaste for the strike. Furthermore, giving to charity can be a public relations boon. So why not implement a virtual strike for junior doctors?

One glaring issue is that this brilliant idea does not translate easily, if at all, to the public sector. Private businesses still lose profit or even make losses during a virtual strike. The government does not make any profit (generally) from the activities of the NHS. All their revenue comes primarily from taxation or borrowing. Junior doctors might turn up to work for nothing but their employers are no worse off as there is no revenue to give away, thus defeating the point of the virtual strike. Getting the government to donate money to charity while the strike continues does not help as this is likely to damage the NHS and other sectors of spending more than the government itself.

However there is a possible, if not incredibly awkward, solution. It would involve cutting the wages of all ministers in the Department of Health, either in part or completely, during a strike (by doctors). This mimics the effect of a virtual strike on a private business, putting a cost on the government whilst maintaining service for the public. John Smith from Surrey could have his biopsy and if he is involved in a traffic accident on his way there, at least he could go to A&E. The negative externalities have been removed from the strike but the negotiation remains. Similar to a director’s board fearing a serious fall in revenue, ministers involved in the negotiations with the BMA would be incentivised by the threat of a disappearing pay packet to reach an agreement quickly. The effect of brinkmanship is preserved as both parties rack up increasing costs but now an avoidable fatality will not be the worst case scenario.

Admittedly, there are numerous issues with this idea. The temporary wage cut for ministers may not be enough of an incentive to compromise. Compared to a junior doctor, ministers generally enjoy a larger salary and will therefore suffer less over the course of a virtual strike. Not only that, salaries are not the be all and end all for the government (though many like to think so). The Conservative Party was voted in and it was in their manifesto to introduce a 7-day NHS so they should deliver on their promise as part of the democratic process. So even if Jeremy Hunt was willing to make concessions out of his own interest, his party as a whole may not be so keen. A cynical solution to this would be to dock the wages of all Conservative MPs during a strike, a ludicrous idea but not much further than what I’ve already proposed.

However, the greatest problem with a virtual strike is that negative externalities are often desired by the striking party. By inconveniencing the general public the government, whose existence depends on their approval, suffers more damage than a wage cut could ever achieve. It would be wrong to claim that the BMA are hoping for casualties but as long as public opinion rests with the junior doctors, the outside consequences of the strike would be more damaging to Jeremy Hunt than it would be to them.

For the time being, neither side is giving an inch. Jeremy Hunt has a democratic mandate to bring in a 7-day NHS but the BMA has repeatedly claimed that this would be impossible without extra funding and the new contract isn’t helping. The deadlock will persist and as the BMA and the Department of Health move towards the brink one hopes that something changes before they both slip and irreparable damage is done.


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