Strike Two: The Ballot That Could Backfire

Has the BMA played the strike card too early?

By launching a new strike ballot this month, the BMA is making a bold political bet — one that might not look risky at first glance, but could carry immense long-term consequences for the union. What exactly went on behind closed doors at BMA HQ, we can only guess — but for their sake, we hope someone at the BMA has done their homework…

Now, let’s talk mandates. A mandate doesn’t just mean winning votes. In politics, a mandate isn’t just a win; it’s a win that counts. A party can get 90% of the vote share, but if only 5% of people turned up, it's hardly a roar of public confidence. That’s why political operators time elections with almost obsessive precision, reading polling data and the national mood. So it’s not just about victory, but legitimacy. A mandate gives the BMA a right to carry out its policies.

First time around

Back in June 2024, the BMA had it. A landslide. An overwhelming 98% of resident doctors backed continued industrial action, on a turnout of 71.2%. For context, that’s more than the 2024 general election turnout of 59.7%. The message was loud, clear, and united. No visible fractures. No wiggle room for opponents to say, “Well, it’s only a vocal minority.” That’s what a mandate looks like. The BMA did their homework — months of prepping online graphics (yes, that one comparing doctors’ hourly pay to baristas), and making the rounds in hospitals to field questions and rally support.

This time, the union’s reopened the ballot — and for many, it feels early. The campaigning infrastructure takes time to mobilise. Resident doctors are stretched. Public focus is split. It takes time to create ‘meaning’ and a sense of unity. If turnout is low or the result tepid, it doesn’t just weaken the strike effort. It opens the door for opponents to say, “See? Even the doctors are losing interest.”

And that’s the political danger. A poor turnout lets ministers and media pundits paint the issue as fringe, or no longer urgent — even if the real story is more complicated. Maybe resident doctors are waiting to see a formal government pay offer. Maybe amidst the backdrop of difficult economic times, they think the timing is wrong. Maybe their priorities have temporarily shifted to things like training reform or workload pressures. But those nuances won’t make the headlines. What will is: “Doctors vote no.”

Will Wes show his cards?

Labour knows this too. Wes Streeting and company are no strangers to strategy. They may choose to sit on a pay proposal, letting the ballot play out. If the result is weak, they can shrug and say, “Unlucky, not our fight anymore.” If it’s strong, only then might they engage.

So, the BMA have taken a monumental gamble. A weak mandate risks signalling to the government, media, and even the public that the appetite for full pay restoration is waning, regardless of whether that’s truly the case. If the BMA falls short now, it could find itself shouting into the void for time to come…

If More Hard Work Equals... More Hard Work, Why Bother?

In the NHS, the reward for hard work often seems to be... more hard work. Take cath lab or theatre lists, for instance. Patients wait days for their angiograms, only for cases to be delayed or cancelled due to staff breaks not aligning. Nurses, radiographers, and physiologists often don't adjust their schedules, leading to stoppages. And why would they? They get paid the same whether five or ten cases are completed.

This isn't about blame — it's about a system that doesn't incentivise efficiency. The current pay structure doesn't link effort to reward. A fee-for-service model, where compensation is tied to the volume and complexity of work, could change this dynamic.

Implementing such a model could address issues like the 30,000 operations cancelled last year due to staff shortages. So could the UK benefit from a fee-for-service model? This one certainly could do with an On-Call deep dive in the future—keep your eyes peeled.

Equal Pay, Unequal Days

Does it make sense for the NHS to pay all doctors the same?

In the UK, no matter the speciality, all doctors are created equal - at least on the payslip.

The idea that all doctors are roughly paid the same per hour, irrespective of their day-to-day realities, has long been a source of quiet contention. Picture an F2 sprinting between crash calls in A&E with barely a moment to breathe — are they really doing the same job, per hour, as their fellow F2 working in Old Age Psychiatry?

Or take the neurosurgery registrar (we’d never hear the end of it if we left them out) — a decade or more out from graduation, clocking relentless hours and weekend shifts. How do we square that with specialties offering earlier CCTs and, arguably, more predictable schedules?"

So here is the bigger question: How should we price medical labour?

Who Pays for Time and Risk?

One rational starting point is training time. GPs, for instance, can often complete specialist training in just three years, entering the consultant pay scale far earlier than their hospital-based colleagues. Should someone who accrues more debt, delays earnings, and sacrifices personal flexibility for longer be compensated differently? At the very least, it’s a question worth asking.

Then there’s risk. And not just clinical complexity — we’re talking real-world legal jeopardy which we could access through Medical Defence Union databases. High-stakes decisions, coroner’s court appearances, and GMC referrals: should indemnity risk and the emotional load of constant scrutiny be reflected in pay? Nearly every other sector prices risk — why not healthcare?

The Free Market’s Invisible Hand

It’s tempting, when faced with the complexities of pay reform, to throw up our hands and appeal to the invisible hand of the market. Let supply and demand do the heavy lifting. We can’t possible know all the market forces which govern supply and demand. If emergency medicine struggles to recruit and ENT is oversubscribed, surely the rational response is to raise pay for the former and leave the latter be?

But this could lead to some pretty absurd outcomes — for instance, in London’s oversubscribed and high-demand market, pay could actually be cut in a city where the cost of living is already through the roof.

In market-based systems, like in the U.S., procedural specialties that generate high revenue like orthopaedics, interventional cardiology, plastic surgery — command the biggest pay packets. Not necessarily because they're harder or riskier, but because they’re lucrative. They generate significant income for hospitals. In the U.S., doctors' personal earnings make up only around 8.6% of total healthcare spending, despite the popular belief that it's their pay cheques driving up costs.

But the NHS doesn’t reward revenue generation in the same way. And if we applied pure market logic within it, we’d risk incentivising doctors to gravitate toward what’s profitable, not what’s needed. That’s a dangerous path. Do we really want a healthcare system that struggles to staff geriatrics or general medicine because they don’t ‘pay’ as well? The moral argument against market logic is that some specialties, while unglamorous or low-income-generating, are vital.

A Talent Bidding War

It’s worth asking: if we introduced variable pay across specialties or regions, what would the landscape of NHS staffing look like? Few would dispute that some specialties are more demanding — whether in terms of training length, workload, or legal risk. But if we allowed open salary competition between trusts or specialties, we risk creating a bidding war for talent.

Predictably, it’s the already desirable, better-resourced trusts — often in urban, affluent areas — that would have the edge. These institutions already attract more applicants due to location, teaching opportunities, and prestige. If they were also able to offer higher pay, we could see an even greater concentration of doctors in areas that are, frankly, least in need of them.

“if you're spending such money on a set of scrubs it defeats the point of scrubs entirely. May as well be wearing some decent formal clothes once you're spending figs money.”

“Something I've learned over the years, when someone is confrontational... "I want a blood test." ",Which blood test...? There are several thousand available...: "I want a scan!", "Which one? Contrast or non-contrast? Which modality?" - Usually quietens them…”

“Reddit and medics often fixate on the negatives — not without reason — but in this cohort, few have worked outside medicine, instead relying on anecdotal stories of others earning easy money and high respect that are mostly fantasy”

What’s on your mind? Email us!

Some things to review when you’re off the ward…

A study presented at the European Congress on Obesity, featured in the news this week, proposed that weight-loss injections like Ozempic could boost the UK economy by helping people return to work—potentially generating an additional £4.5 billion annually in productivity.

Fortunately for our health, there isn’t a drinking game that involves taking a shot every time the government mentions the £22 billion blackhole left by the Conservative government. So, how does the government plan to tackle this shortfall? According to the BBC, it might involve unprecedented cuts to the NHS…

The NHS is launching a new initiative providing obese children with free 'numberless' scales to monitor weight without displaying the actual readings, data from these scales sent directly to clinics, where doctors can monitor progress and provide support. (The Independent)

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Old But Gold? Time to Rethink Retirement

Be honest—how many times have you heard someone mutter, “Should’ve retired years ago,” about a silver-haired consultant still scrubbing in?

By 2050, 34% of the working-age population will be between 50 and state pension age (up from 26% in 2012) - and we’ll need them. The number of over-65s is soaring, dependency ratios are climbing.

According to the UK Government’s Future of an Ageing Population report, supporting older people to stay in fulfilling work is essential to keep our economy ticking. Yet outdated attitudes persist—age is seen as a weakness rather than the asset it is. The biggest irony? While we train our most junior doctors in resilience (forgiving their mishaps and shortcomings), we overlook the literal embodiment of it in our senior colleagues when they aren’t the quickest with the technology for example.

Instead of nudging senior clinicians toward the golf course, we need to start appreciating the decades of wisdom they bring.