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In its long and venerable history dating back 192 years, the British Medical Association used to shy away from being called a “trades union”.

Collective bargaining was for “trades people”; the doctors were independent professionals. Their association was there to campaign for best practice and to offer advice to the politicians regulating health treatment.

That was when the reflex of most medical practitioners was to subscribe to the Hippocratic principle often paraphrased as “first do no harm”.

Much has changed. Today the BMA has no qualms about being described as the “doctors’ union”.

It has freely employed strong-arm negotiating tactics, familiar from industrial disputes, in pursuit of better pay for its members – including strikes, walkouts, deadlines and work to rules.

These have culminated in the current “unprecedented” six-day strike by junior doctors in England, which is due to end at 7am on Tuesday.

There can be no doubt that the strikes are doing harm to patient care.

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NHS England has just reported that 89,000 “appointments and procedures” had to be put off because of the three-day strike in December.

Since the industrial action started last March, 1.2 million appointments have been cancelled and rescheduled.

The BMA rejected requests from the NHS to keep working in critical areas including fast-progressing cancers, corneal transplants and emergency caesareans.

Heated recriminations broke out as the BMA accused hospital managers of “weaponising” so-called “derogation requests” permitting them to recall staff to work if patient safety is “in jeopardy”.

Meanwhile, some A&E departments declared “critical” incidents with waiting times for treatment stretching as long as 16 hours.

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Patient backs NHS despite cancellations

PM failing to fix waiting list backlog

“Cutting NHS waiting lists” was one of the prime minister’s five pledges and this aim is seriously off track. Opinion polls taken during the dispute suggest that just over half of the public back the strikes (53%).

In a survey four months ago, people were more inclined to blame the government for the dispute (45%) than the BMA (21%), although 25% said they were both responsible.

Yet 11 months into the confrontation, the junior doctors, who lose pay on strike days, must be wondering what they are getting out of it. Their demand for a massive 35.3% pay rise still seems out of reach.

Having walked out of negotiations in December, Dr Vivek Trivedi, co-chair of the BMA junior doctors’ committee, now says he might be prepared to engage in more talks, saying “all we want is a credible offer that we can put to our members and we don’t need to strike again”.

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Although discontent over pay is widespread throughout the NHS workforce, most sectors other than junior doctors in England have accepted deals or, at the least, suspended their action.

NHS consultants accepted salary rises of up to 12.8% along with some pay reforms.

The Royal College of Nursing ballot for further strike action failed and a pay rise of 5.5% was imposed.

Health management is devolved. Junior doctors in Scotland accepted a 12.4% pay rise, on top of 4.5% in 2022/23. Junior doctors in Northern Ireland are balloting on a similar offer. In Wales, there is the prospect of a three-day strike from 15-18 January.

When negotiations broke down before Christmas, the government was offering a 3.3% increase on top of the 8.8% already imposed, taking the total for the English juniors above 12%.

A NHS hospital ward
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Junior doctors in Scotland have accepted a 12.4% pay rise

Junior doctors and members of the British Medical Association (BMA) outside Royal Victoria Infirmary, Newcastle, as they take to picket lines for six days during their continuing dispute over pay. Picture date: Wednesday January 3, 2024.
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The level of doctors’ real-terms pay cut is disputed

Are the strikes really ‘saving the NHS’?

By the standards of the other disputes, a reasonable settlement should be within touching distance were it not for the sense of grievance, embodied in the claim that pay has been cut in real terms by more than a third since 2008.

Few independent analysts accept the BMA’s calculation, which relies heavily on RPI inflation fluctuations. In line with recent trends for national statistics, the independent Institute for Government says the CPIH, the consumer price index, would be a more appropriate indicator, meaning a cut of 11-16%.

This was in the post-credit crunch, austerity period when wages across the public and private sectors stagnated.

The public is sympathetic to junior doctors who help to keep them well, but should they be an exception?

Over time, pay structures change. The youngest and lowest paid of those now on strike were at primary school in 2008; is it rational to restore their pay levels to what they were then?

“Junior doctors” is an unsatisfactory catch-all term for a wide range of hospital doctors. “Doctors in training” – which some Conservative politicians attempted to popularise – hardly does them justice either.

The term covers all hospital doctors who are not consultants, ranging from those just qualified and still effectively indentured, to senior registrars.

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First-year junior doctors earn £32,398, rising to £37,303 in the second year and £43,923 in the third. Registrars’ basic pay goes up to £58,000. Full-time NHS consultants earn up to £120,000.

On the picket lines, strikers often argue their action is not about their own pay but to save the NHS because, they say, many of their peers are leaving for better terms in Australia, New Zealand and Canada.

Conversely, as recent special grade immigration figures show, there are many qualified people abroad with conflicting aspirations who are anxious to come here to work in the NHS.

Junior doctor and members of the British Medical Association (BMA) on the picket line outside Leeds General Infirmary at the start a five-day strike amid the continuing dispute over pay, the longest walkout of its kind in the history of the NHS. Picture date: Thursday July 13, 2023. PA Photo.  See PA story INDUSTRY Strikes Doctors. Photo credit should read: Danny Lawson/PA Wire

Much to ponder on how the NHS should work

The additional crisis brought on by the strikes has inevitably prompted some rethinking about how the NHS is working.

Speaking to Sarah-Jane Mee on the Sky News Daily’s How To Fix The NHS mini-podcast series, Dr Adrian Boyle, president of the Royal College of Emergency Medicine, observed “that everything flowed better” in A&E departments because senior doctors providing cover had more direct contact with patients and “there were fewer people coming into hospital for elective work and this meant more beds”.

Those statements about organisation in the NHS should provide consultants, junior doctors and potential patients with a lot to ponder.

The same goes for politicians, who the public holds primarily responsible for delivering their healthcare.

Steve Barclay took an abrasively inactive approach to the various NHS disputes when he was health secretary. In November he was moved to make way for the more emollient Victoria Atkins.

She says she wants “a fair and reasonable settlement” to end the strikes and is open to further negotiations provided the threat of more strikes is withdrawn.

 Victoria Atkins MP
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Health Secretary Victoria Atkins

Shadow health secretary Wes Streeting speaking during the Labour Party Conference in Liverpool. Picture date: Wednesday October 11, 2023.
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Shadow health secretary Wes Streeting

Is the NHS broken – and would Labour do any better?

Atkins’ position is not much different from Wes Streeting, her Labour opposite number.

He has said for months that the disputes should be sorted out by negotiations with ministers and that a Labour government would not meet the 35% pay claim.

Streeting is of the view that reform, likely to discomfort some of the NHS’s vested interests, is more needed than extra cash.

Whatever view they take of the doctors’ actions, public pessimism about the NHS is on the rise.

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Labour won’t match doctors’ demands

Much as they love the NHS, growing numbers of the public say it is “broken” or “not fit for purpose”. There is also a live debate about whether doctors should lose the right to strike, just like the police and members of the armed services.

The pollsters regularly ask the question “should doctors be allowed to strike?”

Last summer, at the height of the consultants’ dispute, 50% said yes, 42% no. By November, support for doctors’ right to strike had dropped to 47% yes, 46% no.

The asking of that question alone would have astonished the founders of the BMA’s precursor, the Provincial Medical and Surgical Association, back in 1832.

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Diogo Jota’s joyous final weeks make his death even more devastating to comprehend

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Diogo Jota's joyous final weeks make his death even more devastating to comprehend

The joy that filled the final weeks of Diogo Jota’s life makes his death even more devastating to comprehend for his family and millions of fans worldwide.

The most illustrious title of his career was won in May, when he paraded through Liverpool with his teammates and the Premier League trophy.

More success came with Portugal as he won the Nations League for a second time alongside Cristiano Ronaldo in June.

And then came the bliss at marrying his childhood love Rute Cardoso, watched by their three children.

Latest: Liverpool players pay tribute to Jota

Just yesterday Jota posted a video from the ceremony on social media alongside the message “a day we will never forget”.

The happiest of days was remembered before the tragedy that killed Jota and his brother Andre Felipe in northwest Spain.

Diogo Jota and wife Rute
Pic: rutecfcardoso14/Instagram
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Diogo Jota and wife Rute. Pic: rutecfcardoso14/Instagram

Brothers – whose careers both developed at their hometown club, Porto – so tragically dying together.

“Football has lost two great men,” Porto president Andre Villas-Boas said, as fans descended on the club’s stadium to mourn.

At Anfield, Liverpool fans are grieving the versatile forward who was so often in the shadow of Mohamed Salah, as he was under Ronaldo at Portugal.

But he knew how to sacrifice stardom to contribute to the squad.

Liverpool's Diogo Jota holds the  Premier League trophy with Wataru Endo and teammates.
PIc: Reuters
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Diogo Jota holds the Premier League trophy with Wataru Endo and teammates. PIc: Reuters

The last of his 65 Liverpool goals was the winner in the Merseyside derby against neighbours Everton in April – helping the club become the record 20-time champions of England.

A Premier League winners’ medal joining those from the FA Cup and League Cup, won by the 28-year-old after he joined the Reds in 2020.

It was Wolverhampton Wanderers who gave Jota a platform to shine in England after he joined from Atletico Madrid.

Promotion was gained to the Premier League in 2018, and they more than just avoided relegation, but secured back-to-back top-seven finishes.

Jota was a reason why.

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Fans react to Jota death

He was also why Wolves could embark on such a memorable European campaign, and scored two hat-tricks in the run-up to the Europa League quarter-finals in 2020.

“The memories he created will never be forgotten,” Wolves said.

For the football world, the loss of such a talent so young will be hard to comprehend.

And so many are reflecting on the fragility of life as football grieves from Liverpool to Portugal – and beyond.

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Grooming victim ‘lives with trauma every day’ – as force investigates crimes involving more than 700 survivors

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Grooming victim 'lives with trauma every day' - as force investigates crimes involving more than 700 survivors

The father of a grooming victim who was raped by more than 60 men has said she still lives with the “trauma every single day”.

Marlon West, 51, said Scarlett, now 20, was an academic student at a school in Greater Manchester.

She was happy with a good friendship group and enjoyed riding her horse, Jasper.

But her life changed after she was attacked by a gang at a bus station – they started bullying her and she decided it was better to become their friends.

An older female member then started grooming her for rape gangs made up of Muslim men, her father told Sky News.

Scarlette's school photo before the abuse began
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Scarlett before she was groomed

Mr West said six men were involved in grooming her from the age of 14 but she was raped by more than 60 before the abuse finally stopped shortly before she turned 18.

By then, she was too terrified to leave home.

“Scarlett isn’t a survivor and a lot of these other girls aren’t survivors,” he said. “The reason being is they’re still living with the trauma every day.”

Mr West, an advanced nurse practitioner for mental health services at the NHS, said his daughter was thrown out of school aged 14 and would go missing for weeks at a time.

On one occasion, he tracked her down to a property in Derbyshire, but when he eventually persuaded police to attend, he was told Scarlett was “safe” with the woman who groomed her and “her friends”.

Scarlett enjoyed riding her horse
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Scarlett enjoyed riding her horse

Mr West said he was “absolutely furious” when police and social services dismissed the abuse as “a lifestyle choice” and was so desperate he put Scarlett into care when she was 15.

“I couldn’t keep her safe,” he said. “It’s the hardest decision of my life.”

But within a week of her returning home, when she had to leave the care system after turning 16, she was going missing again.

Mr West said the female groomer had stayed in contact with Scarlett and “was literally waiting for her” when she came home.

She was then trafficked all over the country, including Bradford, Birmingham and London.

Marlon West and his daughter Scarlett look information on her case
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Marlon West and his daughter Scarlett

Mr West said he had to “scream” at police to track her down before they raided a property in Rochdale where she was found along with heroin and crack cocaine.

Scarlett was arrested and released on bail, but wasn’t charged because she was on a Home Office database as being at risk of trafficking, he said.

“Even though that [arrest] was inappropriate, that stopped it because she was terrified of going out of the house, which she still is now to a certain extent.”

Mr West believes the abuse also came to an end because she was getting older and her abusers were no longer interested.

“This is not just about child sexual exploitation but also criminal exploitation – she was doing county lines, she was picking up firearms for them,” he said.

Scarlett and her dad Marlon
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Scarlett and her dad Marlon

Mr West said any child can be at risk of grooming.

“They’re stereotyping a lot of these survivors, that they’re coming from broken homes, or they’re in care,” he said.

“A groomer doesn’t stand outside a school gate and think, ‘I’m not grooming her because her dad’s a doctor or her dad’s a GP’ – they don’t care. Once they target, that’s it.”

Mr West was speaking as a report by police watchdogs revealed Greater Manchester Police has live grooming investigations involving 714 victims and survivors.

The force said it has 1,099 lines of enquiry relating to potential suspects but only 269 who are confirmed.

“I think there’s more – a lot of survivors haven’t come forward. One, because they’re probably still being groomed and secondly because they’re terrified of GMP and how they’ve been treated in the past,” he said.

“It’s higher than it’s ever been. Services such as police and social services are terrified of political correctness.

“The groomers know they can get away with it because there aren’t many arrests and so it’s increased.”

GMP Chief Constable Sir Stephen Watson promised to go after child rapists and paedophiles “relentlessly” after the publication of the report, which was largely positive about the force’s turnaround in tackling the gangs.

But Mr West believes they are “still failing”, although he welcomed the investigation opened into his daughter’s case.

He said he is “hopeful” the national inquiry into grooming gangs by the government last month “will expose a lot of the cover-ups and give accountability” but is worried about the involvement of services such as councils and police forces because of a lack of trust.

A GMP spokesperson said: “We have met with Scarlett and her father and we’re conducting an extensive investigation into their allegations.

“While we understand the impact of their experiences cannot be undone, we aim to ensure that the experience of the GMP of today would be much improved from that of previous years.”

A Tameside Council spokesperson previously said they were legally unable to comment on Scarlett’s case.

But they said: “Where any concerns or issues are raised we work closely with individuals, families and our partners to provide support and resolve, as appropriate.

“Where individuals aren’t satisfied with the services received, we do have a statutory complaints procedure and individuals can ultimately take their complaint to the Local Government & Social Care Ombudsman.”

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Fiscal rules are silly but important as Reeves has banged on about them and markets care

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Fiscal rules are silly but important as Reeves has banged on about them and markets care

You’re probably tired by now of hearing all about “black holes”.

It’s one of those phrases trotted out by journalists in an effort to make economic policy sound a little more interesting. And in some senses it’s a massively misleading image.

After all, when people talk about fiscal holes, what they’re really talking about is something rather prosaic: the amount of money it would take for the chancellor not to break her fiscal rules.

Those fiscal rules are not god-given, after all. They were confected by the chancellor herself. Missing them will not really result in Britain sliding into infinite nothingness. Even so, whatever you choose to call the dilemma she’s faced with right now, it’s certainly quite a big deal.

Rcahel Reeves NHS 77th birthday
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Rachel Reeves speaks at the NHS’s 77th birthday

And understanding this helps provide a little context for the extraordinary events of the past few days, with markets sliding in the wake of Ms Reeves’ teary appearance at Prime Minister’s Questions.

Following that moment, the yield on UK government debt – the rate of interest we’re being charged by international investors – suddenly leapt higher. Granted, the jump was nothing like what we saw in the wake of Liz Truss’s mini-budget. And those yields dropped down after the prime minister backed the chancellor.

UK’s a global outlier

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Even so, they underline one very important bit of context. The UK has become something of an outlier in global debt markets. For years, the yield on our benchmark government bonds was more or less middle of the industrialised-world pack. But since 2022’s drama, it has hovered unnervingly high, above every other G7 nation.

That speaks to a broader issue. Britain might not have the biggest deficit in the G7, or for that matter, the highest national debt. Others (most notably France, and to some extent, too, the US) face even more desperate fiscal dilemmas in the coming years. But markets do still seem nervous about Britain.

Perhaps that’s because of what they (and we) all endured in 2022 – when British gilt markets stepped briefly over the precipice, causing malfunctions all around the financial system (most notably in obscure parts of the pensions investment sector). But it also owes something to the fact that the chancellor’s own fiscal plans are sailing worryingly close to the wind.

Reeves made fiscal rules matter

The main piece of evidence here is the amount of leeway she has left herself against her fiscal rules. As I said at the start, there’s nothing gospel about these rules. But having created them and banged on about them for a long time, even those of us who are a little sceptical about fiscal rules would concede that breaking them is, as they say, not a good look.

Back in spring, the Office for Budget Responsibility thought the chancellor had about £9.9bn in leeway against these rules. But since then, she has u-turned on both the cuts in winter fuel payments and on personal independence payments. That reduces the £9.9bn down to barely more than £3bn.

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But the real issue isn’t just these U-turns. It’s something else. The stronger the economy is, the more tax revenues come in and the more her potential headroom against the fiscal rules would be. By the same token, if the economy grows less rapidly than the OBR expected, that would mean less tax revenues and an even bigger deficit.

And if you compare the OBR’s latest forecasts with the current average of forecasts among independent forecasters, or for that matter, the Bank of England, they do look decidedly optimistic. If the OBR is right and everyone else is wrong, then the chancellor “only” has to fill in the hole left by those U-turns. But if the OBR is wrong and everyone else is right, things get considerably more grisly.

Even a small downgrade in the OBR’s expectations for productivity growth – say a 0.1 percentage point drop – would obliterate the remaining headroom and leave the chancellor with a £6bn shortfall against her rule. Anything more than that (and bear in mind, most economists think the OBR is out by more than that) and she could be £10bn or more underwater.

Now, there are plenty of very reasonable points one could make about how silly this all is. It’s silly that so many people treat fiscal rules as tablets of stone. It’s silly that government tax policy from one year to the next seems to hinge on how right or wrong the OBR’s economic forecasts are.

Yet all this stuff, silly as it might all seem, is taken quite seriously by markets right now. They look at the UK, see an outlier, and tend to focus more than usual on black holes. So I’m afraid we’re going to be talking about “black holes” for quite some time to come.

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