Junior doctors' row: Time for the nuclear option?

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News that junior doctors have rejected a final "take-it-or-leave-it" offer from the government in the contract dispute means the nuclear option - imposition - is now a real possibility.

Over the past week ministers and their officials in England have been putting real thought into how and when they should make their move. Given the latest developments, expect it any day.

Why now? Quite simply, they've been told the time has come. Senior NHS officials have advised them that the health service needs to start making plans if a new contract is to be brought in this summer as planned.

That's because hospitals would need to carry out a detailed review of rotas and staffing before contract offers are made in May, in time for the August start date.

But once that has been done, the contract could be imposed quickly. Within six months about 80% of junior doctors would be on a new contract - this is because as trainees, most of them quickly rotate through jobs.

That's the theory anyway. But imposition is fraught with difficulties - and ministers know this. If they do impose the contract there will be a collective holding of breath in the corridors of power as they wait to see what junior doctors do next.

That's because the anger and determination of the profession to resist these changes has time and again taken ministers by surprise.

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So how would the BMA react? The union has so far refused to be drawn on the issue in detail publicly.

One option is to carry on with strikes, which they have the mandate to do - although privately there is concern within the union that they could lose public support if they do (the latest poll by Ipsos MORI shows two-thirds back the medics).

Legal challenges are also being discussed behind the scenes, while a mass non-signing of the contract or symbolic resignation from the NHS could take place - but if doctors subsequently turned up at work it could be argued they're effectively accepting the terms.

The fact is there are limited options. The NHS is effectively a monopoly employer after all.

But it would be a risk though to assume that doesn't mean there will be no impact on the numbers staying in the health service. Already one in two doctors who finish the foundation stage of their training - the first two years after graduating from medical school - step off the junior doctor training ladder by not going straight into speciality training.

Some go abroad - to travel and to work - while others are tempted by opportunities in alternative sectors, including the pharmaceutical industry and (apparently) cruise liners who employ ship doctors. And Scotland and Wales would no doubt welcome some of the best English trainees into their health systems given half the chance.

Significant numbers are also working as locums in the NHS, in the knowledge that the demand for doctors means there is good money to be earned by working in a freelance capacity.

Of course, many of these medics do end up returning to training. But even under the existing contract that has not been enough to fill the gaps - there are shortages in a whole host of specialities from GPs to A&E.

If the government does go ahead with imposition and that situation is made worse, questions will be asked in years to come whether the government did the right thing. Imposition may solve a short-term problem, but the long-term effect is unknown. The stakes could not be higher.

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