Counting the cost of NHS strikes

NHS strikes have become such a familiar feature of our lives over the past two years that there is a risk we can become inured to their impact. Here then, is a reminder of the different ways in which strikes can impact the NHS and the people it serves.

Figure 1 Four areas that can be affected by NHS industrial action

The impact on staff

The impact of strikes on the personal finances of NHS staff is hard to assess, partly because striking workers may not completely lose out on pay if they can access union-organised collective funds. But the mounting number of lost working days is still clearly a concern during a cost-of-living crisis that has led to many NHS employers offering staff food banks.

For health care staff who view their work as a vocation (and were already routinely working several unpaid hours a week), strikes can pose the risk of moral distress and injury, where staff feel a tension between their actions and their moral beliefs it can lead to longer-term psychological harm. And with concerns being raised about the impact of strikes on applications to nursing and midwifery schools, it may be that prolonged industrial action will not only take a toll on current staff, but also affect plans to grow the NHS workforce.

Staff who aren’t out on strike are also heavily affected by industrial action. This includes the moral distress to administrative staff who need to tell patients their treatments are being delayed and clinical staff who have their annual leave cancelled so they can cover essential services. As one London chief medical officer has said: ‘Strikes also have a huge physical and emotional impact on our staff. The weeks before strikes are absorbed by reorganising services, negotiating staffing cover, making cancellations and rebooking patients... and the weeks after are spent catching up on pent-up demand, while trying to allow appropriate rest and recovery for staff.’

Because NHS staff are not a homogenous group and strike action can be divisive, strike action may risk fracturing relationships between different types and grades of professionals. In the past year I’ve spoken to more than 100 NHS clinicians who were grappling with the decision of whether to strike and how to support or challenge the decisions of their colleagues. I’ve heard the gamut from ‘If I was in their shoes, I’d be out on strike too’ to ‘I’m sorry but they just need to suck it up’. More than anything, I’ve been struck by how often I now hear the words ‘they’ rather than ‘us’ in these conversations.

The financial impact on the NHS

NHS England has said that through to the end of January 2024, the impact of strikes came with a financial cost of £1.5 billion. And other organisations have said the costs could be even higher. But quantifying the financial cost of strikes is not an easy task.

First, are the relatively direct costs in the here and now, such as additional spending on temporary staff to cover the shifts of striking workers. But additional costs can be stored up too, such as the cover provided by NHS staff who cancel their annual leave to keep services running and who will either have to be paid in lieu or carry their extra leave into future years.

Second, are the costs of lost activity during the strikes. This can become a financial headache for the NHS in the future if it has to catch up with the cancelled and postponed activity by using expensive additional weekend or evening sessions and clinics.

Third is the opportunity cost of dealing with strikes. This includes everything from the time it takes national bodies to produce copious FAQs on the impact of strikes to the headspace of senior leaders in the government, unions and NHS that could have been directed towards other matters. The government estimated that it would cost NHS employers £1 million alone to familiarise themselves with the legislation and guidance around minimum service levels in hospital (including two days of chief executive and board-level time in each NHS provider). So, we know at least that the financial costs of strikes are widespread and substantial – to the extent that the impact of NHS strikes are now being cited in monthly UK GDP statistics.

The impact on patient care

NHS strikes are not the principal reason why the government has failed to meet its commitments to improve NHS hospital waiting times. But at the same time, patient care is clearly being affected by strike action.

NHS England data shows that more than 1.3 million health care appointments have been rescheduled because of industrial action so far (Figure 2). But even this understates the issue – partly because not all NHS organisations routinely report this data, and partly because some NHS organisations book fewer appointments than usual in on strike days in the first place (and hence have fewer appointments to cancel).

So, patients are having to wait longer for care – but how does this affect their health outcomes? Here we enter trickier territory. Analyses of hospital data during previous strikes – particularly the junior doctors’ strike in 2016 – suggest that mortality rates for patients admitted to hospital are not significantly different on strike days. In part, this may reflect the protection put around critical services, such as non-striking staff covering critical care or A&E, and striking staff agreeing derogations (or exemptions from strikes) to deliver care to patients.

But measuring the impact of strikes on the health of the nation is complex. The context is always changing – for example, the 2016 junior doctors’ strike was very different to the present wave of strikes because it was pre-Covid-19 and only involved one largely hospital-based staff group. The NHS has good outcome data on patients who were admitted to hospital during strikes, but not on the outcomes for people who stayed away or were not able to access services. A recent Healthwatch research report suggested cancelling or delaying care (for reasons that include – but go beyond – strikes) had a self-reported impact on both the physical and mental health of patients (Figure 3).

The impact on public perceptions

An even more complex issue is how the strikes might be affecting the public’s views of the NHS and trust in public services. For example, in Healthwatch’s research, 15% of surveyed people said the NHS told them their care was postponed because of strikes, but a further 24% believed ‘strike action was the reason for the cancellation – even though NHS services had not told them this’ (Figure 3).

Previous studies have found the public often hold governments or health service leaders, rather than striking health care professionals responsible for strikes. And, the public in the UK are still broadly more likely to support, rather than oppose, strikes from most health care workers (especially when compared to other striking workers, such as teachers, railway workers and civil servants). But a recent set of polls from Ipsos and YouGov (Figure 4) shows that backing for strikes from medical professionals can also wane as well as wax.

Conclusion

It is helpful to have a structured way of thinking about how strikes are affecting patients and the public as well as NHS staff and services. But there is a risk that we try to over-rationalise something that has never happened before. Something that inflames passions and stokes anxieties. The government and union representatives are not short of reasons to come back to the negotiating table. The breadth of areas that NHS strikes touch, and the depth of the impact they can have, are just two more reminders of what is at stake.