Last week, Jeremy Hunt finally went nuclear. After weeks of increasingly martial language, he announced to the Commons that the government's new contract would be imposed on junior doctors come what may.
Doctors responded to this show of brute strength by erupting in furious condemnation on social media. More poignantly, up and down the country in hospitals like mine, there were tears and despair from many juniors, some of whom have now resolved to quit the job they love and leave the NHS.
For the public - sick and tired of their healthcare being compromised by an industrial dispute as toxic as it is tiresome - the television images of tearful junior doctors must have been utterly baffling. After all, this is a pay dispute, isn't it? One in which both sides are so close to agreement that only a few minor quibbles require resolution? The government and the BMA both insist their only motivation is protecting patients, yet still the sour dispute drags on. No-one wins, but for the patients who are by far the biggest losers, patience must be wearing exceedingly thin.
The first step to conflict resolution is understanding the conflict's root cause. Last summer, the BMA made a fundamental tactical error. Contract negotiations between the government and the BMA had long pre-dated the 2015 Conservative manifesto commitment to a "truly seven-day NHS". Yet that pledge transformed their terms of reference. Now, instead of merely modernising junior doctors' contracts, the aim of negotiations was to deliver a whole new set of weekend services from within the same 'cost neutral envelope'.
That, with hindsight, was the crux point. The BMA should never have accepted the premise that a seven-day NHS, while entirely admirable, could be achieved without proper investment. Cost neutrality is a nonsense. Even Jeremy Hunt's own department has refuted the idea that new seven-day services do not entail investment, with a leaked Department of Health report from this January estimating that 4000 new doctors, plus an extra £900 million a year, are required to deliver a seven-day NHS. That soundbite may sound seductive, but until the government addresses publicly what resources and staff are required to achieve the seven-day NHS, it is a wholly empty promise.
In accepting the premise of cost neutrality, the BMA is inadvertently colluding with the government's façade that you can get seven days for the price of five. Meanwhile, junior doctors are distraught because we know that without extra funding, the burden of delivering this manifesto pledge will fall, ultimately, on us. There are simply no new doctors, let alone 4000 of them. And like everyone working in an NHS with a £30 billion deficit to plug, we are already close to breaking point. Overworked, exhausted, running on empty, we cannot be stretched more thinly to provide new services at weekends. We have nothing left to give, and we know all too well that exhausted doctors ultimately endanger their patients. The marches on Downing Street, the days of industrial action, are for us acts of sheer desperation. Pay is not the issue, but survival: our own and that of our patients.
To end this dispute, the prime minister, whose silence on this matter has been deafening, needs to recognise that sitting silently on the sidelines is no longer an option. His health secretary has become a hate figure for doctors, so it is up to David Cameron to lead from the top. Next, the government must come clean about the thousands of new staff required to provide a genuinely seven-day NHS. The public has a right to decide for itself whether it wishes to commit taxes to this manifesto aspiration. Above all, the government must take its lead from Sir Robert Francis who, in dissecting the causes of the scandal of mid-Staffs, formally recommended that no major structural change to the NHS should be accepted before its "impact and risk assessments" are made public, and debated publicly.
We need to put a brake on imposition. The prize of getting these discussions right is a safer NHS for every patient, every day of the week. To that end, we need an urgent, open review of the affordability, cost-effectiveness and desirability of a "truly seven-day NHS". Every other new technology and drug is subjected to rigorous assessment by the National Institute for Health and Care Excellence to establish whether or not it offers the taxpayer value for money. The seven-day NHS should be no exception.
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