Support or opposition to strike action is often largely influenced by people’s attitudes to the people going on strike and the inconvenience it causes them. If it’s a profession that people admire and think is generally hard done by they’ll sympathise, if it’s a profession that people don’t think much of they won’t. If the inconvenience it causes people is relatively minor, people will understand; if it really puts out large numbers of people, like school or tube closures, then sympathy is less forthcoming. The specific ins-and-outs of the dispute are often impenetrable or irrelevant. It’s who we trust, who is the good guy.

The public hold doctors in extremely high regard and unless they happen to have had a hospital appointment today it’s unlikely to cause most people any direct noticable inconvenience, so you’d expect fairly high support. That’s what the polls show. Ipsos MORI had a new poll for yesterday’s Newsnight which found the public supported strike action emphatically (66% to 16%) when junior doctors would still provide emergency care, and much more narrowly (44% to 39%) if junior doctors would not provide emergency care either. Full tabs are here.

Late last year before the intitial round of strikes were postponed YouGov found a similar pattern – people clearly supported strike action by 51% to 32% when junior doctors would still cover emergency treatment, when strike action would also cover emergency care people were more evenly divided (45% to 37%). Tabs are here.

At present this breaks the way you would expect in an argument between politicians on one side, and trustworthy and overworked people who come to your rescue when you’re ill on the other. If strike action that also involves emergency care goes ahead though public opinion may become more finely balanced.

111 Responses to “Polling on the Junior Doctors Strike”

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    I agree that the Public Sector pay freeze must be stretched as far as it can go now.

    The Junior Doctors of course have just been offered an increase in basic pay.

    I agree that MPs should not award themselves pay increases whilst legislating for Public Sector pay freezes

  2. Correction-of course MPs no longer decide their own salaries.

  3. @Colin

    In real terms, for many public sector workers it’s not been a freeze but a cut. Especially when you then add in pension hits.

    To mention that basic pay has gone up obscures the full effect of the package and how it could be deleterious in future once they cancel the top up payments, (maybe if bankers mess up again!!)

    Oh, have the MPs set up an independent body for their pay? That’s odd, ‘cos they’ve been known to cancel them for other public sector workers…

  4. I think this goes far beyond the specific issues that the BMA and Government are currently negotiating and is, like most industrial disputes, growing a multiplicity of heads as it progresses. That’s not to say that the issues of pay and working hours aren’t important ones for Junior Doctors, but I suspect something else is going on here too. There appears to be particular antipathy towards the Health Secretary, Hunt, and this may well partly explain the BMA’s fairly unusual belligerence, and I also think that the militancy of the doctors stems from a growing disquiet amongst those working within the service about the deteriorating state of the NHS.

    One of the key PR problems for the Government was perfectly illustrated on a local TV bulletin tonight when a Doctor was interviewed about the dispute. Not only did he convincingly rubbish Hunt’s statistics on weekend death rates in hospitals but he did so in the comfortable and cosy manner of your friendly GP. No Bob Crow-type archetypal union bogeyman he, the sort of hideous caricature dutifully wheeled out to frighten Mrs Fangle-Faffer of the Home Counties, instead he was the voice of sweet reason and normality itself. This will confuse and disorientate Mr and Mrs Swingy-Voter of Worcester too. They may well ask themselves what is becoming of us all if people like this are going on strike in our country. They could conflate the dispute with other problems that the NHS is encountering and while, let’s say, a strike by pesky hospital porters can be blamed on a pantomime villain like Mark Serwotka, the sight of nice, fresh faced junior doctors on picket lines presents a whole host of less malleable political problems for the Government.

    One statistic trotted out by the Doctor interviewed on local TV tonight did take me aback, though. He said there were now 30,000 less hospital beds than there were in 2010.

    This is one that Cameron will be desperate to get back in its box very quickly, methinks. It’s not going to script at all.


    Yes- I agree that inflation has eroded public sector pay. Thankfully inflation is the least of our problems just now.

    The merits & demerits of paying premium pay rates for given blocks of working time for Junior Doctors are really beyond my experience to comment on. They are, of course, like so much in the NHS steeped in precedent & history-the very factors which producers interests always highlight when reform is proposed.

    Yes-it is called IPSA-it came into being as Brown’s mea culpa for all that expenses troughing.

  6. @carfrew

    MPs may not rush to abolish their own independent pay review body as I seem to recall that it proposed a 10% pay rise which of course the majority felt honour bound to accept!

  7. @Colin

    “The merits & demerits of paying premium pay rates for given blocks of working time for Junior Doctors are really beyond my experience to comment on.”


    Well you say that now but you did ask about the pay thing in the first place. Anyway, as a voter who has to vote on this stuff you need to know!!

    But the basic concerns aren’t rocket science are they. A package that needs the band aid of top up payments that could be cancelled later. You can see the problem with that.

    Even if you can’t, all is not lost: others reading might!!

    So the punishment for the expenses troughing is to set up a body that awards big pay rises? Does that seem fishy to you Col or is that beyond your pay grade also?

  8. @Hireton

    Yes it seems they can only sideline independent pay reviews when they award other public servants pay rises. No one knows why…


    They aren’t “top up payments” . They are Overtime Premiums-a common enough feature in employment contracts. I have no idea what is or isn’t reasonable for this particular group.
    When I poll up at A&E on a Friday night, all I’m interested in is seeing a doctor for my usual procedure & would prefer to have it before Monday morning. But I always have to wait & listen to the drunks & druggies until “proper” care starts when the consultants turn up sometime on Monday.

    No -it wasn’t “fishy”-IPSA , or something like it, was badly needed to oversee & police expense payments, because MPs couldn’t be trusted .
    It made sense to remove their ability to write their own pay cheques too. Having conceded all this, then one can’t complain when a particular award seems out of kilter. But they could all have refused to take it I suppose-not sure if that was possible.

  10. @Colin

    Does what they are precisely called, premiums or whatever, render them impossible to cancel in the future in this instance? I don’t see how what they are called is the critical issue. It seems like a diversion from the key issue of being able to cancel.

    One does not need to be an expert in employment law to see the problem if they can be cancelled. And if one cannot comment on pay and conditions because too complex, then why raise the issue? Honestly, I go to the trouble of finding stuff to answer your questions and you then say it’s pointless.

    Regarding IPSA, the key point is to contrast with treatment of other public sector workers. Strangely you seem to be doing everything but this!!

  11. @Colin

    One of the major issues is that while yes, on paper the “prescribed working hour limits” have been reduced, they have also removed the penalties for going over these prescribed limits. Which basically means that the limit can’t be enforced, and so there’s nothing stopping Managers deciding to require “emergency attendance” beyond the paper limit.

    And then we’ll be back in the bad old days where it’s always an emergency situation justifying going over the limits. Some Managers even tried this on during the strike to ‘require’ staff to turn up by declaring an administrative “level 4 incident”, so we know this will happen.


    Who says Doctors’ Overtime Premiums might be “cancelled”? Haven’t heard anyone suggest that. Don’t think its an issue on the BMA list is it?

    Yes -if MPs get a pay award from IPSA when they are imposing pay freezes on the Public Sector workforce , that is a contrast. What do you propose-scrapping IPSA -giving MPs the power to decide their own pay again, and subjecting them to public opinion?. I’m not sure how you would like to remove this “contrast” ?

  13. CB11

    “One statistic trotted out by the Doctor interviewed on local TV tonight did take me aback, though. He said there were now 30,000 less hospital beds than there were in 2010.”

    However, it’s less than clear that this is necessarily “a bad thing”. The provision of staffed hospital beds is hugely expensive, and if there are more than are needed, then that is wasteful of resources that could be better spent.

    With the expansion of day surgery units, improved procedures resulting in shorter hospital stays and improved patterns of joint working with social services, one would expect the number of staffed beds required to drop.

    Is Korea (increased number of hospital beds from 6.5 per 1,000 of population in 2006 to 10.3 in 2012) or the UK (reduced from 3.5 per 1,000 in 2006 to 2.8 in 2012) doing “better”?

    Indeed, does asking the question without understanding of the different dynamics make any sense?

    In 2014, E&W had 2.95 beds per 1,000 with an occupancy rate of 84%. Scotland had 4.67 beds per 1,000 with an occupancy rate of 80%.

    Does that comparison have any meaning – considering the different geographies?

    Naturally, in any country, politicians in opposition will attack the government of the day using any selective use of statistics that suits their purpose : then both parties will happily reverse their positions when their roles change!

    Sectional interests will use equally selective statistics to support their claim that they should get more, while journalists will write slanted articles to “get a story”.

    ‘Twas ever thus.


    Yes- I had read about that fear-basically a mistrust of the Management . I had thought that Hunt addressed the penalty thing-but I may be wrong.

    Anyway-we will see what happens. Lets hope ACAS can bang heads together before Patients start to suffer in any serious way.

  15. @Colin

    Just because it isn’t on their list, doesn’t mean it isn’t an issue.

    Like, the concerns Crossbat raises might not be listed either, that after stuff that already happened, like the “reorganisation”, or burdening the NHS because of cuts elsewhere in the system e.g. social care… This could be a line in the sand, but they might not say it.

    The government doesnt always make things as obvious as they could either, do they? E.g. the reorganisation. If the longer term plan is to cut the payments, they’re prolly not going to put it on their list.

    Bait and switch is not uncommon among employers, but usually doesn’t get put on the list.


    I’m happy to stick with the issues which BMA have put before ACAS-seems pointless to invent additional ones.

    Anyway -as I said to JayBlanc-fingers crossed & good luck to Sir David Dalton.


  17. “Sectional interests will use equally selective statistics to support their claim that they should get more, while journalists will write slanted articles to “get a story”.

    ‘Twas ever thus.”


    Yep, FUD abounds, and it’s our job to pick through the bollox, and then the pollsters can check how we did.

    FUD is generally much easier than counter-FUD, just as it is generally easier to destroy than create, but the latter is more appealing as a challenge for that reason.

  18. @Colin

    It’s not an invention. It is a potential issue, whether BMA put it on the list or not. And as the electorate, is in our interests to ensure doctors pay package is appropriate.

    P.S. thought you should know that doctors and nurses lives can be at risk from infection etc. and even the war zone that is A&E these days. It’s not just soldiers who have occupational hazards. Sleep well!!

  19. Whatever the merits of the doctors case, I find it extremely odd that they want hospitals to be fined when they break the rules on working hours. Hospitals are most likely to have broken the rules because they needed to save cash and fining them simply makes the situation worse.
    I thought the government’s original proposal, involving inspection of their employment records and holding management to account for failing to manage, was much more sensible. If managers had to pay the fines themselves however, that would be a completely different matter.

  20. @Carfew

    “It’s not an invention. It is a potential issue, whether BMA put it on the list or not. And as the electorate, is in our interests to ensure doctors pay package is appropriate.”

    You’re right. I suspect there are a lot of issues bubbling under the surface of this dispute and I find it interesting how many junior doctors, when interviewed, bemoan the state of the service they’re working within as much as they complain about pay and working hours. They also refer a lot to the issue of patient safety and how Hunt’s proposals potentially endanger this. Their discontent, and the cause of the dispute and subsequent industrial action, has been sparked by the issues being negotiated, but for junior doctors to strike for the first time for 40 years suggests to me that their discontent is deep seated and extends beyond the specific issues now under discussion. The tacit support they are receiving from consultants and nurses, as well as patients, would also suggest that they are speaking on behalf of most of those who currently work in, and rely on, the NHS.

    That tends to be the case with industrial disputes. Their real causes aren’t necessarily those that first meet the eye. Pent up frustrations about a range of working conditions usually lie behind them. The problem for the Government is that concocting a settlement on pay and hours to end this current dispute won’t necessarily assuage the general discontent and disillusionment which could well rear its head again.

  21. @ Anthony Wells


  22. @ Crossbat11

    ‘That’s not to say that the issues of pay and working hours aren’t important ones for Junior Doctors, but I suspect something else is going on here too.’

    I agree with you… and I imagine that the way that the proposal is shrouded in even more convoluted smoke and mirrors than usual is meant to thoroughly conceal that ‘something’. In the past, those sort of ‘somethings’ have been to harmonise the NHS with the needs of US private healthcare providers and insurers.

  23. Can I point out the difficulties of appraising this strike and any polling about it:

    1) the strike is explicitly against the shareholders (the government) and not against the management (NHS Trusts). A highly unusual situation.
    2) there is very little available about the management’s view
    3) a specific group of employees is involved, but the norms of the profession inevitably stretch beyond their immediate needs (consultants and nurses)

  24. @Crossbat and Syzygy

    Yep, it’s not unusual for there to be other, concealed agendas. With politicians, one may as well assume the worst much of the time. There’s too much material. Political agendas abound. But of course… There can be agendas in discussion. Thus, some peeps, who may have been all too quick to posit agendas in others at times, in unions for example, for some strange reason may find the very idea unthinkable that employers might have agendas.

    Indeed, these sorts of discussions may themselves carry with them some entirely understandable subtexts, e.g. Public vs. Private Sector. Which is a worthwhile topic. But it is interesting how peeps may not employ consistent standards.

    Thus, for example, when private sector peeps get a big raise, they see little problem. Either it’s a reward, or an incentive to attract better staff. But strangely, when it comes to summat really important like doctors, where you might want to attract the best, they are not exactly clambering to pay them more to secure the very best.

  25. “‘Not enough Tories’ in general election opinion polls

    The failure of opinion pollsters to predict the outcome of May’s general election may have been because Conservative voters are harder to track down, a report suggests.”


    I am sure you can think of lots of “issues” in respect of the NHS today-so can I.

    But since the issue at hand is the BMA dispute with “NHS Employers” , we do not need to concern ourselves with anything outside the agenda which the parties have put before ACAS.

    I don’t agree that the terms & conditions of employment of NHS clinicians, and members of our Armed Forces are comparable.

  27. ‘Not enough Tories in polls’.
    I understand what Curtice is saying but am unclear as to why this became a particular problem in 2015 as compared with earlier elections. A sharp decline in response rates perhaps?

  28. Perhaps the increasing bombardment of cold calling has caused a reluctance to engage with pollsters, and there’s something about Tory voters that makes them less tolerant of this than others?

  29. @Andy JS

    Another point that article doesn’t mention is that it was found (as I think we all suspected) that the turnout of younger voters is much lower than older voters. But for some bizarre reason the pollsters are weighting UP the number of 18-24.

  30. @Neil A

    Or maybe they’re busy doing the cold calling??

    I love polling, it’s a smorgasbord of possible explanations…

  31. In the Times today…

    “The extent of the schools admissions crisis. “Ninety primary schools are refusing to accept pupils living more than 300m away as Britain’s booming population pushes classrooms up to crisis point”.

    The smallest catchment area is just 92m… Middle class parents, moving near the most desirable schools to secure places have forced local authorities to shrink catchment areas”.

    The over populated elite thing marches apace…

  32. Also in the Times… “Cameron tells energy firms to cut cost of household bills”.

    “Last May the energy sec. wrote to the chief executives of each of the big six suppliers asking them to cut prices to reflect falling wholesale costs. Since then, wholesale prices have dropped by a fifth and only British Gas has cut bills, by 5% and only on gas”.

    Good to see that our PM realises we cannot just leave things to the market, though it’s gonna need more than a letter, but it does highlight how even Thorium, even Polywells would be no panacea if market is sewn up. Until we get the personal ability to get loads of energy from the quantum vacuum or summat, we are gonna need our politicians to sort the policy thing out.

    The other day in the Times, it was on about a shortage of peeps to regulate the reactors. Selling off our own ability to make reactors has left us struggling to regulate reactors built by others for us (sometimes using tech and peeps they bought from us!!)

  33. Both sides must be hopeful there’s not a terrorist attack on the day of a strike.

  34. Colin – “…………..I wonder if a comparison of Military & NHS salaries needs to be put in the context of terms & conditions.
    The Soldier is essentially on call 24/7 for whatever The State calls on him to do. Including going to war & putting his life at risk for his country.”

    Pay isn’t really determined by the terms and conditions of work but by the difficulty in hiring.

    There’s an unlimited supply of people wanting to join the army because low qualification requirement. The army doesn’t have recruitment problems.

    It’s a whole different thing for doctors. Medicine requires brains, and only about 2% of the population have the intellect and of that number some will be drawn towards more lucrative occupations. No amount of improved schooling will increase that % – you can’t really turn a dull child into a bright one.

    Then there’s the long training – four years at university at £9000 pa paid for by the student, plus another four years internship. The number of people who want to put themselves through that isn’t high.

    And finally the global demand for doctors. The USA, Canada and Australia are sucking in doctors at a terrific rate. Cheese off our doctors and they’ll leave and never come back and we’ll be in a pickle. That’s the crux of the problem – the lack of supply.

    I think the govt should pay them what they want and look to make cuts in areas where there isn’t scarcity of supply, or better still cut down on all the transfer payments the state makes which is where the real wastage is.

  35. Regarding NatCen’s analysis of what went wrong with the polls: they mention that using proper random sampling helped their poll look more like the general election result.

    But they also interviewed 4,328 people – which means their sample is 4+ times that of your average opinion poll, and the bigger the sample, the lower the error rate.

    I wonder if the pollsters could improve their accuracy simply by increasing their sample sizes? It would cost more, but if it gives better results surely worth doing?

  36. @Candy,

    Actually I think it’s the reverse. The army struggles to recruit, and the competition for medical school places is very fierce (hence the high grades requested).

    But for some things, mainly public service roles, I don’t think pay should necessarily only be about market demand (or at least the minimum pay shouldn’t be – obviously if no-one’s applying you have to have a rethink and maybe up the money).

  37. @ Neil A

    I think you need to separate people wanting to study medicine at UK universities (high because the universities are top quality) and people wanting to work in the NHS.

    The supply of doctors in the NHS is clearly low because we’re having to recruit from abroad and are fighting a losing battle with qualified UK doctors being lured to the USA and Australia.

    The army doesn’t have to scour the planet for mercenaries. But the NHS is scouring the planet for doctors. Not sure how long they can do that if they are being outbid on pay.

  38. CANDY

    Thanks-fair points.

    We do seem to compare unfavourably on a doctor per patient basis , with other countries.

    The NHS will eat as much money as we give it & still come back for more. So there has to be the quid pro quo of constant search for value and cost control. And it is here that the Producer Interest of a massive monolithic State enterprise always seems to resist change & reform.

    I cannot help feeling that the whole structure of Consultants & Senior Clinician’s employment contracts is not fit for purpose ( the “purpose” always being, let us not forget, the Care of Patients ).

    Along with Continental European Health spending ratios, should we not insist on Continental European structures, management systems, funding methods-and Health Care outcomes?

  39. @Colin

    I think healthcare is expensive and we’re already doing rather well providing a cheap and cheerful service. Not sure we can cut further there.

    I wish the govt would focus on the things that genuinely wind up the population – like the £250,000 subsidy we send to the multi-billionaire Sultan of Brunei and others of his ilk, because he owns some land in Scotland (the same guy who banned Christmas because he feared the festival was proving too attractive to his citizens).

    Cameron is not even trying to put stuff like that on the table in his EU negotiations. I’m starting to think voting to Leave is the only option to resolve that sort of waste.

    Anyway, there’s loads of things that really need cutting, but the NHS is one of the few areas where we’re doing better on costs than other comparable countries.

  40. CANDY

    I agree that we will have to spend more………….and more & more on the NHS.

    I am not convinced that Producer Interests will allow any politician to truly focus on Patient Outcomes. There are too many structural & procedural shibboleths worshipped in this massive unwieldy organisation.

  41. @Colin

    Healthcare costs are a function of the ageing population. There’s nothing we can do about that – the decision to have loads of children in the 1960’s was taken by the post-war generation before most of us were born. What’s done is done.

    The issue is, can we control costs better than populations with a similar demographic profile and economy to us. As far as I can tell, only Japan is handling things better than us. But no-one in the govt has gone to Japan to work out why and how we can emulate them. Instead they seem to think they can upset doctors without consequences.

    Of course the producers have power – that’s what happens when there are shortages. Medicine is now a global industry and there is fierce competition to a) make money from teaching medicine and b) retain doctors. The NHS might be a state org, but the global medical field is very much driven by capitalism and we are subject to those pressures.

    In the teaching medicine side we’re doing great. Imperial College charges foreign medical students an eye-watering £36,400 per annum, and people are happy to pay for a chance of a medical degree from a top institution. And of course British students are vying to study there too for the bargain basement fee of £9000 p.a.

    In the past those British students would have made their careers in the NHS, because they want to live near dear old Mum and Dad and bring up their children here too. But why would they bother to stay if the govt is being cheap and they can literally write their own ticket in the United States and elsewhere?

    This is not the same as capping the pay of some admin person in the DWP. They arn’t exceptional people in a global market. But the doctors are. It’s the forces of capitalism, and there’s nothing to be done but to bite our lips and cough up till that huge demographic bulge fuelling demand for healthcare has passed out of the system.

    In the meanwhile there are other more fruitful areas ripe for cuts to pay for it all.

  42. Some rambling thoughts:

    I agree with those who say that if the package is insufficiently attractive there will be recruitment and retention crises in a few years time.

    Of course the, arguably excessive, Jam tomorrow, when Junior Doctors end up as a consultants or GPs, is not changing.

    In general, it is unusual for professionals to receive allowances, overtime rates etc except in the Public sector.

    Many the worker the private sector who on becoming salaried rather than hourly paid ends up doing plenty of unpaid overtime but that is the cost of being a manager, supervisor or whatever.

    In principle, a higher basic salary must be better and perhaps Junior Doctors agree but can’t support the Hunt plans for some reason?

  43. New Survation/Daily Record Holyrood poll (but no surprises in polling).

    Holyrood Constituency:
    SNP: 52%
    LAB: 21%
    CON: 16%
    LD: 7%
    Other: 4%

    Holyrood List Vote
    SNP: 42%
    LAB: 20%
    CON: 16%
    LD: 8%
    Green: 9%
    UKIP: 5%
    Other: <1%

    Seats predicted by Weber Shandwick’s Scotland Votes tool.
    SNP 70
    LAB 26
    CON 18
    GREEN 8
    LD 7

    Only 20 per cent are dissatisfied with the Scottish Government’s performance on justice, 22 per cent on education and 27 per cent on health.

    Sturgeon is also by far the most popular politician in the country.

    She has a net favourability score of 27, miles ahead of Kezia Dugdale (-9), Ruth Davidson (-6), Willie Rennie (-7) and Patrick Harvie (0). (Record)

  44. Survation/Daily Record Scotland poll

    EUref Leave – 35% : Remain 65%

    Indyref2 – No 51% : Yes 49%

  45. Survation’s analysis of their Scottish poll – and link to the tables.

  46. @Colin

    Simply repeating your idea that you don’t think we should go beyond the issues prescribed by others doesn’t help to address the drawbacks I pointed out with your approach. Happily, turns out you get my point after all, because in your reply to Candy you are happy to bring up agendas producers might have. It’s just employers’ agendas that are non gratis.

    Bit surprised that you are complaining about NHS and military terms and conditions not being comparable, since you compared them in the first place, albeit somewhat erroneously. I was just helping you with summat you’d missed in your comparison.

  47. @Candy

    I’d agree with most of that.

    All organisations have the opportunity to reduce waste, both in the private and public sector. In some cases, the problem is obvious.

    But I doubt that the NHS is particularly inefficient – having seen the system at close hand, I reckon it is reasonably well organised.

    It seems to me that the problem we have, and a cause of our national failure to improve productivity, is a cultural one: we have far too much pointless compliance, and form-filling, an exaggerated health and safety culture, and a consequent national feeling that ‘nothing can be done’ which precludes reform and innovation.

    A eye-opener for me was when the CE of my local authority complained that central government was imposing an increasing bureaucratic burden upon his staff. Even the bureaucrats are moaning about excessive bureaucracy.

    The official paperwork my business receives has doubled in the last five years under a Conservative government.

    I throw it all in the bin.

  48. CANDY

    The “Producer interest” I was referring to was Senior Clinicians-noteably Consultants.

    As I said, I think their contracts, which not only allow large chunks of their time to be spent in their Private Practice, but seem so often to put their NHS committment last; actually militate against Patients’ Interest.

    I should say that I am not against Clinicians working in Private Hospitals for those clients who can pay & wish to do so. But where, as seems to be the majority case, a clinician works for both, so often the NHS comes last in their prorities. I know this from personal experience, having paid to see an “NHS” Consultant privately ( within days) to avoid a wait of months with the same man.

  49. CANDY

    @”The issue is, can we control costs better than populations with a similar demographic profile and economy to us. ”

    I disagree that this is “the issue” for the NHS.

    I believe the “issue” is two fold :-
    * Achieving the best possible health outcomes for patients per unit of expenditure.
    * Affording a total expenditure which produces national health outcomes which are acceptable by recognised standards.

    I exclude the vexed ( unsolved) problem of the interface between Health Care & Social Care which is driving organisational bottlenecks like bedblocking. It is here that the biggest impact is being felt of the population ageing which you mention

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