Just when NHS strikes in England seemed to be ending, another group of staff has announced its own stoppages – and, as ever, pay is the issue. Eight of the 12 unions that represent NHS personnel in England, apart from doctors and dentists, accepted the government’s pay offer in early May, albeit after months of industrial action. Then on Tuesday the Royal College of Nursing, the biggest of the four unions that had rejected it announced it would not be holding any more walkouts. Too few of its members had voted to endorse up to another six months of strikes in a ballot. Could this be some respite for an NHS that has suffered major disruption since nurses, junior doctors, ambulance crews and others began taking industrial action last December? Not quite. Less then four hours later, consultants gave a dramatic reminder of how angry frontline staff are about seeing the value of their pay shrink so significantly in recent years. In a British Medical Association ballot, consultants – senior hospital doctors – voted overwhelmingly to take industrial action over their 35% real-terms loss of income since 2008-09. The 86% vote in favour was a huge surprise, given that consultants – most of whom earn at least £100,000 and some a lot more – are usually much more reluctant to strike than their junior colleagues. “It’s absolutely unprecedented; a major earthquake,” said one medical source. Consultants are the most important people in hospitals. They can, and do, cover for striking juniors, but the latter are mostly too inexperienced to return the favour. As the BMA consultants committee chair, Dr Vishal Sharma, said: “No one can cover for consultants.” This was echoed by Dr Naru Narayanan, the president of the Hospital Consultants and Specialists Association, a smaller doctors’ union: “Strikes by senior doctors have long been unthinkable.” Unthinkable, but starting soon. Consultants will first walk out on 20 and 21 July. On those days they will maintain a Christmas Day-level service, which means they will cover life-or-death areas of care such as A&E and emergency surgery, but routine care, non-urgent operations and outpatient appointments will be cancelled. Hospital bosses were dreading the two-day walkout, the lobby group NHS Providers said. That’s partly because it will start two days after a five-day strike by junior doctors ends on 17 July, but also because the “double whammy” of stoppages so close together will hugely damage the NHS’s determined efforts to tackle the record 7.3m-strong backlog of hospital care. Strikes have already forced 651,000 appointments and operations to be rescheduled. With two sets of doctors now taking industrial action, the total could hit 1m. The juniors plan to strike for three days every month and the consultants now have a legal mandate to do the same until beyond Christmas. Disruption to NHS care will potentially affect hundreds of thousands of patients, who will be told to wait even longer for their new hip, knee or cataract removal. There is political risk for Rishi Sunak here. The prime minister’s pledge to reduce NHS waiting times looks increasingly implausible, given the depth of doctors’ disillusion over their pay. When Sharma says that “consultants are not worth a third less than we were 15 years ago”, is any minister ready to argue that they are? Public support for striking doctors is not diminishing, despite the huge disruption they are causing. NHS bosses desperately want all these strikes to end as soon as possible, but there is no reason to think they will. As they have done with junior doctors over many months, ministers are displaying what the BMA and HCSA see as the same intransigence towards consultants – a refusal to concede that large real-terms erosion in pay needs addressing or to make proposals to start that process. The medical profession v the government is a marathon trial of strength that is only just getting started.