The strike by health workers in England may have come to an end, but the key question now is whether a resolution can be found to the dispute.

On Tuesday, a four-day work-to-rule begins, while next Monday radiographers will go on strike, potentially affecting X-ray and ultrasound services.

Both the unions and ministers say they are willing to talk, but at this stage a compromise seems some way off – and unions are already talking about more action in the future.

Unison general secretary Dave Prentis spent Monday morning complaining that ministers were “not listening”, while workers on many picket lines were vocal in comparing their pay offer with the 10% MPs were awarded earlier this year.

But Health Secretary Jeremy Hunt is standing his ground. He says giving a 1% pay rise on top of the progression-in-the-job pay rises is simply not affordable.

Unions have been told that they are free to come up with another solution, but that there is no more money for pay.

That means making some kind of compromise on the progression-in-the-job element. These can be extremely lucrative – for senior nurses and midwives they are worth £10,000 – so understandably staff are unwilling to give them up.

Game of brinkmanshipBut to understand the cause of this dispute you really need to go back to 2009. That was the year the then NHS chief executive Sir David Nicholson set the health service an ambitious savings target.

The NHS was told to save £20bn by 2014 – later pushed back to 2015. Sir David was adamant, though, it could not simply be achieved through cuts, but rather it had to come from efficiency savings.

It works out as a productivity gain of between 4% and 5% a year – something the health service had never done before.

Industrial action in the NHS

Name Number of members Action being taken
Unison 250,000 in England Strike and work-to-rule (England only)
GMB 22,000 in England and Northern Ireland Strike and work-to-rule (England and NI)
Unite 92,000 in England and Northern Ireland Strike and work-to-rule (England and NI)
Royal College of Midwives 22,000 in England Strike and work-to-rule (England only)
UCATT (maintenance staff) 480 in England Strike and work-to-rule (England only)
British Association of Occupational Therapists 24,000 in England Strike and work-to-rule (England only)
Managers in Partnership 4,000 in England Strike and work-to-rule (England only)
Society of Radiographers 19,000 in UK Strike on 20 October (UK wide)
Hospital Consultants and Specialists Assoc 2,620 in England Work-to-rule (England only)

Unsurprisingly, it has turned out to be just as difficult as expected. A report by MPs earlier this year showed significant inroads had been made, but the majority of these had not come from efficiency savings.

Instead, the NHS had relied on “quick fixes” – namely pay restraint. Over the last four years there have been two years of freezes and two of small rises.

That has had a significant impact on the pockets of health workers. Figures from Unison suggest health worker pay has fallen by 10% during this period once inflation is taken into account.

But it is easy to understand – in simple money terms at least – why ministers have adopted such an approach. About 40% of the budget is spent on pay and with the NHS facing a £30bn hole in its finances by 2020, the government is under pressure to make resources stretch as far as they can.

That said, ministers know they face a tricky dilemma – and not just in England as staff in Northern Ireland are taking action (see the table above) while ballots are going out in Wales.

Governments tend to avoid getting into disputes with health workers – public opinion normally sides with them – and so a lengthy period of industrial action ahead of an election will be something ministers will be keen to avoid.

Like all pay disputes, it promises to be a game of brinkmanship. But one in which the stakes could not be higher.