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We've been hearing from patients affected by the junior doctors' strike.

Marilyn Mee was scheduled to have a reverse shoulder operation on 13 April at Watford General Hospital.

The 77-year-old patient told BBC News: “So far, I have no news about whether or not my operation will take place on Thursday.

"The theatre is booked, equipment has arrived and two consultants are ready to operate in tandem as long as they are not called to cover for junior doctors.

"I'm on tenterhooks! Having been in horrendous pain for months, the idea of this planned date being cancelled reduces me to tears.”

Marilyn has needed this operation for 18 months and it has been in the diary for three. The procedure will undo a previous one which went wrong, and a new prosthesis will be put in, she says:

This latest four-day strike by junior doctors is expected to have an additional impact on the NHS because it comes off the back of the long Easter weekend.

While consultants - senior hospital doctors - will be filling in for their striking colleagues, some will have booked annual leave for a longer spring break.

The NHS Confederation, which represents health trusts, says this means consultants will not be able to provide the same level of cover as they did during March's 72-hour walkout.

Other consultants may also be more reluctant to put themselves forward for shifts, the confederation added.

One hospital leader said that providing cover during the previous strike meant consultants were owed time off in lieu, making the problem worse.

Michelle Phillips, 39, from Manchester, told us her spinal fusion operation at Salford Royal Infirmary has been cancelled because of the strike, having already been cancelled a month prior.

She'd been given a new date for the operation of 4 May but said that her business in aesthetics training is being affected due to the operation being rescheduled several times.

She experienced a slipped disc two years ago and has subsequently paid privately for two MRIs, a consultation with a consultant and an X-ray to speed up the process.

She said what would have been a 30-minute procedure if she had been seen quickly is now a six hour “major” operation.

“But it's not just that, I’ve got some people helping me at home while I’m off work, childcare has needed to be rearranged, there’s lots of different aspects of how it’s affecting my life.”

Gem O'Reilly
Live reporter

The word junior can often be misinterpreted when it comes to the level of experience doctors have.

It could be someone who is straight out of medical school at foundation year level, or a medic with 10 or 11 years experience.

This is all relative to the specialities doctors go into. For example, it takes longer to become a consultant urologist than it does a GP.

Junior doctors are essentially the cohort of staff before consultant level and they cover a wide range of responsibilities, right from taking bloods and discharging patients to contributing to operations.

Dr Kiara Vincent is an emergency medicine registrar in the East Midlands and has worked in the NHS for 10 years, but is still classed as a junior doctor:

For this reason, a week of strikes will have an impact on operations and hospital procedures.

The national medical director of NHS England, Prof Sir Stephen Powis has said the walk out will put "an immense pressure on staff".

Consultants are set to cover for junior doctors while they strike this week.

Junior doctors in England last went on strike between 13 and 16 March.

The BBC's Alastair Fee explains why staffing will be stretched during this latest round of industrial action.

Nick Triggle
Health Correspondent

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The British Medical Association believes junior doctors are under-paid, saying they get £14 an hour.

That is the amount they get in basic pay during the first year after finishing university – less than 10% of junior doctors are at this stage.

It works out at £29,000 a year. But the average first year junior doctor gets around 30% more in extra payments for things like working unsociable hours.

When they move into year two, their basic pay goes up to the equivalent to £16.30 an hour. Again, 30% more will be paid in extra payments on average.

There are five core pay points in the junior doctor contract. By the end of training they will be earning around £28 an hour in basic – although this can take 10 years to get to.

Once those extra payments are taken into account, that works out at around £77,000 a year on average.

It is likely to be enough to put them in touching distance of the top 10% of earners.

Marilyn Mee, 77, from Watford, is scheduled to have an operation on her right shoulder on this Thursday at Watford General hospital.

She told BBC News that “so far, I have no news about whether or not my operation will take place on Thursday" despite the strikes.

She's needed this operation for 18 months and the procedure will undo a previous procedure which went wrong and a new prosthesis will be put in, she said.

"The theatre is booked, equipment has arrived and two consultants are ready to operate in tandem as long as they are not called to cover for junior doctors. I'm on tenterhooks,” she said.

“I appreciate the junior doctors have worked very hard and do overtime and are not paid very much but I don't believe in striking when it affects people’s health."

An NHS boss has pleaded for the government and unions to resolve the strike amid "massive disruption" at his hospital trust.

Kevin McGee, chief executive of Lancashire Teaching Hospitals NHS Foundation Trust which runs hospitals in Preston and Chorley, told the BBC he has had to stand down some cancer services in order to prioritise emergency care.

Speaking to BBC Radio 4's Today programme, he said: "What I would say to all parties, is please please get round the table and resolve this strike.

"Every strike we have will put more pressure into the system.

"Some of the goodwill we've had in terms of trying to cover rotas... each strike we have, more of that is eroded.

"So we've got to a get a resolution sooner rather than later."

He explained it will take a number of days for the trust to recover and apologised to patients who may have to wait several weeks to be seen after their appointments have been cancelled.

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Health Secretary Steve Barclay released a statement last night about the strikes, accusing organisers of using the Easter bank holiday to their advantage.

“Not only will the walkouts risk patient safety, but they have also been timed to maximise disruption after the Easter break,” he said, describing the four-day walkout as “extremely disappointing”.

Barclay said he had hoped to to begin “formal pay negotiations” with the British Medical Association (BMA) - the union that represents the majority of junior doctors in the UK - last month but “its demand for a 35% pay rise is unreasonable”.

He added this would would result in some doctors receiving a pay rise of “over £20,000”.

Vivek Trivedi, co-chairman of the BMA’s junior doctor committee, has accused Barclay of treating junior doctors “with contempt”, and reminded critics that strike action “by nature is designed to cause disruption to put pressure on the government to do the right thing and come to the table”.

The rest of Barclay’s statement reads:

Image source, David Bell

“I’m 100% supportive” of the strikes, said David Bell, 47, from Chelmsford.

That’s despite the fact an operation to remove a pre-cancerous tumour in his small intestine has been delayed as a result of the industrial action.

This was “frustrating” and left him with “fears”, he told BBC News.

But he explained: “My view is that treating the junior doctors and the NHS fairly is a win-win for patients as well, because I want anyone involved in my care to feel valued.”

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More now from NHS England national medical director Prof Sir Stephen Powis, who has been speaking to Today on BBC Radio 4.

Asked why the health service did not ask the BMA to exempt A&E junior doctors during this strikes, Powis said: "The BMA have been quite clear the derogation [exemption] they were willing to give was a derogation around mass casualties and they were not willing to provide derogations which were the result of the direct effect of strike action.

"But this time round I think they recognise we have worked very hard to provide cover or services such as A&E... if we run into difficulties then we will be talking to the BMA - we have regular meetings scheduled with them throughout strike action.

"And we will have no hesitation in asking for them to assist if we feel like it is needed."

The BMA has refused to exempt any services, in contrast to the nursing and ambulance unions, who did agree to some exemptions in their recent strikes.

The NHS has agreed with the BMA to pull doctors off the picket lines if lives were in danger.

Elisabeth Welsh, 69, from Barrow upon Humber, was due have an operation on her spine at Castle Hill Hospital this morning but the procedure was cancelled last Thursday because of the strike with no new date set.

She has spinal stenosis, narrowing of the spinal canal, and has waited around a year for the operation. Elisabeth says it "restricts more or less everything that I can do in life".

“I respect their right to strike but I feel they are being unreasonable asking for a 35% pay rise," she tells the BBC.

“I also feel the BMA are being extremely militant.

“I thought doctors took an oath and this action goes against the oath that they take.”

Dr Vivek Trivedi, BMA junior doctors' committee co-chair, says the uplift they're asking for is "only to reverse pay cuts we've had - doctors have had a 26% real terms pay cut over last 15 years... and all we're asking for a doctor who's paid £14 an hour to be paid £19 an hour".

"It's not a tall ask and we're willing to negotiate how we get there," he tells BBC Breakfast, however, he says Health Secretary Steve Barclay needs to negotiate with the BMA.

Asked if he's worried about patient safety due to the strikes, he says this is at the forefront of very doctor's decision on a daily basis but "a strike by nature is designed to cause disruption".

He says that last month's strikes showed senior doctors who stepped in to cover junior doctors on strikes were able to maintain a good level of patient care on ground.

He urges Barclay to come back to the table to continue discussions and says that "if he puts a credible offer on the table we can cancel these strikes, we don't have to strike".

During the last strike we examined the BMA's claim that junior doctors are paid £14 an hour and discovered that while that may be true for some, the figure rises quite quickly as their careers progress to £28 after 10 years.

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The junior doctor strikes will cause "significant disruption", NHS England's medical director Prof Sir Stephen Powis tells the BBC.

Speaking to BBC Radio 4's Today programme, Powis says the number of cancelled operations and appointments will be "considerably more than 175,000". That was the number cancelled during the 72-hour junior doctor strike in March.

"Routine care will undoubtedly be affected," he says. "This will take weeks to recover from."

He said the NHS is working hard to protect services like A&E, critical care and maternity services, but explained "those services will be stretched".

He advises the public to use services "wisely" and make use of the 111 phone line, pharmacies and GP surgeries.

The government and doctors' unions must call in conciliation service Acas for talks, a health chief has said.

Speaking to the BBC on Monday, NHS Confederation chief executive Matthew Taylor, whose membership body represents health service trusts, said the government and unions needed to call in mediators to help advance the talks.

"It's depressing that there seems to be no movement at all from the two sides of this dispute over the last few days," Taylor said.

"We should consider asking the government and the trade unions to call in Acas, the conciliation service, to provide some basis for negotiations, because if anything the positions seem to have hardened over the last couple of days."

The body estimates some 350,000 appointments and operations could be cancelled.

Acas can play an impartial role in helping to settle matters when there is disagreement between an employer and group of employees.

Image source, EPA

Hospital bosses in England said last week they could not guarantee patient safety during this four-day strike by junior doctors.

London's Guy's and St Thomas' NHS Trust conceded that patients could be harmed as managers struggled to staff rotas.

Other hospital bosses also voiced concerns over the walkout, which will affect both emergency and planned care.

The British Medical Association (BMA) has refused to exempt any services, but says it has plans to protect patients.

It contrasts with the approach of the Royal College of Nursing and ambulance unions, which excluded key emergency services from strike action.

Instead, the BMA has said it will meet trade union requirements for life-and-limb cover to be provided by considering pulling junior doctors off the picket line if individual hospitals report lives are in immediate danger during the actual strike, which runs from 07:00 BST on Tuesday to 07:00 BST on Saturday.

• Patients at risk during doctor strike - NHS bosses

It's 07:00 BST, which means the four-day strike by junior doctors has officially begun in England.

The industrial action is due to last until Saturday morning.

Stay with us for the latest updates and analysis as these doctors - who make up more than 40% of the NHS's medical workforce - join picket lines across the country.

Jasmine Andersson
Live reporter

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To use the BMA’s official definition, junior doctors are qualified doctors in clinical training.

After completing their medical school training at university - which averages four to six years - a junior doctor will carry out their work under the supervision of a consultant.

A junior doctor undergoes an average of 10 years further training after they leave medical school before they progress to the next stage of their career.

Sam Hancock
Live reporter

The UK’s seen its fair share of strike action in the last few months, with teachers, train drivers and civil servants staging walkouts at one time or another.

NHS strikes in particular have been significant, not least because of their scale - back in November, we saw the biggest action by nurses in the health service’s history and now we’re in the midst of a 96-hour demonstration by junior doctors.

The government claims their pay demands are unreasonable, but unions argue that their members only want what they’ve been denied for 15 years: pay rises in line with the rate of inflation. NHS staff have been staging walkouts since the 1970s - let's take a look at some of them.

1975: Between January and April, consultants protested against proposed new contracts which they said would force them to abandon private practice. In November, it was the turn of junior doctors who took action over pay and conditions set out in new junior staff contracts.

2014: Almost 40 years later, thousands of nurses, midwives and ambulance staff went on strike in England and Northern Ireland. It came after ministers awarded some NHS staff a 1% pay increase, which an independent review board said should've gone to everyone. Then-Health Secretary Jeremy Hunt claimed hospitals would be forced to lay off staff if the award was met in full.

2015: The following year, midwives in Northern Ireland staged a further four-hour strike, saying that 1% pay rise still hadn't been given to all staff - only some.

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2016: One of the most memorable NHS strikes in recent history is the action junior doctors took six years ago. There's an explainer on it here but essentially there was a disagreement over new contracts in England. The strikes marked the first time doctors stopped providing emergency care in the history of the NHS.

2022: In December nurses and ambulance workers joined picket lines across the UK, following failed talks between union leaders and the government. The strikes were some of the most disruptive in NHS history - and carried on into the New Year - leading to Health Secretary Steve Barclay making a new pay offer in March 2023. It includes a one-off bonus worth up to 8.2% and a permanent 5% pay rise from April, which members of numerous health unions are still considering.

2023: And that brings us to the junior doctors’ strikes - the first of which took place last month. As we’ve been reporting, this latest action is due to last for four days, with hundreds of thousands of appointments and operations due to be cancelled.