In a newsletter to NHS workers today, NHSE chief executive Sir Jim Mackey said nine patient safety mitigations had been approved as of Sunday night but noted 18 had been rejected with the BMA calling for ‘extortionate pay rates' for half of these.

An NHS spokesperson said: ‘The NHS is continuing to work hard to maintain more services than in previous rounds of industrial action and early indications show the plan is working with the vast majority of planned care going ahead.

‘Derogation requests for resident doctors to work in exceptional circumstances are being made by the most senior clinical teams on the ground and delays or refusals by the British Medical Association questions their integrity and risks patient safety.'

A BMA spokesperson said: ‘These claims by Sir James – that if "extortionate pay rates were offered to striking doctors," then nine of the 18 derogations that were not granted, would have been granted – are untrue and unfounded.

‘When a derogation is agreed between the BMA and NHS England and which requires a resident doctor to return to work, they do not receive any kind of enhanced payment because those resident doctors are going back to their ward or department to do their usual work. Sir James is clearly quite confused about the derogation process if he is suggesting anything different.

‘Under the agreement we have with NHS England, before any derogation is granted a trust is expected to demonstrate they have done everything possible to incentivise non-striking doctors to cover the vacant shifts. This can include paying enhanced rates of pay and this is a usual practice when asking doctors to take on extra-contractual work, over and above their normal hours and is not exclusive to covering gaps that trusts have failed to adequately plan for during industrial action. However, the claim that the BMA requires increased payments to striking doctors is wholly wrong and Sir James Mackey should withdraw these comments and apologise for the misleading impression they are creating.'