The British Medical Association’s vote to reject the government’s pensions offer seems to raise the prospect of the UK’s white coats downing their stethoscopes, forsaking their consultations with patients and picketing their own surgery or hospital. The 63% prepared to take industrial action over pensions is a big number, and BMA leader Dr Hamish Meldrum’s warning of medics considering protest “unprecedented in recent decades” and the union starting to “work up detailed plans on industrial action” deliberately ominous. Without a government rethink an emergency meeting of the BMA’s ruling Council on 25 February will decide how to run a ballot on industrial action, added Meldrum.

But, as the Department of Health (DH) delighted in pointing out once it had studied the detail of the BMA’s poll, just 7.2% of its membership are ready to actually strike – a miniscule figure by comparison. And only 30.1% believe the coalition’s proposed changes to the NHS pension scheme to be so iniquitous that they should be rejected altogether. And of course the turnout for the BMA’s survey was just 36%, raising obvious questions about how representative it is.

No government ever relishes confrontation with doctors, the most trusted profession. But the DH clearly feels that not just right, but also public opinion, is on its side. It points out: “Doctors and consultants who are among the highest earners in the NHS have benefited hugely from the current final salary scheme arrangements compared to other staff groups. Under the current scheme, a typical consultant retiring at age 60 will receive a pension of over £48,000 a year for life. In addition they will receive a tax free lump sum of around £143,000 – this equates to a pension pot of over £1.7m in the private sector.” Such arrangements are now “unsustainable”, it adds, gambling that defending such lucrative rewards will prove difficult for a well-paid profession, despite the public’s general admiration of doctors’ qualities.

Doctors’ leaders are used to getting their own way when they flex their muscles, whoever is in power. But Labour ignored the profession’s protests to impose patient-friendly longer GP surgery opening times, while Andrew Lansley’s decision to pay almost no heed at all of the BMA’s opposition to his health and social care bill should have ended any lingering BMA belief that it enjoys automatic influence. It is hard to predict where this developing impasse over pensions will end. With a coalition climbdown, or at least sufficient further concessions to persuade medics to back down? Unlikely. Or with the first industrial action by doctors since 1975, when junior doctors took action over their contracts? That now seems unavoidable.

Meldrum says the pension shakeup is “the final straw” for doctors who are about to enter the fourth year of a pay freeze and, in England, are having to contend with a £20bn NHS savings drive and an unpopular restructuring of the system which few think is necessary. Doctors are angry, he says, as they will be “hit hard” because “the amount deducted from their pay for their pensions will go up this April, with further rises in 2013 and 2014”.

“Those at the start of their careers face the prospect of paying over £200,000 in additional lifetime contributions. The normal pension age would increase, with many having to work to the age of 68 before being able to draw a full pension. And the current final salary scheme would be replaced with a new career average scheme, which would leave most doctors with worse overall benefits,” he says. A scheme revised as recently as 2008 should be left well alone, Meldrum adds.

Doctors have a mixed record on getting what they want on the rare occasions they get worked up enough to consider industrial action. In 1990, when Ken Clarke was health secretary, there was much disgruntlement at a proposed new GP contract. But the BMA Council decided not to hold a ballot. In 1975 there was industrial action, by junior doctors angry at their new contracts; agreement on a new deal was reached a month later after ministers decided to resume negotiations. The year before, Barbara Castle tried to stop consultants in the NHS from undertaking private work on top. So consultants took action between January and April that year, suspending goodwill activities and sticking to the letter of their contracts – much medical work relies on doctors performing extra-contractual tasks – which ultimately led to peace breaking out and a deal.

However, the two major health unions which did not ballot their members before the pensions day of action last November – the BMA and the Royal College of Nursing – are now both, very reluctantly, set to do that some time soon. Both say that all the talking so far with ministers and officials has got them nowhere, and that in effect they are being pushed into balloting on industrial action. Nurses have never taken strike action, but that is a growing possibility. That cautious organisations such as the BMA and RCN are now being pushed into the same camp as the more predictable anti-pensions Unison and Unite unions will test doctors’ and nurses’ unity, but could ultimately pose a tougher test for ministers.