The junior doctors' strike caused chaos this morning - with one hospital calling an emergency just 10 minutes after medics walked out.
Doctors went on strike at 8am this morning in a row over new contracts - but had promised to return to their posts in the case of a major incident.
But their industrial action turned into farce when - just minutes after the strike began - Sandwell Hospital in West Bromwich declared a so-called 'level 4' incident.
Dr Roger Stedman, Medical Director at Sandwell Trust, said: 'Over the last two days we have had very high numbers of patients come to hospital, and fewer than usual discharged.
'Because of that we decided to require trainee doctors allocated to ward work to attend Sandwell during today's strike.'
Doctors from St Thomas' Hospital in London hold placards at the iconic location calling to 'Protect Our Doctors, Protect Our NHS'
Junior doctors on the picket line outside Great Ormond Street Hospital in London as medics go on strike for 24 hours in a dispute with the government over new contract
Junior doctors arrive at the picket line outside Maidstone Hospital in Kent on the first of three walk-outs
The NHS defines an 'escalation level 4 incident' as one in which there is 'severe pressure' on the health service, meaning it is 'unable to deliver comprehensive emergency care'.
But the British Medical Association, which is behind the strike, has said doctors at Sandwell should not return to work, as the so-called emergency is not a 'major unpredictable incident'.
A spokesman said: 'Junior doctors should continue with industrial action until NHS England has confirmed and the BMA has agreed – via the agreed escalation process – that a major unpredictable incident is taking place for a specific trust.'
The body had previously warned that the NHS could use the rules to thwart industrial action.
It came as more than 50,000 medics started the 24 hour strike at 8am this morning in a protest against changes to their pay and working conditions.
NHS staff are at about 100 picket lines across England, with a large concentration in and around London.
Thousands of operations and appointments have been cancelled in preparation for today's action as people are warned to stay away from hospitals and only attend if absolutely necessary.
Junior doctors will only provide 'emergency care only' until 8am tomorrow when the strike ends.
This means some of them will still be on rota to work in Accident and Emergency departments and cover other emergency services in hospitals.
The British Medical Association's junior doctors' leader, Johann Malawana, said conditions for junior doctors need to change.
People have taken to Twitter to voice their support for the industrial action today, the first of three planned walk-outs by junior doctors
Doctors form a picket line outside the hospital in Portsmouth as people post pictures on Twitter of their protest
In a video posted to the BMA's Twitter site, he said doctors have 'even been unable to get leave for their own weddings despite months - and even up to a year - of notification in advance', adding that the situation 'cannot continue'.
Junior doctors have taken action after weeks of talks between the BMA and the Government failed to reach an agreement.
Dr Kitty Mohan, from the BMA's junior doctors committee, told the Today programme: 'The assurances simply aren't good enough here.
'We really need proper contractual safeguards in order to keep junior doctors - and their patients - safe.'
Asked if doctors are prepared to go through with all planned strikes, she said: 'It is exceedingly difficult for junior doctors. This isn't the reason why we go into medicine and have a medical career.
'Even today is breaking the heart of many junior doctors and therefore we really urge the Government to negotiate with the BMA.'
Extra consultants, doctors and nurses who are not protesting have been drafted in to provide cover for their striking colleagues while most outpatient clinics and non-essential treatments have been cancelled.
Locums already scheduled to work today will be able to work as normal but a law prevents employers from using agency staff to cover striking workers.
There are also 17,000 junior doctors who are not BMA members who are expected to work.
Further walk outs are planned for 48 hours on Tuesday, 26 January as well as a full walk-out, which will include A&E junior doctors, from 8am to 5pm on Wednesday, 10 February.
David Cameron begged junior doctors to call off their 'damaging' strike, saying it will cause 'real difficulties' for patients and 'potentially worse' scenarios.
NHS England claims that everything possible is being done to ensure the provision of safe emergency care and to minimise the impact on patients.
Yesterday, it issued the following advice to the public:
- Urgent and emergency care services will be available as normal but hospitals are expected to be under additional pressure
- Where possible, people should contact their GP, seek advice from their local pharmacist, call NHS111 or consult the NHS Choices website
- Where it is an emergency, people should call 999 or go directly to A&E
- GP services will be available as normal and anyone who thinks they will need an appointment is encouraged to organise this before industrial action begins
- Any patients who have procedures or appointments affected by industrial action will be contacted by the providers if they need to be rearranged.
- People should be particularly attentive to their health over this period and look out for more vulnerable members of their families and communities.
The BMA will be supporting around 100 picket lines across England, pictured here in blue, as an estimated 45,000 junior doctors are expected to strike from 8am tomorrow
The Green Party's Caroline Lucas and Natalie Bennett joined the picket at St Thomas' Hospital, London
The planned industrial action was suspended last month hours before the first planned walk-out after union representatives and the Government agreed to get back around the negotiating table.
But despite weeks of discussions on medics' proposed new contracts, the BMA last week announced its plans for disgruntled employees to walk out for the first time in 40 years.
Officials said they were confident the contingency plans will provide safe and effective care to patients.
Health Secretary Jeremy Hunt leave home this morning. He has been blamed by junior doctors for the action
'We have tried and tested plans to deal with a range of disruptions including industrial action,' said Anne Rainsberry, the NHS England director overseeing preparations, said.
'As ever, the safety and care of patients is our top priority and the NHS has robust plans in place to ensure those who need emergency treatment will continue to receive it.
'We have been working with hospitals and other NHS providers across the country to ensure we can continue to protect the safety of our patients and provide the urgent services they need.
'We will monitor the situation across the country to ensure these plans are in place, and are ready to respond to any significant increases in pressure in any region over the course of this dispute.'
It said 1,425 inpatient operations and procedures have been cancelled as a result of the strike alongside 2,535 outpatient ones.
It said there were about 4,000 cancellations in total, of which 3,400 are on Tuesday.
The dispute centres around Jeremy Hunt's revised contracts for junior doctors.
He claims the new contracts will make hospitals safer by ensuring more doctors work evenings and weekends when death rates are up to 16 per cent higher.
But junior doctors fear the new rotas will leave them exhausted and prone to mistakes, and that their overall earnings will be slashed.
Under the proposed contract changes, junior doctors in England will get an increase in their basic pay, but will have to work more weekends while guaranteed pay rises linked to time in the job will be axed and bonus pay for working unsociable hours will be curbed.
About 100 pickets have formed across England as NHS staff take part in the first mass walk-out in 40 years
Striking junior doctors hold placards protesting against planned changes to their pay and conditions
Last week, the Health Secretary said the Government thought it was 'making very good progress' in talks and he was disappointed the BMA had called strikes.
He said that 'no government' wanted to cut doctors' pay but changes must be made to increase weekend staffing levels.
The Government's plan to get rid of 'pay progression', or automatic annual salary increases, is reportedly one key sticking point of negotiations.
It is also understood that another key point involves plans to scrap fines imposed on hospitals which force junior doctors to work beyond their maximum hours, as determined by the European Working Time Directive.
The BMA opposes the planned change, which would see a new system overseen by the Care Quality Commission.
Thousands of medical students have also voiced their support to junior doctors by signing a pledge on the BMA website.
England's chief medical officer Dame Sally Davies said on Sunday the strike would 'lead to patients suffering'.
This morning, Jeremy Corbyn told the BBC Radio 4 Today programme: 'We should recognise that junior doctors are qualified, extremely hard-working, deserve to be treated properly and (Health Secretary) Jeremy Hunt should now come to an agreement with them.'
He added: 'I hope that Jeremy Hunt realises the need to come to an agreement very quickly.'
A total of 28,316 junior doctors took part in a ballot in November last year, of whom 99 per cent voted in favour of staging industrial action and 98 per cent for an all-out strike.
Junior doctors on the picket line outside Maidstone Hospital in Kent as a doctors go on strike for 24 hours in a dispute with the government over new contracts
Junior doctors pictured as they they strike outside Great Ormond Street Hospital in London
Junior doctors were set to walk out on 1, 8 and 16 December 1, 8 and 16 but the action was called off at the 11th hour when Acas tried to broker a deal to avoid disrupting hospital services.
Even though these strikes were eventually averted, the threat caused mass disruption to the NHS as thousands of patients had operations or appointments cancelled.
Some 20,000 operations were postponed that had been scheduled for one of the three planned strike days earlier this month.
First hospital calls its doctors back to work amid claims the NHS tried to 'thwart' the stoppage with rules on when medics should leave the picket line
A letter to all hospitals outlining emergency circumstances where junior doctors should be called off the picket line has been seen as an attempt to 'thwart' today's strike, the BMA has said.
Sandwell Hospital in West Bromwich became the first hospital in England to declare a level 4 incident and this morning told its junior doctors they must attend work - less than two hours after the strike began.
BMA chairman Mark Porter said the letter - sent by Sir Bruce Keogh, the national medical director at NHS England last week - described circumstances which occur every day in some hospitals.
But Sir Bruce hit back on the eve of the strike, insisting he was fulfilling his duty to keep patients safe during today's strike.
Mr Porter said some hospitals had placed all their striking doctors on a 'black alert' because of the letters - indicating to all medical staff their hospital is under very high pressure.
Sandwell hospital in West Bromwich became the first to declare an emergency and tell doctors to return
He said this was serving to 'further undermine the level of trust' between doctors and the NHS.
Sir Bruce's initial letter, on January 8, said hospital medical directors should consider calling junior doctors back to work in several circumstances - including sustained problems in accident and emergency departments which cannot be resolved by consultants.
Major incidents should also trigger a suspension of the strike at either local or national level, Sir Bruce said.
But Mr Porter insisted yesterday this did not meet the terms of an agreement reached in advance of the strike.
He said: 'Your letter to medical directors has been interpreted by many doctors as a further attempt to thwart lawful industrial action in favour of which junior doctors voted almost unanimously.
'I fully understand your statutory duties and your need to discharge them. This is, of course, your responsibility and that of managers within Trusts – it is not the responsibility of junior doctors, while taking lawful industrial action to secure a contract that is safe for patients and fair for doctors.'
Sir Bruce said this was a misunderstanding, adding: 'I wish to be very clear, it is not my intention to undermine the legitimacy of industrial action but rather to ensure arrangements are in place where local NHS organisations have plans agreed with the local BMA to ensure patients remain safe if circumstances change.'
NHS Medical Director Sir Bruce Keogh outlined the circumstances in which hospital should consider calling doctors back to work in a letter on January 8, pictured
But in a reply yesterday, BMA chairman Mark Porter said the rules outlined by Sir Bruce had been perceived as a 'further attempt to thwart lawful industrial action'
He said the NHS had to plan for a range of circumstances from 'catastrophic to rising tide events'.
But in a further reply last night, Mr Porter said: 'While I’m grateful for your reassurance that your intention is not to undermine the legitimacy of industrial action, I am still unclear as to why the agreed, rigorous escalation process should now change.
'The instances to which you refer in your letter of 8th January amount, for some trusts, to routine circumstances which can occur almost daily and for which trust managers should have planned in advance, for example, by postponing elective procedures – as referred to in NHS England’s statement issued to the media at 4.09pm today.
'This was the BMA’s purpose in giving as much notice as possible of planned industrial action.
'Your letter of 8th January has already given rise to widespread confusion, so that some trusts, without first postponing elective procedures, appear to be informing doctors that as they are already on black alert, junior doctors will be asked to be present on every ward tomorrow.'
'When we met in November we were in clear agreement that such incidents do not constitute major unpredictable incidents in which junior doctors would be encouraged to call off industrial action.'
'This latest move by NHS England only serves further to undermine the level of trust which doctors have in Government, NHS England and employers.'
Sir Bruce said yesterday his original letter had been misunderstood and in a reply to Mr Porter said he was only trying to ensure safe care during the strike
But Mr Porter insisted last night in a further reply Sir Bruce's letters would only further 'undermine the level of trust' doctors have in the government and NHS England
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