The gloves are off. The 106-year-old Royal College of Nursing (RCN) is about to strike nationally for the first time. They strike, they say, to send up distress flares about the state of their service. Their case is strong: pay for experienced nurses has fallen in real terms by at least 20% since 2010 across the country. Roles are reclassified to different paybands to save on wages. In gruelling 12-hour shifts, in often understaffed wards, they have ever-sicker patients staying shorter times – they worry they can’t care as they should. They are not being sanctimonious when their leader, Pat Cullen, says this is a strike about the state of the NHS and safety of patients, as well as pay. Nurses’ burnout rate is accelerating, with a record 47,000 vacancies in England and 40% fewer working in social care than 10 years ago. For a government missing its recruitment targets, the only enticement is better pay, so facing down the nurses is not an option. Oliver Dowden sounds absurd when he tells Sky, “We have well-oiled contingencies in place”. Where is his phantom army of spare nurses? Agencies will not provide strike-breakers. Brexit stopped the flow of EU nurses; 48% of new nurses still come from abroad, many of them from countries, such as Nepal, that the World Health Organization says should not be targeted by the rich world for recruitment. Dowden’s empty defiance bodes ill for good negotiations, as does the last three health secretaries (Steve Barclay, Thérèse Coffey, Barclay again) failing to make any contact with the RCN, the union complains. How long before it dawns on the Tories that they have zero bargaining position? Not only are nurses leaving the profession, but new entrants have fallen by a record 8% in the past year. Recruiting students, who face the prospect of £50,000 of debt, gets harder when half new recruits’ time is spent working on wards unpaid. Though in theory these student nurses are “supernumerary”, while under instruction they are increasingly used as spare hands caring for patients, doing the same exhausting shifts but paying instead of being paid. Unlike other students, they work too hard to take bar jobs to cover living costs; the age profile is older, and many will have children to look after too. Remember how abolishing that crucial bursary for nursing students in Jeremy Hunt’s time as health secretary led to a sharp drop in nursing students? Wisely, Wes Streeting, Labour’s health shadow, is preparing to bring it back, to be announced when Labour’s whole higher education policy is ready. That may force the Tories to restore it. Now chancellor, Hunt must surely know he has no choice but to settle – or resign. Only months ago, as a protesting chair of the health select committee, he roused up royal colleges – yes, RCN included – to back his push for a workforce strategy in the health and social care bill. He argued vehemently that a rolling 10-year staff plan was essential to train enough doctors and nurses for an ageing population. He complained to me, as to everyone, about a shortsighted Treasury blocking any commitment to future funding. He can’t now escape his own reasoning as to why locum doctors and agency nurses waste a fortune that is better spent on training and higher pay to attract new entrants. His long campaign, and his own book on patient safety, rely on enough well-trained staff. Cullen says the nurses she talks to as she travels the NHS speak of their daily dread facing the wards, where they take on not just their own work but that of those missing 47,000. Streeting, visiting hospitals with food banks for their staff, says: “I can’t blame the nurses for voting to strike.” He hears the acute anxieties of nurses, ambulance crews and all working in A&E. “No one wants a strike. Their pay demands are reasonable.” Would Labour pay up? He says, as in their 1997 manifesto, that they will pledge to restore public sector pay “as circumstances allow”, but as in 1997, he can’t set a date. “We did restore public pay and we will again when we can.” Will there be rows about Labour MPs joining NHS picket lines? Christina McAnea, head of Unison, dismisses that as an irrelevance: it makes “absolutely no difference” whether shadow ministers join striking workers. She tells the Daily Mirror that Labour frontbenchers on picket lines are a “distraction”, and warns off selfie poseurs, saying strikes are “serious”, not a “photo opportunity”. Nurses will not leave their wards or A&E, but their strike will stop elective non-emergency admissions, increasing that 7m waiting list. The RCN ballot, by law, was conducted in each NHS facility: it is expected that Wednesday’s results will show most voted to strike, but some narrowly missed the stringent requirement for a majority on a 50% turnout. A flotilla of strikes will follow, as public sector pay averages just a 2% rise, compared with the private sector at 6% – both far behind inflation, at 10.1%. The RCN’s demand for inflation plus 5% still leaves them paid less than in 2010 – hardly “militant”. If the Tories hope the politics will go their way, public support for a nursing strike stands at 65% for and 27% against. The government has no choice but to negotiate immediately and reach a good enough agreement to keep hold of precious NHS staff and appeal to others to join up. As Margaret Thatcher might say: Tina, there is no alternative. Polly Toynbee is a Guardian columnist