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Thoughts after the first round of NHS strikes

The fact that, after three decades, nurses have gone on strike again in the UK is positive, at the same time we need to have a careful look at the weak points of the strike in order to learn for the future. The following impressions and thoughts after two days of industrial dispute are preliminary and sketchy, limited to experiences in three bigger NHS trusts in the North of England, the Midlands and the South-West. You can find further ideas in our strike newsletter, but more importantly, please write to us and share your own thoughts from your hospital or picket line.

  1. The run up: Problems with the pay campaign and ballots

Despite the initial commitment to a joint pay demand by the various unions within the NHS, the union divisions became apparent early on, first of all when the RCN pulled out of the common platform and raised their separate pay claim back in April 2022. The lack of coordination between the unions was also reflected on the ground in hospitals, e.g. in a major hospital in the south-west, the Joint Union Committee, comprising six different unions, rejected the proposal from a Unison and GMB rep to hold a joint pay rally in front of the hospital. Instead of a visible and collective preparation for the industrial actions, the individual unions limited themselves to emailing, texting, phone banking and other individual outreach to members, plus the very occasional stall in the canteen area. These forms of ‘virtual campaigning’ with a lack of people actually coming together in bigger groups, had already failed during the previous pay campaign, when the unions were still able to blame Covid for their own timidness. 

It was, therefore, not surprising that during the current pay dispute in England, apart from the RCN, none of the other unions (first and foremost Unsion, the biggest union in the NHS) came close to meeting the legal threshold of 50% membership participation in the industrial ballot. Less than 40% of the members of Unison bothered to take part in the ballot, though over 80% of members who participated did vote in favour of industrial action. 

The fact that the RCN met this threshold might be because of three reasons: 

a) at least in the Midlands, friends reported that there were some ‘ward walks’ of RCN activists in the run-up to the ballot, which might have created more of a mobilisation; 

b) their ‘marketing strategy’ was the most visible, timely, and targeted towards strike action. They had planned their promotional materials in advance, and they were focused on answering specific questions around the possibility of nurses taking industrial action; 

c) the ‘professional nature’ of the RCN, the focus on registered nurses and their professional development created more direct links and a certain cohesion. This apparent strength of the nurses is the weakness of the NHS strike, as other groups of health workers, such as housekeepers, porters, cleaners, health care assistants remained largely absent from the dispute.  

The divisions amongst the unions and the top-down nature of decision-making about the strategy of the industrial dispute then became more apparent in Scotland, where unions balloted separately from England and where most unions met the legal threshold for industrial action. Partly because of the wider participation in the industrial ballot, the government in Scotland had increased the pay hike from £1,400, like in England, to £2,200 per year. Despite the new offer still not meeting the pay demand of the unions, the union leaderships across the board decided to re-ballot the membership who rejected the new offer. Despite this rejection, the Unison leadership decided to re-open negotiations with the government, proposing a lower pay increase for Band 5 (general nurses) and above. The Unison leadership recommended accepting it and when 57% of the voting members did so, Unison called on the government in Scotland to implement the pay increase as soon as possible, despite the fact that the RCN continued to ballot their members for a higher increase. The Unison leadership thereby undermined the industrial action of a significant chunk of the workforce in Scotland, signaled good will to the government, and significantly lowered the expectations for the ongoing campaign in England.

  1. The strike preparation from the government, trust management and the unions

In the hospital in the south-west, management and union reps of the joint union committee met initially in talks that treated the upcoming industrial action as a ‘serious incident’, similar to grave accidents, and started discussing possible derogations and exemptions. In contrast, there was no collective meeting of all unions on how to support the RCN strike and no communication towards the members and workers. The only emails that were sent by Unison and GMB to their own members made clear that, as both unions failed to meet the legal threshold, members could not participate in the RCN strike. Trust management sent emails that they respect the right to strike, but at the same time increased payments for bank workers between mid-December and mid-January by 30% for nurses and 15% for the rest, incentivising people to take on extra shifts. At another trust in the south-west, management offered 50% extra pay for shifts on the strike day of the 20th of December. 

In the meantime, the government, at least initially during the week before the first strike day, added some stick to these carrots. On the 7th of December, they first threatened to legally ban strikes in the health sector, but that threat was not repeated until a month later. On the 10th of December they then spoke publicly about using army personnel to replace striking workers. This turned out to be a paper-tiger early on, as the number of potential soldiers was very low (around 600 army drivers and 150 logistical staff compared to a total of 16,000 plus ambulance paramedics who were balloted to strike) as they often lacked the necessary qualifications and knowledge. There were also voices amongst the military that criticised the government’s announcement as it threatened to ‘undermine the morale amongst the troops’, if they felt that they would be used as pawns in industrial actions. 

In England the RCN leadership decided to limit the first round of strikes to 44 trusts out of the 102 that met the legal threshold for strike action (out of 215 eligible in England). There might have been an ‘escalation tactic’ behind the decision to call out only a smaller number of workers, but it caused frustration amongst those members that had voted in favour of industrial action. 

In tandem with this, the main way to limit the impact of the strike action was the co-management between the RCN and the NHS hierarchy of the so-called ‘derogation’, the exemption of certain departments from the strike and/or the imposition of minimum staffing levels on certain wards.

  1. The issue of strike exemption and derogation   

The question of which departments would be subjected to derogation was handled by the top-level of the RCN, together with the medical authorities. Some of the decisions, e.g. to add mental health and community services to the derogated areas caused minor discontent amongst rank-and-file members, but was never openly contested. After the general field of the strike was staked out from above, local RCN reps and committees then decided about minimum staffing levels during the strike. Before we look at how this was done in concrete we should state that this issue is at the heart of the question of who is in control of the strike. Workers on each ward know best what their current patients need in terms of minimum health and safety and would be able to coordinate how many workers can participate in the strike. This act in itself would have boosted a sense of collective control and power. Instead, the way that derogation was negotiated between a few RCN reps and management left a lot of scope for confusion, sometimes deliberately caused by arbitrary management communication, about ‘the right to strike’, and most workers felt pretty manipulated by or disengaged from the process. 

In the trust in the south-west, a very small number of reps negotiated the derogation for all medical wards, stipulating that during the strike days there should be a minimum of four registered nurses and five healthcare assistants. The irony is that even on the best days there are hardly ever five healthcare assistants on the wards, more often than not there are three. The union justified these minimum staffing levels that objectively limited the amount of possible strikers with the following argument: ‘as a union we campaign generally for better staffing levels, so how can we, when asked, agree to low minimum levels during strike days?’ 

Many nurses and RCN members were pretty upset about these minimum staffing levels, as they allowed management to declare that no one who is scheduled to work could go on strike – even though this wasn’t actually true. There were many individual texts and emails from ward managers to people who they suspected would go on strike – allegedly in order to be able to ‘plan for the strike days’. In some wards, managers ‘allowed’ workers to go on strike, often for a limited amount of hours. If your ward sister was more supportive of the strike, it was easier to agree your participation.

Even if this was not intended by the RCN, the way that the derogation process was handled left the management of the strike largely in the hands of the trust hierarchy. We heard of a few cases where nurses decided collectively on a ward level how many and how long to attend the strike picket – more about that below. There was also an individual case where management and nurses complained about ‘intimidation’ by RCN reps who walked around the wards and checked how many people were working and how many were on strike – in general the number of RCN reps and activists were too low to actually ‘sweep’ the wards. 

Things were similar in the hospital up north. “In our Trust the list of derogated areas grew longer by the day, with what seemed like the whole hospital derogated from strike action. The Trust also encouraged staff to think that striking in derogated areas wasn’t allowed, but this felt like it backfired, and a number of staff who weren’t going to strike did so as they felt like the Trust was trying to minimise the impact, and thought they’d been slightly deceptive in trying to do this.”

In the hospital in the Midlands, the picture varied a bit. A comrade reported the following about the derogation process: 

“In our trust there was a quite large derogation committee, made up of non-rep members from across a wide range of areas. Most of these members had not been involved in the RCN before the ballot, they only got involved in ward walks and in spreading the word about the ballot during this pay campaign. However, despite the large committee recruited from the membership I think everyone was at least a band 6. The general attitude (including from the RCN officials involved) was one of wanting to go relatively hard on saying no to the derogation, but there was a lack of confidence at times, and second guessing. The trust sent in very few requests for derogations in the first week when the strike committee was meeting and then bombarded it with an unmanageable amount in the last few days. This might have been a deliberate attempt by management to sabotage the committee or confusion on their part about the actual numbers of strikers, or both. In the end, the trust asked for a blanket derogation of the wards, to which the reply was: ‘Well, we already said you could have night-shift staffing numbers on strike days, that’s enough. If you don’t have these numbers on the day, come to us’ (with some back and forth in the committee on how strongly to put this)…

In the end, this only created more confusion, in part because of the difference between the on- paper night numbers and the real ones. On the day there was an attempt to encourage staff to leave if it was over the normal night number, but this had mixed results. One member of the strike committee ended up being accused of bullying by senior management while doing this, this was at a different site to mine within the same trust. We also know that on several wards they lied about the amount of staff on the ward and had prepared staff to repeat these lies when asked. I know that at least some members of staff left the wards after seeing the numbers were higher than needed and one derogated team decided that their derogation was too generous on the first day and independently chose to decrease their numbers on the second day. There was also continuous fight over the derogation of one postoperative area, which the trust claimed was a High Dependency Unit (covered by national derogation), but which the staff that were working there stated was not. In the end, the professional body side of the RCN got involved, stating, “we helped develop the model of care this ward uses and wrote the definition, it’s not a HDU”.

  1. The actual impact of the strike

It’s difficult to assess the actual impact of the strike on a national level. The Guardian quoted a NHS senior manager after the first day of strike who claimed: 

“I think we do know that there were some real pressure points around emergency departments, for example, including things like the slow transfer of patients out of those departments.In terms of things like routine operations, so far we’ve heard that probably between around 40 to 60% of those routine operations have been cancelled in places where the strikes were held.” 

On a hospital level, the impact of the strike differed sharply from ward to ward. In the hospital in the south-west, some workers reported that they actually had higher staffing levels on the strike day than normally, in particular in the emergency department. On other wards, colleagues said that matrons and managers had to do bed care and bring patients to the toilet – which can clearly be stated as a positive result of the industrial action in terms of educational value (“it’s good if they get their hands dirty every now and then”). On a more subjective note, it seemed that there were more relatives of patients around, perhaps in reaction to the strike, anticipating that a few extra hands were needed for personal care – but that might also have been due to Christmas approaching.   

From the Midlands we received news regarding the use of military personnel: “My trust has a large amount of military staff working in it. In one case a decision was made not to derogate any members of staff on a ward (even down to the reduced night-shift numbers) based on the knowledge that it would have enough military nurses to staff it that day. The military nurses, however, refused to work until someone came up from the picket line to take the handover. In the end one person agreed to go up until 11 am. Apart from this, several elective services were stopped and some wards truly were at minimal staffing numbers, but others were actually above the standard numbers due to the confusion created by the process and the difference between the real standard numbers and the official night numbers.”

  1. On the picket lines

The level of participation in the picket lines can be seen as another indicator for the mood amongst those on strike. 

In one south-west hospital, the RCN reps were first of all concerned with the legal nature of the picket. In the run-up, various leading reps of the joint union committee said that, for example, there should be no loudspeakers and music on the picket, as ‘we would lose support from the public’. This hospital’s actual picket was placed 300 meters away from the main entrance of the hospital. The picket itself was pretty lively, with around 80 people participating at each given point, with a relatively high turnover, also due to the weather – out of a total of 10,000 people who are employed at the hospital. The lively mood was also partly due to the fact that official guidance was ignored and music was playing. It was good to see that many nurses came in ward groups, but then they often also seemed to stay in their groups. From my ward, only four nurses came, though it was good to see that it was recently hired nurses from the Philippines. Also good to see that there were many self-made placards, perhaps even more than official union ones. There were mainly young nurses in their 20s, early 30s, unfortunately only a handful of HCAs, no porters or cleaners or housekeepers. It was good to see groups of student nurses. There were no speeches, which is good, in the sense that we did not have to listen to any ‘official talks’, but bad in the sense that there was nothing that would create collective discussion. Pat Cullen, the RCN leader, did pop by on a whistlestop picket tour, too. People mainly seemed to enjoy each other’s company and the shared discontent with the government, but there were not many discussions about how to strike. There were only three CWU reps and one RMT rep who came for a visit, but they didn’t address all strikers. The main discussion was that the derogation was arbitrary. 

At another south-west hospital, around 100 nurses and supporters were directly outside the hospital and facing a main road. There was lots of public support. There were official picket stewards, but no real distanced separation between them and other strikers/supporters, which was nice to see. 

In the Midlands in general there was a very positive attitude on the picket line, people were excited to be there. Despite the RCN ban on amplified sound and heavy emphasis on the official limits on picket size and having additional supporters separate, we ended up having speeches, music and a crowd of around 200 with no clear separation of the official picket. There was a high level of support for the picket from the public and non-nursing members of staff. We had so much food donated that we had to go round the ward to share it out for the night shift. On the first day there were issues of the senior management hanging out around the picket and the strike committee meeting room. They were trying to get people to come up by arguing that the wards were not at safe levels. This did not occur as much on the second day.

At the hospital in the north there were mostly nurses in attendance, with some domestics and others as well. Staffing levels and stress and being overworked were common themes as much as pay. It felt like it had glimmers of some confidence and a more general ‘fuck it’ attitude as well. We also read about a few ‘unofficial actions’ when it came to the picket lines from a WhatsApp group:

“I’m an RCN member and nurse working in Norfolk. Our picket line was set in Luton last week and it is as far away again on Tuesday. A fabulous like-minded group of amazing nurses started their own unofficial picket at the car park next to Havenbridge House (Great Yarmouth) last week and since then they’ve managed to get RCN to support and change the picket line from unofficial to official!!!!”

  1. Reaction of the government and the union since the strike

The initial threat by the government to ban the strike legally or to undermine it by use of the military remained empty, while the effort by parts of the media to portray nurses as ruthless and greedy people on middle-incomes also largely backfired. According to surveys the public support for the nurses is still high. Meanwhile, Labour continues their anti-strike stance, with the shadow health secretary vowing to fight ‘hostile NHS unions’ that oppose necessary restructuring. 

The union itself used a relatively weak strategy by offering to ‘call off strikes in return for talks’ before the first strike days and by halving the pay demand from an above inflation increase to a below inflation increase (another real wage cut) ‘in return for talks’ before the second round of strikes in January. The RCN hopes that portraying the government as ‘unwilling to negotiate’ alone is enough to get results. This strategy might backfire in various ways. Firstly, by trying to ‘blame the government for the strike because they are unwilling to negotiate’ portrays the strike itself as a negative thing, which weakens workers once they decide to continue the industrial action in a more offensive manner. Secondly, by offering to lower the pay demand without consulting the members they further undermine the sentiment that members themselves are in the drivers’’ seat. You can only blow hot and cold so many times before people get fed up. 

In the Midlands there has been a recognition of the need for greater intelligence gathering based on the response of frontline nurses on the real numbers on the ward as opposed to the official establishment numbers. This could provide an opening for an inquiry based grassroots engagement and taking the lead in the struggle from union officials. 

Another problematic decision by the RCN was to exclude those hospitals who went on strike in December from the strikes in January. This caused confusion and a feeling of being ‘managed’ by the union. The comrade from the north wrote: “We have more RCN strike days coming in January, but the RCN has split the Trusts striking and ours isn’t, which has annoyed staff that I’ve talked to.” 

The negotiation circus continued in January. After the RCN lowered their initial demand the government softened their first stance and offered talks and a possible ‘one off payment’ in the form of ‘hardship relief’. Already in December some Tory MPs had already urged the party leadership to negotiate. For the government it becomes a gamble of how to tame the rail, postal and NHS strikes that are happening at the same time. To ‘buy off’ the RCN might be a way to come down hard on the rail and postal strike. While the unions might schedule their strikes to coincide on the same day, we cannot expect the RMT, CWU and RCN to actively and explicitly join up their strikes, in terms of continuing their action until all of the respective unions’ demands are met.

  1. Proposals

We don’t have major proposals at this point in time, but the following activities might be fruitful:

  • Discuss the first round of strikes and share your experiences – we are happy to circulate them;
  • Discuss with colleagues, first and foremost with health workers who have not been part of the strike, such as porters, cleaners or HCAs, how we can strengthen the strike and make our voices heard;
  • Go in bigger groups of health workers to actively support pickets of other strikers and make them as effective as possible;
  • Discuss the positive and negative experience of your strike with workers on strike at the railways, at Royal Mail and other places;
  • Try to find out more about how the ‘minimum service’ derogation was organised during the more successful health strikes, such as in Germany;
  • Picket private clinics during strike days in order to cause more financial damage – of course considering patients’ health and safety.

Pictures from the Picket – NHS strike in Bristol

High spirits and frozen feet at our picket at Southmead hospital. Our friend, a fellow health care assistant and photo-aficionado, took some nice pictures. You can find him on Instagram: Williamo18

And you can find our strike newsletter here!

Whose strike is it? – Interview with mental health nurse and RCN member

We will try and interview a few fellow health workers before, during and after the NHS strike – if you want to share your experiences, please write to us. You can download our strike newsletter here, for your local pickets and staff rooms…

Could you start by introducing yourself and saying a bit about where you work?

Hi, I’m a registered mental health nurse in the UK, I work in South East England in an NHS community mental health and addictions service.

What kind of impact has the cost of living crisis had on your work on a day to day level?

It’s been felt in terms of the impact on people’s health, stress levels and morale, and how it’s affecting everyday circumstances – differences and inequalities feel more dialled up.

Within the work itself there’s been reduced capacity to respond, more vacancies, more intensive workloads; more standardisation, less options, longer waits for things. It feels like we’re apologising for things more often.

Just on the level of your workplace, how have you and your colleagues responded?

People are supporting each other emotionally and practically at the office and in group chats. Sharing coupons and info around discounts and freebies, breakfast clubs; more talk about ways of reducing bills. Making do with less, changing habits – cooking with microwaves instead of ovens, not going out, spending more time at the office to save on home heating/electricity … Taking on extra shifts with crisis teams, looking for jobs with higher rates of pay, more people talking about leaving nursing indefinitely.

How are you and your co-workers feeling about the upcoming RCN strikes?

All the nurses I’ve spoken with have been supportive of the strikes, if torn about walking out on patients and co-workers.

Nurses in the local hospital trusts are striking, so there’s some buzz about that.

The ballot result for where I work came in just short of the legal threshold for striking, so I’m not sure pay and conditions have been enough of a collective point of conflict here, as yet. It was great to see some mental health trusts amongst the list of those striking, and would be good to learn more of their stories and what helped to get the ballots over.

What was the balloting process like?

The ballots were by postal vote back in October. In the run up there was sustained campaign activity both publicly and through official union communications – email bulletins and briefings, text message canvassing, pop-up demos and stalls in hospitals; lots of press coverage, ads on YouTube!

Strategy has all been centralised by RCN nurses, filtered down in terms of leadership to union branches who’ve overseen local tactics. There’s been lots of training offered – from general organising and canvassing to volunteering at the pickets.

In the trust where I work nurses set up WhatsApp groups to campaign between workplaces, agreeing plans for distribution of materials. There’s been things like ward walks and pop up demos, flyering and information sessions.

At the same time, uptake hasn’t felt so widespread, and I wonder if this can be explained in part by the make-up of community mental health services, where nurses tend to work in low numbers alongside other occupational groups, and maybe miss a collective sense of professional identity you might find in other settings? There’s been a more recognisable campaigning presence at the hospitals, where nurses tend to be more concentrated together. Locally, it’s been these trusts where nurses got the ballots over.

What do you think about how the RCN have been handling it so far?

I was conflicted last March when we pulled out of the collective position on pay. It felt like we missed an opportunity to stand in public with other NHS workers with a pay demand that lifted everybody’s pay and conditions, not just nurses. I wonder if we’re deepening divisions between nurses and other workers as a result of this.

Just on the level of what has been done, the efforts and coordinations this year feel massively developed from previous. The campaign has run since 2020, but the ballot returns this year feel like a culmination of a lot of work and momentum.

At the same time, organisation and delivery of the campaign feels like it’s mirrored the way nursing work tends to be allocated and divided up within the NHS, with top down leadership determining the running and feel of the campaign. Senior nurses in NHS teams/services might also be occupying leadership positions in union branches, which can influence the kinds of relationships it’s possible to have with the campaign. It’s been difficult to take initiative without having to run this back through official union channels. For example, I ordered campaign materials for the office which didn’t arrive, and when I chased these I learned that attending official training in advance of campaigning was really the main process for getting involved. In such a large union it makes sense that some consistency is probably needed, but in context, it can be deflating to have to campaign by rote towards outcomes handed down from above, because so much NHS work gets organised this way! It’s taken being able to get past some of these organisational hurdles to find a connection with the campaign that feels more shared and participatory.

What are you expecting from the dispute?

I’m expecting decision makers will want to minimise NHS disruptions during the cold weather period, so there’s potential leverage there. It’s difficult to know and comment without being involved in the strike coordinations.

I’d imagine strike days are being well planned for in advance, by both nurses and service managers. Interestingly, some striking nurses are also likely to be occupying senior nursing, and managerial positions within NHS trusts, which could be a useful, if competing set of commitments to take into the dispute.

One of the general challenges facing nurses will be finding ways to honour their commitment to patient safety, whilst effectively bringing impact through the strikes. Problems for service systems on those days could end up getting attributed to striking nurses, ramping up divisions, and tension for those on pickets who are taking on more responsibilities through their decision to strike. It’s worth remembering that a regular day in an NHS hospital or service just now is likely to be disrupted, resource depleted and slowed, and this is something nurses are wanting to draw attention to, rather than escalate.

I’m also expecting many nurses to be striking for the first time. It’s been great to have patient groups getting involved. I think there’ll also be strong support from local NHS campaigning groups.

What are the main divisions among nurses? How do you think they’ll play out in the strike? Do you have any thoughts about how they could be addressed?

Some of the formal divisions in nursing are in the allocation of work, different rates of pay, contractual terms and benefits, working conditions and the kinds of work being done. Lower banded or lower paid nurses tend to take up the more intensive, clinically risky and sustained aspects of patient facing work, and this is also the kind of nursing work more likely to be casualised and/or outsourced. Specialist and senior nurses, nurse managers and consultants get paid more and take on more aspects of clinical governance, and are more likely to be working with more substantive employment terms and benefits. These aren’t always clear cut distinctions though, and elements of both care delivery and management will cut across almost all nursing jobs, but this feels roughly where some of the main divisions in nursing labour appear. There are other kinds of social divisions to factor in too, inequalities in how UK nursing work is allocated along lines of race and place, class and gender have been well documented, during the pandemic especially.

When thinking about divisions amongst nurses it’s difficult not to extend this to include the divisions made possible bynursing too. Nurses are divided, whilst dependent on one another, but they’re also heavily reliant on other occupational groups for their work process – healthcare assistants, support workers and carers have inherited aspects of care work that nursing – through professionalisation, has been able to hand off, such as the more embodied aspects of direct patient facing care …

Political and ethical/value differences in how nurses situate themselves towards NHS work are also relevant to the strikes. Nurses opposing, or abstaining from striking are doing so to protect an already straining NHS during a period of high demand, and relatedly, there’s nurses prioritising their professional duties of care to patients and the public over and above the call to fight for conditions needed for care to go well.

In terms of how these divisions might influence or play out with the dispute, maybe it could be generative to ask how our campaigning relates itself to these divisions? If nurses win on restorative pay, what changes and what stays the same? How can we ensure we aren’t going back to work any more divided than we presently are?

Have you been following the disputes led by other unions (the BMA and Unison)? Is there much of a link between their mobilisation and the nurses?

Yes, both the RCN and JDC/BMA disputes feel like they’ve got restorative demands in common.

As for links between different unionised nurses on a day to day level, it’s not something I’ve been involved with where I work, and again this is mainly due to the make-up of the team I’m based in. I’m in touch with some UNISON nurses in other parts of the service, and we’ve discussed the different campaigns and ballots, but in fairly non-directed, observational ways – following the news and official updates, rather than actively organising anything together.

At some of the early demos I went to for the fair pay campaign there was a felt presence of both RCN and UNISON nurses, and in spite of the break RCN made in March, cross-union links look to have held up between nurses and other health/care workers who’ve been active in broader NHS anti-privatisation and protection campaigns. At the Trade Union Congress (TUC) this Summer, RCN nurses turned out to walk with other health-care workers, in spite of being unaffiliated and with no official backing.

Whether and how these kinds of links and bonds can be strengthened, developed and taken back into workplaces is maybe another question.

What direction would you like to see the strikes take?

It would be great if things could develop to a point where they can become more generalised, where we can relate the campaign to health and social care work more broadly. I’m not sure at this point what form this could take, or how to go about it, but it feels like some nurses at least are longing for the dispute to reconnect with the bigger picture. It’s been painful to read the UNISON ballot result because I think some RCN nurses were hoping there’d be scope for coordinated strikes with fellow UNISON workers this winter. If we aren’t together on a collective demand, we could still come together and support our respective ones. I’d like to see things develop, and support more developments in that direction.

And finally, how is the current situation affecting you and your co-workers confidence at work on an everyday level?

It’s been energising to take part in the campaign for restorative pay, to support the challenge to the pay review, against the kind of power relation between nurses and the government it expresses; but honestly I haven’t experienced too much of a shift in confidence just yet, and this probably reflects the scope of the campaign, and my level of involvement.

NHS strike newsletter – Whose strike is it?

Download and distribute the newsletter at your local hospital or picket line!

Got your own story? Write to us!


Inflation is running at 14%, the current pay ‘increase’ by the government is a severe pay cut and the announced increase for 2023 is only 2%. This means more NHS colleagues will leave the job, and staffing shortages will get worse. It’s time to get real.

We haven’t fought in a long time. Apart from the junior doctors there hasn’t been a bigger strike in the NHS for 30 years. Who has the experience to organise the struggle? A successful struggle needs united action by workers on different bands, in different trusts, in different unions. If we look at what has been happening in the last month we can see that the unions won’t be able to organise this unity.

So, what’s been happening?

After pressure, the Scottish government decided to increase the annual wage by £2,200, compared to £1,400 in England. Given the inflation rate, this would still be a real pay cut. Members of most unions refused this pay ‘increase’ and voted for industrial action. Unison officials ignored this, negotiated a lower increase for Band 5 and above and recommended that members accept the offer, while the other big union, the RCN, recommended to refuse. In the ambulance service, the GMB and Unite did not coordinate their strike action so as to strike on the same day.

In the end most unions in Scotland called off industrial action and pushed members into yet another ballot.

In England, the RCN called for strikes on the 15th and 20th of December, but decided that not all members who voted for strike will actually join. Unison didn’t manage to mobilise more than 40% of their own members to vote and failed to MEET the legal threshold in most Trusts. Sending emails and calling individual members at home is not enough to create the collective spirit necessary to organise a strike – none of us saw any visible pay rallies in and outside hospitals in the run up to the vote. The government must be happy that the unions keep workers apart like this.

So, what should we do?

We need independent and open assemblies 

We need independent and open assemblies in each hospital or department, open to all workers, regardless of profession or union membership, to discuss how this struggle should be organised.

In France in the early 90s, health workers managed to coordinate assemblies like this on a national level – before WhatsApp or the internet. Let’s turn the RCN pickets in mid-December into assemblies – or organise them independently if necessary.

At the assembly we can take stock of which wards and departments are present and make sure we invite delegates from those that are absent. We can discuss concrete demands and different actions to enforce them, from overtime boycott, work-to-rule, to strike. We can discuss whether to put pressure on the unions to back our decisions or to go it alone. We could figure out how to coordinate with assemblies in other Trusts.

During recent hospital strikes in Germany, we could see how strong a strike can be if delegates from each ward coordinate the struggle together. As a result of the strikes, workers now get a day off for every five shifts that have been understaffed. Strikes in hospitals are tricky, but they can be effective without putting lives at risk.

There are other ways to put pressure on the government. If thousands of NHS workers would support the current strikes at Royal Mail, universities, railways and food factories by blockading sorting offices, station entrances or factory gates, the government would be in trouble. In Argentina, health workers and teachers blockaded main roads to oil fields and tourist resorts to cause financial losses for the government. By doing so, they managed to enforce a massive pay increase.

These are bold actions. it won’t be easy, And there will be plenty of people trying to dampen down any kind of boldness and initiative. But we, as NHS workers, need to be clear what would be necessary to actually WIN, rather than settle for some crappy deal.

These are new times that force us all to learn together. Write to us and tell us your thoughts and what is happening at your workplace.

We will publish reports anonymously on our blog.

Email us at: / 



We see that more strikes are happening, from universities to railways to the postal services. These strikes are a chance to come together across sectors and discuss what we, as workers, can do to change the current social atmosphere of doom. 

Are the current strikes powerful enough to defend our wages against inflation and attacks like ‘fire and re-hire’? We often see that strikes by different unions and sectors are not coordinated and end up being isolated. We often see that the unions’ fear to break the strict strike laws make our struggle less effective. We often see that fellow workers get frustrated, because the decisions of how to organise the strike are made not by the strikers, but by the union leaders. 

We need to reflect on these questions together and independently, as most organisations have their own interest when it comes to strikes: they only want to recruit us as members or voters. They don’t have an interest in us understanding and leading our own struggles. 

But it is not all about wages. The law tells us that ‘political strikes’ are illegal. They want to keep us in a box. As workers we are supposed to only care about our bread and butter. But as ‘essential workers’ in health, transport, food production or manufacturing, we know how society is run and we have the potential power, knowledge and togetherness to change it for the better.

The current moment is dangerous. We see an escalating global crisis. The fight over markets turns into wars, the climate is going down the drain. The scary thing is that we are in a mess not mainly because powerful and rich people have an interest in keeping things as they are. The scary thing is that even those who we see as powerful, from politicians to big corporations, are not in control of the situation. This society is run in such a fractured way – disjointed by millions of separated companies, government departments, local and national markets, wobbling on fluctuating share and currency values – that no one can claim to be in control. The chaotic reactions to the Covid pandemic, to global supply-chain issues and climate change prove this. 

But the current moment is full of hope. We, as so-called essential workers, know how to run things and could do it much better if we would not have to deal with profit margins and management hierarchies. The current strikes are also a chance to discover this potential. We have the social responsibility to take control of the means to produce our lives and wrest them away from this system that no one controls. If everyone would work only for socially useful purposes, we could all work much less and have time to learn and enjoy our lives.  

In the end this is a question of power: who owns and controls the stuff that we use to produce the conditions for life? If we can lead and coordinate effective strikes, do we use this new power to challenge those who claim to make decisions for us? The current strikes put this question on the table and put a spotlight on our responsibility as workers for the future of society.

For working class revolt, self-emancipation and a better society! / 

Messages from health workers in France

Friends from Toulouse have sent us some material about recent solidarity efforts amongst local health care workers. The main dispute revolved around the defence of Chesnaie, a local mental health clinic, which is supposed to be sold off. In October assemblies with 70 – 80 health workers and patients took place, and the idea to take over the clinic in form of a cooperative was discussed. The second document is a leaflet from local nurses to striking oil refinery workers.

* The struggle for Chesnaie

The clinic in Chesnaie in the Loir-et-Cher department came out of a progressive tendency amongst psychotherapy in the 1950s that criticised the large-scale and inhumane psychiatric institutions and emphasised alternative therapies and social networks around smaller clinics. In March 2022, the director of the psychiatric clinic announced that the clinic was up for sale in a bid called for the 18th of July 2022. A collective of nurses and other staff members got together in order to respond to this brutal announcement as best they could. They organised assemblies, rallies and discussion meetings on mental health, but the management responsible for the sale of the clinic ignored their detailed and viable offer for a cooperative takeover. The struggle continues.

* The leaflet from nurses for striking refinery workers

Solidarity with the strikers of Total and Esso-Exxon

How lucky we are to be able to go on strike! 

Both the energy and the health care sectors are vast and expanding markets, and neither the corporate management nor the representatives of the state, who have their shares in these sectors, can allow any voices or acts of discontent from those who work there. When management decides to give us a few charitable bonuses, these are only a few pennies taken from the billions that make their fortunes. And yet they make us pay for it by denial, requisition and repression as long as they can. And while it will take a lot more than a strike to have space to breathe in this world , it’s a good place to start.

After 13 days of blockades, the strike could not be ignored any longer. It is not a shortage of petrol, but an active blockage of the flows to the petrol stations, which invites in its wake many other sectors of production and services. We welcome this, because it is better than allowing them to shut us up. But those who launched this strike should not be left alone. 

Strikes in the hospital in Toulouse have been going on for three years without changing anything, tangled up in corporatism and depression. And who is aware of this? Who is aware that in Toulouse two months of strikes have kept the emergency room in suspense for the simple demand of better staffing levels and that today 11 health workers are summoned to court to answer for their participation in the strike and the evasion of the repressive ‘requisition of the workforce’ by the state? A strike that in the end secured more staff and better conditions in the emergency room. 

Our health care centre is going to close due to a lack of profitability. As I stand in line at the gas station, I wish I could tell you that you are right to block everything. We won’t die from having to cut back, we’ll die from lack of community care, from misery, from being poorly paid, from working too much and from pollution. 

In the districts of Izards we take care of people whose bodies are worn out by misery. They will probably not have the strength to demonstrate. Dignity is the first care to be preserved for everyone and it will never be profitable. The reason why the government does not care about the health care workers’ strikes is because they do not affect their shareholders’ wallets.

Good luck to all the pickets! 

The nurses of CERAS

CSI-CERAS Care Center


Toulouse, 12th of October 2022

After the strike…

A few updates after recent staffing disputes at hospitals in Germany

Here in the UK, we’re looking at another gruelling effort to mobilise enough of our NHS co-workers to vote against the recent, government imposed wage cut. It would definitely be easier to motivate colleagues if the issue of pay was combined with the problem of stress at work due to chronic understaffing. You can read this insightful interview with a nurse from the UK, which can hopefully help get the ball rolling in terms of discussion and organising. 

In Germany we have seen hospital workers going on strike over staffing levels – initially in the two biggest hospitals in Berlin, then more recently in six university clinics in North-Rhine Westphalia. The main demand of the strikers was to implement a new collective contract, which would guarantee hospital workers who work on understaffed shifts extra time off in compensation. Both series of strikes were successful in the sense that the day-to-day divisions between different wards and groups of workers in the hospital were undermined through collective action and that new staffing-related contracts could be introduced. 

A few months after the strikes, however, the struggle to enforce the details of the contracts is continuing. As long as a collective mass of workers is on the move, management feels that they have to agree to changes. As soon as they only face a few union or works council negotiators, they think that they can go back on their word or find loopholes. Below you can find short updates from Berlin and from North Rhine Westfalia.


Hospital workers in Berlin went on strike for seven weeks to enforce a new contract. Now, nine months later, management is slow to implement the new staffing system. They’re finding loopholes and excuses, e.g. they claim that the development of software to record actual staffing levels takes a long time. As always the devil is in the detail. Management tries to exclude the handover time on understaffed shifts from the calculation of future compensatory time off. They built in traps, e.g. if a lead nurse, who normally has just a coordinating and advisory role, does not explicitly record that she isn’t engaging in bed care at the start of each shift, they will automatically be included as ‘care staff’. 

Workers are also facing an increase in the chances of being moved around internally. If a ward is better staffed, people are moved around to wards where management would have to grant compensatory time off due to understaffing – the small margins to avoid having to compensate workers becomes the prime focus, not actual staffing shortages or care emergencies.

The management of the two hospitals also tries to undermine the future unity of workers. For example, anyone who works on their day off is supposed to be paid a significant bonus, but now groups of workers are excluded from this, such as imaging assistants. Management at one of the hospitals has recently offered a slight pay increase for 800 out of 2,100 workers, but workers who are newly hired for the same jobs will be paid less, which will introduce a two-tier workforce. 

North Rhine Westphalia

In North-Rhine Westfalia, workers at six of the bigger university hospitals went on strike for eleven weeks during summer 2022. Apart from better staffing. workers demanded the end of the ‘flat-rate per patient’ system.This means that hospitals are not paid by the health insurance for the actual work they perform, but instead they receive a fixed amount of money for a specific intervention, e.g. in the case of a kidney operation, they are not paid for the actual (wo)men hours of an actual amount of staff, but a fixed amount for an ‘ideal’ operation.This system is supposed to create an incentive to save money by using less resources – which in the end means, making less workers work more, or focusing on the best paying treatments. As a result of previous protests, bed care has been excluded from this system, but workers in theatres and some other departments are still subjected to it. The strikes did not manage to abolish this division.

Another problem is that the newly-won terms allows management to take one and a half years to introduce the new staffing system. The union also compromised on other fronts. Admin workers, kitchen and transport workers and even ambulance staff are excluded from the compensatory staffing model. Management only offered a puny amount of additionally recruited staff for these hospital sections. This is particularly painful, because it was workers in these sections who massively supported the industrial action. The union also agreed to reduce the number of delegate workers who could take part in the negotiation process. Initially there were 60 worker delegates in the negotiating committee; this was reduced to 18 during the final process of negotiations.

While most workers agree that the strike brought them closer together and that the result is largely positive, it becomes clear that the struggle against divisions and against being ‘managed from the top’ continues! Hopefully we will be able to invite some fellow workers from Germany to a public zoom meeting soon where we can talk about their experiences during and after the industrial action – watch this space!

Online meeting with striking nurses from Germany

Strike demo of health workers in Essen, Germany.

The meeting will take place on the 21st of September, 7pm UK time

Here in the UK we are preparing for industrial action in the current pay round. This is quite a slog – last, but not least because of the vast dimension of the ballot procedure, which undermines worker-led initiatives on the grassroots level. Most health workers in the UK have no first-hand experience of taking action or going on strike.

We need to learn from others. In Germany there have been various rounds of strikes against under-staffing. The strikes were supported by lively mobilisations, the so-called ‘hospital movement’.

We now have the chance to speak with some nurses who have been on strike in North-Rhine Westphalia recently! If you are interested in the meeting, drop us an email and we send you a Zoom link.

If you want you can read following articles in preparation for the meeting, but this is by no means a precondition to take part in it:

an article about the general context of the health sector in Germany; a report about the recent strikes in Berlin and a summary of the wider movement; a comparison of staffing levels in the UK and Germany; finally, a conclusion regarding the result of the strikes.

The struggle for better staffing levels in hospitals – UK nurse interview and a response from Germany

(Check out a new book on working and struggling in the NHS – the ‘Sick of it all’ book’s Facebook page is here. Email us if you are interested in getting a copy or organising a book event. We will organise a book event on the 9th of July 2022 in London, book your free ticket here.)

The struggle for better staffing levels is a struggle against stress, burnout, bitching and bad vibes amongst colleagues and against the neglect of patients. If we are overworked, everyone loses out. During recent and current strikes in Germany, we could see that the struggle for better staffing levels is possible. We translated a couple of articles that you can find here.

In Germany, workers managed to put the ball in management’s court: the new collective contract says that for each understaffed shift that you work, management has to either give you time off or compensate you financially. This should be an incentive for them to finally do something about the issue (- it still has to be seen if that really changes things on the ward floor).

The struggle for better staffing levels is a joined-up struggle. If nurses are overworked, they cannot help healthcare assistants (HCAs) with washing patients or making beds. If, as a result of that, HCAs are overworked, then they can’t give a hand to housekeepers during tea rounds or meal-times. The whole situation is a chain reaction of bad vibes and stress. The question is: how we can turn the fact that we work together and are dependent on each other’s work into a collective strength?

Below you can find some material for discussion. We start with a report from a housekeeper in a hospital in the South-West of England who organised a petition against low staffing levels on her ward. We then have a detailed interview with a nurse about how work is organised and divided on her ward and how staffing levels impact her work. We finally have a response from a nurse in Germany who compares conditions in the UK with his local hospital.

If you work in the health sector, why don’t you send us some notes on your own experiences and thoughts on the matter!

*** Petition against bad staffing levels

I’ve been working on a covid ward in Bristol for the last year, and like most of the other hospital wards, it has been chronically understaffed. Bank workers (who are like internal agency workers) are being sent text messages offering 50% more to come in for extra shifts. Expecting any permanent staff to come in for extra shifts after they’ve already worked three 12.5 hour long shifts when tax claws back most of the extra money anyway, is unlikely, and it’s only a short-term fix. We’re used to chronic understaffing on our ward, but with all of the staff catching covid at one time or another and being off sick, things were even worse.

After being covid-free for a couple of months, we’re now in the middle of another outbreak. Many of the patients need 1:1 care, which we can’t give them. More patients are at higher risk of falls. Many just want a chat because they’re going stir-crazy, and we don’t have time to just sit down with them. Around 6 nurses have left my ward in the last few months, another three are planned to leave over the summer. This is unprecedented. But inevitable when nurses and healthcare assistants are running around trying to keep things from going into absolute meltdown.

A few months ago, a wandering, confused, and aggressive patient, who should have been under 1:1 supervision, punched a worker in the ribs, fracturing one. A patient almost died of a suicide attempt because they weren’t able to be watched continuously. The NHS can do the bare minimum to patch people up, but without a long-term staffing plan – which includes higher wages, shorter shifts, and better terms and conditions – and workers’ fighting back – it will carry on being run into the ground.

On my ward, we decided to write a collective letter to the Chief Exec of the Trust to voice our anger. 40 staff signed it: from cleaners to staff nurses. At the very least we should be letting the people know we are not happy. This was a small first step, intended to galvanise some people into action. I prepared people for the fact that the letter per se wouldn’t do much, but tried to get them to think of ways we could use the letter to widen the action. Predictably, the Chief Exec gave us a standard reply, but the fact that a few of us went to hand the letter in personally, and the fact that we then put the news of it into the union newsletter and distributed this around the hospital made management sit up a bit.

But people on my ward didn’t want to do much after the letter. I suggested we go to other wards, or say we wanted a face to face meeting, but everyone retreated, people got scared and nervous. Many choose to leave the job instead. So, what next? Some of us will do a bigger petition across the hospital calling for solutions to understaffing and stress. In the hospital strikes in Berlin, they demanded extra pay or time off in lieu every time their ward was understaffed. Maybe this is something that most staff can get behind at my hospital. We know we need more action across different groups of workers, different departments, different unions. We just need to try different things at different times to see if anything sparks a more engaged and sustained response from workers. That this coincides with the upcoming pay offer will be important. Let’s see if people are up for it…

*** Interview on staffing levels with a nurse, April 2022

Question: In order to compare staffing levels, it’s obviously important to know what nurses have to do, which differs from place to place, especially of course on an international level. On our ward the usual staffing level is 1:8 for patients in single rooms and up to 1:10 in bays. That means that one nurse and ideally one health care assistant look after eight to ten patients. What does this mean in terms of daily work tasks?

The first thing we do is handover, which can take up to 20-30 minutes. Then the drug round, which often means you have to find the drugs that you need. It’s all still done on paper, the drug charts. The drugs are often out of stock. If you’re lucky they are in the drug trolley that each nurse gets, which contains common medication, such as pain relief or antibiotics. Some drugs might be in the patient’s room if they have their own medication. The next place where you can search is the general cupboard on your ward, but sometimes you have to go to other wards or order from the pharmacy. The drug round can take 1-1.5 hours. In some Trusts you are more protected, you wear a red apron saying, ‘I am doing my drug round, please don’t disturb’, so people can concentrate better and make less errors. General medication is only checked by one nurse, but injections and IVs are checked by two nurses. You often find prescription errors in the drug charts, mistakes that doctors made, for example forgetting to sign a prescription.

If you have the time you then support your health care assistant, like washing patients who need help, getting them dressed or making beds. You then do clinical observations, basically a round of checking blood pressure, pulse, temperature, and so on. If they had the last check at 6 o’clock in the morning they are due again at around 10 o’clock, unless they are poorly and need checking more frequently. That takes you to around 11 to 11:30am. You start your 12 o’clock drug round, which might have IVs in it. Each time you see a patient on the round there might be something they need, like getting to the toilet. Then you have tasks that the doctors requested on their morning round, that should usually be done by then. You might have bloods to take or families to call or people might have to go for scans. Then there is lunch-time, people might need assistance with eating. You then do an afternoon set of clinical observations at around 2 o’clock. There might be patient discharges, then you have to get the notes ready, inform pharmacy, contact district nurses and get them ready for going home. You then have an evening drug round at about six o’clock. There can be a lot of IVs in that. Then you start thinking about writing notes, so eight sets of notes. In general, you have to finish all the paperwork by then. You prepare the handover for the next nurse. The three daily drug rounds definitely take up most of the time, then the observations, in particular when patients deteriorate and you have to do them hourly, then all the documentation.

Question: So what creates the actual stress? Is it that there are too many tasks for the day or is it the way things are organised, for example, because hierarchies and responsibilities are not clear?

Stress can develop because you think you are not doing a good enough job for your patients. I remember having patients who had been given bad news and not being able to spend enough time with them exploring that bad news, because there are a hundred other things to do. If you have an end-of-life patient, you are supposed to check them hourly. You often feel that you’ve failed them, that you had no time to give them mouth care, personal care, some time to talk. The stress can also come from a fear of mistakes. I often found drug rounds stressful, because things were often not clear and you had to chase things up, because otherwise it would fall back on you. Often you have trouble getting hold of doctors or pharmacy to verify information. Sometimes it takes half an hour to sort out one drug for one of your patients. A lack of teamwork can also make people feel stressed. You are visibly stressed while someone sits down and has a cup of tea.

Question: Do you often have to stay longer to finish your work?

When I joined the ward as a newly qualified nurse, the ward manager said: “You’re newly qualified, you won’t go home on time”. For the first four to six months I stayed on late every single shift, at least fifteen minutes, up to an hour. Finishing paperwork, checking things, going back over my drug charts. Then I started to get into more of a routine. Perhaps I became less conscientious about my notes. If patients were well, perhaps I didn’t write each detail down like I was at the beginning. They tell you as a nurse that if you do good documentation and it can be proven, that that speaks in your favour if you ever get taken in front of the NMC [Nursing and Midwifery Council). That’s in the back of your mind. I think when they stopped allowing visitors during the first phase of Covid, we got some of our time back. We wouldn’t be stopped that often and asked questions. We were able to leave on time then. I moved to the high-dependency unit, where you only have four patients. Although people are sicker, you manage to go home on time.

Question: If you had a health care assistant with you, does a staffing ratio of 1:8 feel understaffed?

That can also depend on the skill of the health care assistant. You have some HCAs who won’t do blood sugars or observations or the documentation, because they say they don’t know how. Then you have HCAs who are so trained up, they do your bloods for you. It is such a wide range. The skill mix. And they are not very good at putting a very experienced HCA with a new nurse. Often it is the other way around, experienced HCAs want to work with their friends, the more experienced nurses.

Question: You mentioned that bad teamwork is a stress factor. What is a hindrance to more conscious working together?

I think it’s a culture thing. About feeling you shouldn’t ask people to help you. Some wards are bad at not organising breaks. It’s all done individually, if you find a ten minute slot, you just go on your break. On other wards it’s better organised, there is a clearer structure and you know that you are covered when you are on break – someone knows what has to be done while you are on break. You have a quick conversation with someone, before you go, and they cover you. And you would do it for them, so they don’t have to worry during their break. On some wards that’s not the case. No one would take a message, for example from doctors, while you are away. Everyone just tries to keep their head above water and their section in order.

Question: What would it take to introduce such a bit more conscious cooperation on a ward? The NHS is so formalised and hierarchical that people might often feel that they cannot change anything themselves?

I think unless the nurse in charge doesn’t go to people and tell them that this is your time to go on break, it would be difficult. But then people have also been burnt, when those people who took over during break have made mistakes with ‘their patients’. People stopped trusting each other. Because it will come back on you. They think: “I’d rather do it myself”. In the community you have just one pair of eyes checking that the medication is right.

Question: Who decides whether to take on new patients, even in a situation of low staffing? Do normal nurses have a say?

I think they could, I’ve seen it happen. I’ve been on the receiving end of it. For example, when one of my patients died, the head nurse told me that they won’t immediately report it to the department that retrieves deceased patients from the ward, just to give me a little breathing space and not immediately fill that room again. But I think that when there are planned discharges, that goes above the level of the person that is in charge of the ward. The head nurse reports what potential discharges there are, then the top people will keep on phoning asking how you get on with the discharges. Ultimately is the decision of the people above the ward level.

Question: In Australia in some organised hospitals the union just closes beds if staffing levels are too low.

The problem is that their solution is to bring in agency staff and agency staff can often cause more work for the regular staff, as they might not know the protocol of how to do things. The head nurse or ward manager don’t trust the agency staff, so they give them the easiest patients, the least amount of work to do. The agency staff have no desire, I mean, they don’t have any ties to the ward, they don’t feel the need to help the other staff. That’s of course not always true. Bank staff often return to the same ward, agency staff rarely. There is often an atmosphere towards agency staff: “She earns three times as much as we do for this shift, let her do it”. If you have intensive care skills you earn £40 to £50 an hour. That’s a problematic solution for staffing issues. In the local community hospital they run teams with one permanent staff and three agency staff at the moment. Agency staff come from places like Leeds or Liverpool, they get food and accommodation paid for the four, five shifts that they are here. The feeling of the permanent staff is: why is management not paying for training, why don’t we get unskilled, why are we paying for accommodation?!

Question: In Germany the union demanded that for each understaffed shift that you work you get extra holiday or a compensation payment. What do you think about this, are there other things that could reduce stress?

The skill level is important. If you have more skilled healthcare assistants, that makes your life so much easier. They used to get all kinds of training, but they stopped that. For me. That created also a bit more of a partnership with the HCA. At the beginning of each shift, if I didn’t know the HCA, I would ask them: what can you do, can you do blood sugars, clinical observations, bloods? Sometimes they say they can, but they are not prepared to do it, as they are on a Band 2 shift. At the other local hospital every HCA is trained on the same level; that creates a different situation, when everyone knows what people can do. With staffing we were kind of lucky, because we always had a nurse in charge who didn’t have patients themselves. So they can be an extra person to help out. Another thing that would decrease the workload would be to stop duplicating documentation. Why do I have to write down the same thing in three different charts? IT can make a difference here, it often means that you have all information accessible, rather than having to spend ages looking around for it. My worry when it comes to the German demand is that if I get extra time off after an understaffed shift the ward will be understaffed on a different day. Who stops them from riding me, asking me to come in on my day off? It’s not really addressing the issue of general lack of staff. You give people more time off, the nurses that I know would use it to pick up an extra agency shift.

Question: I guess it’s a double edged sword, as it also makes everything even more transparent by recording each work step electronically and management can squeeze out any spare time. The same with the skill mix, if nursing associates now do a lot of nurses’ jobs, just for much less pay.

True. I just try to get some teamwork going. I tend to inform the HCAs in my section, for example, about what the doctor told me regarding the development of a patient. Some HCAs respond: “Why are you telling me this? This is not my information.” In general many HCAs are not kept in the loop, though they should be. There is a problem of trust, as well. Many nurses think that ultimately it is their head that is on the line, they pay for mistakes that HCAs make. There is no protection in that sense.

Question: All this really hampers communication and cooperation. The HCA knows most about the actual physical-emotional state of the patient, but has little medical knowledge. The nurse checks the main inputs and outputs, but might neither get proper insights from the HCAs or the doctors. The doctors only see the medical notes with the daily reports, really. They only have filtered information. How do you see this problem?

I think it varies. Where I trained it was all done through the electronic system. They would send you messages with instructions, but you might not communicate verbally with the doctors. In other wards where I have worked they really wanted doctors to talk directly to the nurses. Don’t just change something in the drug chart, talk to the nurse about it. For a while they tried whiteboard systems, where doctors would write things down outside patients’ rooms, but they gave that up. Because the doctors change so often, you just start to get into a routine with your doctor and they all move around again and you have to start from scratch. Little things, like, conversations between nurse and patient about their usual medication or changes in their wellbeing, are not passed on to the doctors.You have to challenge them sometimes. If they enter a patient’s room I tend to challenge them: who are you? They are often surprised that I ask. They might be specialists in this or that field, but I want to know what they are doing. If you have eight patients it is difficult to keep up with all these separate conversations. With less patients it is easier to catch what is going on. There is not really a formalised handover between door and nurse. There is only a ward round between doctors and multi-disciplinary staff and the nurse in charge, they go through each patient. The medical team might say the patient is fit for discharge, then the physios say they haven’t sorted the stairlift in the patient’s house yet. The nurse in charge gathers their information from the nurses during the day. There is no direct input from the bedside nurses. In intensive care or in the community this is different, there the nurses participate in these kinds of ward rounds.

Question: Are you as a nurses sometimes asked to do things above your qualification level? And what would it mean if you say no? If I, as a HCA say no, then a nurse will have to do the job. What happens if you say no?

Sure, I was asked as a newly qualified nurse to look after a patient with a tracheotomy, without having had the training. If you say no you open yourself up to pressure from your colleagues. Often it’s not a question of training or skills. They don’t really ask you to do things that you’re not trained for that much. But if a doctor asks me to take blood from a patient I can tell them that I will do it later in the day, showing them the list of tasks that I still have to do. If the doctor wants to get it done before the afternoon, they have to do it themselves. It is hard to handover a job to the nurse on the next shift though, you can get bad vibes, despite all the talk about 24-hour care and the fact that some tasks can wait. There is also no direct financial incentive to do extra training. It looks good on your CV, perhaps in that way there is, if you want to move up to Band 6. You can train as a HDU [High Dependency Unit) nurse, but that doesn’t mean that you get paid more. You just look after sicker patients, perhaps fewer of them.

Question: The difference between HCAs and nurses is that we can’t hand out medication. The difference between nurse and doctor is that you can’t prescribe medication?

Some nurses can, you have to go through a prescriber course. Then there are so-called ACPs, advanced clinical practitioner, that’s a masters course. Then you can diagnose and prescribe. You can essentially do what a junior doctor does. In a way it is similar to a nursing associate, basically a trained HCA who can do what we nurses do. There are some blurred roles.

Question: Is there any collective behaviour regarding being understaffed?

I remember during Covid we were understaffed, we had no people to re-stock equipment. Each time you needed something you had to leave the ward, taking all your PPE off. We wrote an incident report, saying that our staffing was not good enough and that is the impact it had on the patients and us. I am a big fan of putting in incident reports if the staffing is not right. That’s the only way that things are acknowledged. But the feedback we got was: “Every time you put one of these reports in, a nurse has to take the time out of their day to go through it, having less time to help on the ward.”

Question: How easy is it at the moment to just get a different, less stressful job in the sector? That seems to be the main way that people deal with stress. Individually.

There is definitely a, ‘let’s get out’ mentality. A lot of people working in the community wouldn’t go back to the hospital ward. Hospitals always prioritise the emergency departments or intensive care units when it comes to staffing. If you shout the loudest, you get something. I see Band 6 lead nurses tweaking patient reports a bit, showing them as sicker than they are, just in order to keep some staff on the ward. So that you wouldn’t have to send your own staff away to allegedly needier areas of the hospital.

Question: What about the recruitment of overseas nurses, what kind of conditions do they face?

There is one Trust that basically organises the recruitment for all Trusts in the wider region. They go out to Dubai, India, Philippines and do recruitment fairs, do local job interviews. Often nurses already know people here, former colleagues or family members who might also work in the sector. Nurses who arrive from the Philippines or India have a clause in their contract that says that they have to work for a Trust for three years or they will be asked to potentially pay back the recruitment costs. That’s pretty awful. British nurses who went to work in Saudi Arabia, in contrast, were offered a bonus if they stayed for a whole three years. Another problem they are facing is driving, having their driving license accepted. They get three months’ accommodation paid for, then they usually have trouble finding a place to rent. Every Trust has a different policy here. There is a grassroots organisation now that organises monthly Zoom meetings for foreign nurses, where they can share their experiences. They focus, amongst other things, on the issue of language, like, medical language. People might know English, but medical terms are a hurdle. A lot of foreign nurses get stuck on Band 5. They don’t get the training or support. During the pandemic they were often sent to work on Covid wards, over-proportionally often. There is a huge Philippino nurses network, they denounced this practice.

*** Response from a nurse in Germany


If I compare the report to my situation here at the University Clinic in Freiburg I see some differences. Here we have to bear in mind that the conditions at the 40 University Clinics in Germany differ a lot from conditions in the other 1,800 general hospitals.

  • Drug rounds

The general staffing level of 1:8 is more or less the same. But when it comes to drug rounds, they tried hard to ‘liberate’ nurses from the 1 to 2 hours that it takes to do the medication rounds by making the process more ‘lean’. On wards with a lot of standard medication e.g. on orthopaedic wards or post-accident surgery where people get their own medication plus pain relief, medication is prepared and allocated by machines (currently a test-run). The night-shift (two people for 25 to 30 patients) then controls the medication for the whole next day. On wards with more complex medication with a lot of day-to-day changes (pancreatic surgery, oncology) so-called medical-technical assistants (MTAs) prepare the oral medication – again, it’s the nurses on night-shift who double-check. So it tends to be a ‘two-pairs of eyes’ principle, when it comes to oral medication, which, according to my own experience, has lowered the rate of medication errors.

On all wards one shift prepares all IVs for the following shift, meaning using the digital patient data to print the labels with barcodes, getting the IVs dosage from the ward cupboard etc., but the administering nurse does the final preparation. The trays with the day medication are distributed by the night-shift at 5am to patients’ rooms – unless patients have cognitive impairments. IVs and medications are administered in a three-shift system at fixed times (7am, 2pm, 8pm/10pm depending on medication). Even the pain relief has been mechanised during the last two years. There is a type of inhaler for the first three days after surgery, patients were able to self-administer a pre-fixed dosage at certain intervals. This turned out to be too expensive, or the consultants were not able to agree on a common system.

To conclude, a lot of medication work has been taken away from the nurses / nurses have been ‘relieved’ from that work. Not everyone likes that, because administering medication is seen as a core task. From the point of view of the MTAs it is a very repetitive task, e.g. when two MTAs prepare the trays for 90 patients, using scissors to cut the right amount of pills still packaged, so that the nurse only has to pop them. It’s often two older women sitting in a room full of medication, on part-time, with a coffee-machine, doing just that.

  • Division of labour

There are two types of HCAs, the two year apprenticeship as a care assistant is the classic form. More and more people do that, because the three year apprenticeship to become a nurse is made more and more demanding, the exams become more difficult. Many people just want to finish after two years. When it comes to ward rotas, other people work as HCAs as well, such as volunteers, student nurses. Usually there is one HCA per ward. During the early shift there are additional MTAs for taking blood; during the evening and night shifts the nurse has to decide if she takes blood samples herself or asks the doctors/consultants to do it. Then there is a ‘Primary Nurse’ who hasn’t got patients, but deals with admissions and discharges etc. And a so-called ‘Care Expert’ who can be consulted with when it comes to complex questions that nurses are not familiar with. There is usually one ‘Care Expert’ for 6 to 8 wards.

So in a way there are more people located around the nurse who do various tasks, there is a wider ‘skill mix’.

  • Digitalisation

For the last ten years we have been using digital documentation with direct links to the labs and all ‘diagnosis departments’ (imaging etc.). All professional groups have access to this data, using the ward computers. We used to discuss the consequences, in terms of more supervision and surveillance and in terms of what happens to the additional ‘free time’ that is created – will they squeeze more work in, use less people? Before the digitalisation the night-shift had to prepare or reproduce the analogue patient data, which was at least 1 to 2 hours work every night! So they can turn over more patients during the day-shift and need less women-hours during the night. When things were on paper, stuff was always ‘wandering around’ from doctor to diagnosis to nurse. You had to take ‘temporary notes’ or waste time finding the documents. In this sense it saves time. But you also have to sign with your name at any point of documentation.

  • Other comments

I don’t really come across situations where people don’t dare to say that they are not confident or trained to do certain tasks.

Our three shifts are more or less the same length now. The handover has been reduced to 20 minutes. This used to be 1.5 hours, where you would actually have 30 minutes for handover, 30 minutes to chat and 30 minutes to go home earlier.

I think we should ask less about the question of ‘what creates stress’, but the question of ‘how do you work together’ and ‘how can we use this to resist or fight for better conditions’.

Review of ‘Memoirs of a callous picket’, by Jonathan Neale

You came to this work out of love and pride. You find yourself up to the elbows in some ungrateful old man’s shit.”

We reviewed Jonathan’s book while being involved in the publishing of a new book on current conditions and struggles in the NHS: ‘Sick of it all’. The ‘Sick of it all’ book’s Facebook page is here. Email us if you are interested in getting a copy or organising a book event. We will organise a book event together with Jonathan on the 9th of July 2022 in London, book your free ticket here


A few of us now work in the behemoth that is the NHS, and while we were doing some background reading into historical healthcare struggles in the UK, we came across Jonathan Neale’s book, ‘Memoirs of a Callous Picket’. It is a short and readable book, full of useful and interesting information about the wider social and political context in which NHS nurses went on strike in 1982 – this was the biggest industrial action the NHS has ever seen, with nurses at the time demanding a 12% pay increase.

This seems like a million miles away from the situation we, as fellow hospital workers, currently find ourselves in. After all the recognition we got as essential workers during the pandemic, it still failed to materialise into any actual benefit. Last year’s pay offer was a measly 3% that translated into another annual pay cut when inflation was taken into account. The NHS pay campaign last year got nowhere near the mobilisation that would have been needed to get an actual pay rise, and chronic demoralisation is everywhere. How did we get from the biggest nurses strike in NHS history 30 years ago, to the point now where unions can’t even get more than 25% of their membership to come and vote in an indicative pay ballot?

As AngryWorkers, we’re interested in finding out. What can past struggles teach us about today’s situation? How might it be useful to compare the composition of the NHS workforce today with the past? What were the barriers then, and how were they overcome? Can we learn something to help us overcome the existing barriers to workers’ self-organisation within the NHS today?

In order to try and answer some of these questions, we first need an honest and critical reflection of the struggles we’re engaged in. This can be tricky. Often, we’re either ‘too close’ to things, or too far away to make objective assessments. Sometimes, the desire to present things favourably is a powerful driver, either to retain or recruit new members, for personal kudos, to save face. But then learning from these struggles and building a bigger collective knowledge within the working class becomes more difficult.

Neale’s book’s great strength is its ability to be honestly critical about the limitations, both objective and subjective, of tactics and structural constraints. It’s refreshing to read such a book, especially as there are hardly any inside accounts from working class militants anymore. Although he was in the SWP when he wrote this book, his descriptions, for example, of the contradictory positions of union reps and the individualising nature of ‘representation’, are pretty spot on and much clearer than what the traditional left produces nowadays. (He is no longer in the organisation.)

As workers in a big hospital, we know that it’s a microcosm of larger class society. Jonathan Neale knows it too, and the book opens by taking the reader on a tour of the hospital: who works there, what they do, and they relate to each other. It’s a fascinating insight into the complexities of healthcare in capitalism. The surgeons at the top, the cleaners at the bottom; the racist divisions in who does what job; the different banding levels and hierarchies that bleed into how you relate to your workmates; the alienation of doing a job that should involve the nurturing of human beings inside a system that makes it impossible.

“It can be two in the afternoon by the time the last patient is out of bed. Almost time for tea, and toilet, and starting them back to bed, and dinner and toilet. You miss your dinner, your back aches, there’s hardly time to sit down. Your day off you spend sleeping…The result is that patients don’t get what they need. The nurses start to hate the patients or just switch off inside…The ward is the scene of many little human tragedies. As a nurse, you survive by blanking out. In the process, you become a worse nurse. You blank out your feelings and your patients’ feelings. You start treating them as objects or children or ‘patients.’ Anything but adults coping with difficult problems.”(p.21-23)

Class struggle is a balance of objective and subjective forces and the author fleshes these out as he describes how the hospital works and how we, as workers, respond to that over time; how the social relations between workers and between workers and patients changes and under what circumstances. The effect of all this is to make the class struggle real and present, not just some theoretical imaginings. There are human actors and organisations involved, operating on individual or organisational and class solidarity levels at various times. The result is a real attempt at demystification of the process of workers’ struggle. It’s not about some great ‘organiser’ who applies the right methods and gets a ‘victory’, but a complex and often contradictory process.

We need more writing like Neale’s from the left: detailed and personal, at the same time as looking at struggles at various levels: what is happening in the wider political sphere? What are other groups of workers doing and how are they relating to each other? What is going on in the unions – and hospital management for that matter? What’s happening at the rank-and-file level? What kind of organisations and discussions are people involved in? How does this play out in the day-to-day? It’s only when workers start analysing their own struggles that they will be in the best position to fight. In AngryWorkers’ lingo, this is a classic workers’ enquiry. Neale and his counterparts in the hospital were somehow doing it: analysing the way decisions were made, weighing up the pros and cons of different strategies, having an eye to what other workers were doing and whether that changed the wider balance of forces and their own position within it.

“And of course, the sectional strikes did nothing to win the dispute. Most stewards running sectional strikes were only too well aware of that. They were just trying to keep something going inside the hospital while they figured out how to move the TUC…Nobody had an alternative to the TUC. There was no rank-and-file network in the hospitals that could move independently of the TUC.” (p.98)

In reading the book, we were always trying to relate these past experiences to our own as healthcare workers now. What has changed and what has stayed the same? The stuff that hasn’t changed is predictably depressing: surgeons are still at the top and cleaners are still at the bottom; racism is still rife; staff hierarchies are still alive and kicking which makes a united workforce difficult and a culture of bullying pretty much inevitable; the unions are still pretty useless and engage in the same kind of tactics e.g. pretending they’re up for a fight while doing nothing to mobilise for it and then blaming the workers’ lack of appetite for struggle on the fact that things came to a dead-end (see our write up of last year’s pay campaign!); the fact that payslips are still as indecipherable now as they were then! (resulting in probably massive amounts of wage theft that we don’t even notice); the constant attacks to services and conditions; and last but not least, the lack of rank-and-file (self-) organisation that increases the dependencies on the union and more so the case in the 80s, the TUC.

But while a lot of things have stayed the same, many things are different too.

In trying to explain the dynamics of the nursing strike, Neale writes about the fact that the feminist movement of the 1970s and early 80s had an impact on the militancy of the nurses. The 1982 strike, although a defeat, was proof that nurses had questioned their ‘feminine role’ as compliant caregivers and discovered themselves as workers. He draws a link between the movement for women’s liberation and these trade union struggles. There is some more evidence that, at least on the level of legal ‘equality’, things have changed through the struggle of women workers.

He writes that housekeepers and cleaners, who were predominantly female workers, were paid less than male porters. This has changed; now most of the so-called ‘unskilled’ workforce earns pretty much the same. This might well have happened by wage cuts of porter wages, rather than a rise of cleaners’ and housekeepers’ wages, though. He writes that there were 16 different pay grades for auxiliary workers, 18 for nurses and 41 for admin staff. This has been streamlined to seven or eight main pay grades in total. Another example are the nurses’ uniforms, which were still pretty ‘feminine’ back then and are now rather unisex. Also due to the increase in migration and changing attitudes, there are probably many more male nurses now than in 1982.

It is not a contradiction as such that while things might have become more equal between male and female workers, the atmosphere might have become more individualised at the same time, and the health sector workers more separated from the wider workforce. Neale describes how the hospital auxiliary workers’ wages were traditionally linked to pay deals enforced by rubbish collectors and other council workers. Workers were relating more to each other, comparing wage gains and industrial action. An example was when some militant actions by council workers resulted in a wave of partial strikes amongst auxiliary staff in hospitals in 1972-73, kicked off by a spontaneous walkout in Bristol. Since then, Labour and Tory governments alike have tried to break these links.

This is why trade union laws have become much more constricted: the solidarity strike, which was the main way class solidarity expressed itself in the 70s and early 80s has become a dim and distant memory. So it’s not too surprising that, aside from maybe pockets of outsourced hospital workers, rank-and-file activity on this kind of scale has pretty much dissipated too. There was a nationwide junior doctors strike back in 2016, the first in 40 years, but negotiations dragged on for four years and so by the end, only 28% of doctors voted in the referendum to accept the terms of the new contract, which fell far short of what was originally demanded.

The strike has a different significance in healthcare, what with patients’ lives potentially on the line. While the junior doctors’ strike didn’t lead to any more deaths, nurses I’ve had conversations with on the ward are reluctant to strike because they fear letting their patients down and risking their health. While nurses have overcome these fears and found ways around them in some more recent strikes (e.g. Northern Ireland, Germany, USA), the discussions about safer or alternative ways of striking are not yet very advanced in England. So we were interested in what Neale was writing about tactics and strategies in the 1982 strike.

Then, workers and unions engaged in so-called hospital occupations, when workers kept on working despite closure plans for the hospital. This primarily happened after the Labour Party got elected in 1974 and tried to enforce further cuts in social spending. At first glance, the occupations seem pretty radical, or at least more radical than petitions and symbolic protests. The author details several examples of hospital occupations in the mid-1970s, six in London alone, but also points out that they were often an expression of the fact that workers in the wider sector were not organised enough to oppose the cuts through strikes. It was left to the individual hospital to ‘fight it on their own’. Local authorities would at some point stop sending patients, and workers would be stranded. This perhaps merits a longer quote:

In London, the crunch came over the Hounslow Hospital. This small hospital in West London was occupied for months and months. Finally, management came in with strong police protection. They pushed past the lone picket at the front. They forced sick and confused patients into taxis and bundled them off to other hospitals. The staff on the wards didn’t fight back. Partly they were astonished and partly they didn’t want to upset confused elderly patients with hand-to-hand fighting. (…) Management set to work with axes to break up the beds and wreck the wards so the hospital couldn’t be used again. Next day, all papers and the TV news carried pictures of the vandalised wards. If ever there was going to be a strike over the cuts in London, this was it. (…) Mass meetings at twelve hospitals voted to strike the next day. But only the West London Hospital voted for an all-out strike. The rest went for a one-day protest. There was an angry march to the area health authority meeting that day. Geoffrey Drain of NALGO was booed off the platform for refusing to make the strike official. (…) All over London, militants realised that occupations were useless without strike backing. At the next NUPE conference there was an attempt to call for an official strike in support of another occupied hospital: London’s Elizabeth Garret Anderson. The NUPE leadership refused to let it be discussed at the conference. The writing was on the wall.” (p.74)

But there were also smaller examples of successful resistance:

“Take, for example, the porters at St.Francis’s Hospital. In 1976, they faced the first cuts. Management closed two wards. They wanted to re-organise the catering rosters and get the porters to take on extra duties. The enraged porters decided not to cover for vacant posts. The filing clerk on nights had left and hadn’t been replaced. The night manager ordered three porters to get some files. One by one, they each refused and were sacked. One of them was the NUPE branch secretary. By morning, all the ancillaries were out on strike. In three days, management buckled and reinstated the men.” (p.77)

When it comes to the 1982 nurses’ strike, Neale gives us some valuable background: nurses hadn’t been out since 1974; the government had tried to split the hospital auxiliary workers from the disputes of manual council workers (the former would look to see what the latter had won and used this as the basis for their pay demands); the TUC played its own role of cutting hospital strikes off from ongoing disputes in the railways and instead, paraded the health workers through a series of largely ineffective one- or two-day strikes. This meant that the strikes took place in a situation of relative isolation. Still there are some interesting lessons, in particular when it comes to so-called ‘sectional strikes’, where instead of the whole workforce, only a certain department goes on strikes, which then affects the whole operation of the hospital:

“These had been a success in many areas already. Some hospitals had had sections out for twelve weeks. In most general hospitals, quite small sections can bring everything to a grinding halt. Stores, the laundry, the central sterile supplies department and the operating theatre are all crucial. The union collected a levy from all the members in the hospital. This made up the lost wages of the dozen or twenty strikers. Management usually had to agree to reduce the hospital to an accident and emergency basis. (…) The stewards recommended sectional strikes because they wanted to keep something going. (…) The sectional strikes tended to isolate hospital workers. After all, you can’t go and ask other people to strike in your support if you’re not on strike yourself. Unlike a real strike, you just don’t have a horde of people to go on flying pickets and talk to other workers.” (p.97)

Here we might have to see that the answer of the traditional left, which includes the author’s SWP, to any problem of working class struggle is: “Call the TUC to call for a general strike”. Which the TUC never does. Perhaps sectional strikes, if rotating and consciously coordinated by workers, could be a form of effective struggle, especially if they could be used to open up time and space for workers to create conscious bonds with other workers. Wage losses would be smaller, as not all workers are out at the same time, while even a smaller group of workers can cause a bigger impact. By using the time to reach out to other workers, it could avoid the trap that Neale mentions: the resentments of ‘striking for others’, passiveness of those not on strike etc.

Another interesting aspect of the nurses’ strike is that they became contradictory symbols for the wider class. On one side, they were the ‘angels’ that needed support, as they couldn’t go on an all-out strike, as this would endanger patients’ lives. On the other side, they were a massive national force that could, partially, focus the anger of workers in smaller workplaces and sectors that were suffering from the constant austerity attacks.

Perhaps the most important reason people came out was that hospital workers actually had the confidence to ask them. Most workers on strike feel isolated and defensive. We stood up and told them that we were providing emergency cover because it was their mums and dads in that hospital. They’d have [italics] to strike to support us. We spent our working lives caring for people, with few thanks and little money. We felt the working class owed it to us to support us in our need.” (p.102)

Despite the various manoeuvres of the TUC to split strikes in transport from the nurses’ mobilisation, the national strike day on the 22nd of September 1982, “was the largest solidarity strike since 1926”.

So where are we now, and what insights might be useful to NHS workers going forward? AngryWorkers have contributed a couple of articles to a new book, ‘Sick of it all, Work, Enquiry and Struggle in the NHS’, that includes snapshots of the NHS from workers’ perspectives, as well as some analysis of healthcare in capitalism. Because we rated his book so much, we have invited Jonathan Neale to speak about his past experiences at the book launch in London. If you’re a healthcare worker, or interested in the workers’ struggles in the health and care sector, come along! We will be presenting the book, and some reflections from Neale, before having a Q&A and wider discussion about our current situation. The key question Neale raises in the book about strong and independent rank and file action is still the most pressing one, 50 years after this book was written. How do we make it a reality?

Join us on: Saturday 9th July at 3pm
Marchmont Community Centre, 62 Marchmont Street, London WC1N 1AB.
Please buy your free ticket here: 

Missed chances – Report from the annual meeting of the Unison Health Service Group

During the last week of April I participated as a delegate of my Unison branch of a local NHS Trust in this annual meeting that brings together all Unison reps in the private and public health sector. This year, I reckon around 400 to 500 delegates met in Liverpool, average age around 55, mainly white, half of the delegates were women. What could have been a great opportunity of collective working class reflection on changes at work and experiences of struggle turned out to be a pretty tedious series of largely meaningless motions. Nearly all motions limited themselves to moaning about how bad things are, followed by general appeals, rather than concrete proposals. For example:

“Conference therefore calls on the Service Group Executive to: 1. Continue to raise concerns about the impact of pressures within services on staff mental health, calling on employers to provide adequate support.”

People, and often the same people, used these motions to make speeches about how tired everyone is and that everything is the Tories’ fault. The motion would then pass unanimously. It felt like these speeches were mainly used for individuals to be seen and heard, perhaps for future elections. There were only a few snippets of interesting information during the speeches e.g. concerning a recent strike vote at Manchester Community Health against restructuring, which got a 98% endorsement, or that the control room for ambulances in Dorset has a 40% annual staff turnover.

The only contested motion, and the only motion that would have at least a symbolic consequence, was put forward by the Northern Ireland delegation. These guys seemed pretty militant, at least they had some strike experience in the sector recently. They demanded that Unison stop giving evidence to the Pay Review Body, given that they are just a fig leaf for the government. The Pay Review Body (PRB) is meant to give impartial advice to the government about how much the pay increase for NHS workers should be. For more than a decade they’ve more or less suggested the imposition of real wage cuts. 

Their motion was scheduled as number 8. Motion number 7 was put forward by the Executive Committee, which said that Unison should continue to demand a flat-rate, rather than percentage increase, which benefits BME, women, low paid workers – and that Unison should continue to work with the PRB. So if motion 7 would pass, motion 8 would be out the window. There were the usual speeches to bolster the Executive Committee’s motion number 7: we have to be inclusive, support the lowest paid workers etc., which was a cynical move to use ‘minority workers’ to defend the status quo with regards to the PRB affiliation. But at least it came to a card vote on the issue. Around 200,000 votes voted against, versus around 160,000 in favour of motion number 7, meaning that the motion passed, and the conference would have no consequence whatsoever.

On the second day, the head of the union for health workers in Ukraine spoke, representing 600,000 members. She mainly spoke in patriotic terms (“the Ukrainian people”, heroic efforts of the country etc.) and said that their union supports the armed forces financially. The Unison general secretary mentioned that 10 ambulances were sent from London to Ukraine, with medical supplies, otherwise the general discourse was not questioned: the UK has to support the Ukrainian army, they are fighting for Europe and democracy. Not a word about the larger and systemic context of the war or about the class contradiction within Ukraine. A motion from Manchester to speak on the ‘Stop the War Coalition’ march was folded – the SWP lot would probably have used the motion to speak against ‘Nato and imperialism’.

There were a few more interesting smaller fringe and focus group meetings though. I went to a fringe meeting on recent outsourcing disputes, amongst others at Barts Health Trust in London and Princess Alexandra Hospital

The rep from Barts Health Trust claimed that the taking in-house of over 1,400 Serco staff was mainly due to ‘negotiations’, and that negotiations are better than strike – he denounced the ‘strike’ by Unite workers at the Trust as ineffective. The most interesting dispute seems to have happened at Princess Alexandra Hospital around the outsourcing of domestics: 200 members were involved, meeting in church halls, they collected 8,000 signatures in town etc. These workers seemed much more self-organised. There was not much time for questions. Only a short intervention by a member of the Homerton branch regarding the outsourcing and Living Wage campaign of 350 staff.  

The other more relevant meeting was on disputes about whether healthcare assistants (HCAs), who are doing clinical tasks, should be upgraded from pay grade Band 2 to Band 3. From what the audience looked like, many might have been HCAs – they looked poor and knackered. Around 70,000 Unison members are HCAs. In Manchester they got 3 years back pay for HCAs, and nearly all of them are now Band 3. For more background on the NHS pay grades, click here.  

The Trust ended up having to pay £16 million in total. The main HCA activist, an Eastern European woman, was pretty impressive, though at the end of the session there was little space to ask questions, such as: what about the pay loss due to less Sunday/Night-Shift bonus on Band 3; what about people saying that on Band 2 they can choose whether to do clinical tasks or not, according to how stressed they are on the day; what about HCAs often doing clinical tasks only occasionally in order to help out stressed nurses; what about the danger of deepening divisions between HCAs and porters, domestics, housekeepers, if a pay increase is attached to ‘specific tasks’ etc.

Of course I am not the only one who thought that there were a lot of missed chances in a meeting that brought so many delegates under one roof. But then we cannot underestimate the fact that many of these delegates are pretty happy with a ‘cushy’ conference and are perhaps not the most militant workers wherever they work. Still, there many reps are genuinely interested in building rank-and-file workers’ power. Some SWP and Socialist Alliance people (perhaps also other ‘rank-and-file’ oriented people) set up a slate for left-wing Service Group Executive Committee candidates and distributed a leaflet, inviting people to a meeting in the evening. At least the leaflet made some valid points about why the pay campaign in 2021 failed, e.g. that Unison was preoccupied with the difference in claims of other unions, rather than working together – and that they forced people through two indicative ballots. 

There were only about 20 people at their meeting, mainly politicos, I think. They spoke primarily against the mean bureaucracy and then four candidates for their slate-made speeches. Unsurprisingly, their main focus is on the change of the Unison apparatus, though they all seem also pretty involved on the branch level. In a way, this small fringe meeting was another missed chance, as we didn’t really hear self-critical reflections of organising attempts, their limits, difficulties, problems and how people tried to overcome them. The problem is that in the framework and tussle over of a large institution with large funds, everyone wants to portray themselves as successful and victorious, which prevents a sharp analysis of the struggles of our class. 

We handed out 60 – 70 copies of our own Health Workers’ Newsletter (I should have brought more), but people had to march through Socialist Workers and Morning Star lines, so they were perhaps less interested in yet another paper. At least one positive feedback. I think if people actually had a look at the newsletter, they would have been interested, as it provides some more interesting thoughts and info, e.g. on the weak points of the pay campaign 2021, and the recent strikes in Germany, which addressed the staffing question in an offensive manner. If you work in health and are up for supporting the self-organisation of workers’ struggle in the sector, get in touch: