We document a text by a fellow health worker on the question of how to create the conditions for unity within the British Medical Association (BMA) and other trade unions. Even within a single trade union this is not an easy feat, as five years as a union rep have shown us. Largely, trade unions are organisations that mediate and can maintain division amongst workers. This article explores opportunities within unions and where union organising can pose challenges to gaining strength across different groups of workers.
Divide and rule
This article seeks to explore the dynamics used by the government to divide doctors and weaken their overall leverage and strength to make gains and improve terms and conditions. Nearly half of all doctors in the UK are international medical graduates. The British Medical Association represents doctors in the UK regardless of country of origin. During the course of organising around better terms and conditions, resident doctors voted to prioritise UK graduates for training posts. This solution was originally proposed by the government. After the BMA agreed to this policy, international medical graduates have developed a growing sense of disillusionment.
What is a trade union?
Trade unions are made up of members who work and organise together collectively for better pay and conditions through political campaigning and collective and industrial action. Workers who have shared issues and demands come together to discuss and agree on shared goals and strategies. Trade unions are the ‘official’ recognised bodies of specific workers (e.g. the RMT is the National Union of Rail, Maritime and Transportation workers) that facilitate workers to organise and set collective demands and strategies. Most unions will collect member dues in order to pay for staff time, rooms to meet and strike funds etc. In the UK trade unions are subject to specific laws that outline how workers can legally organise, these have changed over time and are currently some of the most restrictive in Europe.
Shared issues are not always overtly connected, employers will often undermine and divide workers to prevent collective improvements being won. For example, before our current equality laws it was legal to pay women workers less than men for the same job, purely based on gender. As a hypothetical example, this is beneficial to the employer for many reasons, not just to make more profit by paying women workers less, but also as a tool to undermine the higher paid male workers. If men wanted to organise or strike for their own demands, the employer could simply leverage the women workers to undermine the men. The employer could temporarily offer higher wages to the women so that they would continue working and allow the employer to sit and wait for the male workers to return to work without giving in to their demands, and subsequently reduce the women’s pay back to the lower rate. This is just a hypothetical example of how an employer could try and separate workers into different groups and exploit them differently to undermine collective organising.
Historically in the UK, when women workers called and organised for equal pay, some men did not see how this was related to their own issues and refused to support their struggle. They didn’t see how one group of exploited workers could be used to undermine another, ultimately hurting all workers in the process. This is why solidarity is a core value in trade unions across the world, together workers have won rights against discrimination, increased pay, better terms and conditions, but only when they stand together.
The government and employers main interest is to maximise production and profit, mainly through suppressing wages, preventing improvements for worker terms and conditions and automation. When workers stand together with a shared understanding of specific targets and escalate their discontent, through collective workplace organising, they are at their strongest. Withdrawal of labour, collective bargaining and disputes are the most effective tools that workers have to win better terms and conditions.
Divide and rule
The government’s position has been significantly weakened due to the gains that resident doctors have made in the workplace. The collective strength and gains made is a significant threat to the overall position of the government who seek to maintain worse terms and conditions for workers, as this is the cheapest (not the most efficient or effective) way to maintain services. Together with employers, the government has identified weaknesses within the BMA amongst workers to attempt to break their collective strength. This is known as a “divide and rule” strategy.
Divide and rule is a strategy where workers who are precarious are separated out from others, so that the unions overall bargaining position and collective strength is reduced. This has the effect of not only weakening the position of workers who are on more precarious contracts in the immediate term, but worsening the terms and conditions for all workers in the long term.
Imagine you are an employer with 1000 workers who are in a union, split 50/50 men and women. The workers are demanding better terms and conditions that you do not want to agree to as it will slightly reduce your profit margins. If all 1000 workers go on strike you will have no choice but to agree to their demands as you will be losing too much money while they are not working. You decide try and divide them by agreeing to the demands but only for women workers. Unless the workers are united in their position, everyone loses out. This requires the workers to understand the wider dynamics of their situation and actively consider what motives and tactics an employer has and how workers different to themselves might be impacted.
Trade union laws in the UK follow this pattern of divide and rule, in the BMA these laws come in the form of restrictions on strike action outside of branch of practice (BoP). For example, resident doctors cannot legally go on strike to support another BoP such as consultants, even if they wanted to. This means if strike action has been successful for resident doctors, they cannot simply continue the strike to support another BoP. The best way to win would be for BoPs to learn from historic wins, mirror collective organising and take their own strike action.
One of the downsides to improving terms and conditions in specific areas, is that workers outside of that criteria may become disaffected, leave or undermine the striking position in the longer term. Moreover, if they become hostile to other workers, they’ll never blame the government and employers, who are ultimately responsible for all terms and conditions. This creates a pool of workers who are more vulnerable to government and employer exploitation, especially if they are outside the union – this would be an example of a successful divide and rule tactic.
Collective organising and workplace rights
One strong example of collective organising is the Grunwick strike, involving migrant women Asian workers in Britain. The Grunwick workers went on strike over poor working conditions in film processing factories in 1976. Many other workers supported these strikes and supported calls for union recognition and the prevention of discriminatory treatment. Although there was a crackdown on collective action, concessions were won over pay and pension rights. The movement was a turning point for the strike movement in the UK and showed that when migrant workers collectively organised, other workers had an actionable way to support them in solidarity.
In recent years, resident doctors have been one of the most persistent groups of workers who have been collectively organising for pay, terms and conditions and increased training numbers. As a result of successive waves of strike action, they have won significant concessions towards pay restoration. Not only that, working conditions and issues within the workplace have been significantly improved with guardians for safe working introduced. More recently, concessions for locally employed doctors to have the same resident doctor terms and conditions have been won. The specialist, associate specialist and speciality doctors (SASC) committee has also been able to secure concessions for more doctors to be moved onto permanent contracts.
Legal bills
The BMA has become massively dependent on escalating issues via legal representation, without utilising more common tactics first (such as informal routes, grievances, collective grievances or strike action). This onerous reliance on legal routes has not provided a marked improvement in terms and conditions or collective pay. Relying on legal escalation does not provide the results that you may imagine. It is time consuming and costly. Whilst they are neutral arbitrators, the employment tribunal service can be skewed towards employers interests. Employers have whole teams dedicated to legal defence, set the terms of employment and are very experienced in the tribunal process. In addition to this, more often than not, claimants will have no experience and are not well represented or prepared.
The evidence required for successful tribunals often exceeds what even the most diligent doctors would record. For example, discrimination cases could require claimants to have physically recorded each incident, for it to be considered ‘evidence’ within the tribunal process. Given that cases of discrimination can build over the course of years, include numerous perpetrators, often include “subtle” or off the books comments or actions – it is easy to see why a doctor wouldn’t have been able to record every incident. Legal recourse does not necessarily provide the outcomes workers want or need and can result in a breakdown of ongoing employment relationships. In a union and in collective actions, workers are more protected, the pressure on employers is much greater and likely to lead to change. This can also help maintain individual relationships in the workplace and offers greater protections.
The tendency towards legal recourse can also lead to disaffection amongst doctors as usually the likelihood of success is often considered to be too low to proceed (on balance with the legal costs). By continuing to see the union as a place mainly for legal representation, members are not considering the true potential strength of the BMA. Through collective organising, members could dramatically improve terms and conditions for themselves and their colleagues. This would be more accessible if there were local active workplace branch structures. Collectivising workplace issues and working with others within the workplace would not only reduce the reliance on legal systems but lead to more successful outcomes that require less pushback, result in much earlier resolution and less detriment to workers.
Overseas recruitment
For many decades the NHS has relied on recruitment from overseas as the number of UK medical students graduating had not kept pace with the number of training places available. In recent years, the lack of capacity and funding for training positions from the government, has resulted in hospitals creating non-training grade positions, often on worse terms and conditions than nationally agreed training contracts. Many of these roles are fixed term or temporary. This allows the government to meet the needs of service, while also creating a more vulnerable group of workers.
Doctors on visas (IMGs), also known as locally employed doctors or specialty grade doctors, are often not on permanent contracts. Keeping IMGs in precarious roles creates a culture of fear amongst IMGs; with concerns that if they speak out against their employers (e.g. take strike action), they may be subject to reprisals in the form of poor references, terminations of contract or sanctions (n.b. it is illegal for an employer to do this in the UK). Some IMGs are concerned about participating in strike action due to their precarious position that the government maintains. IMGs may also be less likely to seek support for discriminatory incidents in work, such as racism and misogyny, or be less likely to be believed if they do seek help. For some IMGs, this has created a hostile environment, allowing employers to exploit and leverage workers against one another.
Being wholly reliant on employers to renew visas, which often include dependants such as partners and children, forces IMGs to balance their right to remain in the UK, against their legal rights to organise as workers. It is then understandable why so many IMGs might tolerate worse terms and conditions. The government forces IMGs to choose between security and fair working conditions. Many hope that after a short period of adversity that they will secure a training post and/or indefinite leave to remain. This is one example of how the government has created and maintains a pool of vulnerable doctors (IMGs) who can be exploited further to break the collective action of other doctors. If you assess the actions of the government within this ‘divide and rule’ lens, then the choices the government has made, such as increasing the salary threshold required for visa sponsorship (making those workers more dependent on employers), suddenly make more sense.
Changing wider political landscape
The wider political landscape is changing in the UK to become more authoritarian with restrictive attitudes towards immigration. One such example is the change to Indefinite Leave to Remain (ILR), which will soon require 10 years of permanent residence in the UK, up from 5 years previously. Similar to above, the increase of racism and hostile attitudes towards immigrant workers can also be explained as part of divide and rule. There is more hostile rhetoric towards migrants than previously, extending from asylum seekers and refugees to professionals in terms of visa restrictions. Ignoring or denying the increasingly hostile environment for all immigrant workers, significantly limits the available pool of support and solidarity extended, leaving IMGs more exposed and vulnerable to attacks by the government.
This type of rhetoric is commonly employed by the billionaire classes and government as a distraction technique away from the root causes of worsening working conditions. It allows billionaires to continue to hoard money and increases the diversion of public funds towards the same private capital. The political party, Reform, are making clear electoral gains across the UK, planning to remove ILR route entirely. Increasingly subjecting IMGs to poorer terms and conditions than their settled counterparts harms all workers.
Campaigns that have been successful have sought to unite with a myriad of other existing groups, including migrant solidarity. Not recognising the narrative that attacks on other migrants have implications on international medical graduates, leaves IMGs more exposed and vulnerable to hostile rhetoric. Unison have launched a visa campaign for social care workers, focusing not only on the workers themselves but extending out much further to include other workers. Organising to improve each individual persons conditions has limitations. When that individuals collectivise and work in solidarity with other groups, it helps further all of the groups’ interests.
Union breaking
Reduced funding and poor workforce planning are what ultimately cause worsening terms and conditions of employment. Unfortunately, the dialogue amongst doctors and the BMA has not prioritised this fact when planning disputes. Widening divisions between doctors weakens the resolve to strike and reduces the effectiveness of collective action to improve terms and conditions overall. It also has the effect of creating a group of doctors, in this case IMGs, whose conditions are worsening, who may leave the union and therefore do not have recourse to union representation. This leaves them more vulnerable to exploitation by employers.
Some IMGs have publicly spoken out and encouraged other IMGs not to participate in strikes. Not only that, some have advocated working for free, working for lower rates or non-engagement with ballots. This not only undermines the position of UK graduates, and BMA as a whole, but it worsens the outcome and position of IMGs as well. An example of this was the recent Resident Doctors Strike offer vote. There was an offer of extra training posts, however, it was not clear if those posts would be converted from existing locally employed doctor (LED) posts. This could worsen the position for other LEDs, as up to 10% of existing posts could be converted to training posts. Due to the lack of participation within the strike mandate, many IMGs were ill-prepared for the results, had grown increasingly disillusioned and left the BMA without necessarily being able to vote against acceptance. This is a successful divide and rule tactic because it has meant that IMGs became separated from other members.
Crucial leverage has been lost and the BMA is in a weaker position in pushing back against generalised underfunding in the NHS, fewer jobs and training positions for all members and worsening terms and conditions.
The government is trying to create a pool of significantly disenfranchised IMG doctors who are publicly speaking out against other doctors and requesting their colleagues do not participate in strike action. This pool of doctors can be easily manipulated by employers and the government as they are without union protections, working in precarious positions and lack support networks on worse terms and conditions. The government wants IMGs to believe that they will be better off if they are divided from other workers, but this has never been the case when the governments plan is always divide and rule.
How to overcome divide and rule
If we want more funding from the UK government for public services, that affects the availability of training posts, jobs, funding for general practice and terms and conditions, we must organise successful campaigns together to win.
This requires careful organisation, conflict resolution and collaboration. When considering how best to organise and improve our terms and conditions, we must consider how to oppose government and employers where they act against our shared interests through collective and industrial actions. This will involve overcoming divide and rule, by finding common ground and shared values with other workers.
To move forwards some practical steps would include:
1) Facilitate more nuanced discussions and make it easier to access local structures and reps. The way in which UK graduate prioritisation occurred in the BMA has caused significant upset between members as people have not felt involved. Many doctors not ordinarily involved in the organising of the union have felt unable to have their views heard because of difficulties in accessing the BMA democratically at a local level
2) Advocate for secure, permanent contracts for all doctors, using the successful recent strike actions as a template
3) Develop a mutual understanding of what can advance each other’s working interests and how to organise campaigns to further those interests via collective actions and bargaining
4) IMGs become active agents and leaders in organising within the workplace, including taking collective action against employers
5) Doctors who are on more secure and permanent contracts, share organising skills in the workplace, in particular with IMGs. Meet and learn from others, gaining skills in how to manage disputes with employers as a way to improve collective power and strength
6) Organise “know your rights” sessions for all workers, to prepare workers and understand what employers can and can’t do. Outwith those sessions, create opportunities for workers to meet for mutual support, training more reps and push for more facilities time
7) Create a shared organising plan and events for all workers within the BMA, by developing a collective strategy that addresses the needs for all doctors workforce planning and priorities.
8) Facilitate a trade union skills development program with mentors who can help to troubleshoot problems in the workplace
Increasing worker collective strength and skills in workplace organising is a vital step towards resolving underfunding within the NHS. This could dramatically improve our ability and capacity to take successful collective organising positions to secure more jobs, training positions and funding. By doctors organising together and more cohesively better terms and conditions are more likely to become a reality.
