’Fragmented Discontent’ in the hospitals

(We translated this article about the current situation and recent struggles in hospitals in Germany for the discussion here in the UK – for the original Wildcat no.107 )

Since Corona, the working conditions and workload of nurses have been discussed intensely: poor pay, no appreciation, permanent overload, staff shortages, professional exodus…. and then there was the Corona bonus! Here at the University Hospital in Freiburg, our real-life experience hasn’t always fitted with this ‘reporting’. Where does this discrepancy come from? And why is there no ‘counter-narrative’ from our side? We came up with four possible reasons, which essentially revolve around the very different working conditions depending on where you work and the overall situation in the sector, which has not only been in upheaval since Corona. The following reports describe the situations in the Freiburg University Hospital and the Berlin Charité, at the time of Corona.

There is a patchwork of wages – from pretty good to pretty bad!

On a national level the average wages for registered nurses with three years of training in 2016 were between 3100 and 3500 euros gross without supplements. In 2021, the TVÖD (collective agreement for health workers in the public sector) is between 3050 and 3750 euros (career entry / highest level) – without shift/weekend supplements and without the new, albeit staggered nursing allowance. Since 2020, the collective agreement of the university hospitals in Baden-Württemberg has been higher: between 3300 and 4200 euros gross, including the new care allowance of 200 euros from 2020. The private players in the hospital sector are also taking the TVÖD as a benchmark in their group collective agreements, which took some tough battles to achieve. A gross salary of 3,000 euros for an entry-level employee is now the norm in the hospital sector. Wages in eastern Germany are still lower! Nurses for the elderly are on an average of 300-500 euros below this – if their company is not bound by a collective agreement, it is even less! The TVÖD covers about half of the hospital sector, i.e. about 500,000 colleagues. A fraction of the other half earn above the TVÖD, with the majority earning between 10 and 20 percent less. While the total workforce in hospitals has remained relatively constant between 1991 and today, the workforce in outpatient care services and inpatient (elderly) care facilities has risen sharply since the mid-1990s (since the introduction of the long-term care insurance!). The increase was most notable in the private-sector (i.e. profit-oriented) facilities.

In nursing homes for the elderly and outpatient services, the TVÖD applies to less than ten percent of employees. The majority of approx. 800,000 colleagues have significantly lower wages. The wage differences are exacerbated by the fact that a lot of care work in nursing homes and outpatient services is done by unskilled or semi-skilled colleagues. The so-called ‘supplementary aids’ at Caritas and Diakonie do a lot of basic care in the outpatient services in addition to the house-keeping tasks, often at minimum wage. ‘Corona’ has led to people from the catering industry, for example, who have become unemployed, ending up in these jobs.

It is not easy to say what a universally binding collective agreement would really have done for people working in the elderly care sector. But the labour law commission of Caritas (a major charity organisation) was remarkably open in its reasons for rejection: “The collective agreement relating to care for the elderly interferes with the structures of our AVR [collective bargaining guidelines of the employers attached to churches], e.g., in the wage adjustment between East-West or our differentiation of pay between daily companions/care workers, etc., and unskilled assistants. This problem could not be resolved.”

The workload is a patchwork – from okay to pretty crappy!

Since 1991, the number of beds in hospitals has decreased by a quarter; in the same period, the length of stay has halved from 14 to about 7 days and the number of cases has increased by a quarter. Meanwhile, the number of full-time employees in hospitals has risen by 50,000, but this figure includes significantly more doctors – at the expense of nursing staff. [1]

There are two ways of reading these figures: Personnel planners and health insurers emphasize the lower numbers of beds and decrease in utilization, which is why they say that there hasn’t been a significant increase in workload. They do not ignore the increased number of cases, but see the solution in a ’focused revision’ of staff cuts, a further reduction in the number of beds, the expansion of outpatient care, an ‘optimization’ of the work processes (digitization!) and, last but not least, in an ‘adjustment’ of the ‘mix of different levels of qualification’ on the wards (this means: the academization of nursing and a deepening of the division of labour). [2]

The counter calculation (e.g. by the union ver.di) sees clear evidence for a significant intensification of work in recent decades, based on the fact that overall numbers of cases have increased, the length of stay decreased and staff numbers have been cut under the ‘flat rate per case’ [Fallpauschale] system.

In our job, it is not easy to measure workload and work intensity in numbers. Nevertheless, it is possible to identify a few common indicators that might differ slightly between hospitals depending on their size, trust owner or financial resources. In private hospital groups, saving on personnel costs is part of the business model anyway. And in elderly care facilities, the personnel situation is even worse.

– After the movement around the ‘care emergency’ at the end of the 1980s, a process of individualization set in. Many took advantage of the wage increases to go part-time; others took further training and specialized courses; quite a few studied nursing sciences and the like. With the restructuring that has taken place since the mid-1990s, many colleagues left jobs in hospitals and went into the expanding outpatient care sector.

– The planners turned the demand for ‘better care’ into an enormous deepening of the division of labour on the wards by means of sub-stratification: internal transport services ‘freed’ us from taking patients beyond the ward boundaries (and thus cut communication, which had been so important for organization during the movement); services for meals and other work, warehouse workers supply the wards with materials, MTAs (medical-technical assistant) prepare medication or take blood samples.

– So-called ‘patient managers’ or the ‘nurse in charge of patient processing’ (a professional category) take over the administrative functions – and are absent from the actual care work. The remaining nurses are relieved of ‘non-professional activities’, but have more stress in ‘areas of high responsibility’. Due to the shorter length of stay, patients on the ward are hardly ever fully independently mobile and the high-intensity work involved in admission, treatment and discharge increases.

The workload changes from day to day and depends on many things: a stressful shift can be okay if you get the work done well with your colleagues; conversely, a shift that is actually chill can be crappy because the cooperation is not good, the doctors are in a bad mood again, the ward manager is annoying, your duty roster wishes have not been fulfilled, a colleague became ill at short notice, or you don’t get along with one patient or another…. Actually, all of these things are also reasons why many people are still in the job: Variety!

But if you have no say in the process and the upper levels of the hierarchy can enforce everything, then it sucks. The disintegration of the ward teams through division and subdivision of labour have made it enormously difficult to resist together. Young colleagues are much more individualistic than they were 30 years ago. ‘Scandalization’ (portraying your general conditions as worse than they are, while accepting that management enforces smaller deteriorations), both toward colleagues and ‘to the outside world’, has become a necessary way to let off steam.

For a sustained period of time, the divisions in terms of wages and working conditions and the widespread individualization prevented broad resistance. This changed in 2015 with the mobilizations and strikes for more nursing staff – but so far only in a relatively small number of hospitals. Spahn’s Ministry of Health has responded with regulations around minimum staffing levels and the outsourcing of care costs from the general case-based flat rates (‘nursing budget’), which contain the total costs of medical treatment. [3]

In Freiburg, a 36-bed intensive care ward is now mostly staffed with 5/4/2 (early/late/night) registered nurses. In other hospitals, five registered nurses have to look after wards with 72 beds, even in the early shift.

The whole place is in a state of upheaval

How many hospitals and beds will there be in the future, and how will this need be determined and implemented? And how will all of this be financed?

‘Flat rates per case’ have been criticized ever since they came into existence. But they have also survived Corona, because there are strong interest groups that want to hold on to them (Spahn is one of them! if only because the standardised ‘flat rate’ allows him to gather data) – but no longer as the sole instrument of control to determine the finance of hospital care. [4]

Beyond all the ideological debates, critics and proponents of ‘market control’ by means of ‘flat rates per case’ actually agree on the changes to the basic structure of hospital planning: the issue is the appropriate mix of local outpatient care and hospitals. Market supporters want ‘community nurses’, registered doctors / GPs (increasingly combined in medical care centres) and large clinics. ‘Leftists’ want a state-planned and financed mix of community care, outpatient clinics and hospitals, in imitation of the socialist past. Such discussions will only be exciting if movements of nurses or workers in general take them up!

‘Recognition’ or broad struggles? What should ‘nursing’ be?

The nurses’ movement in the late 1980s wanted ‘better care’, asking: what are we actually doing at work every day? With what ideas and ideals? Whose emergency is the ‘care emergency’: that of the patients or that of the nurses? Can these two perspectives be brought together? Does an ‘upgraded professional image’ also mean a better hospital? When we fight for more pay and better working conditions, are we also fighting against a society that makes people ill?

These questions and contradictions are entangled together in the minds of colleagues as well as in many struggles and activities, and must be held together in this contradictory way so that they can be solved practically! They are then separated by the planners – and in the collective agreement of the union: For some of the ‘problems’ (and the colleagues!) there are improvements and mostly complicated regulations – the ‘rest’ is postponed (or was not even an issue). The (struggle for the) collective agreement is then not a starting point for further struggles, but puts an end to a mobilization. Or (the contract) even demobilizes, because many are disappointed by the results and can’t understand why it’s over again, when we were just starting having fun…

To demand an ‘upgrading of care’ or ‘more recognition’ is a step backwards, compared to these initial questions and experiences. Quite a few colleagues parrot the trade unions’ slogans or say what the media like to hear. Yet we saw in the spring of 2020 how this is supposed to lull us. It is not possible to mobilize colleagues in this way; at best, it is enough for an online petition!

‘Welfare’ versus economization and market logic?

As an ideal collective body of capital, the state makes health reforms and buys ‘public health’ from the hospital; as a welfare state, it finances it and conducts ‘budget negotiations’ with the hospitals. The employees in the health care sector are also caught between social care and the economy, between providing for others and earning money. Only if our critique of the ‘white factory’ goes beyond criticizing the ‘assembly line care’ can we get out of this deadlock. The ‘white factory’, too, is in its core based on our cooperation and can therefore also mean ‘cooperate in order to fight together’!

The so-called ‘relief collective bargaining agreements’ in about 15 larger hospitals were intended to reduce the burden on care staff. The first agreements were far too vague and quite complicated. They shifted the disputes to new institutions. Years ago, the colleagues in the Charité, a pioneering company, had emphasized: “The fight for implementation begins on the hospital ward.” But the jungle of rules and regulations has been stronger so far and killed off initiatives from below. The newer contracts (e.g. University Hospital Jena) are better. [5]

The business model of recent years (essentially: “do more with less staff”) has hit the wall: it showed its weaknesses in both moral terms and managerial terms (quality deficiencies, lack of staff) and, of course, was also weakened by incipient struggles. A university hospital in Baden-Württemberg has the economic fire-power to react to discontent and change the business model – whereas in Düsseldorf the colleagues had to strike for weeks (with participation of many professional groups) in order to change things. In addition, management uses the ‘relief collective agreements’ to streamline the work process: they introduce new shift-models and so-called flexi services (similar to bank shifts); they cut informal breaks that were previously paid for on night duty; they enforce the expansion of ‘on call’ agency work and other forms of flexible working. [6]

The ‘relief agreements’ to date are the result of the first broad mobilizations in over 20 years. The campaigns were designed for a labour force that had long been passive, individualized, and fragmented by the restructuring of the work process. The union was able to plan in a way that conserved resources – important in the face of declining membership and uncertainty about risk and expense. So far, this has had the high price that the collective agreements apply predominantly only to trained nurses, affect only a few hospitals and thus run the risk of confirming the mentioned tendencies of re-dividing the total workforce (implementation of flexible working and the introduction of a deeper divisions of labour). Therefore, it will be important for people to have the experience of taking part in broad strikes, ‘after Corona’. During a strike the daily cooperation becomes visible – because otherwise it cannot be blocked. For this, connections with other workers must be built, divisions must be addressed and overcome. Striking by means of adhering only to the “Emergency Service Agreement”, is only half the battle. That type of strike saves money for the unions and provides predictability for the employer – but on our side, it’s only ‘half a battle’ fought. [7]

It is not irrelevant whether improvements are achieved by strike or ‘negotiated’! Only in a strike we can gain experiences that will have an impact on how we work day in, day out – the power-relations, the divisions. Nurses have an objective strike problem: our ‘work material’ is people. We can only tackle this problem if we treat the ‘white factory’ as a factory; if we learn to stop working together and to deal with the consequences ourselves. [8]

We will only be able to achieve an improvement in wage and working conditions for all if strikes are extended to more occupational groups and to other hospitals. Otherwise, we will remain stuck in a modernization process of the ‘white factory’ with increasingly fragmented working conditions and varied wages.

And yes, Corona was and is a challenge. The pandemic is a cross-border experience, and our struggles should not fall behind that, we should learn from each other. In mid-March 2021, workers in the British NHS protested against a paltry one percent pay increase offer from the government…

Freiburg, University Hospital

In spring 2020, management reduced the schedule for planned surgeries pretty late, but at the same time they mobilized lot of extra staff: part-time workers were asked to increase their hours, students, trainees and ex-colleagues were called in, ‘old’ ventilators were dug out from the basement…. Many were quite excited about the new challenge.

At the same time, there were some familiar problems: a completely non-transparent hierarchy from top to bottom, incomprehensible decisions and procedures – especially with regard to hygiene and testing strategies. Disputes about hygiene regulations are not new, we have been confronted with viruses and hospital germs for a long time, but the fact that we were affected as a whole sector, not (just) as individuals, was a new experience. The fact that you were suddenly looking after colleagues who had fallen ill made it clear to us, more than all the figures and information about the virus, that something new, ‘something dangerous’ was on the way. In the ‘first wave’, younger colleagues also fell ill, and are still complaining about the now familiar after-effects: sense of smell, nerve problems, difficulties with circulation/breathing. Because hygiene became much more a question of personal safety than before, many colleagues were annoyed that you never knew whether the hygiene rules were made according to a lack of PPE (‘limited resource management’) or actually for safety. Most colleagues would have acknowledged that a balance has to be found between safety and ensuring care – e.g. by means of a transparent testing strategy. But what was sold as a ‘testing strategy’ seemed to us more like flying blind. Patients in the emergency room were tested, fine. Those who were called in for surgery were also tested on admission – but then went through the entire procedure from the ward to surgery and back again before the result was in!

In the case of outbreaks on the wards, the colleagues always had to strongly insist that half-consistent testing was carried out… There are no hard numbers of infected colleagues; if they have been tested by their family doctor, they do not appear in the company statistics. The ver.di personnel council drafted an ambitious paper with demands regarding occupational health and safety, but only a few colleagues found it on the intranet; there were no steps to implement it. Overall, there was a great deal of dissatisfaction – not because of staffing levels, but because of the ‘handling of the virus’, but it remained on the level of individual whining that never turned into something collective.

One main difference between first and second wave was ‘staffing management’. Essentially, they surfed the ‘second wave’ with the normal staffing levels, without providing extra help. Staffing on the Covid wards was/is still quite good, but ‘around’ these wards people were struggling as staff were shifted onto the Covid wards. One of the Covid wards became an ‘infection cluster’ (20 colleagues of different professional groups were infected), which of course again reduced the staffing level. The intensive care units also had only normal staffing levels during the ‘second wave’. This was very stressful for weeks, since the Covid patients required a lot of work for a long period of time – the usual ups and downs of work load were missing. The fact that it still worked somehow was due to an old, very experienced and well-rehearsed core here in Freiburg, who put the brakes on ‘the young ones’ when they got hectic: “One thing at a time, an intensive care unit doesn’t work any other way!” The 2:1 staffing ratio could be maintained, but it became stressful because of hygiene measures when a colleague had to look after a covid and a non-covid patient. The occupancy rates finally started to decrease from mid-January onwards.

Charité Berlin

In spring there was some initial confusion as not enough PPE material was available; protective material and disinfectant disappeared from the freely accessible dispensers, as did soap, masks were missing on the ward, the FFPs were locked up and only issued with a signature. The Charité bosses talked of theft, and for a short time there were bag checks at the exits. Then, due to the scarcity, the instruction was issued to use an MNS-mask over the entire shift, including in break rooms. The hygiene officers added: FFPs were only necessary if an infected person coughed, or had to be intubated or suctioned. Fellow workers were all the more annoyed by the board’s assertion that colleagues were getting infected at home.

In the spring of 2020, there had been a lot of extra personnel, trainees, students and volunteers used, and at times there were rather too many hands…. In the second wave, the wards were asked to provide staff for Covid wards (usually voluntarily), the teams were then smaller and were partly filled up with staff from temporarily closed wards. FFP masks were now standard. The hospital, however, tried to compensate for the financial losses of the spring, and only shut down the scheduled surgery program at a very late stage. Additional intensive care units (ICUs) had to be opened, and experienced ICU personnel were transferred to the new ICU areas. Together with nurses from the normal wards, ‘pairs’ were formed, a so-called ‘skill-mix’, in order to be able to look after the additional intensive care beds. The ICU staff in particular felt that this created additional stress.

After shutting down/adjusting the surgery program, things quieted down on most of the other wards – but infections occurred again and again: Patients became symptomatic, or tested positive – along with one or two colleagues. There are no concrete figures, many have been tested by the family doctor and thus do not appear in the hospital statistics (which we also didn’t have access to). Currently, however, both the Covid infections reported in the Charité and the Covid infections reported via the health authorities are recorded (retrospectively) as occupational diseases.

Starting in the autumn/winter of 2020, weekly swabs of patients became routine, with frequent positive results. During outbreaks, all the ward staff were also tested, which repeatedly led to wards being classified as ‘infection clusters’ and closed. At least one colleague was reported to have died without this becoming a broader issue in the clinic, as was the case with reports of deceased relatives following probable transmission of the virus from hospital to home.

During spring 2020, there was definitely the sense that everyone was trying to get the situation under control. The cooperation between professional groups was more dynamic than usual. It was new for everyone, and you could learn something again. That’s all gone now. Political initiatives such as those of the Krankenhaus statt Fabrik (Hospital instead of Factory) initiative against ‘flat-rate payments per case’ or the current Zero Covid campaign haven’t really entered the wards. In 2016, we pushed through the first collective agreement that was supposed to bring more staff. There was a broad mobilization for this, but it ended up as a paper-pushing exercise about implementation of this or that regulation; the situation has improved in some wards, but not in others. The structures established at that time hardly exist anymore. Currently, ver.di is launching a new organizing effort with online general assemblies and campaigns geared to the upcoming elections in Berlin and at the federal level. It is not yet clear whether the Covid experience in the clinic will lead to new organizing attempts and struggles. The colleagues of the outsourced ‘service operations’ at CFM went on strike alone in 2020, ver.di ‘regretted’ after the arbitration in March 2021 that the outsourced workers were not going to be included in the Charité TVÖD (public sector collective agreement). Workers felt sold out…

Oh yes, the Corona premium…….

Towards the end of 2020, the debate around the Covid bonus also began in Freiburg. The federal state had increased the bonus to about 1.6 million, and with about 15,000 workers, there wouldn’t have been much left per person. In the end, 2,300 workers received between 350 and 1,500 euros. Very few would have minded if there had been no bonus at all. But many were annoyed by the confusing and unfair pay-out – “pay everyone an equal smaller sum, instead of such a chaos” – but again, there was no collective discussion about this.

At the Charité in Berlin, there was a Corona bonus of in total 450 euros, paid over three months during the spring of 2020, which I believe was financed by the state of Berlin. In addition, there was a staggered payment of 300 to 600 euros in autumn 2020 through the TVÖD collective bargaining round. However, the new agreement signed by ver.di stipulates that there won’t be any wage increases until April 2021! The contract expired in September 2020, so there will be no increase for seven months! Or at least only for care staff via the premium – which is paid for by the federal government!

Then the Charité hospital received money from the federal pot for the ‘first wave’; this was divided up according to an agreement with the sfaff council. Some people who didn’t receive any of this money went to the staff councils, but there wasn’t a collective debate around this either.



1 In 1991, there were a total of 875,816 ‘full-time positions’ of hospital workers (part-time positions were added up), 95,200 of whom were doctors, 780,600 general staff, about 45 percent of whom were nurses. In 2019, there will be a total of 928,000 ‘full- time equivalencies’, 168,000 doctors and 760,000 general staff. These shifts are in the logic of ‘per-case flat rates’: physicians bring in revenue, nurses cost.

2 The nursing managers openly state that more staff on the wards, if it is not ‘targeted’, does not equal more quality and less workload. ‘Targeted’ then means new duty times and shift models in order to cover ‘workload peaks’.

3 These lower limits are only an absolute minimum. Regardless of concrete struggles and ‘countervailing power’ in the hospital, management still has the ‘power over the numbers’ in all these new calculation methods, i.e. the possibility to control the work intensity through the flexible deployment of workers / the control of ‘patient flows’. Moreover, in all these calculations, the work of one specific occupational group is separated and calculated as if their work was independent from the total work on the ward, which politically consolidates the divisions of the last decades. And the discussion about a better basis for calculation only distracts from the struggle for better working conditions for all!

4 In addition, so-called “’maintenance payments’ are to be added to finance that the ‘flat rate per case’ does not cover – such as the masks now during Corona.

5 In Jena, shift-related staffing levels were defined for each station. In a three-year transition period, the clinic must pay workers bonus payments or give them extra holidays in case of non-compliance (this also means a jungle of documentation, complaints, proof, calling commissions….).

6 In Freiburg, for example, the overlapping (handover) times between early and late duty have been halved. The young colleagues complain that no meaningful handover is possible anymore – and are then given extra training by management. The fact that this takes up any breathing space in the working day and increases the workload is overlooked.

7 “Striking patients away”: strikes by means of “emergency service agreements”, obligated the employer to ‘empty’ those parts of the hospital that announced their intention to go on strike within a certain period of time (no more admissions, reduction of surgeries, transfer of patients…). Charité management had also signed this “emergency service agreement” because they had not expected such broad participation in the movement, which is an indication of what is possible.

8 In October 2020, there was a five-day strike in Californian hospitals. Because Corona regulations prevented union organizers from entering, the strike had to be self-organized. The colleagues quickly agreed that it would only work if all workers joined in. A separate “emergency service” was set up for the patient areas in order to maintain the necessary minimum care work. Unfortunately, no real improvements have been achieved to date. This could also have been due to the fact that the focus was not on achieving material improvements in wages and working conditions, but on improving financing for the hospital. On this front, the hospital management reacted with new structures (trade unionists on the supervisory boards) and vague promises to reorganize financing.

Share this article:

Read Next:


Issue no.1 – For workers’ and patients’ control of the health industry

There are good reasons why we need more workers’ and patients’ control over the health system


Issue no.1 – Editorial

This magazine represents an effort to create a forum where together with co-workers we can reflect on our experiences, our struggles and our potential to create solidarity


Debate on the current character of hospitals and their restructuring

Friends from France have written a detailed paper on the question – read it here