Around a dozen of us came together in Bristol in order to discuss the conditions and struggles within the NHS. Amongst other areas, there were people working in mental health, as GPs, as NHS catering workers, as A&E and private hospital nurses, as pharmaceutical workers, as therapy support workers and medical students. People came from Bristol, London, Manchester and Cardiff. We discussed, following the broad general themes of this paper on the current moment in the NHS.

 

Centralised spending 

We discussed the fact that it seems that an increasing amount of money is spent on the NHS ‘just to tread water’. This might be due to the general costs for drugs or wages increasing, it might be due to the increased complexity of patients’ care needs, which is often overlooked. The point of the government is that the recent pay increases are not ‘funded’, meaning, they are paid out of the general budget. This is also a propaganda act to make staff and their demands responsible for the lack of funding. The underinvestment, in particular in terms of buildings and estate is blatant – we all shared stories about sewage leaks and collapsing hospital roofs in our respective Trusts.  

We wondered whether the separation of various Integrated Care Boards (ICBs) are meant to parcel out small enough administrative units that could theoretically be further privatised. It also seems that the ICBs are used as an instrument in order to control General Practitioners (GPs) more and how GP practices operate. The doctors who own GP surgeries have themselves recently, via the BMA, pushed for a move towards a ‘dentistry model’, meaning, an increase in patient fees.

At the same time we can see that attempts at privatisation, such as Babylon Health, ran into structural limits. Initially they tried to syphon off the most healthy patients for their digital community health programs, but even still their business collapsed and the ensuing deficit had to be shouldered by local hospital Trusts. 

 

Militarisation

We mainly shared anecdotes, e.g. about many anesthetists in the south west also collaborating with military services. The problematic of a federated data platform, both about patients and staff, seems to be relevant when seen in the context of a potential military emergency – and the handing over of data to army or police commands. A comrade reported about anti-militaristic initiatives of health care workers in Australia, e.g. against US army bases. 

 

Decentralising the deficit

A mental health fellow worker reported about the considerable bureaucratic work at each billing cycle. Local Trust workers would have monthly meetings with the then Clinical Commissioning Groups which seemed a rather pointless tick-box exercise of merely referring to national targets etc..

A friend from a Trust in London made the point that Trust management  stated during a recent industrial dispute eight months ago, that the ‘Trust budget is fixed’ and that any extra wage spending would have to be withdrawn from other services. At that point the local union branch looked at the mechanisms of Trust budgets: it seems that in disputes about pay increases it is easiest to deal either with ‘surplus Trusts’, who have the financial means, or with ‘deficit Trusts’, because they are in a deficit anyway. The most difficult situation is when confronting a Trust that just about breaks even. He also stated that there are no nationally fixed figures of deficit which would determine at which point a Trust would be financially ‘taken over’ by central command. At the same time the local Trusts in Bristol used a very specific figure as a ‘looming threshold’, beyond which they would lose the discretionary power over investment choices etc. It would be good to clarify this. 

A comrade who works for a local mental health Trust stated that Trust management just wants to climb up the ladder within the National Outcome Framework, e.g. by issuing 500 job cuts, without it being clear what kind of rewards or privileges the Trust would gain from being in the ‘top half’. This might be primarily about management status and reputation.

 

Central and local redundancies

We see a relative hiring freeze at most of the Trusts where we work. A GP comrade reported that only three years ago you could pretty much walk into a local job, whereas now there are 60 applicants for each vacancy. A catering worker agreed that while there is a hiring freeze, there is a shortage of staff at the same time, resulting in hospital cafes being closed on a day by day basis. A medical student added that he sees a shift towards blaming international doctors for the lack of vacancies and training opportunities for young doctors. There is a bottleneck especially for F2 training pathways. Another GP friend said that GPs on work contracts have their hours cut, but that this issue is not taken up as much, because the active GPs within the BMA are primarily ‘partner GPs’, who work as contractors, rather than as workers. Under the Additional Roles Reimbursement Scheme (ARRS), practices are encouraged to employ more staff, but at the same time remove GPs from the system.

 

The aggravating health crisis

As mentioned, the budget does not really reflect the increasing complexity of patient cases. For example, we have a hike in patients who need 1:1 care, which due to lack of staff is often watered down to a ‘cohort arrangement’, where one staff member looks after a group of 1:1 patients. At a hospital in Bristol, management announced to experiment with additional video surveillance of ECO 4 patients. At a Trust in London, the A&E saw around 300 patients per day in 2019, by 2026 this had increased to 550 patients, without an increase of staff. At a Manchester mental health Trust patients are outsourced to private hospitals, due to a lack of beds. Currently the bed occupancy of the NHS is over 99%, whereas it should be around 85% in order to leave capacity for acute situations of crisis, such as a pandemic. Mental health patients in Wales are shipped to towns in the north of England, due to bed shortages.  

Generally speaking we can see that the budget and health crisis is passed down the line, so that it’s mainly front-line workers who have to deal with the fall out. 

 

Pressure on migrant health workers

From our experience, migrant worker colleagues tend to be more reluctant to participate in industrial actions in the first five years of their stay, until their indefinite leave to remain is sorted. To extend this period to ten years will have difficult consequences in terms of collective militancy. At a local mental health Trust there are not many sponsored visas anymore. Often the visas of health care assistants are not renewed, while the visas for nurses are. 

In Manchester, only the pay increase on the 1st of April pushed many health care assistants above the income threshold, they would otherwise have been threatened with deportation. In London the situation for migrant NHS workers is generally not as precarious, due to the London weighting, which pushes up their wages. Some Trusts decided not to include the London weighting when reporting to the migration authorities, which could get colleagues into difficulties. International doctors are normally only on one year contracts and with the UK Graduate (Medical Training) Prioritisation Act, their situation has become more precarious.

 

Trade war and pharma

A comrade who works in the pharmaceutical sector gave us a brief overview on the situation. Unlike the UK, there is no organisation like NICE in the US, which would set price controls and assesses the relation between costs and medical benefits of a new drug. This means that drug prices tend to be ten times higher in the US. While the US state wants to reduce the costs at home, it pushes to increase prices abroad. This pressure and the subsequent ‘investment strike’ of major pharma companies pushed the UK government into various adjustments: the raising of the price cap for new drugs and the option for the government to bypass NICE recommendations. Still, unlike in Germany, the prescribers in the UK have no interest in prescribing cheaper drugs – in Germany they can keep the price difference.

As the NHS budget doesn’t increase, the increase in drug prices will translate into pressure on wages and services. The state also restricts the prescription of certain drugs, e.g. GPs have to ration the prescription of weight loss drugs to five patients out of their catchment area of 20,000 users. The general push though is towards ‘quick fixes’ through medication, rather than prevention or actual therapy. There are only very few patient action groups that address the question of medication, unlike the widespread actions in the 1980s around access to HIV drugs. Most patient groups are ‘pressure groups’ for certain conditions, which are often sponsored by the pharma industry. 

 

Limits to large scale privatisation

The various failed attempts at larger-scale privatisation of hospital services seem to show that it is not easy to make much money from running health services. The wages are already pretty low, perhaps they can save on pension contributions. Recently at a Trust in London, the contract renewal for outsourced auxiliary services came up, but the old private provider didn’t want to renew it. Management addressed other public institutions if they want to run the service, but they also declined. The question is how the NHS workforce will be affected or not affected by the upcoming ‘two tier workforce rules’, which are supposed to prevent two tier conditions in the public sector. There were many disputes around the ‘two-tier issue’, in particular around the ‘Covid bonus’, where some outsourced workers on old contracts received the bonus like any other NHS worker, but the staff on new contracts were excluded. At a TRust in London this led to protests in 2023, but workers were reluctant to go on strike. In Bristol we recently had the strike at SecondStep by mental health workers, who were paid less than the equivalent NHS band – but as they are not officially ‘outsourced’ they would probably not benefit from the new rules.  

 

The restructuring of the relation between hospitals and ‘community care’

A comrade from Manchester reported about the conditions in the ‘community care sector’, where a lot of new companies of the so-called ‘third sector’ provide services in supported accommodation on pretty bad contracts, involving 24 hour care etc.. The Trust’s community transformation programme that is being talked about the last 3-4 years now, is still miles away from coming to life. The “community first” approach is going the opposite direction, as the community mental health services are at the point of collapse, and the inpatient beds are full.

At the same time ICBs pay millions of pounds to outsourced “care providers”, who charge whatever they want, as the pressures to get people out of hospital and free up beds are very high. We are still too far from the “Neighbourhood Mental Health services” that they’ve been promising us.

 

General restructuring on Trust level

According to the 10 year workforce plan a large number of health care professionals are supposed to be replaced by AI in the future. This is questionable once you take into account that so far the use of AI has often turned out ‘inefficient’ and contrary to management’s intentions. When used for triage, AI tends to call out ambulances more often than humans and they often had to engage a human ‘re-triage system’. Also when it comes to the Electronic Frailty Index, it seems that this scoring system tends to refer more frail people to hospital and appointments than its human counterpart without a corresponding improvement in patient care. When electronic systems are used for patients’ self-appointment they tend to increase the number of cancellations. In turn there are still many health softwares developed inhouse, for example using the base system Snowflake, which are supposed to have greater use value and adaptability. US-based health software’s, such as Epic, are also problematic, because they do not only prepare data for potential AI use, but also have in-built billing functions that could be ‘switched on’ easily. Looking at software development, it would be good to re-visit the failure of ‘NHS IT’, a large-scale investment program to create a NHS owned data platform. 

We asked ourselves if the No Palantir campaign could use the formal complaint of ‘insufficient consultation’ on a local Trust-level, in order to push against Palantir contracts.

When it comes to the changes in job roles and division of labour it seems that ‘blurring’ roles, such as nursing associates, are actually less propagated now – perhaps also because people feel that they are stuck on Band 4 for ages, partly because of a lack of funding for apprenticeships to advance to Band 5. Also a lot of physician associate roles are being eliminated and many PAs retrain as medical students. This is also due to PAs having put in problematic positions that didn’t correspond to their actual training. These roles and their use also create tension between the professional associations / trade unions, e.g. between the RCN and the BMA: the BMA has been attacking advanced nurse practitioners’ roles, which pissed the RCN off – therefore it was good to see a joint panel at the recent RCN conference, organised by NHS Workers Say No. 

 

Crisis for the patients

There is a notable increase in aggression in A&E over the last five to ten years. This is a fall-out from the crisis in the general health service – people just end up frustrated in A&E. It seems that also the expectation of patients has changed, perhaps because the media tells them that they can get treated quickly, that there are magic treatments available. 

In Cardiff, after weeks of complaints and media reports about the bad conditions in A&E, the Trust finally invested in improvements. It shows that things can be changed. At the same time a lot of discontent is channeled into individual patient complaints or Datix systems. How can we imagine a collective organisation of patients – focussing on concrete situations that need changing, rather than ‘just’ the bigger aim of ‘saving the NHS’? Perhaps it would be good to interview workers who work in Patient Advice and Liaison Service PALS, about their experiences with patient discontent. In Manchester, young mental health patients organise around ‘Just Treatment’ campaign, they sometimes engage in direct actions. 

 

Current disputes and struggles

For decades there seemed to have been an agreement amongst unions in the health sector: “if we all agree to do nothing, no one gets the blame”, but then the RCN got the blame for a bad deal in 2018, which combined with a new leadership that made experiences with nurses’ strikes in Northern Ireland. After the first strike a new generation of reps emerged, but since then we have only seen smaller disputes. The current focus on the rebanding of nurses from Band 5 to Band 6 seems to be a cop out, a sign of not wanting to organise a larger pay strike.

At a Trust in London the nurses in the day surgery service went on strike against the introduction of longer shifts. Initially there were only 40 union members, this increased to 100 during the dispute, with a 90% union density. There was also a small group of cardiac nurses who issued a 100% strike vote against an unsocial shift rota. Another dispute involved workers who engaged in deep cleaning and their re-banding from Band 2 to 3. The latter dispute might have been forced too early, as only one third of staff joined the strike. Another interesting development in London is that Unite wants to establish a ‘union combine’, with around 20 health reps from the London region. Currently one of the focuses is a campaign on the high cost area supplement (London weighting), which is also paid in Cambridge. Otherwise there doesn’t seem to be a national union strategy for the health sector, we primarily see smaller disputes where Unite is involved, such as health visitors in Wales or lab workers in the north of England. The latest ‘national demonstration’ against the cuts in London attracted only 50 health workers and 50 reps. 

We talked about the problem of going on strike in a hospital and the issue of minimum service levels and ‘derogation’. In London Unite’s position was that they would only talk about derogation once the strike had actually started. They largely refused management’s proposals, as the lower levels of staff were not ‘life threatening’ in the areas where management demanded more staff. During the 2026 BMA strike derogation was negotiated centrally – which took away pressure from local reps, but perhaps also control. 

Unison only managed to pass the ballot threshold amongst ambulance workers, but they made a bad experience in terms of how the strike and negotiations went and since then didn’t pass the threshold again. During last year’s pay consultation not a single branch passed the 50% turnout threshold, with most falling somewhere between 10 and 30%. Most of the disputes are now local, primarily involving the re-banding of health care assistants and other lower banded groups. These disputes tend to be ‘staffer heavy’, and led by organisers, rather than by workers themselves. Even during these disputes workers were often disappointed, e.g. due to the lack of understanding what difference social hour bonuses make according to pay band. There were also two relatively successful strikes against privatisation in Essex and Dorset. In Manchester, the psychosis early intervention team managed to enforce the hiring of 21 new full-time positions. 

We recommended re-reading the book “Safety in Numbers” on staffing campaigns and staffing ratios in Australia and California. It would be good to create:

• A balance sheet concerning struggles against outsourcing
• An international comparison of nurses and health workers strikes

We talked about a new workplace newsletter, ‘The Handover’ from south London. It emerged out of the campaign against Palantir and lunch-time protests against the war in Gaza. Hospital workers and students are involved. They addressed local health care assistants who went on strike and organised a petition against Palantir signed by 1,500 colleagues, which could be a contact base for future meetings. 

 

Experiences at a mental health Trust in Manchester

A comrade presented a longer report about conditions and struggles at a Manchester mental health Trust. We will hopefully be able to publish an edited version soon. Some of the main points:

• Underfunding since 2008
• Around 60 to 70% of agency staff in most teams
• Lack of in-patient beds leading to long A&E waits and transfers to other cities
• Only 12% of referred users are actually assessed and only 8% are treated or receive service, there is a 12 months waiting list for talking therapies
• Mental health workers are pushed to mainly deal with safe guarding issues and acute crisis, no time for actual treatments
• New user organisations such as CHARM are organising local resistance, they pushing for a public inquiry into preventable deaths
• After a 2022 BBC undercover documentary about abuse in the mental health system in Manchester the Trust was put under central control for three years – the unions could have pushed more at that point
• Since then successful small disputes by early intervention team and driving porters, but these are very small teams
• Currently there is a dispute about shifting NHS Trust social workers to local authority contracts

 

Independent initiatives within the health sector

We stated that a lot of health initiatives target ‘the public’ rather than the health workers. 

Health Workers for Palestine was censored initially, but managed to overcome that. Many people who became active were not in unions and fairly inexperienced, which might be positive. The Palantir campaign has now 25 branches with some health workers involved, but not really an industrial strategy. An initial success was that some ICBs, such as in Manchester, refused Palantir contracts. After the trade union bureaucracy said they were concerned about Palantir using lawyers against Unison, they have blocked motions. Unison is now less vocal about the issue, with the exception of some outspoken union officials. The BMA has passed a policy specific to opposing Palantir. 

We asked ourselves how the Palantir campaign can be more connected to working conditions, e.g. through the fact that the federated data platform creates more work for nurses, as it is not very functional and cannot be adapted. At one Trust in London unions sent a joint letter to hospital management, emphasising that the software is dysfunctional and expensive. This led to new workers getting involved and wider political discussions amongst some of the less active local unions. Difficulties getting the letter endorsed through the local BMA structures, despite being consistent with national BMA policy, led to a local debate about internal union democracy. 

We had a longer discussion about whether involvement in official trade union structures is promising or not. On one hand the formal structures of the health unions and their integration within both, the labour law and the bureaucratic organisation of the health sector, have guaranteed that there have hardly been any disputes in the sector for three decades or more, despite high degrees of union density. On the other hand, due to the regulated nature of the sector it is difficult to organise strikes outside of the union framework and local branches can often offer some leeway for independent actions. There are lots of members and not many reps, the number of reps has actually been shrinking in many places since Covid. During the current ‘transfer dispute’ in Manchester, health union branches and local authority union branches don’t want to collaborate.  

There are many forms of action that workers can take by themselves, for example bank-shift boycotts or lunch time protests. If more people would focus on such forms of direct actions, instead of getting tangled in formalities, the ground might be shifted. At the same time these actions don’t replace the need for actual strikes. 

 

Future of this meeting

We agreed that it would be good to hold meetings like this regularly and to expand the circle. It would be good to maintain a certain political level to be able to discuss broad tendencies and alternatives, and to bring in people who had actual experiences of disputes to talk about. We are currently planning a second meeting in October 2026.