We document this older contribution to a general debate about the conditions of struggle within the health sector. It was written in late 2021 for the book ‘Sick of it all’. Since then the pressure towards ‘privatisation light’, the flexibilisation of certain job roles (‘physician associates’) and the squeeze on wage components (‘enhancements’) have intensified. It is time to write a new assessment of the current moment – watch this space.

In July 2021 the UK government decided to pay NHS workers 3% more, which given the increase in national insurance contributions and general living costs, turned out to be another real wage cut. In response to the government decision, unions in the NHS recommended that their members vote in favour of industrial action for a real wage increase. None of the unions managed to mobilise more than a quarter of their members to even cast their vote. This failure cannot be explained by NHS workers being happy with their pay and conditions. So, what are the reasons for this?

International lessons

Some people (and quite a few union representatives) said that because of the pandemic we should not engage in public protests or industrial action for better pay, because we would lose ‘public support’. They explained the low turn-out during the union ballots with this reluctance to ‘rock the boat’ during a pandemic. That seems superficial. Health workers in Germany, USA, and France took action during 2021 and they received substantial support. Many workers understand that if we don’t fight for better wages and less stress at work even more workers will leave the NHS. The crisis of the health system is not caused by workers’ struggle, but by under-funding and workers leaving their jobs. Despite their Brexit plans the government is having to recruit more care workers from abroad, as over 40,000 people left the care sector during the second half of 2021. The new workers will have to be paid at least £20,500 a year, which is more than any Band 2 care worker in the NHS, even one who has been in the job for years.

Having said that the pandemic might be more of an excuse for not doing anything, many colleagues sincerely worry about the impact that a strike would have on patients. That is a real issue; we don’t work in car factories or in an Amazon warehouse! One flaw of the last pay campaign was that there was no real discussion about what industrial action could mean in the health sector. We can’t expect union officials to solve this problem for us as it is us who know which parts of our daily work actually save patients’ lives, and which parts are less urgent or just exist in order to satisfy management and bureaucrats. We will need some collective analysis and creativity to find the best ways to put pressure on management and politicians. We have to learn from health workers who actually fought back.

For example, organised nurses in Australia ‘closed beds’ themselves as soon as they could see that wards were understaffed, insisting that it is management’s job to get extra staff. In Austria ambulance drivers went on ‘paper strike’ and didn’t fill in paperwork which was mainly there to allow management to claim money back from health insurance. In Greece health workers and patients formed common assemblies and organised actions to defend local community health services. In Germany nurses went on strike and enforced minimum staffing levels, and during the strike management had to make sure that emergency cover was organised. In the US striking nurses organised their own emergency cover when they saw that their strike action actually posed a risk to patients’ lives. 

In Argentina health workers blocked access roads to oil fields and tourist resorts to cut off financial supplies from the government. There are many ways to take industrial action that don’t ‘harm the patients’.

When we ask ourselves how we can intervene in this or any future disputes within the health sector we should look beyond the confinement of space and time. We should look into examples of health workers’ struggles in the not-so-distant past, and in other countries. Rather than just lamenting that ‘our NHS’ is getting privatised we have to analyse how health work and hospital organisation has changed materially over time and thereby changed the conditions for workers’ self-organisation and struggle.

Struggles in the 1980s

During the late 1980s comrades and militant health workers started to discuss the new conditions of struggle in the sector. This was against the backdrop of a Europe-wide strike and protest wave of hospital workers, which moved from Italy and France to Germany and the UK. These struggles had some common features. In France in 1988 during a national dispute nurses escaped the control of the traditional trade unions and formed assemblies at a hospital level. Each of the assemblies would discuss the next steps of the struggles and send delegates to a national coordination meeting, often attended by several hundred workers. Before social media or even mobile phones workers were able to self-organise their strike throughout a vast geographical area.

In Germany nurses and other health workers were influenced by these new forms of organisation. Health workers formed assemblies, often at a town or city rather than a hospital level. These assemblies discussed both the working conditions of health workers, and the question of what ‘health’ or ‘care’ means in a sickening capitalist society. In these assemblies the experiences of daily self-organisation of the work on hospital wards fused with the experiences of many workers as participants in the squatters’ movement, and the movements against nuclear power-plants or re-armament. After the peak of the protest movement two tendencies within the assemblies became apparent. One tendency wanted to ‘improve care work’ through more holistic approaches and better qualifications for care workers. There were many crossovers between this wing of care workers’ activism and the blossoming ecological movement. The other tendency emphasised that the actual transformation of traditional care work within modern hospitals, the so-called ‘white factory’, had to be analysed more closely in order to find out how to organise strikes on a new and more generalised level.

Neo-liberal restructuring

The concept of the ‘white factory’ related to material changes that took up speed in the 1970s. Hospitals themselves were centralised and turned into large-scale clinics with several thousand workers. In the US in particular the health sector mushroomed in former industrial centres; in the rust-belts low paid health workers took care of worn-out victims of industrial mass redundancies. In the bottom quintile of the American wage structure, the care economy accounted for 56% of all job growth in the 1980s, 63% in the 1990s, and 74% in the 2000s. Work itself was subjected to management analysis, such as time-and-motion studies, similarly to industrial work. Time was allocated for each task and patient and more rigorously controlled. Many ‘menial’ tasks were delegated to low paid and precarious health care assistants, student nurses, and increasingly agency workers. The out-sourcing of some of the support work such as cleaning, kitchen work, or laundry became more prevalent. Certain professional groups, such as junior doctors, became more ‘proletarianised’. Comrades discussed these changes not in order to scandalise them (‘evil industrial health system’) but in order to understand whether some of the contemporary forms of struggle, such as hospital sit-ins, assemblies, occupations, and coordinations, could be seen as the first signs of workers turning the new work structures against hospital management and bosses.

While capital reacted to the violent critique of assembly line work with de-centralisation of car plants and ‘Japanese’ production techniques such as job enrichment, ‘team work’, and quality circles, something similar happened in the health sector in response to the movements of the 1980s. One of the main reactions was a ‘re-professionalisation’ of nursing work. In order to divide nurses from other ‘auxiliary’ health workers and to appeal to their pride as ‘health care professionals’, nurses were given a more formal education, and their tasks were more clearly outlined and separated from other professional groups. With concessions given to the core group of health workers the rest of the sector, and indeed of society, was subjected to neoliberal transformation. 

Similarly to the neoliberal integration of the ‘ideals of 1968’ with their emphasis on individual freedom, the 1990s saw an adoption of the ‘health critique’ of the social movements and its inversion in neoliberal form. The demand for ‘holistic’ healthcare was turned into multiple new commodities, from mindfulness therapies to training on ‘lifestyle choices’, further stratifying patient care along class lines. In parallel to the de-centralisation of the productive system, which had to be tied together by an expanding supply-chain, the health sector, too, became both concentrated in major clinics and de-centralised with a proliferation of domestic care and ‘community health’ institutions. While ‘globalisation’ meant that some production steps were outsourced towards the global south, in the health sector it meant large-scale importation of labour from the south into the metropolitan centres.

The current moment

The 2008 crisis (which by the way affected many privatised nursing and domestic care companies) and more recently the pandemic, came as a shock to the system and to the neoliberal regime. Even the role-model party of neoliberalism, the Tories, had to re-centralise command over NHS trusts with their recent White Paper, given that with easy money drying up the ‘market model’ in the health sector proved to be too unstable and in reality, ineffective. The pandemic destroyed the myth that health is all about personal choices and individual solutions. It is no surprise that workers started to do their bit to question the system in regions where the neoliberal health regime was the most advanced, such in the US. Since the 2000s we saw a massive increase in struggles by health workers, often in so-called private hospitals or health companies. As with teachers’ strikes there is a close relation between workers’ struggles and other experiences of struggle, such as against austerity, environmental pollution in working 

class areas, or police violence. The health workers’ strikes in reaction to the pandemic have now a global scope, in particular in countries which are seen as exporting nations of health labour, such as India, the Philippines, or Nigeria. The question is whether the strike wave that spread throughout Europe in the late 1980s can now reconstitute itself on a global level, perhaps helped along by other aspects of globalised health work: from the transfers of NHS patients to operating theatres in India to the global shortage of blood test tubes due to fragile supply chains and problems with the manufacturer in China.

Here in the UK the US health system is used by the left to demonstrate how bad things can be, and how much we should appreciate the ‘national treasure’ that is the NHS. There is hardly any engagement with the fact that it’s workers in the US who are able to pull off strikes in the health sector, while organising within the NHS feels like wading through treacle. The statist left wear blinkers which only allow them to see ‘private = bad’ versus ‘national = good’. This prevents them from engaging in an actual analysis of the changing work processes and conditions of struggle, disregarding the formal contractual relations of the workers involved. While unions are relatively quick to support struggle for ‘in-housing’ some work (e.g. hospital cleaning) they are equally reluctant to mobilise workers within ‘our NHS’, despite the fact that some permanent workers in the NHS earn less than workers at Lidl or Amazon. The apparent limitations of the mainstream unions’ pay campaigns in 2021 force us to rethink and engage in a proper analysis of conditions on various levels: the work process and division of labour, the use of medical technology, the global character of the sector and its workforce, how state and capital finances and management are intertwined when it comes to the health sector, the relation between the health sector struggles and wider class movements, the question of what kind of role the struggle of workers in the ‘reproductive’ sector can play in a revolutionary transformation. The following sketches are primarily based on a year working as a health care assistant without any prior experience of paid care work.

Work impressions

I have worked in many factories and warehouses but never in a hospital before. The general organisation of a hospital relates to the difference between manufacturing a train engine or caring for humans. Although there are 9,000 people employed at the hospital where I work, which is about as much as the Vauxhall assembly plant where I worked in the 2000s, most of the cooperation between workers happens on a ward level involving 20 to 30 people. There are obviously many workers who provide work for multiple wards, such as cleaners, porters, certain specialist nurses and doctors, but the fact that there are dozens of small and fairly autonomous units makes a hospital more difficult to understand. While even as an assembly line worker I had vague ideas about the work of engineers, the work of doctors seems much more alien. This is only partly due to the fact that the work of doctors is more complex. A major reason is the professional separation of doctors and the fact that medical knowledge is more compartmentalised. Doctors are responsible for certain interventions, nurses are for others, and health care assistants deal with the hands-on care. While the work of an engineer is visible in a changed environment, e.g. in the form of a new machine set-up, a lot of the work of doctors is hidden within the patient and inaccessible medical notes. As in the world of manufacturing, the lack of cooperation and monopoly of information leads to complications, in particular between doctors and nurses, such as medication errors. Apart from handing out medication, the hundred or so other tasks – from making beds to washing patients to re-stocking supplies – is often freely combined between different workers. There is a fair amount of spontaneous cooperation and collective intuition going on – if the atmosphere allows. There are certain labour-saving devices and a ‘rationalised’ organisation of work in order to increase productivity. This starts with patients’ medical information being centralised with computers and mobile tablets, which only partially reduces paperwork. There is talk of electronic meal ordering, as collecting patients’ menus is one of the main headaches for house keepers. Modern hospital beds have alternating air-mattresses which means that patients have to be re-positioned less frequently to avoid pressure sores. The newer models can also weigh the patient. Certain interventions are meant to reduce both labour and certain discomfort, such as urinary catheters. Certain porter tasks, such as waste collection, have been taken over by self-driving platforms, but they are not very efficient. In general though, most of the technological advances will be concentrated in areas such as imaging (MRI), medication (bio-pharmaceutical innovations), and treatment (keyhole surgery etc.).

In a practical sense the ward is run by fairly young nurses in their 20s or early 30s. While there is a manager, he mainly deals with staffing rotas and supplies. The turnover amongst nurses is relatively high, amongst the health care assistants less so. Around 20% of the nurses are from Kerala or the Philippines, with a few of them having previously worked in the Arabic Emirates. The patients on the respiratory ward are mainly older working class people with the usual issues of working class lives. In particular male working class patients have trouble dealing with the passive and receiving position they are confined to. They either become infantile or miss out on care because they don’t like to be cared for. The female carers try to overcome this barrier by a mixture of motherly and flirtatious behaviour; the male carers by being ‘mates’. Overall the hospital functions in many ways as a distribution or sorting centre of social problems. We tend to have many homeless people, prisoners, people with substance addictions, and isolated and neglected elderly people on the ward. Here the medical treatment is often the minor problem, the major problem being how to combine the private family relations and various public institutions in order to being able to ‘release’ them. Many of these patients return frequently.

Wages for care work are pretty dismal. As a Band 2 or 3 health care assistant, who is supposed to know quite a bit about skin care, infection prevention, and various observations such as blood pressure or glucose, you earn just around £10 per hour. The trust runs apprenticeship schemes for around 500 health care assistants. During the one year scheme you do basically the full job, but they pay only 75% of Band 2 wages, which amounts to just above £8 per hour. Even older workers with years of care experience have to go through the apprenticeship scheme. It’s no surprise that people are pissed off about wages – the main issue though is work stress and exhaustion. The shifts are 12.5 hours long and staffing levels are a problem. For the health care assistants shift times have been extended from three 8 to two 12.5 hour shifts in order to save 30 minutes ‘handover time’ where at the beginning of the shift everyone gets an update about the patients on the ward. The trust has scope to make autonomous decisions concerning pay and conditions in order to ‘attract and retain staff’. Trusts paid different kinds of pandemic bonuses or higher bank levels (‘bank’ being a kind of internal agency system) during times of staff shortages. This means that pressure from below can change things, despite the claim from management (and unions!) that everything is fixed on a national level.

The question of struggle today

The unions are pretty absent from day-to-day life on the wards. You hear about the occasional disciplinary or absence review meeting but that’s it. During the 2021 pay campaign the unions didn’t engage in any visible actions; they sent emails to individual members and invited them to information stalls and drop-ins, bribing them with free coffee and canteen vouchers. Only a few people bothered to attend. Although there is a joint union committee comprising seven different unions in the hospital, they refused to have a common rally or action in order to mobilise workers during the pay dispute. Workers see that management reacts to pressure from below, even if that pressure is created by individual workers leaving the profession. During the pandemic there were various small-scale conflicts about PPE and work routines. The question here is how the experiences of daily ‘workers’ control’ at work, in the form of improvised cooperation and division of tasks to run the ward, can fuse with the experience that, if needed, the trust management can increase pay or hire new staff. Currently there is no forum to discuss the potential for small-scale direct action against work stress and the way they could be generalised.

Hospitals are not factories, and care work is not materially changing our social-naturals surroundings. In this sense struggles within the care sector can only develop a limited  horizon of a new society, where life is not defined by drudgery. Struggles in hospitals and community health centres will have more of a role in highlighting and helping us to reflect upon current social conditions and how to break out of sickening social isolation. The intimacy between workers and working class patients can create the necessary new ideas and bonds that can combine with the experiences in the productive sector. This combination will allow workers not only to appropriate, but to transform the means of production, for a less harmful, more joyful way to produce human community.