We summarised this interesting text by Jack Saunders – you can read the full text here. The article talks about the hierarchical origins of the NHS and how the various professional group identities were only challenged by an ‘NHS worker’ identity through struggle. The various waves of migration also shaped the composition of the workforce. Sometimes we have to dig into the past in order to understand our present conditions. Another valuable text on struggles in the NHS can be read here. To quote:
“The first industrial action within the British health system might have been the 1913 “porridge strike” at Rainhill Asylum, where staff working an 80-hour week received free food as part of their wages. The workers were members of the National Association of Asylum Workers. A new menu replaced meat with porridge, resulting in 35 nurses refusing to eat the porridge and return to wards from the breakfast room. Within 24 hours, management had restored meat to the menu.”
On our Vital Signs blog we covered historical texts on the conditions of ‘overseas nurses’ in the 1970s, on nurses in general in the mid-1980s, on the nurses strike in 1982 and on a documentary about a laundry outsourcing dispute in 1985.
The origins and the professional groups
Origins of the NHS, the divisions between ‘professional groups’, only through struggles an identity of ‘NHS worker’ formed, the changes in migration
Far from instantly creating a new unified workforce, the new NHS transposed older hierarchies and divisions from the voluntary and municipal hospitals into the new service. Authority still pooled around the same senior doctors and around the great and the good who had long been the mainstay of hospital administrations under the inter-war mixed economy health system.
For most staff, occupation formed the mainstay of their worker identity. It was only where the service became a site of workplace conflict, particularly when that conflict involved low-status groups, that ‘NHS staff’ emerged as a more coherent identity. When groups like administrators (in 1957) and ancillary staff (in 1972–73) came to make demands on employers and had no wider sympathetic occupational image to draw on, their representatives tried to draw on the NHS’s popular wider public image to make their case.
From its foundation in 1948 the service was one of Britain’s largest employers, employing some 410,000 people across England, Scotland, and Wales. Only the National Coal Board and the British Transport Commission were bigger. From 1961 the NHS was the largest employer in Britain. Its workforce continued to grow, passing one million by 1977.
In 1957 the Ministry of Health recorded forty different categories of professional staff, as well as a further fifty-three groups of support staff. The former included groups like dark room technicians, physiotherapists, laboratory technicians, and remedial gymnasts, while the latter stretched from cleaners and porters to hairdressers and shoemakers. Some of these groups are larger than we might expect from the public presentation of the service. For instance, the early NHS included more building workers of various kinds than it did hospital doctors.
In 1949 the largest single component was the ancillary staff, who comprised 44 per cent of the service’s workforce in England and Wales. A total of 41.8 per cent of the NHS’s employees were nurses, of whom roughly one in seven were part-time, a category that would grow over time.
The most significant expansion was in the proportion of administrative staff as the increasingly complex NHS required more and more bureaucracy. By the end of the 1970s, administrative staff constituted some 12.3 per cent of all NHS employees.
The changes in migration
In 1946, under the Balt Cygnet scheme, the Attlee administration authorised the recruitment of 5,000 women from Estonia, Latvia, and Lithuania, mostly to work in understaffed tuberculosis sanatoria. Significant numbers of women recruited for work from post-war displaced persons’ camps as part of the Westward Ho scheme were also directed towards hospital work, particularly as cleaners. Wartime schemes and postwar NHS recruitment continued the long-standing migration of Irish women to work in British hospitals, principally as nurses and ancillary staff. By 1971, 12 per cent of all NHS nurses were Irish-born.
The Caribbean was another consistent source of nursing labour for Britain, both before independence and after, with Jamaica the largest single contributor. By the end of 1965 between 3,000 and 5,000 Jamaican nurses were at work in British hospitals. In 1977, 8 per cent of all student nurses and midwives were from the Caribbean. South-East Asia was another key source of nurses from the 1970s onwards. The medical profession drew heavily on South Asian physicians to make good the inadequate numbers of doctors produced in British teaching hospitals, and by 1960 these accounted for 30–40 per cent of all junior doctors.
The trade unions
For ancillary staff, the increased involvement of the state in medical care had already granted them national collective bargaining via Whitley councils – a system of joint councils composed of representatives for employers and employees. Gone was the old practice of hospital authorities separately determining wages and conditions, a system that NUPE blamed for poor conditions in the sector. The rise of the NHS represented progress on a political and industrial level for precisely this group, and it was the most unambiguously welcoming of nationalisation.
A 1950 study by Liverpool University on health staff supports Williams’s assumptions. Just 6 per cent of staff nurses were union members, as against 66 per cent of administrative staff and 66 per cent of ancillaries.
NALGO had a rather conservative self-image. After being founded in the late nineteenth century by Herbert Blain (later national agent for the Conservative Party) mainly as a ‘staff association’ for municipal clerks, it remained consistently cautious over industrial militancy and declined to affiliate to the Trades Union Congress until 1964. As it expanded in the post-war period it retained a strong sense of its members as respectably middle class. It is perhaps the only mass-member trade union whose journal depicted its members in top hats, tails, and pin-striped trousers, as Local Government Service did in 1948.
The first national industrial action in 1957
Surprisingly, it was NALGO which was responsible for the first national industrial action in the history of the NHS, a ‘go-slow’ of all administrative staff in 1957 in pursuit of a pay rise. NALGO comprised the majority of delegates on the employees’ side of the administrative clerks’ Whitley council and in December 1957 negotiated a 3 per cent pay rise. When this was vetoed by the government, NALGO organised an overtime ban and instructed its members to impose a ‘go-slow’, whereby its members would painstakingly scrutinise every statistical return to the ministry. One delegate to the union’s special delegate conference, A. J. Eagles of St Helier, Surrey, dubbed this practice an outbreak of ‘meticulosis’.
The dispute was revealing of the ways in which health service staff imagined themselves. The December 1957 leader article in Public Service (the union’s re-branded journal) draws simultaneously on a sense of health service administrators as respectable, responsible, and middle class, and on the wider support of the NHS’s large workforce. In one instance, the clerks are a mere ‘handful of blackcoats’ who are ‘notorious for their reasonableness’ and represented by ‘NALGO, that most pacific of unions’.53 In another, they find themselves at the centre of an uprising by ‘the entire half-million staff of the health service’ and supported by ‘most other blackcoated workers’.
The clerks’ complaints of the late 1950s were the forerunners of what became a consistent refrain for health service staff. By the end of the 1970s almost every category of NHS staff had been involved in protests over inadequate pay and difficult working conditions. Like the clerks, they often referenced the health service as a particularly stingy and exacting employer, extolling their own virtues as employees central to the compassionate care of the sick.
The 1962 pay campaign
Coverage of the RCN-led 1962 campaign for better pay tended to emphasise the long hours, drudgery, and poor pay that confronted nurses, even when the more combative COHSE and NUPE began to talk of strike action.
Towards the end of the 1960s, more nurses, particularly the students and unqualified auxiliaries who faced the worst pay and highest proportion of repetitive manual labour, began to find conventional trade unions more attractive. Even those who remained with the RCN began to expect the organisation to behave more like a union, pushing it to act more aggressively to defend their interests in collective bargaining.
The nature of nursing hierarchy was changing, particularly with the advent of the 1967 Salmon Report. This inquiry re-designed the structure of nursing management in order to improve the status of senior nurses within the hospital hierarchy. This involved shifting from an authority structure that was highly personalised and idiosyncratic, built around the all-powerful figure of the matron, towards a more impersonal system of ‘nurse managers’. The new system also came with increased pay for senior nurses, further widening the gap between the bulk of nurses who were involved in clinical care and the minority of nurse managers.
The 1962 campaign for improved pay reflected the early stages of these themes. Although the RCN remained the majority force among general nurses, both COHSE and NUPE had made modest progress in recruiting from this category of workers by 1962. Their more militant campaigns accompanied the RCN’s robust lobbying effort. The May–June edition of Health Services, the official organ of COHSE, featured a photograph of a mass demonstration of general nurses in uniform on its front cover, above the slogan ‘PAY NOT PENANCE’. A nurse in chains led the protest with a placard declaring her an employee of ‘Paddington concentration camp’. The union claimed to have enrolled some 7,000 new nurses during the 1962 pay campaign, a large proportion of them women general nurses rather than the male psychiatric nurses who had traditionally joined.
The first twenty-four years of the NHS were relatively peaceful in terms of industrial conflict. There were no national strikes at all between 1948 and 1972, and local action was sporadic.
The combative 1970s
With the introduction of workplace representatives (‘shop stewards’) in the NHS from 1969, union activism intensified and became more combative. This was reflected in a modest uptick in strikes and other forms of industrial action, with the ancillary strikes of 1972–73 and strikes by various paramedical staff groups (including radiographers, physiotherapists, and laboratory technicians), nurses, and doctors during 1975–76. The year 1976 also saw NHS staff demonstrate in opposition to cuts to state expenditure imposed by the International Monetary Fund and continue their ongoing campaign (begun in 1974) opposing private practice using NHS facilities. NHS workers were also a significant component of the 1978–79 ‘Winter of Discontent’ strike wave. Conflict continued during the Thatcher governments of the 1980s, with a national strike in 1982 and ongoing conflict over outsourcing and grading throughout that decade.
Discussions over the use of NHS facilities and staff for ‘private practice’ during the second half of the 1970s had the potential to mobilise NHS employees across occupational lines and in defence of an ideological conception of the service. Throughout the NHS’s existence, doctors had engaged in private practice alongside their work for the state. By 1974 much of this took place within NHS hospitals, often with the assistance of NHS nursing and ancillary staff. With the advent of a Labour government in 1974, the unions saw an opportunity to successfully abolish this practice (in line with Labour Party policy), putting an end to ‘pay beds’ within NHS hospitals and to the additional, often unremunerated, work they caused for non-medical staff.
In doing so they found themselves in direct confrontation with the BMA, which defended its members’ rights to private practice within NHS hospitals. For many members of NUPE and COHSE, the existence of private beds, in addition to generating extra work, contravened a fundamental ideological principle of the NHS – that no one could pay for better or quick treatment. Members of NUPE’s Clwyd Health Services no. 1 branch decided to make this point at Denbigh carnival with their float depicting a hospital ward staffed by NUPE members, bearing the slogan ‘This is a National Health Service bed – No Smoked Salmon’.
Struggles against private beds and hospital closures mid-1970s
Hospital staff in multiple locations took direct action against the use of pay beds, usually in the form of withholding services to private patients. Yet there remains a sense that opposition to pay beds was, ideologically at least, primarily a concern of the union’s full-time officers and taken up on an ad hoc basis by working union members. Between 1974 and 1976 both NUPE and COHSE lobbied the government hard to finally fulfil its promise to separate pay beds from NHS hospitals. However, the letters pages of both Health Services and Public Employee featured no letters relating to the issue or the campaign. They remained the usual mixture of abstract political debate and general complaints about pay and conditions.
Over the second half of the 1970s, hospitals and services began to be recommended for closure, with London particularly affected. In its campaigns against these closures, NUPE spoke of ‘saving NHS beds’. Similar rhetoric accompanied a variety of anti-closure protests and hospital ‘work-ins’, including those at Queen Elizabeth Hospital in Bethnal Green and the Royal Free Hospital in North London. Articles about these events were often accompanied by pictures of protesting staff, usually women and often women of colour, from across a variety of NHS occupations, ‘fighting’ for the NHS. Similar rhetoric can be found in union coverage of the protests that followed in the wake of Britain accepting a conditional loan from the International Monetary Fund in September 1976 in order to stabilise the value of the pound. The loan was predicated on significant savings from the government’s budget, much of it concentrated on spending caps for the local authorities and the NHS.
Public-sector staff, particularly NHS workers, responded with mass demonstrations repudiating the cuts. The largest demonstration was on 17 November 1976 and reproduced many themes which reflected emerging NHS staff identities. NHS laboratory workers, marching with the Association of Scientific, Technical and Managerial Staffs Union (ASTMS), brought placards bearing the slogan ‘Fight the cuts, save the NHS’. NHS staff marching with COHSE were given blank signs on which to write their own slogans, and themes reflecting staff investment in the service were prominent. Signs shown in Health Services bore messages like ‘National health not national sickness’, ‘think again Denis [Healey, the Chancellor of the Exchequer] no NHS axe’, and ‘Stop cuts, save NHS’.
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The 1982 health workers dispute
( from: ‘Your health, comrade’, by Ian Spencer)
The scene was then set for the closure of hospitals, which were an important part of the trade union base for the NHS. Very few nurses in mental health were members of the Royal College of Nursing. Almost all staff there were members of the National Union of Public Employees or the Confederation of Health Service Employees and campaigning for a 12% pay rise for all NHS staff. More importantly, health workers were widely supported by solidarity action by rail, mining, post, print and other workers – one of the last times that the TUC organised such action.
Unsurprisingly then, after the defeat of the 1982 health workers dispute, the programme of closures of mental health hospitals accelerated. More than that, the 1982 health workers dispute was the government’s dress rehearsal for the crushing of the miners’ strike. Most of the legislation that was used to outlaw ‘secondary’ picketing and other solidarity action by workers during the miners’ strike was tried out first in 1982 against health workers. The government knew in advance that to defeat the health workers they would first have to come to a settlement with the Royal Colleges of Nursing and Midwifery, which settled for a pay rise above the 4% offered to other staff in exchange for a pay review body that subsequently delivered a significant rise for qualified nurses and midwives only. The longer-term consequences of the loss of that trade union base have been seen by the relative weakness in strike action in the NHS since.
