If the idea of robots taking our jobs wasn’t bad enough, now they want us to keep the robots running for nothing! 
The NHS maintains a service of volunteers, particularly in hospitals. These tend to be retired individuals with some sort of affinity toward the NHS, and often fill purely non-clinical roles such as meeting and greeting, signposting or ferrying patients down the cavernous halls of a hospital in an airport transport buggy. At UHBW management is currently piloting a new End of Life Care Volunteer Service. While we can all agree that palliative and EOL patients don’t get enough care in the current staffing situation, we don’t think that this is a job for volunteers. It’s a job that requires proper training and proper payment.
Sometimes, however, managers request volunteers for other purposes. Against the background of increasingly squeezed budgets, with Trusts cutting jobs, withholding pay rises and constantly seeking efficiencies, management realises that they might be able to fill gaps in staffing with volunteers. At NBT, there was a recent attempt to do just this. A job description was sent out to the Joint Consultative Negotiating Committee – a forum where the Trust consults with Trade Unions – for a volunteer position inputting stock and medicines into the pharmacy robot.
In pharmacy, thousands of pounds worth of medicines are received each day and a huge amount of this stock is fed into a robot which stores the stock and then releases it when required by a pharmacy worker. Filling this robot is a massively time consuming, repetitive, manual job. The stock must be individually scanned into it using unique QR codes so that the robot can register each input and storage location for timely release on request.  
Up until this point, the job of filling the robot has always been a part of a paid role. Due to a disconnect between management’s idea of adequate staffing levels and the reality of the volume of work, the department have been struggling to transfer stock into the robot after receipt quickly enough. The solution, according to the management of the area, is to get someone to do it for free! 
The job role was challenged at the JCNC and has been withdraw, but it raises a wider question. What other roles could management try to get volunteers to do? 
The UK has recently agreed to pay more for pharmaceuticals, bowing to pressure from big pharma companies and the US. The Trusts in Bristol already spend around 1/5 of their budgets on drugs. Instead of challenging big multinationals, the government seems more interested in directing anger towards migrant brothers and sisters who come to the UK to work and live and promising billions in funds for re-armament. This extra money is going to be squeezed from us workers if we don&#8217;t push back. For a longer conversation of pharmacy workers, click <a href="https://www.vitalsignsmag.org/posts/chemical-brothers-conversation-of-three-pharmaceutical-workers">here</a>.
Robots, automation, artificial intelligence, bring it on! But only if it reduces the working hours for everyone and increases our living standards! This will only happen if<a href="https://www.vitalsignsmag.org/posts/thoughts-for-a-working-class-revolution"> we defeat the capitalist class</a>!
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The pharma robot and the volunteer

We interviewed a friend who worked in A&amp;E. It is a first step to share experiences wherever we work and find common grounds to change things. If you want to talk to us about your situation, get in touch!
You said working in A&amp;E was pretty stressful. Can you explain a bit more?
I was in an inner city A&amp;E, and the kind of thing that people think of when they imagine people coming into A&amp;E; stabbings, gunshots, car crashes, falling off ladders etc is a tiny fraction of the actual workload. Huge amounts of people through the door are suffering from mismanaged chronic illness, which is related to poverty and on some level education, and housing, and work, and family situations and all sorts of other, really complicated things. The cliché is that most people suffer from “shit-life-syndrome”, smoking and drinking long term, living in poor housing, stress, mental health, infections, poor diet, lack of exercise. And all these things are layered on top of each other, so it’s very rarely just one thing. People might present with an isolated singular problem, but more often than not there are underlying multiple causes.
To be honest, when I started my training as a paramedic, and started going into medicine, I felt like I had been shown some secret truth of society. Basically, poorer people get sick. Obviously reasonably well-off people get sick as well, but just not in the same way. It’s really obvious but really eye opening, that when you peek behind the curtain a bit you see that society is just structured to make people who are poorer or live in worse conditions much sicker.
You can see that in A&amp;E. As things get harder for people, and as people struggle more in other areas of their lives, A&amp;E is one of the first places that you see it. Mostly, wherever you are in the country, you can call 999 and you will get an ambulance. You&#8217;ll probably get taken to hospital. For most people it&#8217;s an emergency lifeline to getting some level of care, whether it is the care that they need or actually want is another question but for most people it is their only immediate option.
Was the stress that you were confronted with symptoms and situations that you can&#8217;t deal with?
Part of the reason that I found it so stressful is that I went into working in A&amp;E a lot older than most people who work there, having not worked full-time in a while. It&#8217;s a really fast paced setting of really multitasked work with a high level of decision making and juggling multiple things at the same time. Assessing a patient, diagnosing, ordering tests, understanding test results, forming a plan, giving medication &#8211; and doing this for several patients all at different stages of this process at the same time. I felt old and tired and just like “Fuck this. This is horrible”. Of course this experience was exacerbated by the fact that more and more people are getting sicker, the health service is struggling in various ways, more people are coming to A&amp;E because they can&#8217;t get a GP appointment or coming to A&amp;E because they&#8217;re seriously mentally unwell.
Can you speak a little bit to the pressures that might be brought about by these management solutions that we hear about cause? Something like the 4 hour target from admission to discharge either from the hospital or to a ward? Was this heavily enforced? 
I think they might have got rid of the target. I was only in A&amp;E for a year, and the whole thing was in such a state that nobody even bothered talking about it. I remember talking to some people who&#8217;d been there longer and they spoke about it in a way that suggests it was just a bullshit thing that people had to get around by moving people to wards or shuffling them about so it looks like the target had been hit even when patients were still there hours later. So, I don&#8217;t know whether the target was still there when I was working in A&amp;E, or whether they&#8217;d decided to just get rid of it. To some extent though, it was probably something that was introduced with the best intentions but in reality just became something that workers had to get around or fiddle by moving someone to a different department, getting someone discharged on the books but they&#8217;re still there waiting for transport or social care arrangements to be sorted out. I didn&#8217;t really come across it as an issue. 
I can remember some of the worst days during the winter where I would go home at 6pm with patients in bed in A&amp;E, and come in at 7am and the same patients would be in the same place. Sometimes they&#8217;d still be there when I would leave again in the evening. You&#8217;d do handovers where you talked about patients who had been there for 30-40 hours. There&#8217;s all sorts of research which shows that every hour people of a certain age spend in a hospital bed shortens their life by a certain amount, so I think that’s one of the problems with the focus on acute medicine in the health service. You&#8217;re saving people in the immediate term, but they die 3 months later because they have such shit healthcare early on in the process. They don&#8217;t die then, but you probably cause them to fall over and break their hip because they&#8217;ve been in a bed for like 2 weeks.
Was the main reason for this stagnation that the wards were full, or was it that the work that you were doing couldn&#8217;t be done for other reasons? The normal idea is that A&amp;E would work fine if the rest of the hospital wasn&#8217;t so full up.
I&#8217;ve tried to do a lot of reading and talking to people to understand this. I think it&#8217;s a really complicated, multi-factoral (as they say) problem. I think it&#8217;s something that is impossible to confront without a widespread and radical reshaping of how people live and work. I think probably all of the reasons that people give have some element of truth to it. You know, the classic one is that it&#8217;s an underfunded workforce that is tired and stressed. People are leaving, hospitals are out of date and you have an aging population which brings about a series of chronic conditions that go with that. These are all definitely factors, but I don&#8217;t know how much we can put down all of the problems that the NHS has to them. There is an element of truth to the fact that people’s health is getting worse, people&#8217;s mental health especially is getting worse. At the same time other areas of the health system are in disarray. For instance look at dental care, which previously people wouldn&#8217;t have had trouble accessing. There is an issue with health education, people having very little understanding of their own health. This goes hand in hand with an increase in anxiety and depression, where it seems that there is this level of health anxiety now that wasn&#8217;t there before. There are issues around cultural and religious understanding of how health systems work. The isolation of people from wider social networks is another massive factor. Maybe 30-40 years ago, people would live close by to family relations who could reassure and offer some level of care. With this gone, and people being more isolated they tend to worry more, and so you have this loss of a multi-generational knowledge to refer to. It&#8217;s hard to unpick any one of these things from everything else though.
Work gets done in A&amp;E, it just only gets done because people work harder than they necessarily should have to. This is especially true for nurses and HCAs. The level of responsibility and speed that these people work at is incredible. Obviously this is true for doctors etc. as well, but these guys are really bearing the brunt of it. 
I think that if you doubled the staffing in A&amp;E, the work would definitely get done faster, but the bottlenecks aren&#8217;t really to do with people not being able to keep up with the work. The barriers are more around things like discharge towards or discharge to home. When you start looking at discharge to home you have to start looking at the ambulance service who previously, if someone wasn&#8217;t fit to walk or make their own way home, an ambulance or patient transport service would sort them out. A lot of these patient transport services have been contracted out of the NHS now, and the ambulance service is entirely overrun and overworked &#8211; in fact they probably struggle as much, if not more than anyone in the health service. So I think that the biggest bottleneck is definitely around discharge, with some caveats concerning test results and understaffing 
Could you describe the situation in the A&amp;E regarding the relationships between doctors, physician associates and advanced clinical practitioners? Were there clashes of competency between these professional groups? Was there stress around it?
There weren’t clashes in the A&amp;E that I worked in, but I imagine that it varies from hospital to hospital. Where I worked was good, there was no stress between the different roles, and because of the structure of A&amp;E it tends to be much more of a horizontal structure than situations like on wards. In A&amp;E there tends to be a much more collaborative environment between the various professions, so it is a much easier place to get on in a role like mine even though the pace is faster and there’s more time-critical decisions, sicker patients etc. Nurses there tend to be much more experienced and are doing things that nurses wouldn’t do in other areas of the hospital. It’s also a place where newer doctors tend to do a rotation, and you often have the situation where there’s an A&amp;E nurse who’s been working there for maybe 15 years showing the doctors what to do and explaining how things work &#8211; even to the point of double checking what the doctors are doing. So in a way because of the nature of the workload you have this more flat structure which seems different to other areas. The cliché is that surgical wards are particularly hierarchical, and my experience of PAs in hospitals is that PAs on surgical wards are basically the doctor’s dog’s body.
This happens all over the place though. In the same way that there is this growing space in medical care for diagnosis and examination between registered workers like nurses or paramedics and doctors, you now have Health Care Assistants and other medical workers doing jobs that only nurses would do traditionally. So everything’s kind of upscaled a bit in terms of scope of practice and responsibility.
Was there any sort of collective discussion between doctors, nurses etc. around the situation that workers in ED have to face? Was there any sort of common understanding of how these problems could be overcome?
One of the things that is quite depressing about working in the NHS is that everyone knows that it is in an absolute state, and there is some kind of collective understanding about what needs to happen amongst workers. I don&#8217;t think that it&#8217;s a particularly difficult set of solutions to come up with. The problem is a lack of political ability or power to implement the solutions, or even before that to believe that the implementation of those solutions is even possible. My feeling is that everyone knows that it&#8217;s broken, everyone knows how we could fix it – nobody believes it&#8217;s going to happen. Whether that would be through some kind of worker-led transformation, or even through some kind of parliamentary solution. This is, I think, one of the main reasons that people leave. Not so much because it is necessarily broken, but more because people can&#8217;t imagine it getting fixed.
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Working in A&E

This article will be circulated in <a href="https://www.vitalsignsmag.org/posts/vital-signs-no-4">Vital Signs Mag no.4</a>, of which we distribute 1,000 copies within our two local hospitals. Feel free to help us with the <a href="https://www.angryworkers.org/contact/">print cost</a>.
What is the issue?
I work on wards and in theatres. Although it sucks, I am not surprised if male public school bully consultants make young female nurses cry. Some of them are just arrogant choleric dickheads. It surprises me that many female nurses are depressed or even leave the team because of shitty dynamics with other nurses. I am also a union rep and meet people who complain about tensions with co-workers in hospital offices and labs, so it seems to be more of a general problem. Often it is difficult to put a finger on the issue. It’s rare that there is open bullying, it’s a more subtle process of inclusion and exclusion, of cooperation and non-cooperation, of being in the in-group or not. It can be things like who gets a good-bye party or who gets praised on the team WhatsApp. These seem small things, but I can see that they lead to people retreating and feeling down. From working on construction or in factories I am used to people treating each other roughly, but I haven’t witnessed these kinds of exclusionary team dynamics before.
What could be the reasons?
There are very obvious reasons. If you put a group of people under stress, e.g. through understaffing, and divide them through a formal hierarchy, which excludes most of them from information and decision making, you will create a fertile ground for shitty dynamics. Add a high fluctuation to the mix, e.g. through bank or agency work, and it will be difficult for people to establish stable and trustworthy relationships. Particularly in theatres, nurses often focus on the behaviour of consultants and pass their bad vibes down the chain of command. The in-groups form largely around the Band 6 team leaders, and as most of the Band 6 nurses are British, the in-group is also fairly British. There is a shared culture of the usual British witty banter, which is fine, but it also means that the in-group reproduces itself. You only learn the tricks and have a better chance of becoming a Band 6 if you are in the in-group.. But all this seems too obvious.
In the UK it seems that there is something that has been lost that used to be common sense.. People don’t seem to understand themselves as workers, who act in solidarity with other workers because we are forced to cooperate and we are exploited together. There is little sense of basic community. This is perhaps reinforced by the fact that most nurses enter through university degrees, which have the aura of personal career choices, individual debt and so on. There are less clear codes and cultures of ‘being work-mates’. A work-mate is your mate by default, and if they act like a dick or are not pulling their weight you can tell them straight and things are good again. Because this culture is gone or has not been established, people are afraid to talk openly to each other. There is a lot of fake politeness and a lot of gossiping behind peoples’ backs. Hospital management encourages this kind of hypocrisy, as they boast about how anti-racist they are, but then use the fact people depend on work visas to blackmail them. They talk all politely and politically correct about tolerance and dignity, but accept that cleaners, porters, house keepers and many others are only just above the minimum wage despite working for the NHS for decades. Perhaps there is an additional dimension of competition amongst female colleagues &#8211; in recent decades the media and mainstream have emphasised how important career and success is for women’s independence, while at the same time ideas like class solidarity have been undermined.
What can be done?
Of course there are deep psychological reasons for team dynamics. We all play out childhood shit and wish for maternal or paternal acceptance and perhaps there will be some space to heal that in future. But what can we do in the meantime? It’s a bit of a Catch 22. On one hand, the current team dynamics often undermine our ability to act in solidarity and we often don’t stand up for ourselves when it comes to under-staffing or cuts to bank enhancements or other small attacks from management. On the other hand it is exactly a feeling of acting together that could help to overcome divisions and exclusions within the group. So we have to start from the fact that we have to work together and that we all have an interest to organise this in a way that leaves us some space to breath and head-space to think. If someone doesn’t pull their weight, why not ask them straight what’s up? Perhaps they are really exhausted for some reason that is not obvious? Or they don’t get what is happening? Or they are pissed off with you for some reason? Or they might actually just need telling. That’s better than bearing a grudge, gossipping or grassing to management. In the medium-term we can only feel ‘at home’ amongst ourselves and at work if we take over more control over our work environment together. It’s a bit lame to say, but yes, we spend more time with each other, than with our family. We need to have each others’ back.
We come across a lot of people who suffer from and complain about team dynamics, but there is little collective discussion about this phenomena. We are grateful for any comments.
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Team Psychology – What to do about bad vibes amongst co-workers?

This article will be circulated in <a href="https://www.vitalsignsmag.org/posts/vital-signs-no-4">Vital Signs Mag no.4</a>, of which we distribute 1,000 copies within our two local hospitals. Feel free to help us with the <a href="https://www.angryworkers.org/contact/">print cost</a>.
Sometimes you can see the current moment clearer when you look back into the not so distant past. A friend of ours started working as a nurse in Bristol a quarter of a century ago and, after having worked in a different health job for over a decade, has recently returned to nursing. We have asked him what has changed in the meantime. We are always interested to hear about your experience!
 Intro
 I started my nurse training back in 1999 and qualified in 2002. I did a diploma, nowadays most people do a degree and have to pay dearly for it. So I started off in care of the elderly, which is what I am doing now again. I did that for three years and then I went to New Zealand to work. That&#8217;s an interesting topic in itself, the differences in nursing here and there. I spent three years there, then came back to the UK. On my return I worked on the bank, then in cardiology for a few years and then over a decade in a health educational advisory role. I finally wanted to get back into nursing. 
 The composition of the workforce
 When I first qualified in 2002 they had a massive international recruitment drive, mainly colleagues from India and the Philippines. I was new to nursing and they were new to the UK. At that time there appeared to be enough staff and then it became worse and worse and worse. It got to the point where the only way they could solve it was by recruiting internationally again. When they first went out looking for international nurses, they were able to pick the best and most experienced people with 10 &#8211; 15 years of experience. Later more and more international nurses arrive who have just finished their training or had recently qualified. I think the skill mix on the wards probably hasn&#8217;t changed that much, the ratio between nurses and nursing assistants and so on. There has also always been a coming and going of agency staff. 
 That’s interesting! Would also be good to look at the age composition. At least on the wards at Southmead you don’t see many nurses over 40 years of age. Gender-wise, on the other hand, it seems that things haven’t changed that much since the 1980s &#8211; it’s still only around 10 to 12% male nurses.
 That’s right, most male nurses come from India and Africa, whereas only very few UK-trained male nurses come in, at least in acute health care. Perhaps men can more easily avoid getting into debt for a qualification that then pays only a medium wage?
 Working times and conditions
 I think they changed from 8 to 12 hour shifts in about 2010. I&#8217;ve never liked it. Because I spent so many years doing it the old way. With the 8-hour model there was a lot more scope for educational work in the afternoons. You could catch up with things, with the administrative side of things. It just tires you out. But no one stood up against it, not even the RCN trade union. I don’t know what the evidence is in terms of impact on patient care. It can’t be good, I think that are often mistakes made later in the day.
 New Zealand and staffing
 I worked in a normal state hospital in New Zealand. The staffing was very different, ratios of 5 to 1 pretty much guaranteed. The nurse in charge would also take patients, unlike here. What I think was good was that they talked about acuity when planning the work &#8211; acuity meaning, how sick and how much in need of care individual patients were. When distributing work you would make sure that people had only one Level 5 patient (a very sick patient) amongst their five patients. It would be evenly distributed amongst the nurses. Here in the UK you just get one bay, and all patients there might be very dependent. On the other hand there were less nursing assistants. For 25 patients there would be five nurses and one NA, that means that registered nurses would have to do all the washes.
 This can be quite nice for the relationship with the patients, that you don’t just dish out medication or insert IVs! I guess the real stress is to keep the overview &#8211; if you have five patients, that’s fine, but if you have eight or nine you might start struggling keeping an eye on everything.
 People don’t fully understand that if you go from six to eight patients, your workload increases by 33%. People might think “or it’s just two patients”, but it’s actually a lot more work. That is difficult to absorb. 
 New nursing roles and team spirit
 I think one aspect that has changed is that you have way more specialist nurses nowadays. Now you have a nurse for everything, respiratory, stoma, research, you name it. This might be good for individual patients, but it also means that a lot of the staff just floats in and out of wards with little connection to the team and the work requirements and stress. Sometimes they create more work for you. But there at the same time real positives for the patients. Specialist advice when they need it. 
 That’s what friends in Germany say about work on the wards in the 90s, that ‘the ward’ considered itself as one team, from nurses to health care assistants to students to house keepers and cleaners &#8211; but that the splitting up of work tasks have also split up the team. Nowadays you have phlebotomists or domestics who quickly float in and out, and you have new ‘hierarchies’, such as trainee nursing associates.
 Yes, you had this tighter unit where you almost had to do everything. You&#8217;ve had to rely on each other a lot. Today, some of the specialist nurses also think that they are a bit special &#8211; it creates differences. You have more nurses in black uniforms or ACPs (advanced clinical practitioners), meaning, new hierarchies. Their role means they work more like doctors, rather than the nursing team. You feel that a little bit, but it’s only small things.
 Additional work tasks and digitalisation
 I think most changes had already happened twenty years ago. We were already taking bloods or cannulating, something that only doctors would do before. Of course, there are changes when it comes to the use of IT. I am still old school. I used to come in, sit down and write down everything from the handover on a piece of paper. Now you have print-outs. But they have to be up-dated, and they are often not updated. Or people are unsure which bits to take out, so you end up with more and more information, which can become excessive and dense. 
 I think doing observations on an iPad is easy &#8211; if you can find one &#8211; because it’s just figures. But doing intentional roundings etc. digitally would mean that a lot of small personal bits of information (patient was anxious about seeing a relative; patient didn’t like to drink water without squash) that you might write down for the next shift, you wouldn’t enter into the IPad. 
 Relation with management and pressure to discharge
Again, often those people who ‘manage’ the patient flow are quite remote from the ward. But a real positive thing over the last years are the efforts to understand where care is best delivered &#8211; and efforts to provide more care at home. The ‘Hospital at Home’ teams are now more embedded in the discharge process, which is a good thing. I don’t want to see people in hospital, I’d rather they could be home. The discharge pathways are more discussed now, for example the different levels. Pathway zero means you can just go home, for all the other pathways you have to assess the patient when they are at home &#8211; not just when they are in hospital and everything is provided for them. That makes sense, if it is safe for the patient. If it&#8217;s safe for them to go home and then someone can go with them and look and help them have a wash and so on &#8211; over a couple of weeks, making sure that they&#8217;re coping in their own home. It’s just that this requires a lot of staff. We often hear on the ward that the team in the community ‘can only take so many Pathway One’s at the moment’, meaning, they don’t have enough staff to assess the patients with more care needs. So people end up waiting in the hospital.
 And I guess over the last twenty years a lot of community and family structures that could also help people at home have been further decimated.
 I don&#8217;t know what the evidence is on that. One of the great things about nursing is to see that there is love, that there are really strong relationships between people, between couples or siblings and so on. Though there is a close link between poor health and poor relationships. 
 But back to the question of the pressure to move patients on. On one hand we know that things are busy in ED, that it is not good for patients to be stuck there, and we try to find empty beds &#8211; on the other hand you are often overworked to such a degree that you don’t have an interest in moving patients on too quickly. Admitting or discharging patients comes with a lot of administrative work. These pressures can lead to issues moving onto the ward they need.
 The pressure to move patients on is high and sometimes people make the wrong decisions under that pressure, patients end up on the wrong wards and so on. There is a target of moving people out of ED within four hours and that clock is ticking. I can go on a computer and I can see that individual patient’s clock ticking. Then there is actually a chart on the ward that tells us our KPIs &#8211; our ‘key performance indicators’. I know these exist but because I feel we have little control over the working environment. And sometimes it is better to have time to talk to patients and to ask them how they are feeling, rather than churning them out as quickly as possible. 
The increase in administrative tasks also meant that the role of the ward manager has changed a lot in the last ten years. They have become supervisory and May spend less time with patients. Some get involved with the patients sometimes, others not. That also changed the role of the nurse-in-charge, who now coordinates the actual work a lot. There is still a lot of self-organisation, we all have an input when it comes to who works where on a given day.
 The self-organisation element is a difficult one. On one hand big management relies on the fact that the work gets done and they know that people work best once things are fairly horizontal and self-organised. On the other hand they always need someone that they can put under pressure, a person who tells them what is happening and who can pass on order from the top to the ward level. With the bureaucratic tasks and the various computer visualisation of the patient flow they want to make a hierarchy look like ‘objective requirements’ &#8211; it is a hierarchical decision to keep staffing and number of beds limited to a certain number, but with the computer program and figures you just see the ‘objective fact’ that patients are waiting.
 That’s right, you can see the patient flow on the computer system, or things like where medication that is needed to discharge a patient is currently processed, thanks to barcode scanners. It is pretty much in real time. Transport is also digitalised. Then you can see the number of predicted discharges, compared to actual discharges. You can see all the people waiting in ED and how long they are waiting. I can also see where the empty beds are coming up, when people declare them. We can see the pressures and we can understand them, but we don’t have much control over them. Management is all for self-organisation on a daily level, when everything is working smoothly &#8211; but once something is going wrong and people make mistakes, then they enter the scene.
 Bureaucratic tasks of a nurse-in-charge
 Each morning you&#8217;ve got to go through every patient and say they have these and these criteria-to-reside. You have to be sick to be in the hospital. If you are a 50 year old male with family support, you might actually want to go home. But what if you are homeless or if you are 80 and alone? We have whole wards full of people who don’t have criteria to reside, but no place to go. So you have to record this information at the beginning of each shift. 
 Then there are further computerised programs like ‘Safe Care’. There you have to record how sick your patients are and you give them a number, a score. It&#8217;s a bit like the acuity thing I was talking about earlier on. You&#8217;ve got to add all these up and then the computer will go: “Oh, you are 1.5 hours over your allocation.” &#8211; meaning, you have too many staff for this amount of patients with this degree of sickness.
 Beyond the hospital
 All in all the problem is that we don&#8217;t have more beds than we had 20 years ago, but the population is bigger, the aging population is bigger. There were major changes in the NHS structures beyond the hospital. They always invent new names for the various bureaucratic layers, such as the commissioners. They make decisions about how much care people in a certain region can have. They have the capitalist overview, so to speak. I don’t care if the hospital overspends by £1 million, as these figures are arbitrary anyway &#8211; but the commissioners do. There used to be five different ambulance trusts in the South West, now there is only one. So there is a process of monopolisation, while at the same time some work is outsourced to small private providers. This is decided over our heads.
The Trade Unions
The unions in the health sector have seemed to have changed so little over the last 20 years. They were invisible then and are still difficult to see today. There has been industrial action and strikes but really they continue to fail to grasp the real problems people face today. The RCN wants to have a new pay scale for nurses. Meanwhile the lowest paid get pay rises to stop the Trust breaking minimum pay laws. Unison couldn’t get their members out on strike due to anti-trade union legislation. If we can look for collective struggles and stick together we can win more than the unions can imagine.
 
 
 
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The pharma robot and the volunteer

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