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NHS: collective action is the route to control

15 December 2022: nurses in high spirits outside Great Ormond Street Hospital, London. Photo Workers.

The NHS is a prime example of what happens when governments refuse to govern or indeed make any decision. Now the government is attacking the very people struggling to keep providing care in a mess of its own making…

Several factors have contributed to the current crisis in the NHS. But the chief problem is one that is not within the gift of NHS staff to solve: the failure to address provision of social care for elderly people or those with disability. One in three NHS beds is occupied by patients well enough to be discharged from the health service if social care were available.

Just imagine if that could happen. The bed capacity of the NHS would increase by a third, the patients stacked in the emergency departments could be transferred to beds. Patients who have been in the ambulances in the car park could be moved to A&E. And patients on the waiting list could be admitted. Indeed, the all-important flow of patients through the NHS could be started.

This failure to address social care long predates the pandemic. It is now more than ten years since the last serious effort to address the problem with the recommendations of the Dilnot report.


But social care is by no means the only issue. The loss of a third of bed space to social care needs is compounded by a wider problem: there are too few beds.  According to the King’s Fund, Britain has fewer acute hospital beds relative to its population than many comparable health systems.

Even before the Covid-19 pandemic there was a big shortage of beds, and the epidemic has had a significant impact on their availability and use.

‘While the NHS has an almost unbelievable 44 per cent fewer beds than in 1988/89, the number of people in Britain has soared by over 9 million…’

Meanwhile the population is growing. While the NHS has an almost unbelievable 44 per cent fewer beds than in 1988/89, the number of people in Britain has soared by over 9 million.

And don’t forget the toxic legacy of the last Labour government’s Private Finance Initiative scheme, which means that when local areas receive their revenue budgets for the year, a percentage of their funding is already going out the door to service the PFI debt.

In the financial year 2020/21, hospital groups spent £2.3 billion on what are called “legacy PFI projects”. According to an analysis by the Guardian newspaper, just under £1 billion went on costs for essential services such as cleaning and maintenance. A third of the remaining PFI spend – £457 million – went purely towards paying off interest charges. Some legacy.

How to assert control?

In such a situation, how do workers take charge? It is not easy. Exhorting the government to govern doesn’t even begin to cut it. One starting point is for NHS workers to value themselves, given that it is quite clear that government does not.

But valuing ourselves is not enough. It’s just a start. It must be linked with positive, collective action. Otherwise the result will only be the despairing exit of workers saying, “I had to leave as I valued my health/ sanity etc.”

As described in a recent Workers article, many nurses have historically pursued an individualistic strategy of self-preservation by leaving a permanent position to work as agency staff to control work pressures. Others have left the profession altogether, a loss to patients and a waste of their hard-won skills. Over time these nursing staff are impoverished when they lose pension and other benefits.

The solution cannot come from external support campaigns. Health care staff value public support, but as the general secretary of the Royal College of Nursing said in November 2022, “Gratitude is not enough – it doesn’t pay the bills and it doesn’t stop nursing staff leaving the profession…”

The only response must be organised collective preservation – like the decision to take action for pay and patient safety in the NHS by nursing and ambulance staff.

It will not be easy, with the government seeking to close off all routes to effective strike action. Recycling old threats, prime minister Rishi Sunak announced in early December that he wants to legislate to prevent or limit essential workers taking action (see page 24).

In this situation the members of the Royal College of Nursing and Unison currently taking action would be described as lawbreakers. How is the whole working class going to respond to that threat?  Unlike politicians, most workers at any time can be described as “essential”.

Take charge

A key feature of the current disputes in nursing and the ambulance service is the fall in wages relative to the private sector and even other public sector workers. That has made the pay fight a key part of the battle to retain existing skilled staff.  

Retention of experienced staff is step one. But it is equally important to ensure you pass your skills on. So, step 2 in taking charge must entail making the job attractive to new recruits and protecting their learning experience on the job – something hard to do in the current situation.

And yet across the health service experienced staff are taking steps to do just that.

In the ambulance service, for example, the public focus has rightly been on the experience of the patient who spends twelve hours in the back of an ambulance. But these delays also lead to a deskilling of experienced staff and, critically, an almost complete absence of training opportunities for student paramedics.

‘In the ambulance service the current delays risk deskilling a generation of recruits…’

The current delays risk deskilling a generation of recruits. A student paramedic needs to undertake so many electrocardiograms or intravenous cannulations. This is one reason why we see senior paramedics trying to reorganise work within the current constraints to ensure students get the learning they need.

Another example of taking charge in the workplace is the way that NHS surgeons are using their Royal College. They have argued for the formation of surgical hubs as a means of tackling long waiting lists.

In doing so they have also found a way of protecting surgical expertise and of training new staff for the whole surgical team: doctors, nurses and technicians including all the surgeons whose exams were postponed during the pandemic (see Box).

In a recent review of how health care staff managed to reduce the median waiting time for surgery between 2000 and 2008 to a mere five weeks, a King’s Fund report concluded that the key factor was “valuing the people working in the NHS and investing in them”.

Now in 2023 the number of people waiting longer than one year for planned treatment stands at 387,000. Around 2.75 million people are waiting longer than the “legal standard” (to quote the National Audit Office) of 18 weeks.

And against this background we have a belligerent government trying to blame the workforce. The only way for progress is for NHS workers to take control of the situation themselves.

• Related article: Surgeons take the initiative