How Trade Unions Have Fought to Save the NHS
The media says nurses who threaten strike action are undermining the NHS and abandoning patients – but there is no better safeguard of public healthcare than worker organising for better conditions.
Nurses from the NALGO union protesting outside the London Hospital during the nurses' strike in February 1988. (Dean Houlding / Keystone / Getty Images)
Amid the rail strikes last week, the industry’s biggest outbreak of action in a generation, commentators and union leaders began predicting a ‘summer of discontent’ with strikes in sectors across the board.
One of these sectors is the NHS. Unison has said that the NHS staff it represents could walk out if their annual pay offer is not near inflation; the British Medical Association (BMA) has said it would ballot for industrial action in early 2023 at the latest; nurses represented by the Royal College of Nursing (RCN) could also strike if their demands for a pay award of five percent above inflation are not met.
Historically, strike action among NHS staff has attracted substantial criticism from politicians, the public, and other members of the caring professions, for reasons that are specific to the way people thought, and continue to think, about healthcare labour. Medical historians and social scientists argue that key to the professional identities of healthcare workers is the idea that their jobs are driven by vocation and a sense of duty. It is not just work, but a calling or commitment. In the words of former health minister and former nurse Nadine Dorries, approving of the government’s proposed one percent pay rise last year, nurses ‘do their job because they love their job.’
True as that may be, the self-sacrificial ‘hero’ narrative has also been used to justify denying healthcare workers decent pay and basic workplace protections for years, and to undermine their industrial action. In the 1980s, Margaret Thatcher accused striking healthcare workers of ‘hitting out deliberately’ at the sick and increasing the burden on those nurses that ‘would not dream of striking because they would never desert their patients.’
Striking nurses do not want to desert their patients, but when more and more of them are unable to feed their families, they may be left with no choice. In May, six hospitals were forced to set up food banks or food voucher programmes to help their staff cope with the cost of living crisis.
As Thatcher’s antagonism shows, industrial action among the NHS workforce this year would not mark modern members out as uniquely selfish, whatever the government might say; rather, they will be continuing a long tradition of healthcare strikes, which have been a constant feature of the battle to get workers the treatment they deserve.
Saving the NHS
In the mid-twentieth century, a patchwork of unions represented healthcare workers, including the National Union of Public Employees (NUPE), the Confederation of Health Service Employees (COHSE), the BMA, and the RCN, although the BMA only registered as a trade union in 1971, and the RCN in 1976.
The recognition of the RCN and the BMA as unions took place in a major decade for industrial action by healthcare workers in Britain. In 1972, the Department of Employment warned that the NHS had ‘for a long time been able to get by on the goodwill of its employees’. Much like today, rising inflation meant that already low salaries for hospital cleaners, laundry staff, and porters were being stretched perilously thin. At the beginning of the decade, the average pay of a male NHS ancillary staff member was just under £28 a week for 46 hours, compared to £36 a week for 44½ hours for the average male manual worker.
The situation for nurses was similar. By 1974, their real income had increased by just nine percent since the foundation of the NHS in 1948. Low pay affected morale: in 1976, a consultant wrote to the government to say that ‘declining morale, which might soon denude and destroy the NHS, in incurable without applying more money in the right places.’ A hospital administrator agreed: ‘the level of morale for all categories of staff working in the National Health Service is at the present time appalling.’
The latter was gravely concerned about what he saw as the resultant instability of the health service, given the working conditions and prevailing low mood. ‘The need to improve morale is paramount if the Service is to develop or even to be maintained, or possibly to survive.’
The result was industrial action. Nurses who were members of NUPE went on strike in 1974, and in 1975, BMA members followed suit. Between January and April, and following a dispute over the treatment of private patients in NHS hospitals, consultants suspended all ‘goodwill activities‘ (i.e. non-essential/emergency services) in protest. In November of that same year, junior doctors took industrial action over pay and working conditions before an agreement was reached with the government in December.
Between 1975 and 1978, attempts by the Callaghan government to rein in inflation by holding down pay only made the financial situation for ancillary healthcare workers worse. Real wages for NHS and local council employees dropped nineteen percent, pushing many into poverty. After workers were offered another below-inflation pay rise in 1978, unions agreed on a campaign of overtime bans, selective strikes, and ‘working to rule’. By the end of January 1979, half of all hospitals in Britain were forced to offer an emergency-only service, as ancillary staff and ambulance drivers engaged in partial work stoppages. The dispute continued into the spring, but in March members of COHSE voted to accept an offer of a nine percent pay rise. NUPE initially rejected the offer, but eventually opted to accept a slightly modified version of the original deal.
After Thatcher
In the wake of the Winter of Discontent came the Thatcher government, with whom healthcare professionals—and particularly nurses—were repeatedly in conflict. 1982 saw the longest-ever industrial dispute yet experienced in the NHS, when thirteen health service unions sought a twelve percent pay rise. They rejected a pay award that would have given nurses a 6.4 percent increase, and all other workers just four percent, and began a series of selective one-day stoppages that grew in length and intensity. In December, nurses accepted 12.3 percent.
But problems remained, and by January 1988, up to a quarter of trained nurse positions were unfilled in some British cities. Forty percent of nurses still earned less than the ‘low-pay’ threshold, only exacerbating the difficulties of recruiting and retaining new staff.
The following month, NHS nurses across the UK staged walkouts, protesting low pay, unfair salary structures, poor morale, and terrible working conditions. Rodney Bickerstaffe, the general secretary of NUPE, said that health workers were ‘totally demoralised and dejected’. In London alone, strikes took place at more than forty hospitals. According to the trade unions, 6,000 nurses participated in industrial action across the country.
This was the first nurse-led, country-wide strike since the NHS began, but despite its scale, the effect on patients and patient safety was minimal. No hospital was left dangerously understaffed due to the strikes, and just 200 out of 9,000 elective surgeries were postponed. As a result, while Thatcher was less than pleased, most British people supported the strike and the majority backed nurses’ demands for higher pay.
However, at the time, nurses’ dominant union, the RCN, still had a no-strike policy. The trade union only voted to drop its no-strike rule in 1995, in furious response to the Tory government’s ‘miserly’ pay offer of one percent.
The 1988 strikes only ended after Thatcher granted NHS nurses an average pay rise of 15.3 percent. This was less than they had asked for, and failed to bring them in line with comparable professions. But perhaps more importantly, other desperate situations in the NHS, such as low staffing levels and poor working conditions, remained unresolved, and largely remain unresolved today, under another Tory government committed to under-funding and under-resourcing the welfare state.
Industrial action in the NHS has therefore continued well into the twenty-first century. From the junior doctor strikes in 2016 over new proposed contracts to recent walk-outs by security guards at Great Ormond Street children’s hospital and St George’s protesting staff outsourcing, as well as a victory at Bart’s Health, healthcare workers are still battling for their rights.
Thanks to the language of devotion used to justify their exploitation, when NHS staff look ahead to potential industrial action, they may well be worrying about the response from politicians, the public, and the press. After all, it wasn’t that long ago that Theresa May accused the BMA of ‘playing politics’ instead of ‘putting patients first.’
But in the wake of the pandemic, things could be different. While 2020 and 2021 were full of talk of heroism, there was an accompanying increased recognition that healthcare workers are precisely that: workers.
One indication of this shift is a more robust debate about healthcare professional wellbeing and the failures of healthcare institutions to protect the mental and physical health of their employees. Another more worrying indication is the large number of staff exiting the service—those that have already decided, justifiably, that the sacrifices demanded of them are too great.
Since at least the 1970s, the history of the NHS workforce has been a cyclical tale of periodic crisis, industrial action, minimal government concessions, and a frustrating return to sub-standard conditions and pay. This is especially true for nurses and ancillary staff, who have borne the brunt of outsourcing, cuts, and austerity measures. Now, once again, the patience of healthcare workers has frayed.
In light of that cycle, it is perhaps time to look toward a different future—one in which NHS staff are recognised properly as workers deserving of basic rights, or, even better, one in which the structural changes required to bring the NHS back in line with the radical vision it once represented are actually delivered: not just better pay, but better conditions, appropriate expectations, and a more equitable employment structure and culture. This is the NHS we should strive for. After all, applause doesn’t alleviate burnout, and you cannot eat praise.