What strategy for the NHS pay strike?

With both UNISON and UNITE balloting for strike action and action short of a strike in the NHS, there is an urgent need for discussion among health activists of how we ensure the strikes are successful and strengthen our fight for to save the NHS, and don't result in disillusionment and disorganisation of our members.

While a ballot for action is welcome in the NHS, and long overdue, there are serious problems with the action the leaderships of UNISON and UNITE are proposing.

A four hour strike

Firstly, there is the nature of the strike action proposed. UNISON has stated that strike action if the ballot is successful will only be for four hours. UNITE has termed their action a “microstrike”, leaving open its length, but hinting at a short or partial action. I have not seen an explanation for why this is. It is demoralising for reps and members who want a whole days strike action, and creates massive problems logistically for workers to undertake a four hour strike. With a full days strike action, unions can demand the hospital only provide emergency cover, the equivalent of Sunday working; outpatients, and non-emergency services are closed, elective surgery is cancelled and wards run with reduced staff. This frees staff to participate in strike action, and while stopping the hospital working, is no more dangerous to the patients than spending a normal Sunday in a hospital bed.

With a four hour strike, we cannot make such a demand. The hospital will run as normal, and those working with patients on wards or in theatres, or in time critical services like pathology, diagnostic scans (CT, x-ray, MRI) will have to leave work in the middle of extremely busy schedules to participate in the strike, and then return to a massive backlog of patient demands and urgently needed work. This will be extremely difficult to organise, and management will be able to bring massive pressure to bear on all staff not to participate in the strike due to the potential effects on the patients.

A four hour strike will be extremely difficult, if not impossible to organise for most clinical NHS staff, and pardon my cynicism, seems like a conscious decision on the part of the union leaderships to make the strike harder to pull off.

No further action

There is no plan of action beyond the single day. We are being balloted for a single four hour strike, and then a work to rule. No further days are planned. UNITE has said on their leaflet enclosed with the ballot “If we plan to take further actions, we will communicate with you again.” This doesn't give our member the impression that our leaders have a strategy for taking the dispute forward, and if they do have a plan, deprives members of the opportunity to see what it is, discuss it and suggest alternatives.

Trade union activists can look around at other recent strike action and decide for themselves what works and what doesn't. The National Union of Teachers (NUT) had a series of one day strikes, months apart, which secured nothing for their members, and served to demobilise members who grew tired and demoralised of organising one day actions so widely spaced out they lose all momentum and support in between.

In Higher Education, UNITE, UNISON and UCU staged a series of one day actions, again widely spaced out, which again served to demobilise rather than mobilise the workforce, and ended up splintering the strike as participating unions dropped out until UCU alone was taking action. The strength, unity and enthusiasm built up through joint actions was frittered away and the strike action secured minimal gains.

The unions need to announce a plan now, of successive days of action taking place every month, preferably escalating, to demonstrate to the workforce that they have a plan, and are willing to put the pressure on the government needed to secure a win.

A work to rule where there is too much work and the rules are against you

The second component of the action is a work to rule. UNITE are calling for workers to take their breaks, and to leave work on time. While welcome, this is easier said than done, and that advice shows a lack of both understanding of the pressures staff are under, and creativity when it comes to implementing a work to rule.

NHS staff are under massive pressure. All staff whether clinical or non-clinical, are at or in many cases, past breaking point due to the pressure to perform their work and ensure patients are cared for safely and mistakes are not made in an incredibly high pressured and increasingly bureaucratic system.

Those of us in clinical roles are bound by our codes of conduct to complete all our work necessary to ensure our patients are treated with care and dignity, while non-clinical staff are bound by basic human decency to ensure they do a good job and no patients suffer.

Nurses doing ward work are not missing their breaks and staying hours after work because they want to, they do so because those hours are the extra amount of labour time required to provide the minimum of safe basic care in the under staffed NHS. Admin workers are staying at their desks hours after work to ensure urgent referrals are completed so patients do not have to wait longer than necessary for treatment. Porters miss breaks and stay late to ensure urgent patient cases are moved around the hospital, and patients are not left sitting on wards, missing treatments. There are always jobs left over at the end of the shift which the workforce has to hand over, piling more work on the next shift.

In this situation, asking workers to undertake a work to rule when there is simply too much work, and that work is vital for the wellbeing of other human beings will be extremely difficult unless we develop some imaginative and creative ways of reducing our workload and using the work to rule to undermine the bureaucratic and oppressive systems of control implemented by NHS management.

What are our demands?

Finally, what are our demands? This strike is ostensibly to secure the 1% pay rise the government denied us last year. This is paltry, a terribly weak demand that does nothing to galvanise the membership and merely leaves us open to comparison with private sector workers who received nothing in the same period.

We need political demands which tie our strike into the fight to save the NHS, and a wage claim which actually gives our members some relief from the downward pressure on wages exerted by inflation and four years of a pay freeze.

In the US, the Chicago Teachers Union, operating in a climate far more hostile to trade unionism, fought and won better conditions and pay using the strategy of social movement trade unionism. They went out to the communities they served and met community groups, parents associations and won them to supporting their strike, by taking up their demands for smaller class sizes, better funding for schools. Instead of fighting on the narrow basis of pay and terms and conditions, they made their strike about preserving and improving their service.

We have to make this strike about protecting and improving the NHS. Even if we win a pay rise, it won't be much use as the service is dismantled, we are privatised and cut piece by piece. And simply striking for pay without talking about the need to defnd the NHS from cuts and privatisation will allow the government and media to portray us as greedy, and that our demands will bankrupt a service already suffering from cuts and austerity.

The anti-union laws prevent political strikes, but we can ballot and strike over a pay claim, while making clear our demands and actions go further than this and are political in nature. By making our strike about the future of the NHS we can rally the public in support of us, and mobilise public opinion against the government.

My suggestions for demands to put to branches would be:

1. An 11% wage claim for everyone in the NHS, the same as parliament gave themselves.
2. Mandatory minimum staffing ratios for nurses in all services, to protect patients and guarantee them good standards of care
3. The cancellation of all PFI debt, to free up money to pay for wages, the hiring of more nurses, and to repair the damage done by cuts
4. A halt to all cuts and privatisations wherever they are happening

There will be resistance from trade union hierarchies worried about their positions and their jobs if we break the law, but the argument has to be had out that securing successful action to protect the NHS and guarantee our members a living wage takes precedence. Unions should be under the control of their members, and if we want to take action on a political basis they should support us or get out of the way.

Strike for a whole day

A priority for all NHS branches should be lobbying for a whole days strike action. We need to make sure there is broad agreement that we need at least a 24 hour strike to begin the action, and that this should tie in with a plan of escalation.

Reps and branch meetings should be convened and motions passed asking the union leadership to endorse a full 24 hour strike in the NHS as the first day of action. This should be common sense to most reps and members. If enough branches pass motions calling for a proper strike, hopefully the leadership will correct their error.

To ensure they get the message, we should also start discussing how we can make the strike twenty four hours ourselves. Most reps and members will be rightly frustrated with this ill thought out four hour strike plan and the trouble and obstacles it creates for those trying to organise action. This frustration should be enlisted to make the case for branches organising 24 hour strikes ourselves.

A properly organised twenty four hour strike will be safer for patients than a disorganised 4 hour strike with workers walking off wards and out of clinics and leaving patients and other health workers in the lurch. We're being balloted for a strike, people will want to have a “proper” strike, and its safer for patients if the hospital is running according to Sunday working. If we get a ballot for yes, why shouldn't we take the initiative and take a proper days strike action?

While such an action would violate the anti-union laws, its the prospect of branches attempting to organise a twenty four our strike themselves which may force the leadership to endorse such action and make it legal. If we merely pass resolutions, and don't take the practical steps to agitate among the membership and prepare for a twenty four hour action, the leadership won't feel the pressure to move on this issue.

Action, action and more action

One day strikes only work if they are a part of a plan to escalate action, or they come together frequently enough to create an ongoing political issue for the government. I have two proposals for what strategy we should argue for.

Escalating action. This would mean if we manage to get a one day strike in October, then we go out for two days in November, three in December, four in January, and on from there. These should be announced in advance and the dates set so members can prepare, we can collect money for hardship funds and win the argument for striking over the Christmas period when members will want to be saving money for presents for children and family.

Escalating action would ramp up the pressure on the government immensely, and the longer strikes would build up backlogs of NHS work that would be politically deadly for the government, and a huge logistical problem as the extra capacity doesn't exist to clear them quickly. This will be hard to argue for in the face of a vociferous media quick to blame the NHS for any failings, but unions need to be clear that the short term inconvenience due to delayed operations pales into comparison to what will happen if we lose the entire NHS due to government policy. This its why its crucial we make any action about protecting the NHS, not just our pay. The public will accept inconvenience and delays for action to save the NHS, they will be less accepting of it simply for a higher wage deal for NHS workers, as deserving of this as we are.

What is crucial is making sure dates for action are set as soon as possible. Its positively sabotage to wait till after the first strike before calling more action. The union leaderships might want to see what the turn out is first, but they've already guaranteed the turn out for the first strike will be poor by the nature of the action they've called. If members can see there is a plan to escalate action they are more likely to commit, we can have the argument out early with those who are opposed, do the necessary preparation and members will see the leadership has a plan, and their sacrifices will be worth something as they will exert real pressure on the government.

Consistent regular action. This would mean going out once a month every month until the election. While not increasing the pressure as escalating action does, it will create huge political problems for the government. NHS strikes generate huge political pressure on the government. If they happen each month, even if just for one day, that will become a regular source of political pressure and unpopularity for the government. And the last thing they want in the run up to the election is for the NHS to be in the news and NHS workers to be marching regularly in the street.

While one day of action a month is in my view quite conservative and doesn't apply the necessary pressure, it would still be a big undertaking and achievement for a demoralised and in some areas poorly organised NHS workforce. Keeping up regular political pressure on the government through short but regular strike action would keep the NHS in the news, and be politically deadly for the Tories in the run up to the election. They may be more likely to give in and offer a larger rise in an attempt to “buy off” NHS workers ahead of the election, and avoid the possibility of NHS strikes in the run up to the vote.

Creative and radical ways we can work to rule

Given the work to rule is a big part of the unions strategy, we should have a serious discussion among members about how we can use this to our advantage, to reduce unnecessary work and bureaucracy, develop members confidence and organisation and take back control of our work and our lives from the employer.

As stated above, taking your breaks and finishing on time are a serious challenge to most NHS workers, so an effective work to rule has to involve reducing our workload as well. For clinical staff, one tactic might be to organise a boycott of paperwork; all non-essential, non-evidence based paperwork should just be binned. As nurses we complete reams of largely unnecessary paperwork which is not evidence based. It is primarily designed not to aid patient care, but to provide legal cover for the hospital if any errors are committed. It also functions as a labour disciplining tool, giving management instruments for monitoring nurses work, forcing us to work harder to ensure everything is done according to policy. Most of this paperwork is clinically unnecessary, bureaucratic and time wasting. Refusing to do it, and instead just recording written notes would be popular, free up nurses time to complete all their care, take their breaks and (possibly) leave on time, and would not breach our code of conduct.

I am sure other staff groups have similar tasks that have been forced on them by the current target driven and bureaucratic management culture. Identifying these tasks and organising to boycott them would be an effective way to implement a work to rule that would reduce managements power to bully us by removing their monitoring tools (hourly rounding charts, etc), while freeing our time for the things that matter, like patient care and communicating with colleagues.

It also gives us a politically popular message: we're rejecting bureaucratic and inefficient practices in order to give us more time to do our jobs properly and care for patients. That is much harder for management to argue against.

Another tactic would be to copy the lead of Australian nurses. I had the privilege to meet Lisa Fitzpatrick, Chair of the Victoria branch of the Australian Nursing and Midwifery Federation earlier this year. Lisa spoke to the 4:1 Campaign about the ways ANMF members fight cuts and attempts to take away their mandatory minimum nurse staffing levels.

When they organise action short of a strike, nurses block hospital beds. They effectively ban a hospital from admitting patients into 1 in 5 beds. How do they do it? Direct action. The nurses will go round the ward and physically remove the mattresses from every 5^th bed, hide it, lock it in a cupboard, or stick it under a bed where it can't be used.

They then put big “BED BLOCKED” signs on the beds to indicate they can't be used. They keep a couple of beds open in A&E for emergency cases, but they refuse to take more non-emergency patients until their demands are met. This forces the hospitals to scale back or stop all their elective work in order to keep beds free for emergencies. The nurses don't stop caring for patients, they just refuse to let the hospital dictate how many they take, and force hospital management to re-prioritise their work and their admissions. This video of Lisa's talk explains how they do this, why itseffective and how they use the media to their advantage over this issue.

How could this work in a British context? We don't have the organisation or militancy among health workers at present to block 1 in 5 hospital beds in the NHS. But NICE has issued new staffing guidelines, which recommend that nurses should not care for more than 8 patients at a time.

It is completely justifiable that nurses utilise the bed blocking tactic to enforce this new guideline when hospital management is unwilling too. Branches could organise to support their nurse members enforcing the 1:8 ratio on their wards as part of their work to rule. Nurses can state they're "working to rule" to the new NICE guidelines, and they won't work on understaffed shifts, or care for unsafe numbers of patients, according to the new rules.

Petitions could be circulated for nurses to sign asking that get the 1:8 ratio, and pledging not to work if they're forced to care for more than 8 patients, an unsafe number according to NICE and all available nursing research.

On wards where nurses regularly care for 8 or more patients, whenever a patient is discharged nurses should block the bed(s), until the nurse-patient ratio on the ward is 1:8. Those beds then stay blocked until the hospital provides more staff and meets the ratio of 1:8 permanently.

Given that a survey of 526 nurses by the Nursing Times in February 2014 found 44% of nurses saying they regularly cared for 10 or more patients on their wards, and a UNISON survey of 3,000 nurses reporting 45% caring for more than 8 patients, tens of thousands of nurses could participate in this action. We can make our work to rule about enforcing patient safety in an NHS made unsafe by brutal cuts and austerity. We can make our action popular with the public, and reclaim our rightful place as champions for patients safety from creeps like Jeremy Hunt.

These are just a few ideas from the nursing profession, I welcome other health activists contributing their knowledge of their work and specialities to this discussion. We need to come up with ways of reducing our workload, while maintaining or improving patient safety, and putting pressure on trust management.

Developing strike organisation in the NHS

All of the above ideas are predicated on developing much better organisation among trade unionists and health workers in the NHS. If any of this is to happen, branches need to involve their members in planning and organising all aspects of the strike, and we will need cross-union organisation within hospitals and between them. The leaderships of UNISON and UNITE will be wanting to use the strike for their own purposes, and trying to keep whatever happens from inconveniencing the Labour Party in the run up to the election. The calling of the “micro strike” is just the first example of some of the obstacles we may face from our leaders.

There isn't enough of a left presence in UNISON to vote through further action in any of its leadership bodies, and UNITE has refused to call further action in the past when UNISON has called off strikes in health, so any further action is going to have to be a result of pressure from below, from the membership and branches organising and demanding it.

Using the strike to develop a coordination of NHS workers and health branches which is committed to a transforming the fight over pay into a political fight over the future of the NHS Is an opportunity which can't be missed, and will be crucial if we are to have any chance of securing and sustaining further action, let alone winning anything substantial from this fight.

On September 13^th Left Unity is organising a meeting for public sector trade unionists to attend. I urge as many NHS trade unionists and activists as possible to attend and take part as the first step to developing the coordination we need to take this fight forward.

Meeting details
13th September – 12noon – 5pm
Chadswel Healthy Living Centre,
Lower Ground Floor,
Chadswell, Harrison Street,
London, WC1H 8JE
Nearest tube Kings Cross
Venue is wheelchair accessible