The first part of this article addresses the practical problems for healthcare workers’ self organisation, and the relationship between workers, managers and policy makers. The second part of this article addresses the ethical implications of healthcare worker’s self organisation, and the relationships workers have with each other and with patients.
I’ve worked in care homes and home care for the last five years. I trained as a social worker, and during my training worked (unpaid) in two different adult care teams and a drug treatment centre. I’m now a qualified social worker, and currently work in a complex intervention team specialising in older adult’s mental health. This article contains are some of my observations not just from reading around the topic but from my own experiences of working in the industry, talking to other professionals and trying, generally unsuccessfully, to stand up for myself and my friends. I have to admit, I’ve found it easier to see what the problems are than to see the solutions, so this article will mainly raise questions rather than try to answer them. If anyone has any suggestions of what to do in response to the problems I’ve raised, please drop them in the comments section.
Why should healthcare workers organise?
Health and social care is a kind of political football at the moment; it is the industry that has been the most affected by the current government’s public spending cuts, and will see more drastic changes at least over the next five years. Healthcare is an enormous industry in the UK; the NHS alone is one of the world’s biggest employers, so worker’s organizations in the UK need to take seriously the possibility of taking action in this industry. The industry itself seems to be in a state of flux and change; funding for services is growing precarious and privatization is accelerating, while changes in policy like the Care Act 2014 and the Cheshire West judgement and a widening media debate about welfare, social care and mental health are likely to drastically alter the ways in which healthcare in the UK is provided over the next few years. This feels like the right time for workers to begin to talk about organising in healthcare, and for workers to develop effective strategies for organization and resistance. January 2016 saw a widely publicised one-day strike over working conditions by junior doctors, facilitated by the British Medical Association. In the wake of this, it is important to discuss some the problems that militant workers in the healthcare industry might face when trying to fight for their own jobs.
A large chunk of the healthcare industry in the UK is in the public sector. It is an industry in which the big TUC unions (especially Unison) already has strong ties, and there are a range of professional associations such as the BMA, BNA and BASW that exist, nominally to protect members of the registered professions in workplace disputes against their employers. In the face of so much bureaucracy, organizing in the healthcare industry can feel stifling at times. That said, unqualified workers without a professional registry, especially those in the private sector, have no access to representation whatsoever and often seem to have some of the worst working conditions of any workers in any industry, particularly in the case of home care workers[i], so there is a desperate need for a worker’s organisation that can challenge the bosses’ exploitation of workers in this sector.
The structure of the health and social care industry also presents obstacles to effective organizing. The size of the industry itself is staggering, and since such a huge swathe of healthcare provision in the UK is undertaken by state-owned agencies, it isn’t always clear who the bosses actually are. Striking against a local manager or a local trust is likely to be a pointless exercise when the manager in question is following orders from above. Management practices in health and social care are ultimately determined by policy and the resources that are made available to local providers by central government. Healthcare workers looking to organize need to be aware that they are battling not just against their immediate bosses but the government too, to change government policy, not just to end the exploitative actions of a few individual managers. This is a huge task.
Healthcare staff are heavily scrutinized by their employers, and this makes militant organising outside the official channels a potentially dangerous activity for workers to undertake. Obviously any worker would think twice about wildcat action if it meant losing their job, however healthcare workers are more regulated and coerced than workers in other industries and this makes unemployment or disciplinary action a seem all the more threatening. It’s not uncommon for staff applying for jobs in care to have to give references not just from their most recent employers but from every employer over a five year period. There is huge pressure on staff to stay on good terms with their bosses no matter how exploitative the boss may be, since conflict is likely to have repercussions for workers not just in their current post but in future jobs as well.
When applying for jobs, staff typically have to explain or justify gaps in their employment history, so any period of unemployment (such as after being sacked) will seriously hamper healthcare workers when trying to find work. This makes the prospect of losing or quitting a job deeply troubling for healthcare workers, and they may be more reluctant than other workers to antagonize management as a result. Workers are also subject to rigorous criminal records and background checks, so taking direct action even outside of the workplace may seem daunting to workers who risk not only the chance of being arrested but also losing their jobs if convicted of an offence.
Safeguarding laws give managers a whole host of measures to bypass standard disciplinary procedures and suspend or even sack staff more or less on the spot. Officially, these laws exist to protect patients from abuse by staff, but managers would potentially need only a thin pretext of patient neglect in order to bring safeguarding powers to bear to discipline unruly workers. In healthcare, any action that disrupts work could be framed as neglectful of patients, and workers should be aware that management will use this against them. Staff with a professional register have to face not only being sacked if they withhold their labour, but potentially being moved from the register or ‘struck off’ as well, meaning that they could never work in their chosen field again.
All these factors put healthcare workers’ organisations in a precarious position, especially those that try to organise unofficially without even the meagre legal protection granted to workers who undertake state-approved strikes through the TUC unions. It’s partly because of this rigid legal framework that the legalism of the bureaucratic unions has become so rigid. For myself, legalism often felt like my only viable option to win concessions from management. Management would at times overstep their line, and having a good knowledge of law and proper procedure meant that I was able to challenge decisions and, provided an independent mediator was there to ensure fair play,
I did win small victories, but legal battles will always be fought on the boss’s terms and ultimately shore up the system rather than shaking it down. A legalistic campaign, especially one focussed around an individual grievance, can be a lonely place, where your only allies are false friends from higher up the chain brought in to mediate or oversee. You are constantly fighting in the dark, never knowing who is on whose side, which manager is chums with which other manager and what is being said to your workmates about you behind your back. These are not good substitutes for collective organising.
Healthcare and the NHS
The public sector nature of the industry also raises questions about who exactly should be considered a worker. Since everyone, broadly speaking, earns a salary, and there is no profit motive and no production in a material sense it is hard to identify the bourgeois, exploitative element to organise against.
As mentioned above, the TUC unions and the various professional associations tend to dominate the sector. But these are a poor substitute for bottom-up organising. I’m not going to go into much detail here about everything wrong with TUC, since the subject has been done to death elsewhere. However, it is worth pointing out that the professional associations tend to have similarly centralised and narrow working models as the major unions, focussing on individual disputes and rather than wider social change. The exclusivity of the professional associations exacerbates the class divisions that exist between different healthcare workers. The junior doctor’s strike highlights this; the public and media attitude to the strike was much more positive than it usually is in response to large scale strike action. This is in sharp contrast to the vitriol heaped on striking nurses and support workers in 2011 and striking midwives in 2014, and the different treatment that the two groups received reflects the different social attitudes towards doctors as upper-middle class men and midwives as working class women.
Social Care, the Local Authority and the Private Sector
Outside of the NHS, in the murky, semi-privatised world of social care, things become even more complicated. The recent cuts have fallen disproportionately on local government budgets, and as such social care and local authority workers have arguably suffered more than healthcare workers and NHS PCTs have. Adult social care sector works on a PFI system of purchaser and provider, with the purchasing of services carried out by local authority staff and the actual provision of services carried out by private companies or third sector organisations working on public sector contracts. Council-employed assessors (usually social workers) will assess service users’ needs and allocate a budget, which will then be used to buy care for the service user from for-profit providers (i.e a nursing home or a home care agency). Despite the myth of free, comprehensive healthcare, publically owned care facilities are almost extinct in many parts of the UK. For the majority of patients, the staff who provide the bulk of their day to day care are actually employed by private companies. However, because of the procurement system, that local government’s social care budget directly impacts the wages of frontline staff in the private provider organization; it’s an unaccountable system in which pay is capped by stealth, making campaigning for pay increases nearly impossible.
Cuts to the services themselves have had detrimental effects on the wellbeing of service users, and the knock on effect of this has fundamentally changed the nature of work for local authority employees involved in what can loosely be termed ‘welfare’, but it is especially the case in social care. Social workers themselves have perhaps seen the biggest change to their profession. As caseloads increase in volume and severity, social work becomes increasingly driven by crisis and risk prevention, less a matter of helping and protecting people and more a matter of policing and controlling them. The radical tradition in social work is rapidly dying out or becoming a purely academic pursuit with no relevance to the working realities of social care work. Left, Marxist and other radical social workers are increasingly becoming demoralized, and typically either abandon the profession completely or compromise on their beliefs.
Social workers in local authority teams are typically represented by one of the big public services unions like Unison, as well as their own professional association (BASW) and the affiliated Social Worker’s Union. I’ve noticed from my own experiences that groups of social workers tend to be more politically driven than other professional groups like doctors and psychologists, and at times this can show itself in workplace militancy. During a recent meeting in my own team our manager tried to sneak into the conversation that changes to our contracts could potentially involve a pay cut, and was called out and jeered at by the social work team. Almost every member of the team had consulted a union or BASW rep, and most were aware of their rights in relation to the contract and weren’t prepared to be fobbed off by the manager’s jargon and the contract’s small print. Discussions in the group about the new Care Act showed a similarly healthy level of cynicism and mistrust of central government, which could potentially be harnessed into syndicalist militancy. The downfall of social workers, like other white collar socialists in the public sector, is the misplaced faith they have in their official unions to fight for them. Whilst most social workers understand all too clearly the nature of their role in relation to government cuts and privatization, the TUC unions, despite their leftist rhetoric, abandoned the public sector battlefield long ago. Unison publically vowed to oppose the bedroom tax, at the same time instructing reps to advise members not to oppose it in their own workplaces. Whilst workers with the will to struggle continue to divert their energy into the dead-end protests that the likes of Unison offer, genuine organising will always be stifled.
Big, centralized unions increasingly represent salaried professionals instead of waged workers, and have shifted policies and strategies accordingly; these groups seem to pursue an individualistic agenda, where grievances and mediation have become the priority over collective struggles. The difference between a trade union like Unison and an affluent, self-interested professional association like the BMA or BASW is increasingly hard to distinguish. The above example of the contracts dispute is telling; whilst most of the workers had consulted their rep separately, none of them seemed to have discussed the dispute with each other, and the workplace rep hadn’t tried to make contact with the rest of the workforce. The dispute was treated as a string of individual grievances rather than a collective struggle, and this probably sheds light as to why organisations like Unison have failed to keep the floundering social work profession afloat.
The story is different altogether for unqualified social care workers in the provider companies. For care assistants and support workers, the crisis is more practical than principle. NHS and local authority workers enjoy a certain degree of stability and protection in their terms and pay that private sector staff do not have. The social care sector employs a proportionately higher amount of unqualified staff than the medical sector; as well as being underpaid and over-worked, these workers are frequently demoralised by the lack of recognition that their work receives in comparison to their opposite numbers in the NHS. As mentioned above, home care workers in particular suffer from horrendous working conditions. Whilst their work is undeniably skilled and valuable, the pay they receive is often minimum wage or fractionally above, and the lack of paid travel time or paid breaks eat into their take-home wages.
For unqualified private sector workers, organising is particularly difficult. The social care sector makes wide use of temporary employment and ‘bank’ workers on zero-hour contracts. A large portion of the workforce is made up of agency who find themselves never in one place long enough to put down roots and begin networking. Community-based staff, like home care workers and support workers, often lone-work, meaning they can go days or weeks at a time without ever speaking to a colleague and all interactions between staff are policed by management. Long hours and poor pay also lead to high staff turnovers, which is a further block to effective organizing. There is no union, registering body or professional association to represent care workers, care assistants or support workers. This is very little media attention given to the work they do, and much of their efforts take place in private homes or behind the locked doors of a care home, away from the public eye. Among many co-workers that I have spoken to, there is a general feeling that the wider world doesn’t know that they exist.
 These tend to be more affluent workers with degree -level or above qualifications; doctors are the obvious example but social workers, registered nurses, psychologists, midwives and a host of others would also fall into the same category.
 See http://www.communitycare.co.uk/2015/12/16/wasnt-able-give-clients-needed-broke/ or http://www.communitycare.co.uk/2015/12/16/feel-frustrated-lack-value-placed-work/ for examples of worker’s testimonies
 A wildcat strike or similar action would undoubtedly provide this pretext; if the worker isn’t working then the patient isn’t receiving care, so by implication any act of sabotage or unofficial strike could be seen as an act of neglect. This is why the striking doctors were so keen to stress to the press that hospitals would run a ‘Christmas day service’ during the strike; if wards had had to close, the striking doctors would probably have been struck off and sacked.
 See http://www.telegraph.co.uk/culture/tvandradio/bbc/8927036/Jeremy-Clarkson-execute-public-sector-workers-says-BBC-Top-Gear-host.html or http://www.express.co.uk/news/uk/516794/Midwives-vote-strike-over-pay-putting-pregnant-women-risk
 For an overview of what ‘radical’ social work actually is, see http://www.socialworkfuture.org/articles-resources/uk-articles/77-radical-social-work-practice-adults. I am sceptical of this article’s conclusions that ‘radical social work is retrievable in today’s context if it is able to rediscover its humanistic roots’, it’s hard to treat people as human beings whilst simultaneously locking them up in psychiatric wards or taking away their children. Unfortunately, treating people like cattle or naughty children is cheaper and quicker than treating them like human beings, and in the current climate, this is all social workers are permitted to do.
 I was once employed by a company that wouldn’t allow staff to have each other’s phone numbers