The first part of this article aimed to address the practical problems for healthcare workers’ self organisation, and the relationship between workers, managers and policy makers. The second part of this article will go on to address the ethical implications of healthcare worker’s self organisation, and the relationships workers have with each other and with patients.
The healthcare industry is characterised by division. It is split between public sector and private sector, and health and social care. There are often clannish tensions and rivalries between different groups of professionals and workers. It is difficult to formulate industrial strategies for one sector that would be transferable to others. The different sectors of the industry frequently blur and overlap, meaning that workers in the same workplace or team often work for different employers, which makes fighting collective struggles difficult. Overcoming the divisions in the sector is likely to be essential for successful organising.
Divisions among workers
The healthcare industry has previously been organized on trade or craft union lines; with separate organising bodies for doctors, nurses, midwives etc and no representation at all for the unqualified staff at the bottom. Deeper social issues around class and gender, and material differences in pay and conditions, creates a rigid, almost feudal hierarchy among workers with senior consultants at the top, social workers and nurses in the middle and unqualified support workers and HCA’s at the bottom. The differences in terms between registered, salaried professionals and unregistered waged care and support staff give them little common ground from which to organise, and this segregates workers and blocks the potential for a multilateral, industrial union in which all workers are included.
A multilateral union may not be a desirable means of organising when there are such stark class differences between workers in the industry; collective struggle is a difficult concept to apply when some workers earn drastically more than others. Whilst all workers will have their grievances, those who have done well out of the system are unlikely to want to change or end it, so it may be that white-collar professionals prove to be unreliable allies for more militant workers lower down the pay scale.. High-paid professionals may fight their own battles but be unwilling to fight the battles of those whose work they see as less important than their own or, where doctors and social workers do show support for cleaners, porters and care assistants, their concern may be driven by altruism and charity rather than a genuine sense of solidarity and shared struggle. High-paid workers, senior staff members and bureaucrats, whilst still being waged workers, are just as likely to water down radical action as to get behind it.
This class division is felt acutely on the ward; I’ve sat through endless multi-disciplinary meetings and ward rounds where doctors act as if they are holding court. Middle-income professionals like nurses and social workers attempt to mediate, and any care workers lucky enough to be invited contribute little and speak only when spoken to. This is not only characteristic of the relationships between workers in the industry but also allegorical of the wider class divisions in British society. The privileged position of the educated professionals can’t just be put down to superior knowledge but to greater self-confidence and a sense of entitlement that predisposes them to dominate their working class colleagues. There is no reason to suspect a care worker’s union wouldn’t be dominated by the best paid staff, in the same way that a workplace meeting is.
Gender divisions are also stark among social care workers. The health and social care industry employs far more women than men. Women tend to be over-represented in the lowest paid roles and under represented among the highest-paid professionals and management. My social work degree program had roughly 90% female students but only about 40% female lecturers, showing that even where women are an overall majority), they are excluded from the more lucrative positions. In fact, the healthcare industry is one of the most glaring examples of the inherent sexism of the capitalist labour market; the devaluing of care work, nursing and midwifery undeniably stems from the perception of these jobs as being ‘women’s jobs’, and therefore by implication unskilled and trivial. Any social movement built from the healthcare industry will be to a large extent a women’s movement, and hampered by sexism and institutional discrimination as a result.
Healthcare is an industry made up of women, built on women’s labour but ruled and governed by men. When it comes to organising, it must be pointed out that male workers won’t necessarily be immune from structural sexism just because they claim to be radicals, so a worker’s organisation may well fall foul of the same gendered disempowerment that exists within the wider workforce, with a minority of men in key positions able to control the actions of an organisation with a majority of women as members. Historically, sexism within the union movement and the unequal distribution of labour in the workplace and home meant that the worker’s movement largely failed to represent working class women at all. Any worker’s organisation in such a setting will need to give serious thought to the question of gender, to avoid falling into the same patriarchal pitfalls.
Healthcare isn’t like other industries. Although there is no production of goods, working in care can’t be said to be a ‘bullshit’ job in the same way as other service sector work often is. The standard tertiary sector model, in which services are provided to consumers, doesn’t seem to fit in an industry where the ‘service’ is of life and death importance and the ‘consumers’ rarely choose to be there in the first place. Despite the above, workers frequently take a great deal of pride in their work, and many feel understandably torn between standing up to their managers and doing right by their patients. Even for the most disillusioned of workers is likely to feel bound by a duty of care, and simply downing tools isn’t always an option when people depend on your labour for their quality of life. Essentially, what separates care work from work in other industries isn’t the relationship between workers and owners, but the relationship between workers and patients.
Part of the pressure of the job is the emotionally strenuous nature of the work; healthcare workers have disproportionately high rates of depression, stress and suicide, partly due to the horrendous things that most of us witness as an inevitable part of our jobs. Job security, recognition and a fair salary all help to insulate workers against the stressful nature of the job, but this is something granted to only a fraction of healthcare workers. Care assistants and support workers are exposed to injury, poverty, disability and death just as often as doctors and therapists are, and this can be a difficult burden to bear for workers who already feel undervalued, and when combined with the day to day stresses of earning below the living wage.
In talking to colleagues, I found that nearly everyone I worked with was dissatisfied, stressed and close to burning out or giving up. Typically, workers in the lowest paid private sector roles would say that the only reason they did the job in the first place was because of their commitment to the patients. The relationship felt more personal than professional at times; workers (especially lone-workers) often seemed to forget that they were employed in a business, that they were under-paid, managed and exploited, seeing instead only the patient and the necessity of the care that they needed to do. This was exacerbated by the nature of care work in a for-profit sector; financial transaction and budgets are agreed by staff behind closed doors, often working for a local authority or another separate agency which the worker on the front line may know very little about. Many private sector companies are also owned by other, larger agencies who the workers may know very little about other than the name on the pay slip. The capitalist element of the industry is removed from the worker and kept out of sight. In this context, where the entirety of the job becomes about patient care and the profit-making apparatus are almost invisible, it was nearly impossible to talk about striking or industrial action.
This ‘doing it for the patients’ attitude seemed to be endemic amongst the lowest paid, private sector care workers. Almost every conversation I had ended on this note. Workers at times would show a great deal of fighting spirit if they thought that management were causing harm to patients. On one occasion myself and a group of other workers sent a co-written letter to CQC, the care regulating body, identifying potential patient abuse which we thought the managers were complicit in. In doing this in a group, we ensured our anonymity would be protected and that management wouldn’t be able to punish us for whistleblowing. In this case, the level of anger that my co-workers seemed to feel was promising. In this instance, though, we were fighting for others, not for ourselves. The same group of guilt-ridden, stressed and undervalued care workers would have been unlikely to stand up for their own rights with the same passion and self-confidence.
Healthcare workers often find themselves trapped in a double bind, under pressure not only from the demands of management but also from the much more real demands of the patients themselves, whose lives depend on the performance and attitudes of staff. This double bind creates a serious problem for workplace organising; very few care workers would be willing to undertake a wildcat strike if it meant leaving a ward unattended or a patient without vital care. As mentioned above, doing so could expose the worker to allegations of abuse by management. R ight-wing attacks on striking healthcare workers also invariably use this trope. This is why large-scale actions like the junior doctor’s strike are so carefully stage-managed; it is doubtful that the BMA would have authorised a strike at all if essential care couldn’t be organised. In providing perfectly adequate cover during their strike, the BMA ensured almost no disruption to services and effectively rendered their strike pointless in the process. So whilst harming patients during a strike clearly isn’t an option, continuing normal service will not achieve goals as to do so poses no real inconvenience to management. And if strikes are difficult to organise in healthcare, protests and boycotts are even less viable, when so few patients or service users choose to use services in the first place. The idea of an emergency services patient boycotting an A&E department is basically ridiculous.
Managers in healthcare settings and the red top papers often recognize this double bind, and will exploit it to control workers. I have very strong memories of being at work in a private sector care home during a public sector strike. The news was on the radio, and my coworker’s attitudes to the strikers was sneering and disdainful. A common theme of the conversation was that the striking workers (many of whom were NHS nurses) were deserting their duty to the patients. At one point my manager chimed in, saying something like “can you imagine if you lot went on strike? Who would look after everyone here?” here, the ‘doing it for the patients’ attitude was clearly used as a stick to beat the workers with; a kind of inverted form of the divide and rule tactic, where healthcare worker’s sympathy and basic good nature towards working class patients is used to sap their revolutionary energy and allow managers to avoid justice.
Despite the attitude of the Right to striking care workers, worker’s and patient’s concerns about the withdrawal of essential services can’t be written off as simply reactionary, anti-strike rhetoric. Worker’s concerns are part of their role and their professional identity, and any worker’s organisation will need to allow for this. As mentioned above, workers are often more than happy to stand up to the bosses if they are doing so to protect patients. The BMA’s insistence that junior doctors were striking ‘for patient safety’ is perhaps another example of this.
Worker’s organisation should seek to harness this energy. Ultimately, the profit drive in healthcare contributes not only to greater exploitation of staff but to poorer care as well. Workers and patients able to look past day-to-day grievances should be able to find a common enemy in the capitalists at the top and their Department of Health lackeys. Peter Sedgwick made this point in his book Psychopolitics, saying; “When it comes to strike action in hospitals, employees nearly always take a ‘professional’, rather than ‘trade union’, view of their responsibilities and will not leave wards understaffed, even though, arguably, some shock action which places patients in jeopardy would be preferable to continued collaboration with a system which daily harms the sick through routine neglect.” Sedgwick’s point is a powerful one; where healthcare is run for profit not patients, it is collaboration, not resistance, which puts vulnerable people in danger.
Punching down and punching up
As compelling as this is, altruism is not a substitute for solidarity, and it is not entirely satisfactory to claim to be striking for the good of the patients when the patients themselves may feel otherwise. Solidarity between patients and workers is a difficult concept when one group is so obviously disempowered in relation to the other; one is paid and the other pays to be there, one works and the other has the work done to them, one gets to go home at night and the other stays indefinitely.
Worker’s good intentions can often turn to resentment if frustrated, and there is a dark side to the familial attitudes that staff typically feel towards patients. At times, workers caught in a double bind who are unable to challenge their managers will vent their anger on the patients instead.
For me, personally, as a worker, I’ve found this difficult to come to terms with and even more difficult to account for or explain. To give an example, in another home where I worked, night workers were made to work unpaid overtime after every shift, until every resident in the unit was out of bed, washed and dressed. Although the night shift was due to finish at 8am, we regularly wouldn’t leave until 9.30 or 10. Rather than complain to management, though, staff would criticise the patients themselves for being lazy and inconsiderate. Staff sometimes began waking residents up at 5 am in order to finish on time. On a few occasions I saw workers lying to patients about what the time was in order to get them out of bed, using bullying tactics to get residents out of bed when they didn’t want to, or simply ignoring the patients when they protested. Whilst staff had a right to be angry, because they took it out on the residents not the management, no criticism was ever made of the management for introducing this stupid policy in the first place. By doing this, the workers were denying not only their own right to be paid for their work, but also the patient’s right to make choices and run their own lives.
This is just one small example of how workers, when under pressure from management, will turn against patients. More generally, calls by the rightwing media to ease the crisis of funding in A&E units by banning certain patients were met with a great deal of support from nursing staff. Statistically, companies with poorly paid staff, high staff turnover and frequent reliance on agency workers are the most likely settings for patient abuse to occur. I’m reminded of Fran Ansley, the feminist thinker who explained domestic violence in the home by arguing that “When wives play their traditional role as takers of shit, they often absorb their husbands’ legitimate anger and frustration at their own powerlessness.” Poor treatment and abuse of patients seems to work in the same way. Workers who have no power except their power over patients will use that power to make themselves feel better. The only winners are the bosses.
Self-organised worker’s movements can be equally abusive. Peter Sedgwick gives scores of examples of what he termed ‘rightwing syndicalism’ among workers in the psychiatric sector. In the UK, healthcare workers’ unions frequently used strike action to demand the implementation of restrictive, draconian measures to control and coerce their patients, nominally in the name of worker’s ‘safety’. In Italy in the 1970s, Catholic and fascist-aligned nurse’s unions put a major obstacle in the way of the fledgling democratic psychiatry movement.
This reactionary unionism isn’t exclusive to the most exploited workers either; professional associations aren’t immune to self interest. Recently, less than a week after the junior doctor’s strike, two associations of doctors lent their support to proposals to end GP’s ‘fit note’ duties, and to put the responsibility for assessing the fitness to work of disabled ESA claimants solely in the hands of the DWP and its private sector minions in Maximus. The BMA will discuss these motions at its next conference. This is despite objection from disabled rights groups, who have campaigned relentlessly against the DWP’swork capabilities assessments, and the spate of recent suicides among ESA recipients linked to welfare cuts and particularly to the work capabilities assessments.
The above examples provide a good outline of what worker’s organisations should not do. Any movement to defend the rights of workers in the healthcare sector which ignores or tramples on the rights of patients will be a fundamentally reactionary and discriminatory organisation, no more deserving of support than the racist union bureaucrats of the 1960s TUC
The relationship between healthcare staff and their patients and service users is a complicated issue. To understand this debate fully we need to look away from acute medicine and into the fields of social care, disability and mental illness, where the question of who exactly is a ‘patient’ is a political question not just a medical one. Those considered by society as disabled are arguably the worst victims of the capitalist state that worker’s organizations claim to oppose; they are excluded from the labour market, ghettoised into institutions and left at the mercy of an increasingly fickle welfare state. A worker’s organization with a broad commitment to revolutionary change and not just to winning individual victories would need to acknowledge this.
Care workers undoubtedly hold power over patients, especially in fields like psychiatry and social care, where so many patients live in locked wards which they are not free to leave, and are coerced into accepting treatment in the interests of others not themselves. In these settings the caring role is as much a matter of controlling as curing. Many radical patient groups regard the entire healthcare system as an oppressive wing of the state, in which professionals and care workers are collaborators, to be treated with the same suspicion as the police and bailiffs.
Workers may find these views uncomfortable but we can’t simply write them off as inconvenient truths. Social workers in particular need to face up to the fact that, because of the state-endorsed power which we hold, many involuntary users of services will see us as the oppressor rather than the oppressed. If the healthcare industry is hierarchical then it is the patients, not the workers, who are at the bottom of the heap, and for a movement within the industry to be genuinely ‘bottom up’ and emancipatory, it would need to show solidarity with patients’ struggles, not to ignore them as an inconvenience.
A Patient’s Union?
There is no perfect solution to the problem of how autonomous healthcare workers should protect the rights of patients. Ignoring patient’s struggles is clearly not an option. Likewise, for worker’s organisations to altruistically champion patient’s causes by themselves is not a desirable solution. as to do this would be to enforce representation and hierarchy, to speak for patients and to deny them the right to speak for themselves. But allowing patients to join worker’s organisations is also problematic; the two factions would most likely have separate, sometimes conflicting, goals, and unless there was a majority of patients with an equal vote in the democratic process, the workers in the organisation would easily dominate the agenda and reduce the patient’s involvement to a merely tokenistic one. Above all, it is patronising to think that patients couldn’t organise themselves, or to assume that they would want to organise alongside professionals.
Self-organized patient’s groups working independently from professionals have a history in the UK which goes back hundreds of years, especially among psychiatric patients and the users of social care services who identify as Disabled. These range from Liberal and charitable groups like Mind to social justice activists like UPIAS and radical organizations like the Mental Patient’s Union. This tradition is alive and well in the present day; the Hearing Voices Network are one example of a patient-led mutual support and campaigning group that thrives independently from State or professional intervention, and activist groups like DPAC and the Black Triangle campaign have both been involved in anti-cuts action in recent years. A self-organized workers union would need to proactively work alongside patient’s groups, whilst respecting their independence and without taking over or dominating them. Whether the healthcare industry would allow for this to happen is debatable, but no other relationship between worker and patient is acceptable.
 See Selma James, ‘Women, the Unions and Work Or, What is Not to be Done’, 1972 available free at http://libcom.org/library/women-unions-work-or%E2%80%A6what-not-be-done
 For example http://www.telegraph.co.uk/news/nhs/12005176/Striking-junior-doctors-will-put-lives-at-risk-and-heres-why.html, and http://www.the-star.co.ke/news/2015/12/22/patient-dies-hundreds-in-danger-as-msambweni-nurses-strike_c1264472
 Taken from Psychopolitics by Peter Sedgwick, 1982
 See Peter Sedgwick, Psychopolitics, 1982.
 Democratic psychiatry was a movement which aimed to end the segregation of patients in warehouse-style asylums and instead introduce community care, with an emphasis on inclusion and patient’s rights. For a good introduction to the movement see “Reform said or done? The case of Emilia-Romagna within the Italian psychiatric context” by A Fioretti et al. 1997, or read an issue of Asylum magazinehttp://www.asylumonline.net/about-the-magazine/
 See Pam Jenkinson’s chapter in This is Madness: A Critical Look at Psychiatry and the Future of Mental Health Services, PCCS Books, 1999
 Social workers can legally detain people in psychiatric wards against their will. They are also central to the child protection system, which provides the legal framework for the state to remove children from their parents and put them into care.
 Again, see Pam Jenkinson in This is Madness: A Critical Look at Psychiatry and the Future of Mental Health Services, 1999