Healthcare workers: where we stand-fighting on two fronts

Basic overview of the terrain that health workers defending their terms and conditions is being fought on; Fighting both their employers, as well as a supine and complicit trade union bureaucracy. Written by a Solidarity Federation/Anarchist Federation dual carder and Unison steward working in Healthcare.

UK health workers find themselves under the biggest attack on wages and terms and conditions in living memory.

The background to this are the long, slow moves to fragment the public health service into discreet trusts 1. These trusts are expected to compete on equal footing with other trusts, as well as private and third sector providers in a regulated marketplace. This has been rapidly accelerated by the passing of the recent Health and Social Care act 2012 2

Negotiations to introduce national pay and conditions were introduced in 1999 by the previous Labour administration and finally came into effect in 2004. This national pay agreement is known as ‘Agenda for Change’. It covers all members of staff excluding doctors, dentists and very senior managers. Previous to this job banding varied hugely and was based on the old Whitley Council system (introduced during in 1917 to placate growing demands for Workers’ control of industry and essentially unchanged since then). The NHS as a whole in England employs just under 1.5 million staff, making it by far the largest employer in the country.

Agenda for Change introduced an agreement where, at least in theory, job roles are all banded at a similar level irrespective of their geographical location. Pay is matched to the job rather than individual.

Within each pay band are a variable amount of spine points, at the end of each year’s service workers ascend to the next spine point. This proceeds until they have reached the top of the banding. 3 In addition to this there is the nationally negotiated annual pay award. Following an on-going commitment introduced in 2010 to freeze public sector pay, this currently stands at 0% for those earning over £21k, or a £250 flat rate rise if under. Factoring in inflation rises this is essentially a pay cut for nearly every worker in the NHS. 60% of NHS workers have yet to reach their final salary spine point, so in reality progression through these is the only thing helping keep wages stagnant, as opposed to falling, for a majority of workers.


As part of the current government’s commitment to austerity, plans were devised for top down attempts to break national pay agreements. These have been abandoned during the autumn budget statement in favour of leaving it to the market, though there remains behind the scenes a hand on the political tiller giving succour to trusts that chose to opt out. 4 A back door for pay flexibility was via the introduction of Foundation trusts under Labour. Foundation trusts have the theoretical right to opt out of national pay and conditions, though in practice only Southend University Hospital NHS Foundation Trust chose to do this. Up till now this remains the only trust currently outside Agenda for change. There have been attempts by individual trusts to opt out of this agreement, especially those burdened with crippling PFI debt repayments. These have been defeated at a local level, mainly due to the threat of employees gravitating towards the competing local trusts with better terms and conditions, something facilitated by the national agreement allowing employees to keep accrued salary progression. With this in mind a consortium of 20 healthcare trusts in the South West, dubbed the ‘pay cartel’, got together to collectively force through the slashing of workers’ terms and conditions. 5

In addition to this local agreements have been attacked. North Tees and Hartlepool NHS Foundation Trust which employs 5500 workers has instigated pay downgrading, with neighbouring trusts threatening similar action. 6

At the Mid Yorkshire NHS Trust are set to embark on a five day strike over similar plans to downgrade job roles. 7


Representatives of the approximately 20 trade unions who collectively bargain for workers within the NHS have been negotiating at length with the pay cartel. As it stands the deal on the table to “protect” Agenda for Change in England (Scotland and Wales are not affected) is:

1) Performance Related Pay to be introduced with exact implementation to be decided locally. (protected for the lowest paid worker, those in bands 1+2 and first 3 points of band 3). This is the major, major change here. Speaking to UCU members who have seen similar performance related pay in some universities, they inform me that this a form of gatekeeping that unsurprisingly this amounts to a major attack on their ability to earn this money. Unreasonable expectations or unsuitable criteria to set in place, where it can actually be logistically impossible to ever proceed up pay points.

Performance related pay is also currently being fought by teaching unions 8, so would possibly seem to represent the beginnings of a pay model for public sector workers.

2) The removal of preceptorship. This is a pay device that allows newly qualified registered nurses, midwives and allied health professionals to initially proceed at an accelerated rate through their pay points.

3) An agreement to accept strict sickness absence policies and the removal of any payments associated anti-social hour’s rate. This will inordinately affect all care giving staff, who are of course expected to provide a round the clock, 365 days a year service.

4) Staff on bands 8c, 8d and 9 to be placed on a ‘spot salary’. This translates as “pay as low as they think the market can bear”. Whilst these are management roles with the power to hire and fire and instigate structural change, they are also the pay bands responsible for deciding on pay and conditions. From a pragmatic point of view and being clear about the role of the market in this, opting them out of a national agreement is unlikely to engender a desire to fight for agenda for change if they themselves are already opted out of it.

Out of these 20 trade unions (number of healthcare workers they represent in brackets), GMB (30,000) and Unite (100,000) have the rejected the deal out of hand. Unite have explicitly said they are preparing for industrial action in the event of any opting out of Agenda for Change. Other unions have said they intend to accept them, but most including Unison (400,000) and Royal College of Nursing (380,000) are consulting their members with guidance to accept the measures. 9

These moves show that a majority of health trade bureaucracies to be utterly complicit in what amounts to a managed decline of a workers’ T&Cs. The industrial relations equivalent of, “we had to destroy the village in order to save it”. Even on their own terms Unison states that by agreeing with these proposals may still result in trusts continuing to seek to leave the national agreement.

“While there is no guarantee that agreeing to these proposals will hold 100% of trusts in England to AfC, the Health SGE believes these would hold the majority and will be consulting branches to get better information on this.” 10

However with guarantees for unions to have a consultative role in any job re-gradings, and to being involved with local performance related pay structures, the union will retain its primary representative function. When push comes to shove, this is the fundamental bottom line for unions. That is the right to represent workers, including the right to a “consultative role” even if that consultation leads to poor outcomes for their members. In fact we can see how important this role is, how it sees actions by its members as secondary to its own from in this passage, taken from the accompanying Unison consultation briefing (italics by author):

“Over the last year, a number of NHS trusts in England have tried to „break away‟ from Agenda for Change. Members in these trusts have had to organise, campaign and take industrial action to try and stop the employers reducing terms and conditions and moving to local contracts. If members reject these proposals it is likely that the number of these attacks would increase significantly, requiring more members to take action to defend their conditions.” 11

Of course Unison sells the removal of hard, fought T&Cs as a victory. If it can pass these changes it will accept them as the least worse option rather than risk the unpredictable nature of a demobilised rank and file organising initiative, that will be either sclerotic through underuse or even worse from their view point, has the potential to not be under the full control of the union. Unison made its playbook clear during the recent pensions’ dispute. Even with a mandate it did not risk anything more than tokenistic one day strike action. 12

So these moves are a clear attempt to gauge exactly how much the membership will take. Any union member in a branch organised enough to arrange this consultation would be advised to reject this slow erosion of T&Cs and stress the need to lay officers and fellow workers of the need for sustained industrial action to defeat them. If your trade union branch recommends these measures then it makes clear the need for all workers, clinical or administrative, on all kinds of contracts to organise and meet and organise outside the union where necessary.

The fight continues.