How will you protect the patients if you’re on a picket line? I ask a nurse friend, somewhat anxiously. “It’s funny,” she muses. “We are too important to strike; but not important enough to be properly paid.” As Britain heads into a winter of discontent, nurses who worked tirelessly through the pandemic deserve a hearing more than any other public sector group. But it’s not only better pay they need. The NHS has failed them at every level.
The Royal College of Nursing is demanding pay rises of 5 per cent above inflation, which the government can’t afford. But nor can the country afford inaction. Cancer backlogs have reached all-time highs. Poor health has become a brake on economic growth.
The NHS now feels like a vast sinking ship, with staff retiring early or jumping off in frustration, patients facing long waits, and leaders struggling to plug the holes. A vicious cycle of stress and feeling undervalued is leading GPs to become locums and nurses to turn to agency work. “We can’t see the cavalry coming over the hill,” a former RCN president, Dame Anne Marie Rafferty, tells me: “only a mountain of work.”
The immediate challenge is to head off the strikes — and with more than just warm words. But ministers must also think about the system they want to see after inflation abates.
The government prioritised the lowest paid in the last deal. But it might be better to focus on those whose retention makes the greatest difference to whether patients live or die. Research shows these are the highly skilled, mid-ranking, experienced nurses — for whom agency nurses are not a substitute.
Yet the NHS doesn’t properly value that experience, because staff are trapped in a clunky pay system called Agenda for Change. This covers more than a million full-time equivalents working in a huge range of jobs, and across regions where the cost of living can vary widely. Since 2004, it has simplified pay negotiations, and underpinned a national career structure. But paying people according to their “band” does not distinguish between a nurse who is taking blood pressure in outpatients, for example, and one dealing with life or death in intensive care. It does not, in fact, do what it was created to do: deliver equal pay for equal work.
This is a classic example of how the NHS is often its own worst enemy. Good staff reach the top of their “band”, and can then only earn more by being promoted to a different job. But some great nurses want to keep doing what they do well. Instead of recognising and paying them for their experience, we hit them with higher national insurance and pension contributions once they start earning more than £35,000 a year.
Pay and pay structures must be improved. But so must the way the NHS treats nurses. A year ago, an RCN survey of its members found almost six in 10 were considering or planning to leave their post. The main reasons were feeling undervalued and pressured. I have spoken to nurses who have nowhere to get changed, nowhere to sit quietly and shed a tear — and who have to pay to use the hospital car park. The NHS is full of HR people parroting “values”, but riddled with bullying and harassment.
Ten years ago, when I wrote an independent review into junior nursing and care staff for the government, I concluded that the now commonplace 12-hour shifts seemed bad for both nurses and patients. I was told, including by the RCN, that nurses liked the arrangement, because they had more days off to look after their kids. Resigned to the status quo, no one was willing to step back and ask what was actually the right thing to do.
In health and care, studies show that the most dedicated staff are the ones who suffer most acutely from guilt and stress when they feel they cannot give good care. Professor James Buchan, a visiting fellow at the Health Foundation, says that the English NHS “stands out” from some other countries in its lack of stringency in safe staffing. Recent strikes in Australia, he says, were driven by a similar combination of fury over low pay and an urgent need to improve nurse to patient ratios. This is an important part of the RCN’s case. As it says, “nursing is not a heroic deed . . . [but] a safety critical profession”.
One person in government knows all this: chancellor Jeremy Hunt. As health secretary, he fought for safety in the NHS. He also proposed building affordable homes for nurses on spare public-sector land — long commutes and high rents are problems for the profession. The Treasury stopped him. Now as chancellor, he should return to the issue.
Why can’t we build homes for nurses? Why don’t we let nurses park their cars at work for free, and build proper canteens? Why can’t we reassure NHS staff that there is a better future? And why isn’t anyone in charge? The NHS is increasingly a mess of committees, recommendations and targets that run into the hundreds. That is not leadership — and it accentuates the feeling of insecurity among its staff.
It is a sign of how strongly nurses take their responsibilities that fewer than half of the hospital trusts in England have voted to strike. There will now be a row over the RCN ballot’s structure. But the bigger picture is that the government needs to set nursing on a stable path. There are logical reasons to stand firm on the existing 4.5 per cent pay offer: the value of pensions, comparisons with teachers and the private sector. But cold numbers don’t capture the anguish of people who worked tirelessly through the pandemic, many of whom now say they will stop doing the overtime on which the NHS has relied. They need hope.
camilla.cavendish@ft.com
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