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The government certainly has its own agenda for the NHS — privatisation and anarchy. The question is, what is the agenda for those who work in the service?

What next for workers in the National Health Service?

WORKERS, JUNE 2005 ISSUE

The newly elected Labour government has its agenda for the health service, much of it unwelcome to health service workers. It has its origin in Tory policies — the Private Finance Initiative; Foundation Trusts; Value for Money; Independent Treatment Centres and finally, perhaps, abolition of Strategic Health Authorities. There is also a kind of unity amongst the political parties about some of the basic ideas on the health service. For example, that whilst it should be free at the point of need, the service requires for efficiency that the profit motive be introduced, extended and given a place of high standing within it.

Policies
Those of us working in the health service have to ask, why can we not force our policies onto the political parties, rather than constantly reacting to policies from them? If we are to raise this question we should have an answer. What would our policies be which we would seek to have a government carry out?

This would be a refreshing debate indeed, provided it did not drift off into the fantasy land of blueprints for the future which bear no relation to reality. We need to challenge our current thinking: improve it, raise its level and think things that we would want to see carried out in our name.

First, there is the extremely important question of overseas recruitment of nursing and other staff in the NHS. UNISON has been at the forefront of several magnificent efforts literally to rescue health workers who have been brought to this country under false pretences then mercilessly exploited while here. But is it government policies, albeit unofficial, unwritten ones, which lead to this international market in labour? We are encouraged to believe not only that such economic migration is inevitable, but that we should welcome it as something from which we benefit. It is true that workers who originated in other countries have crucially helped shape the British health service. But we have to look a little further, beneath the surface.

Trading in labour power
Many international companies are making a fortune trading in labour power. Recently the Nursing & Midwifery Council struck off more than 80 nurses who had been fraudulently brought to Britain for this trans-national profit motive. When we say that we are opposed to private finance and the profit motive within the NHS, we should extend this principle to those companies making and seeking to make a fortune out of this merry-go-round of trading in skilled labour.

It is a merry-go-round: nurses being trained in countries abroad end up working in Britain, while many British trained nurses are now moving to better-paid jobs in North America and elsewhere. If one was really being cynical one might conclude that this movement of labour is being carried out in an attempt to keep wages to their lowest possible level.

Certainly the movement of labour provides organisational difficulties for trade unions in all countries, and it is heartening to see UNISON establishing contact with trade unions elsewhere.

We have to give far greater weight to our arguments, made already, that we are effectively denuding many developing countries of their most precious asset, skilled labour. It cannot be right for a country with allegedly the fourth largest economy in the world, Britain, to dispossess small African nations of more than half their trained nurses, not to mention the thousands who are drawn from other larger developing countries. While nobody has yet used these words, it is in a way a new kind of colonialism.

Perhaps if we were really to have an ethical recruitment policy we would say that nurses trained here either have to work in Britain or in a less developed economy rather than nurses trained here going into a more developed economy, usually the USA, and that we would take from no country with a shortage skilled nurses.

At present, the only country with such a policy in the world is Cuba, which exports nurses because there is a genuine surplus at home.

Food for thought
What of the structure of the NHS? While this is of importance, it is not something we should get bogged down in. We can and will organise ourselves in whatever structures there are, but it is important to know what is afoot. Structural changes have already been brought about on a large scale since 1997, and the fashion of permanent change instituted by the Thatcher regime has been continued by Blair's. Thus we have seen the creation of primary care trusts (PCTs) and are perhaps to see their rapid diminution in number. We have seen the creation of strategic health authorities (SHAs) from the previously existing districts, and are perhaps now to see an abolition of SHAs.

In particular, in London this raises for us the question of a possible single, London-wide health authority or health management body which would be coterminous with the Greater London Authority. While this would of course create problems for our members working in SHAs and also PCTs, there is a logic in returning to a London-wide administration of health which was pre-emptively thwarted by Thatcher's destruction of all London-wide bodies with the exception of the London Ambulance Service and the London Fire Brigade.

Agenda for Change provides a means to establish a London-wide forum with health employers. Moves to a more succinct London-wide administration of health would provide additional impetus to this development.

Agenda for Change
Agenda for Change is the name that has been given to the current transition in health workers' pay and terms and conditions. These are not changes to be implemented before moving on to the next project. Unions will never move away from pay and terms and conditions as the central reason for being.

There will be constant attempts to improve the wage rates which are attached to the pay bands; constant attention to new and more numerous job profiles; continuing support and assistance to union members developing the knowledge and skills needed to put more pay into members' pockets. Crucially this whole process must be used to recruit to union membership and organise the workforce.

There were many encouraging signs of recruitment to UNISON health branches during the early stages of Agenda for Change. There is now some evidence that this is tailing off and it is hard to see the reason why. Now more than ever we need to be saying to non-members that they should join in order to raise their terms and conditions even further.

There has been much debate over the years about the iniquity of Thatcher's anti-trade union legislation. But perhaps the most iniquitous anti-trade union legislation of all is much older — that which prevents gains obtained by trade unions being confined to trade union members alone. In other words, if Agenda for Change with all its benefits were only to apply to trade union members then we would see a queue round the block of people wishing to join. Especially after its roll-out.

This experience is particularly borne out in new workplaces in the NHS where there is no history of trade union organisation. There, we have run the gamut of employers and unscrupulous workers wanting all the benefits without dipping into their pockets. We have seen attempts to set up project boards with directly elected staff representatives rather than properly accredited union reps. We have seen attempts to stack management-chosen "staff representatives" on to job evaluation and job matching panels and have had to politely say sorry, Agenda for Change is ours. It was created by the trade unions for health workers, and those who are not prepared to contribute should not take a role in forming the future.

Unscrupulous workers as well as employers have to be confronted. Unfortunately, in times of progress such as Agenda for Change, it sometimes brings out the worst as well as the best in health workers. Take the example of a London Ambulance Service worker who as a result of the assimilated pay rates, new unsocial hours payments and high cost area supplements would be gaining a pay rise of around £6,000 a year, perhaps even higher, who has decided to leave the union because it would place his union subscriptions into the higher band.

We should not indulge in some misguided debate about holding subscription levels in order to prevent people from leaving. We need to take on these people and call them what they are - greedy. They have no place in trade unionism.

No set of terms and conditions lasts forever, and we know that Agenda for Change will be fought over just as the conditions provided by Whitley were. We also know, however, that strengthening our hand through trade union recruitment related to the roll-out of Agenda for Change is critical in strengthening our forces for the battles to come. While the job evaluation scheme is the best yet developed and is an excellent objective test of the relative merits of health workers' jobs, we can only guarantee that it will be implemented, as with health and safety legislation, in an organised workplace. Therefore it is our obligation to continue to recruit as it is our obligation to continue to breathe.

Asserting our interest
We have seen major advances since 1997, in most parts perhaps in spite of, rather than because of, any government intervention. What has happened is that we have been able to assert more of our interests than in the previous period. Certainly this is true of terms and conditions, although we have not won the battle in such important areas as foundation trusts and intermediate treatment centres. These latter are a particularly dangerous Trojan horse of private capital and we will no doubt see their growth.

Some practical questions for the future:

Never mind Thatcher or Alan Milburn, the only people that the NHS is really safe with is us, those who work within it. Only we can take responsibility for it.

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