How the NHS Uses Precarity as a Weapon Against Worker Organising

Despite staff shortages, workers on different contracts in the NHS are being pitted against each other for shifts – a tactic designed to prevent them from organising effectively to improve conditions.

While some people spent the Covid crisis working from home and panic-buying toilet roll, life as a frontline worker for myself and other NHS staff carried on as usual. Despite a widespread fear of infection on the wards, for many of us, the option of stopping work was unimaginable—even if we got sick—because we couldn’t afford to.

Like all NHS bank workers, I had no guaranteed hours, but I managed to maintain a consistent level. The uncertainty of Covid-19 meant that a permanent contract would, however, have been preferable, giving me better job protection and peace of mind.

Like health services in many other countries including the US, Canada, Australia, and New Zealand, the NHS is experiencing staff shortages. Several enquiries have been made in an attempt to identify the causes of these shortages, highlighting factors common to other organisations such as short-term illness, poor work-life balance, and maternity leave.

Issues more specific to the NHS include problems with recruiting, retaining, and motivating trainees, graduates, and current employees. During the Covid-19 crisis, the national volunteering push focused on asking people to help the NHS, which in part fed into to the service’s present reliance on agency and bank staff.

NHS bank staff work under conditions similar to ‘zero hours’ contracts, engaged in the workforce on a genuine ad-hoc basis. Their contracts are referred to as ‘bank contracts’ because they are used to create a bank of workers who can be called upon at short notice when staffing numbers and work pressures fluctuate.

Permanent NHS staff can also join the bank and work extra shifts in wards or elsewhere, usually at a higher rate than their hourly wage. But the higher rate for bank staff also comes with an obvious attendant precarity; bank workers are, for example, sometimes used by employers seeking to avoid giving formal employment status and prevent people from building up continuity.

Outside the NHS, zero hours contracts gained popularity in the late 1980s and 1990s. At the height of privatisation and outsourcing, zero hours contracts were perceived as an opportunity for flexibility and cost-saving. Today, they are inextricably linked to low-paid jobs and a lack of employment rights.

The NHS continues to fill staff shortages by spending almost £1.5 billion a year on temporary staff, including bank and agency workers to cope with shortages. Temporary staff supplied by agencies cost on average twenty percent more than those from the NHS’s own banks, despite doing the exact same job, but in the year 2017/18, spending on bank staff was higher than for agency for the first time in several years – a £528 million reduction in agency spend.

If the NHS was to fill its current temporary vacancies with workers from both the staff bank and agencies by offering them permanent contracts that encompassed flexibility, and full employment rights instead of outsourcing, it could free up £480 million to reinvest.

Bank contracts also pose problems in the form of the expectations placed on those working under them. Put simply, we know that we are not meant to be seen as full employees. This means that the NHS as an employer can take a neoliberal approach to how it delegates its hours for bank workers.

Today, in Britain, there exists no maximum shift length across all industries: worktime is calculated as hours-per-week, not hours-per-day. There is a cap of 48 hours of work in a week, taken as an average over seventeen weeks, as well as a mechanism for workers to opt to work more – one at risk of abuse by coercive employers.

Most bank workers in the NHS choose to opt-out of the 48-hour weekly limit to make a decent wage: with the nature of NHS work and lack of guaranteed shifts, why wouldn’t you? While this is perfectly legal, it only exacerbates the issues highlighted before for permanent staff, such a poor work-life balance, which inevitably leads back to the same issue the NHS is trying to avoid – staff shortages.

These employment issues cannot be individualised or separated from one another: they’re all part of a much larger scheme. Certain rights like paid annual leave and paid training days might be available for some bank workers, but very few people are able to take advantage of them, usually because they don’t know they exist.

Most trade unions today that represent the interests of temporary workers operate under the fundamental principle of collective bargaining. A sense of community can be the foundation to establishing a strong tool for organisers, meaning it’s often in the interests of employers to foster an atmosphere of mistrust and competition between workers.

This, in my experience, is what is happening to temporary staff in the NHS. There appear to be more than enough available shifts due to staff shortages mentioned, but these are given as a priority either to permanent staff with better job security, or sometimes, to the bank staff who have good relationships with those organising rotas.

The result is that even booked shifts can sometimes be cancelled and given to someone else. Bank workers have no protection against this uncertainty: awareness is, at present, our only real power. Such dynamics can also result in tensions between permanent and bank staff due to both unreliability and pay discrepancies, despite the fact that we all share concerns about the increasingly challenging working conditions within the Health Service and could benefit from mutual organising. These are the challenges we face.

The increasingly tight grip of the managerial class over the NHS means that these problems are being used to control bank workers, and to perpetuate harmful forms of precarious work. These managers are not unaware of the potential strength of worker power.

What this means is that while fighting defensive positions against the growing abuse of NHS workers—for example, in the form of the laughable three percent pay increase for NHS staff after a year of catastrophe—we should also be thinking bigger about the world that we, as healthcare workers, would like to build; the world that we deserve.