Should nurses strike?

Last weekend I ran an outreach workshop on Zoom for some local sixth formers. We finished with a discussion of whether it is morally acceptable for healthcare workers to go on strike. The group tasked with making the case against industrial action complained that their opponents’ assignment was easier. Like most of my undergraduates, they were instinctive utilitarians: unless healthcare workers had decent pay and working conditions, the sixth formers reasoned, the care provided would be suboptimal. They were too clever to be fobbed off by my suggestion that they invoke the Hippocratic oath; patients would be better off in the end, they argued.

The governing council of the Royal College of Nursing has voted to establish a £35 million strike fund to recompense lost earnings as NHS nurses prepare for the possibility of industrial action. After twelve months of tending to the 500,000 patients hospitalised with Covid-19, too often without adequate personal protective equipment, they have been offered a 1 per cent pay increase.

The health secretary, Matt Hancock, pointed out that other public sector workers’ pay has been frozen, as if that were something to draw attention to. The 1 per cent pay rise, he said, acknowledges the ‘incredible’ work nurses have done during the pandemic, which the government apparently values at about £3.50 per nurse per week; the price of a cup of coffee to caffeinate them through their next twelve-hour shift. Or not even that: with inflation now at 0.9 per cent and set to rise to 1.5 per cent this year, the offer amounts to a pay cut in real terms. Last year, people joked that a doorstep clap is not a pay rise. The crushing punch-line is that a pay rise isn’t a pay rise either.

Yet the argument that nurses are ‘healthcare heroes’ who deserve a pay rise for going ‘above and beyond’ during the pandemic should also be resisted. Decent pay shouldn’t be a prize for supererogatory acts. Nurses have long been underpaid, and their work has always been demanding and essential. Discourses of heroism are a poisoned chalice. ‘Heroism’ describes voluntary acts of undue risk or sacrifice. But nurses’ labour through the pandemic was not voluntary. They worked to pay their bills and put food on the table. If we ignore that fact, we may forget that they must be remunerated well enough to live comfortably. Many cannot. One in five nurses can’t pay their bills; almost a quarter rely on a second job. Staffing the front-line of an infectious, deadly outbreak demands bravery, but for most nurses it was never a choice: had it been, they might, understandably, have chosen not to. More than 150 nurses have died. The risk wasn’t inevitable either. The government put lives in danger through dilatory, fumbled mismanagement, and used healthcare workers as human shields to buy time as it hobbled haphazardly towards the last resort of vaccination coverage.

A year ago, when a distinction was made between keyworkers and others, when the gaps on supermarket shelves could be read, like Morse code, as a sign of what we could and could not do without, when the revolutionary concept of a ‘non-essential purchase’ was normalised, when community support groups sprang up to make sure the most vulnerable were safe and fed, I imagined that our relationship to labour and consumption might be poised to change. A year later, the lesson seems to have passed us by, along with so many others.

A report by the New Economics Foundation, written after the global financial crisis, examined the ‘social value’ of a range of professions. For every pound paid to those whose jobs involve caring for children, the equivalent of up to £9.50 of social benefit is generated. Hospital cleaners produce £10 of value for every pound they earn, and waste recycling workers £12. The work of city bankers, meanwhile, destroys £7 of social benefit for every pound they earn; advertising executives cost us £11, and tax accountants £47. We live in a society in which earnings are inversely correlated with social value.

Nursing is technical work: a range of finely tuned skills and a wealth of knowledge are deployed under pressured conditions. But it is also care work, characterised by the reproductive labour of making sure bodies endure from one day to the next, with their discomfort minimised and their basic needs met, and the affective labour of making patients feelcared for. The stakes are high. Errors can be fatal, while exemplary care can be something like love.

Care work extends into the paid sphere tasks that are performed in the private sphere without pay, usually by women. Rather than underwriting the argument that domestic work also deserves pay (as put forward by the International Wages for Housework campaign, founded by Selma James in the 1970s), this fact unfortunately means that care work is undervalued both in terms of status and remuneration, on the spurious grounds that anyone can do it and it’s often done for free. It has been shown that when women begin to prevail in previously male-dominated professions, pay plummets. Those wishing to explain away the gender pay gap sometimes claim that women choose low-paid jobs, but it’s more accurate to say that anything we touch turns to peanuts. Nine out of ten nurses are women (and around 40 per cent were born outside the UK, so the race pay gap plays a part too).

The cost of this undervaluing is more than society can afford. There were 40,000 nursing vacancies across the NHS at the start of the pandemic, and 36 per cent of nurses are now thinking of leaving the profession, 61 per cent of them because of inadequate pay. Staffing shortfalls lead to the employment of agency workers, which drains the cash-strapped NHS of around £2 billion a year. The New Economics Foundation report does not mention nursing, but even the most conservative estimate of the social value of 40,000 missing nurses is a sobering thought.

If nurses do strike, patient care will be temporarily jeopardised. That’s a regrettable side effect, but it may also be the remedy; strikes are supposed to lay bare the value of workers, to make invisible labour visible. And since industrial action is taken voluntarily in spite of risks to pay, job security, and the well-being of others, it’s also an act of heroism.