As NHS unions ballot for strike action, can they unite and avoid mistakes of past disputes?

Mark Boothroyd, Unite Branch Secretary Guys and St Tommy's writing in a personal capacity, analyses the build-up to NHS strike action and if the movement can learn from past mistakes.


Momentum for strike action has been developing across NHS unions over the past several months. Following the government’s below-inflation pay offer in June, all NHS unions have been preparing for industrial action ballots.

The crisis wracking the NHS is the main driver forcing unions in to action. The horrendous staff shortages, collapse in working conditions and terrible moral injury being caused to staff who are daily forced to provide substandard care to patient. The years of underinvestment, combined with the damage done by the pandemic is breaking the NHS and is forcing unions to respond.

There is also pressure on all unions to deliver after the failure to take action over the government’s derisory pay offer in 20/21 following the initial COVID wave, and the preceding abysmal three-year pay deal that unions agreed to in 2018.

Strike ballots

The Royal College of Nurses (RCN) is currently balloting members, due to close on November 2nd.

The Royal College of Midwives (RCM) held a consultation with members on industrial action; the turnout was 66%, with 75% wanting to be balloted for industrial action. The RCM will move to an industrial action ballot, with dates to be announced.

Unite held a consultative ballot from 8th August to 30th September. Turnout was 52% in Wales, with 74% in favour of strike action, in Scotland 77% voted in favour of strike action. In England, turnout was 37%, with 84% in favour of industrial action.

Unison is holding an industrial action ballot from 27 October – 25 November In England. Scotland’s ballot opened on October 3rd and closes on 31 October, and Northern Ireland’s ballot begins on 25 October and closes on 18 November. Unison is asking members to pledge Yes for the NHS.

The GMB held a consultative ballot and 87% of members voted in favour of strike action. Their industrial action ballot in England will run from 24 October – 29 November.

National vs Disaggregated ballots

The 2016 Trade Union Act has forced trade unions to improve their organising in order to meet the 50% threshold for legal strike action. In the NHS, where turnouts have historically always been low, several unions have already moved to disaggregated ballots.

This is where unions ballot their members by employer, rather than as a national block. This means that even if the turnout is nationally below 50%, individual branches which have reached over 50% turnout in their employer, can still take strike action.

Unite, UNISON, RCN and GMB are all holding disaggregated ballots. Unite moved to disaggregated ballots during the 20/21 pay campaign, however few branches reached the 50% threshold. This year, due to better organising work and new phone banking tools, many more Unite branches have reached the 50% threshold.

Unison has not run disaggregated ballots before in the health sector, and they have the largest industrial branches, so they will have the biggest challenge of getting enough turn out across a large diverse membership. The RCN in contrast also has large branches, however they are concentrated in the wards and nursing professions, making it easier to mobilise the membership for the vote.

All unions should be holding disaggregated ballots and committing resources to ensure as many workplaces as possible meet the 50% threshold. Even if only 20% of NHS workplace branches reach the threshold, this is enough to start industrial action. Other branches can be re-ballotted to try to get them to join the fight in the coming months, using the workers who are already taking action as inspiration.

Lack of campaigning and division

Ostensibly, there is a national campaign between most NHS unions for a pay rise for NHS staff. This #WithNHSStaff campaign was set up in February 2022 in order for unions to jointly campaign on the issue. This campaign has only really existed on social media and in regular meetings between the leadership of the health unions. Even though this campaign has been going on since February, nothing has been done on the ground or to form local campaigning groups in NHS workplaces.

Within a month of being formed, the campaign split over the issue of calling for a definite figure for a pay rise. The national officers of the unions agreed to call for an “above inflation pay rise” as part of the campaign. However the RCN trade union officials had not properly consulted the RCN council on this, and the RCN council rejected this formulation and instead called for inflation plus 5%.

This was criticised as breaking the unity of the campaign by the other unions in a joint statement.

The fact that the different unions could not agree on a figure for the 2022/23 pay claim gives a hint at the divisions between unions and speaks to deeper problems. That most members are largely unaware of this campaign’s existence speaks to the disconnect between union leadership and their members, and the inability of the former to organise the latter.

The RCN Council were correct to agree a figure; it is necessary to make our demands clear and concrete, and so workers know what they are fighting for. It also makes it harder for unions to sell members short if the government offers a below inflation deal.

None of the unions have done anything concrete to coordinate strike action or campaigning on ballots. This may change as more workplaces secure legal ballots, but the lack of work on this is worrying; the level of organisation and co-ordination needed to make strikes in the NHS both safe and impactful is huge, and the fact that it hasn’t begun yet raises questions as to how committed the union leadership are to making co-ordinated strikes happen. It may be up to NHS workers and trade unionists to drive this co-ordination from below.

Legacy of the 2017/18 pay deal

Some of the divisions between unions can be traced back to the events surrounding the 2017/18 pay deal and its aftermath.

In 2017 things looked promising for NHS workers. The RCN held their first consultative ballot of their members, and received a strong vote in favour, although turn out was low. This pressured then Health Secretary Jeremy Hunt to offer to scrap the pay freeze and 1% pay rise limits that had been in place since 2009.

All NHS unions agreed a joint pay claim and submitted it to the government and entered negotiations. This united approach successfully bypassed the Pay Review Body, and unions negotiated directly with the government.

Eventually an offer was made of a 3 year pay deal, of 6.5% over three years, combined with changes to the pay banding structure to shorten the time it took for staff to reach the top of their pay band.

The deal was bad, giving only 2% a year for three years to most staff who were at the top of their pay bands (over 50% of NHS staff are at the top of their pay band). The pay deal pushed some staff in to a higher pay bracket, so pension contributions increased and meant they actually lost money.

Given the recently imposed Trade Union Act and the new 50% turnout threshold, union leaders were sceptical that their members would turn out to vote, and so resigned themselves to accepting this terrible deal.

Most of union leaderships misrepresented the deal to members, taking a few isolated examples where changes to pay band structure and the fact pay would rise over the three years due to normal pay band increases, to say the deal was going to increase members pay by 14% to 25%. Unions either recommended acceptance of the deal, or took no position on the deal. Only the GMB rejected the deal.

A website, was used by all unions to share this misleading information with their members and encourage them to vote for the deal.

An example taken from the front of the website claims the deal would mean an NHS worker on £15,516 (band 2, point 2), would see a pay rise of 14% by the end of the three year pay deal, earning £18,005 (band 2, point 7). But existing pay for workers on band 2, point 7 in 2017 was already £17,978.

The pay deal meant an increase of only £27 pounds over 3 years for workers who were already at the top of band 2. Yet this was represented as a 14% increase!

With misleading information, hugely inflated pay rise figures and the union leaderships pushing for acceptance, a majority of union members voted for the pay deal. When NHS workers received their post-pay deal wages, lots were furious. Many saw only a negligible increase, or even a pay loss as pension contributions increased. Union members were furious with their unions for agreeing to the deal, and many quit their unions in disgust.

In the RCN, a group of members called an Emergency General Meeting and moved a motion of no confidence in the RCN Council over their handling of the pay deal. The entire council had to step down for their part in agreeing the bad pay deal. No other union suffered these sorts of repercussions. There were harsh words in regional and national committees and at national conferences, but no other union leadership was kicked out for their part in the terrible pay deal, which inflicted further below inflation pay rises on NHS staff.

The legacy of bad pay deal on the RCN is they feel pressured to deliver for members in a way other unions don’t. The RCN leadership knows the penalty that could be inflicted on them if they let down members again, and their leaders are unwilling to be tied in to an alliance with other health unions who may be more willing to sell a bad deal to members.

For unions like Unison (which runs the website), the lesson is the opposite; they are extremely reticent to put forward a concrete pay demand, or inflate members’ hopes, and want at all cost to avoid putting forward any concrete pay claim, lest it be hard to sell another below-inflation pay rise to members.

Co-ordinating strikes, avoiding being sold short

The most pressing issue is having as many health branches as possible reaching the 50% threshold over the coming weeks. Once the ballots are over, and we have an idea of how many workplaces can strike, then the question will be how we coordinate strike action, and guard against a sell out deal being agreed

A key demand within unions will be to convene meetings of all branches that achieved legal ballots, so their members can have a say in planning strike action. We shouldn’t accept the strike days being purely called by national trade union officials, who may not see the opportunities for unity that are present at workplace level.

Currently there are no national campaigning groups which bring together significant numbers of trade union activists from across health unions. The vast majority of union activists building these strike ballots are doing so just within their unions structures.

Organising some kind of cross-union co-ordinating body will be necessity, both for encouraging unity over practical issues like co-ordinating strike days and organising emergency cover, but also to provide a leadership organised from workplace activists, rather than trade union officials.

Officials will be under pressure to resolve the dispute as quickly as possible, and may be willing to accept deals that would be rejected if put to NHS trade unionists who have been doing the hard work of mobilising the membership for strikes, and realise how crucial it is that we score a resounding win in this dispute.

There is a danger that, when threatened with the reality of large strikes across the NHS, the government  agrees to an improved pay offer that either falls short of inflation, or that is not fully funded necessitating cuts in NHS services to raise NHS workers pay.

We can see the possibility of this first option with the improved pay offer the Scottish government has made following the ballots by NHS workers in Scotland. While below inflation, this rise is more than NHS workers have received for over a decade, amounting to 9 or 10% for the lowest paid staff.

Unions would have to put such an offer to members, with the risk that many accept this as it is a significant raise, without them having to take strike action. If this happened, the potential of this moment, with all unions seriously balloting for strike action, could be lost. It is crucial given the absolute crisis facing the NHS and the impact of the cost of living crisis, that NHS staff take strike action to show that they are willing to fight, and to secure a pay rise and increase in investment that will begin to repair the service and safeguard our livelihoods.

The other option of a large, but unfunded pay rise may be put forward by the Conservative government in England, as this fits with their agenda of attempting to pit NHS workers against patients. An unfunded, or only partially funded pay rise would force NHS trusts to find the money for the pay rise from their existing budgets, requiring Trust management to cut services and even sack some staff to fund a large pay rise.

This would create great fodder for the right-wing press who are already blaming poor patient care, soaring waiting lists and inability to be treated quickly on NHS staff not working hard enough, rather than the underfunding, understaffing and crippling workloads due to a decade of Conservative neglect of the NHS.

A regular, cross-union national meeting of NHS union reps and workplace activists who have organised the ballots could discuss co-ordinating strikes from the bottom up, could develop messaging to guard against the risk of strikes being sold short, and plan how to take the strikes forward in a united and combative fashion so we can secure what we need for our patients, staff, and the service.

Myself and other union reps are working to make this happen. Please get in touch if you are an NHS trade unionist and agree with what is written and would like to help.

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Mark Boothroyd is Unite Branch Secretary Guys and St Tommys.

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