By Tony Hockley: The first nurses’ strike in December 2022 hit in the same week that the Shadow Health Secretary, Wes Streeting announced that he would not maintain the pretence that the NHS is “the envy of the world”, highlighting England’s dramatic failures in public health.

The strikes come at a time when the NHS is failing to fill 50,000 frontline nursing vacancies, after dramatic declines of investment in health visitors and community nurses, and with unprecedented levels of unmet health need. It is increasingly difficult to retain experienced nurses, particularly those with the highest skills, and a high proportion of nursing students leave even before graduation.

A sombre diagnosis

Deaths of surgical patients are 25 per cent higher in hospitals with the lowest staffing on wards. In the wake of COVID-19, the UK is still suffering excess mortality month after month. NHS hospitals in England are short-staffed and struggling to return to pre-pandemic levels of activity. Those who are admitted to hospital appear to have greater care needs than before and, therefore, stay in hospital longer. In addition, the failure to act on reform of social care means that many patients have nowhere adequate to go after a hospital stay.

These winter strikes are a desperate call for change by those frontline professionals who have stayed loyal to the NHS through very difficult times. This incredible loyalty to the concept of a “free” health system is part of the culture that led Mrs Thatcher’s chancellor Nigel Lawson to describe the NHS as “the closest thing to a national religion” in Britain.

If you cannot recruit and retain professionals, then you cannot provide safe and effective care

It seems ironic that despite rising workloads due to high levels of nurse vacancies and stress-related sickness, the persistence of unpaid overtime, and the imposition of real-terms pay cuts during a cost-of-living crisis, ministers have called for the profession to “be reasonable”. While health ministers pretend that there is a trade-off between “frontline NHS care” and pay, the reality is that pay is central to patient care and to the dangerous state of the NHS. If you cannot recruit and retain professionals (mostly nurses) then you cannot provide safe and effective care, nor can you innovate and deliver the clinical research behind Britain’s “science superpower” ambitions.

Success starts with staff

Britain has tried to buck the market in staff for decades, with inevitable and unacceptable consequences. It is particularly strange that Conservative ministers seem the least able to appreciate the power of market realities for a healthcare workforce. They readily embark on new pet projects and reforms, whatever the budget constraint, with little apparent regard for the impact on the daily challenge of frontline care.

Without the right staff, waiting list targets will only be achieved by compromising care

The Francis Report on excess deaths at Mid-Staffordshire NHS Foundation Trust hit home on this point: “Finances and targets were often given priority without considering the impact on the quality of care”. Ministers pointing to somewhat niche waiting list data on 18-month elective waits as a totem of success, whilst ignoring an exodus of frontline professionals, illustrates the absence of the necessary strategic change. Without the right staff, waiting list targets will only be achieved by compromising care (as occurred in the past).

One of the most basic lessons for any student of health policy is that healthcare is, above all else, about staffing. Staff costs account for around 65 per cent of a health provider’s operating costs. Governments may be alarmed at the size of the pay bill in Britain’s state-run health system, but it is their primary investment in health on which all other investments rest. For all the talk about biotech medicine, advanced diagnostics and “new hospitals”, none of it works without appropriate qualified nurses. The more health technology advances, the more health systems need to hold on to their best and brightest.

Busting myths for better policy

Four myths underpin the prevalent political culture with regard to health staffing:

The first is that there is a trade-off between pay and frontline care. Frontline care is a product of NHS pay. This is particularly true in a tight labour market, when it is easy to leave the NHS, not just for better pay, but also for better conditions and work satisfaction. Scouring the world in search of qualified staff, paying agency rates for temporary staff, replacing record numbers of leavers, and hiking training places are not cheap activities. It is cheaper (and safer) to run a service that retains its best staff, not a service in constant churn. There is little point spending more on training if you cannot retain those trainees.

The second myth is that maintaining the pay rates of NHS frontline staff relative to the private sector will lock in inflation. Across the board, the current drivers of inflation are not income-related. Pay is lagging commodity prices. After several years of real-terms NHS pay cuts and a growing relative pay gap, the Treasury’s incomes policy has clearly reached the end of its viability. To minimise the damage, this must be caught up sooner rather than later.

The third myth is that the NHS can rely on the vocational commitment of nurses, paramedics and other providers, to stick with it through a period of declining real pay and rising work pressures. Thankfully the NHS today is staffed by professionals capable of managing the complexities of modern healthcare. Since the 1990s, nursing has been transformed into a graduate profession and ambulances are now staffed by trained paramedics.

In his influential 1990s work on public service motivation, Professor Julian Le Grand argued that it would be wrong-headed to believe that public services are staffed wholly by altruistic “knights”, rather than egoistic “knaves”. This belief in public service knights creates a culture that implicitly supports low pay through reliance on “intrinsic motivation”.

The final myth is that the problem is solved by the independent Pay Review Bodies. The turmoil of late 2022 made the Pay Review Body report of July 2022 look dated within months. In Autumn 2021, the Review Body was told that some 28 per cent of NHS HR Directors supported an award of more than 5 per cent. By March 2022, NHS providers argued that this would have risen.

The Review Body itself lamented the delay in the process, particularly the fact that due to delayed government submissions, NHS budgets were fixed before it came to its conclusion. Timing artificially fixed the definition of “affordability” within its remit. The Government determines that remit and is rightly accused of “hiding behind the Review Body”. The tail was wagging the dog. Perhaps the promised “independently verified” Workforce Plan will bring about a situation in which the budget is determined by the workforce required to deliver policy plans and not vice versa?

No recovery without safe staffing

With patient safety jeopardised on a daily basis following decades of staffing squeezes, the strikes seem a regrettable but necessary last resort.

The Pay Review Body asked that staff be paid for their overtime and called for more evidence to support wide use of Retention Premia Payments and Recruitment Premia Payments. It also noted a surprising lack of evidence on the reasons for staff leaving (suggesting disturbing levels of NHS employers’ indifference). Ministers can and should act on all of these aspects to start making a difference on retention and breaking the impasse.

The exit of frontline professionals, the inability to replace them, and the current appeals by those who remain need to bring an urgent rethink

It may be hard for a Conservative government to recognise that pay is a major component of an effective health system, and to ease back on one of the only levers it (falsely) believes it has over current inflationary pressures in the economy. It is important, however, to appreciate when an attempt to buck the market has come to its predictable end. The exit of frontline professionals, the inability to replace them, and the current appeals by those who remain need to bring an urgent rethink. The door is only truly open when it is open to talks about pay.