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The Development of the Workforce in the NHS

The National Health Service was a major employer from its foundation in 1948. After nationalising Britain's voluntary and municipal hospitals, the National Health Service took over responsibility for 360,000 staff in England and Wales and a further 45,000 in Scotland. These included 9,000 full-time doctors (with thousands more consultants working in multiple part-time roles), 149,000 nurses and midwives (23,000 of whom were part-time), 128,000 ancillary staff (catering, laundry, cleaning and maintenance), 25,000 administrative and clerical staff, and 19,000 professional and technical staff, of whom the 2,800 physiotherapists, 1,600 laboratory technicians and 2,000 radiographers were the largest groups. This workforce would continue to grow throughout the 20th and 21st Centuries, overtaking the National Coal Board to become Britain's largest employer in 1961. By the end of the 1970s, the NHS had passed 1,000,000 staff and in 2015 was the world's firth largest work organisation with 1.7m.

The Workforce

The NHS has long had one of Britain's most varied workforces, with employees from a diverse range of backgrounds in terms of class, occupation, gender, race and nationality. In 1948 doctors were overwhelmingly men and from middle and upper class backgrounds, and were often privately educated. Nurses in general hospitals were usually women and generally from a mixture of middle and working class origins. Men constituted a significant minority of nurses but were largely concentrated in mental hospitals, where their role historically had been more associated with manual labour, particularly the physical control of the patients. Professional organisations like the Rcn tended to promote the idea that nurses were middle-class professionals, whilst trade unions encouraged nurses to see themselves as workers. Like nursing, ancillary tasks were also heavily gendered with portering and maintenance largely done by men, and laundry and cleaning largely women. Migration was a feature of the NHS workforce from the outset, with nursing in particular a popular job amongst young Irish women.

Increasing demand for health services led to a steady expansion in total staff numbers throughout the second half of the 20th Century and into the 21st century. However, NHS wage rates were usually comparatively low and hours often long and anti-social. Consequently under conditions of full employment in the 1950s and 1960s the NHS experienced regular recruitment crises in virtually all categories of staff, particularly doctors and nurses in some peripheral provincial areas. One solution adopted by health authorities was to encourage married nurses to return to the workforce part-time. In Britain, historically many nurses expected to leave work after getting married and into the 1960s senior nursing posts were disproportionately likely to held by unmarried women. Nurse training also had a very high drop out rate in part related to students leaving to get married (in addition to rejection by some of the strict discipline imposed on them). Part-time work brought many of these women back into the workforce and the NHS was a key site in the growth of this kind of work in post-war Britain, employing 65,000 part-time ancillary staff (mostly domestics) and 79,000 part-time nurses and midwives by 1967.

Alongside this rise in part-time work, hospitals increasingly looked overseas for staff, recruiting particularly heavily in Britain's colonies from the 1950s. By 1955, the Ministry of Health had official recruitment campaigns in 16 British colonies and former colonies. Expansion of the health service in the 1960s under Enoch Powell's Hospital Plan further stimulated NHS demand for foreign-born staff. Despite his racism, as health minister Powell saw overseas recruitment as a means by which to solve staff shortages and hold down wages in the NHS. In 1965, there were more than 3,000 Jamaican nurses working in British hospitals and in 1977, 12% of student nurses and midwives came from overseas, 66% of them from the Caribbean, with substantial numbers also coming from the Philippines, Mauritius and South Asia. Large numbers of ancillary staff also migrated to fill NHS vacancies. Doctors were also recruited from across Britain's colonies and former colonies, particularly from India, Pakistan, Bangladesh and Sri Lanka. Doctors born and qualified overseas constituted 31% of all doctors in 1971. Nurses and doctors recruited by the NHS were often marginalised in job allocation. Early nurse migrants were often forced to re-validate their qualifications on arrival in Britain and instructed to take the less academic State Enrolled Nurse (SEN) training, rather than the more prestigious State Registered Nurse (SRN) qualification. SENs had worse pay and fewer promotion prospects. Similarly, employment discrimination often meant South Asian doctors were forced into less desirable posts in run-down provincial hospitals.

The NHS was also a site of expansion in new categories of scientific and technical workers. In 1967, the service employed 31,000 professional and technical staff connected with diagnosis and treatment, including audiologists, biochemists, dietitians, more than 9000 laboratory technicians, occupational therapists, physicists, physiotherapists, psychologists and radiographers. This category of staff had more than doubled in size ten years later, rising to 64,700 people or 6.5% of the total workforce. Although at the start of the period many of these roles had largely informal career paths, with individuals sometimes recruited as assistants before training as technicians, from the 1970s onwards it became increasingly common for roles to have more formal training schemes and associated degree courses. Professional associations like the College of Occupational Therapists and the Association for Clinical Biochemistry and Laboratory Medicine became better organised and took a greater role both in regulating their professions and in collective bargaining with the Ministry of Health.

The 1980s saw further changes in the NHS' workforce. The Thatcher Government encouraged (and eventually forced) health authorities to put most ancillary services out for competitive tender, effectively outsourcing the jobs of those workers. This led to a substantial reduction in numbers from 250,000 in 1979 to just 90,000 in 1988. Those that remained were largely employed by private agencies and no longer subject to national agreements or trade union collective bargaining. For nurses, the introduction of Project 2000, meant that their professional now centre around degree courses run by universities rather than nurse training courses run by teaching hospitals. This effectively removed student nurses from hospital workforces and helped raise the status of the profession. Much of the physical labour done by student nurses was now passed to a new category of health worker, the Health Care Assistant, a role than mirrors that of "auxiliary nurses" in the early NHS. The status of General Practitioners as outside contractors was largely confirmed by the market-based reforms introduced by the Thatcher, Major and Blair governments. The working lives of Hospital Doctors changed from the 1970s onwards, as career paths and work patterns became increasingly formalised. Set rules on hours were introduced in the 1970s and refined in the 1980s and 1990s to dramatically reduce the number of hours junior doctors were expected to contribute.

Industrial Relations

1948-72

Between 1948 and 1972 the NHS largely remained free of strikes, but nevertheless did experience some other industrial disputes. The foundation of the service was opposed by many doctors, particularly general practitioners, who feared that a state medical service would reduce their independence. Doctors expressed this opposition through their their largest professional organisation, the British Medical Association, which held a number of ballots canvassing its members' (largely negative) opinions on arrangements for the new service. After a threat to boycott the new service, the BMA secured some concessions from Aneurin Bevan, the Minister of Health responsible for implementing the NHS Act. The BMA's intransigence did not stop the new health service coming in to being, but did secure the right to be paid on a "capitation" basis (per patient) rather than on a set salary. More importantly for doctors the government's concessions established the conventional wisdom in the Ministry of Health that changes to the NHS were impossible without the consent of the medical profession, effectively giving doctors a "medical veto". Winning consent from physicians remained a problem for Health Ministers, who faced regular complaints particularly over pay and in 1962 the government gave up control over doctors' pay to the independent Review Body on Doctors and Dentists Remuneration.

The first dispute involving nurses took place when student nurses opened their first NHS pay packets in July 1948. Despite having received a modest pay rise an increase in National Insurance contributions meant their take home pay had gone down. Outraged students at St. Mary's Hospital, Plaistow, organised a protest rally and a march, threatening to resign en masse if their demands for better pay, shorter hours and general improvements in conditions weren't met. The march made headlines but won few concessions from the Ministry of Health. Complaints from student nurses about poor conditions, long hours and low pay were common for much of the post-war period. Up to the 1970s student nurses were responsible for as much as 75% of the physical labour on hospital wards and were often subject to intense disciplinary regimes both on the wards and in their private lives. As late as the 1960s many student nurses lived in strictly-supervised hospital nurses' accommodation.

The conflicts of 1947-48 were not very representative of the prevailing industrial relations culture in the NHS. Despite recurrent complaints about low pay and long hours, NHS staff were not prone to outbreaks of collective protest in the 1950s and 1960s. With the exception of an overtime ban and work-to-rule by administrative staff in 1957, organised by NALGO, the NHS had no formal workplace conflict. Groups of miners, printers, dockers and car workers did stage a one-hour strike in solidarity with nurses' claims for pay increase in 1962, but the nurses' professional organisation the Royal College of Nursing repudiated their actions and generally preferred to trade on respectability rather than militancy. At that time the Rcn was reluctant to refer to itself as a trade union and nurses looking for more conventional workplace representation looked to COHSE and NUPE. The latter was generally strongest amongst ancillary staff and former amongst psychiatric nurses. Recognising the sensitive nature of hospital work both were remained cautious regarding industrial action in the NHS until the 1970s, fearing that advocating anything that might affect patients would drive away potential members. A combination of cautious organisations, staff who often saw their work as a vocation, and the domineering influence of doctors over the rest of the workforce, led to an "old colonial" system of industrial relations, structured largely by personal patronage and paternalism.

1972-1979

This largely broke down in the 1970s with unions like NUPE, COHSE and ASTMS recruiting large numbers of all categories of staff, and professional organisations like the RCN and BMA becoming more aggressive in collective bargaining. In December 1972, ancillary staff, the worst paid and most marginalised section of the workforce, organised mass demonstrations across the country with around 150,000 workers and supporters protesting poverty level wages. Action continued in March 1973 with ancillaries organising the NHS' first national strike. In the years to come other groups took action over similar issues, with nurses mounting a sustained campaign over pay in 1974, radiographers following suit in 1975 under the slogan "no raise, no rays". Doctors also took strike action in 1975, junior doctors walking out over long hours and pay for extra-time and consultants taking action in defence of their right to place their private patients in NHS beds.

Although strikes in the NHS remained rare, changes in everyday industrial relations were more profound. The NHS saw a significant expansion in the number of workplace representatives in this period, sometimes forcing managers to consider the views of sections of the workforce, like the ancillary staff, who they had long ignored. This sometimes caused conflict between different groups. The "pay beds" dispute pitched nurses and ancillaries, who opposed private practice, against consultants, the direct beneficiaries of private practice. Other aspects of the upsurge in workplace activism were less controversial and all categories of staff were active in lobbying central government for better funding. The second half of the 1970s also saw a series of campaigns aimed at saving local hospitals, some of which involved "work-ins" where staff took over hospitals and continued to provide services after authorities had shut them down. In November 1976, health workers took over Elizabeth Garrett Anderson Women's Hospital in 1976, saving it from closure. The occupation of Hounslow Hospital in 1977 was less successful with the local authority forcibly removing the patients after 2 months.

By the end of the 1970s, industrial relations in the NHS were widely considered to be in crisis, with poor management and inadequate personnel procedures causing endemic conflict in a substantial minority of hospitals. The participation of large numbers of health workers in the events of 1978-79 Winter of Discontent was one reflection of this. Ambulance drivers and ancillary staff were both involved in strikes over pay in January 1979, reducing 1,100 hospitals to emergency services only and causing widespread disruption to ambulance services.

1980-2010

As in other workplaces, industrial relations under the Thatcher Government continued to be conflictual. Successive Health Ministers looked to hold down pay in the public sector and to outsource ancillary staff where possible. Following the 1983 Griffiths Report, the NHS also tried to import a business model more similar to the private sector with professional managers taking control over cost control, reducing the power of the medical profession. There were disputes over all of these policies. In 1982 there was another conflict over pay restraint involving ancillaries and nurses. Campaigning by NUPE, COHSE and RCN won a interim pay rise for nurses who were also granted their own independent pay review body, like the doctors 20 years earlier. The status and pay for registered nurses subsequently tended to improve, particularly when nurse education was shifted to university degree courses under Project 2000 in 1986.

Ancillary staff, in contrast, were increasingly marginalised during the 1980s. The Conservative Government put pressure on health authorities to outsource their catering, cleaning, laundry and maintenance services to private companies. Trade unions fought these policies, in some cases successfully, but many hospital services finally ended up in private hands, sometimes with companies who refused to recognise trade unions. Outsourcing largely dissipated the influence trade unions had built up during the 1970s and towards the end of decade increasingly occupied many shop stewards in detailed negotiations over grading and contract details rather than recruitment and organising.

Doctors' relationship with the government deteriorated during the 1980s. The advance of managerialism under Griffiths irritated many doctors, previously accustomed to a dominant role in NHS governance. By 1989 doctors were extremely hostile to government reforms and were active in lobbying against the implementation of the 1989 government white paper, Working for Patients, which introduced an internal market to the NHS. Their defence of public ownership and opposition to market-based reforms marked a substantial shift from doctors' original opposition to the NHS, reflecting how far doctors' mindsets had changed with relation to state medicine.

Relations between the NHS and the government were generally much improved under the Blair Government. Substantial investment in staff and new facilities were appreciated by many nurses and doctors, although there were concerns about the introduction of private sector suppliers, the use of public-private partnerships to fund much investment and the development of a intensive culture of achievement targets. There was also no attempt to reverse the outsourcing of ancillary services, something health service unions linked to recurrent crises over hospital cleanliness.

2010-Present

The return of a Conservative-led government in 2010 coincided with another deterioration in industrial relations. The introduction of further private sector involvement in the 2012 Health and Social Care Act provoked mass demonstrations led by health workers, and some NHS workers also participated in a national strike over pay restraint in 2014. 2016 also saw major industrial action by junior doctors, protesting at the imposition of a new contract aiming to extend weekend working.