The Big NHS Rip-Off

The battle lines for the NHS were re-drawn yesterday when Simon Stevens, the head of NHS England, waged war on private employment agencies. In an attempt to get more nurses on wards the NHS bill for agency labour is 1.8 billion, double what was budgeted. Apparently the NHS is officially being ripped off. In these flexible neo-liberal times, never has an employers’ association ever gone on record in favour of permanent contracts of employment.The title of this new column might sound a bit much. Although actual war has yet to be declared on the NHS, the battle for health is going on at a hospital near you. Over the coming months this column will look at what’s going on from the perspective of the people on the frontline. It’s not fairAs health inequalities become an everyday reality it gets harder to kick stuff under the public interest carpet. With the former chief economist of the World Bank on a book tour about the systemic failure of our economic system, you don't have to be Marx to think that a concentration of capital into 1% of the world’s population is bad news for our collective mental and physical health.The psychosocial consequence of not being able to access joined up health services is that people develop more complex and serious health problems, often ending up in A&E and police cells as a last resort.This is not just a problem for patients but also the people delivering that care. If you go to the frontline two things are obvious. Firstly that the distress of patients is, well, distressing and as demands go up on our health and social care systems so does the pressure placed on the people working in them. Secondly, that the compulsive drive for a 24/7 health system, combined with declining real wages and increased job insecurity then you don't have to be mad to work here but its extremely likely.  Precarious WorkOne of the things that’s almost always overlooked in the NHS debate is the experience of the people delivering these services.There are three rather obvious reasons for this. The first is that the reality of working life is very low down on the political food chain in a system that is dominated by politically set targets and appeals to managerial efficiency. Employment relations just have not been considered important in the debate so far.For example, the NHS’s own workforce database did not collect information about its internal labour agency - Bank staff - until November 2014. They still do not collect information on the number of external contract and agency workers providing NHS services nor, more importantly, whether it makes a difference to patient care.It means that the real financial cost of using externalised labour is actually not known. Liquid FearThe second reason is that the people delivering these services are just too scared to engage in the debate. When you work in a precarious job you are highly vulnerable to precarious states of mind, completely counterproductive for people employed to contain the anxieties of others. It is not just the migrant workers working as nurses for private employment agencies that feel insecure, it impacts everyone working in this system. Precarity is inclusive, with even senior clinicians on permanent contracts unwilling to join the ranks of the self-employed by raising patient safety concerns with management.The Francis reports offer us an insight into the crisis of care in the UK. Impossible health targets managed through command and control management and a stomach-churning rise in racism, whistleblowing and victimisation. According to the people working in it, the NHS runs on a ‘pervasive culture of fear’. This is a culture where nobody can afford to make mistakes and people manage workplace conflict by keeping their mouths shut.It means that people working in health and care are often disorientated by a sense of ‘liquid fear’. A world of work where distinctions between serious and less serious workplace problems can’t be made. The smallest mistake becomes the end of your career and you wake up bolt upright sweating at 3am wondering how you’re going to handle the next ‘informal’ chat with your line manager.This fear goes right up the management chain, with NHS leadership reduced to talking about the very evident financial crisis only from the safety of retirement.  Emotional WorkA third reason why so little is known about employment relations is because of the nature of the work. Caring for people is not like working in IT. Emotional work has never been highly valued in our society, reflected in the bad pay and the ease with which emotional workers are blamed for systemic failure. Billions of budget deficits get passed down through decentralising commissioning, politically set targets translated into work intensification, easier to blame a nurse than succumb to the anxiety of realising that our health and social care systems are failing.When people are scared at work it results in witch-hunts, whistleblowing and tribal warfare. A working culture where staff meetings become an exercise in the yes/no game of talking around the elephant in the room, that targets cannot be met safely.It is at this point that we are all being ripped off. Setting the battle linesWinning the war for healthcare means defending its boarders and choosing our battle lines. Although Stevens’ focus on the employment relationship is a massive opportunity to turn the debate into something meaningful, we don’t yet have a clear picture of what is actually happening on the frontline.This requires that we start where we actually are rather than where we’d like to be. It means being honest and realistic about what can be delivered which can only be determined if frontline workers and managers can talk about the realities of work without losing their jobs.Ultimately this rests on creating a ‘just’ culture where raising concerns is met with the respect it deserves and where people are not charged with fighting losing political battles. Stories from the FrontlineThis new column will look at the reality of our health and care systems from the perspective of the people on the frontline. Precarious work, bullying, racism, and working in teams this column will look realistically at where we stand.To do this we want you to send us your Stories from the Frontline. These will be treated with the respect they deserve - anonymously and with your permission - and used to help reframe the debate about health and social care.Submit your stories here. Today's blog is the first of a new column Battles on the NHS frontline: Stories from the vanguard of health and social care being produced for TheConversation.com about surviving work in health and social care.