In the world of politics, September 2014 was a fascinating month for the UK, not least because the people of Scotland voted in a referendum to determine their future identity as a nation. Of great interest to midwives, and equally momentous in my view, was the Royal College of Midwives’ (RCM's) decision to formally ballot 26 000 midwives and maternity support workers members, for their opinion concerning potential industrial action over issues of pay. At the time of writing this column, many midwives have engaged in the first strike ever organised by the RCM in the 133 years it has existed. The pre-strike polling process constituted a legal requirement for trade unions when they engage in any activity that considers asking their members to break employment contractual obligations (1992). The overwhelming majority verdict, as advocated by the RCM, cemented an unprecedented decision by our profession to take action in order to address pay grievances with this current Government.
The case for industrial action
The RCM has of course not taken this stance lightly and felt compelled to ask its 42 000 members this question in response to the Government's intention to withdraw from a previously agreed pay deal of 1% for all NHS staff. The annual NHS pay award, calculated in relation to the cost of living, has been effectively frozen since the global economic crisis arose in 2010. However, many midwives will have experienced pay rises over this period, commensurate with their assessed competency levels in respective pay scales. Whatever way the number crunching is analysed, it is difficult to conclude anything other than that the real value of midwives’ wages has indeed fallen since 2010. This phenomenon is due to the combination of midwives’ salaries growing very slowly over the past decade by historical standards and consumer price inflation remaining persistently high in recent years. Clearly the actions of the RCM have arisen to reflect the considerable frustration currently experienced by maternity workers over the matter of their salaries.
Given that persuasive evidence suggests falling wages have a ‘severe impact’ on workforce morale (Kube et al, 2010), the question arises as to how the Government justifies the decision to renege on their agreed 1% pay uplift? This behaviour is especially confounding given that the pay proposal was supported by the independent NHS Pay Review Body in its report to Parliament in March (NHSPRB, 2014). Clearly, the Government perceives that the economic problems currently facing the UK reduces their capacity to implement previously agreed pay increases. The principle cause of their drastic action emanates from the huge ‘budget deficit’ that has been accruing in recent years and in 2012–2013 cost the Government £53 billion in debt interest payments alone.
The political context of health care costs
The NHS is frequently characterised as a costly, inefficient service that the UK is privileged to receive. Staff, including midwives, are endlessly exhorted to perpetually improve the cost of services by increasing their ‘productivity’. Yet this culture of endless efficiency has been present for decades, well before the current economic crisis. It was particularly elevated in the early 2000s when the UK held a budget surplus for a number of years. Additionally, the ‘efficiency culture’ was especially cultivated following the decision to increase spending on the NHS. The increased health funding policy of New Labour was retrospectively justified because it brought UK health care spending in line with its European counterparts (Wanless, 2002). This had been recommended by Derek Wanless in a report for the Chancellor of the Exchequer that sought to ascertain what resources were required to provide an inclusive, quality public service based on need, as opposed to ability to pay (Wanless, 2002).
The Wanless report was significant because it assessed health care ‘outcomes’ (survival rates for cancer etc.) and ‘inputs’ (number of consultants), comparing these with European Union countries thereby demonstrating that the NHS had actually been underfunded for years. It also suggested that increasing demand, driven by rising public expectations, would create a costing gap between actual provision and expectations. Therefore, National Service Frameworks (NSFs) were introduced (DH, 1999) to ‘reduce the gap’, providing an objective assessment of the financial costs of implementing a quality service based on clinical consensus. Other more contemporary measures designed to control health service ‘outputs’ are located in Quality, Innovation, Productivity and Prevention (QIPP), measures and Key Performance Indicators (KPIs).
New Labour's NSFs marked the first wave of NHS reforms that principally arose as an attempt to control their significantly increased spending on the health service. Ham noted (2009) four credible reports by ‘independent’ think-tanks and statutory agencies, published in 2003, that offered an affirmative and even perspective on the Government's efforts at NHS reform. The Nuffield Trust's report (Leatherman and Sutherland, 2003), as an independent and comprehensive observer, was especially valuable. It was largely supported by the views within the Commission for Health Improvement (CHI, 2003), Audit Commission (AC, 2003) and The Kings Fund (2005).
However, 5 years later the second wave of NHS reform was more cautious. The Kings Fund reported positively (Thorlby and Maybin, 2007) noting increased staff and infrastructure, reduced waiting times for hospital and primary care. This was balanced against a rise in health care-associated infection and management deficits in one third of sectors. In conclusion, structural changes to the NHS had conferred little benefits to overall operation. In addition, the Kings fund review of NHS performance and funding (Wanless, 2007) highlighted that the high cost of new GP and consultant contracts resulted in no commensurate increase in NHS productivity. These calculations were supported by the Office for National Statistics (ONS, 2008). The King's Fund review also discussed public health as an issue where the government was not succeeding in certain areas, especially in relation to rising inequalities and obesity. The Wanless (2007) review findings were supported by the Nuffield Trust (Leatherman and Sutherland, 2003) but some findings were vehemently contested by certain members of the medical profession (Barer, 2010).
In essence, what the above demonstrates is that politics set the overarching cultural tone by which the NHS operates. This analysis helps to contextualise the problems facing the NHS today. The landscape and language of health care funding has fundamentally changed again under the Coalition Government. The process of privatisation, endorsed and legalised by this Government in the Health and Social Care Act (2012) was also rationalised in economic terms as necessary to increase ‘efficiency’. However, privatization of health services has never been conclusively proven to increase efficiency, despite many such systems existing throughout the world for comparison. For example Cuba is internationally recognised as having one of the most efficient, effective and egalitarian health care systems in the world (Hunter, 2008). All achieved without a profit and loss accounting vision.
Political dilemas facing midwives
So where does the above leave midwives facing the dilemma to strike or not in the current maternity services? I would suggest that our working landscape is more complex than the bleak political rhetoric of simple affordability that we are constantly subjected to, not just in the age of austerity. We are already part of an efficient and highly cost effective health care system when compared with other countries, most notably the USA—where commentators are often minded to describe the NHS as ‘socialist state medicine’. The issue of pay is important, regardless of financial realities and can be tackled in multiple ways. Many midwives have seen their pay downgraded since 2011 and this is both scandalous and psychologically harmful. Politics is also about how the government spends its money. If there really is no more money to add to NHS budget then maybe we could campaign for greater equality in our salaries, compared to Doctors and paramedics for example. Why exactly is our pay so poor compared to these professions, especially when some Doctors received substantial pay increases under New Labour that failed to deliver any service ‘efficiencies’. Perhaps we should try campaigning for more equitable pay structures in the NHS if campaigning for reinstatement of the 1% pay rise is ineffective. There may even be grounds for a legal appeal concerning midwives salaries, based upon gender inequalities in pay and the Sexual Discrimination Act. Now there's a thought…