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Jay Shackford
On the Picket Lines of Britain’s Shattered National Health Service
The N.H.S. is the country’s pride. But rolling strikes reveal a system in the midst of collapse.
By Sam Knight/The New Yorker
January 24, 2023
Last Wednesday, Kareen Gayle, a nurse in the emergency department of King’s College Hospital, in south London, finished her night shift and joined a picket line of about a hundred nurses, trade-union activists, and political supporters on the sidewalk outside. It was rush hour on the first morning of a two-day strike. Red London buses honked their support of the nurses’ homemade placards: “Coping? You’re joking”; “Patients aren’t dying cause nurses are striking. Nurses are striking cause patients are dying”; “N.H.S. Hero to Zero.” Ambulances leaving the hospital gates whooped their sirens. The nurses clapped. Three people banged on drums. Gayle has worked at King’s, which is one of London’s largest and busiest hospitals, for eighteen years—the last eight in the E.R. A single mother of four, she has the instantly healing nurse’s demeanor (deep kindness, zero bullshit) that is required in life’s worst moments. I asked her for an example of how the hospital was struggling at the moment. “We don’t have enough beds, for one,” she replied.
This winter, the Royal College of Nursing, which represents more than three hundred thousand nurses across the United Kingdom, has called the first large-scale strikes in its hundred-and-six-year history. (There was a smaller action in Northern Ireland in 2019.) The main reason is pay. Last March, the R.C.N. requested a pay increase of five per cent above inflation, which at the time was 7.5 per cent. So far, in England, the government has awarded National Health Service nurses a raise of only four per cent. Gayle told me that, if she works her usual shift pattern, her monthly paycheck covers her bills and then runs out after three days. (In December, food prices in the U.K. were 16.8 per cent higher than a year ago.) To stay afloat, she takes on extra shifts, sometimes working six nights a week in the E.R. Her youngest daughter is five. “Sometimes I feel so, so bad,” she said. “Because she says, ‘Mum, are you sleeping with me tonight?’ And I have to say, ‘Mummy has to go to work to pay the bills.’ It’s really sad because you’re missing out on so much.” Next to the permanent exhaustion of working on the wards, skipping breaks while needing to pee, the mood on the picket line was high. The morning was freezing and clear. A late-rising sun lit the tops of the hospital buildings gold.
“What do we want?” A union rep called.
“Fair pay!”
“When do want it?”
“Now!”
The drums banged. The chant subsided. Gayle breathed out quietly: “Let’s hope we get this raise. Oh, my God.”
Britain is a sea of strikes. There is a Web site, StrikeMap.org, where you can scan the country for picket lines—for train drivers, driving instructors, court staff, bus drivers. Forty-nine strikes in Sheffield. More than a hundred around Manchester. This week, paramedics and emergency dispatchers held their fourth stoppage in just over a month. Junior doctors are voting on whether to strike in March. Teachers are planning a series of walkouts next month. The unifying cause of the unrest is inflation— more than ten per cent in Britain—and, often, dispiriting changes to working conditions, usually related in some way to the pandemic. But, though the industrial action affecting the N.H.S. shares some of these grievances, it belongs in a category all of its own, for the risks that it poses to patients, the almost universal reverence in which Britain’s publicly funded health-care system is held, and the fact that the system seems to be falling apart.
Winter crises in the N.H.S. have been as regular as, well, winter for a decade or so. For years, it has been common for the news to fill, from December through to February, with dozens of hospitals declaring “black alerts”—in which they are overwhelmed with patients and have to divert new cases elsewhere. On the surface, the past few months have followed a familiar pattern. The country is in the grip of its first major flu outbreak since the pandemic. Add that to the long tail of covid and a frightening spread of strep-A infections last fall, which killed at least thirty children and alarmed millions of parents, and the system is stretched to capacity.
But a deeper malady is also at work. The unified structure of the N.H.S.—it employs more than 1.2 million people and has an annual budget of more than a hundred and fifty billion pounds—makes people in Britain think it is bigger and better-funded than it actually is. The U.K. has fewer doctors, nurses, hospital beds, M.R.I. units, and CT scanners per head of population than most of its European neighbors. According to the Health Foundation, a nonpartisan research organization, health spending per person in Britain ran eighteen per cent below the European average between 2010 and 2019—a period that coincided with the country’s Conservative-led austerity program, followed by Brexit. The legacy is a vast, and potentially unbridgeable, gap of investment and support for the N.H.S. “This is chickens coming home to roost,” Tim Gardner, a policy analyst at the foundation, told me. “The roots of the current emergency are in the political choices that have been made over the last decade and more.”
In N.H.S. jargon, the system was “running hot”—with chronic staffing problems, delayed repairs, old equipment, family doctors working fewer hours, and the rising demands of an aging population—for years before the pandemic. Three years on, some parts are barely functioning at all. In 2012, about ninety-five per cent of patients in England’s emergency rooms were treated within four hours. Now it is around two-thirds. Last month, the average waiting time for an ambulance for someone having a stroke or chest pains was ninety-three minutes—five times the target. More than seven million people in England—an eighth of the population—are on a waiting list for N.H.S. treatment, up from two and a half million a decade ago. Around one in seven people currently occupying a hospital bed are well enough to leave but don’t have anywhere (usually a care home for the elderly) to go. Every light is blinking red.
Outside King’s, a specialist nurse in the hospital’s cardiology department, who gave her name as Sophie, held up a sign that said “Rishi the Reaper”—a reference to Rishi Sunak, the country’s new Prime Minister. Sophie qualified as a nurse in 2016. “It’s the same shit year on year,” she said. “You go through peaks and troughs. Some days you go in and you’re, like, Nothing matters. I just need to get through the day, focus on the patients, if I stay late, if I don’t have a break. You just have to crack on. . . . Other days, you think, Actually, What am I—? Why am I doing this?”
During the pandemic, Sophie was redeployed to work in the I.C.U. “I had never looked after a tubed, intubated patient in my life,” she said. “Tell me that’s safe.” She took time off with anxiety because she was scared of killing patients. A fellow cardiology nurse stood next to her with a banner that read “Cause of death? Tory Cuts.” The ratio of nurses to patients in their department sometimes reached one to ten, instead of one to four. In some cases, the waiting time for an atrial-fibrillation ablation—a procedure to restore the heart’s normal rhythm—had grown from three months to a year and a half. I asked Sophie if there was any relief in going on strike, in being able to protest and make these problems known. “I don’t think anyone is, like, happy to be here,” she said. “I’m so worried about the amount of work we’ve got to go back to.”
The N.H.S. turns seventy-five this year. I came across a Panglossian article, published in the British Medical Journal, twenty-five years ago, at the dawn of Tony Blair’s Labour government, looking forward to this moment. “Today, unlike in 1998, the N.H.S. is almost wait-free,” the prophecy reads. “Whether by phone or internet, in hospitals or in community health centres, N.H.S. patients and their families can expect dignified, customised, and even cheerful responses from any N.H.S employee they encounter.” In the real 2023, the N.H.S. is more of an idea than a particularly good health service. It is the institution that makes most people—more than sixty per cent—proud to be British, and yet we are somewhat afraid to use it. A recent poll commissioned by the Times of London found that two-thirds of respondents found the N.H.S. currently “bad” and that eighty per cent thought it had deteriorated in the last five years. On a visit to the U.K. last week, Peter Thiel, the American billionaire software investor and a serial N.H.S antagonist, described the country’s relationship with its health-care model as a case of Stockholm syndrome.
“Everyone says the N.H.S. is the envy of the world,” Steve Brine, a Conservative Member of Parliament, who is the chair of the Health and Social Care Committee, told me. “But very few countries in the world copy it. ” That’s not to say that any serious British politicians, including Brine, would ever recommend getting rid of—or even radically altering—it. “There is limited political space to have that debate,” Brine said. In his three months in office, Sunak has been at pains, like every Prime Minister since Blair, to establish his pro-N.H.S. credentials. His father, Yashvir, was a family physician, and his mother, Usha, ran a pharmacy in Southampton, where Sunak grew up. Earlier this month, however, the Prime Minister, who has an estimated net worth of around seven hundred million pounds, primarily thanks to his marriage to Akshata Murty, an Indian tech heiress, managed to get in a tangle by refusing to deny that he uses private health care. “It’s not really relevant,” he told the BBC. “What’s relevant is the difference I can make to the country.”
Sunak’s response to the alarming condition of the N.H.S. (as of last fall, there were more than a hundred and thirty thousand vacancies across the service, around ten per cent of the workforce) has been pallid and vague. He has promised to cut waiting lists, as one of his five pledges for the New Year, and the government has committed two hundred million pounds in extra funding to improve “patient flow”—discharging patients out of hospitals in other settings. But there is no wider argument, or strategy, or hope. “It’s very hard to look at what has come out of government since October, last year, and be convinced that there is a credible plan for the recovery of the health service, or even a particular grip over the situation,” Gardner, the analyst, said. Without energetic reform, Brine didn’t see much changing, either. “If we continue on the trajectory of demand that we’ve got, with an aging population, it doesn’t take a genius to work out that things are going to continue as they are and get worse,” he said.
I caught a bus outside King’s and headed across London to University College Hospital, on the Euston Road. For many years, U.C.H. was my local hospital. It is where my children were born. It is where my mother went with chest pains, last spring, fearing she was having a heart attack. (It was only a scare.) There was a larger, noisier picket line outside the main entrance. A set of steps had been repurposed to make a stage for the nurses and their placards and their chant: “Claps don’t pay the bills,” a reference to the weekly ritual of applauding the N.H.S. during the early months of the pandemic.
At the edge of the crowd, I met Mabel Olding, a senior nurse in the hospital’s hematology department. Olding was self-deprecating about her sign—a careful, polite effort, which she had made on an artist’s canvas. “We Can’t Put Patients First, If You Put Nurses Last!” It was her first time on a picket line. “It’s very emotional,” she said. “It shouldn’t have come to this.” Part of the agony of the current situation is that the structure and heft of the N.H.S.—it is the world’s largest single-payer health system—does give it tangible advantages, in efficiencies of scale and research. Think of the U.K.’s rapid covid vaccine development and rollout. Olding’s department at U.C.H., which deals with blood diseases, specialized cancer care, and stem-cell treatments, is one of the largest of its kind in Europe. But right now it doesn’t have enough nurses. Olding explained that nurse-patient ratios had slipped from one to four, to sometimes one to six, meaning that it was no longer safe to carry out certain procedures. “These people are really ill, and it’s not safe,” she said. “It’s heartbreaking. The amount of times my colleagues come home crying, saying, I didn’t do my best, because I couldn’t.”
Olding didn’t want to be out on the freezing steps. “I love nursing. I’d much, much, much, much rather be in there,” she said, gesturing at the doors behind us. The R.C.N. carries out regular surveys of its members. In the spring of 2020, during the first wave of the pandemic, around a third of nurses were asked to take on more responsibility, for which very few were paid. They complained about inadequate P.P.E. provision and were afraid for their physical and mental health. But only around a third considered leaving the profession. Eighteen months later, within the N.H.S., that number had almost doubled, to sixty per cent. “We’re just tired now,” Olding said. For a decade, or more, Britain’s most precious institution has run on what health analysts call “discretionary effort”—a mixture of vocational calling, not letting people down, and a social ideal—rather than adequate investment or pay. Now the well is dry. Both Sophie, the cardiology nurse, and Olding told me that they hated being called heroes, or any form of rhetorical devotion to the N.H.S. “We are highly trained professionals,” Olding said. “I have two degrees. I have worked really hard. We are not superhumans or angels. We are just people who should be fairly paid for what we do, and we can’t keep going and going and going. But they know that we will, and they play on that.” The chanting resumed around us: “Claps don’t pay the bills. Claps don’t pay the bills.” ♦
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