As of February 2024, Clinical Support Workers in the Wirral have been on strike for more than 50 days. Month after month, hundreds of pickets have gathered by a frozen bus stop outside the Wirral University Teaching hospital in a fight for justice, respect and fair pay. The dispute has become just as bitter as the weather. The NHS ‘Agenda For Change’ national pay structure specifies that band 2 Clinical Support Workers (CSWs) shouldn’t carry out any clinical tasks like dressing wounds or removing catheters. Any CSWs who do those clinical jobs should be moved up to band 3. The vast majority of CSWs in the hospital do clinical tasks, so their union, UNISON, is demanding that they all get moved up to band 3 and back paid from April 2018. Hospital management doesn’t have a leg to stand on: the pay structure is unambiguous, and other trusts in the area have met the union’s demand. But for some reason, the Trust is holding on for dear life, spending vast amounts of precious funding on getting nurses in on overtime rates to cover CSW shifts. CSWs are the biggest single occupational group in the hospital, so the strike is a major disruption of business as usual. After months of action, it has become one of the longest strikes in the history of the NHS. The workers have just won a reballot with a 97% yes vote on a 71% turnout, a result that has legally authorised another six months of potential action.

Inside the hospital, the longstanding NHS crisis rolls on. It’s no longer surprising to see patients receiving ‘corridor care’, stuck in the hallways because there’s no room on the wards. The public debate often seems to focus on a fear that the NHS might collapse at some point soon. It is probably more accurate to say that the collapse is already happening, just in slow motion. Outside, purple flags flutter in the wind. Passing drivers honk to show their support. The pickets, mostly middle aged women, do Zumba, drink tea, and discuss how many layers of socks they’re wearing today. In this article, three workers “Simon”, “Hannah” and “Emily” (not their real names) share their experiences of working and striking in an NHS that is coming apart at the seams.

The Job

The exact responsibilities of a CSW vary depending on what ward you’re on. In general, we aim to meet the needs of patients in a person-centred way, and stick to the care plans set out for each individual patient. This involves a range of possible tasks, including washing, feeding, and clothing. With immobile patients, we have to move them throughout the day to avoid them developing pressure sores. We call this ‘repositioning.’ On top of that, we do all the clinical tasks that the nurses don’t have time for, and generally act as their eyes and ears. The range of clinical tasks is incredible. Between the three of us, we: apply dressings and care for wounds; take swabs; monitor and empty catheters, surgical drains and stomas; identify infections; monitor patients for deterioration; provide one-to-one care for patients with behavioural needs like drug/alcohol withdrawal or dementia; collect observations on blood pressure, pulse rate, oxygen saturation, respiration, fluid balance, and temperature; conduct urinalysis; perform blood glucose checks; carry out pre and post operative care including bladder scans and set up electrocardiograms. Finally, we handle much of the dying process - from comforting people as they pass to what’s called the ‘last offices’, the final care for deceased patients, wrapping their bodies to go down to the morgue.

On a daily basis, we are mostly managed by the nurses in our ward. They can give us specific tasks, but all the experienced CSWs know what we’re doing and have our own routines to follow. We are constantly passing information on to the nurses for them to use in patient care. If there’s a problem with a patient, we’re often the first to notice. Even though we work so closely with the nurses, there can be some tension. Some of them think they’re better than us because they have degrees. We call those ones ‘too posh to wash’: if a patient soils themselves and you need their help, they will walk the other way. One student nurse even said as much to us, “I don’t pay tuition fees to wipe patients’ arses.” It’s strange, though, because often newly-qualified nurses are trained on the job by experienced CSWs. We’ve seen CSWs stepping up to do tracheostomy suctioning procedures on wards where the nurses aren’t able to do it. You develop skills as a CSW, even if you don’t get a degree out of it. But there is a very strong hierarchy between the pay bands in the hospital that stops information going up the chain. Some nurses and doctors never see the realities of patient care, and that causes mistakes. That’s before we even mention the non-medical managers!

The ward manager is officially responsible for monitoring our performance, but they don’t really keep a close eye on us, we just have annual appraisals. They are also meant to make sure our training is up to date and give us the chance to ask for extra training or progression opportunities. It’s a bit pointless, though, because there are no progression routes for CSWs within the trust, so none of the plans we make ever materialise. One of us has been trying to do a specific training for years, but the training has never actually been made available.

We all work slightly different shift patterns, but all of us do two to four 11.5-12.5 hour shifts spread over the week. They can be day or night shifts, but we prefer to work nights because you make more money that way. We almost always work one or two extra ‘bank’ shifts for the NHS’ internal labour agency each week too, to make extra cash. They are really difficult shifts, because you can be sent to different wards where the hospital is already understaffed. Overall, we average between 36-50 hours a week, but sometimes if you need the money you can do a lot more. You can work 12 hours every day for more than a week at a time; your name goes red on the rota, but nobody stops you.

Every patient is different. You can’t take a ‘one size fits all’ approach. We try to build rapport with them and any family or visitors they have. You can build a really strong relationship with people: sometimes they open up about safeguarding issues because they trust us and we listen. We make a special effort to understand their fears and concerns. During COVID, we did everything we could to care for people whose families weren’t allowed in to see them, especially the end of life patients. We helped them to the windows to wave at their loved ones one last time, facilitated their goodbyes over Facetime, and held them as they died. We remember the people who have died in our arms - their names, their stories, even if it was years ago. It never stops being upsetting, but you rely on the support of your colleagues to get through. We’re told to ‘get used to it,’ but if we ever stop feeling empathy for a dying patient, that’s when we’ll know it’s time to quit. We do this job because we want to care for people. It’s our way of contributing. But our commitment to our patients, our vocation, gets exploited by the managers.

All of us have regular concerns about patient neglect and the standard of care being provided by the hospital. People get failed by their medical teams, stuff doesn’t get explained properly to families, and there is near-constant understaffing which means that corners get cut and staff burn out. On some shifts, you end up apologising to patients, but they usually tell us not to worry. They can hear from the commotion in the next bay that we are handling confused or violent patients that we can’t leave alone. There are so many patients who need one-to-one care, but not enough staff to do it. It’s not safe. CSWs often get attacked by violent patients, mostly people struggling with dementia or going through drug/alcohol withdrawal. People get seriously hurt.

We go to our ward managers to raise concerns about patient care. They tell us to fill in an incident form, but nothing ever happens about it. The problem comes from higher up. Even if we start a shift at the minimum safe staffing levels, we often have one or two people transferred to support other wards where staffing levels are even worse. Sometimes we feel like our concerns are ignored because we are ‘only’ band 2s. Bed management in the hospital is always going wrong because of the pressure the system is under, and patients get sent to wards with the wrong facilities. We should all be working together, but the stress means that sometimes medical teams argue amongst themselves when a patient’s care needs have not been met or a serious incident has taken place. It all turns into a blame game. Senior managers don’t listen to the people on the wards, particularly band 2s. We try to pass information up the chain, telling them that even though we might have a spare bed we’re struggling with very unwell, confused or aggressive patients. We say we can only take on a mentally sound, mobile independent patient as we just haven’t got the staff to manage – then next thing you know, another confused, poorly or aggressive patient shows up.

The emotional and physical strain of this work is intense. A lot of workers in the Trust are reliant on fluoxetine (an antidepressant) or Tramadol (an addictive opiate painkiller) to get through their shifts. Hannah got injured a few years ago because she was having to reposition 30 patients every two hours, for the whole shift. That’s 180 repos per shift. An increasing proportion of these patients weigh 20 stone. There should be three or four people repositioning that patient, but there just isn’t the staffing so you end up injuring your shoulders and back. After a shift you go home exhausted. Sometimes you’re that tired you forget driving home, you just arrive at your front door and wonder how you got there. You never get to eat or drink enough on a shift, which makes the exhaustion worse. Mentally, it’s always been a difficult job - but it’s gotten more so in the last few years. Patient centred care has gone out the window. The whole NHS is about box ticking now. It’s all about what’s good for the Trust, not what’s good for the patient. Once you’re at home, you end up thinking about your day and your patients over and over again. You wonder if there’s anything different you could have done to make more time for looking after people, if you could have juggled jobs differently to give yourself an extra five minutes here or there. You feel angry and frustrated about how bad it’s getting on the wards. Sometimes you dread going in and facing it all over again.

That burnout is part of the reason why patient care is suffering. Standards have definitely been falling for the last few years. Nobody on the wards has enough time to do their jobs properly, and over time they get emotionally exhausted. When people are really burnt out, they get worse at their jobs and other people have to try and cover for them, so it’s a vicious cycle. On one bank shift in another ward, Hannah found a poorly patient’s daughter attempting to clean her elderly father after he had soiled himself. They had been left alone without care for so long that she had decided to do it herself, and it was visibly distressing for both of them. Hannah had to step in and persuade the daughter to let her take over. It turned out, the daughter hadn’t been home for 11 days because she was so worried about the level of care her father was receiving. The poor girl was exhausted. People shouldn’t feel the need to do that in order to stop their parents lying in their own excrement. But this isn’t an accident. It’s deliberate - the government wants to privatise the NHS, so they cut funding until it falls apart. Well, their plan is working. The NHS is crumbling.

Why we’re fighting for respect and fair pay

Think about doing our job for an hour. We’ll give you an example. You spend twenty minutes calming down a dementia patient, then change two sets of bed linen, wash a patient, shave another patient, give mouth care to someone who’s dying (wet their mouth to prevent discomfort), feed someone on a special diet, make sure all your paperwork is up to date, and empty all the catheters. You have to run to get it all done, and at the end, they hand you £11.40. What can you buy with that?

Life is tough right now. We each have different situations:

Simon: I am finding things incredibly difficult at the moment. My partner is currently out of work and so I am the only person earning. I just had a summary from my electric company, and over 3 months I topped up £600. Everything is rising other than my wage and it’s causing massive strain. It really frustrates me knowing how hard I work, and the condition I work in, while someone in retail earns a lot more. I have no expendable income and I now rely on cheap frozen foods. I feel unhealthy and miserable. It’s difficult for me to understand why healthcare professionals are on such poor wages when so many people say, ‘Oh I couldn’t do what you do’. There are over 150,000 vacancies in healthcare and that number is rising. One in five carers are over 50 years old. What will happen when those people retire? There is already a crisis in care with the lack of staff and people living longer. This needs to be addressed sooner rather than later as the implications will be very bleak indeed. It would be nice to be paid properly for the job I already do. Being invested in would not only boost my morale and make me feel proud of the job I do, but it would also boost productivity within the Trust. It would free up nurses to deal with the more urgent care needs rather than being bogged down with clinical tasks we are more than capable of carrying out.

Hannah: I live alone but still have the same bills going out each month but with one wage coming in. I have to do extra shifts each month to make ends meet. Everything has risen in price and bills have also had a hike but we are still on very low pay. I don’t pass the criteria to claim benefits as I live alone and have a mortgage so have to live on what I make. I rarely use my heating and always shop in the reduced aisle. I’ve not had to use a food bank yet but know many colleagues who have. This is not only about the money but also recognition and respect for what we do. Being the person a dying patient spends their last hours, minutes, breath with and doing everything you can to make their passing as smooth and respectful as possible takes its toll on you. I remember every patient I’ve held while they died… This is worth more than what we are paid and should be recognised for what it is. So many people say to me “I couldn’t do what you do” - I get that because it takes a special kind of person to be able to.

Emily: I am fortunate that I am married but not everyone can say the same. Some are single, some partners out of work, some partners too ill to work. Although I’m married, I have never relied on anyone else. I do one or two bank shifts per week to top up my wage. Because I can only work nights, I often only see my husband once a week because of our work patterns. I don’t think the up banding will make a massive difference in pay after deductions but it’s about the recognition for the work we do, the care we give, and the dedication. My life would be much less stressful. If I were earning a decent wage for what I do, I wouldn’t have to pick up so many bank shifts, which means more time with my family and granddaughters. I could maybe do family days out, which are a rarity at the moment. My elderly mum lives with us and I often feel guilty that I neglect her and can’t take her out as often as I would like. Those times especially are a huge guilt trip to me as I love her and don’t know how long I will be lucky enough to have her here.

The strike

We don’t know why the Trust CEO has decided to take on the CSWs. We’re some of the hardest nuts in the hospital. We spend all day supporting each other as we deal with constant overwork. A little strike doesn’t scare us. This dispute is just one of the more than 80 campaigns to regrade CSWs (also known as Healthcare Assistants, HCAs) in NHS Trusts across the country. So far many of these campaign has won without taking strike action but in February CSWs at seven sites across two trusts in Teeside voted 96% for strike action on the same issue.

At the start of our campaign we established an organising committee of union members representing each ward of our hospital. These have been identified as people who other colleague’s feel comfortable approaching. First we held a series of meetings to see what members were saying and discuss how we could be moved up to band 3s so that we’re properly paid for the work we do. When we realised the trust wasn’t listening to us, we started balloting for strike action. It was our job to get everyone’s details up to date, explain what going on strike would mean, and deal with any worries anybody had. We were instrumental in organising how the strike would work in a way that everyone of our members felt comfortable with.

Even after the first few days of action, the Trust didn’t want to talk to us. We announced more strike days, which then finally forced the Trust to sit down and talk. At first the Trust only wanted to talk to UNISON through the branch secretary and regional officer. That would have meant there were no CSWs actually in the room. That wasn’t acceptable, after all the decisions made in those negotiations would have a direct impact on us. The Trust didn’t like the idea, but we announced even more strike dates, and so they agreed to let seven of the organising committee members attend negotiations. The negotiations started okay, but after a few meetings it was clear we weren’t making progress. It got worse and worse, and now the Trust aren’t engaging in talks at all. They send the same communications over and over saying they are ‘willing to resume talks’ but then they won’t actually negotiate.

We’ve learnt a lot since the strike started in September. When a group of workers’ come together to say ‘enough is enough’ and show their power - that’s the real meaning of unity and solidarity. And when you do that, you find that there are people who are willing to help the downtrodden workforce rise up and demand to be respected. It’s shown us the reality of the NHS: they’re willing to spend money on anything but patient care, and they don’t care about the workforce. As long as the i’s are dotted and t’s crossed they’re happy. They throw money at everyone except the ones who are owed it and deserve it. It might be true that the lowest paid work the hardest, but everyone deserves to have a voice.

There are hard things about the strike, too. Some people are still going into work and crossing the picket line. Even with strike pay from the union meaning that we’re not losing wages, they still insist on scabbing. Then they have the cheek to complain about being run ragged. They go and do overtime for extra pay, then come and ask us if there’s any news about the fight. They want the reward of back pay and up banding but won’t fight for it. They think they are gaining respect from managers and colleagues for going in, they don’t understand they don’t and won’t care about them. To the trust managers they are just a number and a number only.

Hannah: I was in an abusive relationship for many years and my self worth was taken away. Whenever he realised I had had enough and was about to leave, he’d take me out for dinner and have a romantic evening to make me feel special and valued… It kept me there for more than a decade. I think this is why staff members are going into work. They want to feel needed, wanted, respected and valued by the Trust so will cross the picket line to get it.

What we’re seeing in the hospital is just a symptom of a wider process - the systematic disintegration of the social fabric. You can see it happening in the patients we admit. Every winter it gets worse. Pensioners with respiratory illnesses and neglect because their homes are freezing; people who are malnourished and hypothermic; people sent in from care homes that are too short staffed to cope with their own residents; people who have had a fall and lain there alone for days until the police force entry. We can’t discharge people because the social care system is so broken that there’s nowhere for them to go, so they get stuck taking up beds. On some level, everyone knows this is happening, but it seems like people are unable to move past apathy. We are doing our bit to change that.

It’s interesting to think about what a better healthcare system might look like. First, we need to get back to basics, and invest in patient care and hospital facilities. We could save money by having a clear-out of managers, and make staff retention better by improving wages and conditions. Executives waste so much money at the moment - they need to be held to account, not just moved on to another Trust. At the moment they get shuffled around into all these offices where nothing seems to happen but everyone is on band 7 or higher. If it was up to us, we would get rid of a lot of higher management. There are far too many execs that aren’t needed. They are on whopping salaries, and for what? Running the NHS into the ground, dividing workforces, and blaming the lowest paid employees. The hierarchy between bands and the division of work it creates needs to change. Everyone working in the hospital should spend time caring for patients. The politicians running the health service have no idea about what it’s like to work in a hospital. There’s nobody in the government who we trust to fix this. It’s going to take radical programmes and processes.

The problems we face aren’t unique. Every worker in Britain knows what it’s like to be denied respect and fair pay, from people who sweep streets to people who work in offices. We should all be on strike together, because we all deserve better. There needs to be an uprising. Nothing less will do.