After we spoke to a friend in Germany about his long-standing independent workers’ group at his hospital, we visited another comrade who has been working and organising as a nurse since the late 1980s. We had a long conversation about the question whether the recent strikes for better staffing levels in various German hospitals, the collective experience of health workers of having a significant social responsibility during Covid and the various health-related initiatives of the left-wing milieu have resulted in a convergence and perhaps a recomposition of working class politics. We compared the current mobilisations with the experience of self-organised assemblies during the nurses’ strikes in the late 1980s. We talked about the potentials and pitfalls of the new union delegate system and the various problems with the new collective contracts on better staffing levels. Our friend told us about his understanding of current initiatives amongst critical medical students and doctors and about his own efforts of intervening in the situation of the hospital where he worked for decades. We highly recommend this article to anyone who is interested in strategies for working class power, in the health sector and beyond.  

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Strikes, Covid, health initiatives: a recomposition of working class politics?

Our first question would be whether subjectively the recent strikes for collective contracts relating to hospital staffing levels have somehow produced a recomposition, a new workers’ militancy and consciousness, both amongst and within the hospitals. For example the recent nurses strikes managed to involve a lot of the apprentices, but also created a new relation to the general public, if we look at various initiatives, such as ‘Krankenhaus statt Fabrik’ (‘Hospital not Factory’), that discuss health and the support of strikes as a class question. The second question would be what role Covid objectively played in all of that, because of the fact that there all of a sudden was a public discourse about the health system, about what kind of decisions are taken and why. Perhaps we can discuss the subjective factor, the strike, and the objective factor, Covid, on the specific background that in Germany there are historic spaces for this type of debate, such as the ‘Verein Demokratischer Ärzte und Ärztinnen’, but then there is also a new generation, speaking about ‘Care Revolution’ and so on. Is all this moving towards a recomposition?

I thought about this and I noticed a contradiction, when it comes to McAlevey and organising in general, which I have trouble explaining. The contradiction is that in the 1980s, during the first hospital movement, we had a mass of fellow hospital workers, who were able to meet weekly in general assemblies and, on top of that, for additional meetings in specific work groups. Locally this involved 50 to 100 people and was a substantial effort. Today, when I sit in a Ver.di trade union meeting, for example in preparation of the upcoming strike, and the local union official announces that we will be sent three union organisers from the head office then you can hear people sighing “thanks god for the organisers, we would have never managed on our own, no one has got any time”. I don’t know why people today think that they lack the ability or time to organise themselves. This puts a certain stamp on the question whether there is a recomposition happening. It looks as if without the union structure, nothing would happen – structure in terms of a basic service and organising framework. The changes of the diagnosis related groups (DRG) System back in 2019 (before Covid) are the result of the hospital movement – and the financial basis for the ‘Relief Contracts’ (Entlastungs-Tarifverträge) over recent years. There is a ‘political recomposition’ relating to the discussions and regulation around the hospital/health sector, and there is a ‘union recomposition’ to a certain degree, but I would be more skeptical whether there is a recomposition in the sense of a (collective) subject with an impact for the workers in the whole health sector, in terms of self-organisation, overcoming of divisions etc.. It is important to say though that the improvements in the ‘big hospitals’ that have been won through strike campaigns have had an impact on ‘the territory’, meaning the smaller hospitals and even care homes. In these other workplaces, wages have risen in part due to the strikes, as employers attempt to avoid a situation where workers move to those facilities with better conditions that have improved as a result of strikes – of course, on the other hand, new migrant workers are seen as another ‘solution’ to this problem.

The nurses’ strikes in the 1980s

Why do you think nurses in the 1980s were able to do all this by themselves?

People were subjectively willing to invest time. They knew that if you want something, you also have to do something for it. And they did it, with a high degree of involvement. They chose to spend the time necessary in order to achieve their goals, which was the case even though these workers had children and other obligations much the same as workers do now. It has something to do with individualisation. That’s when you need a union that “picks people up where they are at, as individuals”, as they often say. The meeting structures in the 1980s were different from town to town. In some hospitals the meetings were in close touch with the trade union, in others, like in Freiburg, they were quite independent. We went to all the local hospitals and care homes ourselves to distribute leaflets and to invite people. People did it and you didn’t have to justify yourself, like, “why are you doing this? Where is the trade union?”. We organised the assemblies and demos ourselves, invited the French colleagues for info events, as they had already been on strike, and so on. We did our things and if a guy of the trade union was present, that was okay, as well, who cares. For some of the more organised political people the critique of trade unions might have been important, but otherwise people just got on with things. 

So one reason might be that people might not feel that they are in a common situation, even if they work in the same hospital? There are now many more different professional groups, people from more diverse backgrounds? Perhaps the subject that we try to address is less defined?

Yes. Back in the 1980s we used to speak of the ‘ward staff’, to put it shortly, the workforce on a ward was organised within a pretty flat hierarchy. Today we have new hierarchies, a lot of different (new) professions. We always criticised the main demand of the (nurses’!) movement back then: “for better care” or “we don’t want to do these menial tasks that are not part of a qualified nurse’s job description”. We criticised that, we said “it’s not about me not wanting to clean or to make beds, but what I need is time to do these tasks”. What is ‘care’? It is a kind of myth that is defined differently for historical periods or countries. In Germany it includes bedpans and washes, in other countries it doesn’t. As already mentioned, as a nurse in the 1980s you did all jobs, from bringing medication or patients from one end of the hospital to the other to handing out food, the actual care, all the planning and bureaucracy. Back then you didn’t see who was the nursing student, who was someone on compulsory national civil service, who was the ward head nurse. It was a ‘ward team’, that included everyone. You had a kind of unity or homogeneity back then. At the same time, this shouldn’t be overestimated, as we did not manage to mobilise the other professional groups either, such as porters or cleaners. It was a nursing workers movement.  

 Migration also played a role. At the beginning of the 1990s a wave of migrant workers arrived, primarily from (ex-) Yugoslavia. Individually they had very high expectations regarding the type of work they wanted to do and the pay that they would be receiving. These were very skilled nurses in relation to us, and many of them were quite ‘shocked’ to work under ‘German conditions’, where nurses had to tasks that required less skills, too. But for a collective dispute they were a bit lost, as they had other problems: the difficulties of settling down in a new country, learning the language, even if they were very quick at learning German. The following generations of migrants were probably even more difficult to integrate into collective struggles. The workers from the so-called ‘actually-existing socialism’ in East Germany did not get involved much, later on we saw a similar absence of newly migrated nurses from the Philippines and Albania. It might not be an explicit purpose of the bosses, but as a side-effect, organising has become more difficult. But more recently, nurses from the Philippines and the other countries, after ‘resolving’ the problems of recognition of their training/qualifications and other problems, are in some places taking part in the union campaign.

Perhaps another important factor is that in the 1980s, many people had already made experiences as participants in other movements – from the big movements against nuclear power or re-armament to the ecological movement. They came to work in the social sector, but they already knew how to organise themselves. These were not only political people, there were also many people involved in cultural stuff, bands and things, which tended to be more self-organised compared to today. These were all more collective experiences that played a role. Today you have some movements, too. You could imagine that a few of today’s apprentices also take part in the climate movement, but somehow that hasn’t reached the hospitals yet. Or perhaps only in the form that many people in the climate movement also only address politicians and the media and the hospital movement runs the risk of repeating that mistake. Today people enter the hospital already individualised. You first have to break that. Otherwise it would be primarily the normal trade union form of organising, meaning, organising people as individual members, rather than a collective workforce. But in order to do that we have to look at the actual composition of the work-force and the way how the organisation of work has changed. 

Team delegates and the problems with the new collective contracts

Let’s come back to the strikes. We watched some documentaries about the strikes in North-Rhein Westfalia and had an online meeting with some of the activists – and they seemed much more clued up, collectively organised and active than comparable new union activists in the UK. They were quite impressive, self-confident “we sat with 300 other delegates in a hall and debated it out” and so on. What do you think?

These strikes had a long prelude, it started in 2015 or even before. Ver.di has realised that the classic strikes that we had in hospitals since the 1970s didn’t work anymore. Back then it was mainly the porters, cleaners, the canteen staff and so on who actually went on strike, and the operation theatres. Their strategy was to shut down the theatres for two days, which would hurt the hospital economically. The union had to change that model as it had become ineffective. I went to the strikes in Essen in 2022 myself. I was always in two minds. The assemblies were indeed impressive, because they managed to bring many people to attend and because they were loud and massive meetings, in contrast to the usual trade union strikes, where you just sign your name at the picket in the morning and then go home again. This time the union had thought about things to do, for example they organised the so-called ‘strike university’, with talks and cultural events. But we shouldn’t let ourselves be blinded by this too much, either. When I left the picket and walked around the hospital, it was actually pretty much business as usual. I often didn’t understand how they managed to keep the hospital running like that during a strike. It was clear that if people in the kitchen and catering were on strike then there was no food available during that day and management had to come up with a solution. They had to source it from outside or, like during one of the strike days in Essen, the admin workers and managers worked in the kitchen themselves. That’s kind of funny and you were actually able to see that the strike had a direct impact. But I think that all the various minimum service level agreements and derogations that Ver.di has signed, because they are historically very afraid of being forced to pay financial compensation or fines, have resulted in a serious weakening of the impact of strike action. During the ‘strike universities’ the organising team gave out the slogan ‘strike the patients away’, which is a slogan or strategy that fits well with the derogations and other agreements (by announcing the strike the hospital management would vacate patients from certain areas or would not admit new patients). Before the strike in Freiburg they agreed in very fine detail that, for example, if on ward X staff agrees to go on strike then the ward manager has to document it, then they have to go to the strike leadership of the union, they then go to hospital management, they then say “okay, give us ten days notice, then we will empty the ward”. You could call this ‘strike the patients away’, but perhaps it’s more honest to say that it is a form of arrangement that allows the colleagues to take part in the picket, because the ward is officially closed. Patients who were supposed to be there for elective treatment don’t turn up at all, they join the waiting list, and emergency cases are treated elsewhere, on non-striking wards. At the Charite in Berlin they managed to close as many as 20 wards in this way. It kind of works as an event, I think. It is impressive, it produces impressive figures for the union’s press release, and also produces results, as the collective contract agreements for the nurses got better – and very complicated! But if you see it from the perspective of recomposition – in the sense we mentioned above, which means also, “what do people actually learn during a strike”, then things become more opaque. At one of the local meetings I asked “what do we do if the bosses don’t sign the derogation agreement?”. This is something that could happen – and has happened in some hospitals. Then all of a sudden things look a little precarious and deflated. There was no alternative plan. In the 1980s we were often not able to go on strike, because we capitulated in front of the problem of what it means to strike in a hospital. So we decided to refuse doing certain tasks that were not of major significance for the patient, like certain documentation. A bit like a work-to-rule. This type of action presupposes at least a broad common discussion about the concrete work, which the derogation tactic of Ver.di today does not. They produce dozens of pages of agreements that mainly experts understand. For most hospital workers today this is the normal functioning of things, they don’t question it. 

You also said that the agreements are so complicated, not just to understand, but also to apply, in terms of keeping track of how many understaffed shifts you worked and what you should get in compensation, that a lot of colleagues now say for the upcoming strikes that they just want more money, pure and simple. An agreement about work stress, which looked very progressive on the onset, turned into a disappointment?

Here in Freiburg we had the second ‘relief’ collective agreement on staffing levels after it had been agreed at the Charite. At the time that the agreement was reached, it was highly contested. No one was really happy with it. There were hard conflicts, because Ver.di enforced it from above. A part of the negotiating committee said that they would not sign it in this form, because it was too bad, complicated and non-committal. On the day of negotiations many members of the union committee were already on their way home, when the bosses’ side made slight changes to their offer and the union signed the agreement even in the absence of some of the committee members. The issue is that all ‘relief’ agreements leave themselves open to bosses attaching other changes to the ‘relief’ measures. In Freiburg management said that you get better staffing levels or holiday points for having worked on understaffed shifts, but you only get this if we can change the shift patterns and the working hours. In concrete terms this means, for example, that the hand-over times between shifts were reduced. At the time we wrote a leaflet about this, criticising these changes. By being able to request these changes the bosses’ side took over control again. This seems to be the outcome of many of these agreements, that the bosses are at the steering wheel again. The staffing rules are never formulated hard enough, so that they would function for you, they are too complicated and open to interpretation. So it was interesting to hear in last week’s strike prep-meeting that a few people said “we don’t want this anymore, we want more money, less work”, which means that higher wages is the best ‘relief contract’ as it would allow for a reduction of the working hours – many nurses work only part-time nowadays.

The agreements might be complex because also the institutional framework is complex and always changing, for example the relation between state, health insurances and hospitals. What’s the latest?

They have re-regulated the way that they account for care work in the flat-rate calculation for specific treatments. Because there was so much criticism that the old system would force or at least encourage the hospitals to save money on care work. There used to be a general cap or budget within which hospitals were supposed to operate. When wages increased, the cap stayed the same initially. This always caused problems, the hospitals resolved it by reducing the number of care staff or building costs. They would not touch the doctors and consultants, because their treatment brings the money. In Germany we said, “the doctors sit at the till”, because they write the bill. During the first twenty years since the introduction of the system they increased the number of doctors, while cutting the number of care staff. So Ver.di used to engage in campaigns with slogans such as “the cap must go” – meaning, the restrictions of the hospital budget. So five years ago, under Health Minister Spahn (2018 to 2021), the health insurance companies were forced to compensate the hospitals if care workers wages were raised or if they hired more care workers. In a second step the cost for the care provided ‘at the hospital bed’ was taken out of the general calculation for the DRG (diagnosis related groups); – bed care accounts for about 20 percent of the DRG budget. The DRG is a kind of flat-rate system: the hospital gets payments for a particular procedure, disregarding how long the patient actually stays in the hospital. This means that hospital managers only focus on ‘well paying’ procedures, try to get rid of patients as fast as possible with the least amount of staff. With the care ‘at the hospital bed’ taken out of the restrictive calculation, the hospitals had more breathing space to hire more care staff and to push less for the ‘fastest possible care’. Now other professional groups, like doctors, who provide services to the patient that are not categorised under care also want to be taken out of the DRG system. This is interesting, in the sense that in the last twenty years there was a change in the hierarchy, with the outsourcing of a lot of work. This opened a gap between nurses and service workers, such as porters, cleaners, house keepers. But unlike ‘care at the bedside’ by nurses, this service work is now not compensated for financially. So mainly the private hospitals, which have outsourced the most, now say that they will hire more care staff again, because under the new system nurses engaging in ‘direct bed care’ are financially compensated, but then these care workers will do the menial tasks again – like portering and housekeeping, because once nurses do this work, the hospital gets financial compensation. That’s a funny reversal, kind of. We have a comrade who works in a hospital in the north. His main job is to argue with the people in the insurance offices about what is paid and what is not paid under the DRG for each case. He has to code the various treatment cases to get the reimbursement, but the insurance might discover a discrepancy between the official coding of a case and the patient’s medical notes. Then the arguments start. The whole system also means that there is a bigger pressure to get people out of hospital quickly. Prior to the DRG system you used to have people who came into hospital days before their surgery and they stayed for a week after surgery. Today these might be day cases. The result has been higher discharge levels of patients, and much more bureaucratic work relating to patient admission / discharge.

Additionally they don’t care that the same person might now need visits from the community nurse each day – who has to drive 50 miles to reach them – because that’s a different financial pot. The conditions in the community sector, where nurses do home visits, are even harder. The health insurances, who act as general managers, are even more prescriptive when it comes to telling them how long they can take for this or that task. The last innovation is the introduction of the PPR 2.0, a system of measuring the time needed per patient in order to then calculate the staffing levels. PPR 2.0. refers to the first PPR implemented in the 1990s, and abandoned after it became obvious that a lot more nurses were needed. In the 1980s we circulated leaflets against the PPR out of three reasons: firstly, against the measuring of our working time, but also against the measurement of the patients; secondly, against this handover of the control over the working conditions to the management; thirdly, against the ‘hiding’ of our needs as workers – nurses only talked about ‘patient safety’, instead of openly fighting for their interests. Today the PPR is seen as a progress….

In other hospitals there are people whose main job is to pimp up the DRG code, for example, they add points for ‘music therapy’, because the patient had a radio in the room. They have experts in hospitals who check the annual revisions of the DRG system and decide “pace maker surgeries have been revalued, we can make more money with that, let’s focus on that next year”. It’s not an effective system, in the sense that decisions are not made depending on ‘capitalist productivity’, but according to decisions by the bureaucracy. Different topic. In our NHS hospital they make some money with commercial trials, I wonder if that is also the case at a university clinic in Germany?

  I am not sure about this. I am not sure how this type of research plays out financially for the hospital. We are also not involved in research work in any way as normal ward nurses. We don’t notice that such trials are happening. What we notice are vacancies for research nurses or ‘study nurses’, which are financed by separate institutions or companies. These research nurses tend to be carrying out medical studies and trials. They just document surveys and studies. Here in Germany any further training for nurses beyond the basic level combines medical knowledge and skills on one side with managerial skills and functions on the other. This is a problem here, it’s disgusting, and I have a lot of arguments with colleagues who decided to go for further training or ‘career advancement’. There are now five, six university courses. These are not courses to deepen your knowledge on cardiological or respiratory issues, not at all. I would not have a problem with that kind of medical qualification. That might even be interesting. It’s all managerial. The normal ward is now run by three head nurses, it used to be just one ward nurse. These three head nurses have different tasks. One does ‘care organisation’, they are responsible for things such as staff rotas, she might have done a classic course to become a ward manager. Then you have another one who has studied ‘care pedagogy’, I don’t even know what their concrete task is. Then you have the third one who might have studied ‘care science’, they have the responsibility for the medical management. They don’t have enough staff yet, but their plan is to have three leading nurses like that. Another general course would be ‘public health’. Below this level there are also levels of ‘medical expertise’, but they are also combined with hierarchical functions. I could become a stoma-manager, then I am the main person in the whole hospital to keep up to date with stoma care. 

Then there is always a public argument about the number of hospitals. Around 20 years ago I think we had 2,500 hospitals in Germany. This has come down to 1,800. The neoliberals, the hardcore reformers, say that we need a system like in Sweden or Denmark. If we would apply their ratio of hospitals per inhabitant then we would only need 600 hospitals in Germany. The left-wing normally says “no, we defend every hospital”. I’d say it’s difficult, because we debate this reform under the conditions of a capitalist system. It’s always about money and resources, not about quality. The number of the hospitals is the result of the reform period in the 1970s, a period of investment into labour power and infrastructure. Back then every town also had its own swimming pool and its own hospital. No one likes to be in a hospital, we should debate local alternatives, like the ‘Poliklinik’ in the former DDR, but we must be careful: what is now discussed in Germany in language such as ‘more ambulant treatment’ is a capitalist restructuring process.

Initiatives amongst medical students and doctors during the strikes

During historic strikes in the UK, for example in the 1970s and 1980s, the striking nurses became symbols of the ‘good conscience of the working class’. The fact that nurses had to go on strike and visit ship-yard or mining workers meant that there was some kind of felt obligation from other workers, for whom it was much easier to go on strike, because they worked in industries, to also show their militancy. But it also meant, perhaps, that hospital workers took the hard struggle out of the hospital and found other ways to exercise economic pressure, e.g. by supporting industrial workers. More recently this happened in Argentina, where striking teachers and nurses blocked roads towards the oil fields. With the increase in general strike activities, also in Germany, do you think that this kind of new tactical relations between nurses and workers in other sectors can develop? Or is it more on the political level that new things can develop, in the sense that there was a lot of public discussion during Covid about ‘health’ and things like the ‘care revolution’?

This somehow didn’t happen during Covid. Here in Freiburg the feminist comrades who organised around the ‘Care Revolution’ are pretty fed up. They said that they haven’t found any lever or possibility to enforce things. A lot of ‘building of alliances’, but in the end you run into walls. There were overlaps between this political wing and the strikes, of course. There was an alliance to support the strikes, where the Critical Medical Students were present, Ver.di was also present, and the people from ‘Care Revolution’. The Critical Medical Students have chapters in various towns in Germany, here they are all younger, they are in their first two, three semesters of their studies. Some of them are part of the wider political scene. I think that they are sometimes not critical enough towards their own role as future doctors and also not critical enough towards the trade union. They produce papers on many topics, such as abortions, but it seems that they primarily see their role as providing ‘an alternative view’. They look at the courses of their medical degree and see if it has racist aspects or if it lacks gender justice. That’s cool, of course, but it also remains relatively toothless. Perhaps it is worth re-engaging in a discussion with them, starting from the question of the medical hierarchy more fundamentally, of which they will become a part. They have now joined the Association of Democratic Doctors, people who have debated ‘the classless hospital’ in the 1970s.

Can you say more about this association? In the UK they are unknown. What did they do in the 1970s, what do they still do, how connected are they to daily life in the hospitals?

I am too young to say anything first hand, but I read up about it. You had a very broad ‘health movement’ in the 1970s. The movement related to the fact that since World War II  there had been an absolute lack of hospitals and the existing hospitals were old and in bad shape, due to a lack of funds. So, there was a ‘modernisation’ of the health system during the time of a SPD reform government under Willy Brand. The ‘Health Movement’ began to question the prerequisites. What is ‘health ‘ in a capitalist society? How is it related to work and exploitation, and so on. A mixture of quite general questions and quite concrete investigations. A lot of knowledge for example about the effects of night shifts, or certain toxins, but also wider concepts that we use now stem from that time, such as ‘prevention’. People like the Democratic Doctors pushed this into the public discourse, by saying that “we don’t just treat people, that is not medicine, we have to ask why people get ill”. They produced the Jahrbuecher Kritischer Medizin. They analysed, in a critical sense, what kind of toxins we have to deal with, which make us ill. They analysed the situation in the chemical industries regarding working conditions and hazards. They were all socialists of some sort. But the discussion about ‘the classless hospital’ never became practical as such. The movement itself was massive, they had conference-like ‘health days’ that were attended by 10,000 people. But it never was a movement within the hospitals, only at their fringes. It was not by chance that the movement split at the end of the 1970s and the so-called ‘alternative medicine’ emerged as a separate current. 

What is the Democratic Doctors influence today?

I would say they largely disappeared  – as part of a movement – during the mid-1980s. With the recent new strike movements they reappeared. They certainly play a role, I would say. My colleagues at the hospital don’t know them, but they play a large role for the left or anyone who wants to discuss changes in the health system. They process a lot of material regarding, for example, privatisation or the so-called ‘flat rate per patient’ financing model. They play a role as local union activists, some of them are still working as doctors in various hospitals. And they are part of the mobilisations around the hospitals. Their main perspective continues to be focused on preventive medicine, the abolition of private health insurance, the hospital sector… and so on. 

But it looks like that nowadays they mainly deal with the quantitative and formal aspects, for example whether such and such reform is good or not or this or that financing model. Do they still look at the material substance of medicine and the conditions that make us ill. It used to be materials like asbestos, what is it now? Or do they provide a critique of certain modern medical technologies and procedures, which become ever more complicated and cannot be understood or criticised easily. Do they still try to popularise a certain medical understanding?

Perhaps this has become less prominent recently. They have become experts when it comes to this complicated health reform or the also very complicated reforms of the hospital sector. This might also be due to the fact that most of them are over 60 years old now, so the experience and focus changes. But there are still important publications of different aspects of ‘health in a capitalist society’. Just look in their newspaper. But it is not so clear how this work is related to the hospital mobilisations. The younger Critical Medical Students undertake probably the fifth attempt to grapple with the question of medical sociology. They dig up the old surveys and analyse new surveys on life expectancy depending on class and where you live, and so on. They kind of rediscover this for themselves. They also want to change the content of the medical degree in that regar d. 

So it somehow also remains on the level of fairer redistribution, not a critique of actual medical science and technology in its capitalist form. We already mentioned that the so-called ‘alternative medicine’ often focuses on those sections of the health sector that require low levels of capital investment and technology, such as mental health or midwifery. But can we really imagine what a socialisation of ‘specialist knowledge’ (Spezialwissen) could look like, for example of neuro-surgery? I feel the left has retreated into a niche of ‘care’, where it is about direct personal relations, and has left the advanced sectors of knowledge and technology to bourgeois science and multinational corporations of the medical-industrial complex.  

That’s a major problem. In one of the Wildcat articles I drew a parallel between the chemical workers’ strikes in Porto Marghera in the 1970s and the hospital strikes, in the sense that the bosses also told these chemical workers that they would lack the knowledge of how to shut down a complex chemical plant safely during strike – and they proved them wrong. In the advanced industrial sector these workers had the necessary knowledge. They were able to do this because they managed to overcome knowledge barriers of various professional groups and combine into something collective. In the hospital you might have a similar situation, with knowledge being scattered amongst many professional groups. The focus on ‘care’ just reproduces the separate status of the nurses’ mobilisations. Beside all the discussions relating to the ‘professionalisation/appreciation’ of nurses, the ‘knowledge gap’ between medical professions is getting deeper.

The whole thing becomes more acute when you don’t just talk about strikes, but about social crisis and what would happen if we had to take the whole thing over. There, a re-engagement with critical medical professionals might be necessary, just to find out some of the basics. For example, do we need the current 6,000 different corporate medications for high blood pressure or would three different types do – I wouldn’t even know how to start answering that question, because I know little about the production process. Why does a single shot of a certain cancer treatment cost 8,000 Euro, what are actual production costs, what were the costs for the development, how much did go to all the patent lawyers?

Political intervention

For us, all of this raises the question of organisation, in a revolutionary sense. We cannot just run from strike to strike. Strikes will always have a structural limit. How can we imagine a process where the struggle is combined with socialisation of knowledge and a debate about social transition? This question is at the heart of our hospital newspaper project. Moments of crisis like Covid can be catalysts in that, because everyone realises the precarious state of the current medical system, but without an organised force that combines social knowledge it won’t ‘just happen’. 

After comrade Tronti had died recently I read his text on ‘extremism and reformism’ again, because he was the comrade who pushed the copernican shift and claimed that the class struggle precedes or determines capitalist development. But at the same time he was the first who said in 1968/69 that these struggles themselves are not sufficient, they haven’t achieved the leap. That’s when he pulled his theory of the ‘autonomy of the political’ out of his hat, which tells us that, of course, we always have to fight class struggles and that they have to be generalised, but at the same time it needs a political level, for example to ‘fix/institutionalise’ achieved successes. What is certain is that the trade union led struggles don’t lead to a generalisation or expansion. None of the strikes here has even touched the neighbouring hospital. This is given by the structure of the collective contract itself. The contract determines where the strike happens. Facing these isolated strikes the left then shifts completely to the detached political plane and they talk about how bad the general health reform is, how the ‘flat-rate system’ has to change. This discourse remains detached from the actual struggle. Most of my colleagues still don’t know what the ‘flat-rate per patient treatment’-system is. We have to do that ourselves, getting organised within the hospitals, the union won’t do it. And Covid was less of a catalyst, more of a trauma for workers here. No one wants to talk about that anymore. At the same time it pushed topics into the discussion, such as scarcity of certain material or supply-chain issues. People realise that something has to be re-organised – but this was a very short effect. I think it is important, when it comes to interventions and newspapers, to express all these challenges in terms of transition and various levels of knowledge, otherwise the horizon becomes too small. We can’t just collect union news from various hospitals. In the big university hospital where I worked for years, which has a quite ‘old’ and bureaucratic works council and union structure with a close relationship to the hospital management, it was always clear that being part of this structure would not allow to ‘resolve’ all the political questions we mentioned. I don’t think there will be general solutions, such as this or that reform, rather there is a need to always discuss the concrete circumstances and struggles.

What were your experiences with forms of political intervention in the hospital over the years?

Since the 1980s I always tried to refer to a current point of conflict and use leaflets to discuss it with the wider work-force, or at least to invite to a meeting to discuss it. Often these were topics that were not picked up by the union or the official staff representation. But at some point this stopped working. You didn’t get an echo anymore. And often I tried it with considerable effort. In my old shared house there were seven, eight people who helped with distributing leaflets in the morning at 6am. I often joined them, but over the years that changed. The question of repression became more apparent. The upper hierarchy started to ask questions. It also wasn’t necessary to hand them out by yourself. I always had five, six colleagues, most of them part of the left, who were also unhappy with what the trade union was doing. The composition was always good when there were additional colleagues who were not part of the left bubble. So we had a small crew. But shortly before these strikes for the relief contract started it became less easy to explain why we thought we should do things independently from the union. Most of the left colleagues are now part of the official union structure. No one understands why we should still meet independently. Today it should be quite obvious that a political initiative has to address the whole class composition in the hospital – that was also the case in the 1980s, but due to ‘historical reasons’, the nurses became the main focus. 

Are there any informal structures amongst workers at your hospital? For example in the UK there are many Facebook Groups by workers from the Philippines or Kerala or from African countries. 

Of course, people often arrive in groups. For example, the new nurses from Albania have training and language courses together and at least at the beginning they might live in the same dormitories together. Of course they talk amongst each other about problems, but these are not connections that could easily become political connections. The challenge would be to organise across rather than within these connections in order to break the group isolation. 

Our collective contract ends soon, then the next wage negotiations begin. We have an individual collective contract for the four university clinics in the federal state. So our contract negotiations and potential disputes happen with a temporary gap to the collective contract of the public sector, which is valid for most of the other hospitals in the federal state. Ver.di organises both contracts, but there are no connections between us and the other public sector disputes. There were debates whether we should at least synchronise the time when the contracts run out, but they always find a reason not to do it. In Freiburg itself you don’t have other public sector clinics, only the hospitals run by the church institutions, which again are different in terms of contracts. So there are at least five different contracts amongst local hospitals then: the university clinics with their own contract, the national public sector clinics, the federal state clinics with a different collective contract, the church related hospitals and the private hospitals. Within our hospital the service workers, like cleaners or internal transport, have their own sub-contract with different negotiation and potential rounds of industrial dispute. And the doctors are separate, as well, of course. 

What chances do you see to create a national network of comrades who work in the sector, first of all to establish some kind of continuous exchange and debate? What kind of channels exist outside of Ver.di? There is the FAU, what else?

I still have a mailing-list of contacts, there is also a small website of independent hospital groups. But there wasn’t much debate and most of the groups have integrated themselves within the union. I also tried to organise face-to-face meetings of various comrades who work in the sector. It was very hard going. The union itself has changed. The structure that was based on local shop-stewards has disintegrated. Some of the shop-stewards were fairly political and they got frustrated. Others retired. The ‘team delegates’, this new form which developed out of the recent hospital campaigns, are today mainly part of the union structure. 

The team delegates and union strategy

We could say that a shop-steward was active day in and day out, like a union militant, and a team delegate is more a campaign activist during concrete disputes.

These team delegates were mainly created in the so-called ‘light-house’ hospitals. These are hospitals where they had already a base or a stronghold and which they had selected to become sites of exemplary disputes that would ideally radiate towards others, like a ‘light-house’. It has been primarily university clinics that were chosen as such light-house places. There they had a degree of organisation of 20% plus. The union has clear criteria for deciding which hospital is a ‘light-house’ and which not. Have there been previous strikes, for example. It somehow works, in the sense that under the condition of a general shortage of labour, if you sign a good agreement in a ‘light-house’ hospital, it will create a magnetic field, meaning, the other hospitals will have to follow if they want to retain their staff and don’t want to lose them to the ‘better employer’. There are perhaps 30 of such ‘light-houses’ in Germany. It radiates even into the elderly care sector. Before the labour shortage they wouldn’t hire people from an elderly care background. Now even management of care homes have to orient themselves towards the general hospital conditions. Now most workers in care homes are recent migrants. Back then many people chose to become an elderly care nurse, because you had more autonomy. You are more independent than in the hospital, where nurses are often just the hands of doctors. But that has changed, not many are left in the care home. Returning to the subject of the team delegates, initially anyone could become a team delegate, but now, at least here in Freiburg, they have transferred the team delegates to the local Ver.di group, meaning, it is only for union members. Initially the team delegates were younger colleagues, who got motivated during their first dispute. Now that the delegates are also part of the local Ver.di group, it is largely the old union guys that are left – but also a generation of young guys, who engage themselves in the ‘new union structure’.

Another question regarding the 1980s nurses movement and the situation today. In the 1980s the movement definitely had an international dimension, with France, the UK and Germany at least. Do you see something similar happening now, after the pandemic, with more militancy amongst health workers in most countries, in particular the US, UK, Germany perhaps?

There are strikes and mobilisations in every country you mentioned. For the 1980s we can say that it was particularly the French experience  – the coordinations as a new form of self organisation – that had an international impact. The actual ‘union recomposition’ has certain limits. For example Ver.di has to make a major effort in order to get things off the ground in the hospital mobilisations. There is not so much self-activity. Because the effort and resources required are so high for the union, they only focus on nurses. They don’t have the capacity to include everyone, even if they themselves would theoretically support it. Some officials say openly “there is nothing for us to win by expanding to other professional groups”. “If they join us on their own accord we are happy, but we don’t have the resources otherwise.” The fact that they are so self-contained as a nurses’ mobilisation also means that there were not many interesting links between strikes in the health sector and recent strikes of postal or transport workers. There are rare occasions, as a comrade of ours told us, where Ver.di bundles up some striking Amazon workers and drives them to a nearby strike picket of shop and retail workers. But that’s all in terms of connections. Then politically, since the war in Ukraine started, the unions are integrated through the so-called ‘concerted action’, where the SPD government, employers and unions decide about certain economic decisions together. Most recently they agreed on measures such as to push tax free inflation compensation payments instead of permanent wage increases. This allows the employers to plan ahead in relative tranquility. The deal in most sectors was: long wage contracts, which means less disputes, plus low permanent wage increases and higher tax free one-off payments.