When Pat Cullen, the general secretary of the Royal College of Nursing, had her first meeting with Steve Barclay, the health secretary, in November last year, her union had just been balloted on strike action. “We’d just got our mandate,” she says, speaking at the RCN’s office in central London, an august building full of plaques. “And our results were really significant. So I knew that we had one opportunity to prevent a strike that was going to be enormous – the largest nursing strike in the world.”
Cullen is warm yet formidable, with a calm, level manner, but an unsettling habit of really listening and weighing her words. There are no dead zones in her sentences, which puts you on your mettle – although it didn’t, apparently, have that effect on Barclay. “It was an introductory meeting, collegiate and respectful,” she says.
They talked through many of the wider problems affecting nurses: the high levels of violence and aggression that they face from patients and what might be driving that; the incidence of sexual assault in the workplace in a predominantly female profession; systemic racism. Barclay listened intently. “And then I said to him: ‘Look, the elephant in the room is pay. If we are to try and prevent the strike action, we need to get round the table and talk about this.’ And he said: ‘You have to understand, economically it’s very challenging. But let’s talk.’ Then he got up and left.”
The RCN is arguing for a pay rise of 5% above retail price inflation, which is currently at 14%, but Cullen says that after a decade of intermittent public sector wage freezes nurses “were on the back foot starting off this period, their pay having dropped by almost 20% [in real terms]. This government has lambasted us for asking for 5% above the rate of inflation, but it’s actually the restoration of their pay. It’s not really a pay increase, when you think about it.”
Not every service in England reached the turnout threshold – 50% – for strike action, although all of Scotland’s and Northern Ireland’s did, plus all of Wales’s bar one. “And those organisations that didn’t make the thresholds that this Tory government has put in place, in many of those areas we missed it by a handful of votes,” Cullen says. “They’re now in constant contact, asking us to reballot them.” She wasn’t bluffing: the nursing staff in large parts of the NHS were about to go on strike for the first time in the RCN’s 106-year history (although nurses in Northern Ireland had led the way three years earlier).
December arrived and Barclay called a second meeting. “The line was drawn for us as soon as we walked in the door: ‘We’re not here to talk about pay.’ I continued to talk about pay and said: ‘It’s two nights before the strike. Are you going to negotiate with me?’ I did most of the talking. He closed his books. And he and his team said: ‘We can talk about non-monetary issues, but we’re not talking about pay,’ and walked away. He didn’t say this, but I certainly left thinking: the PRB [pay review body] is more important to this man than the NHS. And more important than patients. And certainly more important than the nursing profession.” The PRB had recommended increases in its previous round.
Cullen had been travelling the “depth and breadth of England” since September – “every hospital, practically. And I spoke to hundreds and hundreds and hundreds of nursing staff, on the wards and in their departments and in their communities. And I came away thinking things were even more challenging than I thought they were.”
As long ago as 2017, Theresa May was asked on air to admit that it was “surely wrong” that nurses were having to use food banks; the general assumption that they are probably doing OK is long gone. But, Cullen says, the cost of living crisis has brought this to a new level. “Some of those nurses cried with me. They walked with me and showed me food banks that they were reduced to using. They talked to me about the fears they had about their children going back to school and they couldn’t afford their shoes; about [hospital] trusts setting up uniform exchange arrangements for them, so that they could get secondhand uniforms for their children. It was heartbreaking. I can’t emphasise enough how much our nurses are struggling every single day just to keep themselves afloat.”
Every nurse I have spoken to – as well as some people working in social care – has colleagues who have left for retail jobs, despite their high levels of often specialist training, because it is paid equally well, with better conditions and much less jeopardy. “We have 47,000 unfilled posts,” Cullen says. “Can you imagine being a ward sister, coming in to 40 very ill patients at six o’clock this morning? Out of those 40 patients, you’re actually staffed for 25. The rest are on corridors and half your workforce is missing. You’re spending your morning trying to ring your current staff that have just left the hospital, begging them to come back and work a few more hours. It’s dreadful. It’s absolutely dreadful. And this government has just turned their back on them.”
Until very recently – more on that later – Rishi Sunak echoed Barclay’s approach, saying there was no scope for pay increases and therefore very little to negotiate. The intransigence has been noted by many unions, across multiple sectors, who sound almost surprised by it. One Unite negotiator, Onay Kasab, described his conversation as “an insult to every single one of our members”. Ministers seem to be taking a novel position: that unions are much like kidnappers and sensible people never negotiate with them. What they might not know is that Cullen has spent her life negotiating – and previous opponents were probably tougher.
The 58-year-old came into nursing in 1982, inspired by her mother’s care for her learning-disabled sister. She has four other sisters, also nurses, and a brother. Her father died when she was 13 and her mother was keen that they all “got a government job and saw the world”. They lived in a very Republican village in Northern Ireland at the height of the Troubles and her mother was worried they would “get into the politics”. In turn, Cullen tried to badger her son, 32, and her daughter, 27, into nursing; both refused. (He is a plastic surgeon and she is a teacher.) Their father, Enda Cullen, is a GP.
Cullen started in Belfast as a mental health nurse. “You spend a lot of your time negotiating with patients, through very challenging periods in their lives and very challenging behaviour,” she says. “I would have been nursing people who would have displayed very high levels of aggression, particularly when I moved on to work in forensic mental health and prisoner healthcare.”
One of her earliest campaigns – as an individual, rather than through the RCN, although she has been a member throughout her career – was to stop mentally ill patients having their belongings taken away over behavioural infractions, which she thought was an insult to their dignity. “I don’t deal well with injustice. When it stares me in the face and I know it’s wrong, I can’t let it pass by.”
In the 80s, she could see the impact of the Troubles on people’s mental health all around her. “Even as civilians living through the conflict, we could always see the need to negotiate and to get around a table and work things through and come to an agreement,” she says. “That was just something we did, from negotiating ourselves through army checkpoints, coming and going when we were at school, to trying to make a 7am shift, running late, having three checkpoints to get through.” It explains her manner – emollient but doughty – and it also makes me worry a bit for her adversaries. She isn’t a woman who wants to give up. She is a woman who wants to get to work.
While nurses saw their pay erode over the past decade, Covid heaped on a different kind of pressure. Cullen is careful not to blame everything on the pandemic, because she thinks it takes the spotlight off policymakers’ long-term mismanagement of the NHS. Undeniably, though, Covid has left its mark. “I have never seen the health and wellbeing of our nurses so poor. Every single nurse gave everything they had during a pandemic – everything,” she says.
“They worked night and day, moved out from their families, went and lived in makeshift hotels. Some of them slept in the hospitals. They worked in the most incredible conditions in intensive care, some of them working 14- or 16-hour shifts, without the proper equipment, going into situations that were unknown to every single one of us and fearing for their own lives.” Many nurses have been diagnosed with PTSD since Covid emerged; many others were killed by the disease.
At the start of the pandemic, Cullen was the RCN’s director in Northern Ireland. She vividly remembers having to drive from place to place, looking for any PPE they could find. “And we all got a clap on the doorstep. But on the day that the pandemic is supposedly over – it’s not over – those nurses don’t just return to normal health. Their health has significantly suffered, emotionally and physically. They are absolutely exhausted. They’ve had to get up, dust themselves off and get on with the next crisis. But this is even worse: they’re heading into it with totally depleted physical and psychological systems. They can’t do it.”
She was in her previous post when the nurses of Northern Ireland had their first ever strike, in 2019. About that decision, she says: “It’s not me that’s taking an industrial action. It’s our nursing staff.”
Let’s go back to all that clapping. “By the government, it was all veneer,” Cullen says. “It was the right thing to do at the time, to stand out and clap on the doorsteps of Downing Street and elsewhere. But there is no doubt that, very quickly, the claps became slaps, and they have slapped those nurses now as hard as they possibly can, and left them behind. Every single nurse sees it, every single nurse believes it.” But public regard for nurses has always been – and remains – extremely high. “The public believes in nursing because nursing believes in the public,” Cullen says.
Nurses are an extremely hard group to demonise, even when they are on strike. The RCN raised hundreds of thousands of pounds for its hardship fund in donations from the general public in a matter of weeks. Carmel O’Boyle, an RCN branch and board chair, describes people joining the nurses on picket lines and bringing food with them, “because, in the north-west, people know how to join a picket line”. They ended up with so much food that, even after they had made parcels for the people losing their day’s wage, they donated most of it to a food bank.
So the government’s starting position – that nurses can safely be ignored – never looked like it would get past public opinion. Earlier this month, Sunak began to realise that, floating the possibility of a one-off hardship payment. “The first we saw of it was through the media,” Cullen says. “And yet they say: ‘We won’t negotiate through the media.’”
This proposal doesn’t look likely to cut it: “I find that insulting to those nurses. It’s almost a charitable approach,” Cullen says. “And it’s not going to allow us to retain or recruit nurses. There’s no workforce plan in place for nursing. There’s no strategic planning anywhere in the health service. It’s all just reactive stuff. And that’s symptomatic of how this government makes decisions. They make on-the-hoof decisions to try and get them over the next couple of weeks.”
If Sunak meets the nurses’ union even halfway, he will be gambling on the hope that he can pick them off as the people’s favourite striking workforce and it won’t affect his negotiations with other sectors. Structurally, he might have a chance – the RCN is not affiliated to the Labour party and not a member of the Trades Union Congress. “At the same time, we fully believe and support what other trade unions are trying to do and stand by them,” says Cullen. “And if you think of the ambulance strike at the minute, what they’re looking for is exactly what we’re looking for: to improve the lives of their workers and to make sure that we run an NHS that is fit for purpose.
“Is this the total demise of the health service? Is this where we consign the NHS to the history books to say this is what we had and we didn’t look after it?”
Her “No way!” is silent.
