Angels no longer fear to tread

Nurses are not known for their militancy. So what has pushed Sarah- Jane Anscomb and her colleagues to the brink of industrial action?

In the bravura new world of St George's Healthcare NHS Trust Hospital in south-west London, where patients have become clients, and an electronic sign on the wall of Accident and Emergency says that the wait for a sprained ankle or a crushed finger will be two hours, you will find Sarah-Jane Anscomb, a 30-year-old junior sister, dealing with the following minor ailments: a cyst behind an ear, a twisted ankle, a child with a high temperature, a footballing injury to a leg, a knee injury, a cut wrist (accidental), a cotton bud stuck in an ear, a painful eye, an abcess in the groin, assorted face injuries, a man assaulted over the head with a mug, a boy who kicked a chair not the ball, and a woman who broke her hand hitting a wall when she meant to hit her dog.

Everyone calls her SJ. SJ has been working in A&E since this new block opened in 1988, and she is not pleased with many of the changes she has seen in the last six years. First there was the salary mayhem over clinical regrading, and then the trust opt-out, which introduced concepts not previously associated with her profession, such as productivity pay and performance targets.

She wonders how her employers can quantify what she does. Her job is about care, reassurance, supervision, telling people how long they will have to wait to see the doctor, "more with words than my hands," she says, but the people on the floors above reward turnover.

The rewards now are not enough. Two weeks ago the Government announced a guaranteed annual pay rise of only 1 per cent, less than inflation, less than junior doctors and consultants. SJ is a calm woman, and from what I could see a model nurse, but increasingly these days her patience and goodwill give way off-duty to exhaustion and exasperation. She says she has not known a time of lower morale among her colleagues, nor such a feeling of militancy. And for the first time that she can remember, the possibility of strike action is no longer just a distant threat.

On Tuesday SJ met her first client just before 7am, a man who had been waiting with earache for an hour. St George's sees about 200 people a day in A&E, and all over Tooting, Clapham and Balham this morning people were falling off stools and jamming fingers in car doors and suffering from acute asthma. And so the trickle became a flood, and the wait lengthened, and the staff coped as well as they ever do, and by lunchtime about 30 people had left the hospital strapped and rattling with analgesics.

For this SJ gets £15,640, plus a little for unsocial hours and an average £1,500 London weighting - pre-tax, for a 37-and-a-half-hour week. After tax, the 1 per cent pay award will add about £10 per month, which she'll put towards her £230 monthly mortgage on her two-bedroom flat in Mitcham, or her £184 monthly car repayments, or her gas or electricity or phone. In the evenings she rents videos, or meets friends, and on days off she goes to museums, anywhere with free admission. She just gets by, but she wonders about the student nurses and the newly qualified, struggling on minimum wages of between £7,125 and £11,320.

Local pay bargaining - conducted between nurses and their trust - may yield between 0.5 and 2 per cent more, still probably less than the nurses' demands. "We're clearly not asking for a ridiculous amount," SJ says. "We're asking for 3 per cent because we know the NHS can afford it."

SJ is a local steward with the Royal College of Nursing, responsible with eight others for about 1,500 members in her Wandsworth area. In her holdall she carries a copy of Newsline, the RCN newsletter, which discusses pay in plaintive tones: "How much longer can we expect nurses to be paid less than the police or people working in banks?" asks Christine Hancock, RCN General Secretary. "Nurses are now at full stretch - what more does the Government expect?"

The problem is, that was last year, when they were awarded the 3 per cent they've been denied this year. This is what SJ finds hardest to understand: having met all targets, and assumed more responsibilities, the rewards have become fewer, and the incentives less.

She also carries a copy of the Nursing Times, with its letters page full of unfamiliar rage. "It is a well-known fact that nurses lie down to be trampled underfoot," writes a male nurse from Gwent. "Perhaps if the new generation of nurses coming through the system stood up for themselves instead of surrendering all the time, we may gain more credibility and the professional image to which we aspire."

"I am outraged at the atrocious [pay] awards," writes another from London. "The image of the nurse as `angel' must cease herewith. Nurses need to pay mortgages and feed their families ... those nurses who are proud of the angel image must consider the damage this is doing to the profession ... if you do not take a stand now it will be assumed that you are content with your lot."

Once, SJ saw nursing as a career, not a job, viewing it with a good deal of idealism. She comes from a small farming community in Buckinghamshire. Her brother followed her father into the Navy, but she "wanted to help people", she says, blushing. She did four years' training at St George's, and got her first job at St James's in Balham, once the set for the television nurses drama Angels, since closed.

Eight days after her move to St George's she "walked into something that looked like hell", the aftermath of the Clapham rail crash. Most days since, it's been calmer, and the worst she sees in the Minor Unit today is a shattered wrist.

She dreads the Monday late shifts, and bank holidays, and the uncontrollable drunks. Every week she encounters aggression and violence, and she regrets that her department is sealed off by a security door. She can understand why more young students are not attracted to her profession, and why a shortage of qualified nurses is now a problem that becomes worse each month.

She foresees many obstacles over local pay bargaining - the time this will take away from other duties, the new conditions the negotiations will demand. It may also set nurse against nurse if a trust awards more to its staff than a neighbouring one.

On 30 March the RCN will join forces with the rival nurses' union Unison, and with the Royal College of Midwives and the Health Visitors' Association, in a day of public protest. We will see a lobby of Parliament, and rallies and demonstrations and petitions. A work-to-rule policy may be introduced.

There are few more poignant images of societal breakdown than picketing nurses, but it is a picture with which we may become increasingly familiar in the coming months. The RCN and RCM are both likely to ballot their members on their current no-strike agreements.

"Obviously some people will claim that when you go into nursing you know it's not going to be well-paid," SJ says. "But there are limits of exploitation. I do think the public realises we've got a case." And then of course there is the issue of conscience, and the well-being of patients, the reason she became a nurse to begin with. She knows, she knows: she has struggled with this one many times, and of course she doesn't wish to see anyone suffer. But she now wonders what more she can do, and what else she can give.

In what may be seen, rightly, as an act of tremendous altruistic symbolism, she decides to donate blood. This is not a media stunt; she does it every three weeks, lying on a couch for 90 minutes while the South Thames Blood Transfusion Service spins off her plasma and platelets. On Tuesday the book she read to pass the time was about intensive care, and from time to time she set it aside to consider the agenda for this afternoon's union meeting. Talk of industrial action would provoke great passions, she was sure, and moves towards a strike would win much support. Even a year ago she never thought it would come to this.