Collective agreement for health protection and minimum staffing levels at Charité Berlin

Article in the Perspectives series by Matthias Neumann(article as PDF) Charité is a joint operation of Berlin's university hospitals. In May 2016, the employees here fought for a collective agreement on minimum staffing levels on the nursing wards. This collective agreement has been enforced for years in the face of persistent resistance and is currently set to become a model for industrial action in other hospitals. There is much that is new and special about the dispute at the Charité. This will be illustrated below [caption id="attachment_2117" align="alignnone" width="640"] Photo: Nate Pischner. Licence: CC-BY.
At the joint UmCare conference (16-18 October 2015) organised by Care Revolution, the Rosa Luxemburg Foundation and DIE LINKE, people from academia, politics and activism came together to look for strategies for health work, care and assistance. At the joint protest action, some participants created a symbolic net and expressed their anger at the daily pressure on time and money in the health and care sector in combative speeches and self-made signs.[/caption] The fact that industrial action is being taken with the aim of deploying more nursing staff on the wards is unusual and is a reaction to the massive work pressure that nurses are exposed to in hospitals. This pressure is not caused by the content of the work, but by the framework in which the nursing staff do their work. And this framework has been massively changed to the detriment of carers with the introduction of flat rates per case in 2004. Flat rates per case mean that every case of illness or injury is allocated a cost via the DRG (Diagnosis Related Group) system, according to which the hospital receives remuneration. While the recruitment of additional doctors results in additional billable services, such as operations, nursing staff are purely a cost factor in this system; it is profitable to consolidate and rationalise their work as much as possible. ver.di, the trade union, addressed the unbearably increasing workload of nurses in April 2011 with the campaign "The pressure must come off" for better working conditions in hospitals. In doing so, the union aimed to achieve statutory regulation of minimum standards for staffing wards with nursing staff. In this way, the minimum staffing levels should be universalised so that hospital companies do not achieve cost advantages by employing fewer nursing staff. The Charité works group decided not to wait for a statutory regulation to be enforced, but to strive for a collective agreement on minimum staffing levels on the wards. In contrast to a campaign for a law, this also involved the use of industrial action. The core of the demands at the Charité was a staffing ratio on the wards of one nurse to five patients; in intensive care units, the goal was a ratio of 1 to 2. [caption id="attachment_2120" align="alignnone" width="640"] Photo: DIE LINKE parliamentary group in the Bundestag. Licence: CC-BY.
ver.di-Charité strike demonstration on 23 June 2015 in front of the Bundestag[/caption] It then took three years from the start of the "The pressure must come off" campaign to the start of collective bargaining, during which the Charité management systematically delayed and refused to negotiate. In April 2016, Charité employees secured a collective agreement on health protection and minimum staffing levels. The union members approved the agreement by a large majority (almost 90 per cent). Staffing ratios were set for intensive care units (1:1 to 1:3) and the paediatric clinic (1:6.5). This was not achieved for the "normal care wards", three quarters of the Charité's wards. However, there are orientation values, compliance with which is to be ensured by a health committee with equal representation and a neutral ombudsperson. Beds can be closed if the minimum standards set for working conditions are not met. This would result in financial losses for the company. This agreement, which remains a compromise, will initially run until June 2017. The result of the years-long dispute alone is remarkable and uncharted territory. However, much of the dispute itself is also instructive and helpful for care activists inside and outside hospitals. Three areas seem particularly important to me:

1. It became apparent that the neoliberal restructuring of hospital funding, which exposes nurses to the effects of cost pressure, makes hospital companies more vulnerable in labour disputes. In the 2011 strike, in which the gradual realignment of wages to the public sector wage agreement was enforced, the strikers forced the closure of 40 wards with almost half of the beds at the Charité, while at the same time cancelling 90% of operations.[1] With this strategy, they took advantage of the fact that, according to the principle of flat rates per case, the hospital loses revenue for every operation cancelled and every patient not admitted due to a lack of beds. During this five-day strike, Charité suffered losses of around €5.5 million[2]. At the same time, the ward closures enabled more nurses to take part in the strike, as the emergency service could be restricted and nurses were freed from the dilemma of being responsible for the well-being of the people they care for in addition to their interests as wage earners.The fact that comparatively short strikes, such as in 2011 and 2015, or even the credible announcement of a strike, such as in 2014, had such an impact probably shows two things: firstly, the system of flat rates per case actually makes hospital operations vulnerable, and secondly, the management had to assume that the workforce would be able to hold out united for a longer strike.
2. The hospital employees were involved during the strikes and also in disputes below this threshold to an extent that is unusually intense for a DGB trade union. Three examples illustrate this. The adoption of the 2014 collective agreement was decided at a public general meeting, and the collective bargaining commission also submitted the result of the 2016 collective bargaining negotiations to the organised employees for a ballot. During the 2015 strike, collective bargaining advisors from the workforce played an important role in establishing the flow of information between the wards and the strike management. However, activists on the wards also played a key role in the 2014 collective agreement and continue to do so now. After all, only those working on the wards as "experts in their own cause" can provide feedback on whether the regulations will lead to an improvement in working conditions and whether the management will comply with them at all. This is why Carsten Becker, Chairman of the ver.di works group, sees the collective agreement as activating: "We can work every day to improve our working conditions."[3] The works group had already previously supported this everyday fight against the overworking of nursing staff with the "emergency call campaign". Here, ward teams were encouraged and supported to report overwork and quality losses in care and to demand measures to remedy the shortcomings. Co-operation with the staff council gives ward employees a realistic potential threat: while they announce their refusal to provide services over and above their employment contract, the staff council can refuse to agree to overtime. As a result, this can lead to the closure of wards. In addition, ver.di published seven selected emergency calls in June 2015 and also publicly scandalised the conditions at the Charité.
3. The desire to consider the well-being of patients was often seen by trade unionists as an obstacle to the willingness to take effective industrial action in hospitals and other areas of paid care work. The activists at the Charité tackled this problem in different ways by highlighting how the dignity and safety of patients are also jeopardised by a lack of and overworked staff: From the outset, the works group publicised the fight for more staff on the wards and the motto "More of us is better for everyone". The emergency call campaign also emphasised how the understaffing of individual wards affects carers and patients alike. The fact that such problems are brought to the public's attention is a step that should not be underestimated: here, an employee representative body is mobilising social support by refusing to cooperate with the management in presenting the conditions in the hospital as intact.

[caption id="attachment_2122" align="alignnone" width="750"] Photo: 123Comics. Licence: All rights reserved.
The Berlin Alliance for More Hospital Staff was founded in July 2013 to show solidarity with the strikers, but also to assert their own interests in good nursing care in hospitals.[/caption] In addition to this general reference to patients' interests and the interests of caring relatives, trade unionists, together with care activists outside Charité, put this reference on an organisational basis. In July 2013, the "Berlin Alliance for More Hospital Staff" was founded . Since its foundation, the alliance has supported ver.di's demands for a collective agreement, but is not purely a solidarity committee. In addition to the working conditions of the employees, the activists in the alliance are also concerned with self-care. Active members support the nurses' struggle because they themselves want to experience care and encouragement on a ward, because they do not want to suffer an infection from a hospital germ. They support the fight for more staff and against flat rates per case because they do not want to be overburdened with caring for relatives who are discharged too early. In this way, an alliance of people in different care positions - paid care workers, unpaid care workers, those dependent on care - has come about. Such an alliance can be a model for other initiatives in the Care Revolution network. On the one hand, there are very pragmatic reasons for this. An external alliance of supporters can do many things that a trade union is not allowed to do or that may not be enforceable within it. For example, when the management managed to avoid arbitration in March 2014, the alliance still organised the demonstration planned for the start of the strike as a solidarity event. And a support alliance that is based on a comprehensive understanding of care needs is an offer to the many individual, organised and unorganised people who want to work for change in hospitals out of their own interest. All too often, however, there is a lack of tangible conflicts and seemingly achievable goals. And last but not least, an alliance that acts on the basis of a comprehensive care perspective can spread the idea of the care revolution: People from different care positions can stand up together for their respective interests when they set out to shift the conditions under which care takes place in hospitals, for example. It is to be expected that we will soon have more opportunities to participate in such alliances. Because the example of the Charité is contagious. A collective bargaining committee has been formed at the Vivantes clinics in Berlin, which wants to push through a collective agreement similar to the one at Charité. The kick-off conference for a "TV Entlastung Berlin-Brandenburg" collective bargaining movement will take place in Berlin on 1 November 2016. The same is planned in Baden-Württemberg[1] Wolf, Luigi: Patienten wegstreiken. Industrial action at the Charité. In: Luxemburg 1/2013, p. 12-17[2]Latza, Jan; Kirsten Schubert: Pflegenotstand in der Fabrik Krankenhaus. In: analyse&kritik 587/2013[3]Johannes Supe: Interview with Carsten Becker. Finally there are demands on quality. Junge Welt from 30 April 2016