The current debate over the 2021 pay rise for nurses in England challenges the compact between the ‘state’ and those citizens who make an exceptional contribution to society. The COVID crisis has been compared to a war, and like soldiers, many nurses have risked their lives and health to ensure that the NHS has been able to save our own lives and health. How should they be rewarded?
We all exist within social communities. The strength of our communities depends on the formal and informal reciprocity of contributions and rewards between individuals. At the macro level, this community is the population within our country, and through the transaction of our contribution through taxes, we receive services from government. Beyond taxation, we might contribute to society through choosing to provide our time through employment or voluntary work. Governments deliver the services expected by its citizens, either through direct employment of staff or through contracted private companies. Some roles require a direct contract between the employee and government to represent the ‘state’, such as the civil service, the security services (intelligence, armed forces, police), criminal justice system, and diplomatic services. Some functions may be contracted to government such as education, health services, sanitation, public infrastructure; or even purchased as a private service by citizens. Individuals who work in roles that support society (rather than solely for their private benefit) may be rewarded by pay, employment stability, security of pension, or non-financial benefits such as beneficial entitlement to public services such as subsidised housing, preferential taxation.
In theory, the formal and informal relationships between society and government employees reflect the value of these citizens to society. Let’s consider this through the compact between society and its armed forces. Armed forces exist to protect the security of the ‘state’, with the ultimate sanction of using lethal force to destroy its enemies. This may result in members of the armed forces becoming injured or killed. Recognising this risk, many countries provide social and welfare support to members of the armed forces and their families that exceeds that provided to other government employees or citizens. As an example, the US ‘Post 9/11’ GI Bill provides substantial financial support for education and training for service personnel, Veterans and family members at a cost of $12Bn (FY2019 budget) for 800,000 participants; furthermore, the US Department of Defence (DoD) spends $56Bn (FY2019) on military health services for 9.4 million beneficiaries (serving personnel and their families) and the Veterans Administration spends $76Bn for to provide healthcare to 9.2 million entitled retirees.
In the UK, many of the equivalent services funded by the US DoD for armed forces personnel and their families are already provided by central and local government through general taxation (e.g. healthcare by the NHS and education by Local Authorities) so there is less need for expenditure by the UK Ministry of Defence on welfare benefits. However, UK armed forces families are able to access subsidised housing, allowances to pay for private education, relatively valuable pensions, and generous occupational arrangements for death or ill health attributable to military service. Beyond this, and building on the wave of public support for the armed forces attributable to the large numbers of personnel injured and killed from the conflicts in Iraq and Afghanistan, there has been sustained pressure on the UK government to develop the Armed Forces Covenant. This government policy reflects the ‘promise by the nation ensuring that those who serve or who have served in the armed forces, and their families, are treated with fairness and respect in the communities, economy and society they serve with their lives’. The Armed Forces Bill 2021 will create ‘a new Duty on public bodies in the areas of housing, healthcare and education to have due regard to the three principles of the AF Covenant: the unique obligations of, and sacrifices made by, the Armed Forces; the principle that it is desirable to remove disadvantages arising for service people from membership, or former membership, of the Armed Forces; and the principle that special provision for Service People may be justified by the effect on such people of membership, or former membership, of the Armed Forces’ (Armed Forces Covenant). The political and social journey to bring these ideas into legislation has taken over 15 years across government administrations of all political persuasions.
So, returning to the debate about nurses pay and the 2021 financial ‘reward’ for service during the COVID 19 crisis, the government faces the challenge of ensuring appropriate recognition for individuals and groups who have provided support to society that has been unique and involved personal sacrifice. It could be argued that the same principles contained in the Armed Forces Covenant also apply to nurses and so it would be easily to extrapolate these into a similar package of beneficial services, including pay, to this professional group. However, the range of identifiable groups (doctors, police, teachers, social care workers, volunteers etc) to whom this definition might apply and the numbers involved is substantially greater than the discrete and identifiable group labelled ‘the Armed Forces Community’.
As the UK approaches a ‘new normal’ in which the core activities of society (commerce, education, health, transport etc) have recovered to a sustainable level of activity, it will be important to consider how to acknowledge and recognise those whose contribution to society during the crisis has been disproportionately unique.
How should the ‘state’ make this recognition? …. Who should be excluded? … How can these decisions rise above politics? …. Can this be done quicker than the creation of the Armed Forces Covenant?
Written by Professor Martin Bricknell CB
Martin Bricknell CB is Professor in Conflict, Health and Military Medicine at King’s College London. He left the UK Defence Medical Services after a full career that culminated in the appointment of Surgeon General. His research focusses on civil-military relations in health systems.