Health trade unions need to collaborate rather than compete for members. If they do not, says Andrew Cole, they will lose the ground they have gained under this government

These are heady days for health service trade unions. They are represented on a host of taskforces implementing the NHS plan; they have a guaranteed seat on the interview panels for private finance initiative bidding, and they can take much of the credit for the human resource agenda that is now being enacted in trusts and authorities around the country.

Bob Abberley, head of health at Unison, says he sees health secretary Alan Milburn as 'often as needed' and special advisers on an almost weekly basis. This contrasts with one meeting a year - as part of a TUC delegation - when the Conservatives were in power.

'The difference is We are now part of the family. '

And it is true that in the early 1990s trade unions tended to be seen as at worst a threat, at best an irrelevance. The idea of a Conservative health minister seeking the advice of a trade union such as COHSE or NUPE would have been laughable.

Unison and MSF representatives may now be on first-name terms with health department civil servants and be represented on all the right committees, but what does that really mean in terms of power and influence? Brian Edwards, professor of healthcare development at Sheffield University, and a former NHS manager, suggests unions' influence on health policy under Labour has been no more than marginal and even this has been won at the expense of influencing pay and jobsecurity issues.

'The acid test is, are health service staff any further up the pay league than 10 years ago? If the answer is that they're not or have gone backwards, then it would suggest they've got their priorities wrong. '

David Hunter, professor of health policy and management at Durham University, feels the unions have been neutered by their involvement in policymaking and anxiety about saying anything that could cost Labour the next election. 'To some extent they all seem to speak the same modernising language - It is a bit like The Stepford Wives. '

The danger is that the unions' own members may start to feel short-changed, he suggests. 'People may well start to ask: 'Why should I be a member of a trade union?'' All this reflects the central dilemma faced by both health unions and professional organisations under a Labour administration - should they be in Tony Blair's big tent or outside it? 'Most unions have tried to be in the tent on the grounds that It is pretty cold outside and We have been outside for a long time, ' explains MSF's head of health, Roger Kline.

The 18 years of Conservative rule were miserable ones for most health unions, which reached their nadir in the early 1990s with an anti-union ethos that spread from government to many of the new trusts set up under the internal market. Gagging clauses became commonplace and many trusts tried to bypass unions altogether.

The wholesale move to contract out cleaning, catering and portering services made a huge dent in union membership - particularly Unison's.

Overall the number of ancillary staff dropped by 30 per cent while most of those who remained found themselves in the private sector.

Curiously, the Conservative years only had a marginal impact on the overall proportion of union membership in the NHS - which at around 62 per cent, remains one of the highest in any work sector. But both Unison and MSF admit their numbers were hit. It is only in the past couple of years, partly as a result of a Labour government and a more sympathetic climate, that membership is on the increase once more.

The major exceptions to this trend were the single-profession trade unions or 'professional organisations' such as the British Medical Association and, especially, the Royal College of Nursing. Indeed the RCN was the one organisation whose membership continued to rise throughout the Conservative years, climbing from 177,000 in 1980 to 302,000 by 1995. It now stands at 330,000.

For a variety of reasons nearly all the major unions are virtually unrecognisable from the organisations that operated in the health service in 1990.

In Unison's case that is so because it didn't exist. It was formed from the merger of COHSE, NUPE and NALGO in 1993, becoming in the process the biggest health union, as well as the biggest trade union in the UK, with a combined current membership of 1. 3 million. At the time of the merger it claimed membership of 1. 4 million.

MSF, which was itself born out of the merger of ASTMS and TASS in 1988, has also expanded its health sector significantly, taking both the Community Practitioners' and Health Visitors'Association and community psychiatric nurses under its wing in the past 10 years.

The image of the trade union has also changed.

Whereas unions used to exist primarily to lobby for better pay and conditions, most now offer a range of services including insurance, mortgage help and cheap holidays.

Even more significant is the growth of educational and professional development opportunities. The RCN has a long tradition of this, but Unison, for instance, now offers nursing courses, as well as a number of 'return to learn' courses for those with no qualifications.

Both the college and Unison have also invested heavily in direct helplines providing members with information and advice at the push of a phone button without having to go through the normal branch route. 'Not everybody feels comfortable about not channelling advice through the regional and branch offices, ' admits Unison local government officer Malcolm Wing, 'but often members do not want advice, they want information and Unison Direct is the quick way to get it. '

Yet most agree the central reason for joining a trade union in the first place remains the same - a desire for protection and insurance when things go wrong. And this can mean a delicate balancing act for unions attempting to pursue a more proactive agenda. As former Institute of Healthcare Management deputy chief executive Suzanne Tyler observes: 'Unions are always trying to be at the cutting edge of practice and professional development. The trick for them is to make sure that the gap between them and their members doesn't get so big that the members become disillusioned. '

Not everyone feels that the unions have got this balance right. Chris Hart, a team leader at the Maudsley trust, quit as a full-time official with Unison in 1995 because he felt the merger of the unions had diluted the health focus and massively increased the bureaucracy. He believes the union has become much more of a service-led organisation rather than a forum for collective action.

One of the results, he says, has been the decline of trade union activism and the disappearance of many hardworking representatives at local level.

As a result the gulf has grown between headquarters and the grassroots membership.

'There is much less activism than there used to be, ' says Mr Hart. 'Most health workers do not really know where their organisation stands on a number of issues. ' This can in turn undermine national representatives in their negotiations with government. 'They know how weak the relationship is between the national organisation and the branches. '

Unison is not alone in facing this accusation. Ray Rowden, who was an RCN officer in the late 1980s, and stood for president earlier this year, has noticed a falling-off in the number of college stewards, together with smaller branch meetings, and blames this on growing 'control freakery' at the centre.

'There is a sense of distance from the leadership and no clear idea of where the college is going, and I think that distance has grown in the past 10 years. ' Headquarters needs to connect more with its members, he feels, and that will not be achieved through cosying up with government. 'Does the average staff nurse worry about the amount of time Christine Hancock gets with the minister?'

The unions are quick to emphasise the benefits for members as a result of their collaborative approach to government. These include the minimum wage, a raft of humanresource and equal-opportunity reforms, and a number of nursing innovations, such as NHS Direct, the involvement of working nurses on PCG boards and the creation of nurse consultants.

Bob Abberley believes many of these gains would have been unimaginable under the previous government. He also points out that health staff have received above-inflation pay increases which would have made them think 'they were in dreamland if this were a Tory government'.

'Generally a lot has improved in the past three years and I think that comes from us being involved at the policy table. 'He points to Labour measures to stamp out racism and violence in the workplace, concerted plans to increase staff numbers and moves to introduce a new pay system.

Nevertheless, the special relationship has failed to produce the goods in some important areas. Despite bitter opposition from the TUC-affiliated unions, the government has forged ahead with the private finance initiative, for instance. Other crucial decisions, such as the private-sector concordat and the extension of London weighting, reportedly took most unions by surprise. Moreover, the continued delays on one of their most prized aspirations, the new pay structure, is testing patience to the limit.

Roger Kline accepts the benefits of uniongovernment collaboration have not been as great as many expected and that in England in particular there have been clear limits to the partnership.

He also acknowledges that unions may have exercised a degree of self-censorship in order to maintain good relations. 'There are issues we do not speak out about on the grounds that if we want concessions on 'x'we may have to speak more softly on 'y'. '

For instance, when it became clear that despite union opposition the government was not going to change its position on PFI, MSF changed its focus to concentrate on retaining members' jobs and conditions within a PFI framework.

'We have moved from the issue of principle to the practicalities, ' says Mr Kline.

But he stresses that union members can benefit as much from better policy as better pay. Improved pay will not be of much use to members in the path labs if the service gets privatised, he points out.

'Having an influence in policy is not an alternative to campaigning - It is campaigning in a different way. '

At the same time, trade unions always have to remain in touch with their members' priorities.

'Members understandably want to know why it is that pay policy under Labour hasn't delivered what we had hoped it would, ' he says. 'But our answer would be that there is still a good chance it will. '

There is no doubt the next few years will test the strength of the social partnership to the limit. But that is only one of a number of challenges - both internal and external - that unions are likely to face.

The growing fragmentation of the workforce, with more work being conducted in the community and people's homes, is going to make it increasingly difficult to organise, while the trend towards providing services in the private and voluntary sector is likely to hit union membership.

At the same time devolution poses logistical and strategic dilemmas for unions which have naturally inclined to a centralist approach. Some unions, such as Unison, have done more than others to decentralise and set up a truly federal structure. But all face the problems of spiralling costs and sorting out the exact relationship between the four countries.

In future, unions will probably represent a more disparate and fragmented workforce with a much more federalised power structure. Above all, the health unions have to face the fundamental question of how they can continue to grow at a time when many factors are pulling in the opposite direction. Growth has become essential to finance the growing raft of services on offer - as well as giving them the all-important industrial and political muscle.

Brian Edwards predicts larger and more generic unions but believes that could be their downfall because they would no longer be able to represent the special needs of specific groups.

An intriguing alternative, put forward by Bob Abberley at Unison, is a realignment of functions and membership within existing unions. 'I think It is time trade unions in the health service started coming together rather than looking to compete for each others'members, ' he says.

The RCN's decision to open its doors to healthcare assistants has not helped matters in this respect. But he believes it might still be possible for Unison and the RCN to find a means of co-operating rather than competing.

One of his declared ambitions when he became head of health in 1993 was to establish a new relationship between Unison and the RCN. There could be several models for this, but he doesn't discount the idea of a realignment where all registered nurses are represented by the RCN and all nursing and healthcare assistants by Unison.

'That wouldn't be easy for the membership of the RCN or Unison, ' he admits, 'but at the end of the day it could be good for health workers.

'We need to grow up as organisations and do what's best for the health service and health workers. Collaboration is always better than conflict. '