The nurses' dilemma (1982)

From the November 1982 issue of the Socialist Standard

In any dispute over their pay, nurses are in an extremely difficult position. The desire to care for other human beings and to accept responsibility for them when they are in need is a compelling desire for most, if not all of us. The gratification of this desire is intensely rewarding and the great majority of working people, their lives eclipsed by a nine-to-five routine, may speak with envy of the nurses' privileged role. It is true that nurses may in some instances be moved to acts of gross inhumanity. whether by occupational stress or shortcomings in their private lives; this is amply demonstrated by recent well-publicised reports of sustained brutality towards patients at the Rampton Hospital. But for the overwhelming majority of nurses, and for all workers with a direct involvement in patient care, the patients' needs command immediate concern and attention.

Thus it is only in the last few years that nurses in this country have even threatened industrial action. In their ballot on the initial 6.4 per cent pay offer. RCN nurses refused an offer for the first time ever. Even while some nurses are striking in defence of that refusal a few creep back, conscience-stricken, through picket lines, to bring fish and chips to the patients or reassure themselves that the remaining staff can cope. After the IRA bomb attack in Hyde Park, large numbers of local health workers called off their strike in order to look after the victims; and the TUC Health Services Committee still insists upon its code of conduct, according to which emergency services must be maintained throughout the strikes. In effect, all health workers (but above all the nurses) are morally blackmailed not to strike.

Can anyone doubt their desperation, when people accustomed to such selfless actions can bring themselves to dismantle beds (at the West Cheshire Hospital) to prevent further non-emergency admissions? Can anyone believe that they watch the waiting list for surgical operations at St. Thomas’s Hospital in London mounting to the 8,000 mark, and hear a district health administrator in Doncaster announcing that "it may be the case that some patients are dying" with equanimity? Some health workers even called for a one-day suspension of the accident and emergency services. These people are not murderers, whatever the newspapers may say.

The tragic fact is that there can be no progress towards their simple quest as they do their gruelling work for the benefit of others, unless they are also ready at times to endanger the lives of their patients and dependants by industrial blackmail. All workers are mercenaries, who must sell their abilities to an employer or else go hungry; and just as the buyer must learn those highly-valued attributes of the successful businessman — hard bargaining and ruthless persistence — so also must the worker, if he or she is not to be degraded to the barest minimum of subsistence. Mercenaries learn quickly that conscience and devotion to "duty" are luxuries which, at times, they cannot afford.

Any illusions about the NHS being a service created with the humane motive of free care for all, are dispelled if we consider why health services in a rudimentary form were available to workers as early as the mid-nineteenth century. Is it credible that tyrannical employers, bleeding their workers for every last drop of profit, should have subsidised medical attention for their sick and injured wage-slaves, solely for the latter's benefit? The major improvements in sanitation, the building of many early hospitals and workhouses and the proliferation of doctors in Britain during the nineteenth century, were generally limited to those areas where industry needed a fit and healthy workforce, rather than those parts where people's needs were greatest. London and the major English conurbations had well-established systems of relief for the sick, the disabled and the most impoverished males, long before the centuries-starved and diseased peasants of Ireland (then part of the Empire) received any succour. And when conditions at last began to improve in Ireland, as in underdeveloped parts of all nations, they did so first in industrial centres (in the North), only benefiting people in the populous but economically backward country districts as they gave up their ties with the land and put themselves at the service of their new industrial overlords.

The myth of the NHS as an island of welfare in the sea of capitalism is fast waning as the recession puts increasing pressure on the provision of services. The taxes levied to finance these services are a burden ultimately on employers, who are prepared to provide maintenance services to their workers for reasons of efficiency; but in a recession even this is threatened. Workers cannot withhold taxes or channel them as they might wish. If someone earns £4,000 a year "after tax", that is all he or she earns. Taxes are only what the boss is prepared to give his government, in order that we may be fed and watered, trained and controlled, and mended when we are broken. "Our"national income tax has been a confidence trick from the first, to make us seem better off than we are, and to encourage in us a spurious pride in "public" projects — be they hospitals or wars — over which we have no control.

The NHS did not represent a departure from the economic imperative of capitalism, although this is not to say that some politicians and reformists might not, in 1944 as in previous years, have had humane motives. But the important point is that only while such relief brought economic advantage to the owners of industry would they fund such a programme. The NHS aimed to extend the existing "breakdown service” for workers to the poorest and most vulnerable to disease after the slaughter of the Second World War — who would be needed to rebuild the profitable economy in the post-war years. Similar attempts were made in other European countries at the time. In the end, however, the proclaimed commitment of the government of 1944 to ensuring "that in future every man, woman and child can rely on getting . . . the best medical and other facilities available" was empty verbiage. The amount of money spent on building new hospitals and health centres remained virtually constant throughout the 1950s, and staff training showed only a moderate increase. The prosperous industrial centres, where health services had previously been concentrated, continued to see the largest developments in health care, while the most outlying districts and those inner city districts where viable industry had been depleted by war, depression and the decline of established trades were generally neglected. Julian Tudor Hart, a GP in South Wales (one of the more deprived areas) has referred to this as the "Inverse Care" law, according to which the greatest effort is devoted to providing for those least in need. The others, who because of their birthplace or their bad fortune offer insufficient returns on commercial exploitation, must go short.

The same artificial economic restriction leads to an emphasis on "curing" rather than caring, and to the neglect of services to the elderly and the mentally handicapped. Life expectancy has increased since 1870 as a result of improved food and water supplies and sanitation. Therapeutic medicine has had little effect. Improvements in the conditions of the working class within capitalist society are only paid for if they can generate an overall increase in profitability. It has been clear since 1948 that the NHS could not hope to improve health care for workers up to the standards enjoyed by the rich.

Aneurin Bevan's Ministry of Health, after protracted squabbles, left the consultant physicians and surgeons ample opportunity to keep pay beds in NHS hospitals, even giving their private patients priority in the use of NHS staff and facilities (the practice is still widespread). From the start, these private beds were set in comfortable surroundings which contrasted sharply with the spartan appearance of the wards. Private clinics continued to grow separately, and Labour administrations have turned out to be as keen as any other to scotch moves towards their abolition. For while no government would dare to cut off its pay-masters' access to the best medical care, at the sort of price that only they and their best-paid hirelings could afford (up to £1,600 a week in some chic London hospitals) no government could hope to provide such facilities for the whole working class. Even BUPA can provide its poorer clients with no more than cheap nursing-home accommodation and decidedly second-rate treatment.

All this must not be taken to mean that the NHS is cheap. Government predictions put its net cost next year at £8-9 billion (around 40 per cent of total "public expenditure"). So it is hardly surprising that in a recession expenditure is cut back — by Labour and Conservative governments. The closure of hospitals, the growth of waiting lists, the continuing discrimination against the "Cinderella services" and the mounting toll of deprivation and disease (for example, whooping cough) in under-financed districts are in a very real sense inevitable to the working of the present social system, as is the call for increased efficiency (lay-offs) to compensate. This is the profit motive in action: this is the legacy of capitalism. And if, at the same time as the hospitals are closing, ad-men still pimp for the booze and tobacco companies, fortunes are spent teaching children to suck their teeth away, factories spew their toxic wastes into the environment. and homelessness, poverty and unemployment eventually drive one in nine of us into mental illness — then that is also the inevitable legacy of capitalism.

So no special responsibility for the plight of the patients can be laid with the health workers. The profit system created much of their sickness to begin with. The profit system required the running-down of the health service in response to the recession in the trade cycle. And the profit system obliges nurses and porters, like all other workers, to resort to desperate and sometimes inhuman measures, if they are necessary for their survival.

Strategy for victory

Certainly, the history of the trade union movement contains some relative successes. After 1824, when unions were first legalised in Britain, wages and working conditions showed a marked improvement. Since that time, employers have seldom dared to impose such inhuman conditions upon unionised workers (in peacetime at least) as were commonplace before 1824. Both private employers and governments regularly consult unions over wage-fixing, and from this fact there has arisen the popular myth of union power.

But, like the provision of health care, the legalisation of union activity could only take place when it was likely to contribute to the smooth running of capitalism. To a certain extent, legalisation was prompted by the realisation that the unions simply would not go away; but there was more to it than that. For in so far as they discipline their own members, maintaining order on the shop floor, unions play an important part in capitalist production. In a recession. when production is being cut back anyway, the strike weapon is far less effective than in times of boom.

Trade union action is weakened by the lack of democracy, where decisions about the running of strikes are left to minorities. The elevation by union members of some workers as leaders makes it easier for the employers to defuse the impact of the action by selective sackings, such as that of Philip McIntee. NUPE shop steward at the London Hospital in Whitechapel, on 19 August.

Workers are forced to struggle constantly through trade unions even to prevent living standards being reduced, and sometimes in this circular struggle the insanity of the system of wage labour leads to painful dilemmas such as that faced by the NHS workers. Strikes by any workers, be they coal miners, sewage workers, lorry drivers or fruit pickers, if they are to hurt the employer are also likely to hurt other workers. They must also hurt the strikers themselves, if only by the temporary drop in earnings. It may make them generally unpopular, and it may lose them their jobs. If they win their dispute, it may be at the cost of other concessions; if they lose it. much bitterness will remain. Whether the industry concerned is private or state owned, and whether the government is Labour or Tory makes no difference to this. Labour governments tried to limit wage increases by legislation and have called in troops to break strikes, as well as making cuts in public services. British Rail workers are the latest to have learned the true position of state employees, and the NHS workers must do so too.

The real solution to the health workers' dilemma lies beyond the struggle over wages. All of the wealth in society is produced by wage- and salary-earning workers. This society exists because workers consent to profits and wages, the factories which provide wealth as well as poisoning us, the media which enlighten and mislead us, and the hospitals which cure us, only to send us back to be damaged further. It now is time for us to take control of them all. to realise the next economic and social stage of human social evolution. Then, medical resources need be limited only by the rate at which it is possible and desirable to produce them, rather than by the artificial barrier of financial viability. The task of caring can be a joyful one, in which all can participate freely. 

PC