Never trust a Trust (1993)

 

From the November 1993 issue of the Socialist Standard

The government has recently announced that thirty more district health authorities are to become self-governing in the fourth wave of trusts, and that the remainder will follow suit within two years.

The National Health Service enjoys considerable public support and attempts to return to private medicine have to be carried out cautiously whilst protesting vociferously that there is no such intention. But despite this cautious approach at least three-fifths of all self-governing trusts have run into financial difficulties. And in August, four London hospitals announced that they were going to cancel routine operations for the rest of this financial year. With seven months to go, from the date of these cancellations, to the next financial year, the waiting list for treatment will continue to grow, with pain and discomfort for patients.

The financial difficulties experienced by the health service trusts is only to be expected as an internal market does not put any more money into the system but costs considerably more to administer it. Whilst administrative costs have risen sharply to cope with the extra paperwork many newly-qualified nurses have been unable to obtain jobs and others have been given temporary contracts, only to find themselves unemployed three or six months later.

Despite the greater technological expertise required for modem nursing, the number of qualified nursing staff fell by 5.2 percent between September 1990 and September 1991 according to the Department of Health. But unqualified staff have increased by 17 percent. (Nursing Times. 1993, no.7)

The increase in total staff has been necessary to compensate for the removal of student nurses from the wards into colleges for the Project 2000 training courses. This change from traditional training methods has been introduced to improve academic standards and technical knowledge but also to pay students less by giving them grants instead of employing them as salaried workers.

Despite the dearth of jobs, financial hardship and the prospect of unemployment at the completion of training has led to a 5.5 percent wastage rate for Project 2000 students compared with 4.7 percent for students undertaking traditional training (Nursing Times). While the government juggles with the figures and nurses find out the hard way that professional status counts for little in the job market, the waiting list for treatment has increased by 60,000. A number of hospital trusts have changed nurses’ patterns of shift work, worsening their conditions of service and reversing some of the hard-won gains of the last thirty years. The Bradford Hospital Trust announced up to 300 redundancies shortly after it became a trust.

During recessions the bargaining power of workers is weakened and they are vulnerable to attacks upon their living standards. This will always be the case while capitalism lasts because trade unions tackle effects and not causes. Thus, any gains made during booms will be attacked by employers when there is a surplus of labour during a slump.

The government has repeatedly stated that it wishes to reduce public expenditure. Indeed, public health service employees have been held to a 1.5 percent pay increase this year (equivalent to a pay cut after allowing for inflation), and a proposed wage freeze for next year.

At first glance it seems curious and inconsistent to try to reduce expenditure on the one hand and to increase it on the other by opting for a system of management which is much more expensive. But a consideration of the ideological and political motives underlying the formation of the National Health Service and the reasons for the attempts to dismantle it show that both courses of action are consistent with capitalism’s priorities. When Henry Willink, Conservative Minister of Health in the wartime Churchill coalition government presented the 1944 White Paper setting out the proposals for a unified national health service, free at the point of use, centrally funded and administered by Local Authorities it was because it was recognized that after the sacrifices made by the working class in fighting a lengthy war to protect the capitalists’ interests they were not prepared to accept a return to the heartbreak conditions of the 1930s. It was also recognized that, with an acute shortage of labour, a reliable health service would be needed to conserve workers’ health in the critical postwar years of reconstructing industry. It was also necessary to provide concessions to blunt working-class militancy as strikes would have placed British capitalists at a disadvantage with their competitors.

A centrally-administered health service was more efficient and cost effective than the fragmented, piecemeal provision of health care which had hitherto been available in the 1930s. But by the 1980s, capitalism’s priorities had changed. A worldwide recession had reduced the capitalists’ profits making less money available for social programmes; a large pool of unemployed labour had weakened the power of the trade unions and made it no longer necessary to conserve the health of all the workers. The National Health Service now represents a cost against production that the capitalists would prefer to see drastically reduced if not abolished.

The NHS is an institution welcomed by the working class and its abolition, however desirable from capital’s point of view, is politically damaging, therefore, the moves towards replacing it with private services have been gradual. Laundering, catering and Portering services have been contracted out private companies in the last few years with reduction of staff, lower wages and poorer working conditions in the majority of cases.

Once all district health authorities become self-governing trusts it will be possible to break the power of the trade unions by dismantling the Whitley Council which negotiates health service employees’ pay. The trusts will be able to set their own pay and conditions which will lead to further downward pressure on wages. And with each trust being independent and no longer part of a nationally administered service then a national strike by health service employees over a dispute in an individual trust would be considered to be an illegal "sympathy" strike. Also with an internal market in place it will be possible for a hospital trust to break a strike by sending patients to other hospitals.

It has been claimed that the internal market, with buying and selling of health care on business lines, can make the most efficient use of resources and expertise by sending patients to other hospitals for services which may be in short supply in their own areas, but the 60,000 increase in the waiting list for treatment shows this not to be the case. There is a consultation process between health districts, regional health authorities and the public at each trust application but the public’s response is not disclosed by the Department of Health. We can be certain that if the public’s response to hospital trusts was enthusiastic then this would be widely publicised and trumpeted as a vindication of the government's policies. The secrecy surrounding this information is an attempt to conceal the lack of support for their plans. The announcement by the Government that it intends all health districts to become trusts within the next two years makes a mockery of the so-called consultation process and makes the public meetings little more than a declaration of intent.

In addition to the plans for NHS trusts, the 1989 White Paper Working for Patients (sic) provides for a range of optional extras such as single rooms, television and a choice of meals for those who wish to pay for them which will create a two-tier system with only basic amenities being provided for the poor and better services being provided for the not-so-poor.

A visit to any of the older district general hospitals will provide evidence of expensive refurbishment having been carried out on some of the surgical wards whilst, in many cases, even basic repairs are not carried out on the geriatric wards, reflecting capitalism's attitude to non-producers. Obviously, the majority of elderly patients will be unable to pay for "extras’' out of their pensions. A return to Victorian values, particularly the Victorian workhouse, is beginning to look an unpleasant reality for the poor and needy.

The government’s policies have caused problems for the mentally handicapped. Dr David Tod, President of the National Association of Fundholding Practitioners, told the Conservative Party conference in October that he cannot accept any more mentally handicapped patients in his practice without extra funding (Independent, 9 October).

The proportion of pay which general practitioners earn from the number of patients that they have on their books has been increased from 46 percent to at least 60 percent and this has, predictably, led to a reluctance to treat patients requiring a lot of medical care. There is no doubt that further attacks will be made on the NHS and that the present cumbersome structure is being set up with a view to selling it off to private speculators in due course. For the poor, only the most basic provision will be retained, and the mentally ill will continue to swell the ranks of the homeless as long-stay hospitals continue to be closed without adequate alternative care being allocated.

But the attacks on the NHS provide an object lesson to those who wish to reform capitalism. The reforms were gained only after years of struggle, implemented when it was no longer in capital’s interests to obstruct them, and are being reversed when it was no longer expedient for capital to accede to workers' demands and a recession makes it difficult for workers to resist the encroachment upon their living standards. Nothing less than the complete overthrow of capitalism and its replacement by socialism can prevent this happening to reforms over and over again.

Carl Pinel