Why nurses are angry (1993)

From the November 1993 issue of the Socialist Standard

In September nurses from University College Hospital (UCII) in central London went back to work after a six-week strike. What made them angry enough to strike?

Why is it that approximately two months ago south London hospitals were crying out for extra nurses to care for patients on the wards, but there was not an agency nurse to be found?

A recent survey done by the Institute of Manpower Services found that one nurse in four would leave the NHS if they could. Why?

The creation of the internal market within the NHS has meant there is increasing pressure on trusts to keep within their budget. With the old system it did not matter if budgets weren’t kept to, the money was just replaced. In the new system if you don’t keep within your budget, then you don’t meet your contracts and eventually you go bankrupt like any other business.

In trusts most of the money goes on nurses’ wages (they are the majority of the workforce).

Constant pressure

There is constant pressure to cut this budget and this lias been addressed in a variety of ways.

First, freezing posts as nurses leave. Second, possible redundancies, though on the whole this has not been widespread as yet. However in the College of Health Studies where I work, there has been an amalgamation of two colleges of nursing which involved redundancies. The College is about to amalgamate with a further two colleges of nursing and more reductions are planned. It has been suggested that the 183 teaching posts in the three colleges will be cut to 52.

Third, alteration to nurses’ hours. Nurses have traditionally worked a shift system of earlies, middles, lates and nights. The hours are different from hospital to hospital but used to be roughly: Early: 7.30am to 3.30pm; Late: 1.30pm to 9.30pm; Night: 9pm to 7.45am.

Managers did not see why there should be an overlap of nurses on duty between 1.30pm and 3.30pm. This did not appear to be cost effective. What were the nurses doing during this time? On investigation it was found that education of students and professional updating of staff went on. As the extra nurses were not directly involved in patient care, managers felt it was a waste of time having them and altered the hours accordingly. Extra money was also being paid to the night shift for working "unsocial hours"; again managers fell this could be tampered with in some way.

At one particular hospital the nursing shift hours are now: Early: 7am to 3pm; Late: 2pm to 10pm; Night: 9.45pm to 7.15am. This hospital may have reduced the nursing budget on hours, but its sickness rate has soared and it is having to pay agency staff to work.

Finally, alteration in ward skill mix. There is a trend to employ more care assistants (unqualified nurses) instead of qualified staff, who are paid more. This leads to a decrease in the quality of nursing care given to patients.

Two research studies (Skill Mix and the Effectiveness of Nursing Care, Centre for Health Economics; York and Ward Nursing Quality and Grade-Mix, Report No. 504, York University’s Health Economics Consortium.) showed that where wards were staffed wholly by qualified nurses the standard of care given to patients was high, but where wards were staffed with combinations of unqualified and qualified nurses the standard of care delivered to patients was lower.

Fragmented care

This appears to be because unqualified staff cannot give the total nursing care to the patients. For example, they lack the knowledge to interpret signs and symptoms and cannot give out drugs. This means that patient care becomes fragmented and patients have to wait for qualified nurses to gel to them to give them the appropriate drugs or interpret symptoms.

All these points mean that there is an increase in pressure on nursing staff which results in frustration because they cannot give the nursing care they want to.

A Trust’s survival depends on getting contracts from Health Authorities and GP fundholders. Since the reforms there has been an increase in productivity within hospitals. This increase in throughput of patients has a tendency to mean early discharges, which puts extra pressure on nursing staff to ensure that discharge arrangements are ready and that there are enough beds for patients coming in. It may also mean patients go home too early — and have to be readmitted. The government says that wage increases will come from increased productivity. But if contracts are completed early. Health Authorities and GP fundholders have no more money to buy more treatment for their patients. So hospitals simply have to stop work. Eventually this will mean that hospitals cut the number if nurses so that, although the amount of work remains the same, there are fewer people to do it and it takes all year to complete. This situation is worse in London due to high overheads and London weighting etc. For example Camden and Islington Health Authority stopped all elective surgery at some central London hospitals in September because it had used up all its money with these expensive Trusts.

The planned reduction in junior doctors' hours means that some things previously done by doctors will become the remit of the already overburdened nurse. Again, nurses are cheaper to employ than increasing the number of doctors.

All these things mean that the nurses are increasingly having to alter the way they care for patients and are increasingly leaving the patient's bedside, for which they have been trained, to deal with administration issues such as discharge arrangements or managing bed vacancies.

No wonder the nurses at UCH said enough is enough.

If the Tories win another general election, the next step is obvious. Trust hospitals will simply become private hospitals, contracting with both private health insurance companies and Health Authorities for their income. And Health Authorities themselves will simply stop buying some treatments. A Labour government would be no better as they would still face the fundamental problem of how' to finance an NHS which will need more and more money for research, new drugs and so on.

Within capitalism it is impossible to deal effectively with disease and illness with the NHS or any other healthcare system as the emphasis is on profits rather than peoples' health and researching into causes of ill health. The only way in which to have a proper Health Service is to form a society which is based on peoples' needs: socialism. Finance and the fundamental problems it brings will disappear as it would be a society based on need rather than profit. Emphasis would be on prevention — at the moment this is too costly. The McKinleys’s river approach ( where individuals are falling into a river and drowning and Health care staff pull them out. patch them up and send them back to the top of the river, where they fall back in again) would stop and society will address the reasons why people fall into the river, such as bad housing, air pollution, etc. All individuals would be looked after in the appropriate place hospital or community. In hospital, there would not be the pressure on beds that there is now and people could spend as much time there as they need, and when discharged to the community there would be the proper resources available

Adele Atkinson

NHS Crisis: A Socialist Nurse Speaks Out (1991)

From the June 1991 issue of the Socialist Standard

The Socialist Standard interviews socialist nurse, Adele Atkinson.

We both know that the NHS has always been a get-you-back-to-work service to keep workers in a fit state to produce profits, so what’s new about the new reforms?

The NHS reforms, brought in on 1 April this year, are designed to ensure that the NHS conforms to market demands. All services within the NHS are being priced and sold within an internal market: GPs must buy services from hospitals, hospital departments specialising in one area from those specialising in another, and so on. 

These new contracts for services can only be entered into if the buyer has the money in the budget. No money to buy, no contract; no contract, no provision of service. 

The original aim of the NHS was ostensibly to provide free health care paid out of state funds; now each sector of the NHS must rely on its own budget and constantly think in terms of the market. This is just making explicit what was already implicit in the financing of the health service.

How does capitalism manage to price illnesses?

This is done in accordance with a system called ICD (International Classification of Diseases) which classifies diseases as being more or less costly than each other, and also by DRGs (Diagnostic Related Diseases) which suggests how long a patient will need to stay in hospital and how much medical attention will be needed. 

This is a crude pricing system and its means that many pieces of technical equipment are unused because nobody can afford to buy their use; for example, this is the case in the burns unit where I have worked for years.

What will happen to burns patients in the future – if, for instance, the burns treatment costs too much for their local health authority to pay for?

They will be put on general wards where they will have less specialised attention and where there will be a much greater risk of contracting infection – burns victims are very prone to infection. This is happening now.

So, these cost-cutting policies by so-called economic experts hurt real people?

Let me give you an example of this. There was a woman waiting for sterilisation at Guy’s hospital in London. She had been on the waiting list before 1 April. After 1 April Guy’s refused to do the operation unless her local health authority, which had no contract with them, would pay the cost. The local authority wouldn’t pay; the operation did not take place.

How do workers in the NHS feel about this?

Morale in the NHS is very low. It is clear to many workers what our employers think we’re worth. The RCN has criticised the reform, but will take no defensive action, such as striking. The other unions, COHSE, NUPE and NALGO are going to merge and that should make us stronger. But, you see, in the end it doesn’t matter to the financial whizz-kids who are running the NHS what we think. 

Opting out can be carried out by hospitals on a minority decision by the people who work in them. Senior staff, such as consultants, have been bought off: they’ve been put on management boards called Clinical Directorates where they are made to choose how to spend the budget. In other words, skilled medical practitioners are being dragged into the dirty work of having to play the health market – and then defend the decisions to the rest of us.

Guy’s Hospital became a trust on 1 April, in accordance with the reform, and then sacked nearly a thousand workers. Why?

Because it’s not “cost effective” to have so many London teaching hospitals all competing for the same population with the same services. So, despite the chronic length of waiting lists, Guy’s decided to close down its least marketable services – mental health and care of the elderly, I should think. Guy’s did this in the knowledge that there would be a public outcry. The plan is to get the outcry and the demonstrations over quickly and then the other hospitals can start cutting services and laying off workers. Mind you, Peter Griffiths and Karen Caines, the top managers at Guy’s, are paid £90,000 and £50,000 a year respectively. And they are being paid to ensure that costs are cut and budgets are kept to, regardless of human lives lost.

As a socialist, what way out do you see from this mess?

We need a society where the production of everything – everything from food to housing to health care – is provided on the basis of need, not sales or profit. 

The market is a crazy way of distributing – in fact, it rations – what people need. There will never be a fully decent health service as long as there is the market.

In a non-market, socialist community what do think will be the main changes in the way you, as a nurse, will do your work?

For a start, socialism will be able to provide decent care for the elderly. These now take up half the beds on the orthopaedic, chest and other medical wards. They are seen as a burden. What gain in there in paying the price of keeping them alive? In a socialist society real care – and that takes a lot of time, a lot of people – will be possible. 

Also, people with learning difficulties – those currently dismissed as mentally handicapped – can be more integrated into the community. A lot of people are currently left in hospitals because the society beyond can’t be bothered, or lacks the cash, to care for them. I also think that socialist hospitals will keep patients in for longer periods. At the moment hospitals do their best to throw patients out so that their beds can be filled, new money can be made. People need to be properly looked after and capitalism isn’t letting us do that as well as we can and should.

The NHS, from Birth to Old Age (2018)

From the July 2018 issue of the Socialist Standard

The National Health Service began seventy years ago, on 5 July 1948. One initial consequence was an enormous rush of patients who needed treatment that was now free at the point of use. One doctor, who had qualified on that very day, referred to:

   the colossal amount of very real unmet need that just poured in needing treatment. There were women with prolapsed uteruses literally wobbling down between their legs … It was the same with hernias. You would have men walking around with trusses holding these colossal hernias in. And they were all like that because they couldn’t afford to have it done. They couldn’t afford to consult a doctor, let alone have an operation. (Quoted in Nicholas Timmins: The Five Giants)

There had of course been progress in medical care before the NHS, such as big reductions in infant mortality, increases in life expectancy and much-improved treatment of infectious diseases such as TB. Better sanitation and so on had helped, but medical knowledge had improved too. During the Second World War, the Emergency Medical Service had provided free treatment, not just to war casualties but also to war workers, child evacuees and so on, and had resulted in the creation of a national blood transfusion service.

The Beveridge Report of 1942 advocated the establishment of ‘A national health service for prevention and comprehensive treatment available to all members of the community’. In reality, it was a way of getting workers who were ill well enough to go back to work; and, like most things under capitalism, it was done on the cheap. The talk of prevention entirely missed the point that much illness – both physical and mental – is caused by the way society is arranged, with dangerous and unhealthy living and working conditions and a great deal of stress inflicted on people.

The idea of free treatment lasted just three years, as in 1951 charges were introduced for dentures and spectacles. For the NHS cost far more than the government had expected: two-thirds more than predicted in its first nine months alone. The view that, as better care made people healthier, the cost of the NHS would fall turned out to be an illusion. As time went on, the idea of treatment that was free for all was gradually abandoned more and more, since the capitalists’ taxes simply could not pay the full cost and patients had to bear some of the burden. Free eye tests, for instance, were dropped in 1987. Nowadays only certain categories of people receive free dental care, and a medical prescription costs £8.60 per item (with a number of exemptions).

There were many changes over the years, partly as a result of advances in medical technology, such as transplant surgery, and the introduction of magnetic resonance imaging. But a constant theme was the mismatch between what was needed for patients and what could be afforded. Technical advances meant expensive new equipment had to be purchased; and people are living longer, resulting in them having more and more conditions that need to be treated. There have been frequent reorganisations, and privatisation and outsourcing have become commonplace, all undermining further the original vision of free and equal treatment for all, and they have been introduced in similar ways by both Labour and Conservative governments. Problems with, and cuts to, social care mean increasing difficulties for the NHS, which has more patients to cope with.

A nurse who is a socialist was interviewed in the June 1991 Socialist Standard. She made the point that the reforms brought in that year in April were to ensure that the NHS conformed to the demands of the market. She noted too the absurdity of applying price considerations to the provision of health care: ‘many pieces of technical equipment are unused because nobody can afford to buy their use’.

A particular problem in recent years, though no doubt it existed before, is that of stress among NHS staff. Almost two-thirds of young hospital doctors ‘say their physical or mental health is being damaged because pressures on the NHS are putting them under intolerable strain’ (Guardian online, 11 February 2017). There are also issues with recruitment, some but not all of them due to Brexit and the uncertainty that has created. Employing and retaining general practitioners is a particular problem, with many GP surgeries closing because they simply cannot be staffed. At present there is in all a shortage of at least forty thousand medical staff.

According to the British Social Attitudes survey, public satisfaction with the NHS was at 57 percent in 2017, a drop of six points on the previous year. The main reasons for being satisfied were the quality of care, treatment being free at the point of use, the attitudes and behaviour of staff, and the range of services and treatments available. Dissatisfaction was due to staff shortages, long waiting times, lack of funding, and government reforms. Despite all its problems, though, people consider that the NHS remains a key part of the welfare state.

A decent health care system would have increased resources, and treat both staff and patients far better than happens now. The socialist nurse mentioned above stated, ‘socialist hospitals will keep patients in for longer periods. At the moment hospitals do their best to throw patients out so that their beds can be filled, new money can be made. People need to be properly looked after and capitalism isn’t letting us do that as well as we can and should.’ In fact it is arguable whether keeping patients in for longer is such a good idea, and a socialist health service might well put far more emphasis on prevention rather than cure. But decisions about such matters will be made on the basis of what is in the true interests of those being treated, rather than what serves capitalism and profits.

Paul Bennett