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

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

World Review: Poor Health Wanganui (1995)

From the August 1995 issue of the Socialist Standard

One can’t help but notice the supreme irony surrounding the name of the Wanganui area Crown Health Enterprise (CHE)—Good Health Wanganui. Good Health Wanganui is in very bad health having just had the hard word that it has too high a level of service compared to other CHEs around the country and therefore will have its funding slashed. Two hundred and forty-six jobs will be lost from the beleaguered CHE along with 30 percent reduction in some surgery over the next three years in order to "break even". The Dominion (13 June) reported:

“‘Other services would also be downgraded because the Government believed the crown health enterprise had been providing more services than necessary’, chief executive Ron Janes said yesterday.

'The situation is utterly disappointing,’ Mr Janes said. To have the spare capacity to be able to help those in need and not use it is bad enough. But to also shed that capacity so it will not be there when future policies show more vision is worse.’"

Janes must have been rapped over the knuckles for telling the truth as his first statement was followed later with a less critical statement, after a phone call from the CHE Minister Paul East's office.

The Dominion continues in the same article:

“The salaried Medical Specialists Association said more cuts were pending, with plans to contract out support services such as x-rays, pharmacy and laboratories, while references to reducing the cost of continuing care for the elderly to market level and promptly discharging new mothers were ominous."

On the same day, the Evening Post carried a report that the

"Hutt Valley Health CHE will have to severely cut back or close several services over the next two years because of proposed funding cuts.

The cuts are coming because the Government had told CHE it will stop funding to cover deficits by 1997. That means hospitals will have to make do with funds provided by RHAs (Regional Health Authorities). CHEs say those funds are inadequate to meet growing demand for services."

Since the dose of "free market" restructuring given to the old Area Health Boards by the National government, things have been going from bad to worse. Now after being split into autonomous competing companies, Crown Health Enterprises are run on strict business lines, where running out of budget is a final thing. CHEs contract out various services such as catering and cleaning but still must survive on the vote of money from the state via RHAs. CHEs are in direct competition for resources and supplies.

Recently the CHE in Lower Hutt ran out of budget for operating theatres three-quarters of the way through the year. The remaining three months without money meant an idle theatre but still a large and growing waiting list for operations. That’s not to say that the waiting lists were much smaller under the previous regime, but that restricted state funding has become more obvious.

Getting the chop

Various CHEs have been in the media recently for turfing patients—mainly elderly—out on the street in the wintry dead of night in the interest of cold-blooded efficiency. Also patients have been abruptly discharged supposedly because there is nothing seriously wrong with them, despite protestations and then promptly dropping dead. Funding restrictions have meant that the over-70s are no longer receiving certain operations such as knee replacements and in one very highly publicised case a man who needed kidney dialysis was refused and left to die. Doctors are forced to make life-and-death decisions because of the absence of sufficient funds, and the elderly are the first to get the chop, in keeping with the system that sees workers as economic units, rather than as human beings. Elderly workers are regarded as having too many miles on the clock and are too expensive to maintain.

Have no doubt in your mind that the capitalists’ idea of the perfect worker is one who remains healthy all their working life, works hard to the day they are put on the scrapheap and promptly drops dead thereby releasing the capitalist class from having to fund their hospital repairs and pay for their dotage. This is not necessarily because the capitalists are heartless cruel people but because the logic of a competitive system of society which has a fundamental need to accumulate capital at all costs for survival.

The Returned Services Association (RSA), well-known as being a bastion of conservatism recently criticised the government’s treatment of the aged citing as examples:

• There had been no catch-up in pensions for the elderly despite a thaw after the three-year freeze. Meanwhile, the cost of living had risen markedly, leaving many senior citizens on or below the poverty line.
• Medical and elective surgical treatment for many had been put on hold as waiting lists grew longer, with operating theatres closed for part of the year as funding allocations were used up. Asset-testing meant assets were required to be used to pay for full-time care in rest homes often causing the long-saved-for family home to be sold-up and unable to be passed to the next generation.

It is interesting in this connection to note that the old much debated topic of Euthanasia has popped up again with a private member’s bill named "Death with Dignity” being introduced in the New Zealand parliament and recently the Northern Territories of Australia passing a bill allowing voluntary Euthanasia under certain circumstances.

No doubt a few wealthy members of society like the thought of workers topping themselves to eliminate the expensive care needed to attend to the terminally-sick. Undeniably, there are certain aspects of Euthanasia that are humane, but in a system of society like capitalism, it is open to abuse, to service those who would benefit from reduced state expenditure.

The Evening Post (1 June) reported that:

"the government has told public hospitals to increase profit by restricting surgery and other services, says the Medical Association.

Chairman Dennis Pezaro said a letter from the Ministers of Health, Crown Health Enterprises and Finance to country's 23 CHEs showed the health reforms were a 'sham'. . . . This means hospitals must not do more operations than they have been paid for . . . Since die health reforms, surgical waiting lists have increased by about 30 percent to 80,000 despite hospitals increasing the number of operations."

According to Health Minister, Jenny Shipley:

"the reason for the instructions was to prevent the problem with the previous area health board system, where hospitals ran up large debts doing uncontraced non-urgent work and then sent the bill to the taxpayer."

So why does the government show so much concern to "the taxpayer” while at the same time is practically oblivious to the needs of many workers in desperate financial situations, the unemployed, the sick, and families struggling to survive on low income? The answer is both simple and complex. Complex because of the mythology surrounding capitalism; simple because the answer is that it is in effect the capitalist class that ultimately pays the burden of taxes, including PAYE and GST. which are a charge on profit, rent and interest for the services provided by the state.

Obviously, the less tax charged by the state, the more profit left over for reinvestment and consumption by the owners of capital, or allowing them to remain competitive in the face of competition in depressed markets. You didn’t really think that you were going to benefit from promised tax cuts did you? There are a hundred ways of skinning a cat, and the claw-back of the extra take-home pay is relatively easy in times of high unemployment (look how easy it was to make the public servants put up with many years of no pay increase while inflation reduced what they could buy with their frozen wages).

In New Zealand, health represents over 10 percent of total government expenditure, and is the second largest single government expense next to social welfare (25 percent); which is why both are under attack. This is happening worldwide; governments around the world are attacking social welfare, trying to reduce the infrastructural costs to capital, in order to remain competitive in an ever more competitive market. Is this a spiralling effect? Yes. But of course reducing expenditure can have negative effects when taken too far, as needed workers become unproductive because of ill-health, broken marriages, poverty-driven social disintegration, crime etc.—but just how bad can it get? Do you want to wait around and find out? Or do you want to do something about it while you can? It’s a choice between roll-over-and-die, or stand-up-and-be-counted—counted for your active support for free access; no money, voluntary labour; no employment, democratic administration; no government.

Dave Tildesley,

World Socialist Party of New Zealand

Who Pays for Health Care? (2008)

From the August 2008 issue of the Socialist Standard

This year is the 60th anniversary of the National Health Service. Workers like it, but capitalists don’t, at least not any more. Why?

That the NHS became old enough to claim its bus pass last month will be a source of pride to members of the Labour Party – something to hold in their hearts as the gloom gathers around their fading regency over Britain.  60 years of providing health care free at the point of use is something that socialists can acknowledge, albeit with qualification.  Likewise, the continued existence of such a service sticks in the craw of the purist ideologues of capital, and serves as a constant irritant to the rapacious demand of capitalism for profits.  That accounts for why the health service remains at the heart of the political battlefield.

For example, when the Daily Telegraph celebrated the fiftieth anniversary of the end of food rationing in 2004 they used it as an excuse to have a pop at the health service.  After all, if rationing – which they claimed was, in effect, a National Food Service, was not needed, then why have a National Health Service? (www.telegraph.co.uk/money/main.jhtml?xml=/money/2004/07/03/cmian03.xml). Socialists would, of course, argue the exact opposite – and that is what the Torygraph’s hacks were exactly afraid of, the threat of the good example.

So afraid, that they try to turn it into the bad example.  Following the most energetic proponents of capitalism, they maintain that state run services cannot be efficient.  This is a line that ultimately stems from the Austrian economist Ludwig Von Mises, who argued that without markets in capital (i.e. productive goods) rational resource allocation could not be made.  His latter-day followers would argue that the NHS can only function because it can approximate the prices of its goods from general society; but, that in that approximation it still cannot achieve due efficiency.

Others follow the other Austrian economist Freidrich Hayek in asserting that without entrepreneurship, the managers of a state bureaucracy lack incentive and drive, and thus do not serve the customers (i.e. patients) as well they might.  These folk would also argue that information does not flow freely within the NHS, and cannot effectively do so, for much the same reasons.  They point to manipulation of statistics and fiddling to meet central government targets as proof of this.

It has been traditional to use waiting lists as proof of that inefficiency, and Labour has spent the last ten years desperately trying to prove those waiting lists can be eliminated.  These, though, only exist because the NHS is a government bureaucracy that aims to treat everyone – were it a market led system, those lists would become invisible, as those who couldn’t afford to pay would cease to present themselves, and the dreaded rationing would occur unseen.  Indeed, that was the situation at the foundation of the NHS, where the war had seen the state discover just how unhealthy the population was when they were shanghaied into battle.

Another favoured trick has been to compare, say, the number of expensive scanners in the United States to those in the UK.  Although the US does have higher numbers, much of that is driven by different medical priorities, and, more importantly, different donor priorities.  As much medicine in the US relies on charity (itself a sign that markets cannot provide the service required) their funding is subject to potlatching – spectacular donation one-upmanship in which big, shiny projects will be privileged over more mundane treatments.

Of course, the NHS has had serious funding/allocation problems. In its early days demand was much higher than anticipated, and so consequently it cost more. (Link.) Since the 1980’s successive governments have tried to rectify its perceived shortcomings through creating pseudo-markets.  The problem is, however, for the die-hard agents of capital, pseudo markets will never be good enough.

This can be seen from the more recent propaganda.  Following a Office of National Statistics report in April this year the Telegraph proclaimed “NHS gets more money but productivity falls”. They alleged that “billions of pounds of extra investment in the health service has led to a 10 per cent drop in productivity,”  because:

“Although more patients are being treated on the NHS with more operations being carried out, more drugs being prescribed and the population enjoying better health, the rise has failed to match the increase in investment, a report from the Office of National Statistics shows.”

That is, although all of these manifest improvements were occurring, the Telegraph spun it as a decline in productivity which meant that “unless NHS productivity can be improved the principle of a health service funded out of general taxation may become unaffordable, experts warn.”(Link)  All this because the ratio of money spent to the outputs achieved declined (or rather, the outputs did not rise as fast as the increased expenditure)

The cold, cold logic of capital: if the returns aren’t good enough, if the money could be more profitably spent elsewhere, then it should be so.  The actual concrete outcomes become a secondary consideration behind the magnitude of the capital involved.  Another recent government report indicates how this might weigh on the capitalist mind.  The report, the annual “Value added scoreboard” (www.innovation.gov.uk/value_added/default.asp?page=76) looks at company accounts in the UK and across Europe to show which firms have added the most value to the economy.  It defines value added as: Value Added = Sales less Costs of bought-in goods and services:

“Value Added can be calculated from a company’s accounts by adding together operating profit, employee costs, depreciation and amortisation/impairment charges.”

That is, it does not measure value as a ratio of total capital invested, but as a fraction of year on year expenditure.  For the government and for capitalists, it’s a measure of how well firms are meeting peoples’ desires (apparently).  For socialists, this is a very good thing to measure, since, after all, this shows pretty accurately how much workers are exploited for – all that value added is our unpaid labour being realised – something like £646 billion in the top 800 companies.  Of that, £3.5 billion is accounted for by “health care equipment and services.”  Given that the NHS costs an annual £89.7 billion it’s clear that were its services to be made commercially available, then the headline value added figure for the UK would rise, and health care as a sector would leap up in terms of the national league tables.

Capital with its incessant drive – accumulate, accumulate – looks upon all that capital, all those potential profits, all that money pouring into the NHS and dreams of taking it for itself, of taking out its state rival and bringing the riches and all that potential surplus value into its own cold avaricious arms.  It would also mean not having to pay the dreaded taxes that the government snatches.

Although socialists recognise the benefits the NHS brings to workers who otherwise would not have access to healthcare, they are far from the ardent uncritical supporters that the membership of the Labour Party tend to be.  They see that although the NHS suggests possibilities for how a service free at the point of use and based on needs could be organised, fundamentally, it is not free from the market system and a long way from being the fount of joy Labour supporters proclaim it to be.

Although the NHS has to simulate markets internally (much as many big companies do) it actually exists within a market economy.  It competes to buy drugs, materials and even staff.  When the Telegraph bewails that much of the money poured into the NHS over the last ten years went into wages and salaries, it is commiserating over its own basic principle: that people should try to enrich themselves and get the most for their skills and abilities that they can.  NHS workers are compelled by the threat or prospect of poverty to play the market game as best they can.

Likewise, it must buy hospitals and premises from commercial builders and landowners.  It has to pay the form of rent known as a patent to the drugs manufacturers. And it has to have the payroll clerks, the accountants, the procurement officers, the lawyers and the whole array of staff specifically to manage all of this market activity, adding greatly to its cost.

Further, technical innovation comes with a market drive.  As the BBC points out in a special report for the anniversary, “all the new machines and robots that are becoming available for health care cost a fortune, can the NHS afford to keep up with innovation?” (news.bbc.co.uk/1/hi/health/7477627.stm). As with any other industry, capitalism is constantly revolutionising the process of healthcare.  More and better results can be achieved with more and better machinery – that is with ever greater capital investment.  Personal healthcare has always been relatively labour intensive, and it would be politically inconvenient to try and rationalise staff costs the way that an ordinary capitalist firm would – with wage cuts and redundancies.

This interweaving with the market system also nullifies some of the wilder claims that the NHS is a massive benefit to the working class – many capitalist states manage to exist without such a system.  Health costs are, for the most part, not optional, you either need treatment or you don’t (though the poor are long adept at putting up with ailments it’s too dear for them to pay to relieve).  By hook or by crook, if the employers want to have a workforce fit to perform their role, it’s going to have to pay for health care.  This can either be done through wages directly, or as a workplace benefit or through the state.  If provided as a state or private benefit, it simply has the effect of lessening the upwards pressure of wages by workers who need to pay for their and their loved one’s treatment.  If it was paid directly through wages, employers would have to risk paying those sums to workers who might never need health treatment: i.e. they’d be paying them (in the employers’ eyes) too much.

Let’s be clear, this is an automatic effect of the wages system. The proponents of the NHS are sincere (for the most part) in believing that it brings a massive benefit to society.  Certainly, it helps the Labour Party by being a threatened cherished item to rally their supporters around and with which to beat the Tories.  The wages system, though, which will only return to the workers the price the market will bear for sustaining their ability to work can snatch with one hand what the state gives with another.  Our health and well being only matters so far as it enables employers to use us for profit, as can be seen in those parts of the world where surplus population is left to rot.

The health service, also fails to address that other feature of the market system: inequality.  The figures are quite starkly clear.  For example, in the London Borough of Camden – home to some of the most deprived parts of the country – the difference in life expectancy can be a decade.  A man living in Belsize ward can expect to live to be 80.2 years old, while less than a mile away in Kilburn the life expectancy is 69.9 years.(www.camdenpct.nhs.uk/pages/go.asp?PageID=621).  Just a mile or two more away in Somers Town (the ward which includes Kings Cross station, and St. Pancras International – with the longest Champagne bar in the world) death rates are 35 percent higher than the national average.(Link.)

This is part of a worsening trend:

“During the period 1972-6, the gap in life expectancy between social classes I and V was 5.4 years for men and 4.8 years for women. By the time New Labour succeeded the Tories in government, these gaps had risen to 9.4 years and 6.3 years respectively.” (See tables 1 and 3 in: ‘Life expectancy by social class’, UK Government Statistics.  

 “Kill, kill, kill, killing the poor”, as the Dead Kennedy's sang.  It is clear that the effects of poverty, and the associated lifestyle are deleterious to health, and that simply having the services available of the NHS isn’t sufficient to stop the theft of years from the working and unemployed poor.

Pik Smeet

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.

An accountant's charter (1989)

From the November 1989 issue of the Socialist Standard

In January the government published its White Paper Working for Patients which put forward its plan for reforming the National Health Service. The leaks and rumours of the previous year were shown to be substantially correct and the government spent £1m on presenting its controversial proposals in an attempt to allay public fears, gain acceptance for the changes, and lessen the hostility which the majority of doctors and nurses had expressed.

Although the Health Secretary, Kenneth Clarke, has claimed that the White Paper puts patients' interests first it reads more like an accountants charter, with its emphasis on management restructuring and financial arrangements. The White Paper aims to provide a greater collaboration between the NHS and private medicine, with tax relief on private medical insurance for the over-60s and extensions of competitive tendering which would put more services in addition to laundering, portering and catering in the hands of private firms. There would also be leasing of hospital facilities for commercial ventures such as shops and advertising.

Cheltenham Health Authority has anticipated this trend and spent £15,000 persuading firms to support hospitals in the area in return for publicity such as wards being named after them. The district general manager, Jim Hammond, has not ruled out the possibility of nurses advertising companies on their uniforms, although existing rules may prevent this from happening (Nursing Times 10 May. 1989).

Opting Out

The Health Secretary will have wide powers of appointment on the new NHS policy board and this will extend right down to the general managers of large hospitals, ensuring that pressure can be applied, if necessary, to carry out the government's policies. The government hopes to see the majority of Britain's acute hospitals opting for self-government, with the establishment of NHS hospital trusts which would allow these hospitals to set their own rates of pay and conditions of service for staff and. within limits, to borrow money.

The government knows that if rates of pay are negotiated separately in each hospital it will be difficult for the trade unions to operate effectively. At the independent hospital of St. John of God, Richmond, for example, nursing staff are faced with pay cuts of up to £3,000 a year. A skill shortage has been forecast for the 1990s, and with hospitals competing against one another this strategy could rebound if pay rates are increased in some areas to attract skilled staff, causing pay rates to spiral upwards instead of being reduced.

It is significant that the larger acute hospitals should be encouraged to opt for self-governing status as these have the greatest potential for making a profit in private medical schemes. Long-stay hospitals for the elderly, which have a relatively poor profit potential, have not been included at this stage.

Hospital trusts, formed by the hospitals opting for self-government, will remain within the NHS but will be easier to privatise in the future, in much the same way as shares were introduced into the Trustees Savings Bank. Fifty such hospitals have been chosen to receive computers to monitor patient care systems, making it easier to calculate the costs of individual patient care.

Although Kenneth Clarke has stated that the self-governing hospitals will need consultants' co-operation to be involved in management, and that the applications seeking self-governing status are voluntary, he has pledged tough action against consultants who oppose his “reforms". It would seem that the only freedom of choice on offer is the freedom to accept the government's changes.

Two-tier System

Some of the changes in Working for Patients are unobjectionable. It is proposed that appointment times be reliable and that out-patient clinics have quiet and pleasant waiting areas. But these improvements are due to the fact that the present chaotic conditions in most out-patient clinics cause 3.5 million working days to be lost by people waiting for appointments in NHS hospitals and, therefore, it makes good economic sense to improve the system. Patients are to be given rapid notification of the results of diagnostic tests, clear information and sensitive explanations of what is happening to them. These changes are long overdue improvements in current practice, but there is nothing in the White Paper to solve the staffing shortage in pathology laboratories which causes delays, or the long hours and stressful conditions endured by junior doctors which can sometimes lead to a lack of sensitivity in dealing with patients. These reforms may be no more than platitudes to make the White Paper more acceptable to the general public.

The development of a range of optional extras such as single rooms, television and a choice of meals for those who wish to pay for them will create a two-tier system with basic amenities being provided for the poor and better services being provided for the wealthy. In addition, the improvements to hospital facilities will make future privatisation a more attractive proposition for investors.

All of this is in keeping with capitalism's aim of keeping state provision to a minimum because a centrally-funded health service represents a cost against production. The wealthy are able to avoid the hardship caused by the lack of an adequate health service by purchasing private care. The burden of ill-health and caring for dependent relatives falls upon the working class, who are unable to accumulate enough from their wages to afford expensive hospital treatment.

The provision of 100 new consultants' posts in acute specialities will help to reduce waiting lists for hospital treatment but has been added to the White Paper as an afterthought and is clearly designed to "buy off” the junior doctors, who will have a slightly better chance of gaining promotion. Doctors have become increasingly militant over the hours that they work. The average weekly hours worked by junior doctors in the UK is 83 compared with 72 hours in Austria and West Germany and 48 hours in Portugal and Italy, according to the British Medical Association. It is estimated that 140 deaths a year are related to doctor fatigue in surgery alone (Which? Way to Health, April, 1988.)

The exploitation of junior doctors has been increased as a result of the 1987 circular issued by the Department of Health which required health authorities to cut the amount of money spent on locum cover to replace doctors who were sick or on holiday. It is claimed that the new posts will reduce the hours worked by junior doctors but consultants tend to create work for their staff not lessen it.

But it is not just junior doctors who are threatened: some managers have been told that their future is at stake if they do not express an interest in self-government, claims Jimmy Johnson, a consultant surgeon at Halton hospital, Cheshire [The Independent, 16 June, 1989).

Internal Market

The White Paper will raise the proportion of pay which general practitioners earn from the number of patients that they have on their lists from 46 per cent to at least 60 per cent. This will force doctors to have larger practices if they do not wish to see their incomes decline. It will also make them less willing to take elderly patients who require a lot of attention, preferring larger numbers of younger patients who are less likely to be ill. There will also be reserve powers to allow the Department of Health to control the number of doctors in contract with the NHS, which could force some doctors to take up private practice or become unemployed.

From April 1991 large general practices of at least 11,000 patients will be able to hold their own budgets with which they can acquire hospital treatment for their patients. They will be able to improve their practices with the money they save on treatments, a temptation to avoid referring patients for more expensive forms of medical or surgical intervention.

Prescription costs will be reduced by the imposition of financial penalties for doctors who over-prescribe. While it may be beneficial to reduce the amount of drugs used, there is a risk that this heavy-handed approach will encourage doctors to prescribe cheaper alternatives rather than the best medicines available.

The most controversial change is the setting up of an internal market which will allow health authorities to buy care from each other. It will permit hospitals with expertise in particular fields, such as hip replacements or heart transplants, to sell their services to both NHS and private hospitals to earn revenue. Despite the government’s protestations to the contrary, this is a backdoor method of introducing privatisation. There is also the risk that hospitals will concentrate on the services that can earn them money to the detriment of less profitable branches of medicine like the care of the mentally ill, the mentally handicapped and the elderly. High-cost treatments, except for private patients able to pay large fees, will become unviable and this will accelerate the creation of a two-tier system of care.

As expected, the White Paper contributes nothing towards preventative medicine, but this is only to be expected as the state functions to protect and facilitate capitalism, which makes profits by selling goods and services to those who can afford them; there is no profit if they are not needed in the first place. The deprivation of the wage and salary working class which is inherent in capitalism is the main cause of ill-health. While capitalism lasts health care, whether state-funded or private, reformed or otherwise, cannot cure society’s ills.

Carl Pinel

“Uneconomic” hospitals to close (1992)

From the July 1992 issue of the Socialist Standard

Less than a week after winning the general election the new Conservative Secretary of State for Health, Virginia Bottomley, indicated that “uneconomic” National Health Service hospitals will be closed. It is believed that a special commission, under the chairmanship of Sir Bernard Tomlinson, will recommend the closure of one of London's 14 teaching hospitals. Speaking about this possibility Virginia Bottomley stated:

  Hospitals have always closed. At the end of the war there were 300,000 TB beds in this country. Now there are about 300. So there must be change (Independent, 17 April).

This is a blatantly dishonest comparison. TB hospitals have closed because tuberculosis has been practically eradicated due to improved living standards since the end of the Second World War, greater natural resistance to the disease, and immunisation. To close beds because they are expensive to maintain in spite of the need for them is an entirely different proposition.

Bottomley added:

  It is too early to say what the recommendation of Tomlinson will be, but I will not hesitate to take whatever decisions arc necessary to ensure that further generations of Londoners can have the best possible health service.

This example of Orwellian “doublespeak” claims that health care can be improved by reducing its provision. Already the closure of small hospitals, with loss of beds, and the concentration of most of the remainder into large district general hospitals, has led to many people in rural districts living considerable distances from the nearest hospital.

The reduction of hospital beds over the last 25 years led to record waiting lists of over a million people needing treatment by 1991. Political expediency prompted by an impending general election this year has led to patients waiting for treatment for more than two years being attended to. But there have been claims that this attempt to clear the back-log of politically embarrassing long-term problems has sometimes been at the expense of patients with more serious problems of a shorter duration.

Waiting lists
Some health authorities have reduced their waiting lists by the simple expedient of not carrying out certain categories of operations unless the patient opts for private treatment.

The closure of beds in psychiatric hospitals has led to long-term mentally ill people swelling the number of the homeless in Britain's major towns and cities. And Lord Justice Mustill has attacked the lack of provision for mentally ill offenders who move between prison and the community without anyone taking proper responsibility for their care (Guardian, 21 March).

The pressure on hospital beds has led to hospitals having to be “closed" to acute admissions on occasions because there are no beds available. Family doctors and medical staff in casualty departments are obliged to waste valuable time in telephoning other hospitals to find out if there is a vacant bed. This involves considerable delay in getting an ill patient admitted for treatment; can remove patients considerable distances from their families; and taxes the resources of the over-stretched ambulance service because of having to make longer journeys.

The ambulance service is already struggling because of the effects of the government’s economies without these added problems: in Greater Manchester there has been a reduction of 40 posts since August 1991 and further redundancies announced recently (Manchester Evening News, 28 April).

A consequence of the shortage of hospital beds and the need to be seen to be “economic" leads to the premature discharge of patients from hospital to convalescence at home. This has led to higher rates of re-admission in the last few years. But as turnover of patients is seen to be the barometer of efficiency irrespective of whether death or discharge is the reason for leaving hospital, the reduction of hospital beds can only aggravate matters.

There have been attacks on health care provisions in other ways: prescription charges have been increased several times more than the rate of inflation, and the charge for sight-testing have deterred some workers from having their eyesight tested as frequently as they should. Dental charges have increased considerably and in some areas it is difficult to find a dentist prepared to undertake NHS work.

It is expected that most health authorities will become self-governing trusts within the next two years and more family doctors will become budget holders to buy treatment for their patients.

Buying treatment
But an internal market does not provide more money for the NHS; it merely shuffles existing money between hospitals at greatly increased administrative costs. And with doctors being obliged to keep costs down, because of the risk of being labelled "uneconomic”, there is the likelihood that patients will get the cheapest rather than the most appropriate treatment. Because doctors can incur financial penalties for over-prescribing but may use money that they save on treatments to improve their practices some people in high-risk groups (diabetics, the elderly and the long-term mentally ill) have greater difficulty in registering with a doctor.

The debates over the numbers of patients treated and on the waiting list misses the point that poverty is the main cause of ill health. Unskilled workers are four times more likely to die from ulcers than the wealthy and are also more prone to develop heart disease. The Health Education Council’s 1987 report The Health Divide found that there was a difference in life expectancy of more than eight years for men in the most affluent parts of Sheffield compared with the poorest areas.

The large number of patients requiring medical treatment under capitalism (rather than being a matter for congratulation) is an indication of how poor the workers’ health is. Capitalism with its poverty, stress, alienation and pollution is unable to remedy this.

Nevertheless, the NHS, despite its shortcomings, does ameliorate some of the misery of illness caused by capitalism. But because health care “free at the point of use" represents a cost against production it is vulnerable to attack in a recession when there are a larger number of workers than are needed to meet the capitalists' requirements.

But poverty is not an inevitable part of the human condition. A socialist society producing goods for human needs and not for the market; a society of co-operation instead of the competitiveness, hostility and suspiciousness of capitalism could make the high levels of ill health and the long waiting lists for treatment a thing of the past.

Carl Pinel

Editorial: Capitalist Health Warning (2017)

Editorial from the April 2017 issue of the Socialist Standard

On 4th March 2017, tens of thousands of people marched through London in support of the National Health Service. This winter, hospital waiting times had grown and in the Accident and Emergency (A&E) wards, patients were stranded on trolleys while waiting for beds to become available. This has been exacerbated by the crisis in social care, where elderly people have had to be cared for in NHS hospitals, because of a shortage of places in care homes. Last year, there was a dispute with the junior doctors, who objected to new contracts, which would worsen their working conditions. This is against the backdrop of a squeeze in government funding made in response to the economic downturn in 2008-2009.

The NHS was established in 1948, ostensibly with the principle that health care would be provided free to all regardless of their ability to pay. Although hailed as a great ‘socialist’ achievement at the time, it arose out of the recommendations of the Beveridge report. During the Second World War, many in the ruling class believed that the working class should receive some payback for their sacrifices. However, they were not entirely driven by altruism, as they hoped that the workers would become healthier and more productive. Around this time, there was the beginning of the post war economic boom based on the reconstruction of industry, which made commitments, like this one, affordable.

However, like every product or service in capitalism, health care has to be paid for, which is funded mainly from general taxation and national insurance, the burden of which falls ultimately on profits. Charges for prescriptions were introduced by the Conservative government in 1952. These were abolished by the Labour government in February 1965, only for them to be reintroduced at a higher rate in June 1968 by the same government, albeit with a wider range of exemptions.

In 1990, the Conservative government attempted to control costs by introducing an internal market into the NHS in England, with the establishment of NHS trusts. In 1992, the Private Finance Initiative (PFI) was introduced, in which private firms would be contracted to provide funding for public sector projects. The Labour government supported its use for the NHS and it also established NHS Foundation trusts, which provided more scope for the involvement of private companies. Under the Health and Social Care Act 2012, NHS primary care trusts and strategic health authorities were abolished and more control of NHS funds given over to GPs, who have the freedom to engage private contractors.

Many campaigners blame the Conservative government for the woes of the NHS. However, as experience has shown, Labour have no more solutions to the problems of the NHS than have the Tories. The problems lie not with the Tories, but with the capitalist system itself. The quality of health care depends entirely on the vagaries of the market. If profits are running high, then extra crumbs can be thrown at it, but if profits are falling, then the health service will be squeezed. Only under socialism can the best health care be guaranteed.

Sick service (1984)

Book Review from the March 1984 issue of the Socialist Standard

The NHS: A Picture of Health? by Steve Iliffe (Lawrence and Wishart 1983 p/b £3.95 224pp).

This book, written in a fluent, easily readable style, examines health politics from the industrial revolution to the present time.

The author, a general practitioner in North London, is already well known to readers interested in health politics as a regular contributor to medical and political magazines, as a member of the editorial committee of Medicine in Society and a pamphleteer for the Communist Party of Great Britain.

The first chapter deals briefly with the years leading up to the formation of the Health Service and describes how, in the 1830s, cholera, syndicalism and chartism "emerged from the slums and threatened to harm the established order" and that although repressive measures followed, the government realised that some reforms had to be made to reduce the threat to established power.

The political motives underlying the 1911 National Health Insurance Act are examined with its attempts to undermine the influence of the new Labour party; placate labour agitation; provide a fitter fighting force for the impending war with Germany; make the working population believe that the war was worth fighting on the promise of substantial social change. The 1948 National Health Service was "to be a 'jewel in Labour's crown", the greatest public institution in the new socialist Britain. Unfortunately, the reality did not conform to either fantasy” (p. 24).

The pay and conditions of Health Service workers in the next two decades are discussed in more detail. The author describes how manual workers in the National Health Service during the 1960s were among the lowest paid workers in the country and that the government, uninterested in providing adequate Health Service funds, exploited overseas workers who were recruited to fill the gaps. The low market value of manual and domestic work is seen as the major obstacle to better pay, outweighing the weakness of health workers' unions. The last decade is examined in greater detail — the cuts in the level of services provided; discontent among health service unions; higher rates of disease and death among working class people.

The closure of mental hospitals without adequate alternative provision causes mentally ill people to drift into the “homeless, workless population that sleeps in cardboard boxes and derelict buildings, rummages through litter bins and provides police, courts and prisons with an unpunishable stratum of hopeless recidivists” (p. 103). Steve Iliffe describes how administrators

. . . were able to use loopholes in the regulations to accelerate change. "Temporary" closures could be announced, without recourse to consultation through the CHCs (Community Health Councils) and quietly be made permanent, later on (pp. 122/3)

The author discusses the mixed economy of health and states: "Only the Communists and the far left advocate economic renewal aimed at a preserving and expanding public services". No evidence is given to back this statement and, indeed, socialists are aware that only a socialist, moneyless society can resolve the contradictions of capitalism.

There are two very interesting chapters on commerce and professionalism, and class, consumerism and resources. The author describes how market forces have developed a health service which treats rather than prevents disease because of the profits to be made. Professionalism is seen as the setting up of "trade secrets" and is based “on the idea of service and the practice of trade" (p. 46), placing control in the hands of professionals.

In looking at attitudes to smoking the author makes some interesting comments about Russia;

The USSR faces a chronic labour shortage and has many reasons to pursue a health provision policy, but these appear to be offset by other economic and social considerations

and

Only by denying that the USSR is socialist can we maintain the myth that socialism will solve our current problems, and then we have only hopes, dreams and the thoughts of assorted prophets, past and present (pp. 176/7).

Also there are odd statements such as: "British 'socialism’ is at its strongest when shaping the state, even when it shapes it in the interests of capital”. The book concludes:

The right has the market relationship as its basic form of social organisation. So far Labour has concentrated on a different relationship between state and citizen, that was designed to modify the market relationship In the future it may not be able to gain much advantage from this approach, and will have to think again about social organisation and the role of the state. The development of participatory democracy now, in experimental ways, could inspire that new thinking and shift the initiative in health politics further to the left than it has ever been before.

The NHS: A Picture of Health? is a stimulating book for the arguments put forward, and for the brief, but interesting history of health services in this country. However, there are considerable areas of disagreement and it is the political tactics, opportunism, reformism and compromise embodied in the final paragraph which socialists entirely repudiate.

Carl Pinel 

Editorial: Caring is Not Enough (2012)

Editorial from the May 2012 issue of the Socialist Standard

A system is not a thing which is capable of caring for anything or anyone, it simply performs the functions it was set up or adapted to perform. Capitalism is set up to enable the pursuit of profit for private gain, regardless of other ‘external’ outcomes. The chief beneficiaries of this system do care but only about protecting their interests. Their main concern is for the wellbeing of their own future, and short term gains always take priority over less profitable long term considerations. Such questions as the health and wellbeing of workers are treated as externalities, as is the state of the planet, now being plundered and abused to irredeemable levels through reckless use of its resources and pollution of land, water and air.

Governments don't care; corporations and shareholders don't care, except for upholding the status quo to protect the bottom line. Endless promises are made pre-election and endlessly broken afterwards. Elected politicians, unelected paid advisors and supposed experts working together deliver one failure or crisis after another, following policies and goals that usually fly in the face of public opinion. Meanwhile the electorate, who have no meaningful part to play in the decision-making process, are expected to meekly acquiesce.  

Nevertheless, capitalist governments to some extent have to buy this acquiescence. Modern societies do not consider it acceptable to turn out the old, the sick or the poor to die in the gutter, even if they are no practical use as workers, so state administrations have to invest in looking busy by funding a ‘support’ industry which is forever the subject of new approaches, paradigms and target-led initiatives. In this issue we have personal accounts by three socialists of their experiences in the caring and support services which show just how big a gulf there is between what governments say in their speeches and what they really care about.

None of this will come as any surprise to most Standard readers. But it is encouraging that the almost universal acceptance of the status quo by politicians, economists and the media is being challenged by growing numbers of people around the world who do care and who do believe there are alternatives. Many people are starting to realize that, if the whole world has to live with and bear the consequences of decisions made about it, then it follows that this decision-making process needs to belong to all the people of the world. And that means getting involved, and giving proactive support to the struggle for revolutionary change. A system embodying genuine participative democracy as a fundamental principle is in the best interests of everyone, but it won’t come about if people don’t work for it, however much they care.

Why doesn't big business support a national health service?

Cross-posted from the blog, Stephen's Blog.

It is often argued that a "single payer" health insurance system run by the federal government or a national health service would be in the interests of American big business apart from the health insurance companies. The growing burden of healthcare costs on the economy would be brought under control, and companies would no longer have to pay insurance premiums for their employees. Companies in Britain and Canada are quite happy with the national health service in those countries.

So why does big business not promote a real healthcare reform? This is the question asked by Doug Henwood in Issue 120 of his Left Business Observer (a publication that I highly recommend for its astute analysis of American economic and political developments; see here).

Apparently some people offer a "web of influence" explanation that focuses on interlocks (overlapping membership) between insurance companies and other companies and on the role of insurance companies as a source of finance for other companies. Henwood presents detailed evidence to show that these are not very significant phenomena.

Basing himself on testimony from researchers who have interviewed top executives on the issue, Henwood states that some (perhaps even many) executives support "single payer" in private but are reluctant to make their views public for two reasons.

First, they worry about the possible reaction of other firms with which they do business. Small companies especially are considered hostile to "single payer." They do not stand to gain in terms of costs because they do not provide health insurance to their employees, while they would have to bear part of the additional tax burden. So they would see such a reform as an attempt to shift costs from big business to small business.

Second, they are afraid of "encouraging would-be expropriators." One informant formulates this fear as follows: "If you can take away someone else's business -- the insurance companies' business -- then you can take away mine." In other words, the politics of capitalist class solidarity trumps the economics of cost reduction.

Henwood adds another consideration: "Employers like workers to feel insecure. Fear of losing health coverage makes workers less willing to strike or resist pay cuts or speedups."

At least in this case, it is misleading to view reform politics solely as an arena of conflict among diverse business interests. It is also an arena of class struggle.

Stefan