Proper Gander: Going public about going private (2024)

The Proper Gander Column from the May 2024 issue of the Socialist Standard 

There are several connotations with the word ‘private’, in relation to ‘private hospitals’ or ‘private healthcare’. The description means that they are privately owned companies with the purpose of generating profits for their shareholders, with medical treatment as the product they sell. The word ‘private’ also suggests that these hospitals are select, and separate from the NHS and the majority who use it. This isn’t always the case, as shown in Panorama’s investigation NHS Patients Going Private: What Are The Risks? (BBC One). The word ‘private’ also implies being reluctant to reveal too much, so the documentary was of some use in highlighting issues which private hospitals would sooner be made less public.

One of the symptoms of the ailing NHS has been increasing delays for treatment, with more than six million people in England in the worrying position of coping with a worsening condition while they wait their turn. In an effort to reduce the length of waiting lists, some of these patients have been referred to private hospitals for surgery, with the costs paid from NHS funds. In 2023 around 800,000 NHS patients were handled by private hospitals in this way. Many of these went to one of the 39 hospitals run by Spire Healthcare Group plc, the second-largest private provider in the UK. Since 2021, Spire has treated more than half a million NHS patients, contracts for which have made up around 30 percent of its revenue. Reporter Monika Plaha looks at two aspects of how Spire runs which have had a devastating effect on some of its patients: staffing and arrangements for dealing with emergencies.

Spire’s management of its staff was questioned after two surgeons they employed were separately exposed as dangerously incompetent. Since then, concerns have focused on low staffing levels, especially at nights and weekends, and how alert people can be during back-to-back shifts. Resident doctors have been contracted by Spire for up to 168 hours a week including nights on call, whereas doctors’ working hours in the NHS are capped at 48 a week. Almost all the ex-Spire doctors interviewed for Panorama were worried about the consequences of their high workloads and protracted shifts. Hiring insufficient numbers of staff is one of the most obvious ways of minimising costs to maximise profits, regardless of the more obvious risks to patient safety. For the documentary, Spire provides a bland statement that it now has ‘robust safeguards’ and resident doctors only work ‘when adequately rested’.

The programme also describes failings in how private hospitals have dealt with complications during surgery, whether suffered by referred-in NHS patients or those paying directly. Most private hospitals don’t have intensive care or high-dependency units, so when a patient’s condition deteriorates or a procedure fails, they have to be transferred to an NHS hospital for emergency treatment. Moving a patient during a crisis carries risks, made worse by having to rely on an ambulance which could take hours to arrive, even when the hospitals are close to each other. The programme features interviews with people who have tragically lost loved ones due to complications which Spire hospitals couldn’t cope with and which weren’t dealt with by an NHS hospital in time.

Private hospitals don’t have facilities to deal with crises because they tend to treat medical issues less likely to have serious complications which require care in a high-dependency unit. And they tend not to deal with high-risk operations because these come with additional costs for specialist surgeons or equipment, and would therefore be less profitable. In other words, patients with complex conditions aren’t financially attractive. As Sally Gainsbury of the Nuffield Trust points out, around a third of NHS patients have health issues too complicated to be managed in private hospitals, so they must wait longer for NHS treatment. This is exacerbating a two-tier system where healthier people can be treated quicker privately. One way of reducing this disparity would be for private hospitals to have adequate intensive care facilities, avoiding the risks with transferring patients back to NHS hospitals in emergencies. But this requires investment, raising costs which will mean that fewer people will be able to afford private treatment, whether funded through the NHS or not. So far, private healthcare organisations like Spire have been reluctant to invest in facilities for crises, or sufficient numbers of staff. Despite this, and the criticisms made of it, Spire is aspiring to carry out more complex procedures and have longer-term contracts with the NHS. This isn’t with the aim of helping out the beleaguered ‘public’ sector, but to extend its market share. Last year, Spire’s profits increased by over 30 percent to £126 million, and any expansion will be guided by what’s likely to generate further profits rather than by meeting need.

Reformists call for the NHS to have more funding so it doesn’t need to refer patients to private hospitals, but there will never be enough money for the utopian NHS they want. Even if a government wanted to adequately fund the NHS, other economic imperatives would prevent this, especially the need for profit which guides the system overall. The ‘public’ ownership of the NHS means that it isn’t directly profit-driven, but it still has to survive in the profit-driven system, alongside and inter-dependent with private healthcare.

Every day, skilled and dedicated staff in NHS and private hospitals perform life-saving operations which would have looked like miracles just a few years ago. Somehow, they carry on despite the obstacles put in their way by the system they work in, such as the routine of long shifts in understaffed wards because this minimises costs, or having to gamble on surgery being straightforward because other hospitals with facilities for dealing with crises are overstretched. Trying to overcome these obstacles with reforms or revised contracts or reallocated funding is a never-ending struggle because this approach can’t change the system which creates the problems. It only addresses the symptoms without curing the cause.

Mike Foster

Voice From The Back: Coal, steel and blood (2002)

The Voice From The Back Column from the February 2002 issue of the Socialist Standard

Coal, steel and blood

For generations apologists for capitalism have churned out the lie that modern war is caused by different ideologies. We have been told that the First World War was a war against militarism and the Second was a war for democracy against fascism. The socialist view is that war is the logical outcome of economic rivalry and now one of the pillars of capitalism confirms our view, inadvertently while he discourses on another subject. As Tommaso Padoa-Schioppa, the Italian economist who is now a major influence at the European Central Bank, has written: “It can hardly be denied that establishing joint supra-national management of coal and steel – the two fundamental natural resources of the nineteenth and early twentieth centuries, over which France, Germany and the rest of Europe fought cruel wars was a highly political project.” Observer (9 December).

The cause of poverty

For almost a hundred years the Labour Party have argued that poverty can be abolished inside capitalism. Socialists have always argued that capitalism with its class divisions and production for profit is the cause of poverty. The latest figures on Labour’s failure to deal with poverty inside capitalism illustrate our point. “More families are classified as very poor now than under the last full year of Conservative government, according to new research. The number of people living in households with less than 40 per cent of the average income in 1999-2000 was 8.3 million, 100,000 more than in 1996-97, a study published today by the Joseph Rowntree Foundation says.” Times (10 December).

Terror thugs and terrorist teachers

Under the heading “Terror thugs groom future suicide killers” The New York Post (11 December) reported that kids between 4 and 8 years of age were being taught how to be suicidal terrorists by the Palestine terrorist group Hamas. What they didn’t report is that the US government are also guilty of “robbing kids of their childhood”. “On another front, the Pentagon has succeeded in establishing its first Military Institute, as a public middle school in Oakland, CA. The school’s 1,200 cadets, whose average age is twelve, wear uniforms, perform military drills, and are instructed by military approved teachers.” (WWW.CITIZEN-SOLDIER.ORG).

Who needs the brain scan?

One of Labour’s election boasts was that it would improve the NHS, but what is the reality? “A medical scanner costing millions of pounds is being used to treat pets at an NHS hospital which does not have enough nurses to treat its patients . . . News of the animal treatment scheme comes as the Bedford Hospital Trust has warned it will have to close an operating theatre to avoid a £3 million deficit by the end of the financial year.” Observer (23 December). It is good news for well-heeled pet owners though. A London divorce lawyer was delighted that her 13-year-old poodle had a brain scan and prompt medical treatment at the hospital. This must be a great consolation to workers waiting for treatment on Labour’s new, “improved” NHS.

Inappropriate tears

After the horrendous events at the Twin Towers the outgoing Mayor of New York Rudolph Giuliani talked about the site being devoted to a memorial to those killed. The new mayor Mike Bloomberg would now like to distance himself from such foolish, unelectable sentiments. “Mr Bloomberg all but ruled out using the whole site for a memorial. He said that the value of the 16 acre property and the demands of the area for jobs and businesses meant that it would be inappropriate to devote the whole of the space to a single monument.” Times (5 January). Sympathy, condolences and sentiment are all very well, but inside capitalism profit is the driving force, so let us not have inappropriate tears. Although as human beings, they are the only ones we’ve got. Nearly 3,000 human beings died that morning. We still cry, inappropriately, of course, at the madness of capitalism.

Scandal? What scandal?

Under the headline “Scandal of NHS beds auction” (Observer, 6 January) reported that more than 10,000 private patients were treated last year in the UK’s NHS hospitals. That these patients jumped the queue for treatment and cited the case of NHS patients having to wait six months to a year for a heart by-pass operation while for a fee of £15,000 “they can be operated on almost immediately by a surgeon of their choice”. So where is the scandal? Inside capitalism if you are poor you can be homeless, if you are rich you can live in a beautiful house. If poor you will probably get a sub-standard education, if rich you can get the best that money can buy. That is the way capitalism operates – if you can afford it you can buy the best medical treatment, if not get to the back of the queue.

This is progress?

All the slaughter, maiming and terror of the recent Afghanistan conflict was justified according to the Western press by the wonderful improvements in human rights in that country. A report in the Brussels newspaper (Le Soir, 19 December) would seem to indicate that this is far from the truth. “Public executions, stonings and amputations are going to continue in Afghanistan in accordance with the Sharia law, a top Afghan magistrate has stated, while promising more fairness and clemency than during the time of the Taliban. “For example, the Taliban used to hang the bodies of victims in public for four days”, the judge Ullah Zarif explained, “we will only expose them for a short time, say 15 minutes”. As for those guilty of adultery, they will certainly be stoned ‘but we will use smaller stones’, judge Zarif said.”

Cooking the Books: Bottom line building (2008)

The Cooking the Books column from the January 2008 issue of the Socialist Standard

Like everyone else with an email address we get loads of spam. Most go straight into the trash can, but the subject of one – “Crack Patient Paying Problems with these Helpful Hints” – caught our eye. It turned out to be a plug for an audio-conference in America on “Tried-and-True Ways To Get Chiropractic Patients to Hand Over Their Dues”. The message began:

“Getting patients to pay their bills at your chiropractic office isn’t always the most successful part of the visit. And even a handful of patients who don’t pay their bills can start adding up – and hurting your practice’s bottom line. But you can learn less-stressful way to collect pays, deductibles and co-insurance in this 1-hour session. Your expert speaker, Marty Kotlar, DC, CHCC, CBCS, will provide strategic advice on everything from gathering patient information to forming an office policy explaining the patients’ financial obligations. Don’t miss this bottom-line-building session . . .”

Chiropractics is an “alternative medicine” that is regarded by most conventional doctors as quackery (it is based on the idea that by manipulating the spine you can deal with ailments in other parts of the body, a bit like reflexology claims for manipulating your toes). But that’s not the point since no doubt teleconferences also take place in America about how conventional doctors can boost their bottom lines too – except that it does not fit in with the caring image that “alternative medicines” seek to cultivate as a way of attracting paying customers.

In Britain NHS doctors – and patients – are freed from this stress since the doctor’s fees are paid to them directly by the government. Not a solution, we imagine, that Marty Kotlar will be proposing in his teleconference, even though chiropractors in Britain would dearly like to get in on the act and even though doctors’ practices in Britain are, with government encouragement, going the American way and converting themselves into profit-seeking businesses. Of course to the extent that they take on private patients these medical businesses do face the problem of getting patients to pay up, as do unrecognised “alternative” practitioners and NHS dentists. So perhaps, after all, they could learn something from listening in to Marty Kotlar’s “bottom-line-building session”.

Most people, in Britain at least, find it abhorrent that people should have to pay for medical treatment and health care. And they’re right; if you are ill, you should get treatment whether or not you can afford to pay for it. Socialists go further. We say the same as-of-right access to what you need should apply across the board, to housing, heating, electricity, food, clothes, transport, entertainment.

But this will only be possible once the means for producing these things have become the common property of the community as a whole instead of being, as at present, provided by profit-seeking businesses owned by rich individuals, corporations or states.

Desperate lies (2006)

From the September 2006 issue of the Socialist Standard

The man who faced the choice of dropping dead while waiting on the NHS list or bluffing.

Early in August, a story broke about retired painter and decorator, Roy Thayers, having to lie in order to be free of terrible pain he’d been suffering for years, because of heart trouble.

A cardiac specialist warned the 77-year-old that he needed a lifesaving operation as soon as possible, because he was in danger of having a fatal heart attack at any time. He was told the coronary angioplasty treatment he required would not be available from the NHS for nine months because of a waiting list, but added that by going private, Roy could have the operation within a week. Being penniless, Roy had the option of dropping dead while waiting on the NHS list or bluffing. He chose the latter, and said he’d pay, when he knew he couldn’t.

He managed to stall requests for payment by hospital administrators, claiming he mislaid his chequebook. His operation took place quickly, he wrote out a “Mickey Mouse cheque” for the £8,500 cost the very next day, knowing he’d have to face the consequences later.

Speaking of his ploy, Roy said: “I love life, I love my dogs, I love fishing – why should I die for the sake of money?” Indeed, why should bits of paper decide who lives and who dies, or who eats and who starves, or who has a comfortable home and who has a stinking hovel, and so on?

 

It’s sick and idiotic. But seeing how, under capitalism, goods and services are provided to make profit – not meet needs – this system has created a universal comparison commodity (a.k.a. money) against which other commodities can be measured. Comprising paper notes, metal discs or mere digital data, this comparison commodity exists in order that those with something others need can make its supply dependent upon receiving a specified amount of this measuring tool. No money, no provision.

When Tony Blair developed a dicky ticker, naturally, he got treated very quickly. No long delay for the likes of him. Not forgetting that the Oxford Radcliffe NHS Trust, having provided the PM with his cardiac catheter ablation operation, shortly afterwards decided to deny this treatment to others in order to cut costs and meet the government’s six-month waiting-list targets.

Of course, Roy hasn’t managed to defeat capitalism by writing his rubber cheque. For a start, as he said himself, “I paid into the NHS for years to look after me, but the doctors were telling me they wouldn’t, so who’s robbing who?” Furthermore, the Primary Care Trust (PCT) in charge of the hospital that treated him was soon threatening to send in the bailiffs, and he eventually settled on repaying his debt at £25 a week from his meagre pension.

No doubt, private health care enterprises will now do their utmost to ensure people have sufficient funds before they get treated in future. So although the money-loving Sun tabloid praised Roy for being “canny”, and the profit-hungry Mirror said “well done”, don’t count on acquiring desperately needed medical care by the same method.

The fact is, no one should have to come up with devious methods to obtain critical health care or any other essential services and goods. In a decent and rational world these would be available according to need – not how much money people have depending on how much, or little, capitalism has allowed them to have in return for their exploitation and control by a minority ruling class.

The only reason this appalling and damaging situation continues is because we allow it. If all those unhappy and irate with the way they’re made to live, work and struggle on pitiful pensions came together with the aim of getting rid of the system which allows a super rich minority and their money mechanism to control, deprive and manipulate this majority, then capitalism would be in serious trouble.

Roy Thayers is also quoted as saying: “The real working classes of this country – the ones who have very little money – have been abandoned by their own government.” From his own experience, Roy might well now accept that this government (and those before it) has never had the needs of the electorate as its priority. The main concern has always been looking after British capitalists, not the working class majority.

The answer isn’t more money for the NHS – since in a competitive world, there’ll always be pressure on all governments to keep cutting back on state funding, and increasingly make people pay directly for what they need. No. The answer is a society with no money at all.

That’s the only way to end the idiocy where, these days, NHS hospital employees are being told by PCTs to stop “overperforming” by providing treatment too quickly, because the government then financially penalises the Trusts for not adhering to minimum waiting times (as a result, one gynaecologist said he now spent more time doing sudoku puzzles than treating patients). And a moneyless society is also the only way to end the obscenity of driving people to desperate lies and deceit to obtain vital life-saving treatment that should be available to all – not just those sufficiently well off or powerful.

Max Hess

Concerning “A National Health Service” (1944)

From the June 1944 issue of the Socialist Standard

The White Paper issued in February 1944 dilates on proposals for a National Health Service. This is the result of discussions with various bodies including the British Medical Association (which may be termed the doctors’ trade union), the Royal Colleges, Voluntary and Municipal Hospital representatives. In the words of the report:-

The Government . . . want to ensure that in future every man and woman and child can rely on getting all the advice and treatment and care which they may need in matters of personal health; that what they get shall be the best medical and other facilities available; that their getting these shall not depend on whether they can pay for them, or on any other factor irrelevant to the real need—the  real need being to bring the country’s full resources to bear upon reducing ill-health and promoting good health in all its citizens.

As Socialists we are not impressed by this show of good-will; we give due regard to the capitalist need for healthy workers, and to the date of publication – viz., during a period of something very like war weariness, when accounts of Jap atrocities are needed to pep up morale.

We will digress for a moment to examine the state of medicine at this time in relation to the working class.

Ideas regarding a State medical service for all, not just for insured workers as prevails at the present time, are by no means new, but in their previous forms they have met with opposition from both the British and American Medical Associations. In their organ, the British Medical Journal, the BMA have expressed fear that the present “free” choice of doctor will cease. That freedom of the present choice will be apparent to most workers, but should any retain illusions, they may be quickly dispelled. A worker may not choose a Harley Street specialist, but most have a general practitioner engaged in panel practice, unless he is prepared to spend his meagre earnings on doctor’s fees. The doctor chosen is usually the nearest, in order to save time. Frequently nothing is known of his or her qualifications, letters after the name conveying no more than would hieroglyphics. When the choice is made, unless the worker is extremely ill, he attends an overcrowded surgery, perhaps being allowed five minutes of the doctor’s time. He may, however, not get this, for it has long been the custom for doctors with large panel practices to employ assistants – e.g., newly qualified doctors. The assistant sees the panel patients whilst the doctor attends his fee-paying patients. (This practice is in abeyance during war time, due to the calling up of young doctors, so the poor panel patient gets less time than ever.)

In these days of specialisation, the general practitioner cannot completely attend to all his patients’ requirements. Equipment and the services of dispensers and secretaries are costly. The White Paper recognises this fact and proposes Health Centres in which a group of doctors could practise with staff and equipment provided. The private patients also suffer under the present system. Their own doctor may administer palliatives instead of sending them to the appropriate specialist for radical treatment.

The BMA have also feared they may find their members working in the guise of civil servants subject to control, which they state would stifle initiative and responsibility towards those sacred trusts, their patients. The American counterpart went so far as to remove from membership any doctor taking part in salaried practice, until prevented from so doing by an order of the Supreme Court in 1942.

Much of the opposition to a National Health Service arises from the inability of doctors to regard themselves as members of the working class. They are, in their own opinion, a class apart, members of the highest profession, rendering selfless service to mankind. No doubt many start with the highest ideals, but few keep them. This is not intended to portray doctors as battening ghoulishly on the lay public, but like all others, they are caught in the cleft stick of capitalism. The doctor is an expensive product; he must keep up certain appearances, and bring up his children in like manner. To be successful he cannot escape the sordid struggle for life under capitalism. He must sell his labour power in order to live, as does his meanest panel patient. These facts are not readily appreciated by the BMA, who, however, by their resistance to salaried schemes, have compelled the doctor to sell in the open market.

Nevertheless, the views of the BMA have not been wholly representative of opinion here or in America. In  a leading article, The Lancet (January 22nd, 1944), anticipating the proposals in the White Paper, commented on the advantages to the patient of co-operation between local authorities, hospitals and the doctor, now inadequate, and states that hitherto most attention has been paid to the convenience of the doctors concerned. Unpopularity of central control may be the reason for this outburst. “Enough of this bureaucratic planning; give me my own show and let me get on with it”. The article continues: “The answer to him has already been given. ‘The needs of the sick are endlessly variable; the resources of medicine are multifarious; and only a large adaptable, sensitive, smooth running organisation will fit one to the other in the largest number of cases.'”

Similarly the attitude in the USA, where there is no National Health Insurance, is changing. Reviewing Kaiser Wakes the Doctors, by Paul De Kruif, New York (a work demonstrating the success of shipbuilder Kaiser’s medical scheme for workers in the mushroom ship yards of the Pacific coast, employing 60 salaried doctors), The Lancet of February 19th, 1944, quotes De Kruif’s confession. Hitherto, he had “remained content with official medical explanations that this prepaid medicine was unethical; 100,000 doctors could not be wrong.” It now appears that they could. At the present state of development it is uneconomic for the doctors to sell their labour power in the open market, as the worker cannot afford to buy it, and his health suffers in consequence. The needs of war-time industry here and in the States require workers to receive expert medical attention in every sphere, in order to return to work rapidly and make the wheels of capitalism spin. Note the recent accent on “rehabilitation”. In times of slump the breakdown of a few workers is immaterial when others can be drawn from the reserve army of the unemployed. The present arrangements, in which the general practitioner works alone, are not conducive to the production of efficient, healthy workers. “Accident proneness” is inevitable in sub-healthy states. Also the fact that the worker’s wife has no panel doctor has come to be realised as an anomaly overdue for remedy. As she must be a fee-paying patient, she often fails to seek necessary advice, and comes to accept ill-health as part of her life.

The widespread influence of the BMA compelled the Government to accept its offices in the recent discussions. The White Paper is throughout a sop to the BMA, reiterating again and again that “the patient should choose his own doctor”. The suggested arrangements for the entire population to be covered by insurance has the advantage of simplicity, but not so the arrangement of general practitioners. The Health Centres proposed will be used by a group of doctors who will see their patients there instead of at their surgeries. A salary or equivalent will be paid to them but – and what a large “but” it is – the doctor may still have private fee-paying patients. The report states, however, that no one must be given “reason to believe that he can obtain more skilled treatment by obtaining it privately than by seeking it within the new source”.

Socialists may suppress a smile at so naive a hope. What reason is there to suppose that a doctor now giving greater attention to his private patients than his panel will not continue to do so under the new scheme? It is not hard to visualise a doctor seeing his erstwhile panel patients at the Health Centre, receiving his salary for so doing, and then rushing off to see his private patients. True, the better equipment provided at the Health Centre may even be an inducement to persons of means to attend, so that private practice declines and the doctor ceases to sell his labour power in the open market, but what then?

Will the doctor’s salaried position enable him to see his true place in society? Time will show, but under neither this proposed scheme nor any other will the worker get the requisite attention. Under any scheme in capitalist society expenditure is resisted at every step, as has been the case with housing for the workers (not their masters), sanitation, education and the like. Even the Beverage scheme for health insurance requires that large scale unemployment shall not obtain; such statements serve to demonstrate the hollowness of capitalistic schemes, for it is powerless to prevent unemployment, which is inherent in its constitution. Only under Socialism, where the wages system  will no longer exist, and where the workers will enjoy the fruits of their labour under ideal conditions without exploitation, can doctors truly serve their fellow-workers, and a real health service for all be established.

W. P.

NHS – 75 years of socialism? (2023)

From the August 2023 issue of the Socialist Standard

July 5 2023 was the 75th birthday of the National Health Service. The media celebrated, events were held, paeans of praise for what generally is considered to be the golden public utility. Such was the glister.

All this was tarnished somewhat as medical staff are having to resort to striking in an attempt not just to increase pay, but rather to restore some of the value after years of salary stagnation. As prices have continued rising this has been a period of reducing real wages.

The main story for the media has been and remains increasing waiting lists, the difficulty of securing GP appointments and overwhelmed A & E units. All the while governments of all flavours have pursued an attritional process of privatisation.

However, the NHS is commonly cited, by members and supporters of the Labour Party, as an example of socialist legislation undertaken during the 1945 to 1951 Attlee administration. Even those who now openly admit that Labour is not socialist will use the NHS to convince, perhaps mainly themselves, that it once was.

Certainly there was socialist-sounding rhetoric spouted at the time. Aneurin Bevan, who is usually identified as the politician responsible for the NHS, said, ‘No society can legitimately call itself civilised if a sick person is denied medical aid because of a lack of means.’

Previously William Beveridge, whose report instigated what became known as the Welfare State, declared, ‘A revolutionary moment in the world’s history is a time for revolution, not for patching.’ He would go on to be ennobled and leader of the Liberal Party in the House of Lords.

The context for such sentiments were the previous years of protracted immiseration leading into the Second World War and a recognition that measures were required to prevent social breakdown, a situation inimical to capitalist prosperity.

Bevan made a political statement that, by removing one word, can be assented to by socialists. ‘How can wealth persuade poverty to use its political power to keep wealth in power? Here lies the whole art of Conservative politics in the twentieth century.’ Subtract the word ‘Conservative’ and the piece poses a question relevant then and now.

Bevan’s myopic political view could see only the Tories as being the problem, on occasion referring to them as vermin. What he apparently could not see was the real problem, why a ‘sick person’, or any person, has ‘a lack of means’.

Despite Beveridge’s imperative his report led not to revolution, but to patching. Wherever the worst traumas of capitalism were diagnosed a welfare state patch could be applied. A hundred years previous to the NHS a Royal Commission into public health identified the need for the state to act.

Appropriately, acting on the Commission’s findings, the Liberal Party played a leading role through the latter nineteenth and into the twentieth centuries. The Welfare State, and the NHS in particular, were further social and political developments of this imperative to develop a functioning capitalist society.

In his report of 1942 Beveridge costed a health service at £130 million annually. By 1948 the actual cost was £400 million, which, in the present, would be £11.2 billion. This represented a significant investment by the state on behalf of capitalism.

Thirty years on, this annual amount had risen to £5,200 million (£38.4 billion present day equivalent), on its way to £160.4 billion in 2023. The figures seem to indicate that the NHS becomes increasingly expensive.

In the 1950s waste and bureaucracy were being regularly identified as contributing unnecessarily to the cost of the NHS, as it continues to be today. While this may well be correct the significance is probably not so great.

The number of nurses employed in 1948 was 125,000 along with 5,000 consultants for 480,000 beds. At present there are approximately 1.4 million full-time employees in the NHS servicing about 140,000 beds.

Far fewer beds but much higher costs, certainly not explained by bureaucracy. 37% of NHS spending is on staffing. How much greater this would be if nurses’ real wages, for instance, were restored to 2010 levels. Nurses have effectively involuntarily been subsidising the NHS for over a decade.

Then there are the pharmaceuticals and the impressively wide array of technological devices, scanners and monitors etc., plus food, services such as cleaning and equipment like surgical tools and walking frames, not forgetting buildings. All supplied by capitalist industries with ever increasing potential for profits.

The NHS is effectively a market place which is why the forces of privatisation have increasingly muscled in. This is not being facilitated by the Conservatives alone. The Labour government of 1997 to 2010 launched the Private Finance Initiative of hospital building, along with other tendering measures for services.

It is now an accepted commonplace for NHS procedures to be carried out in private medical facilities by staff employed by both. This is by no means a recent development in thinking about the provision of health care.

Talking of medical provision in a 1943 radio broadcast, the then prime minister Winston Churchill used the expression, ‘From the cradle to the grave’, a phrase that can be traced back to the founder of The Spectator Richard Steele in 1709.

What Churchill was referring to was the possible development of social insurance to finance individual medical care. He was not advocating state intervention.

While medical provision remains largely, though by no means entirely, free at the point of use, the figures above demonstrate that from the very outset the NHS was not, and most certainly is not, free. This is not to deny the beneficial worth of the NHS. That is also true of many services and features of capitalist society.

To directly address the question posed in the title, the answer is straightforward, no! The NHS is not, and never was, a socialist organisation. A defining socialist axiom is, ‘to each according to need’, in a worldwide society that does not have money to limit the extent needs can be met.

As medical procedures and technology have advanced so has the amount spent increased significantly from £11 billion in 1948 (at today’s values) to over £160 billion in 2023. A figure that continues to be inadequate and, therefore, a limiting factor in meeting need either by delay or even denial of treatment.

When politicians claim to have increased spending on the NHS they are correct. What they, or any of the parties, do not address is that while capitalism continues there cannot be sufficient funds. Ultimately, such spending is drawn from the overall pot of value created by an economic system prioritising profit making. While income tax seems to be a payment by individual workers’ wages, that simply means it becomes a factor in each person’s salary requirement paid by employers. An extra penny in the pound tax rise for workers is an extra penny in the pound employers have to pay.

A few years ago an otherwise amiable American appeared incredulous that I, and the British in general, could tolerate a National Health Service. Why did we put up with such an obviously socialist, communist, system?

By communist he meant the by-then failed soviet state capitalist system. Inadvertently he had identified something those who equate the NHS with actual socialism have missed. It is the state intervening socially on behalf of capitalism.

There can only be a truly socialist health service in a truly socialist society. For that to be achieved, merely advocating ever greater spending must give way to actively working to abolish capitalism. Then there can be socialism, a really healthy society.

Dave Alton

Toothache? Pay private fees or do it yourself (2023)

From the August 2023 issue of the Socialist Standard

Many will know that, while most people have to pay something for NHS dental treatment, it is still free to a certain section of the community: children and pregnant women and new mothers. But, as George Monbiot pointed out in his column in the Guardian on 2 March:

‘Every child in the UK is entitled to free treatment by a non-existent dentist. Some people on benefits, pregnant women and those who have recently given birth also have free and full access to an imaginary service. Your rights are guaranteed, up to the point at which you seek to exercise them’ (tinyurl.com/s7epuzad).

Dental practices, being profit-seeking businesses, consider that what they are paid for treating NHS patients is not enough – they claim that in some cases it doesn’t even cover their costs – and so are increasingly reluctant to offer it and have not been using up all their NHS funding. In February it was reported that ‘Around £400million allocated for dental care went unspent this year because of a shortage of dentists willing to do NHS work’ (tinyurl.com/yrrpakv2).

What this ultimately means is that any patient requiring urgent treatment is forced to make a choice between suffering or paying privately for the treatment there and then.

With private dental treatment running into the hundreds, sometimes thousands of pounds, it is obvious that those on lower incomes are really faced with no choice at all.

The system does appear to offer an alternative. Since 2006 the necessity to ‘register’ with a particular dentist has been abolished. What this means is that a patient whose regular dentist is unable or unwilling to provide NHS-funded treatment can shop around for another dentist prepared to treat them under the NHS.

The reason this only ‘appears’ to be an alternative is because it is another of Monbiot’s rights to a non-existent service. You won’t find another dentist prepared to treat you as they won’t find it profitable. So, when you look at those same low-income families and elderly people who can’t afford to ‘go private’, you see that really this is not much of an alternative at all.

In any event, going to another dentist obviously can involve increased travel costs if the dentist is out of the area. While merely inconvenient for some it could mean the difference between having the treatment and not for others such as the very low-waged who do not have access to personal transport or the rurally housed elderly who rely on poor public transport coverage. When you add the psychological factor of forcing people to see a dentist they are unfamiliar with which, as we know, can have a particular impact on older members of our community, you can see why so many people elect to wait for their own dentist to be able to do the work or forgo the treatment altogether.

There is another option – DIY dentistry – which, apparently, some have been taking. As Monbiot noted:

‘The result, in one of the richest nations on Earth, is that people are extracting their own teeth, making their own fillings, improvising dentures and sticking them to their gums with superglue, and overdosing on painkillers’.

We continue to be forced into a situation where, when we need treatment which is vital to our health and well-being, we either pay extortionate private fees, are forced to seek out another dentist at our own cost or, if none of the above are possible for us because of our financial situation, simply wait, with our condition worsening.

In socialism dental treatment would be provided freely to anyone who needed it. Unshackled from the financial pressures of the capitalist system, freed from the necessity of eking out an inadequate funding budget, the health services would be able to treat all those in a timely fashion to the best possible standard.

The fact is that no-one should be forced to make such dire choices when it comes to this or any other area of their health. The NHS was originally intended to implement the admirable principle: ‘Treatment free at the point of need’. Where our dental treatment is concerned, this principle has long had a thread tied between it and the door handle, and the door slammed shut.

Fear or Freedom ? (1991)

From the June 1991 issue of the Socialist Standard

We live in a society which is full of scared people. Millions of men and women who are scared of powers which they do not control. At work you fear the boss, even if you have never met him—even if he only ever manifests himself through the anonymity of a company logo. The boss is Capital and Capital is King: if the economic overlord does not like you, if you are not delivering the profits to order, then you will be thrown out of a job. The incessant insecurity of employment will be transformed into the nightmare insecurity of unemployment.

If you are an unemployed wage slave you live in the constant fear that you will become too poor to exist. You stand shaking on the verge of the living hell reserved for workers who have no money. If you have a home you fear falling behind with the mortgage payments or rent. Repossession is your constant threat. If you are homeless and have joined the growing army of workers who must sleep on the streets, then be sure to fear the friendly reminder of your poverty from the policeman's boot. When you walk down the streets of most cities you are scared. Who is behind you? The ethic of competition makes you prey for the bully who robs from the poor. You are scared of war. Unless you are crazy, in a world crammed full of the weaponry of mass destruction you feel miserably insecure about the prospect of the next full-blown market shoot-out.

The media, over which the vast majority has no control whatsoever, thrives on popular fears and depicts a world of beasts, be they East Enders' wretched brutes who fight and con one another or the ugly caricature of Dirty Harry: Winner Man. The government, with its laws and machinery of coercion, scares you: “Do as we say or suffer the force of violent sanctions". You submit because you are frightened not to. Fill in the census with its meaningless questions about ethnicity, discuss your sex life with the Department of Social (In) security official, keep off the grass and away from the Earth because it does not belong to you. We live in a "Keep Off—Keep Out— Keep Quiet" culture, and if you think of resisting, beware, for you may be labelled The Enemy Within. You fear the price of resistance; who knows how the powers that be will retaliate?

Fear is characteristic of the normalised wage slave. You were sent to school to learn to become scared. You were taught the skills of conforming, obeying and stifling awkward criticisms. Indeed, you were taught to be afraid of your own fear: it is not "manly” to be scared. It is "manly” to suffocate your self-respect until you have a slave's contentment with the sound of the whip hitting someone else. It is so much easier to down eight pints of lager and cheer in unison in a football stadium than to face up to the fears which this social system thrusts upon us.

This fear which is the daily companion of most workers is not something natural. To be sure, there are natural fears: physical dangers which threaten all of us occasionally and some to the extent that it destroys them. But most of the powers which assault the working class are the product of the way that society is organised. They are the socially-created effects of a social cause. The cause of our fear is the capitalist system.

The truth about capitalism

Under capitalism the means of wealth production—factories, farms, mines, media, means of communication and transportation—are owned and controlled by a small minority of the world's population. The world is run for the purpose of accumulating profits for that capitalist minority. In the pursuit of profit, the needs, feelings, hopes and dreams of the vast majority. who are the wealth-producers, will inevitably be hurt. Capital uses (exploits) the working class and also it abuses us in many ways. It makes workers subjects of a set of economic, political and social relationships which we do not control. In fact, even the capitalists do not control the workings of their system—the system ultimately controls the capitalists and the governments which rule on their behalf. The truth about capitalism is that the workers are economically disenfranchised from real power and the bosses only imagine that they are in charge; everything is chaos and disorder: nobody knows what will happen next.

Under capitalism it is quite sensible to be scared. The record of the system is one of persistent disasters, usually unexpected. Just as one social problem is apparently being reformed out of existence two more emerge to plague us. Plans and policies to improve the system fail, either immediately or in the long term. Optimistic prospects of peace collapse when new ruling gangs with unforeseen appetites for profits make war a necessity. In late 1989 the capitalist leaders were celebrating the end of the Cold War, the outbreak of world peace, freedom from the threat of military strife—and exactly a year later they were preparing for a potentially global war commencing in the Middle East. Even at its moments of greatest hopefulness, capitalism only offers the reasonable observer grounds for worry.

The result of this fear-inducing system is a society characterised by socially-caused suicide statistics (rising in recent years amongst teenagers) and massive addiction to drugs, both legal tranquillisers offered to the fearful by helpless doctors and the illegal variety, used as an illusory form of escape by those for whom fear and insecurity have become too much. This system sells escape as one for the most sought after commodities. Holidays offer a fortnight of artificial relief from the worries of everyday wage or salary slavery; there is escape through film and escape through astrology and escape through bopping up and down to the sterile non-songs of Jason, Kylie or the latest packaged boil-in-the-bag superstar. Escape is the dream of the captive. The prison of capitalism, which captivates us in the trap of working for wages and buying everything we need for money, makes the fantasy of escape an appealing one.

Mass emotional repression

Capitalism requires repression. Not only that visible, brutal, blood-stained repression which comes out of the barrel of a gun. or other means of state coercion. Mass emotional repression is the order of the day. Workers must learn to know their places, fear stepping out of line, feel afraid to question what it is not for us to question—run and hide, mentally if not physically, when talk of freedom is in the air. The “fear of freedom" (to use the term popularised by Erich Fromm, whose writings have much to offer us in examining the psychology of capitalist life) is amongst the greatest barriers to majority socialist understanding in the world today.

The problem is that to understand the possibility for social revolution—socialist liberation—people have to want to be liberated. to become free, to overcome the forces of oppression. For many workers such a desire for freedom is too much to cope with. To think about the socialist demand that the we should emancipate ourselves from wage slavery involves making the admission that we are now slaves and then accepting the desire to be something better. This recognition presents a difficulty to workers who have become accustomed to their condition: the happy slaves and the victims of fear who tremble at the thought of seeing what the system has reduced them to and what they could rise to become in a free society.

In a socialist society humans will be free. The most basic social freedom of all is free access to the goods and services we need. Capitalism can never offer such freedom. The market is the antithesis of free access. Socialism means that the common store of global wealth, including all services and the widest artistic opportunities, will be free to all. There will be no money. Each will take from what is available according to their needs, just as all will give to society according to their abilities. Co-operative, democratic human freedom will prevail.

With this economic freedom from the shackles of the market will come a profound emotional freeing of people from the burden of living in fear of powers beyond them. No more bosses, no more gods, no more money-worship, no more moral absolutes. Stateless, leaderless and classless humanity will be free to explore what we want to make of ourselves. The dreams which had previously been confined to fear-free utopian visions will be on the social agenda. Humans will be free to live with a consciousness unhindered by the fears which come from always having to look over your shoulder.

The psychological freedom which many have sought through individualist therapy or mystical diversions is only going to be possible when there is a collective fightback against the fear-culture of capitalism. If the movement for socialism is small today it is not because most workers have heard our ideas and rejected them. Nor is it the case that those who have rejected socialism have done so consciously. For millions of workers the dream of being free from all the fearful strains of life under this anti-life system is a powerful one. What is needed is the strength to act and the knowledge that conscious, democratic action for socialism is the way out. To our fellow frightened workers we say: Don’t be afraid; it’s time now to give the capitalists something to worry about.

Steve Coleman

Blogger's Note:

Illustration by George Meddemmen.

Voice From The Back: When Margaret Beckett (2000)

The Voice From The Back column from the September 2000 issue of the Socialist Standard

When Margaret Beckett . . .

. . . took on responsibility for science as trade and industry secretary after the 1997 general election, there were hints that the government’s priorities for science would change. Beckett suggested that improving the quality of life was just as important a goal for science as creating wealth. But over the last four years, the potential financial benefits of science—and in particular the creation of high tech spin-off companies based on new scientific discoveries—have dominated government science policy . . . The £1bn unveiled last month for science facilities by chancellor Gordon Brown signals his continuing interest in the financial benefits of science. Guardian Science, 20 July.

The inadequacies of the NHS are well known. 

How awful the position has become is illustrated by the journalist Katie Grant. In praise of private medical care she inadvertently blows the whistle on capitalism: “Thirty percent of all hip replacements and 20 percent of all heart surgery is done privately. A million people are treated in private hospitals each year . . . Private insurance does not make you a parasite. Quite simply, it offers you the best hope of staying alive” (Times, 15 July). And if you can’t afford private insurance?

It is criminal!

The annual cost of crime in Britain is £60 billion—more than £1,000 a year for every man, woman and child in the country . . . The figure . . . is the result of a four-year study by the leading American economist David Anderson, whose paper “The Aggregate Burden of Crime” was recently published in the Journal of Law and Economics . . . “Society will never rid itself of crime,” says Anderson, “but when you take into consideration the resources that could be conserved or reallocated in a crime-free society, the costs are absolutely staggering.” Observer, 23 April. Quite so! But socialist society will be free of property crime because we shall all own the wealth and have free access to it. The basic cause of such crimes will have gone.

Shafted

We’ve been sacked, fired, made redundant, become supernumerary, down-sized and terminated. As members of the working class we are used to the various terms for being unemployed. But the recent demise of the internet company Boo.com revealed yet another euphemism to disguise our wage slavery: “What is certain, however, is that after the world’s biggest on-line fashion retailer went bust, 300 young people who had previously thought of themselves as role models for a generation of dot.com entrepreneurs were out of work. In the lingo of the New Economy, they were not so much unemployed as unplugged” (Times, 14 June)

Star letter

It is not often that Socialists come across a letter that they can completely agree with, so have pleasure in the following published in Radio Times (29 July-4 August):

  “Money makes the world go round, according to Polly Toynbee. Before money, she asserts, human life scarcely rose above the animal level, with no scope for thought or creativity. Are we to take it that she has never seen any native American or Australian aboriginal art, wonderful cultural creations form societies without money? 

  As to the future, she tells us that human nature is just too fallible for us to match our production to human need without money to mediate the process. Even in today’s capitalist society, moist people feel that certain things are too important, too personal, to be bought and sold—sexual relations, for instance, and human organs for transport. 

  In future, people may come to feel that selling our time, skill and effort to an employer for a wage or salary is an unacceptable loss of our freedom and humanity.”

Gates’s billions

Bill Gates is reported to be worth $65 billion. As befits a man of such tremendous wealth he has a house that cost $50 million: “As a rich man’s folly it equals William Randolph Hearst’s San Simeon Castle in California, for which the press baron ransacked Europe for antiques. His Shangri-La is all high tech, stuffed with electronic gadgetry. It is mostly buried beneath landscaping, with a 60ft pool, dining for 100, an underground garage for 20 cars, 45 rooms, and electronically controlled music and lighting in guest rooms directed by a pin in the visitor’s clothing. Lights come on automatically as a person moves around, but can be switched on and off manually (so it can be done). It is so massive that neighbours call it Gates convention hall” Herald, (15 July). What future generations in a socialist society will make of such ostentatious wealth contrasted, as it is, with the plight of thousands of homeless in the USA, can only be wondered at.

Freedom of choice

Freedom of choice is everyone’s right. Use it wisely! . . . We invite you to test-drive a Seville at your nearest Cadillac Retailer . . . On the road price £39,925.00.

Medicine’s private parts (1981)

From the December 1981 issue of the Socialist Standard

At this time of queues to the Bankruptcy Court there is very little cheer in the boardrooms of Britain where, as we all know, they can clink a sherry glass or two in salute to a pleasing balance sheet. Yet here is one chairman who can report in terms of glowing optimism:

  It is with pleasure I present the accounts for 1980 . . . most positive encouragement from the government . . . the service given to subscribers continues to be of the very highest standard . . .

The author of these self-satisfied, not to say smug, words is John Phillips, chairman of Private Patients Plan (PPP), one of the larger organisations providing insurance for medical treatment outside the National Health Service. Private treatment is currently a boom industry; PPP’s subscribers have risen from 10,000 in 1950 to 313,000 in 1980 and over the same period its “Excess of Income Over Expenditure” from £12,000 to £4,010,000. And PPP have only about 20 per cent of the market, which is dominated by the 75 per cent held by British United Provident Association (BUPA). Each week during 1980 an average of 15,000 people joined a private health insurance scheme and if this trend continues, by 1985 one in five of the population will be covered.

So if people are rushing in their thousands to be ill the private way, what of the National Health Service, once described by the author Alan Sillitoe as “ . . . probably the greatest single factor in this century in creating a new pride in the English working class”? The aims of the Service, when it was introduced in 1948, were set out in no less glowing terms by Aneurin Bevan, whose job as Minister of Health at the time made him a sort of midwife to its birth:

   Society becomes more wholesome, more serene, and spiritually healthier, if it knows that its citizens have at the back of their consciousness the knowledge that not only themselves, but all their fellows, have access, when ill, to the best that medical skill can provide. (In Place of Fear).

What was Bevan talking about? Before the National Health Act 1946 hospitals were run in a number of different ways, by local authorities or by charities. They held flag days or sold their wall space to the advertisers of patent medicines in order to raise money. Their standards, relying on local initiatives, varied widely from place to place. It was by no means the kind of efficiency a capitalist state might demand from its medical services. The Act effectively nationalised the hospitals, grouping them under Regional Boards appointed by the Minister. The declared intention was to achieve an overall adequacy at the highest level which could be afforded.

Like all other hospital employees, consultants were to be paid a wage but they were also allowed to keep some private beds in NHS hospitals. In other words, the Act by no means killed off private practice and these seeds have subsequently flourished. At the time there was hostility to this from some sections of the Labour Party but more serious by far was the opposition Bevan encountered from the doctors. At the end of it all, even with the many compromises he had had to make, Bevan was satisfied with what he later called ".  . . the most civilised achievement of modern government”.

The workers too were enthusiastic; believing that they had a genuinely free, all-embracing, super-efficient health service immediately available at need, they registered with it in their millions. By 1952 only a rich (or eccentric) 1.5 per cent of the population were still outside the Service.

Well it did not happen as Bevan promised. To describe the average experience of a National Health Hospital as civilised is sometimes to reshape the English language. In one of the newest hospitals, for example, people who have been referred to a consultant by their GP wait to be seen in an area which, as the morning wears on, comes to resemble a minor battlefield. Then the consultant has little time to treat the patient in a civilised manner; little time to discuss the problem, to give a prognosis, to present the options. Having pronounced on what should be done, the choice presented to the quivering mass of flesh and bones and blood under the probing hands is to take it or leave it.

If the consultant decides (it should be “advises” but let that pass) on some sort of in-patient treatment then there is the fearsome matter of the waiting list. For some operations this can run into months, even years, of discomfort, pain and disability. At the Congress of the British Medical Association last October a Glasgow doctor warned that the waiting list for psycho-geriatric patients is so long that “seventy-five per cent of (them) die before they are admitted.” (Among the wards, macabre jokers insist that that is a common method of cutting the waiting list.)

But for those who survive the wait the great day eventually dawns and the patient is, as they say, admitted. Already in some anxiety, they are at once submitted to a process of depersonalisation, rather like going into prison. To begin with, inmates are made immediately distinguishable from everyone else because they are only allowed to wear nightclothes. In fact—although only the paranoid would think this is to prevent them escaping—they are forbidden to keep their day clothes in the hospital. The patients’ day is pummelled into a shape to fit in with the hospital’s needs; the institution is far, far greater than the sum of the individuals it theoretically exists for. As the doctors sweep on their rounds though the wards, treatment is more or less imposed; there is no time for them to inform, still less to argue about it. It takes some courage for an inmate, half naked and supine, surrounded by white coats and silvered, spiky instruments, to insist on knowing what it is proposed to do with their body. And they might lose remission, if they don’t absorb those anonymous drugs regularly pumped into them.

Not all of this springs from any historical arrogance of the medical profession. The NHS does not directly make a profit but it is required to work within limits of cost and it is often under the axe of government economies. Hospitals are what is euphemistically called under-capitalised they often can’t afford the latest and the best equipment and have to rely on charitable efforts to buy civilised things like a body scanner. Staff levels are kept at a minimum, which means that nurses are worked to the limits of safety (and often beyond; it is common for a ward full of sick people to be overseen during the night by a single, unqualified nurse). A Professor of Geriatric Medicine told the BMA in October:

  We have old people in accommodation which would have been useful for dogs, cats or race-horses twenty years ago. It is still fashionable to put the elderly into hospitals which have been discarded.

Such standards of civilised treatment do not apply to the private patient. The same consultant who is offensively off-hand to his wretched queue of NHS patients in the morning is courteous and gentle in the evening when he conducts his private clinic. Everything—the necessary tests, medication, surgery—is described, sometimes with helpful notes and diagrams and the patient is helped to make their own decision about their own body. They leave, feeling not at all wretched, with the great healer’s hand reassuringly on their shoulder.

Private in-patient treatment usually takes place in a separate room with its own bathroom, TV, radio and telephone and it is lubricated by the attention of plentiful, ever-attentive nursing staff. There is rarely any delay in admission: having chosen the specialist, the patient also names the day for admission and almost always the consultant can miraculously fit this in with other commitments. Organisations like BUPA spell this out as if it were miraculous when in fact it represents what should be the very minimum standard of care and treatment.

So why isn’t it the minimum? The NHS was designed for the working class — a sort of Tesco Stores in contrast to the discreet, exclusive shops of Belgravia which admit the superior class of capitalist society. The first object of the NHS is to repair workers to the point at which they can be got back into the exploitation process and for that the crowded out-patients clinic, the large boisterous ward and the casualness of the doctors will suffice. For the rich — for the exploiters — there have always been havens where the very best is available for those who can pay places like the Harley Street Clinic (where it costs between £560 and £1029 a week just to stay in bed); the London Clinic (£770 to £973) or the Wellington Hospital (£1225 to £1750).

Of course anyone paying that sort of money is not going to be handled with any discourtesy; no mere consultant surgeon will make decisions about them without fully discussing the matter. Medical care, like all other services in capitalism, is a commodity. It is produced — that is to say, doctors and nurses are trained, hospitals are built, equipment manufactured — to be sold and in the process to contribute to the overall driving force of capitalism — the realising of profit and the accumulation of capital.

There is a mass of evidence — recently the Brenner study and the Report of the Working Group on Inequalities in Health — to point to the conclusion that illness is a matter of how we get our living, of where we live, what stress we are subjected to in the act of survival in property society. In summary, the evidence says that avoidable illness is a problem for the working class, who are forced to live by selling their abilities to work for a wage. It hardly matters to the class who buy those abilities — to the owning, exploiting capitalists. For the workers, sickness brings additional despair as the bills mount up and perhaps their job is in jeopardy; a recent report from the Office of Health Economics states that the level of unemployment may now act as an incentive for workers not to go sick.

The failure of the NHS to ease that despair has left a gap which the private insurance schemes are trying to fill. They offer sick workers the prospect of a little comfort at a time when it is needed and that is no bad thing. But that is the limit; it is rather like shopping in Sainsburys instead of Tesco. As the NHS goes into further decline and private medicine picks up some of the pieces, there will be pressure on this sector too and there is no reason to think that it will cope any better with it than has the NHS. It will be operating under the same inhuman priorities which leave little room for civilised standards. To see the problem as one of sick people is to start at exactly the wrong end of the stethoscope, for it is the basis of society which needs attention.

I

Ripping off the Patient (2014)

From the October 2014 issue of the Socialist Standard

The president of the Zambia Medical Association Dr Munjajati recently revealed that the current health delivery system in the country cannot protect patients seeking private medical attention from flagrant overcharging. His remarks tend to highlight the fact that Zambia has a two-tier health system within public hospitals. Fee-paying hospital wards were introduced in 1980 by the UNIP government of Dr Kaunda. Those with enough money could be hospitalized in fee-paying wards in order to receive proper medical treatment .

The reluctance of the current Patriotic Front government to boldly check and regulate the operations of privately-owned hospitals and clinics is because to do so would be against the government’s policy of economic liberalization. Private health care is encouraged in the belief that an increased role for entrepreneurs and competition in the delivery of healthcare will result in a more efficient and effective healthcare system. Thus the search for financial gain determines the quality of healthcare systems. But the values of free enterprises and the economic benefits that may flow from a more efficient healthcare system can only be achieved at the cost of other and more important values – including a concern for fairness, the dignity of people and community-centred ethics that places people before profits.

Caring or looking after the sick is a calling of special dignity and importance. The striking nurses were dismissed by the Labour Minister in 2013 on the allegation that they had failed to uphold the oath of allegiance they swore when they graduated from Health College – to serve others out of compassion. To go on strike for reasons of salary increments was anathema to the values that guide governments and their civil servants. This is the oath to serve the people out of love and compassion, without regard to the standard of prevailing salaries and poor conditions of service. In that case, by the same standard, it would be the task of every government to make access to healthcare as free as possible. But they don’t.

There are relatively small amounts of legislation regulating the operations of health facilities compared to laws governing health personnel. The existing legislation regulating the operations of both private and public health hospitals was introduced by President Michael Sata when he was minister of health. In 2002 the MMD government went on to introduce consultation and medical fees in both public hospitals and clinics. Economic liberalisation entailed the acceptance of the lurid fact that free health care and education was a cost to the government. Hospitals, schools and colleges were de-centralised under health and education boards.

Under the system of private healthcare, the opportunities for ripping off patients seems endless. There is nothing in place to regulate the prices that are charged by service providers and hence the price differences in goods and services from one private health provider to another. Grading of private health facilities does not exist on the ground due to the salient professional ethic surrounding medicine. Due to the prevalence of HIV/AIDS and the mystery surrounding the disease and its causes, Zambia has seen a proliferation of traditional herbal therapies and traditional healers. It is not illegal in Zambia today to sell and advertise traditional herbal medicines that have not even undergone a laboratory scrutiny.

The introduction of free male circumcision in public hospitals emphasises that lack of a regulatory framework. The public health system exists in a state of corruption. Private surgeries are stocked with medicines siphoned from public hospitals. There is no treatment protocol and this results in over-servicing; a private doctor will prescribe ten supplementary drugs for the sake of advertising his business. Most private hospitals are under the control of lay managers whose primary interest is to make a profit. Thus under the system of private health care doctors promote profit-producing drugs, surgeries and tests. Medical treatments and counselling that lack profit potential are discouraged. The commercialization of private healthcare has led to the abandonment of human virtues that are essential for a community – caring for old people, compassion and charity, especially for the less privileged members of the community.

The zeal and altruism that is displayed by doctors and nurses in their primary concern for the alleviation of pain and sickness has been hijacked by the profit motive. Indeed the prevailing ideology says that political states or governments have a duty to protect the interests of the citizenry, through providing them with law, security and healthcare. But the provision of healthcare under capitalism is hamstrung by the principle of free enterprise with its competition and profit. The income and wealth disparities between the working and capitalist classes translate themselves into standardized economic, political and social programmes. The vision of free healthcare, and other services cannot obtain under a capitalist state. It is only in socialist society that health care will be characterized by its capacity to serve the good of every member of society. The sense of responsibility by those engaging in providing free medical care will demonstrate the individual and social virtues necessary for the wellbeing of a classless, moneyless and stateless society – socialism.

Kephas Mulenga

The State of Medicine (1982)

From the June 1982 issue of the Socialist Standard

The National Health Service was sold to us as a guarantee of health and security but is itself now the invalid of the Welfare State. If not actually bankrupt, it suffers from a lack of much needed investment. If not completely chaotic it is periodically shaken by massive reorganisations which attempt to relieve its administrative problems, often by reintroducing a system previously condemned as restrictive and inefficient. In April 1974 a “three tier” structure was imposed, which severed all links with local authority control; now the latest reorganisation has brought back the District Health Authorities, which include local councillors. At the receiving end of all this are the aptly- named patients, who bring their ailments to the surgery or the hospital in the hope that the NHS is alive and well and competent.

This hope is sustained by a popular misconception of the role of the state as the beneficent, munificent parent of us all its children. This concept springs from the belief that only the state has the resources to run something which is both essential to everyone’s interests and wide enough to operate in that way. For example, the Armed Forces are supposed to protect “our" country, “our" freedom, “our" way of life. The driest of Tories would never suggest that the forces should be owned and financed by private companies—quoted on the Stock Exchange, subject to take-overs, asset stripping and the rest. In the same way, when the coal mines were seen as necessary to the efficient and profitable operation of British industry they were taken away from the fragmented, competitive set-up of the private pit owners and were nationalised.

It was on the same theory that the NHS was born. Before the war, medical services in Britain were disjointed and unco-ordinated, varying in resources and efficiency from one area to another—and not necessarily in accordance with the demands for them. There were over a thousand voluntary hospitals, from large establishments with the most modern equipment and some weightily distinguished consultants down to the small, struggling cottage hospital. About 2000 more hospitals had been founded by local authorities or had sprung from the sick wards of workhouses. They were often precariously financed, living off donations, bequests and flag days, even selling their wall space to the advertisers of patent medicine, which must have been rather confusing to the patients. This haphazard development extended to the other branches of medical care such as GPs, medical inspectors and so on. There was a compulsory medical insurance but this covered only wage earners, excluding their families and was not valid for any treatment other than by a GP.

The war gave an opportunity radically to reshape this confusion into some sort of order and a basis for this was provided by the state-run Emergency Medical Service (EMS) which was at first designed to deal with air raid casualties but whose scope was widened to take in other categories such as evacuated children. The EMS directly employed doctors and nurses, for a wage, and it took over entire hospitals so that by September 1941 it controlled ½ million beds.

At the same time the government was aware of the need to proffer some promises of a better world after the war. as an encouragement to the people who were suffering in the battles, under the bombs and so on. The most famous of these pledges was the Beveridge Report, prepared by a committee which started its work just as Germany was invading Russia and which produced its findings in late 1942. Beveridge promised that “a comprehensive national health service will ensure that for every citizen there is available whatever medical treatment he requires, in whatever form he requires it”.

The coalition government accepted Beveridge’s health service proposals and before their defeat in 1945 two ministers Ernest Brown (National Liberal) and Henry Willink (Conservative) presented plans for a National Health Service on the model suggested in the Report. It was of course left to the Attlee government to push through the necessary Act, to fight the British Medical Association over doctors’ pay and conditions—and eventually to take the credit for what they wrote into history as a great humanitarian reform.

Experience, and the adaptation of the NHS to the everyday needs of a society based on class privilege, have exposed the reform for what it is. Only the most myopic devotee of the NHS would now claim that its services are of the highest possible standard and are freely and equally available to everyone. There is a swelling tide of frustration and disillusionment with the NHS; the 1979 Royal Commission on the NHS commented: “Nor does the evidence suggest that social inequalities in health have decreased since the establishment of the NHS. The position (of partly skilled and unskilled workers) appears to have worsened relative to those in (professional and managerial jobs).”

An essential part of the best treatment is that it should be immediately available; most conditions which need attention can only get worse the longer they are neglected. But one of the big problems of the NHS are the waiting lists, which are well above the half-million mark. An especially grisly economy operates in the waiting lists: economy because it is a matter of resources which are expensive and therefore scarce, and grisly because it often means the death of some of those who are kept waiting. As might be expected, Enoch Powell has described the situation in stark, heartless words:

  If the hospital resources are to be continuously used, there must be awaiting list, a cistern from which a steady flow of cases can be maintained. Private practice can afford to have gaps because patients are buying time. (A New Look At Medicine and Politics.) 

This probably sounds very sensible on the Stock Exchange, or to government ministers who are aware of their responsibility to run this society in the interests of a small minority. The actual flesh and blood people, who suffer and die in the queue, can be expected to see it differently. In the case of kidney disease, for example, the decision to treat or to abandon the sufferer to die is largely dependent on their place in the economic order of priority. One leading kidney specialist has described the dilemma:

  The financial situation is now so acute that children are having to compete with adults for treatment and they tend to lose out because priority has to be given to adults who have families to look after and mortgages to maintain. (Quoted in The NHS — Your Money Or Your Life, by Lesley Garner.)

Many people are trying to escape these obstacles by buying their way into private treatment. The result has been a boom in the insurance schemes like BUPA and Private Patients Plan. Most of this expansion comes from companies who are paying to insure their workers; from their point of view the pay-off is in a quicker, planned admission to hospital, less time off work and easier access to the patient while they are in hospital. (The numbers of people insuring themselves, in contrast, is falling.)

But the private sector too operates on something of a delusion. The kind of insurance which is affordable by wage earners covers only a limited range of ailments—typically, an operation which requires only a brief stay in hospital both before and after the event. It does not cover the chronically sick, the lingering terminally ill, the physically or mentally handicapped, the old people who need intensive nursing during a senility which intensifies towards death. These sorts of ailments can be treated privately but to do so would cost the sort of money which is beyond the scope of the insurance schemes. As one consultant in mental handicap put it: “In mental subnormality you see the patient for the rest of their life”. It is, then, no surprise that BUPA favours a mixed state and private medical service, with the private schemes taking the cream of the short-term patients while the NHS grapples with the rest. A foreseeable result of that would be to depress the state service even further, as investment, doctors and nursing staff were attracted into the private sector.

Whatever the outcome of this conflict, we can be despairingly confident that the basic, vital facts about health and sickness will receive only scant attention. The vast majority of death and disease today does not happen through an accident, nor is it unavoidable. For example, thirty million people die every year from starvation, simply because they are too poor to escape from a famine which itself is the result of the production of food as commodities rather than to meet human needs. Then there are the “industrial” diseases like asbestosis, which are a direct consequence of the way in which some workers get their living and which inflict a brutally slow, agonising death on their victims. More subtly, there is the sickness which can be written into the death certificate as due to other causes but which is in fact the result of the jobs their victims do or the places where they live.

The Working Group on Inequalities In Health recently reported that a labourer, a cleaner and a dock worker are twice as likely to die as is someone in the “professions”; they are twice as likely to suffer respiratory and infectious diseases, have trouble with their circulatory and digestive systems. The distinction is a false one, since both “labourers” and “professionals” are members of the same class but the point is made; it is the former who in many ways suffer the harsher degree of exploitation, the heavier weight of impoverishment. More evidence comes from Professor Harvey Bremner of John Hopkins University, who has spent some twenty years studying the subject. Bremner is convinced that economic stress on workers stimulates physical and mental illnesses; specifically he says that a rise of one million in unemployment over five years could cause an extra 50,000 people to die and 60,000 more cases of mental illness. He also says that Scottish workers are under a peculiar stress, due to a more severe competition between industries there and this is reflected in sickness striking quicker, and more harshly, when there is unemployment.

So it comes down to a matter of class. The working class—those people who need to sell their working abilities in order to live—include those who do the dirty, monotonous, dangerous work as well as those who do the stressful, ulcerative jobs in “management” and the “professions”. It includes the people who crowd into cramped, jerry-built homes under the pollution of industrial capitalism. The other social class, who do not have to work because they own and control the means of life, can afford to live away from all this; they experience no stress of insecurity, their homes are spacious and leisured, they have access to the best of diets. If they want it that way, their lives can be a continuous recreation. The medical care they can command was typified in Tudor Hart’s Inverse Care Law. which laid down that the availability of good medical care varies inversely with the needs of the people it serves. Simply, they can have the best of everything—the best homes, food, education, medicine.

This class do not need the National Health Service, which was designed for the workers, to patch them up and get them back to work as quickly and as productively as possible. Whatever medical care is available to the working class exists only because it contributes, in the short or the long run, to the production of profit and the accumulation of capital. One of the reasons for setting up the NHS, for example, was that it is cheaper to pay for the hospitals, GPs, health centres and the rest through taxation than through the complex process of means testing, claims and rebates which was operated in the private system. Doctors who have trained for years to relieve sickness are persistently faced with agonising choices, based on the demands of a balance sheet rather than human comfort and survival:

   If I abandon or downgrade the patient with advanced cancer of the stomach in favour of two patients with hernia, how do I make a cost benefit analysis? How do I equate the loss of six months dyspepsia-free survival with the economic utility of the return of two breadwinners to work? (Garner, op. cit.)

Well, she or he can’t. The NHS is sick because at best it is struggling against the inexorable demands of the social system in which human needs count for little. Capitalism deprives its people of their dignity in many ways — in sickness and in health and in the end in their tragic, unjustifiable deaths.

Ivan