NHS: Continuing bourgeois attempts at dismantling
Following the Second World War in which the major part in defeating fascism was played by the Soviet Union, its prestige rose, at that time, very high among workers in Europe. More people than ever were admiring the Soviet system, especially its publicly owned and free health service. The British ruling class, aware that the millions that they had trained in warfare were now coming home wanting something better than they had before the war, offered British workers the National Health Service as part of a package designed to keep them from the path of revolution.
The NHS is often seen as the sole creation of the ’45-50′ Labour Government headed by Attlee, but in fact some of the ‘groundwork’ for this had been laid by the previous wartime coalition Government under Churchill. It is therefore clear that its formation had been decided on by the ruling class independently of whatever was to be the outcome of the 1945 election. The NHS was an instant hit with British workers, and Government spending on health in the first 5 years of its existence leapt from £6 billion to £11 billion.
The years passed. Changes, not always good, came and went. But it was not long before elements of the bourgeoisie turned their greedy calculations towards the profits they thought could be extracted from healthcare. However, the NHS remained publicly owned and to some extent publicly accountable. Its main vulnerability, however, arose from the fact that when the NHS was formed, the right of privately owned medical services to exist alongside of it was preserved.
In 1979 the General Election resulted in a win for a Tory Government led by Margaret Thatcher. Initially this government had its hands full with war abroad on the back of which the 1983 General Election was also won by Thatcher. During that first Thatcher term there was an attack on the solidarity of nursing staff through a scheme for re-grading nurses on an individual basis which set them against each other. Those who gained from the scheme, with honourable exceptions, supported it, while the majority, who made no gain and even suffered as a result of it, opposed it. In the following Tory term a war on trade unionism in general and the NUM in particular was waged which resulted in considerable weakening of the entire trade-union movement. By the time Thatcher came to her third win in 1987 serious long term plans had been put in place for the NHS for profiteers to leech off the NHS. These included:
The idea of establishing the NHS as an independent statutory body with decentralised financial accountability and an end to national wage bargaining for NHS staff.
Bringing the NHS and private care together in an integrated market.
It was planned to devolve all responsibility for patient care to directly funded district Health Authorities while dismantling the Regional Health Authorities and, of course, their planning function. It was also part of these plans to encourage individual hospitals to compete for patients.
Also on this list was the plan to create a national health insurance scheme jointly with private companies to promote the use of the private sector and eventually support the practice of paying for all treatment.
Lastly, the idea was mooted to rename the ‘NHS’ to reflect a new business era.
It is very helpful to ponder on this list when trying to understand how we got where we are and how all governments, of whatever hue, have basically followed this 1987 programme to privatise the health service in order to divert taxpayer cash away from patient care and into corporate profit.
Between 1987-88 the introduction of competitive tendering for catering, cleaning and laundry services signalled the start of the privatisation campaign proper. Although there were some early victories by unions in some individual hospitals, the fight to save the ‘publicly-owned’ NHS never really became national in any significant way. The unions NUPE and COHSE took the matter to the TUC asking for national backing across all industries and they won near unanimous support on the conference floor. However, the support from the TUC leadership was minimal to put it as charitably as possible, and never went beyond words and a couple of ‘days of action’. The workers in individual hospitals fought as best they could within the confines of local struggles but the assault of the bourgeoisie against them was overwhelming.
In 1989 the so-called internal market was created. This created separate entities within hospitals splitting their functions, requiring the different entities to ‘purchase’ services from others when caring for a patient, rather than have a single budget for the whole hospital. This practice was absolutely pointless unless you were aiming at eventual privatisation – yet still we continued to hear the mantra that the NHS was ” safe in our hands” solemnly chanted by successive Health Ministers. This year also saw trials of GP practices becoming ‘fund-holding’ units buying services from hospitals.
The ‘internal market’
In 1997 the Tory Government under Major, which had obviously kept to the 1987 ‘script’ regarding the NHS, was replaced by a landslide Labour Government led by Blair. While this was greeted by many trade union leaders, as well as left opportunist groups and their publications as a great victory, it soon dawned on almost everyone else that, although the names of the parties and individuals in government had changed, the main direction of policy had not. It was business as usual under new management. This was the time of PFI which we were told was a brilliant way to use private money to bolster the cash-strapped publicly-owned services including the NHS. In reality it meant the private sector harvesting a regular and very rich income from NHS capital financing through knocking down hospitals (and other public buildings) rebuilding them as privately owned hospitals which are then rented back to the NHS on expensive long term contracts. This policy has seen the physical property of the NHS disappearing at an alarming rate. Servicing the often outrageously overpriced financial contractual obligations imposed by PFI is a constant drain on the funds that a hospital has, which for staff has invariably meant fewer jobs and more work for less money. For patients it has inevitably meant a seriously deteriorating service, long waiting times for essential clinic appointments, cancelled operations, and problems arising from staff being too few and massively overstretched.
Following a 2001 visit to Spain by Alan Milburn where he saw a hospital built by the Spanish Health Service, but entrusted to a private company (under a policy called ‘health foundation’ by the Spanish), the idea for developing the next stage of privatisation was formed. In 2003 Foundation Trusts were brought into being by the Labour Party. This scheme gave semi-independent status to ‘deserving’ hospitals. Basically a Foundation Trust is free to provide services as its directors see fit, as well as being free to borrow money on the private financial market, to enter into joint ventures with private companies, set its own terms of service for staff and, like all good private ventures, to go ‘bust’ and to be taken over by a private enterprise. In fact, the major cause of the Mid Staffs Hospital disaster was its striving to jump through the hoops for achieving Foundation status that had been set by the then Labour Government, resulting we are told in the unnecessary deaths of upwards of 400 patients. The deadly mixture, in the Mid Staffs hospital and health authority managements of greedy people and a few stupid ones thrown in to provide scapegoats should things go wrong was a recipe for disaster. Yet this is probably the same ‘mix’ that can now be found in most, if not all, hospitals and health authorities across the country. The greedy most responsible for the Mid Staffs disaster have mostly moved on to other lucrative positions within either the NHS or private health companies.
In 2004 a new GP contract was introduced allowing corporate provision of GP services turning the local doctor’s practice into just another company whose main business is the realisation of maximum profit.
2007 saw a set of private sector providers identified to support the commissioning of services by the Primary Care Trusts.
2010 was a General Election year and, as we know, the Tory and Lib-Dem parties formed a coalition government. But before we discuss what this government has done since its election, we should remind ourselves, in case anybody is still delusional enough to believe that Labour is ‘better’ than the Tories or ConDems, of Labour’s manifesto for that election. It said “we will continue to press ahead with bold NHS reforms” and that ” all hospitals will become Foundation Trusts” warning that “underperforming Foundation Trusts will be taken over“. Lastly, for the avoidance of any doubt, the Labour manifesto promised that “Foundation Trusts will be given freedom to increase their private services“!
ConDem assault on the NHS
So now we come to the present situation and, as we are now talking about what is happening under the coalition government, I will quote from a doctor cum journalist, Max Pemberton, writing in that well known left-wing daily The Telegraph. On 1 April this year, the Health and Social Care Act came into force. This Act did away with the Primary Care Trusts and handed over everything to clinical commissioning groups (CCGs) which were new bodies it created whose function is to buying in medical services to meet local demand. Dr Pemberton, writing that same day, was quite candid about what was happening. After pointing out that initially on the surface there will seem to be no difference, he writes ” But, beneath the surface there will have been a dramatic shift in the way that healthcare is being delivered. Its impact should not be underestimated. ” He continues ” As of today CCGs are responsible for commissioning the work – that is to say, treatment – undertaken in the name of the NHS. They will be responsible for organising and paying for care, and deciding who will provide it. For the first time in NHS history, the majority of treatments will be put out to tender: private organisations will be competing to win contracts to provide NHS healthcare. ” He also reveals that “… the NHS Reform Bill, as first published, was like a jigsaw puzzle with crucial pieces missing, the pieces that would reveal exactly what was being planned. It wasn’t until a few weeks before the law came into effect that those missing pieces became available, when the Health Secretary, Jeremy Hunt, quietly announced the new regulations and attempts were made to push them through parliament. What was now clear was that the regulations effectively forced CCGs to put all services out to tender to the private sector and forbade them to favour the NHS as the provider.
“After a public outcry and criticism from the House of Lords at the way the Government had slipped in the Section 75 regulations at the eleventh hour, Hunt had them hastily rewritten. But most experts agree that there was no meaningful change .”
Pemberton also tells us that GPs may be able to keep ” some services within the NHS, but only in particular circumstances, such as when no private sector provider comes forward to bid. Everything else is up for grabs. It will take time for this change to slowly spread throughout our healthcare system, but it will. ”
Looking at a likely future scenario Dr Pemberton goes on: ” say for example you need a knee replacement. The provider commissioned to deliver this by your local CCG will have stipulated in the contract what work it will undertake and how much it will get paid. This is fine if you’re a straightforward case. They do the operation, you’re discharged and they are paid the set fee. But what happens if your knee operation is more complicated?
“What if your knee joint has twisted and is now deformed (it does happen), which means the surgeon has to avoid damaging the nerves that run down your leg? All of a sudden, the provider won’t turn such a tidy profit on your knee replacement. This is outside of the terms of their contract. So they reject you and discharge you back to the care of your GP. And what then? There’s no longer an NHS to pick you up because this private organisation has taken over knee operations in your area. So where do you go ?” And he states further ” In the new NHS, everything will be about payment by results, because this is all the private contractors are interested in.” Then he repeats the obvious question “…what about chronic conditions? Or treatments where the chances of success are low and complications high?” Max Pemberton ends his article somewhat pessimistically pointing out that the ” NHS’s strengths – resources, expertise and the united focus on the patient – are being replaced by a fragmented and atomised service, bound not by a duty of care but by a contract and driven, not by what is best for the patient, but by the cost of the encounter. It will be a slow, insidious creep but it’s coming. Be prepared. This is the way the NHS ends: not with a bang but a whimper .” We can forgive Dr Pemberton’s pessimism as, if nothing is done, his description is exactly what will happen. Doing nothing, however, is not a course of action we would recommend.
We know that the CCGs are already being formed into bigger and bigger clusters to buy in bigger and more widespread services; we know that the staff in the hospitals and ambulance services are being stretched beyond any hope of performing their jobs properly, the way they would want to do them, causing grievances and complaints. These are not generally made known to the public – NHS hospital trusts having recently spent £15 million on silencing almost 600 staff. An unknown but probably significantly higher number of potential whistle blowers have undoubtedly succumbed to threats and intimidation from management.
On 9 May, also in the Daily Telegraph, Laura Donnelly reported the speech of former Tory MP, David Prior, head of the Care Quality Commission (CQC), speaking to a conference held by the King’s Fund, the health think tank. Mr Prior is quoted as saying that NHS emergency care is “out of control” across large swathes of the country and that “… the healthcare system is on the brink of collapse and regulators cannot promise to prevent further scandals like Mid-Staffordshire.” But in classical farce style he followed that by claiming that “If we don’t start closing acute beds, the system is going to fall over.” He reaches this conclusion on the basis that because GPs have increasingly opted out of out of hours care, more work has been created for A&E departments. It must be remembered that this option had been given to GPs as an inducement to go along with the new GP contracts system, a measure aimed at further weakening the NHS as a wholly publicly owned service free of charge at the point of use – GPs opting out of out-of-hours care does of course place a further burden on A&E departments – albeit not nearly as much as staff shortages and low morale – but it is no answer to start starving one area of hospital care (acute beds) in order to keep another one going (A&E). How can neglecting one category of patients seriously be put forward as the solution for a shortfall in facilities for treating another category? No, the answer cannot be found through closing even more beds. As Professor David Oliver, former national clinical director for older people was quoted as saying in the article ” the loss of more hospital beds would mean more elderly people would be left being treated in corridors and on any flat surface available.” He might have added: “if they are lucky”!
Now looking back at that ‘jobs to do’ list produced in 1987, we can see that pretty much everything can now be ticked off – with the exception of the name change. This is a pity because if they’d changed the name perhaps most people would have seen through all the deceptions performed by the main political parties in (and, it could be argued, out) of office over the years.
So given that this is the state of our NHS, what do we do? It doesn’t matter who we vote for in a General Election does it? They have all done their bit in setting up the NHS for milking by the multi-nationals who want to get into this very lucrative business, haven’t they?
Kevin McKenna writing in The Observer, Sunday 16 June 2013 (‘Bring on a British revolution – it’s long overdue’). Mr McKenna has a romantic and rosy view of what the Labour Party used to be but, that apart, his words should ring some bells when he says: ” At least the Russians and the French got there in the end. In Britain… all we managed were a few uncoordinated riots and querulous behaviour at places such as Spa Fields, Bristol and Manchester. And, as the historian John E Archer has pointed out, many of these disturbances were carried out by people who wanted to maintain the status quo, not to overthrow it .” Mr McKenna mixes two different revolutions here, In Russia of 1917 there was both a bourgeois revolution and, in October, a proletarian revolution, while France only did the bourgeois revolution that Britain had already carried out! His theory on why the British never had a revolution (and here we must suppose he means a proletarian revolution) is simply that ” Britain, the world’s most belligerent country, was in a state of almost constant warfare in the 18th and 19th centuries. If we didn’t have our own wars to fight, we would soon find someone else’s war in which to get stuck in. Thus, there was simply no time for the working class to get properly organised. To fight a war, you need money and poor people. Britain always had an abundance of both. The money came from increased taxation of the poor who saw a war as an opportunity for a few years of guaranteed bed, board and wages, which was more than they could count on in Britain .” Again, this is a simplification ignoring the buying off of a significant portion of the working class by our masters, the creation of an upper working class elite who would mislead the workers in the interests of our imperialist rulers. And as for money for wars coming solely from increased taxation of the poor, why does Mr McKenna think Britain was fighting all those endless wars if not for spoils and putting whole nations in bondage? However, he goes on to ask why today “…in the face of so much inequality, corporate dishonesty, police brutality and political corruption, do we simply grumble and stage good-natured and orderly marches, with multigrain sandwiches and infants in prams? Why do we continue to be bought off with endless royal jubilees, worthless Olympiads and the creeping militarisation of a country whose soldiers are treated like heroes for fighting wars against developing world nations ?” He finishes this short article with the following fine sentiments ” The real wonder of the 2011 riots in England and Wales isn’t that they happened at all but that there weren’t more of them, that they didn’t last longer and that there was so little violence. A British revolution is long, long overdue … but perhaps we simply don’t deserve one .” We agree with much of this but would insist loudly that not only do we deserve a revolution, we will have one – and some of us are trying to educate workers and are organising for just that.
So why when talking about saving the National Health Service as a wholly publically owned and free at the point of use institution do we arrive at revolution as the answer? Quite simply, the NHS does not exist in a bubble: it is part and parcel of our society, where working class people are coming under growing oppression. The ruling class manages all too often to divide us on lines of colour, of employment, of sex, age and a host of other things, but people are starting to see beyond that and understand that if we want an NHS that is always accessible, publicly owned and free, if we want all our children to get a decent education, if we want decent homes and jobs for everyone and a quality retirement at the end of a working life, then we are going to have to change from a system that says protect the profits of the rich before all else! And that doesn’t come easily or without struggle but it can be done.