March … and then?
Defending the NHS requires party politics, argues Mike Macnair
On Saturday March 4, we will be marching to assert our wish to defend the national health service, under Unite the union’s slogans, “No cuts, no closures, no privatisations”. It is important that as many of us as possible do march.
The reason is that a demonstration is fundamentally a way of saying to the government: ‘Look! There are lots of us, and we support our demands strongly enough to march!’ If only a few of us turn out, the result is that our opponents can point to the small numbers as evidence of lack of support. (This is true of all too many ‘routine’ demonstrations called by various campaigns without enough thought about effectiveness.)
At the same time, just turning out to march on Saturday is not enough. The ‘crisis’ in the NHS is not a short-term phenomenon or some sort of mistake by government. For this reason the term ‘NHS crisis’ is misleading. It is the product of conscious decisions made by governments since 1979 at the latest, and more particularly since 1989 and the introduction of ‘internal markets’.
In 1979-89 it became clear that the private health insurance companies could not deliver full-spectrum health provision at anything like a reasonable cost, so that the Thatcher government’s initial policy of encouraging private health insurance as an alternative to the NHS by providing tax relief failed. The push for privatised health provision thus had to shift towards creating ‘less eligibility’ (as in the principle of the Poor Law Amendment Act 1834) for the public service.
The policy is essentially one of squeezing resources for treatment in the public service and using the media to talk up the resulting problems, to create an atmosphere of ‘crisis in the NHS’ and hope eventually to win a majority for changing the system to an insurance-based one. This has several aspects.
In the first place, all through the history of the NHS the pharmaceutical industry has remained in private hands; and the state regulation of new pharmaceuticals since the mid-20th century has tended to increase oligopoly in the sector, permitting predatory pricing. The cost of medicines has therefore been a permanent, albeit varying, requirement to support shareholders, managers and private lenders, as well as actual production and research.
Post-1989 this model has been expanded in several directions: notably adding a requirement to support shareholders, managers and private lenders to cleaning and catering companies through ‘contracting out’; and most spectacularly in the ‘private finance initiative’ scams operated since the time of the Major government, from 1992, placing NHS buildings into private hands and at exaggerated costs.
The ‘internal market’ arrangements created after 1989 have also served to reduce transparency of budgets and facilitate the introduction of ‘efficiency gains’: ie, cuts primarily to staffing, producing demoralisation.
Similar schemes of manipulation and false accounting by HM treasury (contrary to section 17 of the 1968 Theft Act) drove many dentists out of the NHS in the early 1990s. More recent manipulation of general practitioner and junior doctor contracts, together with the massive payments available to locum agencies, threaten similar results in relation to doctors.
The ‘internal market’ and, more generally, managerialisation, has massively increased the share of administrative costs and managerial salaries in total health expenditure. In the 1970s the Pearson Commission on compensation for personal injuries remarked on the relatively low administrative costs of the NHS.1 Today, thanks to marketisation and managerialisation, a much larger share of total health expenditure goes on administration.
Meanwhile, systematic attacks on local government expenditure, having particular effects on provision for the elderly and beginning most visibly under the Wilson and Callaghan governments with the ‘IMF crisis’ of 1976, have produced ‘bed-blocking’ in the NHS, meaning that elderly patients cannot be discharged.2
None of what I have said is to deny the existence of real pressures on health expenditure as a share of total social product. It is natural that increased ability to treat illnesses, and increased life expectancy, resulting from better knowledge of human health, will produce increased demand for health provision. (It is not true that this increased demand is absolutely unlimited, contrary to the claims of Tories and their marginalist economist fiends: the present actual functionality of the NHS, in spite of all the scare stories, is evidence in itself that most people do not seek treatment when they do not need it.)
But, accepting that there is a real increased demand, this is a matter of making social choices about what share of the total social product we should spend on health. Under the cover of this issue, Tory (and Blairite) NHS ‘reformers’ have siphoned off funds which the majority have agreed should be spent on health, to pay for PFIs, managerialism, locum agencies, contracting-out firms delivering reduced standards of cleanliness at increased costs, and so on.
These are deceptive policy choices made in pursuit of privatisation and for the benefit of party donors in the private health and financial sectors. Hence my description of the actual accounting and budgetary arrangements as amounting to offences under the 1968 Theft Act; it could be added that the whole scheme is an elaborate and long-running conspiracy to commit offences under the 2006 Fraud Act!
It is not a short-term crisis. And it is not a matter of mistakes, which government could be ‘persuaded’ away from by the mere opposition of large numbers. All the elaborate scams of ‘NHS reform’ have arisen because the Tories were unable to persuade a majority to reject the NHS in the 1940s, have been unable to persuade a majority to do so ever since, and they (and the Labour right since Callaghan’s time) have sought both to undermine popular support for the NHS and to chip away at the edges and get private firm trotters in the health trough through these scams.
To overcome the problem requires fundamental changes in government policy. Such changes would necessarily not be only in relation to NHS organisation itself.
In the first place, what I have already said indicates that addressing the problems affecting the NHS requires a change in the budget affecting the NHS - and, thus, also affecting everything else government does. How much additional government income can be expected from increased taxation? How far would achieving increased taxation require major reforms to the courts and legal profession to get rid of ‘strict construction’ tax avoidance scams? What other expenditures can and should be cut?
Secondly, the policy commitments to privatisation go deeper and wider than just the NHS. There would be major savings available through demarketisation, demanagerialisation, and ending PFIs and other forms of contracting out. To achieve savings by making such changes would involve radical legislation.
But it would also involve much more by way of general policy changes. PFIs were not only an accounting scam to put more money into the hands of City finance houses (and their lawyers and the accountancy-management consultancy firms).3 They were also an accounting scam to evade the operation of the restrictions on public-sector deficits under the treaties of Maastricht and Nice.4 Equally, the apparent death of the Transatlantic Trade and Investment Partnership is apparently fortunate for the survival of the NHS;5 but the draft Trade in Services agreement would more rigorously attack public health services as a form of protectionist ‘non-tariff barrier’.6
(By the way, this should indicate the uselessness of the ‘left remain’ policy. While ‘left Brexit’ hopelessly seeks economic autarky and ‘socialism in one country’, ‘left remain’ counterposes to this a policy of ‘Always keep a hold of nurse, for fear of finding something worse’. But the place of ‘nurse’ is played by the current, deeply corrupt and anti-democratic European Union institutions, and the free trade ideology of Maastricht and Nice and of the neoliberals more generally - which genuinely drives privatisation and anti-union laws.)
In short, saving the NHS requires us to march on March 4. But marching on March 4 is not enough. We need a radical change of government and of government policy.
There is a potential trap here, as much as there is in the idea that marching is enough. It is common to argue that we need a change of government, because the Tories are enemies to the NHS. Therefore we need a Labour government. Therefore, it is argued, we need an electable Labour Party - which means getting rid of Jeremy Corbyn and his allies (I do not add, ‘getting rid of the influence of the left in the party more generally’, because it is perfectly clear that, beyond the top leadership, the party right remains fully in control in spite of Corbyn’s two victories in leadership elections).
But we have excellent reasons to suppose that electing a Blairite or similar Labour government would not save the NHS. I have referred already to the PFIs, contracting-out arrangements, manipulation of GP contracts, and so on, as part of the scams which are gradually squeezing the NHS to ‘less eligibility’, and bleeding off blood for the vampires of the City. These policies continued throughout the Blair and Brown administrations.
In reality, Blair was ‘electable’ precisely because he was committed to continuing the policies of the Thatcher and Major administrations in relation to NHS ‘marketising’ ‘reforms’ (and all the other crap).
In ‘ordinary’ times, ‘first past the post’ means that UK general elections are decided by the approximately 10% minority of ‘floating’ or ‘swing’ voters. These voters imagine that they are sophisticates who have got beyond political ‘tribalism’. In reality, the ‘floating voters’ are merely characterised by a gullible willingness to believe whatever is the latest scam which the käufliche Presse, the bribed media, has come up with: from Tony Blair the moderniser, to ‘Cleggmania’, to Ed Miliband as Wallace, to ...
The result is that a Labour Party which does not take steps to combat the power of the mass media to set the agenda, and hence wins office by accepting the media’s lies, will never be able to change the fundamental terms of the policies which have been set by the preceding Tory (or coalition) government.
The acute paradox of the present situation is that Corbyn was elected by a revolt against media-management Labour; but he and his advisors, retaining the commitments to bureaucratic managerialism ingrained into them by years in the milieu of the managerialist trade union bureaucracies and managerialist Labour, and seeking a way into office through conventional media-management means, are still stuck within this framework (and on the road, hence, to defeat in the next general election).
How, then, can we create political conditions for an actual defence of the NHS, meaning the reversal of the whole systematic policy of undermining it pursued by Conservative, ‘electable Labour’, and Con-Dem governments?
The starting point is that, while a large majority of people support the NHS through gut instinct, they are too readily persuadable to accept the various ‘market reform’ scams which have served to undermine it. Lying behind these is the general argument that planning is utopian and inefficient, and socialism merely leads to Brezhnevism. Witness, for example, the attacks on the NHS of rightwing extremist Paul T Horgan on the Conservative Woman website.7 Most people can see at a gut level that it is better to have an NHS than to have a US-style system; but the long shadow of the failure of the Soviet bloc still lends a spurious credibility to ‘market reform’ scams.
By now, it ought to be completely obvious that the claims of neoliberal capitalism to offer a better alternative to Soviet-style bureaucratic planning are, in fact, based on no more than the superior military production power of the imperialist centres. ‘Market reform’ has impoverished the former Soviet Union and much of eastern Europe; hence in part the pressure of eastern European migration to Britain. China, while partially marketised, has not followed the advocates of radical closures of state industry, and so on. Nor has the period of neoliberal ascendancy produced political and cultural liberty in the former Soviet bloc, but Putinism and other forms of nationalist authoritarianism elsewhere.
What is lacking in Britain is a political party that will aggressively make the case for socialism in general, including socialised healthcare and the NHS. Such a party would, equally, aggressively promote alternatives to the bribed media and its narratives.
A political party is essential because the problem is one of governmental policy and general social choice. The idea current around the far left - that all we need to do is resist more, get on the streets, and so on, rising to direct action - cannot address the underlying problem. Suppose we occupied hospitals (or even just A&E units) threatened with closure. How would the staff be fed? Where would the medicines, surgical equipment, and so on, come from?
The decisions need to be taken to support a public health service on the scale of the general material division of labour. That means minimally at the scale of the state, and in reality at a European scale. Tasks for a political party, not just for street campaigning and sectional industrial action.
The relation of such a party to Labour would not be one of simple competition. Labour could be a permanent general front of all the workers’ organisations - trade unions, cooperatives, left parties - if it abandoned its present system of bans and proscriptions and similar exclusionary rules (vigorously at work in the last months as the right wing seeks to drive out opposition under various pretexts).
But even on those terms, Labour could not be defined by offering a radical alternative to capitalism as such. The task of offering such an alternative is the job of a communist party. The loss of such a party, leaving behind only fragments, mainly committed to bureaucratic centralism and obsessed with ‘direct actionism’, is the major obstacle to an effective defence of the NHS. To take action to create one would be a small step - but would produce an immensely powerful lever for this defence.
1. Royal Commission on civil liability and compensation for personal injury (1978).
2. See, for example, ‘NHS bed-blocking rises 42% in a year, new figures show’ The Daily Telegraph January 12 2017.
3. Perhaps also building contractors; but the building contractors did pretty well under the old regime of building NHS facilities with funds raised by taxation and government borrowing, so that the change is probably mainly for the benefit of the City.
4. Discussion of the rules by J Weeks: ‘Why we need to rewrite the Maastricht rules’ Social Europe March 7 2016 (www.socialeurope.eu/2016/03/need-rewrite-maastricht-rules).
5. See CJ McKinney, ‘TTIP and the NHS’, May 20 2016: https://fullfact.org/europe/does-ttip-mean-privatisation-nhs.
6. https://en.wikipedia.org/wiki/Trade_in_Services_Agreement; www.globaljustice.org.uk/resources/what-tisa-and-why-we-need-stop-it.77i. Eg, ‘The NHS was born in crisis’, January 16 2017: www.conservativewoman.co.uk/paul-t-horgan-nhs-born-crisis.