A health service worthy of the name
As the NHS approaches its 70th anniversary, James Linney calls for a radically new approach
On July 5 1948 the national health service came into existence - a momentous achievement for the working class in Britain. For the first time there would be a comprehensive health service provided free at the point of need. With the creation of the NHS and the welfare state, the working class had won a precious shelter, under which some protection was available from the devastating storms that the capitalism of the 19th and first half of the 20th centuries had brought.
This weekend tens of thousands of people are once again taking to the streets to express their solidarity with that notion in the face of eight years of sustained attack by the Tory government. Inadequate funding and attempts to erode its services are nothing new, but the NHS has never faced a crisis as urgent as the current one - giving its 70th anniversary a significance beyond the usual nostalgic hyperbole that we get on such occasions: a time to protest rather than celebrate.
The reality is that the NHS’s very existence has never before been hanging by such a precarious thread - one that, if it were to break, would see it fall into the grateful jaws of the private health companies who have been waiting patiently for their opportunity. Their appetite for this final feast has been whetted over the past 30 years by both Tory and New Labour governments. Private finance initiative contracts, the outsourcing of peripheral services and the creation of the ‘internal market’ are just a few examples of the (lucrative) ways in which the NHS has had its funds and services sliced off to the benefit of the private health industry.
The 2008 financial crisis and the subsequent ‘age of austerity’ gave the Tories an opportunity to accelerate this erosion. The Health and Social Care Act 2012 (HSCA) was not so much a reorganisation as a veiled assault on the NHS, and it has already led to a feeding frenzy for private health companies, albeit a limited one (for now). It must be conceded that the HSCA was a clever move: it was sold to the public and medical practitioners as a way to give GPs more power by transferring direct control of the NHS budget to them. Yet buried in the act were two principles that may still prove fatal: the severing of the department of health’s responsibility to provide a comprehensive, free health service; and the imposition of the ‘any qualified provider’ (AQP) clause.
AQP tendering meant that the newly created clinical commissioning groups (CCGs) had a legal obligation to put health services out to tender to all providers, including private health companies. CCGs were told that they must enforce the department of health’s ‘efficiency savings’ (known as cuts to you and me). Meanwhile private health firms, such as Virgin, with their team of lawyers and accountants and access to large amounts of capital, have been gleefully cherry-picking NHS services by offering then on the cheap. Since 2012 it has been open season for these companies to poach elective surgical services, as well as those for medical imaging, mental health, drug and alcohol dependency, the running of GP surgeries and entire hospitals, etc. What is more, they are granted the benefit of using the NHS logo - leaving most people completely unaware of the extent to which it has already been privatised.
All the time this asset-stripping has been going on, the NHS workforce has become increasingly demoralised. Nurses’ training bursaries have been abolished and junior doctor contracts leave them working longer with fewer breaks, putting patient safety at risk. There are more than 100,000 unfilled staff vacancies, four million people waiting for surgery at any given time, more than 500,000 people waiting more than 18 weeks for a hospital appointment, while accident and emergency waiting times are the worst they have ever been.
A bleak picture, I know - surely there must be some good news for the NHS, as it approaches 70? Well, Theresa May would have us believe so. Last week she announced her idea of a birthday ‘gift’: a proposed increase in funding to 3.4% annually, or £20 billion a year by 2023. Well, only the most politically naive will not immediately recognise that this ‘gift’ is a cynical and transparent attempt to distract from the omni-shambles that is Brexit. Firstly, it is worth pointing out that, whilst 3.4% is better than the zero growth of the preceding eight years, it is woefully inadequate to tackle the current crisis: for a start, it does not even match the historical average annual growth in spending of 3.7%. As has been widely reported, it also falls below the 4% extra the Institute for Fiscal Studies (IFS) and King’s Fund both calculated would be needed just to keep the NHS able to continue providing basic services. In the words of the IFS report:
To secure some modest improvements in NHS services, funding increases of nearer 4% a year would be required over the medium term, with 5% annual increases in the short run. This would allow some immediate catch-up, enable waiting time targets to be met, and tackle some of the underfunding in mental health services.1
Theresa May is no doubt hoping that after years of brutal cuts this will produce the gratitude of those deprived - like a starving prisoner, who is suddenly offered some small scraps of food. Of course, given the pitiful state of the NHS, any extra funding, no matter how insufficient, should not be dismissed, right? Well, yes, but, as we will see, even these measly funding increases come with strings attached.
These strings relate to how the funds are going to be spent. A clue was given by May during prime minister’s questions on June 20, when she stated that the extra money being made available will go towards developing local STPs (sustainability and transformation plans). STPs and their corollary, accountable care organisations (ACOs), are the next phase in health secretary Jeremy Hunt’s plans for privatisation. Both are an attempt to further decentralise and deconstruct the NHS and open the potential for health, finance and insurance companies to win long-term contracts, where they would have responsibility for providing all the health and social care for a given region. This is an idea that has been transplanted directly from America and is a clear stepping stone towards a fully insurance-based, privatised health service. We only have to look to the US to get an idea of the consequences - in the richest country in the world over three million people have no health insurance and nearly two-thirds of all bankruptcies result from medical bills.2
A group of activists and doctors - including Allyson Pollock and, before his death, Stephen Hawking - have been leading a campaign to oppose ACOs and has secured a judicial review to test their lawfulness. These activists have also drafted an NHS Reinstatement Bill,3 which proposes reversing the HSCA and opposes any form of privatisation. Despite a motion supporting this bill at its 2017 annual conference, Labour had previously stated that, if in power, it would continue to work within the post-HSCA structures. However, thankfully shadow health secretary Jonathan Ashworth this week came out in support of the bill, stating:
Our commitment to reinstate the NHS remains and takes on even greater importance … we recognise the status quo is not an option. Jeremy Corbyn and the shadow health team will begin over the coming months to consult on the future of NHS structures with relevant professions, trade unions, patients and campaigners, about our proposals for the next Labour manifesto.4
This - along with John McDonnell’s promise to bring PFI contracts, which have been crippling the NHS for decades, back ‘in house’5 - is a welcome development, but Labour’s overall position on the NHS has been weak, to say the least. In its manifesto for last year’s general election it promised only a 2% annual growth in NHS spending!6 In a recent BBC interview, Ashworth said that after May’s funding announcement Labour would now match the 3.4% - plus “some more” - but he was unable to specify how much more.
Matching the Tories ‘plus a bit’ is not good enough and neither frankly is trying to simply reverse the past eight years of Tory wrecking policy. Just like the very idea of the NHS when it was proposed 70 years ago, we need radical solutions - this time in order to save it.
Nye Bevan is credited with creating the NHS. A Welsh Labour MP and son of a miner, he was considered radically leftwing - of the type which the majority of today’s Parliamentary Labour Party would no doubt wish to see purged. For Bevan the NHS was the product of ‘socialist’ ideology:
The national health service and the welfare state have come to be used as interchangeable terms, and in the mouths of some people as terms of reproach. Why this is so it is not difficult to understand, if you view everything from the angle of a strictly individualistic, competitive society. A free health service is pure socialism and as such it is opposed to the hedonism of capitalist society.7
Of course, the NHS is not, and never has been, “pure socialism”. It has always been at the mercy of global capitalism - when it comes to the conditions of the working class who staff it or the international pharmaceutical companies who profit from it, for example.
Neither does Nye Bevan deserve the credit for the creation of the NHS: its existence resulted from the growing political awareness and power of the working class - on the back of two world wars, which saw workers slaughtered in their millions and often struggling in poverty. The NHS and the welfare state were a compromise that British capitalism was forced to make because it was fearful of the potential for a revolutionary working class movement. It is a testament to this potential that, despite the Tories’ ideological opposition to the very idea of an NHS, they still dare not come out openly and challenge its existence: hence the strategy of starvation and privatisation by stealth.
So this is what we need to consider on the ‘Our NHS is 70’ demonstration. However, while demonstrations are a valuable tool for expressing discontent and attracting more people into the movement, they are not a substitute for working class organisation. In the short term, a Corbyn government is the best practical hope for the survival of the NHS over the next seven years, let alone the next 70.
But within the Labour Party we must fight for more radical solutions. To name a few, we should demand an NHS run by representatives of its workers and those who rely on it, democratically elected; substantial improvements in the wages and conditions of all NHS workers; and the socialisation of the pharmaceutical companies on which it depends.
Simultaneously we must fight for a society based on radical, working class democracy - a society of genuine socialism, far beyond what Bevan aspired to 70 years ago.
7. A Bevan, ‘In place of fear’ (1952): www.sochealth.co.uk/national-health-service/the-sma-and-the-foundation-of-the-national-health-service-dr-leslie-hilliard-1980/aneurin-bevan-and-the-foundation-of-the-nhs/in-place-of-fear-a-free-health-service-1952.