06.07.2023

Aneurin Bevan: Labour minister of health on first day of NHS, July 5 1948

Road leading nowhere

After 75 years the NHS has been driven into permanent crisis. The government’s ‘comprehensive workforce plan’ is no solution, it is mere electioneering, writes Ian Spencer

On June 30 the government published the “first comprehensive workforce plan for the NHS, putting staffing on a sustainable footing and improving patient care”.¹ Looking very much like the first salvo in an upcoming general election, the ‘NHS long-term workforce plan’ aims to increase recruitment by loads and retention by loads more.

This is remarkable, considering that workers are leaving the NHS in droves for more lucrative or less stressful work, or retiring at the earliest opportunity - 170,000 left in England last year.² Between 2018 and 2022 nearly 43,000 people aged 21 to 50 quit the Nursing and Midwifery Council register.³ This is compounded by the fact that nursing is also an aging population, with many due for retirement during the period covered by the plan.⁴

The aims are of Bojo proportions: medical school places are to double to 15,000 a year; GP training places are to increase by 50% to 6,000; adult nursing places are to rise by 92% to nearly 38,000 - all of this by 2031‑32. The plan estimates that more than 204,000 new support workers will be required to meet demand over the next 15 years. Phew! Most of the targets are to be achieved by the mid-2030s, by which time the present Tory government will be a distant memory. As with all such plans, it is ‘ambitious’, ‘bold’ and not before time, as NHS vacancies currently total 112,000 and, without it, the staff shortfall will be “between 260,000 and 360,000” by 2036-37.

As always in contemporary political rhetoric, we see the ‘rule of three’: train, retain and reform. Training does not just focus on numbers. Pharmacists are to eventually be allowed to prescribe, for example, and there are plans to increase the number of “physician and nursing associates”. In other words, the increased supply of healthworkers will be facilitated by shortening the training of doctors and nurses, among others, and the creation of subordinate, lesser-trained staff grades. The amount of time nurses spend in clinical placements will drop from 2,300 hours in three years to 1,800 hours. There seems to be a studied insomnia in the plan. Prior to 1990 almost all nurses were trained as NHS employees - apprentices, if you will - who were paid a wage while they studied.

Medical schools are to move from five- or six-year degrees to four years: “In future students undertaking shorter medical degrees will make up a substantial proportion of the overall number of medical students.” If you are concerned about the quality of care that you are likely to receive, then rest assured that “Doctors and nurses would still have to meet the high standards and outcomes defined by the regulator.” So regulation will take the place of training and staff experience.

The plan for retention is also bold, aiming to “ensure up to 130,000 fewer staff leave the NHS over the next 15 years”. This will be achieved by “improving culture, leadership and wellbeing”. At no point is there a suggestion that pay rates are an important part in recruitment and retention.

Many of the supposedly innovative ideas, such as apprentices, nursing and physician associates, have already been in place for some time, but to a limited extent. There have been advanced nurse practitioners with limited prescribing powers for some time, undertaking some of the more mundane duties carried out by GPs. However, “By 2036-37, there will be over 64,000 nursing associates working in the NHS, compared to 4,600 today.” There will be 10,000 physician associates by 2036-37.

Professions

The history of healthcare is the history of class struggle. Historically, the professions have represented a conservative group. At the foundation of the NHS, Aneurin Bevan famously attributed the acquiescence of the medical profession to their mouths being “stuffed with gold”. In other words, concessions were made, so that consultants were still going to be able to serve their private patients. GPs would have the status of independent contractors to the NHS and the British Medical Association became one of the most powerful unions in the country - in no small part due to the legal monopoly they had over the prescription of medication and referral for treatment.

The BMJ (originally British Medical Journal) in its response to the plan is in no doubt that “Delivering the NHS workforce plan depends on implementing major reforms, which will challenge professional organisation and power.”⁵

The plan is taking place at a time when all professions allied to medicine are in an unprecedented struggle with the government over pay. The reserve army of labour is not exerting much influence in forcing down workers’ pay in health and social care. At the same time, anti-union legislation has weakened action by nurses, who did not vote in sufficient numbers to continue their pay struggle. However, workers resist in other ways. They leave healthcare and get a better-paid job elsewhere or else move between employers, looking for higher pay or to get off the shop floor. One way around this is to break up the occupational cohesion of the professions or buy off one section against another.

The history of nursing is instructive in this. In 1919, during the House of Lords debate on the Nurse Registration Act, Lord Ampthill said: “… if we don’t give [nurses] what they want [nurse registration] we will drive them into the arms of the Labour Party.”⁶ Naturally, this would not worry the ruling class today, but two years after the Russian Revolution, one year after the Labour Party adopted clause four of its constitution and in a year that saw the police on strike in London and Liverpool, it caused the noble Lords some disquiet.

In the years of defeat for trade unions that followed the 1984-85 miners’ strike, steady inroads have been made into the concessions to the professions previously made. The ‘state-enrolled nurse’ has been recreated, with the development of nurse associates, and in the social care sector ‘senior carers’, with the authority to dispense medication, have been introduced. Nursing degrees, whose courses were over four years in the-1980s, were reduced to three and the proportion of time spent in clinical placement was increased at the expense of formal study. Currently, student nurses have no choice but to take out the same student loan as any other student - which can mean a £45,000 debt in order to start a job paying £28,000. Debt bondage, from education and housing, seems to be a growing feature of declining capitalism.

Future

Politicians, such as Sajid Javid and Tony Blair, are now talking openly about the “unsustainability” of the NHS. However, while piecemeal privatisation will continue under whichever party wins the next election, the plan aims to give a clear impression that that there will be increased investment in the NHS for the time being.

There is already a steady drift towards private healthcare, which quite a sizeable minority now use.⁷ And, if, as seems likely, the next government will be a rightwing Labour one, Keir Starmer has given every indication that he will not change the current trajectory of piecemeal healthcare privatisation, just like Tony Blair when he led the Labour Party.

In the meantime, investment in healthcare provision both from within the UK and abroad continues apace. Bupa, Four Seasons Healthcare, Cygnet and many more besides offer healthcare but also some, such as Cygnet, take NHS patients and can be ‘branded’ as NHS as part of the ‘mixed economy of care’ that was instituted by the New Labour government.

One of the main arguments put forward for the need for change is the “ageing population”: “Over the next 15 years, the population of England is projected to increase by 4.2%, but the number of people aged over 85 will grow by 55%.” There has been widespread discussion, even in the mainstream media, about the need to integrate social care in some way, otherwise it is difficult to discharge in particular elderly people from acute care in hospitals. Yet the plan refers to the social-care sector, where there are 165,000 vacancies for jobs - less well paid and with worse terms and conditions than for NHS staff. In fact, one of the frequent complaints by the private-care sector is that they cannot compete with NHS pay and still make a profit. In 2021-22 no fewer than 44% of nurses in adult social care left - most of the care is now provided by ‘support workers’ on minimum wage levels.

The government is clearly investing in research to bring about a US-style ‘minimum data set’, which would allow the routine reassessment of those receiving NHS care while being lodged in care homes.⁸ For example, the National Institute for Health Research is currently funding the testing systems which are used in the US and Canada to assess eligibility for state funding. In fact, subscribing to a minimum data set is a pre-condition for funding from Medicare/Medicaid in the US. As things currently stand in the UK, someone can be resident in a private care home but funded by the NHS, if their needs are primarily medical. But that does not include dementia, which is regarded as falling within the ambit of social care. This has led to a de facto ‘dementia tax’, in which almost one’s entire estate with a value over £14,500 will be used to finance the necessary care.

Free health and social care must be a central demand of any socialist movement. The NHS, founded in 1948, saw the rationalisation and nationalisation of an existing hotchpotch of Poor Law, voluntary and private provision. It was nationalised in large part because it was not working. But it has never been subject to democratic control by its workers or wider society. While we cannot and should not pretend that it is an island of socialism in the way that John McDonnell has, it is imperative that we defend the NHS as a free service that also embodies another important future aspect of socialism - distribution according to need. However ill or disabled one is, the care is free. Private insurance seldom, if ever, will cover existing long-term conditions. Free social care needs to be again extended to those living with dementia.

The last 40 years have seen the underfunding and gradual dismantling of a service which was affordable in the context of post-war reconstruction and the need to make concessions to the working class. The cold war was a pressing priority for the ruling class. We only need to look at societies where the market is given free rein. The USA spends more on healthcare than any other country in the world, but achieves worse health outcomes for the working class than many poorer countries.

Inequalities are widening worldwide. The most basic of human needs, such as water, food, housing and healthcare, are now once again central to class struggle in the wealthiest countries. In the context of Nato’s proxy war against Russia this will only get worse.