NHS at 60
The real history of the struggle for a national health service
The NHS has always been fiercely defended as the
biggest social reform the British working class has won. But it has been
under increasing attack for 30 years. Although still widely valued, its
image has been tarnished by years of underinvestment, cuts and scandals.
New Labour’s increased spending swells business profits rather than
public services. JON DALE reports on how the NHS was won and whether it
can survive.
THE NATIONAL HEALTH Service was born on 5 July 1948.
Memories of life before the NHS are passing into history. Those who
witnessed 1930s poverty recognised the great achievement of guaranteed
healthcare for all, regardless of ability to pay.
Medical treatment has always been available to the
wealthy. For centuries they mostly wasted their money! However, 19th
and early 20th century advances in surgery and medical science
meant ill health became treatable. The advantage of wealth in giving
access to these treatments became real.
Before the NHS, family doctors (General Practice)
charged for their service. Low-paid families called a GP as a last
resort, borrowing from neighbours or the pawnbroker to pay the bill.
Better-off workers paid into ‘Friendly Societies’ as insurance. In some
areas, workers banded together to pay a doctor with a weekly stoppage
out of their wages. These ‘clubs’ were also organised by trade unions.
Some cottage hospitals were built with workers’ contributions,
particularly in mining areas like South Wales.
State medical services were regularly debated at the
Trades Union Congress (TUC) from the early 1890s, winning majority
support. The ‘new’ trade unions, representing unskilled workers, argued
that their members could not afford higher subscriptions to provide
benefits, and that such activities were diversions from their main aim:
improved wages and working conditions. They argued that keeping enough
funds to meet benefit obligations might inhibit unions from taking
costly industrial action.
Confronting two big-business parties in parliament
and chained by anti-union law, unions took the giant step of organising
their own political party. The Labour Representation Committee, formed
in 1900, quickly gained MPs, becoming the Labour Party in 1906. A new
mass workers’ party on the scene changed the landscape. Trade union
militancy grew rapidly before the first world war. TUC membership
doubled between 1905 and 1914 to four million. There were 1.9 million
strike days in 1907, 38.1 million in 1912.
To stem the flow of workers towards Labour and
socialist ideas, the first National Health Insurance Act was passed in
1911. Lloyd George, Liberal chancellor of the Exchequer, assured
employers it would calm the unsettled workforce and raise productivity
by reducing sickness absence. The ruling class also worried whether
"stunted, anaemic, demoralised" slum dwellers could defend its empire.
The act provided medical insurance for lower-paid
workers. They had to pay a contribution of fourpence a week. The
employer paid twopence and the state threepence. This entitled the
worker to free GP consultations, medicines and sickness benefit, but not
hospital treatment, dentistry, opticians, artificial limbs, X-rays,
physiotherapy or district nursing. Non-wage earners (mainly women and
children) were excluded. Bosses were grudgingly prepared to spend money
keeping workers on the tools, but on no-one else.
The act was not universally welcomed by workers.
Labour’s leader, Keir Hardie, retorted: "What was the answer received
when a minimum wage of thirty shillings [£1.50] for all and eight
shillings [40p] per day was demanded for those who worked underground in
unhealthy conditions? No, say the Liberals, but we will give you an
Insurance Bill. We shall not uproot the cause of poverty but we will
give you a porous plaster to cover the disease that poverty causes".
Many trade union and labour activists believed government reforms would
strengthen the capitalist state, buy off sections of the working class,
and divert attention away from the struggle for socialism.
National medical insurance was not administered by
the state but by ‘approved societies’, supposedly operating on a
democratic and non-profit basis. Eventually, there were over 7,000 of
these, although large profit-making companies like the Prudential
dominated. Seventeen percent of contributions went on administration,
not including wasteful duplication of buildings and equipment, or the
cost of regulation. This was far more than for state-run unemployment
insurance – a lesson for today’s increasingly fragmented services.
As the Labour Party grew, it gained power on local
councils, using it to provide welfare services and unemployment benefit.
Local authority spending almost doubled between 1900 and 1913. Many
women in the Co-operative Guild campaigned for better healthcare for
mothers and children. The East London Federation of Suffragettes
converted a pub to a maternity centre, renaming it The Mother’s Arms,
from where a nurse ran clinics, dispensed cheap maternity foods, and
gave health education. A small group of doctors founded the State
Medical Services Association in 1912, with the initial aim of getting
the 1911 act extended to all.
A land fit for heroes?
THE FIRST WORLD war temporarily halted workers’
growing militancy. But soon soldiers’ horrific suffering and women’s
increased factory work produced an even greater mood for change. The
1917 Russian revolution inspired workers across Europe. Lloyd George, by
now prime minister, warned: "The working class will be expecting a
really new world. They will never go back to where they were before the
war". He promised a "land fit for heroes", hoping to convince workers
that life would improve without them following their Russian cousins.
The Labour Party’s 1918 conference almost
unanimously passed the socialist Clause Four of its constitution,
calling for nationalisation of the means of production. At the general
election that December, Labour called for full state ownership of
hospitals and other health facilities, full-time salaried doctors and
other personnel providing both curative and preventative services, the
setting up of health centres and administration of health services by
local authorities. The programme went on to demand the reconstruction
"not of this or that piece of social machinery but of society itself".
Labour’s vote leapt from 400,000 (in the previous election of 1910) to
2.5 million.
Despite Lloyd George’s ‘heroes’ promise, an even
greater strike movement exploded after the war. In 1919, a general
strike swept Clydeside. Troops were sent into Glasgow, and also to
Liverpool when police went on strike. Army mutinies occurred.
1919 saw the new ministry of health created. A year
later it produced a report proposing changes in the National Health
Insurance Scheme, new health centres and other reforms. But these plans
were never implemented. In 1921, miners’ wages were cut. Union leaders
of the Triple Alliance (miners, dockers and rail workers) failed to
organise united strike action in response. The resulting demoralisation
led to a fall in union membership and strikes. With the pressure off,
the government’s health plans quietly gathered dust.
The working class soon recovered. When miners’ wages
were cut again in 1925, a general strike was threatened. Buying time (to
prepare strikebreaking operations) the Tory government set up two royal
commissions – on the mines and national insurance. The latter reported
in 1926, recommending an expansion of benefits to cover workers’
dependents for the first time. But once again, a defeat for the working
class in the general strike led to the report being shelved. Advances in
health and welfare services followed militant struggles, as in 1911,
when the capitalists feared the cost of withholding reforms, possibly
threatening their rule, were greater than conceding them.
Defeated in trade union action, workers turned to
political action, electing a Labour government in 1929. Economic crisis
led to prime minister Ramsay MacDonald joining the Tories and Liberals
in a national government. Labour shifted sharply to the left. Its 1932
and 1933 conferences called for a profound socialist transformation of
society.
The Socialist Medical Association replaced the State
Medical Services Association in 1930 and affiliated to Labour in 1931.
Its programme, A Socialised Medical Service, was included in the 1934
manifesto: "The medical service must be planned as a whole… preventative
as well as curative… the service must be complete and it must be open to
all, so that poverty shall be no bar to health…"
A healthcare catastrophe
WITH THREE MILLION out of work and subject to the
humiliating means test, the effect on working-class health was shocking.
Eighty-three percent of children in Durham had rickets (soft bones from
poor diet). The Workers’ Birth Control Group campaigned with the slogan:
"It’s four times as dangerous to bear a child as to work down a mine". A
vaccination against whooping cough was available, but 2,000 still died
each year because no mass immunisation service existed.
Even sections of the ruling class recognised that
big changes were needed. Harold Macmillan, later a Tory prime minister,
summed up this mood: "It had become evident that the structure of
capitalist society in its old form had broken down… The whole system had
to be reassessed. Perhaps it could not survive at all; it certainly
could not survive without radical change".
The hospital system was creaking. Specialists and
treatment were available to the rich who could pay. For everyone else
there were ‘voluntary’ or local authority hospitals. Voluntary hospitals
were run as charities. Consultants were unpaid. They treated those who
could persuade or bribe a governor to gain admission, and who had a
condition the consultant could teach on and display his skills. In this
way he built up his private practise. (It was an overwhelmingly male
profession.) Despite turning nurses and students on to the streets for
regular hospital flag days, voluntary hospitals faced growing debt. Pay
beds were introduced to try to stave off bankruptcy.
Patients with chronic conditions, and who did not
have the money to pay, had local authority hospitals. Until 1928 these
had mostly been workhouses – grim Victorian institutions with few
trained staff, set up "to establish a discipline so severe and repulsive
as to make them a terror to the poor and sick and prevent them from
entering". Nineteenth century public policy had aimed to keep out all
but the most desperate so taxes could be kept low.
The second world war brought the hospital crisis to
a head. The chaotic and unplanned system was totally unprepared for the
expected numbers of military and civilian casualties. The Tory
government set up the Emergency Medical Service in 1939, controlling
over 1,000 voluntary and 1,500 local authority hospitals. Wartime
planning and government financial backing succeeded where the pre-war
patchwork had failed. This increased support for post-war change, as did
the exposure for the first time of many doctors and middle-class
patients to the horrors of the ex-workhouses.
War speeded up the application of medical advances,
like antibiotics, blood transfusion, laboratory services and plastic
surgery. Medicine had an increasing range of treatments that really
worked. Charity and private enterprise had proved unable to develop care
in the way that public planning did.
Once the early patriotic wave waned, the ruling
class became increasingly worried about the mood of the armed forces and
working class. "In the aftermath of the war there will be a strong and
widespread temptation to abandon the sense of a common effort for a
common cause, to resume the rivalry between capital and labour for the
extraction of a maximum profit from the process of production… If such
trends were to prevail… our whole society – national as well as
international – might well be in sight of disaster". (The Times
editorial, 8 March 1941) Memories of the Russian revolution still
haunted them!
The Beveridge report
THREE MONTHS LATER, Sir William Beveridge was
commissioned to draw up plans for a welfare state. His task was to
instil confidence amongst troops and workers that victory would benefit
them and their families.
In the week before his report was published, The
Times leader thundered once again: "Overwhelming evidence comes from
factories and mines that fear of mass unemployment after the war is a
common obsession, that it induces a cynical mood amongst many workers,
and that the sense of a positive gain to be derived from the war – apart
from the immediate aim of defeating and uprooting Hitlerism – has still
to be won… On many sides lack of confidence in the future after the war
has been a serious moral hindrance to the war effort". (26 November
1942)
There was enormous interest in the Beveridge report.
On publication day a queue a mile long formed outside the government
bookshop in London. Seventy thousand copies were sold by mid-day.
Beveridge proposed a social security system, economic policies to
maintain full employment, family allowances and a national health
service. His proposals for the latter were largely based on the British
Medical Association’s moderate plans.
The New York Herald Tribune reported "that he had
made it plain… that he was thinking of social insurance as only one
aspect of the general problem of demobilisation, of restoring peace-time
production, and establishing a new society in which the maintenance of
private enterprise will be related more accurately than in the past to
the needs for government action".
Taking up this theme and warning against opposition
from the capitalist class, The Times wrote: "So far as employers’
contributions it can hardly be claimed that the annual sum which British
industry is to be called on to pay is an excessive price for a healthy,
contented and fear-free labour force… Any discussion of Britain’s
ability to pay the price of social security is necessarily bound up with
much broader considerations… if the economy of the world at large, and
of this country in particular, is to be placed on a basis of expanding
prosperity and recognition of the needs of the common man, then the
ability of Great Britain to finance the modest programme of the
Beveridge report, as well as the corresponding social reforms in other
spheres, is beyond question. If these conditions are not fulfilled, if
the world reverts to the competitive and restrictive economy of the 20
years between the two wars, then not only the Beveridge report, but the
whole economic, social and political structure of this country is in
jeopardy". (5 December 1942)
Tory health ministers then put forward various plans
for a national health service. (The phrase was first used in 1944.) But
there were no details about when anything would be done and it was
Labour that swept to power with a massive majority in the 1945 general
election. Bonfires were lit and people danced in the streets. The
Parliamentary Labour Party sang the Red Flag in the House of Commons.
The strategists of the British ruling class were in
no doubt of the powerful mood for change. They had evidence of similar
pressure across Europe. There was an outpouring of hatred for ruling
classes who had collaborated with Nazi occupiers against their own
working class. Workers overthrew Benito Mussolini in 1943, taking
control in many areas and rejecting the king. Mass uprisings shook
Warsaw and Paris in 1944. Civil war raged in Greece where the ruling
class, backed by British armed forces, attempted to reinstall itself.
Meanwhile, the Soviet army occupied Eastern Europe
and part of Germany. Capitalism was abolished and replaced with
deformed, bureaucratic workers’ states mirroring Stalin’s regime. The
second world war ended with a strengthened Soviet Union and weakened
European capitalism. But the leaders of the workers’ parties – social
democratic and Communist – saved capitalism by diverting this
revolutionary wave into safe channels. American dollars then poured into
western Europe to ensure capitalism was stabilised.
The National Health Service
THE LEADING LEFT-winger in the Labour government,
Aneurin Bevan, became minister of health. Brought up in poverty in the
South Wales coalfields, his father had been a founder member of the
Tredegar Working Men’s Medical Aid Society. Embryos of a new society
based on collective workers’ organisation can develop within capitalist
society. Bevan applied this on a larger scale with his design for the
NHS, although without any element of workers’ control.
The main components of the NHS were nationalisation
of hospital services with free access; planning at regional level,
enabling more equal distribution; everyone could register with a General
Practitioner and receive free medical care; dentistry was freely
available for the first time; opticians provided free eye examinations
and glasses; prescription medicines were free. The money for this came
from central government, raised through taxation, although as early as
1951, Labour introduced charges for prescriptions, glasses and dental
treatment.
There were weaknesses built in to the NHS from the
start. Pharmaceutical, medical supply and hospital construction
industries were left in private hands, able to extract massive profits
from the public sector. Bevan compromised with doctors’ leaders who
wanted to maintain their private practice. In fact, they probably
represented a minority of their profession and most doctors would have
signed up to work in the NHS. Private practice proved to be a cancer
which, partly cut out, grew back in later years.
Most general practice continued as a cottage
industry of single-handed doctors working from their houses or shop
premises. Such investment as did take place was geared towards treatment
of acute ill health, keeping workers healthy enough to make profits for
their bosses. Services for chronic illness, the elderly, mentally ill
and disabled remained poor relations.
Although the immediate threat to capitalism had
lifted, the 1951-64 Tory government maintained the NHS intact. Any
attack on it would have aroused massive opposition. At a time of
economic growth and almost full employment, big business continued its
contribution towards the cost.
Rising living standards during the post-war economic
boom improved health greatly. Better nutrition and housing, vaccination
programmes and antibiotics cut the scourge of childhood and maternal
deaths. Previously untreatable conditions became treatable with new
drugs, kidney machines and transplants, joint replacements,
chemotherapy, radiotherapy and many more.
However, investment in new facilities was slow and
financed at the expense of health workers’ low pay. Eventually hospital
ancillary workers took strike action in 1972 against the Tory
government. In 1976, there was an actual cut in NHS money, when Harold
Wilson’s Labour government gave in to demands from the International
Monetary Fund during an economic crisis. There was another ancillary
workers’ strike in 1979.
Co-operation to competition
MARGARET THATCHER’S ELECTION victory later that year
coincided with a worldwide recession in which British capitalism was hit
hard. Every past gain of the working class came under ferocious attack.
Public spending was slashed, as were taxes on big business and the rich.
Even then, the popularity of the NHS prevented the
full frontal privatisation experienced by other nationalised industries.
Instead, funding was squeezed. Waiting lists grew, so more patients went
private. Ancillary services like cleaning and catering increasingly went
out to private contractors.
The trade union and Labour Party leaders failed to
organise effective national opposition. After the defeat of the 1984/85
miners’ strike, they acted like rabbits caught in car headlights. Their
inaction only encouraged the government to go further. Councillors were
removed from health authorities, isolating these bodies from local
pressure. Hospitals were taken out of the control of district health
authorities and run by trusts. An ‘internal market’ was established,
with parts of the NHS purchasing services and other parts providing
them. Competition increasingly replaced co-operation.
NHS administration had been amongst the cheapest of
any health service in the world. This started to change with the
introduction of these business practises. Between 1989 and 1992, 30,000
extra administrators were taken on, while the number of nurses fell by
26,000.
A series of scandals hit the headlines – patients
lying on trolleys in hospital corridors overnight waiting for an empty
bed, or dying for lack of intensive care. These were a major factor in
the Tories’ 1997 defeat. The day before the election, Tony Blair
famously said there were "24 hours to save the NHS".
However, New Labour’s election accelerated the
process started by Thatcher. After expelling Marxists and then ditching
the socialist Clause Four, Labour had stopped defending a publicly-run
welfare state. It maintained Tory spending plans for two years. Then
real NHS spending eventually doubled. But a swelling torrent of this
public money poured into private, profit-making corporations.
The hospital construction programme is now totally
dependent on the Private Finance Initiative (PFI). New hospitals belong
to private companies, which hire them back to the NHS with guaranteed
profits for 30 years or more: 126 current and planned PFI schemes were
worth £15.5bn in April 2007. A sample of eight PFI schemes showed
interest payments rose from an average 4.5% to 16% – like buying a house
with a credit card instead of a mortgage! Local health centres have
another version of PFI – the Lift programme. The trade union Unite
estimated that private companies earned £23bn profit over the length of
their contracts from the building and delivery of services through PFI.
Contracts worth £5bn for operations on NHS patients
have gone to Independent Sector Treatment Centres, run by private
companies. They are 11% more expensive and produce worse results than
NHS hospitals. They have even been paid for treatments not carried out.
Meanwhile local NHS services lose funding and face closure.
‘Payment by results’ means hospitals are paid a
nationally agreed tariff for various treatments. This puts patients on a
fast-moving production line. The sooner they are discharged the quicker
another can be admitted, maximising income. There is no time to
thoroughly clean before the next person climbs into bed.
This dizzying pace is an important reason for
hospital infections like MRSA. Privatisation and cutbacks of cleaning
have also contributed. Health workers are under great stress from this
‘assembly-line’ pressure. They cannot give patients adequate time and
personal care. Now, health secretary Alan Johnson proposes to grade
nurses, with competition to see which team smiles most, while holding
pay rises below rising prices! Relentless work pressure contributes to
the NHS compensation bill paid for mistakes growing to £2bn (in 2005).
Foundation hospitals are run like independent
businesses, competing for ‘customers’ (patients) against other parts of
the health market. A deficit in one area used to be balanced by a
surplus elsewhere. Today, there is a struggle for survival so
co-operation is impossible. The Wales health ombudsman recently upheld a
complaint against Cardiff and Vale NHS Trust and Cardiff LHB after a
pregnant woman was denied a routine £100 injection. He said: "Yet again,
a patient in Wales has been let down simply because individual NHS
bodies are trying to protect their own budgets". (Western Mail, 6 June
2008)
The Americanisation of health
ADMINISTRATION COSTS HAVE soared from 5% in the
1970s to 20% today, an extra £10bn a year. Management consultants, often
advising job and service cuts, cost a further £1bn a year. The next step
down this road is private sector management being brought in to run
‘failing’ NHS hospitals, announced by the government on 4 June. Trusts
underspent around £3bn last year. If they were commercial companies this
would be profit.
The ultimate health market is the USA. It spends the
highest proportion of gross domestic product on health in the world. But
30% goes on administration while millions still face bankruptcy if they
need medical care. That’s the ‘benefit’ of the free market – free for
big business to profiteer while poor people are free to go without. New
Labour is steering the NHS towards these rocks.
It is no coincidence that US health corporations are
muscling in on the NHS market. Blair’s health policy adviser became
European president of one of the largest, United Health (UH). Chan
Wheeler, Commercial Director of the NHS (a post created by New Labour on
£300,000 a year), was a former UH director on a fraud charge in the USA
over share dealings. "Independent sector providers will weave and
integrate with the NHS", he has said, "and I hope we will start to just
think of NHS-registered providers of care, so it doesn’t matter whether
they are acute trusts, foundation trusts, independent sector or
voluntary providers". (Health Service Journal, May 2008)
UH has been awarded contracts to run several general
practices under the Alternative Provider Medical Services scheme. UH,
Virgin Health and co see these contracts as ‘loss leaders’, getting
their foot in the door to win much more lucrative prizes.
Primary Care Trusts (PCTs) spend hundreds of
millions of pounds. Controlling their budgets would allow companies like
UH and Virgin to direct spending to the clinics and hospitals they own.
Johnson has offered contracts worth £70bn to a possible 14 private
companies who will then ‘help’ PCTs commission services. Four of these
companies are big US health insurers.
Lord Darzi’s proposed polyclinic in every PCT is
part of this plan. Of course, having local facilities like X-ray,
physiotherapy and some outpatient clinics would be welcome. These all
used to exist in cottage hospitals, which were closed in the name of
‘efficiency’ and ‘modernisation’!
However, the wheel is not turning full circle. New
Labour wants privately owned clinics directly competing with existing GP
and hospital services – as a cuckoo ‘competes’ in the nest. Over 100 GP
surgeries could be closed in the first eight areas of London to have
polyclinics. Those who use GPs most – the elderly, parents with young
children, and chronically sick people – are least able to travel but
could be miles from these ‘super health centres’. Continuity of care,
where one or two GPs know us over many years, will be lost.
The £12.7bn NHS computerisation scheme is four years
behind schedule – after five years work. Two of the original ‘big four’
contractors have quit. One of them, Fujitsu, has been struggling to
persuade doctors and NHS IT workers of the benefits of Millennium – a
system designed for American hospitals. In the eight hospitals it has
been installed in so far, feedback has been awful. At least one trust
was forced to take on over 30 extra staff to cope with its problems.
The IT project has produced some benefits, for
example storing and retrieving X-rays electronically. But there is a
threat to patient confidentiality if computerised records are available
to 300,000 health staff. Its unspoken aim is to allow private health
providers access to patients’ records and so compete more effectively
with existing services.
Fighting the rule of profit
OVER THE LAST decade the NHS drugs bill has soared
from £4bn a year to £8.2bn. The Pharmaceutical Price Regulation Scheme
is a voluntary system setting a cap on the profits each company can earn
selling branded medicines to the NHS. The current scheme, running from
2005 to 2010, allows drug companies to make returns on capital between
8.4% and 29.4%. Drug companies have huge profit margins – in excess of
14.3%, against a business average of 4.6%. Yet the number of genuinely
new medicines – as opposed to copies of those already on the market – is
decreasing. This industry must be nationalised and integrated with the
NHS.
National health insurance was introduced in 1911, as
class struggle heightened and a new workers’ party grew. After the
second world war an aroused working class, determined to end the pre-war
miseries it had endured, threatened British capitalism’s future. Its
anger resulted in a massive victory for Labour, which introduced the NHS.
Today, the absence of a mass workers’ party is allowing capitalism to
take back reforms it felt forced to concede in the past.
Labour today shares a name with its 1945 forerunner,
but little else. It is wrecking the NHS. Behind the NHS logo,
multinational corporations swell like leeches on the contracts they are
awarded.
Every headline about hospital infection, delays or
tragic errors (often linked to overwork and understaffing) weakens
support for the NHS. Those aged under 35 have never known a time when
the NHS was not being rubbished in the media. All three main parties use
this propaganda to justify so-called patient ‘choice’, meaning the right
to choose private GPs and hospitals for NHS-funded treatment. ‘Failing’
public hospitals are threatened with closure, to be replaced by
commercial hospitals, instead of being given the investment and staff
needed.
Johnson is now to allow NHS patients to pay for
expensive and sometimes unproved drugs currently unavailable on the NHS.
(Sunday Times, 15 June 2008) Post-code rationing must be abolished, but
this ‘co-payment’ is a further step towards wealthier patients getting
the best treatment. The difficulty now in getting NHS dental treatment
shows the future for the rest of the NHS, if all Labour’s plans go
through. A two-tier system is returning, 60 years after it was ended.
A massive movement is needed to save a free
universal health service. Trade unions need to fight but, like 19th
century unions, have no political voice. The key task is to build a new
mass workers’ party. A socialist programme is needed to rebuild the NHS,
ending the rule of profit over health and reconstructing "not this or
that piece of social machinery, but society itself".
|