There are many articles and programmes that detail the inadequacy of the NHS preparation for the current pandemic. Panorama (BBC documentary) told us that the stock of personal protective equipment (PPE) contained no gowns, the Kings Fund (a think tank on the UK health service) how few doctors, nurses, hospital and intensive care beds there are in the UK compared to other developed countries, the Economist how in April the testing for the coronavirus in the UK stood somewhere between the USA and Ecuador.
At the same time we are called on, not just to applaud the NHS once a week, but to love it, to identify with it as our institution, as a model for health services everywhere. But the real NHS is an institution of the capitalist state which sends its employees to look after infectious patients without the necessary PPE, deports elderly patients from hospitals to care homes without testing for Covid during this crisis. The real NHS which for years before this crisis has habituated us to long waits in casualty and interminable waiting lists for surgery.
This coronavirus pandemic has shown up the inadequacies and failures of all health services under the capitalist system. Despite the very real differences in their resources, or lack of resources, the degree of organisation by the state and the degree of involvement of private firms, they are all based on two essential aspects of capitalism: the nation state and the need to extract as much value from those who work in the sector for as little money as they can get away with.
“Protect the NHS”… from patients
In mid March hospitals were ordered to discharge 15,000 mainly elderly patients, either sending them home, or parking them in care homes, to free up beds needed for the Covid-19 patients. The NHS coped at the expense of these patients, and the care home residents and staff who caught coronavirus from them: thousands died of it. It is not as if the world had not been warned of the need to prepare for a pandemic, the WHO, virologists and epidemiologists having been watching for pandemics for decades. It is not as if the British government had not been warned of the degree of unpreparedness for a pandemic in Exercise Cygnus in 2016 which showed the NHS was unable to cope, and was therefore never published as too frightening.
Throughout the history of the NHS there has been constant pressure on the resources available. In 1949 the NHS had 10.2 hospital beds per 1000 of population, essentially what was taken over from the voluntary hospitals, by 1976 it had fallen to 8.3 per 1000. In this time antibiotics had made a great difference and the old TB and fever wards could be largely closed. However beds have continued to be lost so that by 2017 there were only 2.5 per 1000 population with acute and general beds having fallen 34% since 1987/88. More to the point bed occupancy has risen from 87.1% in 2010/11 to 90.2% in 2018/19, regularly going over 95% in the winter, which is a dangerous level, as the Kings Fund shows: “Arguably, NHS hospitals have never been under greater strain than they are today. Population growth, combined with an increasing proportion of older people more likely to need health care, is driving greater demand for NHS hospital treatment ... The NHS is only now coming to the end of a prolonged funding squeeze and is in the midst of a staffing crisis. Adult social care has seen staffing and demand pressures rise and is still waiting for the fundamental financing reform it urgently needs. Current levels of occupancy mean the average hospital in England is at risk of being unable to effectively manage patient flow leaving it vulnerable to fluctuations in demand.” One result of this austerity has been the well-publicised number of deaths above the average for the time of year, which to date have reached nearly 60,000, particularly in hospitals and care homes during the Covid-19 pandemic.
For international comparisons, Sweden with a similarly low level of hospital beds at 2.2 per 1000, has also been able to protect its health service at the expense of care homes, with half the deaths of those over 70 in care homes. Germany’s health service is better resourced, 8 beds per 1000, but still subject to austerity cuts. The fall in the number of hospital beds is an international tendency.
“Protect the NHS” … from foreigners
A "child presented with leukaemia required intensive care treatment and to start chemotherapy. … Hospital unwilling to start chemotherapy until deposit funds provided therefore treatment delayed". For those reaching retirement age, especially those working in the health service, this is exactly the sort of thing we were told would never happen here with the NHS. This is what happened in the USA with private medicine. Let’s read on: "case needed to be reviewed by a specialist centre to determine treatment options, but they refused to see her as ‘not eligible for NHS care’…” And it is not only foreign children who have been denied treatment. Part of the Windrush scandal was that we saw a number of patients denied treatment when they could not prove they had a right to it, even after living in the country since childhood – and even if they had life threatening conditions.
These days we hear more about the ‘need’ to protect the NHS from “health tourism”. This xenophobic campaign does not just date to Boris Johnson’s populism, nor to Theresa May’s “hostile environment” for migrants: we can see the same arguments put forward by the last Labour government when home secretary Jack Straw castigated “bogus asylum seekers” who might be coming here and using ‘our’ public services.
However, the ruling class are having a little difficulty with their propaganda about protecting the NHS from these ‘health tourists’ who keep taking NHS resources, when so many of them are in fact working in health or social care and putting their lives at risk in the NHS. The surcharge for migrant workers is due to increase from £400 to £624 in October and until the recent government U-turn on the issue, the many immigrant health and social care workers would have had to pay it with only medics excluded.
In fact the NHS, and the welfare state more generally, was never a “free gift” nor a reform won by the workers. Its aim was “to secure income for subsistence on condition of service and contribution and in order to make and keep men fit for service” in the words of Beveridge. To keep workers fit for work, or for military service.
Capitalism is based on the nation state, and in this global pandemic which affects the whole world, each state, each national health service, is scrabbling in a spirit of ‘every man for himself’ against every other for PPE, for resources, for testing. The USA is threatening the WHO to withdraw funds. Several countries have accused China of industrial espionage into work on a vaccine. Instead of the cooperation needed to face a global threat, to produce a vaccine, each nation protects its health service, its profits, its imperialist interests. The limited cooperation they have managed in the past is giving way to national self-interest – to the detriment of their ability to limit the danger of this pandemic.
“Protect the NHS” … at the expense of health and social care workers
A survey by the Royal College of Nursing found that the vast majority of nursing and midwifery staff felt they and their families were at risk because of their jobs, and that if redeployed they were not adequately trained. More than half worked beyond their contracted hours and the majority did not expect any overtime payment for this. Meanwhile government spokespeople were lying about the availability of PPE and testing, and calling on the population to applaud on Thursday evenings and put up rainbows in our windows to support the NHS – the very NHS that is neglecting the safety of nurses and other workers in the face of a deadly infection! Like soldiers on the front line, like cannon fodder! In fact Belgium threatened to conscript health workers, much to their indignation.
This is not just some aberration during the pandemic but the way health services, just like any other capitalist concern, treat their employees. There has been an increase in the intensity of work in hospitals, with the number of beds having halved, while the number of patients treated increased. There are increasing vacancies for qualified nurses, with the gap plugged by support staff such as health care assistants. This has been worsened since 2016 with a drop in the number of nurses from the EU coming to the UK. In these circumstances there is always a moral blackmail on health workers to “go the extra mile” for patient care. It all adds up to an increase in exploitation, just as we see in every health service worldwide and in every sector of the economy.
Solidarity with health workers doesn’t come through weekly applause for their employer, but through proletarian solidarity, solidarity with them as exploited workers whose interests conflict with the NHS, and whose struggle for better pay and conditions is inevitably a struggle against their employer, the capitalist state.
Nationalised or privatised, the NHS is still a capitalist institution
Those on the left would have us protect the NHS from privatisation, or even claim that a nationalised health service is somehow socialist. This is a left wing version of the lie that it is “our NHS” because it is run by the state. We are talking about an institution of the capitalist state: “The wage itself has been integrated into the state. Fixing wages at their capitalist value has devolved upon the state organs. Part of the workers’ wages is directly levied and administered by the state. Thus the state ‘takes charge’ of the life of the worker, controls his health (as part of the struggle against absenteeism) and directs his leisure (for purposes of ideological repression)”. So the state takes charge of part of the wage for maintaining the health of workers, and employers do not have to pay health insurance, in the same way that the state pays a part of wages through universal credit or housing benefit so that capitalists can pay lower wages. Nationalised or privatised, health workers are exploited by capital, either through the state for the benefit of the national capital as a whole, or through a company which sells its services to an insurer or the state. This is why state and privatised health services carry out the same policies, above all the same policies of exploitation.
One advantage of a privatised health service for the state is that it is directly subject to the laws of the market, and so can go bankrupt, because there is no government there to bail it out. This is why everywhere there have been moves to make hospitals and other health care institutions keep strictly to their budgets and put services out to tender particularly since the 1980s, under the Thatcher government and in the Blair years. Because the British bourgeoisie relies so much on the ideology of the NHS it has put a lot of emphasis on state control of what should be done – and also what should not be prescribed or carried out because it is not ‘cost effective’. As we note in an article on the response of the German health service “what is more important is that the management of the hospitals has been very heavily submitted to the laws of the capitalist economy for all the funding bodies (including the public and church authorities). This applies, for example, to the rationalisation of work processes … the employees are squeezed like lemons to push the accumulation of value in the health care industry to the highest possible level. The patient faces the carer for whom he becomes a commodity, the social relationship becomes a service, the work process is subject to enormous time pressure and compulsion. This perversion describes very well what Marx analysed as objectification, dehumanisation and exploitation”.
 In which many who had arrived, legally, in the UK in childhood were treated as illegal immigrants, see https://en.internationalism.org/content/16763/windrush-scandal-nationali...
 The economist and Liberal politician whose report during World War 2 for the coalition government formed the basis of the ‘Welfare State’ put in place by the Atlee government after the war.
 Internationalisme 1952: ‘The evolution of capitalism and the new perspective’, https://en.internationalism.org/ir/21/internationalisme-1952#_ftnref1