Seventy years of the National Health Service, founded in 1948, has been celebrated on TV, by a service at Westminster Abbey, and by numerous events in hospitals. The NHS is, in its own words, “our country’s most trusted and respected social institution”. Even those who protest at the way it is run do so because they are against “the assault on the NHS” (Socialist Worker 3/3/18). People love the NHS, and want to protect it. It all seems too good to be true, a national institution loved by all from the Countess of Wessex at the service in Westminster Abbey (even if royalty invariably use private hospitals) to the poorest in the land, and from right to extreme left of the political spectrum. This ideology, supported by all the bourgeoisie’s political forces, is based on many falsehoods.
The NHS lends itself to this ideological celebration partly because it offers medical treatment, often free at the point of use. There are many who are alive today because of that medical treatment. Also most NHS employees love their jobs caring for patients. These reactions are often translated into the idea that “I love the NHS”, especially by workers on strike and those aiming to support them. This confuses the NHS as a capitalist institution carried out by the state on behalf of the economy, judged in terms of monetary value, and the work that goes on in health care judged according to the human needs it fulfils. It is also, no doubt, a better poster institution than sewage and waterworks which are equally necessary to our health and life expectancy.
The circumstances of the formation of the NHS
The NHS is often presented as a gain won by the working class through the Attlee Labour government of 1945. Or perhaps “I thought that after the war the bourgeoisie introduced [the NHS and the welfare state] because they were scared of the threat of revolution and the influence of communist ideas, and all the returning soldiers were a real threat to the “social order”. However, the working class was still defeated at the end of the Second World War. The Great War of 1914-18 was characterised by fraternisation on both the Western and Eastern fronts and ended by the start of the German revolution 100 years ago, following the Russian revolution in 1917. However the revolutionary wave was defeated, ushering in a period of counter-revolution and freeing the bourgeoisie to unleash the barbarism of the 1930s and 1940s. Class struggles never completely stop in capitalism, and there were limited strike movements even in the dark days of the war, notably in Italy in 1943, but the fact that the whole war could be conducted and brought to a successful conclusion without a commensurate reaction by the working class showed that it remained defeated. Not only was the working class in no condition to force the ruling class to grant reforms, but capitalism had entered its phase of war and revolution, its decadence, when it was no longer in a position to grant meaningful, lasting reforms to the whole class.
It is true that the ruling class was well aware of the danger the working class had represented at the end of the previous war, and it certainly acted to head off undeniable discontent toward the end of the Second World War. One example is the carpet bombing of civilian areas during the war, the better to pre-emptively massacre proletarians. Another was for advancing Allied forces to hang back and allow the German army to put down any resistance before entering. This was the meaning of Churchill’s idea of letting the “Italians … stew in their own juice”, i.e. let Germany put down the workers in 1943, or the Russian Army standing aside to enable the crushing of the Warsaw Uprising of 1944. To the extent that the establishment of the NHS and the welfare state responded to this fear of the working class they did so by making workers feel loyalty towards and dependence on the state rather than their own capacity for struggle and solidarity. Discontent was also channelled into support for the Labour Party, although the Conservative Manifesto of 1945 shows they were not backward in advocating a “comprehensive health service” where “no one will be denied the attention, the treatment or the appliances he requires because he cannot afford them.”
The introduction of the NHS was certainly related to war. The British state had first become aware of the need to improve the health of the working class at the time of the Boer War when so many volunteers were unfit for military service. In fact the NHS and the welfare state were as much the product of the wartime coalition as the Labour government. The 1945 election was won by Attlee who had been the deputy Prime Minister in the Coalition which had overseen the preparation of these policies. The 1944 Education Act extending secondary education was carried out by the Coalition. The NHS and welfare state were based on the Beveridge Report, by a Liberal economist, harking back to ideas put forward by Lloyd George before the First World War, and another Liberal economist, Keynes, was responsible for the ideas of full employment and state stimulation of the economy. It was also part of a process of nationalisation (Bank of England, mines, railways, iron and steel…) which, although not supported by the Tories, followed on from the years of state direction of the economy during the war.
Even before privatisation
One of the ideas given for defending the NHS is that the real problem is privatisation. After all we don’t see people going round saying “I love BUPA”, even when some people have private health as part of their pay, nor even “I love Medicaid”. However, we should see what Beveridge said was intended by the welfare state: “The plan is not one for giving to everybody something for nothing and without trouble, or something that will free the recipients for ever thereafter from personal responsibilities. The plan is one to secure income for subsistence on condition of service and contribution and in order to make and keep men fit for service.” From the horse’s mouth you have it, the NHS is to keep workers “fit for service”, in work or in the military.
It was always the proud boast that in the UK we do not look for evidence of insurance before giving treatment, like they do in the USA. But the NHS has always been a compulsory, universal, National Insurance. Long before ‘privatisation’ this was demonstrated by a British national living in the USA without health insurance who returned in the hope of getting treatment for terminal cancer, only to be faced with a bill for her treatment in an NHS hospital because she was not insured here. She returned to the USA where she was entitled to Medicaid. This kind of thing has become much more systematic with campaigns against “health tourism”, guidelines about who can and cannot be treated on the NHS, and the “hostile environment” for immigrants which requires health services to scrutinise each patient’s right to treatment, or otherwise. But the principle remains.
Before ‘privatisation’ money was already a major concern in running the NHS, in particular a concern to keep costs down. There was always a long waiting list for treatment. The number of beds was steadily reduced. GP surgeries, always run as small businesses, were often in an atrocious condition. It was no golden age. ‘Privatisation’, integrating more private money and private health facilities into the NHS, has gone along with greater state control: targets, regular inspections, pressure to amalgamate small GP premises into more cost-effective businesses, guidelines to direct which medications and treatments can be used, all in the interest of moving more care out of hospitals, which are expensive, into “the community”.
State capitalism and the social wage
We have seen that the NHS was part of a wave of nationalisation by the post-war Attlee government, and that this followed on from the state direction of the economy, including health services, during the war. We have also seen that the need to have men fit for military service was what first prompted the ruling class to take an interest in improving the health of the working class. This is no accident, state capitalism itself is an aspect of the adaptation to a system of imperialism and war, or at least preparation for war. Left to itself and the control of the market, capital concentrates, often into huge multinational concerns that dwarf many small nations. State capitalism concentrates at a state level for political and military reasons, typically supporting or taking over loss-making industries necessary to the national economy, and typically this has been developed particularly around a war effort.
“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).” The unions have been integrated into the state, and the state regulates minimum wages, and also takes over paying an aspect of wages, for instance with tax credit (or the universal credit to be brought in) and housing benefit that subsidise the wages paid by capital. The NHS is also an aspect of this.
The ideology of the NHS and welfare state as taking care of its citizens is very dangerous. Workers are encouraged to identify with those parts of the state that appear to benefit them, such as the NHS, and through this to humanise the state and identify with it as a good citizen. We should forget that it is imperialist, forget its involvement in various military adventures, forget its repressive role. This identification can also be used to sow divisions in the working class, the idea that the benefits are for the good citizens that have already contributed and should be denied to immigrants who have only recently arrived.
With this identification with the NHS, and through that with the state, we would be led to imagine that it can be induced to act in our interests if only we campaign hard enough or vote for the right people. In reality the state belongs to the ruling class and runs its imperialist war machine. Alex 8/9/18
. See ‘The NHS is not a reform for workers to defend’, written at the time of the 50th anniversary of the NHS, for more details, https://en.internationalism.org/wr/303/nhs-reforms
. “Attlee was so far from being a passionate ideologue that his wife Violet once casually observed: “Clem was never really a socialist, were you, darling? Well, not a rabid one”.” https://www.theguardian.com/politics/2001/mar/14/past.education
. ‘Internationalisme 1952: The evolution of capitalism and the new perspective’, https://en.internationalism.org/ir/21/internationalisme-1952#_ftnref1