A discussion in March on ‘Defending the NHS ’ on the libertarian internet discussion forum libcom.org posed some very important issues about how workers in the NHS can defend themselves, and how we as a class can struggle against hospital closures and cuts in services. All agreed that the NHS is an expression of state capitalism, no one held that it is a wonderful reform and the envy of the world as we used to hear in the 1970s and 1980s. This is a forum where we find people questioning what capitalism has to offer us, and of course, 40 years of cuts and shake-ups have inevitably removed a lot of illusions.
But we need healthcare, we need it even if we cannot afford to pay for a hip replacement, a stay on coronary care, or even a prescription charge. However bad it is, however long the wait for an appointment or treatment, however that treatment is restricted by lack of resources or NICE guidelines, the fact that we can get to see a doctor without paying upfront is valued and relied on by workers in Britain as an essential part of the social wage. This is particularly so when we contrast it with the situation in the USA described by contibutor Booeyschewy where something like 50% of workers have no health insurance, essentially no access to healthcare.
Does fighting for access to health services, or even for the pay and conditions of workers in the NHS, involve defending the NHS against privatisation? Several arguments were raised in favour of supporting the NHS in order to defend our social wage: that private healthcare is not inclusive; that privatisation and the internal market are the means by which the government is attacking our health service provision; and that we defend our wages even though we want to see the end of capitalism and wage labour.
For Joseph K “… ‘market provision does not mean bad care’ for those who can pay, whereas in principle and with waiting lists, the NHS treats the poorest workers too” and for Magnifico “the question is whether or not it represents an increase in the social wage in comparison to the free market healthcare system we are moving towards”. We all know that there are many countries in the world, including the USA, where healthcare is only for those who can pay, but various examples were given of private or partly private systems which are equally inclusive, such as those in France and Germany. In fact when the Labour government was trumpeting its commitment to the NHS, it was promising to raise spending to match the levels in those two countries. As Ernie (for the ICC) pointed out “the discussion has already shown that the NHS has not marked a real improvement in workers’ health beyond the state’s provision of the most basic care … This provision is determined not by some ideological concern for the health of the working class as expressed through the NHS, but by the ability of the state to pay. This is the nub of the question and it is the same everywhere no matter what form healthcare takes. Throughout Western Europe healthcare is being cut back for the working class and it has been doing so for several decades” and went on to show that health services in Europe have made no difference to health inequalities. An ICC sympathiser, Demogorgon, pointed out that the NHS has always been partly private since GPs, the great gatekeepers of the service, were always private businesses. We could add that this does not stop that part of the NHS being completely integrated into state capitalism: GPs are financed and essentially set up in business with a franchise from the state.
Nevertheless, every attack is couched in terms of privatisation, budgets, market forces, so how can we defend against hospital closures etc without defending the NHS against privatisation? Magnifico takes the view that “it is national-level marketisation reforms which are the method the government are using to shut down hospitals and A&E departments - they make them responsible for their own finances, then don’t provide enough money for them to function, then put their closure down to abstract ‘market forces’ so it’s not really anyone’s fault. If the NHS was integrated as it is in Scotland and was in the rest of the UK pre-Thatcher then this would be much more difficult”. Another contribution put even more strongly the view that the privatisation of the NHS makes it even harder to defend ourselves: “But once the NHS is completely broken up and privatised, as the government plans for it to be in a few years time, of whom will we make the demands for this increase in the social wage?” These contributors show the main interest that governments, all governments, have in ‘privatisation’. The first is to remove the protection of state subsidy, which can no longer be afforded: this applied to British Steel and British Coal in the 1970s and 1980s, it applies to the nationalised industries that have been allowed to go bust in Eastern Europe, India, China, as much as to the NHS. The second is to disguise the role of the state in driving the attacks, to make the attack the responsibility of this or that trust, rather than government policy – and to the extent that the role of the state cannot be hidden, which it can’t, we can be misled into defending state control and weakening our struggle. As Demogorgon points out “The use of ‘privatisation’ is part of the local ideological cover for this universal attack. It’s no different to the way workers are always laid off when one company takes over another or even when a company is nationalised.”
So, when we all agree on the need for workers in the NHS to defend their pay and conditions, and the need to defend ourselves against cuts in services, is the question of defending the NHS just like the question of defending wages? For example “defensive struggles over healthcare in the UK, take the de facto form of ‘defending the NHS’ - even if we should reject that as a slogan for the raft of reasons discussed?” As Joseph K puts it “I mean we may be in fact defending workers’ conditions and our social wage, but while our struggle remains defensive, surely this is inseparable from the form in which it is administered, as the attacks are in the form of privatisation/marketisation? I mean, here by ‘de facto form’ I’m talking of practice, whereas you’re talking of an ‘ideological prison’ - so is what is at stake our propaganda as much as our praxis? I mean, leftists may support healthcare workers striking from a ‘defend the NHS’ viewpoint - we’d do so from a class viewpoint, stressing that the NHS per se is not what’s important”. Joseph K is quite right to emphasise that we need to support a struggle on a working class basis even if it is imprisoned behind the unions or workers find themselves marching behind bourgeois slogans. If we believe that the unions or leftists are leading a struggle into a dead end, to defeat, it is our responsibility to say so. The question raised here is what is the role of the ‘defend the NHS’ slogan in a struggle? If we take the analogy of a struggle for wages, that struggle does not depend on supporting the notion of ‘a fair day’s pay for a fair day’s work’ – which we know is impossible. If we take Demogorgon’s analogy of a company takeover, how may times have we seen workers asked to put their trust in this or that takeover bid, to accept substantial redundancies and other attacks so that the company can continue? Isn’t this always done with the illusion in defending the local or national economy? This has been the case with the various incarnations of British Leyland in the Midlands, and is the case for workers at Airbus today. We would argue that the slogan ‘defend the NHS’ has an equally negative effect on workers struggling to defend themselves when it comes to the NHS, as Ernie shows: “… to drown struggles in struggles to defend the NHS or to support health workers i.e., to keep a struggle separated from wider struggles. These are real dangers and make the waging of effective struggles difficult for health workers. A very informative example of this was the wildcat health workers’ strike in February 1988. This struggle was potentially a very explosive struggle and one which drew on the lessons of the miners’ strike. It began when the government started to test out the waters about cutting unsocial hours payments. Workers at one of the main Leeds hospitals heard about this and walked out on unofficial strike. This struggle spread to other hospitals and areas like wildfire. We heard of nurses going to car plants and pits to call out workers. The unions were left speechless for a while (the true nature of the struggle was hidden in the media). Finally the union got a hold of the situation and called a demonstration in London and called on workers to return to work, the government also dropped the idea of cutting unsocial hours like a hot potato… However, the movement had passed its peak by the time of the demonstration and the union had put a stop to the efforts to call out other workers.
… In many ways it is a question of health workers rejecting the idea of being a special case, of having to link their struggle with the defence of the NHS -something the unions are endlessly pushing- and seeing the attacks they are under as part of the wider attacks that will be crucial to the development of the struggle.”
Magnifico takes the opposite view: “linking defence of health workers’ jobs with defence of the NHS does make it part of a struggle for the interests of the wider working class.” This view does not recognise the pressure on workers in the NHS to see themselves as primarily giving a service, rather than being workers earning a living. How for example are midwives in East London to react right now: faced with a crisis in maternity services, they are being asked to work 6pm – 9pm to catch up a backlog of antenatal care. Are they to defend the NHS and the service given or are they to react as workers and resist the attack? The health workers described by Ernie in 1988 reacted as workers, with a strike and an attempt to spread the struggle. That made their struggle stronger. Alex 5.5.07