Health service jobs under attack, hospital closures, inadequate services getting even worse. This has led to a discussion on the libcom internet discussion forum (https://libcom.org/forums/organise/defending-nhs ) about whether defending the social wage means defending the NHS. Many important questions have been raised. We aim to return to the questions raised in this discussion in a future article. For now we are reprinting an article we wrote in 1998 for the 50th anniversary of the founding of the NHS as a contribution on why we do not regard this state institution as a reform to be defended.
Even when it is clear that the NHS is under funded, even when it is clear the ‘new’ money promised is largely a con, even if you or a relative has been waiting for a year or more for an outpatient appointment just to get on the waiting list for treatment of a painful condition, even then the idea that the NHS is a genuine reform of capitalism remains very powerful. This is an idea which has been celebrated by all shades of bourgeois media on the 50th anniversary of the founding of the NHS this summer. It is, however, an idea that is wrong, a lie to try and tie workers ideologically to the state and its increasing control over society.
In contrast to the reforms of capitalism’s ascendancy
“During the period of capitalism’s ascendant phase, increasing wages, the reduction in the working day, and improved working conditions were ‘concessions wrested from capital through bitter struggle... the English law on the 10 hour working day, is in fact the result of a long and stubborn civil war between the capitalist class and the working class’ (Marx, Capital Vol. 1). In decadence, the bourgeoisie‘s concessions to the working class following the revolutionary movements of 1917-23 represented, for the first time, measures taken to calm (8-hour day, universal suffrage, social insurance etc) and to control (labour contracts, trade union tights, workers’ commissions, etc) a social movement whose aim was no longer to gain lasting reforms within the system, but to seize state power.” (‘Understanding the decadence of capitalism’, part VI, International Review 56).
The lasting reforms of the last century could be fought for, and sometimes won, because capitalism was expanding production and developing new areas of the world. These reforms, limitation of the working day, education, despite the resistance of the bourgeoisie, also benefited capitalism as a whole by improving the health and productivity of the workforce.
However, these were not the only gains of the struggle for reforms. Such immediate results were not the main aim “because such activity prepares the proletariat, that is to say, creates the subjective factor of the socialist transformation, for the task of realising socialism.” (Reform or Revolution, in ‘Rosa Luxemburg Speaks’) The struggle was a vital contribution to the development of working class consciousness and organisation.
The NHS, in contrast, was not the product of a stubborn struggle by the working class, but the conscious decision of the government of national unity in World War 2. It was planned in the report by Liberal MP Beveridge in 1942 and the White Paper, A National Health Service in 1944. In spite of all the ideological hype when it was finally introduced by the Labour government in 1948 it was never intended to be a free gift to the working class. “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.” (Beveridge, quoted in: ‘Britain: the welfare state’, WR 14).
However the measure was designed to ensure workers not just “fit for service” but also socially controlled. “Having learned its lessons from the 1917-23 revolutionary wave, the world bourgeoisie did all it could to make sure that the end of die 1939-45 war did not give rise to another proletarian outburst. It thus combined a savage repression of the isolated workers’ revolts that did occur (Italy, Germany, East Europe, Vietnam), with a series of conciliatory methods aimed at convincing the proletariat that its struggle against fascism had not been in vain..., in Britain the Labour government came to power, pledged to the building of a ‘Welfare State’ for the benefit of the working people.” (‘Theses on the class struggle in Britain’, WR 7).
This took place as part of the whole process of formalising the state capitalist control of all aspects of society that had been present during the war. Industries that had been controlled and directed by the state for the war effort were nationalised, hospitals included. The measure involved the state taking direct control of a part of the workers’ wages to direct according to the needs of capitalism “The wage itself had been integrated into the state. Fixing wages at their capitalist value has devolved upon state organs. Part of the workers’ wage 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).... while socialist society will defend the individual against illness and other risks, its aims will not be those of capitalist Social Security. The latter only has meaning in the framework of the exploitation of human labour. It’s nothing but an appendage of the system.” (‘On state capitalism’, from Internationalisme, 1952, quoted in International Review 21).
Fit for slaughter
The NHS that came into being on 5th July 1948 was built on and systematised “pieces of a health service, some provided by voluntary bodies, some by local authorities, either under public health or public assistance powers but without coordination.” (Health Trends, vol. 30, no. 1, 1998). All these pieces of the health service had been brought in to ensure sufficient fit men to fight and die in the imperialist wars that have dominated this century.
The Boer War marked a turning point. Only 50% of volunteers were fit for military service, leading to an outcry about the “spectre of physical deterioration and racial degeneration”, uniting all sections of the ruling class. “An Empire such as ours requires ... a race vigorous, industrious and intrepid” was how Roseberry expressed it (quoted in Socialism in Britain, Callaghan). The Interdepartmental Committee on Physical Deterioration investigated the situation and a school health service was set up on the basis of its findings. In 1911 came the national scheme for health insurance, making the working class pay for the health care the state knew was necessary for efficient workers and soldiers.
However, by the ’30s the health services were still run by various Approved Societies, voluntary groups and local councils. It was the preparation for war that concentrated the minds of the ruling class on the need to reorganise and rationalise this. In World War II, services for casualties, including not only major wartime injuries but care of evacuated children, were organised by Health Departments. That organisation was the basis of the NHS.
Since the various steps in the development of the health service and the NHS have been stimulated by the needs of imperialist war, the death and destruction of two world wars is the cost against which we have to measure the inadequate provision of the NHS.
When the NHS came in it was part of its ideology that it should be free at the time of use. The introduction of charges for glasses and false teeth in 1951, and since then for eye tests, dental checks, and prescriptions has rendered that a fiction. Unless, of course, you need advice only.
The NHS can, of course, point to the increase in life expectancy of about 9 years, to 74.6 years for men and 79.7 for women in 1996, and a dramatic decrease in infant mortality, over the last 50 years. Given the development of medical science over that period it would be shameful if these statistics had not improved. Immunisation against an increasing number of diseases, the development of antibiotics, intensive care, have meant that a number of diseases, particularly infections, no longer cause the number of deaths they did 50 years ago. In addition we have been in a period in which imperialist war has largely been confined to the peripheries, and the worst effects of the economic crisis have been deflected onto the much weaker economies in the ‘third world’.
Nevertheless, there are clear signs that the NHS cannot go on delivering the level of health care we are used to, and that capitalism needs, let alone keep up with the improvements that could be put in place as medical science advances. And it certainly cannot make up for the appalling toll that the crisis and decomposition take on workers’ health, no matter what medical advances are made.
Already at the beginning of the ‘80s the European Commission had made it perfectly clear that “in the last few years the lower rates of economic growth have made it much less acceptable for the proportion of publicly financed social expenditure in the national product to continue to increase.” (Quoted in ‘Capitalism’s health service: no gain for the workers’, WR 56). The result is that services are cut. Administrators are sent in to count and cut costs, while health care services are cut. In particular hospital beds have been consistently cut, having fallen from 10.2 per 1,000 in 1949 to 8.3 in 1976. And that was before the bulk of the efficiency savings started! If an old hospital is closed, beds are lost. When new hospitals are built - new facilities - the first question is ‘how many fewer beds can we cope with?’ While propagandists for the NHS can point out the freeing of the old fever hospital beds, that excuse went out of date 40 years ago. Now we have the annual winter bed crisis, and sometimes recently even a summer bed crisis, as in East London this year. Beds for the mentally ill have been particularly badly hit. The old policy of locking the mentally ill up in inhumane institutions where they could be forgotten has been replaced by the policy of ejecting them into ‘the community’ where they are woefully neglected. This is very disruptive for the largely working class districts where they are dumped.
It is hardly surprising that the health service has been among the first aspects of working class living standards to come under attack. Because it is part of the social wage, given indirectly, and only needed by any particular worker at certain times, it is particularly easy to cut this without provoking a working class reaction. Workers in the NHS have been attacked very intelligently, with the most brutal job cuts and pay cuts imposed on the most isolated sectors (as at Hillingdon).
What, then is left of the struggle against absenteeism? It has simply changed from one based on health care to one based on repression, with doctors employed for the express purpose of judging who is fit for some form of work. And some attack this task with great zeal, ordering that those with learning difficulties or crippled with arthritis should seek work.
When we turn to the inability of the NHS to make up for the toll of the crisis, TB provides an excellent example. The introduction of effective anti-tuberculosis drugs in the ’40s, combined with the improved social conditions in the immediate post-war reconstruction period, led to an enormous reduction in the ravages of this disease. TB wards emptied. Public health doctors even thought immunisation might no longer be necessary - 15 years ago. Now the disease is returning, not just imported among immigrants, not just among AIDS victims, but also among the poor, the overcrowded, and the victims of the economic crisis. A disease that should no longer exist is becoming a growing threat.
Avoid the trap of defending the NHS
The NHS is not a reform to be defended as an institution as the leftists would have us believe. It is not a question of how the capitalist state organises this particular part of itself, whether money comes from Public Sector Borrowing or the Private Finance Initiative. There is no golden age of the NHS to return to.
In particular workers in the NHS need to avoid any identification with their employer. To defend their interests brings them directly into conflict with the NHS.
Alex, September 1998.