More than 50,000 health service jobs are due to be lost, including doctors, nurses, midwives and ambulance personnel. In fact Trusts plan to shed 12% of qualified nursing posts over the next 4 years, while the NHS already relies on their unpaid overtime, carried out by 95% of nurses with more than 1 in 5 doing this every shift. Small wonder that the RCN Chief Executive notes this “could have a catastrophic impact on patient safety and care” (Nursing Times, 12/4/11). At the same time NHS staff are not just facing the public sector pay freeze but also a threat to “allow employers to agree locally with their trade unions to freeze incremental pay progression for all staff groups, in return for a commitment to provide a guarantee of 'no compulsory redundancies' for all staff in bands 1 to 6” (www.nhsemployers.org), along with plans to allow more health care providers to ignore national scales and set their own pay. In other words, there is an attempt to drive down pay, as well as changes to the pension scheme.
The key to understanding the changes going on in the NHS today is cost-cutting. According to the Public Accounts Committee “under the previous government, only £15bn of £35bn savings promised in Labour's 2007 comprehensive spending review had been achieved... and of those reported savings, just 38 per cent were definitely legitimate value for money savings” (www.publicservice.co.uk/news_story.asp?id=14649). It’s not about this or that Labour or coalition government, or ideology, but – like the pensions, like benefits – simple cost-cutting.
Reform at the service of ‘efficiency savings’
The heart of the current reforms is to transfer control of 60% of the NHS budget to consortia of GPs, abolishing the Primary Care Trusts, many of whose staff have already left or been made redundant. “One underlying political goal is to hand hard decisions about the rationing of care to GPs, the most trusted part of the health service” (The Economist, 9/4/11). This effort to make GPs feel responsible for the NHS budgets wasn’t invented by Andrew Lansley, the health secretary, but was already implicit in fundholding in the 1980s and in ‘commissioning’ of services by the PCTs with GPs elected to their boards, as it is in the software that invites doctors to prescribe the cheapest medication, in the encouragement to refer to the least expensive hospitals, in the effort to standardise and reduce the number of referrals to hospital. And with the new reorganisation NHS organisations will no longer allowed to overspend – unlike the banks they will be allowed to fail, to go bankrupt – rationing will be tighter and tighter. Putting GPs in charge won’t make the choices any better; they will be determined by the resources the state allocates, not who is nominally responsible.
There is already a deterioration in services as a survey of 500 GPs showed (Guardian 19.4.11). 54% said waiting times had gone up for musculo-skeletal conditions with 30% seeing a restriction in orthopaedic services, 42% that waiting times had gone up for neurology. Three quarters noted cuts in fertility treatment, 70% in weight loss treatment – during an epidemic of obesity, and 40% noted restrictions in ophthalmology. Not surprisingly they are more likely to refer privately for those patients with insurance. And that is before the next £20bn savings are made!
At the moment there is a ‘pause’ in the Health and Social Care legislation, and a government ‘listening exercise’. This is an exercise in which the public has to listen to government PR, as when Cameron addressed various healthcare charities “Your organisations, which are hugely trusted and understood by the public and by users of your organisations, can help us make the argument that change, that choice, that diversity is not about privatisation, it's actually about improving healthcare” (www.politics.co.uk). It is likely that the consortia in charge of 60% of NHS spending with have slightly wider representation, but there is no chance whatsoever that the reorganisation will be put in question.
Privatisation = more state capitalism
Another aspect of the NHS reforms is the increase in the number of private companies involved in delivery of services, with the use of “any willing provider” instead of seeing the NHS organisations as preferred, even more private companies will come in. For many this is seen as an ideologically driven effort with the aim of “Handing the entire NHS budget across to the private sector …” (Dr Kambiz Boomla, East London GP, Socialist Worker 22/1/11). First of all we need to understand what the private sector offers the NHS, as an example of how state capitalism works. First of all we must never forget that the whole point is to drive down costs, and in the long term, because there is an economic crisis. The aim of bringing in more competitors is to get cheaper services, as it was with competitive tendering for ancillary services back in the 1980s, as it was with the internal market. Cheaper services, as always, on the back of increased exploitation of the workers in them.
Introducing more private companies also has added benefits when pay and working conditions are being attacked and services cut. On the one hand the private business can take the blame rather than the NHS or the government. On the other, when workers struggle to defend themselves the law and the unions will tell them to confine their action to those who have the same employer – for instance a particular private provider – and this will be even worse if pay and conditions starts to vary between various providers.
Dr Boomla goes on to say “it will fundamentally undermine the founding principles of the NHS”. This is not so. The fact of a two tier health service was never even put in question by the NHS as those who could afford it have always been able to buy themselves prompter treatment in better surroundings with better staffing ratios. And these days that includes those who cannot afford private treatment here, but can find the money for cataract surgery in India. If you visit a dentist in Eastern Europe it is cheaper than on the NHS – many do.
The NHS has never excluded private businesses at any time since it was founded in 1948. GPs have always remained ‘independent contractors’ with a local franchise, as did pharmacies. Larger private enterprises have made money through interest on bank loans, selling drugs, building hospitals etc. What has changed with the need to reduce costs is not just the increase in exploitation of staff, but the fact that less of them are directly employed by NHS bodies and there is more internal competition. This isn’t weakening state control but strengthening it – through better control of budgets; through better integration of the NHS and private healthcare providers into the bureaucracy as the directors of the various companies sit on the boards of the trusts and consortia; ever tighter control of what healthcare can be offered.
We need healthcare, but that doesn’t mean we have to defend the NHS or its mythical ‘founding principles’. On the contrary, to defend our hospitals, our health, our jobs or our conditions, means to come up against one of the many heads of the NHS hydra, and through it, the capitalist state.