Reports of the state of collapse of the NHS have become routine, indeed daily, fare over the past few months. Soaring waiting lists; ever-increasing ambulance and A&E wait times; the appalling state of mental health services, especially those for children; the impact of utterly inadequate social care services on the NHS; the lies that are routinely told about levels of NHS funding, of new funding, of extra funding beyond new funding, of targeted funding in addition to the extra funding, and the constantly recycled deceit that there are 40 new hospitals in the pipeline for completion by 2030, a number expanded more recently to an equally fictitious 48. A new book, NHS under siege, sets out what has happened over the last 12 years to bring about this state of affairs.
Beyond the contributions of the two editors, the book includes more than a dozen essays from clinicians and trade unionists detailing the destruction that has been inflicted on the NHS since 2010 – the impact of the pandemic on an already threadbare service, the abandonment of proper staff planning and its consequences, for instance for primary care services. The editors themselves, Lister in particular, provide much-needed detail on how the NHS has been driven into the ground by real-term cuts in funding despite all the smoke and mirrors deployed by a government determined to hoodwink us into believing the contrary. In reality, everything the government claimed and continues to claim about increased NHS funding is just lies.
Lister provides a detailed account of how the nominal increases in funding from 2010 were eroded by the need to deal with deepening hospital deficits, which were in turn the consequence of trying to meet increasing need without concomitant finance. ‘Extra’ funding was constantly needed because what had preceded its announcement was never enough; the government also on at least one occasion used the trick of rebadging old money as new when Boris Johnson, on becoming prime minister, ‘announced’ additional funding which had already been promised by Theresa May in the dying weeks of her premiership. It was under Johnson that the mendacity of the government was to reach a staggering new level with his promise of funding for 40 new hospitals in summer 2019 (p 37). The details revealed that only three of these were actually new hospitals: the overwhelming majority were either extensive refurbishments of existing buildings or departmental additions to them. In October 2020, the number was increased to 48 – but they included those which had been under construction for some years, for instance, the Royal Liverpool Hospital (started 2014, and delayed by the collapse of Carillon and then by the need to rectify faulty construction). By the time the pandemic arrived, 9,000 (approximately 9%) hospital beds had been closed, and 22% of those in mental health services as well; waiting lists had soared from two million to 4.5 million (p38).
Yet the book has a critical weakness when it comes to meeting its declared aim, to ‘inform and strengthen the fight for the NHS’. Nowhere does it ask: is the continued existence of a state-funded health service free for all at the point of use compatible with a capitalist system in profound and deepening crisis? Yet this is surely the key question. The book is associated with the campaigning website SOS NHS (see pp6-7). This presents three demands: two are for emergency funding of £20bn for the forthcoming winter, and to pay staff properly. The need for these cannot be disputed. The third one, however, is for government to ‘invest in a fully publicly-owned NHS and guarantee free healthcare for future generations’. There is no indication as to how this might be achieved, especially since it has proved impossible over the decades of the NHS’s existence, and the book does not help at all.
The conundrum is that such a guarantee is necessary for the working class – and yet also clearly impossible, and the book ducks any answer. This leaves it bereft of substantial ideas for the campaigning work it says it wants to enable. Thus the chapter ‘Fighting back – a long, honourable tradition’ (pp183-194) lists past campaigns and existing campaigning organisations together with their publications, but in the end just exhorts the reader to ‘act on the words attributed to its founder Aneurin Bevan: “The NHS will last as long as there are folk left with faith to fight for it”.’ The final chapter, ‘No peace of mind, just a lot of worry for us all’ (pp276-281) by the normally astute commentator Roy Lilley is as pessimistic as its title.
To address the conundrum we have to go back to basics. A nationalised health service is the cheapest and most efficient way of meeting the health needs of the working class under capitalism as it does not have to be profitable. So the ruling class is not opposed to the NHS as such: it simply regards its level of health care provision as too generous for the working class. And although it seems that the working class pays for the NHS through taxation, in fact the worker never sees this money nor has any choice about its deduction. Such state expenditure is in fact financed through part of the surplus value extorted by the ruling class. Taxation is merely the means by which this transfer to the state takes place. Such a transfer of course reduces the surplus value or profit available for profitable capital accumulation – and in conditions of capitalist crisis the ruling class will not tolerate it. Furthermore, since most of state health care is directed towards the maintenance of those who do not produce profit for the capitalists because they are disabled or retired, there is an added reason for the ruling class to cut it back.
NHS and state welfare
The post-World War Two establishment of state welfare services, including the NHS, was born out of political necessity. The British ruling class needed social stability to allow it room to reconstruct the imperialist world order. It could not afford a repetition of the massive working class unrest that followed the First Imperialist War, fuelled as it was by the victory of the Russian Revolution in 1917. The 1945 Labour government, therefore, sought to head off possible political turmoil by directing a massive increase in state economic intervention. Part of this involved the establishment of central government control over local authority and voluntary hospitals to create a national health service. Yet it was set up as an illness service: ‘a lopsided system’ where ‘curative, hospital-based medicine dominated at the expense of prevention, health promotion and community services, and high priority was given to the treatment of short-term episodes of acute illness to the care and rehabilitation of the chronically ill.’ (Wendy Renade, A future for the NHS?, p9). The profitable conditions of the post-war boom meant that the ruling class was prepared to fund services of which the working class was a major beneficiary. However, the advent of crisis conditions in the 1970s heralded five decades and more of ceaseless NHS reorganisation to try and contain expenditure; increasingly costs were passed on to the working class through rising prescription charges, restriction of NHS dental services, and payments for long-term social care.
The depth of the crisis today, compounded as it has been by the pandemic and now by the spiralling cost of energy, has set absolute limits on future NHS expenditure. There can be no guarantee of free health care
for future generations – under capitalism, that is. To suggest otherwise would be to believe that the antagonism between exploiter and exploited can be suspended or even abolished. And that is the impasse that the contributors to NHS under siege and its editors find themselves in: they want a decent NHS, but they don’t want to upend the capitalist system. Yet the state of the NHS gives the most powerful argument for socialism – a genuine welfare state. And there is of course the example to prove this: Cuba.
Lister himself has previously applauded the achievements of the Cuban health care system (John Lister: Health policy reform – Driving the wrong way?, 2005, pp258-60), in particular its refusal to accept any of the neo-liberal nostrums imposed by the World Bank and IMF on the health systems of most of the rest of the world. He highlights the Cuban emphasis on public health and primary care with the family doctor system; its massive clinician training programme; the development of its biotechnology industry and the success it has had in developing vaccines for meningitis and hepatitis B as well as anti-retroviral drugs; its international health brigades and the medical training programme for students from underdeveloped countries, then in its infancy. He also notes that the system and the consequent gains in health survived the collapse of the socialist bloc, in particular that health care spending grew by 59% between 1994 and 2000 (that is, during the Special Period of economic crisis). He concludes both that ‘Cuba’s leadership has not responded to economic pressures by reversing previously progressive health care policies, by wholesale privatisation and market-style measures, or by cutbacks and closures in public provision’ (ibid p259), and that ‘it is the combination of high-tech, hospital and primary care that has laid a firm foundation for health improvement’ (p260). Nor does he ignore the fact that Cuba has achieved all this despite the US economic blockade – yet he does not give any view as to why and how Cuba has achieved all this, and in particular he does not acknowledge that it is because it has a completely different social system.
Lister and Davis’s NHS under siege demonstrates how an absence of a theoretical understanding of the capitalist system leads to idealist conclusions. Since it offers no contradictory statement, the reader has to assume that the problems of the NHS can be resolved within capitalism, presumably with sufficient determined struggle. Yet equally it is evident that the experience of the last 12 years tells us that this is an impossibility. Lister, Davis, SOS-NHS et al separate the defence of the NHS deliberately from the struggle for socialism. This is the ideological essence of opportunism. In their view, socialism is not on the agenda: the ‘broad forces’ they would argue that are needed for their campaigns either reject socialism or do not understand it. It is therefore unrealistic, indeed idealist, to raise the issue; instead, NHS campaigners have to be hard-headed and practical, keeping their demands ‘moderate’ and ‘sensible’. Yet there is nothing moderate or sensible in promoting the idea that a health service which meets the needs of the working class can be guaranteed under capitalism, or that it should be fought for on those terms – it is a delusion. Being hard headed and practical today means presenting the current and future state of the NHS as convincing evidence for the immediate need for socialism.
Robert Clough
■ NHS under siege – the fight to save it in the age of Covid
Ed. John Lister and Jacky Davis,
Merlin Press 2022, 90pp, £9.99
Fight Racism! Fight Imperialism! No 290, October/November 2022
