The NHS: from social reform to corporate takeover
The National Health Service (NHS) is seen as the greatest reform won by the working class in Britain. Seventy years on from its establishment by the Labour government that came to power in the immediate post WW2 period it still enjoys unprecedented levels of public support. It was such affection that prompted the infamous comment by former Conservative chancellor Nigel Lawson that “the NHS is the closest thing the English people have to a religion”.
However it would be complacence
to assume that continued public support for the principles that underpinned
the NHS mean that it is operating according to those principles or that
it is the same institution it was in the past. The health service
is not separate from society and how it has developed, from its creation
to the present day, mirrors the economic and political changes that have
taken place over that period. We live in a capitalist society that
has class as its defining characteristic and in which class struggle -
the relative power of labour and capital, of workers and bosses - is this
most important factor in shaping that society.
This can been seen very clearly in relation to the development of health services in Britain. Prior to the emergence of mass trade unionism and a mass working class party in the early 20th century the concept of public provision of health care barely registered. Health care was the preserve of the rich and what provision did exist for the poor was largely left to charities and religions orders. It was workers organising around their own demands for improvements that first brought about action at a government level in the form of the National Insurance Act of 1911.
Further steps towards a comprehensive health care system came in the early 1940s. These were partly due to the demands of war. A response to injuries to the civilian population as a result of aerial bombardment was the creation of the Emergency Medical Service which saw aspects of health care planned on a national basis for the first time. However, there also plans being developed for the establishment of a welfare state in the post war period. The most significant of these was the report written up by William Beveridge in 1942. In relation to health it called for “a health service providing full preventative and curative treatment to every kind of citizen... without an economic barrier at any point.”
It is the case that sections of the British ruling class did favour reform but it certainly wasn’t universal. Prime Minister Winston Churchill claimed that such plans were unaffordable while the director of the Confederation of British Employers complained that: "We did not start this war with Germany in order to improve our social services." Other figures took the view that reform was necessary to prevent something worse from their perspective. In a parliamentary debate on Beveridge report the Tory MP Quintin Hogg warned that: "If you do not give the people social reform, they are going to give you social revolution."
Whatever the views of the representatives of capital there was certainly a recognition of a desire for change amongst the working class that required a response. Another element in this was the existence of the Soviet Union, which had gained prestige on the international stage, and to which many workers looked as a socialist alternative to capitalism.
In the general election of 1945 the Labour Party won a landslide victory for its programme of social democratic reforms of which the creation of a national health service was a central plank. Aneurin Bevan, a former Welsh miner and leader of the Labour left, was appointed health minister. The initial plan he brought forward for a national health service had a number of components – the nationalising hospital services with free access; planning at regional level; registering everyone with a General Practitioner; making dentistry freely available; providing free eye examinations and glasses; and making prescription medicines free. The money for this was to come from central government, raised through general taxation.
Bevan’s plan faced opposition.
In parliament the Conservative Party voted against the bill to create the
NHS no less than 21 times. There was also opposition from charities,
churches and local authorities who didn't want the government taking control
of hospitals. The fiercest opposition of all came from the medical
profession who feared a loss of privilege and income. One former
chairman of the BMA even compared plans for a national health service to
In the face of this opposition the Labour government made significant concession. NHS consultants could continue private practice with private beds in NHS hospitals; GPs and dentists remained self-employed, contracting to provide services to the NHS. These private elements were built into the NHS from the start. Pharmaceutical, medical supply and hospital construction industries were also left in private hands, enabling them to extract massive profits from the public sector.
This failure to challenge property relations means that the NHS, even in its heyday, cannot be described as socialist. It was a reform within capitalism. However, it was a genuine reform that contributed to better conditions for the working class. In the post WW2 period the welfare state - alongside an expanding economy - saw rising living standards and greatly improved health. Better nutrition and housing, vaccination programmes and antibiotics cut the scourge of childhood and maternal deaths. Previously untreatable conditions became treatable with new drugs, kidney machines and transplants, joint replacements, chemotherapy, radiotherapy and many more.
Yet this “golden age” of capitalism was not to last and as profits fell and the economy stagnated in the 1970’s the foundations of the post WW2 settlement came under attack. There was a ferocious assault on organised labour and public services. The NHS experienced a funding squeeze; waiting lists grew with many patients forced to go private; and services like cleaning and catering went out to private contractors. There was also restructuring with hospitals taken out of the control of district health authorities and run by trusts. An ‘internal market’ was established, with parts of the NHS purchasing services and other parts providing them. Competition increasingly replaced co-operation. Another feature of attempts to introduce commercial practices to the health service was a significant increase in administrative costs.
This assault on the NHS has continued over the past twenty years. Under the New Labour government of Tony Blair and Gordon Brown privatisation of the health service accelerated rapidly. This saw the creation of Foundation hospitals which are run like independent businesses, competing for ‘customers’ (patients) against other parts of the health market. Operations on NHS patients went to Independent Sector Treatment Centres, which were run by private companies. Hospital construction became totally dependent on the Private Finance Initiative (PFI) under which new hospitals belong to private companies, which hire them back to the NHS with guaranteed profits for 30 years or more.
Under New Labour spending on the health service eventually doubled but a greater and greater portion of this was going to private, profit-making corporations. Their whole policy revolved around making the health service a more attractive proposition for private investors. This demonstrates why it is not enough to simply call for more funding for NHS without saying where it should go of how it should be used.
The privatisation drive has continued under the current Conservative led government. It introduced the the Health and Social Care Act that requires all contracts for NHS funded work to go out to tender. The NHS has also been forced to make £20 billion of ‘efficiency’ savings involving cuts to both staff wages and to patient care.
Under successive governments the welfare reforms of the past are being rolled back. This is wholly bound up with the crises of capitalism and the accompanying retreats of the trade union and socialist movements. The offensive will only cease when it meets opposition from a revived and determined workers movement.
Health care provision in Ireland has been, and continues to be, underdeveloped. As a consequence of the country’s domination by imperialism, and also of the weakness of its labour and socialist movements, the potential for social democratic reforms is greatly reduced.
Since partition health and social care in the south has largely been under the control of the Catholic Church. This was partly a result of the limited resources available to the state but also of a conservative counter-revolution that empowered the Church as a bulwark of the social and political status quo.
The consequences of a health and social system in which religious dogma prevailed were horrendous - particularly for women. We need only think of the scandals of Mother and Baby Homes, Magdalene Laundries or the brutal symphysiotomy procedures (in which women in childbirth had their pelvic joints severed). However, it would be wrong to think that such horrors are confined to the past. The case of Savita Halappanavar - who died after being denied an abortion - was only six years ago.
Even today after so many abuses have been brought to public attention, and even after the successful Repeal the 8th campaign, the Catholic Church still retains its privileged position in the health and social care sector. To advance on the issue of women’s health - never mind on the broader failings of the southern health service - this needs to be challenged.
In the northern state there is the NHS which is - in some respects - better than the system that exists in the south. However, it is important to note that was not a result of organic reform within the north. Rather it was a by-product of polices introduced at Westminster. Indeed, the reactionary nature of the Stormont government saw it initially oppose the extension of the welfare state to Northern Ireland.
The dependent relationship between the northern state and Britain has seen the health and social care system follow closely the policies pursed by governments at Westminster. Over the past thirty years this has seen the adoption of all the policies directed towards privatisation - from outsourcing to private financing. This has taken place in both periods of direct rule and devolution. The most recent version of Stormont pushed the privatisation agenda hard - outsourcing more procedures to private companies, taking on more PFI liabilities and proposing major restructuring. This agenda has remained constant irrespective of what party has been in charge of the Department of Health.
The one area where the north does depart from Britain is in the area of abortion. With an almost a total ban it probably has the most restrictive regime in Europe. During the recent period of devolution it become even more restrictive when the DUP health minister Edwin Poots altered the guidelines to deny abortions in cases of fatal foetal abnormality. This was accompanied by threats of draconian legal action against medical staff.
It is an often repeated claim, especially from trade union leaders, that the means to solve the problems within public services is a restoration of the Assembly and the Executive. However, the record of the devolved institutions on these issues is very poor. This is not just a case of the parties having the wrong polices that they could be persuaded to change. Fundamentally the existence of Stormont - which was made explicit in the Fresh Start Agreement - is now dependant on the continuation of austerity and the dismantling of the welfare state. Rather than offering a defence to workers the advocates of devolution are actually demanding more sacrifices.
As it stands the health service and the broader welfare state are in a poor state. The benefits of the reforms introduced in the past have been greatly diminished as the system becomes more subordinated to the demands of capitalism. If the current trends within the health sector continue the NHS will be reduced to a corporate logo. In these circumstances it is not enough to say defend the health service or call for more resources. To make a difference the dynamic of the class struggle in society has to change. This means workers pushing back against the capitalist offensive - organising in communities and workplaces and developing their own independent programme.