FEASIBLE SOCIALISM
Julian Tudor Hart MB BChir DCH FRCP FRCGP
The National Health Service, past, present & future
- Introduction
- Foreword
- PART 1 : THE PAST
- Origins of the National Health Service
- From all according to their ability, to all according to their need
- Underprovision and oversale
- Choking their mouths with power
- PART 2 : THE PRESENT
- Consumerism, science, and the language of production
- Consultations as units of production
- Primary care: potential wealth, actual poverty
- Managed competition
- Who cares?
- PART 3 : THE FUTURE
- Professional accountability: who to, what for?
- Purchasers, providers, and the future of clinical autonomy
- Participative democracy
- Feasible socialism
Introduction
Feasible Socialism provides an easily readable, referenced account of how the National Health Service (NHS) developed from 1948 to the market "reforms" of 1989, how it could resume progress as a democratised public service when Conservative rule is brought to an end, and how it could provide a practical core for development of a socialist economy, rooted in our own history and culture.
Despite being given free to the whole population according to need, by doctors and nurses with little idea of what anything cost, the NHS provided more cost-effective public service than any of its fee-paid or insurance-based international competitors. We discovered a cash-free economy which was both popular and effective.
In their attempt since 1989 to purge the NHS of these social elements, and force it into the mold of industrial commodity production, the Conservatives have shaken the service from top to bottom. Here and there this has created new opportunities for long-overdue innovation, but its more general effects have been to inflate management costs, demoralise much of the NHS workforce, and accelerate a socially irresponsible shift from continuing labour-intensive care, to episodic technology-intensive "cure". There is no evidence of any of the improved cost-effectiveness predicted by its promoters and apologists.
Now as never before, everyone who works in or uses the National Health Service needs to understand what is happening, how and where to change course. This book provides that understanding.
Foreword
The first aim of this book is to provide an easily readable, referenced account of how the National Health Service (NHS) developed from 1948 to the market "reforms" of 1989, and how it might resume progress as a democratised public service. A secondary aim is to convince a new generation of health workers, and others seriously concerned with the NHS, that they need to do more than merely hold good opinions. Something must be done, with urgency and intelligence, together with others who share your concern. The Socialist Health Association (formerly the Socialist Medical Association) was a great force in the past, and could be in the future, but this won't happen unless we understand the new world we live in, where it came from, and where we must go.
The book raises four fundamentally important issues.
- First, despite being given free to the whole population according to need, by doctors and nurses with scarcely a notion of what anything cost, the NHS provided more cost- effective public service than any of its fee-paid or insurance-based international competitors. We seemed, almost inadvertently, to have discovered a cash-free economy which was both popular and effective.
- Secondly, the attempt since 1989 to purge the NHS of these social elements, and force it into the mold of industrial commodity production, has shaken the service from top to bottom. Here and there this shaking-up has created new opportunities for long-overdue innovation, but its more general effects have been to inflate management costs, demoralise much of the NHS workforce, and accelerate a socially irresponsible shift from continuing labour-intensive care, to episodic technology-intensive "cure". There is no evidence of any of the improved cost-effectiveness predicted by its promoters and apologists, and every reason to believe that costs will continue to escalate.
- Thirdly, vesting all public responsibility for personal care in professionals effectively accountable to nobody, without which the NHS could probably not have been born in 1948, must now be recognised as having become a fundamental constraint on future progress. Accountability to appointed, unelected managers has been a disaster. Health workers must be accountable to someone; why not to the people they serve? A critical mass of both health professionals and the public are now ready for a new era in health care, the transformation of patients from an essentially passive status as consumers, to become active co-producers of health gain. This sometimes glib concept could become an extremely powerful idea if it were translated into specific, concrete, practical clinical terms. This would open up new perspectives for local participative democracy which could begin to undo the damage done to the NHS by aggressive managerialism, without returning to the complacent stagnation of unaccountable professionalism.
- Fourthly and finally, these conclusions suggest that when the NHS resumes its natural advance as a socialised, locally accountable public service, it may have more to teach Britain's disintegrating industrial base, than to learn from it. By suggesting new ways in which common ownership of the means of production, distribution and exchange might be realised, other than through centralised control in a bureaucratic state, Clause Four of the Labour Party's Constitution could become a means of escape from the idiot-logic of production for profit, rather than an embarrassing anachronism.
To keep the book short enough for a mass readership, many important topics have been dealt with summarily, or not at all. The most important of these is the pharmaceutical industry, and other for-profit industries supplying the NHS. This is such a large and important subject in its own right, and so long overdue for fundamental re-evaluation from a principled socialist standpoint, that it really requires another book in its own right. Further reading on most other topics is indicated in the references.
This book could not have appeared without the generous imagination of the National Council of the Socialist Health Association, particularly Doug Naysmith, Tony Jewell, Christine Hogg and Joy Mostyn. I am also grateful to my former partner Dr Brian Gibbons for encouragement, and critical reading of early drafts.
18 August 1994
This book is dedicated to the memory of Dr Hugh Faulkner, 1912-1994, chairman of the Medical Practitioners' Union, lifelong supporter of the SHA, and unacknowledged principal author of the 1966 general practitioners' Charter, the most (many might claim the only) successful reform of the NHS since 1948.
GLOSSARY
| ACUTE | Of sudden onset and short duration |
| ANTICIPATORY CARE | Continuing medical care in which health professionals not only attend to patients" wants but are also on the lookout for present and future needs |
| CAESAREAN SECTION | Delivery of a baby by cutting open the uterus. |
| CHOLECYSTECTOMY | Removal of the gallbladder |
| CHRONIC | Of slow onset and long duration |
| DAY-CASES | Patients admitted to hospital for treatment who return home the same day |
| ELECTIVE | Planned in advance |
| EMERGENCY ADMISSIONS | Admissions to hospital that are not planned in advance |
| ENDOSCOPY | Use of an endoscope, a flexible telescope that can be introduced either through a natural opening (such as the mouth or rectum). Popularly called "magic eye". |
| ENDOSCOPIC SURGERY | Surgical procedures accessing body cavities such as the chest or abdomen through an endoscope, causing smaller wounds, less internal disturbance, and allowing much shorter stays in hospital. Also called "keyhole", minimal access, or minimally invasive surgery. |
| EPISODIC CARE | Medical attention restricted to one single procedure or episode of illness (as opposed to continuing care) |
| HYSTERECTOMY | Removal of the uterus |
| IN-PATIENTS | Patients admitted to hospital who stay one or more nights |
| LOCAL MEDICAL COMMITTEE | A committee elected by family doctors to represent their interests to the Health Authority |
| MORTALITY | Death rate |
| OUT-PATIENTS | Patients seen at hospital but not admitted to a bed either as a day- case or as an in-patient |
| PRIMARY CARE | Medical and nursing care provided in the community from family doctors" surgeries or health centres, and other sources of health professional advice to which people have direct access, such as chemists, dentists, and opticians |
| REFERRAL | Temporary transfer of responsibility for a patient by one professional to another professional for specialist advice or a specialised procedure |
| SECONDARY CARE | Medical and nursing care provided in local hospitals (normally District General Hospitals) by referral from primary care |
| TERTIARY CARE | Medical and nursing care outside the usual range of a District General Hospital, normally by referral from a DGH specialist. Examples are neurosurgical units, burns units, renal (kidney) units, and thoracic surgery units for open heart operations and operations on the lungs |
ABBREVIATIONS
| BMA | British Medical Association |
| DGH | District General Hospital |
| GNP | Gross National Product |
| GP | General Practitioner |
| FHSA | Family Health Service Authority (formerly Executive Councils, then Family Practitioner Committees (FPCs) |
| HA | Health Authority |
| MPU | Medical Practitioners" Union |
| NHS | National Health Service |
| OECD | Organization for Economic & Cultural Development |
| QUANGO | QUasi Non Governmental Organisation |
| SHA | Socialist Health Association |