“The transcendental authority of England is its people”. A people’s Health Service demands new beginnings. In the light of bitter opposition to Tory plans for the NHS, isn’t it time to look at a co-operative model as an alternative?
Those who work within the NHS should be able to manage GP surgeries, hospitals, research and educational units – indeed all areas of the health and care system within an employee-managed network based on co-operation.Co-operation, of course, already exists in the operating theatre, where a team works with dedicated co-ordination as part of a normal work process. And it’s to be found in other areas of the NHS but the trouble begins when its members step outside this co-ordinating framework to become, respectively, members of the ruling, middle or working class.
Surgeons rule their team of doctors as did boyars of old Russia. At various stages of expertise, doctors are dependent on the goodwill of the “Mister” and seek a favourable nod from the next consultant in order to improve skills and gain a higher rate of pay and position for those in his/her team. As for non-medics, they take their chances with their own managers. But here wages and conditions are more directly obtained via union/ NHS negotiations.
Nor does the power of the “Mister” end with determining the fate of junior doctors. It stretches far wider – to “chummy” relations with members of the boards of governers, Carlton Club meetings, stately homes and ties through marriage, or public school. Such factors help to determine the way that the NHS proceeds on its pastoral care of the needy in our society.
This unique structure came about as a result of Nye Bevan’s necessary compromise, made to win support for getting a universal and all embracing health system as a going concern.
If it is thought that the mighty changes introduced into healing the sick by Nye Bevan trimmed their power, let them think again. It elevated them to a new and commanding height in the British economy, culture and society. Put a leading surgeon in charge of a reform within the NHS and the outcome is geared to shifting the chairs around to provide a more comfortable position for a capitalist government to claim that changes that worsen middle and working people’s welfare are changes for the better.
The Guillibaud Report
Following the victory of Bevan’s view that a National Health system paid from taxation was superior to health provision from private insurance companies came the Guilleband Report of 1956. This had been set up by an alarmed Conservative government, certain that the NHS was ruinously expensive and a threat to financial stability. It decided that a Commission would confirm this threat, and allow them to disband this collectivist, heretical body before it did more damage to capitalistic individualism.
Conservative disappointment was huge when it reported that contrary to media scare stories, the NHS was not a strain on resources – and, indeed items previously dropped from the free provision introduced in 1948 (free prescriptions, dental and ophthalmic services) could be re-introduced without straining resources.
Guillebaud’s other discovery was that the NHS’s percentage of the GDP was hardly different from that in pre-war Britain – some three per cent. The reason? Before the war, those working on low wages could obtain sick and other benefits from National Insurance. But wives and children were excluded, as were employees on higher salaries. As a result, a galaxy of private insurance companies gained weekly payments to cover the cost of sickness, death, etc., with many GPs running a collecting system to pay for the treatment of wives and children.
Shortly after the NHS and other social benefits were launched, most health insurance companies dried up. Only a few survived, catering mainly for the rich. The majority of citizens followed the consensus that there was no point in paying twice for something that was provided for out of general taxation. And the ragged assembly of government asylums, local authority maternity, fever, cottage and voluntary hospitals were brought together along with GPs’ surgeries (held in shops, spare rooms or wherever). They were assembled into a more logical structure to meet the needs of the population. The NHS began to become a landmark institution, respected for its coverage of all – including visitors from abroad who needed medical attention whilst they were here. It was particularly respected for its GP coverage and for arranging for hospital check-ups or admittance, which collectively covered the whole of the country – even isolated islands and hamlets.
A DIFFERENT DOGMA:
But there was still an inherent dogma amongst Treasury officials and their political heads that only a ruling class drawn from an aristocracy or well-heeled business professionals had the know-how to run the country. But somehow this aberration had slipped in. It was true that many industries had been nationalised by the 1945 Labour Government. But these were commercial bodies, clapped out after the war and without investment in new technology. These needed Government cash to fatten them up to become competitive again. Conservative opposition was at the time largely cosmetic, designed to keep the class struggle burning in the breasts of their local activists. Whilst the workforce in the newly nationalised industries may have had ideas that it allowed them to share control of management, the 1945 Government soon scotched that notion, and the existing management carried on almost as before. Meanwhile, with every family in contact with their local GPs, the NHS became as integral to people’s lives as the local grocers’ shop. One supplied food, the other health – the difference being that one required payment for goods whilst the other came free.
AND A NEW ETHIC:
Changes in organisation, and the steady, if slow, improvement in hospital provision and employees’ working conditions, with shorter hours, better pay, holidays, pensions. etc., added to the moral uplift of serving the sick and needy. The medics’ Hippocratic Oath to “do no harm” began to pervade the entire fabric of NHS service. An exceptional example of this was the response by junior doctors in the mid-1960s to like-minded Canadian colleagues locked in struggle in the province of Saskatchewan. Local GPs were boycotting attempts by the Co-operative Commonwealth Federation government in the province to bring in a health care system similar to the UK’s NHS. Doctors from Britain moved into the province and helped to ensure that the new system wasn’t stillborn. The CCF government won, and now Canada’s health care system is much closer to ours than that in the USA.
By the 1960s/’70s, “Butskellism” had produced a balance in Parliament and elsewhere which allowed consensus management to emerge within the NHS. It found its best expression in the joint teams formed to work with NHS Estates on the design and building of new hospitals, making up for the loss caused by Treasury niggardliness. More facilities for training doctors, nurses and other staff were also provided. However, by this time it was clear that the NHS was falling behind Europe. Not in the coverage of all its population, in which Britain had a clear lead, but in the provision of health infrastructure and facilities – modern hospitals, convalescent homes and other after-acute-care treatment. The Treasury and Exchequer’s response to criticism was to point to Government spending which was on a par with other countries – implying that our problem was one of staff productivity.
A BREAK IN THE CONSENSUS:
The philosophy of consensus and its practice of mutual working within the NHS broke down as a result of Barbara Castle’s attempt when Health Minister in the mid-1970s to introduce a new programme to bring less privileged areas of the Health Service up to a higher standard via a Resources Working Party. This meant taking out of the system the bed spaces used by consultants for their private patients.
Even in times of need, consultants had kept beds empty to meet anticipated private patient demand. In 1975 rank and file staff revolted and refused to service these beds at the new Charing Cross Hospital at Hammersmith. Barbara Castle recognised the cause of the problem, and used it to support getting pay beds out of the system. Temporarily the strikers won, but the outraged private sector phalanx who were using NHS facilities for treating cash paying patients, or those from BUPA and other insurance companies, mobilised to defeat Castle. Callaghan, who had replaced Harold Wilson as Prime Minister, capitulated to the consultants. They could now place private patients wherever in NHS hospitals. And Barbara Castle was sacked.
THATCHER ON THE ATTACK:
Carlton Club type debates involving privatising consultants, Thatcher-minded politicians and BUPA prepared the ground for Thatcher’s campaign to Americanise Britain’s National Health Service – ignoring advice from Norman Fowler (her longest serving Health Secretary) to leave well alone. The system was working, and covered the entire population. Thatcher followed simple grocer shop economics. She saw every pound not in her father’s till but spent by local authorities and governments on public welfare as an infringement of the principle that just as her father paid for all living expenses and welfare benefits out of the labour and enterprise of running his shop, so should every customer pay for their welfare out of their wages. This soon became lifted to a code of conduct which attributed all deficiencies in society to money spent on social welfare. If this expenditure ceased then all would be well with Britain – and soon with the world, when we joined the Thatcher/Reagan axis. This was elevated to become a core strategy for privatising the NHS. It took the form of introducing managers from commercial companies, to break the “chummy” culture and end the improved consensus-working of NHS staff. This would be replaced by units of managers on fixed term contracts and quantitative goals to meet. Financially, there was a need to increase the NHS budget because of technical improvements and a growing population with an increasing life expectancy. And as people aged, their demands on hospital beds increased. Thatcher’s answer was to transfer the problem to local authorities under the rubric of “Care in the Community”, without providing or ring fencing the necessary money.
Then a whole barrage of financial instruments were introduced into hospital budgeting to cover claims that hospitals were inefficiently run or too costly to manage. During the 1990s Inland Revenue valuers were instructed to add an additional six per cent to the rateable value of NHS buildings. They also had to assess land at market valuations based on maximum values. Adding the Private Finance Initiative to all the Thatcher-style financial juggling, and then factoring in the costs of the paperwork for running an internal market between each section of the NHS, and the result were about £20 billion – almost a fifth of the annual cost of the NHS.
NEW LABOUR – AND CAMERON’S HEALTH & SOCIAL CARE BILL:
New Labour carried on with this process of privatising the NHS from its election in 1997 to its defeat by Cameron’s Conservatives in 2010. Now they, through the Health and Social Care Bill, which is now completing its passage through Parliament, are the final stages of breaking up the integrated health system into fragments suitable for capitalist concerns to acquire and operate as profit making enterprises.
Among the policies being put forward in the Bill is that of letting loose the “bug” of greed amongst GPs in former partnership arrangements., who will now find themselves part of business enterprises with the salaries of individual doctors in a particular surgery now going as a lump sum to a “principle” who will allocate as he/she sees fit to junior doctors, and then pocket the remainder. Within this new “profit” environment GPs (who will be transferred from small practices into large consortiums) will have the strain of competing amongst themselves for position, as well as competing against other consortia fighting for patients to meet “bottom line” situations controlled by entrepreneurial managers and CEOs.
GOODBYE TO YOUR NEIGHBOURHOOD GP:
The new structure will be going into place within the first phase of closing down Primary Care Trusts. A third of the NHS budget will be handed over to the new commissions which will control GPs, and this is scheduled to be completed by mid 2012. Preparations will be undertaken to have all GPs in their allotted consortiums by April 2013. Thus the neighbourhood GP service – the bedrock which collectively links patients with the common benefits of a unified National Health Service – comes to an end.
RESCUE PLAN:
To rescue the NHS from the privateers, we will have to pick up on the programme attempted by Aneurin Bevan and which Barbara Castle also took on board – ie, to end private beds in NHS hospitals, provide neighbourhood health centres (modelled on that launched in Peckham), and create a new Resources Working Party to provide a levelling up of all NHS facilities, thus transforming an “only go when you are sick” approach into a “keep healthy and cure sickness” service Thus, there should be:
No financial juggling, such as Public Sector Dividend, or six per cent valuation upgrade
No valuing of land at market rent levels but at permitted planning use
No “engineering” of pensions to place a false burden on NHS books
No private beds within the NHS – and no facilities for private practice by NHS staff.
There should be provision for:
Recovery hospitals for patients discharged from acute or specialist hospitals but not yet fit for home nursing.
Convalescent homes for patients requiring recuperative treatment.
Neighbourhood nursing homes for long-term sickness.
Care housing and homes, and day centres as appropriate to needs.
The transfer to the National Debt of all Private Finance Initiative costs.
A review of the Peckham Experiment and its philosophy.
“Peckhams” have in-house facilities, such as swimming pool, gymnasium, sports facilities and wellbeing – as neighbourhood community centres which link people as neighbours, families, children, etc.
A SEA-CHANGE NEEDED:
Implementing all these suggestions requires a sea-change in English politics, which would embrace its patient population in its entirety.
Patients should elect a neighbourhood forum to provide patient intervention teams, to ensure that their neighbourhood GPs continue to provide street or village coverage. Forums from neighbourhoods should be elected to ensure that Primary Care Trusts continue and co-ordinate NHS facilities within their area. Where these have been disbanded, these neighbourhood forums should establish “shadow trusts”, to intervene to ensure the continuation of area health provision.
Crucial to the success of patients organised in such forums will be the support of NHS staff. These should move from being subservient employees of CEOs engaged in the privatisation of the service at the diktat of a Conservative Prime Minister to the establishment of a directly democratic structure in which each employee has an equal say and vote – a co-operative form of employee self-management.
THE SANCTION OF THE PEOPLE:
To bring about such changes we also need to gain the sanction of England’s people. In 1948 93.1 per cent of the population registered as patients under the NHS. As the transcendental authority of England is its people (above a Parliament of divided political parties), a referendum should be held in each Parliamentary constituency to gain the approval of such a programme. This should then be put to a free vote in Parliament. Thus voters, as patients, as neighbours and as people, could express their verdict.
ALAN SPENCE lives in Central London, and is chair of the Bury Place Residents’ Association,Camden. He is a keen supporter of the co-operative movement – and like many of us, has first-hand experience of the NHS!