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    Summary

    The current National Health and Care System has shown the fact that a system can run on the basis of an ethic of altruism and public service, not profit.

    The hospitals have always held primacy in our system, and reorganisations have tried to rebalance the system in favour of community health and primary care.

    Public Health has been weakened by the 2012 Act and enjoyed more prominence during the period of Primary Care Trusts when it was integrated with Primary Care. This situation needs to be restored

    Health and Care need to be integrated regionally and the paper argues for Combined Authorities to be given overall control.

     

    No, the title was not a typo. There is more to healthcare than the NHS which we all know and love. Health Care includes Public Health, Social Care, Pharmacy and Dentistry, and they all need to work together. The present crisis has shown this. This is something which many experts in the field have acknowledged for years; doing something about it has proved elusive and difficult. This present crisis has shown not only the heroic dedication and commitment of the staff, but also the gaps and problems which need to be rectified, so perhaps this is the time to try and do it.

    In this paper I have tried to set out some sort of roadmap of the problems we need to tackle. That is why I have called the objective a National Health System, rather than the current NHS, but have preserved the iconic brand which is known all over the world. I once met mountaineers in a foreign land who praised the NHS.

    I am not an academic. I have taught about how the Health System works, but more practically I have been a councillor, worked for the NHS, served on a Clinical Commissioning Group and now Health Education England. I wrote a book about how the NHS should be organised with Sunderland University, and I will draw on bits of that in this paper, but my knowledge comes mainly from my practical experience. (“What Sort of NHS do We Want?”, Searching Finance, 2012)

    How we arrived at the present position

    There is much ignorance amongst the public as to how the NHS actually works. It is certainly very fragmented, but still able to respond as a national system, which has been shown by the present crisis. Many fondly think there was a “golden age” back in the 1950’s when the NHS was first established.  Aneurin Bevan boasted of a national system where the “sound of a bedpan dropped in Tredegar would reverberate around the Palace of Westminster”.

    We all know establishing the NHS was a political struggle and what emerged was a messy compromise. The immediate problem was sorting out hospitals which needed investment after the war. I can remember seeing pictures of my Grandmother, who was a hospital almoner, lining up the nurses to go out with the collection tins. Hospitals seem to have dominated ever since although they deal with a minority of the people who use the system. There are more patient contacts with GPs, carers, Public Health programmes ,  and Social Workers. Local Government had played an important role in health before 1948, and Directors of Public Health were important people. Much of what we would now call primary care was still run by local authorities up until the major reorganisation of 1974.  Strong central control was the way things worked in 1948, a legacy of the war – the NCB, British Railways, The National Grid and even the New Towns. The new NHS was no different.

    Initially Governments thought that a strong NHS would improve health and once the backlog of bad health had been dealt with, costs would reduce. This of course did not happen, so managing the NHS became a constant struggle between improving the service and keeping a lid on costs. In 1974 all health services came under Regional Health Authorities and this remained until the next major reorganisations at the end of Thatcher’s period in power. This was when the concept of the “market” was introduced into the NHS.

    At that time the model of the big top-down organisation was being challenged both in the public and private sphere. Although big organisations were still centrally controlled from the top, they wanted more flexibility locally to restructure and adapt to changing conditions at the bottom. Even the army now operates like this. The idea was that those who planned a service would commission it from who could provide it best. Commissioning meant what the service was going to be had to be evaluated and planned. The NHS had to think exactly want it wanted and the best, and most cost-effective way, of achieving it. This does not necessarily mean using the private sector. Other NHS and not for profit organisations are often involved. But it was never a free-for-all. The NHS was still in charge. Resulting from the Thatcher reforms there was a privatisation of many ancillary services such as cleaning, maintenance and catering. For clinical services there was still a preference to commission NHS and not for profit organisations. One consequence of these changes was that local authorities outsourced much of their social care provision, mainly for economic reasons.

    The Labour Governments after 1997 modified the model, introducing both Foundation Hospitals and Primary Care Trusts. In my opinion the PCTs were a very progressive reform, and one for which the Blair Governments, Frank Dobson and Alan Milburn received very little credit. They brought together Public and Community Health and allowed a high degree of local government involvement since they covered the same areas as local authorities and usually had councillors on their boards. Under the Blair Government resources were diverted to PCTS, and also prioritised deprived areas such as Easington in County Durham. There was a real push to reduce health inequalities. In my experience the PCTs also put a considerable amount of resource and effort into engaging with the public. In some ways this was a “golden age” for engagement, compared to the much less robust arrangements which replaced them.

    The Black Report in 1979 pointed out that despite large investment in the NHS, health inequalities persisted.  Professor Townsend, one of the main authors, mentioned Easington in a later report and visited Peterlee to explain his ideas. The dominance of the Hospitals in the system had led to a neglect of both social care and the promotion of health in the community. To reduce inequalities meant placing far more emphasis on how people lived, the conditions in which they lived and looking after them in the community when they were frail or unwell. Successive reports re-emphasised what the Black Report had said.

    The Primary Care Trusts were an attempt to redress the power balance with the hospitals. More resources were given to community and public health, which were now integrated. GPs had a major role. The PCTs were coterminous (horrible NHS word) with local authorities, and the Director of Public Health was now appointed jointly between the local authority and the PCT.  Cooperation was much easier. Many PCTs had councillors on their boards. The PCTs now had more power to negotiate with the hospitals to get better deals, and work with them. At this stage commissioning was mainly for other public sector and voluntary organisations. The NHS was the “preferred provider”.  The PCTs made considerable progress in improving public health, such as the reduction of smoking and teenage pregnancies, and set up many community initiatives.

    In my opinion the PCTs were a very progressive reform, and one for which the Blair Governments, Frank Dobson and Alan Milburn received very little credit. They brought together Public and Community Health and allowed a high degree of local government involvement since they covered the same areas as local authorities and usually had councillors on their boards. Under the Blair Government resources were diverted to PCTs, and deprived areas were prioritised. There was a real push to reduce health inequalities. In my experience the PCTs also put a considerable amount of resource and effort into engaging with the public. In some ways this was a “golden age” for engagement, compared to the much less robust arrangements which replaced them.

    I think I should make a few remarks about commissioning.  Many on the left regard it as synonymous with privatisation. This simply is not so.  As explained above the NHS is not monolithic and contains many different sections and specialities. Some of commissioning is straightforward – estimating the number of routine, predictable operations required in a year, like hip replacements. Then it is about negotiating the best deal with a provider.  But some is more complex, such as public and community health which requires constructing alliances between different organisations. Using a private provider is not a necessary part of this at all.

    All this was changed by the infamous Social Care Act of 2012 which established the Clinical Commissioning Groups. It compelled contracts to be put out for public tender, so private providers could apply, and often threatened to sue if they thought they had not been fairly considered.

    Councillors were not allowed to be involved, and their only oversight was through Scrutiny Committees. Public Health was handed back to local authorities. A strong national agency, Public Health England was created to exercise many of the responsibilities which PCTs had previously done including disaster planning and campaigns to reduce smoking and other habits deemed to be harmful to health. I will say more about the consequences of that later.

    The CCGs were a result of lobbying by a minority of GPs who wanted to commission directly without the NHS bureaucracy and pressure from private providers who wanted a bigger slice of the action. The Government thought they could use them to reduce costs. The whole enterprise was ill thought out and very disruptive. It is a useful lesson in the sort of “creative destruction” advocated by the likes of Dominic Cummings. The idea being that somehow once the bureaucratic shackles of the NHS and local government had been thrown off, GPs would somehow emerge as the heroes of the NHS and challenge the dominance of the Trusts. I can remember attending seminars before the new act was implemented where it was even advocated that two GPs could form a commissioning group. How they would work out the necessary plans and calculations was not thought about. I can remember a seminar about the changes entitled “Breaking Though”.

    In reality it was only a minority of GPs who wanted to run the NHS.  Most of them simply wanted to get on with their jobs which were demanding enough. Much of the pressure came from private providers, aided and abetted by members of the government anxious to reduce costs and eliminate, as they saw it, unnecessary bureaucracy.  Andrew Lansley, in many other ways a fairly level-headed man, seemed carried away by it all, and David Cameron and Nick Clegg did not really understand it. The only contribution by the Liberals was to ensure lay representation on the new CCGs. The reorganisation was described by one critic as “visible from space” and disrupted the NHS for several years.  Patterns of cooperation between agencies, carefully established over time were either disrupted or had to be carried on “under the radar” in the new competitive model. A new bureaucracy had to be established from the PCT staff to perform commissioning.

    One hospital (Hinchinbrooke) was taken over by a private company which could not cope and had to hand it back to the NHS.  Many private providers attempted to run the new 111 services, but now most of them are organised by Ambulance Trusts.

    The idea behind the 2012 Act was that there would be a free market. The CCGs would commission the most efficient service, public or private.  Collaboration, whether between hospitals and other parts of the NHS was not, in theory, allowed. Private providers could take the NHS to court if they thought the NHS had an unfair advantage. In practice, however, the national NHS kept a firm grip on things. There is always the need in the NHS to pool risk.  If there is an outbreak or crisis in one area the whole system has to pitch in.

    The 2012 Act led to an extremely costly and disruptive reorganisation. Many health professionals soon realised that it did not work. In reality the bureaucracy expanded, and much energy had to be expended negotiating between different parts of the NHS. The majority view was that if the NHS was going to cope, two things were necessary. Firstly, more resources needed to be directed to promoting good health, and thus reducing those diseases which were caused, or exacerbated, by a bad lifestyle, such as diabetes. Secondly an ageing population meant more people would need care in the community, rather than treatment in hospital. If they did not receive this care, then they would end up in hospital, as so called “bed blockers”.  Hopefully if policies to address these objectives could be put into place it would reduce unnecessary hospital admissions.

    Local health professionals have tried to negotiate arrangements for CCGs, Hospitals and Local Authorities to work together.  These were originally called Strategic Transformation Partnerships, abut have now morphed into Integrated Care Systems.

    Simon Stevens, Chief Executive of the NHS, said in the Five Year Forward View

    “The government will not impose how the NHS and local government deliver this. The ways local areas integrate will be different, and some parts of the country are already demonstrating different approaches, which reflect models the government supports, including: Accountable Care Organisations such as the one being formed in Northumberland, to create a single partnership responsible for meeting all health and social care needs; devolution deals with places such as Greater Manchester which is joining up health and social care across a large urban area; and Lead Commissioners such as the NHS in North East Lincolnshire which is spending all health and social care funding under a single local plan.”(Implementing the five Year Forward View 2017)

    More detailed plans for ICSs have been set out last year

    The NHS Long-Term Plan set the ambition that every part of the country should be an integrated care system by 2021. It encourages all organisations in each health and care system to join forces, so they are better able to improve the health of their populations and offer well-coordinated efficient services to those who need them.(The NHS, Designing Integrated Care Systems in England 2019)

    It is important to notice the word “Systems”. These ideas rely on different organisations working together. They do not pool budgets, and have no one accountable management, just committees who liaise.

    The trouble is all this is against the 2012 Act. Manchester eventually commissioned other NHS organisations to deliver its community health services, but was threatened with court cases from private providers. All that would have wasted a considerable amount of public money.

    The Conservative election manifesto recognised the system was not working in 2017 and proposed changes to the rules.  All this has since been forgotten about with the dominance of Brexit but will eventually have to be addressed.

    Some on the left see the ICS’ as some sort of conspiracy, implying that there is a secret plan to fragment the NHS and then sell off parts of it. Simon Stevens is often portrayed as being some sort of ogre who is using his American experience to somehow smuggle American health companies into this country.  Remember that health is largely organised on state lines in America, and the insurers who pay for much of it want single organisations whom they can work with. I think the reality is somewhat different. Many think Simon Stevens is a shrewd operator who managed to secure additional funding for the NHS.

    Ever since I have been involved with the NHS there have been efforts to join up health and social care at a community level, and to challenge the dominance of the hospital Trusts.  In the early 2000’s the former Sedgefield Borough Council worked with their Primary Care Trust and Durham County Council to effectively integrate services by putting social workers, district nurses and housing officers in the same room, and Easington PCT considered integrated care initiatives.  The Sedgefield initiative worked at a grassroots level because it did not involve redesigning systems.  As soon as you tried to set up a new structure people retreated into their bunkers.

    It is much easier to set up an integrated system in theory than in practice. One senior insider I spoke to recently said that negotiations to set up an integrated care system locally were not getting very far because of vested interests. Different organisations have different hierarchies and systems of accountability.  They are also keen to hang onto their budgets.  It looks like a solution will only be reached if the NHS imposes it, and they do not have much spare energy for that at the moment.

    I remember the days before local government was reorganised in Northumberland and Durham, and District and County Councils were merged into the present unitary ones. The Government asked councils to work out ways of working together. There were interminable liaison meetings between the different councils which got precisely nowhere, each one wanting to preserve its own interests. Eventually the Government imposed a solution.

    Insiders also tell me there is very little interest from councils in the new arrangements.  Although in practice working relationships between the local authority and the NHS in most areas are good, some councillors appear to prefer the scrutiny role than actually being responsible for the service.

    So overall I think the problem is not so much a conspiracy to carve up the NHS as some on the left seem to think, but rather getting our fragmented system to work together for the benefit of all of us.

     

    Where we are now

    Most people on the left believe in a publicly run health service, free at the point of use. They also value the dedication of the staff and think they should be better rewarded.

    Socialists also dislike privatisation.  There is a difference between having to use the private sector if nothing else is available and the obligation to put services out to tender regardless of whether they are functioning properly as happens now. Efforts to integrate services are also hampered if parts are privately owned, as private providers may not disclose their information and not cooperate. (I remember my efforts on the CCG to get Capita to produce its accounts to the Audit Committee for a service they provided.)

    Privatisation often results in poor staff conditions and pay.  I think nearly all Labour Party members would wish a future Labour Government to repeal the 2012 act and restore the NHS as the preferred provider.

    That is the easy part.  Now we get to the difficult issues of how we organise an integrated service in the future and ensure it is accountable. Let me stress now that I do not want another major reorganisation. Our NHS staff do not deserve that. Rather we must think about how what we have now can be made to work better.

    I have not said much about Social Care, either personal, which is delivered at home, or residential in care homes. It is widely accepted that the situation is at crisis point. The paper by Professor Paul Corrigan is an excellent starting point. A recent briefing by the Nuffield Trust emphasised the dimensions of it. (Nuffield Trust, Election Briefing Nov 2019.)  Here are a few statistics:

    We believe the scale of the workforce challenge has so far been underestimated: our new calculations show that just providing a basic package of care of one hour per day to older people with high needs would require approximately 50,000 additional home care workers now. To provide up to two hours would need around 90,000 extra workers. ( Then there is the question of where they would come from if Brexit is implemented)

     

    A decade of austerity has seen government funding for local authorities halve in real terms between 2010–11 and 2017–18,* which has led to councils tightening the eligibility criteria for care. It is known that there were 20,000 fewer older people receiving long-term social care services in 2017/18 than in 2015/16, but this is likely to understate the problem – estimates of unmet need go as high as 1.5 million.

    Constraints on public sector finances in recent years have meant that fees paid by councils to the organisations that provide home and residential care have been cut repeatedly. The predominant approach used for buying services from providers incentivises organisations to provide a bare minimum of services and nothing more. Some 75% of councils report that these organisations have either closed or handed back contracts in the last 6 months, creating enormous disruption and discontinuity for those receiving care.

    The problems of Care Homes have been highlighted by the current pandemic. There are roughly 11,300 care homes in the UK who look after 410,000 residents. Most of their income comes from fees paid by residents or their families, with a minority provided by local authorities.  In practice the private fees subsidise the public ones which are often insufficient to cover the costs of the residents. Sally Copley of the Alzheimers Society says “The whole system hasn’t been working properly for some time”.  Many staff are on zero hours contracts and staff shortages are endemic as Professor Corrigan pointed out. Staff are paid far less than they are worth and do not receive adequate training nor professional recognition.

    We all have formative experiences which make us socialists. One of mine was in a care home where a member of my family was a resident. I knew two married members of staff well. Both were dedicated to their work and the residents.  They were always cheerful.  I can remember them saying with great enthusiasm how they had saved up enough to take their young family to Great Yarmouth for a week in the summer.  Their work deserved far more reward than that. I though “something has to be done about this”.

    A proper care system would assess people on the basis of clinical need, not ability to pay.  At the moment there is continuing health care, provided by the NHS, which is free,  for those thought to have health issues, but domiciliary and residential care largely has to be paid for by the clients or their families except for the minority who benefit from a stringent means test. Dementia is not classified as a medical condition.  Many people feel this system is unfair. A senior commissioner I spoke to said she would rather commission “care” which would be provided by professionals trained by the NHS, rather than try and distinguish between continuing health care and social care.

    At the last election the Labour Party promised free personal care for those over 65, as in Scotland.  As the Nuffield Report points out this does not include assistance with cleaning and general supervision.

    One of the best assessments of the cost of integrating health and social care was done by Kate Barker and associates for the Kings Fund in 2014.  They looked carefully at what social care involves, and how it could be paid for. There are different levels of social care, and they conclude that the same principles should apply as to the NHS.  Afflictions can strike anyone, rich or poor, so care funding should come from the public purse. The costs of care and treatment should be publicly funded, although this might not include the actual “hotel charges” for residential care. The authors suggest various ways to raise the extra funding, such as means testing free TV licences, and requiring those (usually better off) who continue to work after the retirement age to pay national insurance.  There would of course be a need for those on higher incomes to pay more tax, possibly after the age of 40, and the Government should consider a wealth tax which in reality for most would be a tax on your home. There are various avoidance schemes and tax loopholes for the wealthy which could be closed.

    There would probably be agreement amongst socialists that health and social care should be integrated and paid for out of taxation, but it is no good thinking only the rich would have to pay.  Everyone would have to pay something.

    Finally, there is the issue of Public Health. Transferring it to local government has not been a success. The budget, supposedly ring fenced, has been diverted to other local government departments because of the squeeze on local authority finance, and last year some of the poorest authorities took a very big hit. Durham lost almost 40% of its public health funding. Yet even in its diminished state, The Centre for Health Economics at York has estimated that expenditure on Public Health is four times more effective in promoting health than that spent on the NHS. Simple common sense tells us that keeping people healthy is better than curing them once they are ill.

    Several distinguished epidemiologists, including Professor Allyson Pollock at Newcastle, have argued that the marginalisation of Public Health locally has severely reduced the country’s ability to deal with the coronavirus epidemic. Back in PCT days Public Health had the resources and plans to deal with disasters, often pooling risk with others.  Now that has been transferred to Public Health England, leaving local authority public health departments to deal mainly with schemes to keep people fit. Worthy enough, but nothing like the resources they used to have.   A regional public health response might have led to better testing and efforts to contain the virus. The Government’s response has been “one size fits all”. Restoration of the importance of Public Health and its reintegration with the NHS should be a major aim of policy.

     

    Policy Objectives

    Our policy objectives will be ambitious. We might need a five year, or even ten year forward view to coin a phrase.

    We seek an integrated National Health System, encompassing the National Health Service, Social Care, Public Health, with links to Pharmacy, which has a role in primary care, and Dentistry, which is not a totally public service although the NHS controls the training. But we do not want a major reorganisation again. Our dedicated health and care staff do not deserve that. What we want to do is give the present system more resources and steer it in the right direction. Repealing the 2012 Act would be a priority.

    We must ensure that particularly in social care staff are paid a decent wage and given proper access to training. The present system which relies on the minimum wage and zero-hour contracts must end.

    The first thing we know is that all this will cost more than it does now, although integration may produce some savings. A future Labour Government has to be honest about this. It is no good promising a few rich people will pay, as the public simply will not believe it. It is a good principle that everyone should contribute to something which is part of national solidarity, so all feel that it is theirs, but contributions have to be proportionate to the ability to pay.  A proper revaluation of properties, which is akin to a wealth tax, would raise money through the community charge to make a substantial contribution to social care.  An increase in National Insurance, earmarked for the NHS should be considered, provided that it became more progressive.

    Then we come to the whole issue of Governance.  Despite showing little enthusiasm, local government needs to be involved in the whole strategic planning of the NHS. But they must not see it as simply concerning their own territory, so to speak. The present structure of Foundation Trusts should stay, but Public Health and Commissioning Services should be reintegrated into Primary Care Trusts, in my opinion one of the most successful NHS organisations in its long history of restructuring. The PCTs would have oversight of Pharmacy and Dentistry. Many of the responsibilities transferred to Public Health England should be restored to the PCTs. Their boards should contain both professional and local government representation.

    There is a need for a regional dimension in all this.  When the Northumbria Trust reorganised its A&E provision to build a super emergency only hospital at Cramlington it did not consider the effect on major hospitals in Newcastle like the RVI. Patients in Hexham, for example would find it easier to go there than to Cramlington. This is just one example of where a regional perspective would have been useful.

    Local authorities’ power over social care providers need to be strengthened. At present there is a real mixture of providers, commercial companies, charities, cooperatives and individuals who provide personal care as a small business. There is a strong argument for integrating the private sector, which is virtually bankrupt anyway, into area trusts responsible to local authorities. Standards and remuneration need to be strengthened.

    Trying to merge different organisations would be very difficult and disruptive. The result could be some unwieldy bureaucracy which would be difficult to manage and slow to react to changing needs and priorities. Accountability should be pushed upwards. We need to have some sort of accountable umbrella which ensures that hospital trusts, PCTs (coterminous with local authorities) and Social Care, which is regulated by local authorities, all work together. There will always be oversight from NHS England, NHS Improvement, and the Care Quality Commission, but these bodies are mainly regulatory.  There needs to be a more local system of Governance and Oversight.

    Nationally the country is moving to a system of Combined Authorities which at present oversee economic development and transport.  Manchester has also had community health added to its powers. A combined authority does not take powers away from local authorities.It has power and oversight over services provided by other organisations. Its membership is delegated from existing councils, with a mayor if that is agreed. It would seem logical for a combined authority to exercise oversight over the Foundation Trusts, PCTs and Local Authority Care in its area and produce a plan to ensure they work together. The CCGs now cooperate to cover larger areas in any case. That way we preserve flexibility within the system without adding another layer of bureaucracy,and move towards the integrated National Health System we want.

    I want to end by stating that as socialists we owe a great deal to the NHS and Care Services. They are an example, much admired elsewhere, of how a publicly run system can be successful, and that duty and altruism more important motivators of human conduct as making a profit.  It is our duty to ensure it is funded and run properly.

    David Taylor-Gooby, author on the NHS and member of the Socialist Health Association

    May 2020
    1 Comment

    Jeremy Corbyn wrote a long letter to Boris Johnson on 31st March.
    As well as wishing him a speedy recovery, Jeremy made some strong points about aspects of the current crisis, and asked for immediate action on:

    • Full PPE now for Health and social Care workers
    • Test Test Test
    • Expand Social Care
    • Enforce Social-distancing and Protection
    • Bolster Support for Workers
    • Lead a Global Reponse

    (the 4  pages of the letter are attached)

    Posted by Jean Smith on behalf of SHA member Diane Jones.

    Leave a comment
    Unite national officer for health Colenzo Jarrett-Thorpe said: “At this time of national emergency caused by the coronavirus pandemic, it is right that the legal protections covering whistleblowers in the NHS are highlighted.
    “Unite, which has 100,000 members in the health service, will be monitoring the situation very closely in the weeks ahead and will give maximum support to any member who may face disciplinary procedures as a result of raising legitimate concerns, for example, the lack of personal protective equipment (PPE).
    “The current legislation protecting whistleblowers has been further underpinned by the NHS Staff Council statement of 28 February and the English Social Partnership Forum statement on 1 April.
    “Any NHS worker that suspects they are being victimised for whistleblowing should contact their ‘freedom to speak up’ guardian which every trust in England should have in place. If they are a union member, they should contact their workplace representative or local union office.
    “There have been anecdotal stories on social media that some NHS bosses may have been clamping down on those wishing to expose failings in the system and improve the well-being of patients. If we discover concrete evidence that this is happening, we will act immediately to support our members.”

    The NHS Staff Council statement of 28 February 2020

    https://www.nhsemployers.org/-/media/Employers/Documents/Pay-and-reward/NHS-Staff-Council—Guidance-for-Covid-19-Feb-20.pdf?la=en&hash=70C909DA995280B9FAE4BF6AF291F4340890445C&hash=70C909DA995280B9FAE4BF6AF291F4340890445C

    English Social Partnership Forum Joint Statement on Industrial relation – 1 April 2020

    https://www.socialpartnershipforum.org/media/166314/SPF-Covid-19-statement-final-and-formatted.pdf

    Protection for whistleblowers in the UK is provided under the Public Interest Disclosure Act 1998 (PIDA).The PIDA protects employees and workers who blow the whistle about wrongdoing.

    For more information please contact Unite senior communications officer Shaun Noble

    Email: shaun.noble@unitetheunion.org

    Twitter: @unitetheunion Facebook: unitetheunion1 Web: unitetheunion.org
    Unite is Britain and Ireland’s largest union with members working across all sectors of the economy. The general secretary is Len McCluskey.
    Leave a comment

    The Socialist Health Association (SHA) published its first Blog on the COVID-19 pandemic last week (Blog 1 – 17th March 2020). A lot has happened over the past week and we will address some of these developments using the lens of socialism and health.

    1. Global crisis

    This is a pandemic, which first showed its potential in Wuhan in China in early December 2019. The Chinese government were reluctant to disclose the SARS- like virus to the WHO and wider world to start with and we heard about the courageous whistle blower Dr Li Wenliang, an ophthalmologist in Wuhan, who was denounced and subsequently died from the virus. The Chinese government recognised the risk of a new SARS like virus and called in the WHO and announced the situation to the wider world on the 31st December 2019.

    The starter pistols went off in China and their neighbouring countries and the risk of a global pandemic was communicated worldwide. The WHO embedded expert staff in China to train staff, guide the control measures and validate findings. Dr Li Wenliang who had contracted the virus, sadly died in early February and has now been exonerated by the State. Thanks to the Chinese authorities and their clinical and public health staff we have been able to learn about their control measures and the clinical findings and outcomes in scientific publications. This is a major achievement for science and evidence for public health control measures but….

    Countries in the Far East had been sensitised by the original SARS-CoV outbreak, which originated in China in November 2002. The Chinese government at that time had been defensive and had not involved the WHO early enough or with sufficient openness. The virus spread to Hong Kong and then to many countries showing the ease of transmission particularly via air travel. The SARS pandemic was thankfully relatively limited leading to global spread but ‘only’ 8,000 confirmed cases and 774 deaths. This new Coronavirus COVID-19 has been met by robust public health control measures in South Korea, Taiwan, Hong Kong, Japan and Singapore. They have all shown that with early and extensive controls on travel, testing, isolating and quarantining that you can limit the spread and the subsequent toll on health services and fatalities. You will notice the widespread use of checkpoints where people are asked about contact with cases, any symptoms eg dry cough and then testing their temperature at arms length. All this is undertaken by non healthcare staff. Likely cases are referred on to diagnostic pods. In the West we do not seem to have put much focus on this at a population level – identifying possible cases, testing them and isolating positives.

    To look at the global data the WHO and the John Hopkins University websites are good. For a coherent analysis globally the Tomas Peoyu’s review  ‘Coronavirus: The Hammer and the dance’ is a good independent source as is the game changing Imperial College groups review paper for the UK Scientific Advisory Group for Emergencies (SAGE). This was published in full by the Observer newspaper on the 23rd March. That China, with a population of 1.4bn people, have controlled the epidemic with 81,000 cases and 3,260 deaths is an extraordinary achievement. Deaths from COVID-19 in Italy now exceed this total.

    The take away message is that we should have acted sooner following the New Year’s Eve news from Wuhan and learned and acted on the lessons of the successful public health control measures undertaken in China and the Far East countries, who are not all authoritarian Communist countries! Public Health is global and instead of Trump referring to the ‘Chinese’ virus he and our government should have acted earlier and more systematically than we have seen.

    Europe is the new epicentre of the spread and Italy, Spain and France particularly badly affected at this point in time. The health services in Italy have been better staffed than the NHS in terms of doctors/1000 population (Italy 4 v UK 2.8) as well as ITU hospital beds/100,000 (Italy 12.5 v UK 6.6). As we said in Blog 1 governments cannot conjure up medical specialists and nurses at whim so we will suffer from historically low medical staffing. The limited investment in ITU capacity, despite the 2009 H1N1 pandemic which showed the weakness in our system, is going to harm us. It was great to see NHS Wales stopping elective surgical admissions early on and getting on with training staff and creating new high dependency beds in their hospitals. In England elective surgery is due to cease in mid April! We need to ramp up our surge capacity as we have maybe 2 weeks at best before the big wave hits us. The UK government must lift their heads from the computer model and take note of best practice from other countries and implement lockdown and ramp up HDU/ITU capacity.

    In Blog 1 we mentioned that global health inequalities will continue to manifest themselves as the pandemic plays out and spare a thought for the Syrian refugee camps, people in Gaza, war torn Yemen and Sub Saharan Africa as the virus spreads down the African continent. Use gloves, wash your hands and self isolate in a shanty town? So let us not forget the Low Middle Income Countries (LMICs) with their weak health systems, low economic level, weak infrastructure and poor governance. International banking organisations, UNHCR, UNICEF, WHO and national government aid organisations such as DFID need to be resourced and activated to reach out to these countries and their people.

    1. The public health system

    We are lucky to have an established public health system in the UK and it is responding well to this crisis. However we can detect the impact of the last 10 years of Tory Party austerity which has underfunded the public health specialist services such as Public Health England (PHE) and the equivalents in the devolved nations, public health in local government and public health embedded in laboratories and the NHS. PHE has been a world leader in developing the PCR test on nasal and throat samples as well as developing/testing the novel antibody blood test to demonstrate an immune response to the virus. The jury is out as to what has led to the lack of capacity for testing for C-19 as the UK, while undertaking a moderate number of tests, has not been able to sustain community based testing to help guide decisions about quarantining key workers and get intelligence about the level of community spread. Compare our rates of testing with South Korea!

    We are lucky to have an infectious disease public health trained CMO leading the UK wide response who has had experience working in Africa. Decisions made at COBRA and announced by the Prime Minister are not simply based ‘on the science’ and no doubt there have been arguments on both sides. The CSO reports that SAGE has been subject to heated debate as you would expect but the message about herd immunity and stating to the Select Committee that 20,000 excess deaths was at this stage thought to be a good result was misjudged. The hand of Dominic Cummings is also emerging as an influencer on how Downing Street responds. Remember at present China with its 1.4bn population has reported 3,260 deaths. They used classic public health methods of identifying cases and isolating them and stopping community transmission as much as possible. Herd immunity and precision timing of control measures has not been used.

    The public must remain focused on basic hygiene measures – self isolating, washing of hands, social distancing and not be misled about how fast a vaccine can be developed, clinically tested and manufactured at scale. Similarly hopes/expectations should not be placed on novel treatments although research and trials do need supporting. The CSO, who comes from a background in Big Pharma research, must be seen to reflect the advice of SAGE in an objective way and resist the many difficult political and business pressures that surround the process. His experience with GSK should mean that he knows about the timescales for bringing a novel vaccine or new drugs safely to market.

    1. Local government and social care

    Local government (LAs) has been subject to year on year cuts and cost constraints since 2010, which have undermined their capability for the role now expected of them. The budget did not address this fundamental issue and we fully expect that in the crisis, central government will pass on the majority of local actions agreed at COBRA to them. During the national and international crisis LAs must be provided with the financial resources they need to build community hubs to support care in the community during this difficult time. The government need to support social care.

    COVID-19 is particularly dangerous to our older population and those with underlying health conditions. This means that the government needs to work energetically with the social care sector to ensure that the public health control measures are applied effectively but sensitively to this vulnerable population. The health protection measures which have been announced is an understandable attempt to protect vulnerable people but it will require community mobilisation to support these folk.

    Contingency plans need to be in place to support care and nursing homes when cases are identified and to ensure that they can call on medical and specialist nursing advice to manage cases who are judged not to require hospitalisation. They will also need to be prepared to take back people able to be discharged from acute hospital care to maintain capacity in the acute sector.

    Apart from older people in need there are also many people with long term conditions needing home based support services, which will become stressed during this crisis. There will be nursing and care staff sickness and already fragile support systems are at risk. As the retail sector starts to shut down and there is competition for scarce resources we need to be building in supply pathways for community based people with health and social care needs. Primary health care will need to find smart ways of providing medical and nursing support.

    1. The NHS

    In January and February when the gravity of the COVID pandemic was manifesting itself many of us were struck by the confident assertion that the NHS was well prepared. We know that the emergency plans will have been dusted down and the stockpile warehouses checked out. However, it now seems that there have not been the stress tests that you might have expected such as the supply and distribution of PPE equipment to both hospitals and community settings. The planning for COVID-19 testing also seems to have badly underestimated the need and we have been denied more accurate measures of community spread as well as the confirmation or otherwise of a definite case of COVID-19. This deficiency risks scarce NHS staff being quarantined at home for non COVID-19 symptoms.

    The 2009 H1N1 flu pandemic highlighted the need for critical care networks and more capacity in ITU provision with clear plans for surge capacity creating High Dependency Units (HDUs) including ability to use ventilators. The step-up and step-down facilities need bed capacity and adequate staffing. In addition, there is a need for clarity on referral pathways and ambulance transfer capability for those requiring even more specialised care such as Extracorporeal Membrane Oxygenation (ECMO). The short window we now have needs to be used to sort some of these systems out and sadly the supply of critical equipment such as ventilators has not been addressed over the past 2 months. The Prime Minister at this point calls on F1 manufacturers to step in – we wasted 2 months.

    News of the private sector being drawn into the whole system is obviously good for adding beds, staff and equipment. The contracts need to be scrutinised in a more competent way than the Brexit cross channel ferries due diligence was, to ensure that the State and financially starved NHS is not disadvantaged. We prefer to see these changes as requisitioning private hospitals and contractors into the NHS. 

    1. Maintaining people’s standard of living

    We consider that the Chancellor has made some major steps toward ensuring that workers have some guarantees of sufficient income to maintain their health and wellbeing during this crisis. Clearly more work needs to be done to demonstrate that the self-employed and those on zero hours contracts are not more disadvantaged. The spotlight has shown that the levels of universal credit are quite inadequate to meet needs so now is the time to either introduce universal basic income or beef up the social security packages to provide a living wage. We also need to ensure that the homeless and rootless, those on the streets with chronic mental illness or substance misuse are catered for and we welcome the news that Sadiq Khan has requisitioned some hotels to provide hostel space. It has been good to see that the Trade Unions and TUC have been drawn into negotiations rather than ignored.

    In political terms we saw in 2008 that the State could nationalise high street banks. Now we see that the State can go much further and take over the commanding heights of the economy! Imagine if these announcements had been made, not by Rishi Sunak, but by John McDonnell! The media would have been in meltdown about the socialist take over!

    1. Conclusion

    At this stage of the pandemic we note with regret that the UK government did not act sooner to prepare for what is coming both in terms of public health measures as well as preparing the NHS and Local Government. It seems to the SHA that the government is playing catch up rather than being on the front foot. Many of the decisions have been rather late but we welcome the commitment to support the public health system, listen to independent voices in the scientific world through SAGE and to invest in the NHS. The country as a whole recognises the serious danger we are in and will help orchestrate the support and solidarity in the NHS and wider community. Perhaps a government of national unity should be created as we hear much of the WW2 experience. We need to have trust in the government to ensure that the people themselves benefit from these huge investment decisions.

    24th March 2020

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    One on International Trade dispute settlements and the other on Social Care.

    These are not official SHA policy.

    Issues for the NHS during UK Trade deal Negotiations

    As socialists we have an almost irreconcilable set of principles

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    DELIVERED AT JULIAN HART’S FUNERAL — JUNE 16th 2018

     

    Julian and I were chatting once about heaven and hell, as you do. He didn’t believe in either, but supposing he was wrong, he thought he might be allowed into heaven, not as a believer, you understand, but for good behaviour.

    Julian always wanted to be a doctor in a mining village, partly because his father had been a colliery doctor in Llanelli; partly it was the romance of mining practice as popularised in AJ Cronin ‘s novel The Citadel; but mainly it was the sort of community to which he wanted to belong.

    And belong he did. As Gerald Davies, one of his patients, said in a BBC documentary , Julian wasn’t aloof like the other doctors, the headmaster and the colliery manager. He lived in the village and shared the common experience.

    He wrote about it for medical students, “No one is a stranger; they are not only patients but fellow citizens. From many direct and indirect contacts, in schools, shops and gossip, I have come to understand how ignorant I would be if I knew them only as a doctor seeing them when they were ill.”

    Julian loved his patients – not romantically, of course. The opposite of love in this context is indifference and Julian was never indifferent. He hated when bad things happened to his patients, especially when they could have been prevented. In his last 28 years at Glyncorrwg, there wasn’t a single death in women from cervical cancer.

    In his book A New Kind of Doctor, he described a man, invalided out of the steel industry after a leg fracture, aged 42. With no further use for his big muscular body, he had become obese, had high blood pressure and cholesterol, got gout and was drinking too much. 25 years later, Julian described how, after 310 consultations and 41 hours of work, initially face to face, eventually side by side, the most satisfying and exciting things had been the events that had not happened: no strokes, no heart attacks, no complications of diabetes. He described this as the real stuff of primary medical care.

    At a seminar in Glasgow, we asked Julian what happened next. The man had died, of something else, a late-onset cancer I think, but when Julian told us this, there was a tear in his eye. His patient had become his friend.

    This was Dr ‘art, without an “H”, as known to his Glyncorrwg patients. None of this explains why Dr Julian Tudor Hart became the most famous general practitioner in the history of the NHS.

    In 1961 with large numbers of very sick people, huge visiting lists and a nearby colliery that was still working, the Glyncorrwg practice was extremely busy. His initial base was a wooden hut. It took five years to reach a stable position.

    He was the first doctor in the world to measure the blood pressures of all his patients. Famously, Charlie Dixon was the last man to take part, had the highest blood pressure in the village but was still alive 25 years later. Julian became an international authority on blood pressure control in general practice and wrote a book about it which went to three editions and was translated into several languages, with a companion book for patients.

    What he did for patients with high blood pressure, he did for other patients, delivering unconditional, personalised continuity of care. After 25 years he showed that premature mortality was almost 30% lower than in a neighbouring village – the only evidence we have of what a general practitioner could achieve in a lifetime of practice.

    It’s said that behind every great man there is an astonished woman. Behind Julian, was a great woman. When Deborah Perkin was planning her BBC documentary, the Good Doctor, (which we keep showing to medical students and young doctors), I said to her, there is something you have to understand. There’s two of them. Mary was his partner and anchor every step of the way.

    Glyncorrwg was the first general practice in the UK to receive research funding from the Medical Research Council. Mary and Julian had both worked with Archie Cochrane and his team at the MRC Epidemiology Unit in Cardiff where they learned a democratic type of research in which everyone’s contribution was important and the study wasn’t complete until everyone had taken part. And so, in Glyncorrwg, there was the Shit Study, the Pee Study, the Salt Studies and the Rat Poison Study, all with astonishing high response rates.

    Julian counted as a scientist anyone who measured or audited what they did and was honest with the results. Brecht’s The Life of Galileo was his favourite play and he often quoted Brecht’s line, “The figures compel us.” Julian didn’t pursue scientific knowledge for its own sake. His research always had the direct purpose of helping to improve people’s lives.

    He had a talent for the telling phrase. His Inverse Care Law stated that the availability of good medical care tends to vary inversely with the need for it in the population served, or more simply, People without shoes are clearly the ones who need shoes the most.

    When Sir Keith Joseph, a Conservative Secretary for Social Services, announced that
    “Increased dental charges would give a financial incentive to patients to look after their teeth,” Julian commented, “The government has not yet raised the tax on coffins to reduce mortality, but Sir Keith is assured of a place in the history of preventive medicine.”

    Julian’s friend and fellow GP, John Coope from Bollington in Lancashire, admired Julian’s nose for what mattered in the published literature. In his book The Political Economy of Health, that magpie tendency was on display, the footnotes comprising one third of the book and worth reading on their own. A Google search could never assemble such a mix. Goodness knows what readers made of it in the Chinese translation.

    He lectured all over the world – in the US, Australia, Kazakhstan, Italy and Spain in particular. Julian could deliver formal lectures but for brilliance and exhilarating an audience he was at his best in impromptu, unscripted exchange.

    When principles were at stake, Julian could argue until the cows came home. In his younger years he took no prisoners. A famous medical professor reflected that he had been called many things, but never a snail.

    Dr Miriam Stoppard arrived in the village to interview Julian for her TV programme, determined to cast him in the role of a doctor who made life or death decisions concerning his patient’s access to renal dialysis and transplant. They battled for a whole afternoon, Stoppard trying to get Julian to say things on camera that fitted her script. He defied her, ending every sentence by mentioning how much dialysis and transplant surgery the cost of a single Trident missile could buy. She went away defeated and empty-handed.

    I was surprised once at Paddington station to see him with a copy of the London Times. He was no fan of the Murdoch press. On boarding the 125 for South Wales, he laid out the newspaper as a tablecloth and over it spread a messy, aromatic Indian carry-out meal. If businessmen in their smart suits wanted to sit next to us, they were very welcome.

    Standing for election to the Council of the Royal College of General Practitioners, Julian topped the poll. What he offered GPs was a credible image of themselves as important members of the medical profession – alongside specialists, not beneath them.

    Julian was humble in himself but ambitious for his ideas. He accepted with ambivalence the honours and sentimental treatment that came with age but he never lost his edge, and if we are to celebrate his life it should be by holding to the principles he held dear.

    The work of a general practitioner is immeasurably enhanced by working in, with and for a local community, for long enough to make a difference.

    Everyone is important, the last person as important as the first, and the work isn’t done until everyone is on board.

    Julian was the “worried doctor”, anticipating patients’ problems, not waiting for them to happen, and then avoiding them by joint endeavour.

    Drawing on his reading of Marx, he saw health care as a form of production, producing not profits but social value, shared knowledge, confidence, the ability to live better with conditions, achieved not by the doctor alone but by doctors and patients working together. Patients were partners, not customers or consumers.

    The NHS should never be a business to make money but a social institution based on mutuality and trust – the ultimate gift economy, getting what you need, giving what you can, a model for how society might run as a whole. In re-building society, co-operation would trump competition, not marginally, but as steam once surpassed horsepower. The Glyncorrwg research studies showed glimpses of that social power.

    My daughter Nuala met Julian many times. Losing him as a person, she said, was like the Mackintosh Building at Glasgow School of Art, burning down. We lost someone dear, a big part of our lives, an institution, a one man “School of ‘Art”, full of life, light and creativity.

    Julian’s gift to us today is not the example he worked out in the microcosm of a Welsh mining village over 25 years ago; it is the present challenge of how we follow and give practical expression to his values in local communities in the future. In honouring his memory, there is work for all of us do.

     

    Professor Graham Watt
    MD FRCGP FRSE FMedSci CBE
    Emeritus Professor
    General Practice and Primary Care
    University of Glasgow

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    Radical Statistics  (Radstats):  2019 Annual Conference & AGM

    Liverpool:  Saturday  23  February  2019

    Inequalities  and  the  Life-course  – the  Impact  of  Austerity  across  Generations

    Key questions for this conference include: How do inequalities affect life chances?  What effect has austerity had on inequalities across generations?     Does austerity affect younger cohorts differently than older ones? How does this differ across social groups, class, gender, etc.?  How to measure inequalities across the life-course?    What data exists; what is needed?

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    Mean societies produce mean people

    Babies haven’t changed much for millennia. Give or take a few enzymes this perfectly designed little bundle of desires and interests has not needed to evolve much. Of all primates, the human is the most immature at birth, after which brain growth accelerates and is ‘wired’ according to the kinds of experience the infant has. Provided there are a few familiar and affectionate people there to care continuously for him or her, baby will be fine. If not, evolution has taken care of that too. You live in a cruel world and treat him roughly? He will develop into a compulsively self-reliant and ruthless individual with little concern for others. Mean societies produce mean people. Through attentive care in the early years we may hope to produce thoughtful, curious and confident young people but our social arrangements are essentially hostile and competitive. Having a baby is regarded as an expensive undertaking rather than as a contribution to the future of society.

    Encouraged by successive governments our world is geared to markets. “It’s the economy, stupid” means you can’t do anything without considering the immediate cost. The more this idea takes hold the stupider we become. The current government’s dedication to continuous welfare cuts hits children disproportionately. Neoliberalism is the enemy of children.

    Evolutionary imperatives

    This is not the environment in which humans evolved. An infant in a hunter-gatherer band – the way we all lived for 99% of our time on the planet – would have spent many hours being held, and not only by the mother. “Infants with several attachment figures grow up better able to integrate multiple mental perspectives”. We are programmed from the start to seek out third positions, to acquire the “capacity for seeing ourselves in interaction with others and for entertaining another point of view whilst retaining our own, for reflecting on ourselves whilst being ourselves.”

    Systematic comparisons between sedentary foraging and farming people living now in neighbouring parts of the Congo basin show how much more egalitarian the foragers are. Men and women see themselves as equal. They hold and converse with their tiny children more intensively, they let the baby decide when to wean and teach them to share from an early age. Violence is rare, though teasing is common. Such children are more socialised than in the west and at the same time protected from catastrophe in the event of the mother’s death. Amongst the farmers, in contrast, “corporal punishment is not an uncommon response for young children who do not listen to or respect their parents or older siblings”.

    In the modern world little public money is available for perinatal services, parental leave, for quality child care and universal education, affordable and secure homes, healthy food, subsidised transport and energy, sports fields, swimming pools, libraries, parks and playgrounds that make rearing children and adolescents more manageable and more successful. Tax, like children, is seen as a ‘burden’. So governments of all parties sign up to reducing it, yet still find money for bank bailouts and unsustainable wars. Whether local or national, tax should be a contribution to the common good, an instrument of social justice. It is collected from citizens, for citizens. In the current climate this equation is neither acknowledged nor understood. Yet something has been understood that was not clear before. There is a greater recognition that early intervention is a good idea: “the brain can be sculpted by experience”; the sooner the better.

    Start at the beginning

    When a woman becomes pregnant her physical and mental states impact on her child. From conception onwards the health and resilience of children – and the adults they will become – is compromised by stress, diet, maternal weight, drugs, genes and insecurity in their parents. Besides the impact on the mother herself, anxiety and depression during pregnancy and after it have significant long term effects on the child’s physical and mental health – particularly on boys – generating huge social costs. Pregnancy is a dangerous time for some women. The most socially deprived mothers are more likely to have very premature births or perinatal death. Low birthweight leads to poor outcomes; early intervention can reduce that.

    Elegant research shows how already by a few months old babies are engaged in triadic relationships; they are affected by tensions between the adults caring for them. When caregivers are uncooperative infants may be “enlisted to serve the parents’ problematic relationship rather than to develop their own social competence”. Children will more likely thrive if caregivers – parents and grandparents, childminders, daycare and children’s centre staff, nursery teachers – get on with one another, like a good team. “Communication between parents and care providers is crucial to the quality of care.”

    The routine availability and presence of health visitors and other staff supporting new parents and of Sure Start centres for children and families create the conditions for reliable care of children. In a context of skilled early years provision, infants whose parents are paid to spend time with them in the early months are less likely to die. “A ten week extension in paid leave is predicted to decrease post neonatal mortality rates by 4.1%”. This remarkable finding represents just the tip of an iceberg of developmental damage and pathology, modifiable by intensive early support for families.

    Better training and pay for early years staff improves outcomes and reduces turnover. UK needs to learn from continental Europe the tradition of pedagogic professions: proper pay, status and training for the job, particularly when the families most in need are hard to engage. Looking after small children is demanding and stressful, requiring continuous professional development such as reflective discussion groups in which colleagues both support and learn from each other. Work with young families is a professional skill.

    Inequality undermines trust

    A collaborative partnership between caregivers does not in itself cost money, but is undermined by social disintegration, the most poisonous source of which is rising inequality. In Britain this has reached levels not seen since the 1920s. The much maligned 1970s was actually the most egalitarian in our history. Consider this: one index of social health is the number of boys born in comparison to girls. Because the male fetus is more vulnerable to maternal stress, women produce fewer boys when times are hard. (For example there is a fall in the ratio of boys to girls a few months after disasters such as massive floods or earthquakes, or the terrorist attack on 9/11). In England and Wales the highest ratio of boys to girls occurred in 1975. In terms of contented mothers it was the best of times.

    Inequality creates stress in parents who can’t keep up, and anxiety in the better off who fear sliding down. No one is comfortable on a steep slope. It makes all of us less trusting and more averse to communal commitments, such as respecting our neighbours and paying tax. Infant mortality, mental illness, drug abuse, dropping out of education, rates of imprisonment, obesity, teenage births and violence are all higher in unequal countries like ours.

    Though often disappointed, our ancient baby is born to expect some kind – a rather conservative kind – of socialism. What will today’s infants be talking about in 2050? If they know any history they will regret lost opportunities; our collective loss of vision that led to wasted generations. The success of the post war consensus was due in part to the fact that it lasted longer than one or two parliamentary terms, so that children could grow up, get educated and housed, find partners, get work and free healthcare without overwhelming instability or despair. The needs of a baby born today are precisely what they were for one born in the 1950s, or 50,000 years ago. New knowledge of infant development is catching up with evolved wisdom, yet we continue to ignore both, and build bigger obstacles to secure attachments.

     

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    Although it was written 130 years ago, William Morris’s essay on how we live and how we might live could equally have been written this year as an introduction to the Labour Party manifesto.

    The values to which Morris aspires are precisely those to which today’s Labour party aspires. The enormous public support for our manifesto and for our socialist leadership echo Morris’s yearnings for a truly egalitarian society based on social solidarity and valuing diversity and culture. The way in which Morris describes his idea of health carries the same ‘face validity’ as does the World Health Organisation’s famous definition.

    By William Morris

    The word Revolution, which we Socialists are so often forced to use, has a terrible sound in most people’s ears, even when we have explained to them that it does not necessarily mean a change accompanied by riot and all kinds of violence, and cannot mean a change made mechanically and in the teeth of opinion by a group of men who have somehow managed to seize on the executive power for the moment. Even when we explain that we use the word revolution in its etymological sense, and mean by it a change in the basis of society, people are scared at the idea of such a vast change, and beg that you will speak of reform and not revolution. As, however, we Socialists do not at all mean by our word revolution what these worthy people mean by their word reform, I can’t help thinking that it would be a mistake to use it, whatever projects we might conceal beneath its harmless envelope. So we will stick to our word, which means a change of the basis of society; it may frighten people, but it will at least warn them that there is something to be frightened about, which will be no less dangerous for being ignored; and also it may encourage some people, and will mean to them at least not a fear, but a hope.

    Fear and Hope—those are the names of the two great passions which rule the race of man, and with which revolutionists have to deal; to give hope to the many oppressed and fear to the few oppressors, that is our business; if we do the first and give hope to the many, the few must be frightened by their hope; otherwise we do not want to frighten them; it is not revenge we want for poor people, but happiness; indeed, what revenge can be taken for all the thousands of years of the sufferings of the poor?

    However, many of the oppressors of the poor, most of them, we will say, are not conscious of their being oppressors (we shall see why presently); they live in an orderly, quiet way themselves, as far as possible removed from the feelings of a Roman slave-owner or a Legree; they know that the poor exist, but their sufferings do not present themselves to them in a trenchant and dramatic way; they themselves have troubles to bear, and they think doubtless that to bear trouble is the lot of humanity; nor have they any means of comparing the troubles of their lives with those of people lower in the social scale; and if ever the thought of those heavier troubles obtrudes itself upon them, they console themselves with the maxim that people do get used to the troubles they have to bear, whatever they may be.

    Indeed, as far as regards individuals at least, that is but too true, so that we have as supporters of the present state of things, however bad it may be, first those comfortable unconscious oppressors who think that they have everything to fear from any change which would involve more than the softest and most gradual of reforms, and secondly those poor people who, living hard and anxiously as they do, can hardly conceive of any change for the better happening to them, and date not risk one tittle of their poor possessions in taking any action towards a possible bettering of their condition; so that while we can do little with the rich save inspire them with fear, it is hard indeed to give the poor any hope. It is, then, no less than reasonable that those whom we try to involve in the great struggle for a better form of life than that which we now lead should call on us to give them at least some idea of what that life may be like.

    A reasonable request, but hard to satisfy, since we are living under a system that makes conscious effort towards reconstruction almost impossible: it is not unreasonable on our part to answer, “There are certain definite obstacles to the real progress of man; we can tell you what these are; take them away, and then you shall see.”

    However, I purpose now to offer myself as a victim for the satisfaction of those who consider that as things now go we have at least got something, and are terrified at the idea of losing their hold of that, lest they should find they are worse off than before, and have nothing. Yet in the course of my endeavour to show how we might live, I must more or less deal in negatives. I mean to say I must point out where in my opinion we fall short in our present attempt at decent life. I must ask the rich and well-to-do what sort of a position it is which they are so anxious to preserve at any cost? and if, after all, it will be such a terrible loss to them to give it up? and I must point out to the poor that they, with capacities for living a dignified and generous life, are in a position which they cannot endure without continued degradation.

    How do we live, then, under our present system? Let us look at it a little.

    And first, please to understand that our present system of Society is based on a state of perpetual war. Do any of you think that this is as it should be? I know that you have often been told that the competition, which is at present the rule of all production, is a good thing, and stimulates the progress of the race; but the people who tell you this should call competition by its shorter name of war if they wish to be honest, and you would then be free to consider whether or no war stimulates progress, otherwise than as a mad bull chasing you over your own garden may do. War, or competition, whichever you please to call it, means at the best pursuing your own advantage at the cost of someone else’s loss, and in the process of it you must not be sparing of destruction even of your own possessions, or you will certainly come by the worse in the struggle. You understand that perfectly as to the kind of war in which people go out to kill and be killed; that sort of war in which ships are commissioned, for instance, “to sink, burn, and destroy”; but it appears that you are not so conscious of this waste of goods when you are only carrying on that other war called commerce; observe, however, that the waste is there all the same.

    Now let us look at this kind of war a little closer, run through some of the forms of it, that we may see how the “burn, sink, and destroy” is carried on in it.

    First, you have that form of it called national rivalry, which in good truth is nowadays the cause of all gunpowder and bayonet wars which civilized nations wage. For years past we English have been rather shy of them, except on those happy occasions when we could carry them on at no sort of risk to ourselves, when the killing was all on one side, or at all events when we hoped it would be. We have been shy of gunpowder war with a respectable enemy for a long while, and I will tell you why: It is because we have had the lion’s share of the world-market; we didn’t want to fight for it as a nation, for we had got it; but now this is changing in a most significant, and, to a Socialist, a most cheering way; we are losing or have lost that lion’s share; it is now a desperate “competition” between the great nations of civilization for the world-market, and tomorrow it may be a desperate war for that end. As a result, the furthering of war (if it be not on too large a scale) is no longer confined to the honour-and-glory kind of old Tories, who if they meant anything at all by it meant that a Tory war would be a good occasion for damping down democracy; we have changed all that, and now it is quite another kind of politician that is wont to urge us on to “patriotism” as ’tis called. The leaders of the Progressive Liberals, as they would call themselves, longheaded persons who know well enough that social movements are going on, who are not blind to the fact that the world will move with their help or without it; these have been the Jingoes of these later days. I don’t mean to say they know what they are doing: politicians, as you well know, take good care to shut their eyes to everything that may happen six months ahead; but what is being done is this: that the present system, which always must include national rivalry, is pushing us into a desperate scramble for the markets on more or less equal terms with other nations, because, once more, we have lost that command of them which we once had. Desperate is not too strong a word. We shall let this impulse to snatch markets carry us whither it will, whither it must. Today it is successful burglary and disgrace, tomorrow it may be mere defeat and disgrace.

    Now this is not a digression, although in saying this I am nearer to what is generally called politics than I shall be again. I only want to show you what commercial war comes to when it has to do with foreign nations, and that even the dullest can see how mere waste must go with it. That is how we live now with foreign nations, prepared to ruin them without war if possible, with it if necessary, let alone meantime the disgraceful exploiting of savage tribes and barbarous peoples on whom we force at once our shoddy wares and our hypocrisy at the cannon’s mouth.

    Well, surely Socialism can offer you something in the place of all that. It can; it can offer you peace and friendship instead of war. We might live utterly without national rivalries, acknowledging that while it is best for those who feel that they naturally form a community under one name to govern themselves, yet that no community in civilization should feel that it had interests opposed to any other, their economical condition being at any rate similar; so that any Citizen of one community could fall to work and live without disturbance of his life when he was in a foreign country, and would fit into his place quite naturally; so that all civilized nations would form one great community, agreeing together as to the kind and amount of production and distribution needed; working at such and such production where it could be best produced; avoiding waste by all means. Please to think of the amount of waste which they would avoid, how much such a revolution would add to the wealth of the world! What creature on earth would be harmed by such a revolution? Nay, would not everybody be the better for it? And what hinders it? I will tell you presently.

    Meantime let us pass from this “competition” between nations to that between “the organizers of labour,” great firms, joint-stock companies; capitalists in short, and see how competition “stimulates production” among them: indeed it does do that; but what kind of production? Well, production of something to sell at a profit, or say production of profits : and note how war commercial stimulates that: a certain market is demanding goods; there are, say, a hundred manufacturers who make that kind of goods, and every one of them would if he could keep that market to himself, and struggles desperately to get as much of it as he can, with the obvious result that presently the thing is overdone, and the market is glutted, and all that fury of manufacture has to sink into cold ashes.

    Doesn’t that seem something like war to you? Can’t you see the waste of it—waste of labour, skill, cunning, waste of life in short? Well you may say, but it cheapens the goods. In a sense it does; and yet only apparently, as wages have a tendency to sink for the ordinary worker in proportion as prices sink; and at what a cost do we gain this appearance of cheapness! Plainly speaking, at the cost of cheating the consumer and starving the real producer for the benefit of the gambler, who uses both consumer and producer as his milch cows. I needn’t go at length into the subject of adulteration, for every one knows what kind of a part it plays in this sort of commerce: but remember that it is an absolutely necessary incident to the production of profit out of wares, which is the business of the so-salled manufacturer; and this you must understand, that, taking him in the lump, the consumer is perfectly helpless against the gambler; the goods are forced on him by their cheapness, and with them a certain kind of life which that energetic, that aggressive cheapness determines for him: for so far-reaching is this curse of commercial war that no country is safe from its ravages; the traditions of a thousand years fall before it in a month; it overruns a weak or semi-barbarous country, and whatever romance or pleasure or art existed there, is trodden down into a mire of sordidness and ugliness; the Indian or Javanese craftsman may no longer ply his craft leisurely, working a few hours a day, in producing a maze of strange beauty on a piece of cloth: a steam-engine is set a-going at Manchester, and that victory over nature and a thousand stubborn difficulties is used for the base work of producing a sort of plaster of china-clay and shoddy, and the Asiatic worker, if he is not starved to death outright, as plentifully happens, is driven himself into a factory to lower the wages of his Manchester brother worker, and nothing of character is left him except, most like, an accumulation of fear and hatred of that to him most unaccountable evil, his English master. The South Sea Islander must leave his canoe~carving, his sweet rest, and his graceful dances, and become the slave of a slave: trousers, shoddy, rum, missionary, and fatal disease—he must swallow all thIs civilization in the lump, and neither himself nor we can help him now till social order displaces the hideous tyranny of gambling that has ruined him.

    Let those be types of the consumer: but now for the producer; I mean the real producer, the worker; how does this scramble for the plunder of the market affect him? The manufacturer, in the eagerness of his war, has had to collect into one neighbourhood a vast army of workers, he has drilled them till they are as fit as may be for his special branch of production, that is, for making a profit out of it, and with the result of their being fit for nothing else: well, when the glut comes in that market he is supplying, what happens to this army, every private in which has been depending on the steady demand in that market, and acting, as he could not choose but act, as if it were to go on for ever? You know well what happens to these men: the factory door is shut on them; on a very large part of them often, and at the best on the reserve army of labour, so busily employed in the time of inflation. What becomes of them? Nay, we know that well enough just now. But what we don’t know, or don’t choose to know, is that this reserve army of labour is an absolute necessity for commercial war: if our manufacturers had not got these poor devils whom they could draft on to their machines when the demand swelled, other manufacturers in France, or Germany, or America, would step in and take the market from them.

    So you see, as we live now, it is necessary that a vast part of the industrial population should be exposed to the danger of periodical semi-starvation, and that, not for the advantage of the people in another part of the world, but for their degradation and enslavement.

    Just let your minds run for a moment on the kind of waste which this means, this opening up of new markets among savage and barbarous countries which is the extreme type of the force of the profit-market on the world, and you will surely see what a hideous nightmare that profit-market is: it keeps us sweating and terrified for our livelihood, unable to read a book, or look at a picture, or have pleasant fields to walk in, or to lie in the sun, or to share in the knowledge of our time, to have in short either animal or intellectual pleasure, and for what? that we may go on living the same slavish life till we die, in order to provide for a rich man what is called a life of ease and luxury; that is to say, a life so empty, unwholesome, and degraded, that perhaps, on the whole, he is worse off than we the workers are: and as to the result of all this suffering, it is luckiest when it is nothing at all, when you can say that the wares have done nobody any good; for oftenest they have done many people harm, and we have toiled and groaned and died in making poison and destruction for our fellow-men.

    Well, I say all this is war, and the result of war, the war this time, not of competing nations, but of competing firms or capitalist units: and it is this war of the firms which hinders the peace between nations which you surely have agreed with me in thinking is so necessary; for you must know that war is the very breath of the nostrils of these fighting firms, and they have now, in our times, got into their hands nearly all the political power, and they band together in each country in order to make their respective governments fulfill just two functions: the first is at home to act as a strong police force, to keep the ring in which the strong are beating down the weak; the second is to act as a piratical body-guard abroad, a petard to explode the doors which lead to the markets of the world: markets at any price abroad, uninterfered-with privilege, falsely called laissez-faire,1 at any price at home, to provide these is the sole business of a government such as our industrial captains have been able to conceive of. I must now try to show you the reason of all this, and what it rests on, by trying to answer the question, Why have the profit-makers got all this power, or at least why are they able to keep it?

    That takes us to the third form of war commercial: the last, and the one which all the rest is founded on. We have spoken first of the war of rival nations ; next of that of rival firms : we have now to speak of rival men. As nations under the present system are driven to compete with one another for the markets of the world, and as firms or the captains of industry have to scramble for their share of the profits of the markets, so also have the workers to compete with each other—for livelihood; and it is this constant competition or war amongst them which enables the profit-grinders to make their profits, and by means of wealth so acquired to take all the executive power of the country into their hands. But here is the difference between the position of the workers and the profit-makers: to the latter, the profit-grinders, war is necessary; you cannot have profit-making without competition, individual, corporate, and national; but you may work for a livelihood without competing; you may combine instead of competing.

    I have said war was the life-breath of the profit-makers; in like manner, combination is the life of the workers. The working classes or proletariat cannot even exist as a class without combination of some sort. The necessity which forced the profit-grinders to collect their men first into workshops working by the division of labour, and next into great factories worked by machinery, and so gradually draw them into the great towns and centres of civilization, gave birth to a distinct working class or proletariat: and this it was which gave them their mechanical existence, so to say. But note, that they are indeed combined into social groups for the production of wares, but only as yet mechanically; they do not know what they are working at, nor whom they are working for, because they are combining to produce wares of which the profit of a master forms an essential part, instead of goods for their own use: as long as they do this, and compete with each other for leave to do it, they will be, and will feel themselves to be, simply a part of those competing firms~s I have been speaking of; they will be in fact just a part of the machinery for the production of profit; and so long as this lasts it will be the aim of the masters or profit-makers to decrease the market value of this human part of the machinery; that is to say, since they already hold in their hands the labour of dead men in the form of capital and machinery, it is their interest, or we will say their necessity, to pay as little as they can help for the labour of living men which they have to buy from day to day: and since the workmen they employ have nothing but their labour-power, they are compelled to underbid one another for employment and wages, and so enable the capitalist to play his game.

    I have said that, as things go, the workers are a part of the competing firms, an adjunct of capital. Nevertheless, they are only so by compulsion; and, even without their being conscious of it, they struggle against that compulsion and its immediate results, the lowering of their wages, of their standard of life: and this they do, and must do, both as a class and individually: just as the slave of the great Roman lord, though he distinctly felt himself to be a part of the household, yet collectively was a force in reserve for its destruction, and individually stole from his lord whenever he could safely do so. So here, you see, is another form of war necessary to the way we live now, the war of class against class, which, when it rises to its height, and it seems to be rising at present, will destroy those other forms of war we have been speaking of; will make the position of the profit-makers, of perpetual commercial war, untenable; will destroy the present system of competitive privilege, or commercial war.

    Now observe, I said that to the existence of the workers it was combination, not competition, that was necessary, while to that of the profit-makers combination was impossible, and war necessary. The present position of the workers is that of the machinery of commerce, or in plainer words its slaves; when they change that position and become free, the class of profit-makers must cease to exist; and what will then be the position of the workers? Even as it is they are the one necessary part of society, the life-giving part; the other classes are but hangers-on who live on them. But what should they be, what will they be, when they, once for all, come to know their real power, and cease competing with one another for livelihood? I will tell you: they will be society, they will be the community. And being society—that is, there being no class outside them to contend with—they can then regulate their labour in accordance with their own real needs.

    There is much talk about supply and demand, but the supply and demand usually meant is an artificial one; it is under the sway of the gambling market; the demand is forced, as I hinted above, before it is supplied; nor, as each producer is working against all the rest, can the producers hold their hands, till the market is glutted and the workers, thrown out on the streets, hear that there has been over-production, amidst which over-plus of unsaleable goods they go ill supplied with even necessaries, because the wealth which they themselves have created is “ill distributed,” as we call it—that is, unjustly taken away from them.

    When the workers are society they will regulate their labour, so that the supply and demand shall be genuine, not gambling; the two will then be commensurate, for it is the same society which demands that also supplies; there will be no more artificial famines then, no more poverty amidst over-production, amidst too great a stock of the very things which should supply poverty and turn it into well-being. In short, there will be no waste and therefore no tyranny.

    Well, now, what Socialism offers you in place of these artificial famines, with their so-called over-production, is, once more, regulation of the markets; supply and demand commensurate; no gambling, and consequently (once more) no waste; not overwork and weariness for the worker one month, and the next no work and terror of starvation, but steady work and plenty of leisure every month; not cheap market wares, that is to say, adulterated wares, with scarcely any good in them, mere scaffold-poles for building up profits; no labour would be spent on such things as these, which people would cease to want when they ceased to be slaves. Not these, but such goods as best fulfilled the real uses of the consumers would labour be set to make; for, protit being abolished, people could have what they wanted instead of what the profit-grinders at home and abroad forced them to take.

    For what I want you to understand is this: that in every civilized country at least there is plenty for all—is, or at any rate might be. Even with labour so misdirected as it is at present, an equitable distribution of the wealth we have would make all people comparatively comfortable; but that is nothing to the wealth we might have if labour were not misdirected.

    Observe, in the early days of the history of man he was the slave of his most immediate necessities; Nature was mighty and he was feeble, and he had to wage constant war with her for his daily food and such shelter as he could get. His life was bound down and limited by this constant struggle; all his morals, laws, religion, are in fact the outcome and the reflection of this ceaseless toil of earning his livelihood. Time passed, and little by little, step by step, he grew stronger, till now after all these ages he has almost completely conquered Nature, and one would think should now have leisure to turn his thoughts towards higher things than procuring to-morrow’s dinner. But, alas! his progress has been broken and halting; and though he has indeed conquered Nature and has her forces under his control to do what he will with, he still has himself to conquer, he still has to think how he will best use those forces which he has mastered. At present he uses them blindly, foolishly, as one driven by mere fate. It would almost seem as if some phantom of the ceaseless pursuit of food which was once the master of the savage was still haunting the civilized man; who toils in a dream, as it were, haunted by mere dim unreal hopes, born of vague recollections of the days gone by. Out of that dream he must wake, and face things as they really are. The conquest of Nature is complete, may we not say? and now our business is and has for long been the organization of man, who wields the forces of Nature. Nor till this is attempted at least shall we ever be free of that terrible phantom of fear of starvation which, with its brother devil, desire of domination, drives us into injustice, cruelty, and dastardliness of all kinds: to cease to fear our fellows and learn to depend on them, to do away with competition and build up co-operation, is our one necessity.

    Now, to get closer to details; you probably know that every man in civilization is worth, so to say, more than his skin; working, as he must work, socially, he can produce more than will keep himself alive and in fair condition; and this has been so for many centuries, from the time, in fact, when warring tribes began to make their conquered enemies slaves instead of killing them; and of course his capacity of producing these extras has gone on increasing faster and faster, till to-day one man will weave, for instance, as much cloth in a week as will clothe a whole village for years; and the real question of civilization has always been what are we to do with extra produce of labour—a question which the phantom, fear of starvation, and its fellow, desire of domination, has driven men to answer pretty badly always, and worst of all perhaps in these present days, when the extra produce has grown with such prodigious speed. The practical answer has always been for man to struggle with his fellow for private p05session of undue shares of these extras, and all kinds of devices have been employed by those who found themselves in possession of the power of taking them from others to keep those whom they had robbed in perpetual subjection; and these latter, as I have already hinted, had no chance of resisting this fleecing as long as they were few and scattered, and consequently could have little sense of their common oppression. But now that, owing to the very pursuit of these undue shares of profit, or extra earnings, men have become more dependent on each other for production, and have been driven, as I said before, to combine together for that end more completely, the power of the workers—that is to say, of the robbed or fleeced class—has enormously increased, and it only remains for them to understand that they have this power. When they do that they will be able to give the right answer to the question what is to be done with the extra products of labour over and above what will keep the labourer alive to labour: which answer is, that the worker will have all that he produces, and not be fleeced at all: and remember that he produces collectively, and therefore he will do effectively what work is required of him according to his capacity, and of the produce of that work he will have what he needs; because, you see, he cannot use more than he needs—he can only waste it.

    If this arrangement seems to you preposterously ideal, as it well may, looking at our present condition, I must back it up by saying that when men are organized so that their labour is not wasted, they will be relieved from the fear of starvation and the desire of domination, and will have freedom and leisure to look round and see what they really do need.

    Now something of that I can conceive for my own self, and I will lay my ideas before you, so that you may compare them with your own, asking you always to remember that the very differences in men’s capacities and desires, after the common need of food and shelter is satisfied, will make it easier to deal with their desires in a communal state of things.

    What is it that I need, therefore, which my surrounding circumstances can give me—my dealings with my fellow-men—setting aside inevitable accidents which cooperation and forethought cannot control, if there be such?

    Well, first of all I claim good health; and I say that a vast proportion of people in civilization scarcely even know what that means. To feel mere life a pleasure; to enjoy the moving one’s limbs and exercising one’s bodily powers; to play, as it were, with sun and wind and rain; to rejoice in satisfying the due bodily appetites of a human animal without fear of degradation or sense of wrongdoing; yes, and therewithal to be well-formed, straight-limbed, strongly knit, expressive of countenance—to be, in a word, beautiful—that also I claim. If we cannot have this claim satisfied, we are but poor creatures after all; and I claim it in the teeth of those terrible doctrines of asceticism, which, born of the despair of the oppressed and degraded, have been for so many ages used as instruments for the continuance of that oppression and degradation.

    And I believe that this claim for a healthy body for all of us carries with it all other due claims: for who knows where the seeds of disease which even rich people suffer from were first sown: from the luxury of an ancestor, perhaps: yet often, I suspect, from his poverty. And for the poor: a distinguished physicist has said that the poor suffer always from one disease—hunger; and at least I know this, that if a man is overworked in any degree he cannot enjoy the sort of health I am speaking of; nor can he if he is continually chained to one dull round of mechanical work, with no hope at the other end of it; nor if he lives in continual sordid anxiety for his livelihood, nor if he is ill housed, nor if he is deprived of all enjoyment of the natural beauty of the world, nor if he has no amusement to quicken the flow of his spirits from time to time: all these things, which touch more or less directly on his bodily condition, are born of the claim I make to live in good health; indeed, I suspect that these good conditions must have been in force for several generations before a population in general will be really healthy, as I have hinted above; but also I doubt not that in the course of time they would, joined to other conditions, of which more hereafter, gradually breed such a population, living in enjoyment of animal life at least, happy therefore, and beautiful according to the beauty of their race. On this point I may note that the very variations in the races of men are caused by the conditions under which they live, and though in these rougher parts of the world we lack some of the advantages of climate and surroundings, yet, if we were working for livelihood and not for profit, we might easily neutralize many of the disadvantages of our climate, at least enough to give due scope to the full development of our race.

    Now the next thing I claim is education. And you must not say that every English child is educated now; that sort of education will not answer my claim, though I cheerfully admit it is something: something, and yet after all only class education. What I claim is liberal education; opportunity, that is, to have my share of whatever knowledge there is in the world according to my capacity or bent of mind, historical or scientific; and also to have my share of skill of hand which is about in the world, either in the industrial handicrafts or in the fine arts; picture-painting, sculpture, music, acting, or the like: I claim to be taught, if I can be taught, more than one craft to exercise for the benefit of the community. You may think this a large claim, but I am clear it is not too large a claim if the community is to have any gain out of my special capacities, if we are not all to be beaten down to a dull level of mediocrity as we are now, all but the very strongest and toughest of us.

    But also I know that this claim for education involves one for public advantages in the shape of public libraries, schools, and the like, such as no private person, not even the richest, could command: but these I claim very confidently, being sure that no reasonable community could bear to be without such help to a decent life.

    Again, the claim for education involves a claim for abundant leisure, which once more I make with confidence; because when once we have shaken off the slavery of profit, labour would be organized so unwastefully that no heavy burden would be laid on the individual citizens; every one of whom as a matter of course would have to pay his toll of some obviously useful work. At present you must note that all the amazing machinery which we have invented has served only to increase the amount of profit-bearing wares; in other words, to increase the amount of profit pouched by individuals for their own advantage, part of which profit they use as capital for the production of more profit, with ever the same waste attached to it; and part as private riches or means for luxurious living, which again is sheer waste—is in fact to be looked on as a kind of bonfire in which rich men burn up the product of the labour they have fleeced from the workers beyond what they themselves can use. So I say that, in spite of our inventions, no worker works under the present system an hour the less on account of those labour-saving machines, so called. But under a happier state of things they would be used simply for saving labour, with the result of a vast amount of leisure gained for the community to be added to that gained by the avoidance of the waste of useless luxury, and the abolition of the service of commercial war.

    And I may say that as to that leisure, as I should in no case do any harm to any one with it, so I should often do some direct good to the community with it, by practising arts or occupations for my hands or brain which would give pleasure to many of the citizens; in other words, a great deal of the best work done would be done in the leisure time of men relieved from any anxiety as to their livelihood, and eager to exercise their special talent, as all men, nay, all animals are.

    Now, again this leisure would enable me to please myself and expand my mind by travelling if I had a mind to it; because, say, for instance, that I were a shoemaker; if due social order were established, it by no means follows that I should always be obliged to make shoes in one place; a due amount of easily conceivable arrangement would enable me to make shoes in Rome, say, for three months, and to come back with new ideas of building, gathered from the sight of the works of past ages, amongst other things which would perhaps be of service in London.

    But now, in order that my leisure might not degenerate into idleness and aimlessness, I must set up a claim for due work to do. Nothing to my mind is more important than this demand, and I must ask your leave to say something about it. I have mentioned that I should probably use my leisure for doing a good deal of what is now called work; but it is clear that if I am a member of a Socialist Community I must do my due share of rougher work than this—my due share of what my capacity enables me to do, that is; no fitting of me to a Procrustean bed; but even that share of work necessary to the existence of the simplest social life must, in the first place, whatever else it is, be reasonable work; that is, it must be such work as a good citizen can see the necessity for; as a member of the community, I must have agreed to do it.

    To take two strong instances of the contrary, I won’t submit to be dressed up in red and marched off to shoot at my French or German or Arab friend in a quarrel that I don’t understand; I will rebel sooner than do that.

    Nor will I submit to waste my time and energies in making some trifling toy which I know only a fool can desire; I will rebel sooner than do that.

    However, you may be sure that in a state of social order I shall have no need to rebel against any such pieces of unreason; only I am forced to speak from the way we live to the way we might live.

    Again, if the necessary reasonable work be of a mechanical kind, I must be helped to do it by a machine, not to cheapen my labour, but so that as little time as possible may be spent upon it, and that I may be able to think of other things while I am tending the machine. And if the work be specially rough or exhausting, you will, I am sure, agree with me in saying that I must take turns in doing it with other people; I mean I mustn’t, for instance, be expected to spend my working hours always at the bottom of a coal-pit. I think such work as that ought to be largely volunteer work, and done, as I say, in spells. And what I say of very rough work I say also of nasty work. On the other hand, I should think very little of the manhood of a stout and healthy man who did not feel a pleasure in doing rough work; always supposing him to work under the conditions I have been speaking of—namely, feeling that it was useful (and consequently honoured), and that it was not continuous or hopeless, and that he was really doing it of his own free will.

    The last claim I make for my work is that the places I worked in, factories or workshops, should be pleasant, just as the fields where our most necessary work is done are pleasant. Believe me there is nothing in the world to prevent this being done, save the necessity of making profits on all wares; in other words, the wares are cheapened at the expense of people being forced to work in crowded, unwholesome, squalid, noisy dens: that is to say, they are cheapened at the expense of the workman’s life.

    Well, so much for my claims as to my necessary work, my tribute to the community. I believe people would find, as they advanced in their capacity for carrying on social order, that life so lived was much less expensive than we now can have any idea of, and that, after a little, people would rather be anxious to seek work than to avoid it; that our working hours would rather be merry patties of men and maids, young men and old enjoying themselves over their work, than the grumpy weariness it mostly is now. Then would come the time for the new birth of art, so much talked of, so long deferred; people could not help showing their mirth and pleasure in their work, and would be always wishing to express it in a tangible and more or less enduring form, and the workshop would once more be a school of art, whose influence no one could escape from.

    And, again, that word art leads me to my last claim, which is that the material surroundings of my life should be pleasant, generous, and beautiful; that I know is a large claim, but this I will say about it, that if it cannot be satisfied, if every civilized community cannot provide such surroundings for all its members, I do not want the world to go on; it is a mere misery that man has ever existed. I do not think it possible under the present circumstances to speak too strongly on this point. I feel sure that the time will come when people will find it difficult to believe that a rich community such as ours, having such command over external Nature, could have submitted to live such a mean, shabby, dirty life as we do.

    And once for all, there is nothing in our circumstances save the hunting of profit that drives us into it. It is profit which draws men into enormous unmanageable aggregations called towns, for instance; profit which crowds them up when they are there into quarters without gardens or open spaces; profit which won’t take the most ordinary precautions against wrapping a whole district in a cloud of sulphurous smoke; which turns beautiful rivers into filthy sewers, which condemns all but the rich to live in houses idiotically cramped and confined at the best, and at the worst in houses for whose wretchedness there is no name.

    I say it is almost incredible that we should bear such crass stupidity as this; nor should we if we could help it. We shall not hear it when the workers get out of their heads that they are but an appendage to profit-grinding, that the more profits that are made the more employment at high wages there will be for them, and that therefore all the increditable filth, disorder, and degradation of modern civilization are signs of their prosperity. So far from that, they are signs of their slavery. When they are no longer slaves they will claim as a matter of course that every man and every family should be generously lodged; that every child should be able to play in a garden close to the place his parents live in; that the houses should by their obvious decency and order be ornaments to Nature, not disfigurements of it; for the decency and order above mentioned when carried to the due pitch would most assuredly lead to beauty in building. All this, of course, would mean the people—that is, all society—duly organized, having in its own hands the means of production, to be owned by no individual, but used by all as occasion called for its use, and can only be done on those terms; on any other terms people will be driven to accumulate private wealth for themselves, and thus, as we have seen, to waste the goods of the community and perpetuate the division into classes, which means continual war and waste.

    As to what extent it may be necessary or desirable for people under social order to live in common, we may differ pretty much according to our tendencies towards social life. For my part I can’t see why we should think it a hardship to eat with the people we work with; I am sure that as to many things, such as valuable books, pictures, and splendour of surroundings, we shall find it better to club our means together; and I must say that often when I have been sickened by the stupidity of the mean idiotic rabbit warrens that rich men build for themselves in Bayswater and elsewhere, I console myself with visions of the noble communal hall of the future, unsparing of materials, generous in worthy ornament, alive with the noblest thoughts of our time, and the past, embodied in the best art which a free and manly people could produce; such an abode of man as no private enterprise could come anywhere near for beauty and fitness, because only collective thought and collective life could cherish the aspirations which would give birth to its beauty, or have the skill and leisure to carry them out. I for my part should think it much the reverse of a hardship if I had to read my books and meet my friends in such a place; nor do I think I am better off to live in a vulgar stuccoed house crowded with upholstery that I despise, in all respects degrading to the mind and enervating to the body to live in, simply because I call it my own, or my house.

    It is not an original remark, but I make it here, that my home is where I meet people with whom I sympathize, whom I love.

    Well, that is my opinion as a middle-class man. Whether a working-class man would think his family possession of his wretched little room better than his share of the palace of which I have spoken, I must leave to his opinion, and to the imagination of the middle class, who perhaps may sometimes conceive the fact that the said worker is cramped for space and comfort—say on washing-day.

    Before I leave this matter of the surroundings of life, I wish to meet a possible objection. I have spoken of machinery being used freely for releasing people from the more mechanical and repulsive part of necessary labour; and I know that to some cultivated people, people of the artistic turn of mind, machinery is particularly distasteful, and they will be apt to say you will never get your surroundings pleasant so long as you are surrounded by machinery. I don’t quite admit that; it is the allowing machines to be our masters and not our servants that so injures the beauty of life nowadays. In other words, it is the token of the terrible crime we have fallen into of using our control of the powers of Nature for the purpose of enslaving people, we care less meantime of how much happiness we rob their lives of.

    Yet for the consolation of the artists I will say that I believe indeed that a state of social order would probably lead at first to a great development of machinery for really useful purposes, because people will still be anxious about getting through the work necessary to holding society together; but that after a while they will find that there is not so much work to do as they expected, and that then they will have leisure to reconsider the whole subject; and if it seems to them that a certain industry would be carried on more pleasantly as regards the worker, and more effectually as regards the goods, by using hand-work rather than machinery, they will certainly get rid of their machinery, because it will he possible for them to do so. It isn’t possible now; we are not at liberty to do so; we are slaves to the monsters which we nave created. And I have a kind of hope that the very elaboration of machinery in a society whose purpose is not the multiplication of labour, as it now is, but the carrying on of a pleasant life, as it would be under social order—that the elaboration of machinery, I say, will lead to the simplification of life, and so once more to the limitation of machinery.

    Well, I will now let my claims for decent life stand as I have made them. To sum them up in brief, they are: First, a healthy body; second, an active mind in sympathy with the past, the present, and the future; thirdly, occupation fit for a healthy body and an active mind; and fourthly, a beautiful world to live in.

    These are the conditions of life which the refined man of all ages has set before him as the thing above all others to be attained. Too often he has been so foiled in their pursuit that he has turned longing eyes backward to the days before civilization, when man’s sole business was getting himself food from day to day, and hope was dormant in him, or at least could not be expressed by him.

    Indeed, if civilization (as many think) forbids the teasization of the hope to attain such conditions of life, then civilization forbids mankind to be happy; and if that be the case, then let us stifle all aspirations towards progress—nay, all feelings of mutual good-will and affection between men—and snatch each one of us what we can from the heap of wealth that fools create for rogues to grow fat on or better still, let us as speedily as possible find some means of dying like men, since we are forbidden to live like men.

    Rather, however, take courage, and believe that we of this age, in spite of all its torment and disorder, have been born to a wonderful heritage fashioned of the work of those that have gone before us; and that the day of the or~an1zation of man is dawning. It is not we who can build up the new social order; the past ages have done the most of that work for us; but we can clear our eyes to the signs of the times, and we shall then see that the attainment of a good condition of life is being made possible for us, and that it is now our business to stretch out our hands, to take it.

    And how? Chiefly, I think, by educating people to a sense of their capacities as men, so that they may be able to use to their own good the political power which is rapidly being thrust upon them; to get them to see that the old system of organizing labour for individual profit is becoming unmanageable, and that the whole people have now got to choose between the confusion resulting from the break up of that system and the determination to rake in hand the labour now organized for profit, and use it’s organization for the livelihood of the community: to get people to see that individual profit-makers are not a necessity for labour but an obstruction to it, and that not only or chiefly because they are the perpetual pensioners of labour, as they are, but rather because of the waste which their existence as a class necessitates. All this we have to teach people, when we have taught ourselves; and I admit that the work is long and burdensome; as I began by saying, people have been made so timorous of change by the terror of starvation that even the unluckiest of them are stolid and hard to move. Hard as the work is, however, its reward is not doubtful. The mere fact that a body of men, however small, are banded together as Socialist missionaries shows that the change is going on. As the working classes, the real organic part of society, take in these ideas, hope will arise in them, and they will claim changes in society, many of which doubtless will not tend directly towards their emancipation, because they will be claimed without due knowledge of the one thing necessary to claim, equality of condition; but which indirectly will help to break up our rotten sham society, while that claim for equality of condition will be made constantly and with growing loudness till it must be listened to, and then at last it will only be a step over the border, and the civilized world will be socialized; and, looking back on what has been, we shall be astonished to think of how long we submitted to live as we live now.

    1 Falsely; because the privileged classes have at their back the force of the Executive by means of which to compel the unprivileged to accept the terms; if this is “free competition” there is no meaning in words.

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