By Daphne Liddle
THIS YEAR has seen NHS trusts throughout England facing huge deficits and resorting to drastic cuts in jobs and services that match those of the Tory years in the early 1990s and lost the Tories the 1997 election. It has also seen unprecedented levels of local demonstrations against these cuts. People from working and middle classes who normally take no interest in politics have been driven to take to the streets with banners and placards by the threat to their local services.
The cause of these cuts is in the capitalist system itself and the need for capitalism to continually find new sources of profit and in particular the revival of the most extreme monetarist policies under the Thatcher government in the 1980s. The reasoning behind this theory is that the market should rule every aspect of life; to allow anyone so much as an aspirin without them paying for it is immoral and leads to idleness and sponging off of others who work hard to pay for everything they use or consume.
It is an economic policy that values money above people. The market serves the rich; their every demand stimulates a supply along with innovation and invention of new products. But it totally ignores the needs of the poor who have no money to bring to the market.
The monetarists believe that ideally the role of government – both central and local, is to meet once a year to hand out contracts to the private sector to actually deliver all public services – at a cost of course. The decisions as to which companies will get the contracts will be based on advice from private sector finance consultants.
The monetarists regarded the NHS and all forms of state welfare with horror. NHS inefficiencies were ascribed to an inexhaustible source of demand, which would eat up more and more taxpayers’ money as work-shy workers thought up more and more health problems to suffer from.
For the workers, the NHS was the crowning glory of modern post-war society, where anyone who needed healthcare would get it regardless of ability to pay. Banished forever was the nightmare question: “Can we afford the doctor?” that blighted every working class sickbed. It was created just after the Second World War when the organised working class (mostly just demobbed) was strong in Britain and in the world with the Nazi-defeating Red Army high in prestige. The ruling capitalist class at that time preferred to concede state welfare rather than risk revolutionism. But they begrudged it and when the organised working class in Britain became weaker – after the defeat of the 1984 miners’ strike and the decline of the Soviet Union – they decided to withdraw it, but stealthily.
This is the policy of the capitalist ruling class and is not dependent on any particular political party. Whoever sits on the front benches of the Palace of Westminster, the capitalist class dictates the important policies.
The first stage of the assault came in the 80s with the closure of many hospitals, especially those for long-term patients and the transfer of those patients into “the community”. The idea sounded fine, releasing people from institutionalisation to be cared for in their own homes by visiting doctors and nurses. But of course the extra funding for those community services never materialised and people were left to sink or swim. Many with mental health and addiction problems ended up as a part of the growing army of homeless people in cardboard boxes on the streets of our cities.
Then in the early 90s under the Major government, NHS hospitals were pushed into acquiring “trust status” – becoming independent of local health authorities. The role of these local health authorities – who were accountable to elected local councils – was diminished. When the NHS trusts were founded, each with a board of trustees which included senior medical staff and local business people, they formally had to buy the land and buildings of the hospitals from the Government, with the aid of mortgages. This meant that they all came into being in deep debt and with a drain on their funding.
At the same time the Tory government, under Health Secretary Virginia Bottomley, set about a new and drastic round of hospital closures, especially in London, which was deemed to have far too many hospitals. This ignored the fact that the big London teaching hospitals took patients with difficult health problems from all around the country for the best specialist care. The cuts in the number of hospitals and hospital beds led to fast growing waiting lists.
At the same time hospitals were compelled to privatise their cleaning and other ancillary work – brining in private companies to do the work. These companies made their profits in the only possible way by employing fewer people on lower wages. Standards of cleanliness in hospitals dropped and diseases like MRSA started to take hold in the wards. This infection is easy to pick up and many hospital patients get the germs on their skin without knowing. But if this infection gets inside the body, for example through an open wound, it is a killer because it is resistant to most of the antibiotics that doctors can prescribe.
The Tories also set up an internal market within the NHS. Trusts were funded according to how many treatments were carried out. Each episode in a patient’s total care was logged as a separate treatment – for example an x-ray was regarded as an extra treatment to an operation. This called into being an army of administrators, accountants and pill counters – another useless drain on the trusts’ budgets.
It also encouraged trust managers to try to cram in as many treatments as possible, with patients being speeded through their care and discharged to make way for new patients as fast as possible. People were sent home to be cared for “in the community” far too fast. Many had to be re-admitted quite quickly with complications that developed from lack of care. But the managers were happy because it led to more treatments for them to notch up.
The standard time in hospital after childbirth was reduced from 10 days to six hours. Patients who had major heart surgery were discharged within a couple of days to terrified families who did not know how to cope with loved ones who clearly needed highly expert care. This was supposed to be supplied by visiting doctors and nurses; sometimes they came, sometimes not; it depended on communications between the hospital and local doctors. Some elderly and helpless patients were discharged to homes where they lived alone with no one to care for them. If the local support teams were notified, they were cared for, if not they were left to suffer alone and unaided, sometimes for days. All this happened while the local support teams were suffering cuts, reorganisation and privatisation of home-help services.
Commercial finance consultants (their huge fees yet another drain on trusts’ budgets) were brought in to advise hospital managers. They saw extremely expensive intensive care beds and infant cots standing empty and unused most of the year, so they reduced the numbers to save money. Then in mid winter the regular and predictable rise in need for intensive care beds and cots rose; desperately ill patients and premature babies started to be carried from one end of the country to another to find the intensive care treatment they needed. Many did not make the journey. We began to see the regular winter horror of hospital corridors full of patients on trolleys, needing urgent admission but with no beds available. Waiting lists for elective surgery grew even more.
The Tories also dreamt up the Private Finance Initiative (PFI) – a system of financing the building of new hospitals or major reconstructions of old ones using money put of by a consortium of financiers. To the Government the advantages were that this scheme avoided large capital expenditure being made from the government funds for public facilities like schools and hospitals – a form of financing that was outlawed by the European Union. Instead the repayments to the PFI companies appeared as smaller regular yearly costs – along with maintenance and so on – which was acceptable to the EU. It also provided great opportunities for capitalism to make profits. It meant that total costs over the period of the PFI contract – usually 30 years – multiplied dramatically. For example, the former military Queen Elizabeth Hospital on Woolwich Common in south east London was due to be restructured as a major NHS hospital (the last remaining open NHS hospital in a borough that used to have eight). Costs were estimated at £26 million when the project was to be funded by a central Government grant but at £90 million when PFI was introduced.
PFI contracts were binding on the NHS trusts for 30 years or more. The contracts were kept very secret for “commercial” reasons so that on occasions the NHS trust managers did not even know what companies were involved in the PFI consortium. Anti-PFI campaigners were denied any detailed information and to this day do not know who, at the end of the contract, ends up owning the buildings and land. Are the contracts a form of mortgage with the property belonging to the NHS at the end or a form of rent, with the private sector owning it all at the end? That is a commercial secret.
This state of affairs played a large part in the Tories losing the 1997 general election. The ruling class was pushing the destruction of the NHS too fast and backed off a bit. When Blair began his premiership he stopped the internal market in the NHS and put a lot more public money into the NHS. It began to recover slightly and services improved.
But Blair embraced PFI gladly – it solved Government budgeting problems by turning big lump sum grants into yearly instalments, thus pleasing the EU – and allowed a vote-winning expansion of hospital building and renovation. One of the first Acts passed by the New Labour government was a guarantee that any risk taken by PFI companies would be underwritten by the Government. The capitalists could not lose.
But PFI hospitals invariably have fewer beds than the old hospitals they replace – the number is determined by the PFI companies – by businessmen, not by medical staff. The actual work of putting the buildings up has been to sub-contract and sub-contract again, leading often to poor quality work. The buildings are unlikely to last much beyond the length of the PFI contracts; healthcare practices are changing so fast now they will probably be out of date by then anyway.
Since then many PFI companies have sold their contracts on to other companies and the contracts have been rescheduled so the trusts have to pay much more interest.
The Government claims that not so many hospital beds are needed now because techniques such as keyhole surgery mean shorter stays in hospitals. Also from time to time the Government comes up with new initiatives for people with chronic conditions such as asthma, some heart conditions and so on to be treated in their own homes by community doctors and nurses instead of being admitted to hospitals.
Meanwhile, the local doctor services had been undergoing a transformation into primary care trusts (PCTs). Doctors were encouraged to work together in small groups and to include practice nurses, who would deliver routine care for minor problems, carry out health screening tests and immunisations. The doctors were given large budgets with which they could buy hospital care for their patients.
This was supposed to give patients a “choice” in what care they received and where they got it from. The actual choice is made by the doctor but 90 per cent of patients prefer to be treated at their nearest hospital. The Government seems totally unaware of the fact that long-distance travel when seriously ill is very uncomfortable. A more distant hospital may have better facilities but the trouble of getting there, and subsequently attending out-patient clinics, outweighs most benefits.
Local doctors also benefit from the attentions of the sales teams from the major drug companies, who fund medical conferences in nice holiday spots like the Bahamas and many other perks. The drug companies realised long ago that when a doctor prescribed one of their drugs for a patient with an acute (short-term) condition – for example an infection – they make so much profit, the patient gets better, no longer needs medicine and the profit stops. But if the patient has a chronic condition (permanent), like diabetes, asthma, high blood pressure and so on, the patient has to take medicine for the rest of their lives and the profit goes on and on. Some medical experts believe that real cures for these chronic conditions could bankrupt big drug companies.
In China most of these conditions that are considered chronic in the West are considered acute in the East. Asthma is regarded as a childhood ailment that is completely cured by a combination of herbs and acupuncture but mainly by a change in diet – avoiding certain foods. Incidentally, Chinese visitors to the West are stunned at the volume of confectionary sold to adults. To them, sweets are only for children – and only then as treats – and people lose their taste for them as they grow up.
In the summer of 2005 the Government put forward a plan that would change PCTs from bodies that delivered direct care to patients into administrative bodies that simply bought care from private medical companies: the monetarist dream come true. The Government all the while has been urging doctors to use their spending power to send more and more patients to private hospitals and clinics.
In December 2004 the Blair government was almost defeated in the House of Commons by a backbench rebellion when it passed the Bill that would introduce “foundation” hospital trusts. These trusts would be freed from Government constraints to use their budgets as they chose. They would be able to borrow money from finance companies and engage in commercial enterprises to raise money. But they could also face bankruptcy if they got their sums wrong.
And this is what has happened. Most trusts eagerly went for foundation status but they had been set up to fail from the start. They began with deep debts from their very inception and by now invariably loaded with long-term heavy PFI commitments. But they drew up business plans and expected to be able to cope by increasing their rate of operations and other treatments and reducing waiting lists by doing so.
But they did not take into account the growth of private sector hospitals and clinics, with the Government putting heavy pressure of PCTs to use them wherever possible. So the private sector took a large volume of routine operations, leaving the more complicated – and therefore expensive – cases for the foundation trusts. Within a year the foundations trusts had run up serious deficits. Foundation status had also reintroduced the internal market into the NHS, making hospitals compete against each other and against private sector hospitals and clinics.
They hoped the Government would bail them out but it flatly refused, telling the trusts they must sort out their own financial affairs.
The effects of this were felt earlier this year as trusts throughout England (Scotland and Wales are lucky enough to have democratic control of their own health services) realised they had to make drastic economies – cutting thousands of jobs and reducing services and provoking a storm of protest. The health service unions are playing a leading role in organising this protest, which also involves patient groups, pensioner organisations and many local community groups.
But there is worse to come. Predictions are that next year’s deficits will be as bad if not worse than this year’s. Job cuts have led to big redundancy payments but the worst problem is the way the Treasury works. When any Government department cuts buildings and jobs, the budget to sustain those jobs and buildings is also cut. Furthermore trusts are still obliged to pay for PFI buildings even if they are no longer used. So we end up with empty wards that the trusts cannot afford to staff but which still have to be paid for.
There is only one way that trusts can make a dent in their huge debts – and a small army of Government financial consultants has been going round the country pointing this out to the trusts. They must engage in more commercial activity. Those empty wards could be used for private, paying patients, or subcontracted to private healthcare companies.
More extra services could be offered to patients – at a price.
So now cash desks are starting to appear near the reception desks in major hospitals. And services that were once part of standard treatment are now being offered as extras at a price. For example a seriously patient needing a room to themselves will be offered such a room “for £30-a-night” extra, when previously the decision would have been based on their need and the availability of single rooms. It is clear that very soon the standard of treatment will depend very much on the ability to pay – not just for extras but for basic care. The monetarists are winning.
Stopping this process depends entirely on the strength of the organised working class. This is a struggle that cannot be left to health service unions alone. Every union in the country must become actively involved in the struggle. The ruling class must again learn to fear the strength of the working class as it did in 1948.