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From The Socialist newspaper, 14 September 2006

Health Service condition critical

Our prescription - a socialist NHS!

THE NATIONAL Health Service is in deep crisis.

For all the Blair government's talk of putting more money into the NHS, the main effect of their years in office has been an increase in cuts, closures and privatisation.

These attacks have created opposition on a huge scale.

At the end of August around 30,000 people marched through the small town of Hayle in protest at cuts and closures of Cornwall's hospitals.

So what would a socialist health service be like? ALISTAIR TICE offers his own ideas.

FOR A start, a socialist health service would put a stop to New Labour's privatisation madness! Socialists would open up the accounts of big business within the NHS. This would expose the business secrets hidden behind the 'commercial confidentiality' clauses of the notorious Private Finance Initiative (PFI) contracts in the NHS.

Scrapping the PFI rip-off would not only save billions of pounds but also stop locking the NHS into paying for buildings and projects that may not even be 'fit for purpose' in 30 years' time.

Private hospitals, independent treatment centres and corporate-owned care homes would be taken into public ownership and incorporated within the NHS. Private care homes would be required to meet minimum standards of service provision, staffing levels, pay and conditions or be taken over.

A socialist health service would nationalise the pharmaceutical and medical supplies industries. The cost of drugs makes up 10% of the entire NHS budget. Multinational drugs companies take £billions out of the NHS through overcharging, price-fixing and blocking cheaper generic drugs.

Profit

Worse than that, the medico-industrial complex dictates that NHS policy tends towards treatment rather than prevention. It also chooses to pursue profitable treatments for common western ailments rather than killer diseases (like HIV/AIDS) in poor countries.

Freeing up the NHS from the grip of the drugs industry would also allow rigorous, scientific research into alternative and complementary therapies such as acupuncture, osteopathy, chiropracty and homeopathy. Some of these may prove more effective in certain cases and certainly cheaper.

And brand new fields like Stem Cell research, which may provide treatment for hereditary and degenerative conditions, could be invested in, freed from the constraints of profit and of reactionary ideology a la George Bush.

One of the founding principles of the NHS was that it is 'Free at the point of use'. Tony Blair still repeats this mantra as he hands over ever more services to the private sector. But it's not true. There are charges for prescriptions, dental and eye examinations and treatment, convalescence and for many aids, adaptations and equipment for disabled people. All these should be scrapped.

In any case, what's the point of 'free at the point of use' if the waiting list is a year, 18 months, or longer, and you can't afford to be off work or stand the pain any longer, and are forced to go private. That's not free! Socialists would make health care 'Free at the point of need.'

Collective participation

TONY BLAIR talks about patient choice in the health service but what say do ordinary people have when their local hospital is closed? Most people don't want to choose between travelling miles or going to a private treatment centre. They want good-quality, publicly funded, free health care in their local area.

Socialists really would put patients at the centre of the health service. All of us will be users of the service at some time in our lives. We should be 'active' patients. Active in the sense that as individuals we participate in our own health care by taking informed decisions, rather than being the passive recipients of experts' treatment as in the paternalistic doctor-patient relationship - or worse still the customer in the provider/customer marketplace.

We should also be 'active' by collectively participating in deciding on health needs and priorities both nationally and in our local area. There should be a national census of the nation's health. From that a plan could be democratically drawn up of what is needed in terms of prevention, public health, hospitals, clinics, doctors, nurses etc.

Resources would then be allocated for these plans to be implemented at a local level, rather than through New Labour's 'commandist' top-down system of crude targets.

To achieve this would require the integration of all aspects of health services: primary care and hospitals, health services with social services, public health and community care. So the internal market of purchasers and providers with Trusts competing for patients as customers and 'Payment by results' must be scrapped. Integration not competition should be the watchword.

Health care should be brought closer to the patient, but not by New Labour's unfunded 'care in the community' which is mere rhetoric to justify cutting hospital services. And not by doctors' surgeries in Boots and eye-tests at Asda!

Real community care focusing on public health with more health visitors, doctors and nurses would shift health care away from being hospital-centred, and away from just treating illness to actively encouraging well-being.

The public health system in Cuba shows the possibilities. There, the GP-to-patient ratio is three times higher than in Britain. Family doctors are attached to neighbourhood polyclinics (health centres) serving the local community.

These primary care teams provide for most health care needs, including dealing with over 50% of emergencies. This has resulted in hospital admissions declining by 25% over the last 20 years and hospital waiting lists of only one to two weeks.

Cuba is a poor country. It has a planned, publicly owned economy but is administered in a bureaucratic, top-down and undemocratic way. Imagine what would be possible in Britain, the fourth richest country in the world, with a health service that was publicly owned, publicly funded and democratically controlled within a broader, planned economy.

Too many managers?

"THERE ARE too many managers, suits, and clipboards" is a common complaint. "Bring back the matron" is another often-voiced opinion. It's true that since the Trusts were set up by the Tories 20 years ago, supposedly to get rid of bureaucracy and run the NHS more like a business, there are now three times as many managers.

Even worse, last year Trust bosses employed private management consultants costing over £1 billion to advise them on who to sack! The NHS used to be the most efficiently run health service in the world with only 4% of its budget going on administration.

Now with increasing layers of bureaucracy and the costs of the internal market, that figure has risen to nearer 20%, nearly a fifth of the entire budget goes on administration! What a waste!

Obviously the health service needs to be managed. The "Bring back the Matron" demand expresses people's desire that the NHS should be run by staff who actually work in it and know how to do the job. But the old matron system was very hierarchical and 'commandist'.

Instead, socialists would introduce democratic workers' management at every level, from the hospital ward and local health centre right up to a regional and national level.

One of the things that health service workers pride themselves on is being part of a team. That must be a team of equals when it comes to having a say in how the health service is run. Cleaners are as vital to the NHS as surgeons as the MRSA superbug scandal has proved. So, all staff would be represented on elected committees to manage the health service.

And the local community, the users of the service (and we're all potential patients) would be involved in the management of local health services as well. In this way it would be possible to democratically decide local health plans and needs.

For example, it may be decided that an old hospital should be closed as more patients are treated by the primary care team and the saved resources better used to fund a new health centre - such decisions would be taken after a real consultation, not the fake ones we have now after the unelected, unaccountable and undemocratic Trust bosses have already imposed their cost-cutting decisions!

Dedication exploited

THE CARE and dedication of health service workers has always been exploited. Governments and managers have taken advantage of workers' reluctance to take industrial action because they don't want to harm the patients. This would stop.

All health workers would be employed by the NHS and should be paid a decent living wage, at least the European Decency Threshold of currently £8.40 an hour. On top of that, experience, skills and extra training and responsibilities, currently scarcely recognised, should be rewarded properly.

Agenda for Change, the Blair government's job evaluation system in the NHS could, in principle, have provided a framework for evaluating job descriptions. But it was deliberately under-funded, so it has led in many cases to an equalising down of pay. In any case, many Trusts are now effectively tearing up Agenda for Change by abolishing posts and arbitrarily downgrading staff as part of their cost-cutting.

A socialist NHS would immediately end split shifts, long shifts and other unsocial working patterns that make staff ill and can put patients at risk. A big increase in staffing numbers would be needed to make this possible. For a start, the newly qualified nurses and midwives who can't get jobs now due to the cuts would be taken on.

Many nurses and other paramedical staff would return to work in the NHS if it offered decent pay and shorter or more flexible hours. The only nursing agencies needed would be an NHS 'bank' or pool to provide cover in the event of sickness and emergencies.

Staff training would need to be expanded, especially of primary care workers and paramedics. More doctors would be needed. Medical training needs to be opened up to challenge the class snobbery inherent in the consultant/doctor system, which has created a professional elitism and often a distinct lack of reassuring bedside manner.

In-service training would allow health workers to train-up with the appropriate salary increase. More students would be encouraged by the scrapping of tuition fees and the restoration of a decent living grant.

There is a case for a maximum salary for managers, consultants and GPs. Private practice would be ended and all medical staff, including GPs, would become fully salaried NHS staff.

In the short-term it might be necessary to retain specialists through high salaries (especially as they could no longer 'stuff their mouths with gold' through private practice) but as more doctors trained within a socialist health service then the ethos of public service would become more of a motivation than lucrative financial rewards.

That is the case in Cuba where the maximum salary differential in their health service is 5:1 and thousands of doctors would rather volunteer to work in the shanty towns of Venezuela than in private practices in the USA.

How would we pay for it all?

MORE HOSPITALS and health centres, more doctors and nurses, more pay... How are we going to pay for it all? In the short-term, billions of pounds would be saved by stopping the PFI and privatisation rip-off, by scrapping the internal market, sacking the management consultants and cutting administration costs through democratic management, and by ending the drugs swindle. That would release existing health spending for new investment.

In going private, some people argue that they are helping the NHS by not taking up its resources when they can afford to pay. But in reality the private sector drains resources out of the NHS. Socialists would increase the percentage of public spending on the NHS by cutting back on the billions of pounds wasted on war and armaments.

Certainly, there is an enormous demand for health service resources, and new medical breakthroughs and technologies will always cost more money. However, with a democratic system of workers' and community management. society will be able to decide where funding and investment is most needed or can be more effectively used. And some advances can save money, like microsurgery which can be done as a day case instead of a lengthy inpatient stay.

More resources would be directed to the 'Cinderella' services such as mental health, care of the elderly and disabled, which have always been under-funded because they have less of an economic return. And public health, which has always been part of the rhetoric but only ever allocated 1% of NHS resources, would be made the top priority.

Then, in the longer run, health care costs to the nation could actually be cut as the mass of the population enjoy better health. There would be fewer working days lost through sickness and stress, fewer hospital admissions and less drugs dispensed.

And yes, people would live longer too, which rather than causing a pensions crisis, would mean longer to contribute to society should people opt to, and longer to enjoy the benefits of better health in work and a properly paid retirement. Why should we expect to die only two years after retirement!

Prevention not cure

HISTORICALLY THE greatest advances in the nation's health have come about as a result of public health measures such as clean water, sanitation, cleaner air and decent council housing. Yet in a capitalist society there will always be huge disparities in health between the rich and the working class.

26 years ago, Professor Douglas Black wrote The Black Report - Health Inequalities in Britain which highlighted this divide but was suppressed by Margaret Thatcher, the Tory prime minister at that time. Those inequalities have grown since due to Thatcher's and now Blair's neo-liberal policies.

For a socialist health service to work, a socialist government would have to address these inequalities. Policies such as a decent minimum wage, benefits and pensions, full employment and a shorter working week, and cheap affordable housing to rent or buy, would eradicate poverty which is the biggest single cause of illness.

With a decent standard of living - and a food industry run publicly to ensure that nutritional concerns were not compromised by big business priorities of profitability - people would be able to afford better diets.

With less stress and more leisure time people would be less likely to smoke and drink alcohol to excess, and more likely to exercise, again reducing the incidence of major illnesses such as heart and lung disease and obesity.

A cheap, decent, integrated public transport system would start to cut down car congestion, reducing road traffic accidents and pollution. Occupational diseases and accidents at work would be reduced through better health and safety protection and corners not being cut in the chase for profit.

Yes, this all sounds pie in the sky under the present capitalist system. But the resources and technologies already exist for all of this to be possible. But it would require the socialist transformation of society to make it happen. Then health care would be geared to prevention rather than cure, and well-ness rather than illness. Through public health education, everyone could become an active patient, an expert in their own health.

The National Health Service's principles embody socialist values - from each according to their ability to each according to their needs.

We must defend and improve the NHS with socialist policies to make this a reality.