Socialism in sick times
Socialism and the NHS
There is a sleight of hand in almost every public conversation about the NHS. Like the old “buy one, get one free” marketing strategy, it’s anachronistic because you’ve obviously “bought one” before you got the other one “free.” Similarly, the NHS is not “free at the point of service,” despite politicians’ unending incantations that it will remain so every time a government on either side of the aisle is accused of trying to privatise it.
Citizens, permanent residents and those with right to remain in the UK pay to use the NHS through taxation and National Insurance contributions. Others living here on temporary visas are obliged to pay hefty fees of as much as £3,120, often on top of their taxes, to gain access to the service. There are prescriptions, procedures and services for which the NHS requires payment regardless of your nationality or visa status. So “free” is a misnomer on its face.
Still, the NHS is a marvel, the greatest legacy of the twentieth century’s working-class victories in the UK. By the end of the Second World War, many Britons believed that a new world would be rebuilt from the ashes of the old. Under a newly elected Labour government, health minister Aneurin Bevin ushered in the National Health Service Act 1946, sparking a huge public endeavour that relied on what we now call ‘the post-war consensus.’ After the unprecedented destruction wrought on three of the planet’s five continents during the war, Britain’s workers demanded nothing less than a transformation of civic and social life.
The construction of a National Health Service from whole cloth answered that demand. A project of its scale and scope was made possible by the widespread belief that if society could mobilise for ‘total war’ then it could be mobilised for a superior peace than had ever been achieved before—it was a vision of total peace. You could call this kind of ambitious, far-reaching civic engineering ‘socialism.’
But it wasn’t beliefs, desires or political ambitions that brought the NHS into being. The massive cost of the war effort, human and financial, and the urgent need for workers to rebuild the country’s ruins, provided the working class with added economic and political leverage. Trade union density grew from a little under six million before the war to nine million in 1946 as men returning from the military re-joined the workforce. An organised working class were not only better positioned to make demands but to act decisively if these demands weren’t met.
This leverage got results. A quick look at the history of strikes in the UK shows a gap in the post-war period all the way up to the mid-1960s—not because a disorganised labour movement was crushed by the property-owning class but precisely the opposite. The Labour Party won a landslide victory at the 1945 election, ousting the hated Tories and their “national hero” Winston Churchill. The ballot precluded the need for the bullet as political parties campaigned on popular policies that they would genuinely have to deliver on.
Old threats to capital from before the war, subsumed in the united front against fascism, soon reappeared. The Soviet Union emerged as a key power on the world stage, despite losing over twenty million lives to the fighting. Having liberated Germany and most of the concentration camps as they swept the Eastern front, communist allies couldn’t be so easily characterised as enemies (though this wouldn’t last long in the Anglosphere). Quintin Hogg, later a Tory MP, warned in 1943 that ‘we must give them reform or they will give us revolution.’ Britain’s ruling class—including Labour Party leadership—rightly perceived that communism’s call for radical social transformation would prove a threat to their own legitimacy if the men and women who sacrificed so much for victory were not rewarded handsomely.
Perhaps some had to hold their noses, but social democrats, liberals and conservatives alike broadly supported the creation of a welfare state and a National Health Service, a mixed economy that included nationalisation of key industries, a policy of full employment and a more central role for trade unions in policy making. It was time to put away the stick and hand out carrots as fast as possible.
So there never was a time when the British public hasn’t paid in full for the NHS. It’s the standalone instance when we got what we paid for.
From its inception, the service has been at once a kind of beacon for socialism but also a bulwark against further working class demands for a comprehensive shake up of property relations in Britain. Since the 1970s, the beneficiaries of this property relationship have chipped away at the other working-class gains of the post-war consensus through a radical restructuring of the economy often called ‘neoliberalism,’ providing us with a glimpse of what’s in store for the NHS.
But as the neoliberal dogma of free market fundamentalism proved untenable in light of the coronavirus pandemic, the British state took a much more interventionist approach to managing the economy. And now those interventions for the public good are being rolled back at the same time that inflation and the twin crises of housing and the cost of living begin to bite. Unlike in the post-war period, those of us who sacrificed are expected to sacrifice some more.
Capital never lets a good crisis go to waste—neither should we.
The NHS is the last vestige of a demand for ambitious—you might even say revolutionary—social restructuring to benefit regular people; a glimpse of what total peace might have looked like had a wider revolutionary project succeeded. Can its successes
or its failures provide a model for socialism today? Or does its slow starvation carry a message that public health is bestowed upon us from above—that the future is already written and that we are certainly not the victors?
The NHS and Civic Identity
It’s fair to say that people generally get used to what they’ve got. Capitalism has a way of naturalising the social relationships that dominate our lives. If you’ve always lived in a country where healthcare takes a huge bite out of your paycheque—or where you simply can’t have it because you can’t afford it—this becomes the normal state of affairs. After all, you’re just one person who needs to eat, find shelter, and scrape together the means of returning to work again tomorrow.
Likewise, if you live in Britain you’ve always had the NHS; it’s hard to imagine life without it. You were probably brought into the world by an NHS midwife, nurse or doctor. Even if you’ve barely ever used it, you know someone who has.
You’ve also probably heard horror stories from the US of people dying from totally preventable diseases because they couldn’t pay for treatment. You may have heard that a third of crowdfunders exist (and mostly fail) to pay for such treatment or to avoid “medical bankruptcy”—some phrase! You might have thought to yourself, ‘what a shame,’ relieved at the foreignness of such a scenario.
Or perhaps the NHS has badly let you down—maybe you’re one of the many people on these outrageously long waiting lists that pepper the headlines. You might be one of the millions of Black or minority ethnic people in Britain on the sharp end of health inequalities outlined in a recent report by the NHS Race and Health Observatory. Maybe you’re a transgender person
struggling against outdated gender recognition procedures; or a woman who suspects she’s got endometriosis and has struggled for years to get a doctor to take you seriously instead of blandly telling you to ‘get pregnant or have an IUD fitted.’ Maybe you think the NHS shouldn’t be free because there isn’t a “magic money tree.”
In any case, for good or bad, the NHS helps form the contours of your civic identity.
Most people in this country don’t have the time or the wherewithal to stop and consider life before (or in the absence of) public healthcare. Why would they? So much discussion about the NHS begins with blind spots and unexamined assumptions, good feelings littered with gaps in knowledge that are easily exploited by an owner class (and their representatives in Parliament and the media) whose interests are diametrically opposed to the very idea of a “free” health service. Capital sees all nationalised public utilities as untapped revenue streams, profits just crying out to be realised.
And they’re not wrong, if we use the American system as the standard for-profit healthcare model.
For-profit Healthcare is Class War
The American healthcare industry is worth around $4.5 billion and, as one of the fastest growing industries in the world, its value is projected to increase by around 50% by 2028. A Brookings Institution report describes how the healthcare sector employs one tenth of American workers and accounts for a quarter of government spending. Americans spend more than any other country in the world on healthcare—more than twice as much as people in Britain. Even by US standards, Americans now spend 290% more on healthcare than they did in 1960 (adjusted for inflation).
Despite—or more likely because of—the industry’s profitability, health outcomes in the US rank the lowest among high-income nations. A study conducted by the Commonwealth Fund shows that the US has the highest rate of women dying in childbirth in the developed world, with the vast majority of these deaths being preventable. Infant mortality, a key marker of a country’s health, is also among the highest in the US compared to other wealthy countries—and disproportionately so for Americans who aren’t white.
Covid has exacerbated the already existing American healthcare crisis: the CDC reported last year that US life expectancy dropped by a whopping 1.8 years, mostly due to coronavirus deaths—the largest one-year drop since the Second World War. In the decade before coronavirus hit, American life expectancy was trending down in part because of an opioid epidemic orchestrated by Purdue Pharma and its owners the Sackler family. The Sacklers harvested $10 billion in profits from their highly addictive and often lethal drug OxyContin.
While people with access to the higher end of healthcare in the US report among the best health outcomes in the world, they are an absolute minority. As the Brookings report points out, a mere 5% of the American population accounts for half of all healthcare spending. Commonwealth Fund president David Blumenthal stated it bluntly to CNN: ‘In no other country does income inequality so profoundly limit access to care as it does [in the US]’.
The immiseration facing workers in the US is evident in the number of people who are either underinsured, have only limited access to state programs like Medicare or Medicaid, or have no healthcare coverage at all. An NCBI report relates how ‘[a]round 45 million Americans under the age of 65 lack health insurance cover, and far more US citizens than UK citizens report that the cost of healthcare is a barrier to access.’ This same report showed that the NHS delivered the most equitable healthcare of all the countries studied, with the proviso that waiting times for treatment were usually longer.
This parlous state of healthcare helps capital discipline American workers. Employers and policy makers leverage access to insurance cover, treatments and medications to keep wages low while also limiting the power of workers to organise and fight back. The Brookings report notes that employer-funded health insurance can represent as much as 26% of a worker’s pay packet and is ‘one of the largest categories of consumer spending’. You’re less likely to quit your job, or form a union, or go on strike if the threat of losing access to healthcare dangles over your head like the sword of Damocles.
The economically coercive relationship between workers and those who provide them with healthcare—or withhold it from them—perfectly reflects the underlying class antagonisms in American society. Bernie Sanders weaponised these antagonisms in both his 2016 and 2020 presidential campaigns. He frequently cited the ridiculous discrepancy between the price of insulin in the US, where it can cost as much as $1,400 a phial, compared with neighbouring Canada, where the price averages at one tenth of that. The for-profit American healthcare system was in some ways an easy target because the profits are so huge and the unfairness of the system so glaring.
But despite the enduring popularity of flagship policies like Medicare For All, which still ranks high in voter polls, Sanders’s campaigns failed in the face of ruling class reaction. Whether his target audience were put off by the idea of “socialism” as liberal and conservative media outlets insist, or because they simply didn’t believe that Bernie could seriously overcome the excesses of American capitalism—or because of outside interference in the democratic process—the Bernie Sanders campaign could win nothing but the argument.
With Jeremy Corbyn’s efforts on this side of the Atlantic collapsing for much the same reasons as the Sanders campaign, we’re reminded that being right is never rewarded with an endowment of power because power is won, never endowed. And it isn’t won with superior arguments.
European Healthcare Models
While European countries with comparable populations and economies to the UK almost all have some version of universal healthcare, they’re often comprised of for-profit service providers, with a larger proportion of people paying for health insurance, either privately or combined with state subsidies.
European healthcare services tend (with notable exceptions like Portugal and the Scandinavian nations) towards what Americans call single-payer or multi-payer systems, where most healthcare costs are guaranteed for all those but the wealthiest, while leaving open a market for private health insurance.
In Germany, for example, their multi-payer system operates by making health insurance mandatory, with people on lower incomes, retirees and others eligible for publicly funded coverage. This theoretically remains a form of universal healthcare—though in practice that’s not always the case, especially for people with complicated migration status. It also leaves many workers reliant on employers for health insurance, echoing the American model. France’s healthcare system is primarily publicly funded, with government spending on healthcare similar to that of the UK. Their system works as a form of social security covering the bulk of expenses, with the additional requirement to purchase a top-up ‘mutual’ health insurance. Most people in work earning an average salary will pay for their visits to the doctor or other medical treatments and will be reimbursed either in part or entirely, depending on the treatment and their personal circumstances.
Germany and France have broadly similar health outcomes to the UK and there are relative merits to the European model compared to ours, mostly around choosing your doctor or varieties of treatment for the same illness. But their systems commodify healthcare and are not as straightforward, nor as cost-effective, as a fully nationalised health service. Germany
and France spend more on healthcare per person than the UK—£4,432 and £3,737 respectively, compared with Britain’s £2,913.
Sick People in High Places
The UK demonstrated a contradictory public health and executive response to coronavirus compared to other countries under discussion. Key differences were reflected in the outcome of the initial vaccine rollout.
Now—overall vaccine uptake since the early stages of the pandemic has varied wildly within the UK and other countries, with the symbolic value of being vaccinated fuelled by a tenacious antivax sentiment and a virtue-signalling reaction to it, both more attuned to political culture than to health.
That said, when the vaccine was first introduced and lacked a coherent cultural-political valence, its rollout demonstrated countries’ varying abilities to rapidly acquire, distribute and deliver vaccine shots to people who needed them. So let’s leave the cultural and political questions around the vaccine aside.
The NHS had great success getting shots into arms despite the devastating underfunding of the past several years. Harkening back to the ‘total war’ of the thirties and forties, the government appealed to a nostalgic wartime sense of our civic identity, using the NHS to obscure the class divisions brought to the fore by the pandemic. In fact, while the government publicly took credit for the UK Covid-19 Vaccines Delivery Plan, it was left to NHS workers to plan and enact the rollout, as reported in The London Economic last year.
Thanks to the service’s centralised structure and its administrative capacity to plan orders of medicines on a national scale, at relatively lower costs than private healthcare bodies (a feature of the service’s greater buying power outwith the pandemic), Britain easily acquired the vaccines the country needed. It also used its network of localised trusts to ensure that the vaccine was distributed equitably across the UK, in many instances with logistical support from the Ministry of Defence.
The vast majority of the 1,500 vaccination sites established at the outset of the pandemic were NHS-affiliated spaces such as hospitals or pharmacies; some were places of religious worship, with a small fraction of commercial premises. The people administering the shots were either NHS nurses and doctors or volunteers organised under their guidance.
Many of those on the frontline of the vaccine rollout performed this organisational feat without sufficient PPE—due to the government’s failure to secure adequate equipment on time. We now know that the contracts the government awarded to private companies for PPE through their ‘VIP lane’ has lost the taxpayer £8.7 billion in wasted or unusable equipment.
To add insult to injury, during the initial rollout almost none of the frontline workers and volunteers administering shots were themselves eligible to be vaccinated—ministers’ pin badges and performative tears notwithstanding.
Despite governmental malfeasance, NHS workers’ organisation and personal sacrifice led to over forty-three million doses of the vaccine being administered in the first six months of its rollout—an astonishing accomplishment for which workers deserve more than clapping.
But Boris Johnson’s band of bunglers squandered the early success, allowing the virus to spread almost uncontrolled through their evident (though unspoken) policy of herd immunity. Ministers encouraged people to visit restaurants just as the curve started to flatten, with their ‘Eat Out to Help Out’ scheme leading to a predictable spike in infections, hospitalisations and deaths.
The UK currently suffers one of the highest proportional death rates among rich countries, with over 160,000 covid deaths reported —though the Financial Times has pointed out that these numbers are likely underestimates because deaths in excess of the annual average are far higher.
The catastrophic US response speaks for itself.
While European countries struggled to contain the virus in the early months due to the EU fumbling their plans and negotiations around vaccine supply and production, most advanced economies on the Continent have managed to outperform the UK in terms of deaths per hundred thousand: Germany currently stands at around 144; France around 203; the UK 240.
There’s only so much the NHS can do.
European capital may not be able to make the same emotional appeal to people’s civic nostalgia for a post-war institution like the NHS, but they don’t need to. German and French workers have not faced the same level of immiseration from covid that UK workers have, mostly down to their comparatively generous social security protections (including up to 100% paid sick leave) and the rules around eligibility being eased further and for longer than here in the UK.
Socialism in Sick Times
Every generation is an heir to its past. It wasn’t an impersonal liberal-democratic order that endowed us with a National Health Service—working class people feeling their power at a unique moment in history demanded and won it. But if we lose the NHS, so too will those who come after us.
In the UK today, there is a democratic deficit that reduces public participation in decision making to an occasional box-ticking exercise. No one voted capitalism into existence and it isn’t possible to vote it out. This democratic deficit needs to be addressed at the workplace, the hospital, the care home—wherever we find the encroaching threshold of capital’s dominance over us.
In the light of the Tories’ manifest arrogance and corruption—the illegal parties during lockdown, the fat contracts handed out to friends and campaign donors, etc.—people can clearly see the class dynamic at play. NHS workers are uniquely positioned to build class consciousness and worker power by seizing on the public’s goodwill to take industrial action against privatisation.
One of the primary assumptions of the ruling ideology is that introducing market forces into public institutions produces efficiencies; that reshaping public bodies into private businesses competing on a market leads to better outcomes. The dictum, implied or stated outright, is that greed is good. As we’ve seen with the American healthcare system, which is the market model at its purest, this couldn’t be further from the truth.
Nevertheless, market forces are being thrust upon the NHS as never before with the government’s Health and Care Bill. The bill, which recently received Royal Assent, will rip apart the centralised structure that’s characterised the NHS since 1948, replacing it with 42 Integrated Care Systems (ICSs) comprised of existing public health bodies like GP surgeries and trusts—but with the crucial addition of private enterprises. The Health and Care Bill will also give the Health Minister unprecedented power to intervene in the service at every level—enabling him or her to deskill and defund the role of nurses and other frontline workers while bloating the ranks of highly-paid business administrators, as reported in the Morning Star.
These ‘reforms’ could be the end of the NHS as we know it. According to doctors, unions and groups like Keep Our NHS Public, it will enmesh the service with the very same vampiric American corporations that have decimated US healthcare and the workers who rely on it. These parasites will suck the lifeblood out of our NHS while sly politicians point to the record sums being pumped into the service—only to be bled out by shareholders.
It’s unlikely that the antihuman market forces threatening to devour the NHS will produce a healthcare system like in Germany or France. It’s more likely that our service is gutted to the point of being there in spirit but as a shell of its former self, an inferior option for those who can’t afford expensive—but highly profitable—private health insurance. We simply cannot sit by and watch the NHS swirl around the plughole of for-profit healthcare.
However, that history hasn’t been written yet.
Because the NHS is such a successful model for a nationalised social utility—an imperfect yet clear vision of total peace central to any socialist project—capital desires all the more to see it dismantled. This covert attack on the NHS strikes at the heart of our expectation of public healthcare and its role in civic identity. As such, it has the potential to bring the democratic deficit of British property relations sharply into focus. It can illuminate the class struggle as a fight to disentangle health from wealth; to recapture social necessities that already belong to us, ones that we’ve earned.
But as the fate of democratic socialists like Bernie Sanders and Jeremy Corbyn has shown, good arguments don’t win power. That patient died on the table. It will take NHS workers and the public alike standing up for the service, even if that means entertaining the previously unthinkable possibility of strikes and other forms of industrial action. We don’t have the same leverage that we did when the NHS was founded, but this post-pandemic attack on workers from all sides puts the nature and scope of the struggle in perspective.
In the words of the Greek poet and partisan Odysseus Elytis:
For the sun to turn it takes a Job of work,
It takes a thousand dead sweating at the Wheels,
It takes the living also giving up their blood.