The State of Medicine
The National Health Service was sold to us as a guarantee of health and security but is itself now the invalid of the Welfare State. If not actually bankrupt, it suffers from a lack of much needed investment. If not completely chaotic it is periodically shaken by massive reorganisations which attempt to relieve its administrative problems, often by reintroducing a system previously condemned as restrictive and inefficient. In April 1974 a “three tier” structure was imposed, which severed all links with local authority control; now the latest reorganisation has brought back the District Health Authorities, which include local councillors. At the receiving end of all this are the aptly- named patients, who bring their ailments to the surgery or the hospital in the hope that the NHS is alive and well and competent.
This hope is sustained by a popular misconception of the role of the state as the beneficent, munificent parent of us all its children. This concept springs from the belief that only the state has the resources to run something which is both essential to everyone’s interests and wide enough to operate in that way. For example, the Armed Forces are supposed to protect “our” country, “our” freedom, “our” way of life. The driest of Tories would never suggest that the forces should be owned and financed by private companies—quoted on the Stock Exchange, subject to take-overs, asset stripping and the rest. In the same way, when the coal mines were seen as necessary to the efficient and profitable operation of British industry they were taken away from the fragmented, competitive set-up of the private pit owners and were nationalised.
It was on the same theory that the NHS was born. Before the war, medical services in Britain were disjointed and unco-ordinated, varying in resources and efficiency from one area to another—and not necessarily in accordance with the demands for them. There were over a thousand voluntary hospitals, from large establishments with the most modern equipment and some weightily distinguished consultants down to the small, struggling cottage hospital. About 2000 more hospitals had been founded by local authorities or had sprung from the sick wards of workhouses. They were often precariously financed, living off donations, bequests and flag days, even selling their wall space to the advertisers of patent medicine, which must have been rather confusing to the patients. This haphazard development extended to the other branches of medical care such as GPs, medical inspectors and so on. There was a compulsory medical insurance but this covered only wage earners, excluding their families and was not valid for any treatment other than by a GP.
The war gave an opportunity radically to reshape this confusion into some sort of order and a basis for this was provided by the state-run Emergency Medical Service (EMS) which was at first designed to deal with air raid casualties but whose scope was widened to take in other categories such as evacuated children. The EMS directly employed doctors and nurses, for a wage, and it took over entire hospitals so that by September 1941 it controlled ½ million beds.
At the same time the government was aware of the need to proffer some promises of a better world after the war. as an encouragement to the people who were suffering in the battles, under the bombs and so on. The most famous of these pledges was the Beveridge Report, prepared by a committee which started its work just as Germany was invading Russia and which produced its findings in late 1942. Beveridge promised that “a comprehensive national health service will ensure that for every citizen there is available whatever medical treatment he requires, in whatever form he requires it”.
The coalition government accepted Beveridge’s health service proposals and before their defeat in 1945 two ministers Ernest Brown (National Liberal) and Henry Willink (Conservative) presented plans for a National Health Service on the model suggested in the Report. It was of course left to the Attlee government to push through the necessary Act, to fight the British Medical Association over doctors’ pay and conditions—and eventually to take the credit for what they wrote into history as a great humanitarian reform.
Experience, and the adaptation of the NHS to the everyday needs of a society based on class privilege, have exposed the reform for what it is. Only the most myopic devotee of the NHS would now claim that its services are of the highest possible standard and are freely and equally available to everyone. There is a swelling tide of frustration and disillusionment with the NHS; the 1979 Royal Commission on the NHS commented: “Nor does the evidence suggest that social inequalities in health have decreased since the establishment of the NHS. The position (of partly skilled and unskilled workers) appears to have worsened relative to those in (professional and managerial jobs).”
An essential part of the best treatment is that it should be immediately available; most conditions which need attention can only get worse the longer they are neglected. But one of the big problems of the NHS are the waiting lists, which are well above the half-million mark. An especially grisly economy operates in the waiting lists: economy because it is a matter of resources which are expensive and therefore scarce, and grisly because it often means the death of some of those who are kept waiting. As might be expected, Enoch Powell has described the situation in stark, heartless words:
If the hospital resources are to be continuously used, there must be awaiting list, a cistern from which a steady flow of cases can be maintained. Private practice can afford to have gaps because patients are buying time. (A New Look At Medicine and Politics.)
This probably sounds very sensible on the Stock Exchange, or to government ministers who are aware of their responsibility to run this society in the interests of a small minority. The actual flesh and blood people, who suffer and die in the queue, can be expected to see it differently. In the case of kidney disease, for example, the decision to treat or to abandon the sufferer to die is largely dependent on their place in the economic order of priority. One leading kidney specialist has described the dilemma:
The financial situation is now so acute that children are having to compete with adults for treatment and they tend to lose out because priority has to be given to adults who have families to look after and mortgages to maintain. (Quoted in The NHS — Your Money Or Your Life, by Lesley Garner.)
Many people are trying to escape these obstacles by buying their way into private treatment. The result has been a boom in the insurance schemes like BUPA and Private Patients Plan. Most of this expansion comes from companies who are paying to insure their workers; from their point of view the pay-off is in a quicker, planned admission to hospital, less time off work and easier access to the patient while they are in hospital. (The numbers of people insuring themselves, in contrast, is falling.)
But the private sector too operates on something of a delusion. The kind of insurance which is affordable by wage earners covers only a limited range of ailments—typically, an operation which requires only a brief stay in hospital both before and after the event. It does not cover the chronically sick, the lingering terminally ill, the physically or mentally handicapped, the old people who need intensive nursing during a senility which intensifies towards death. These sorts of ailments can be treated privately but to do so would cost the sort of money which is beyond the scope of the insurance schemes. As one consultant in mental handicap put it: “In mental subnormality you see the patient for the rest of their life”. It is, then, no surprise that BUPA favours a mixed state and private medical service, with the private schemes taking the cream of the short-term patients while the NHS grapples with the rest. A foreseeable result of that would be to depress the state service even further, as investment, doctors and nursing staff were attracted into the private sector.
Whatever the outcome of this conflict, we can be despairingly confident that the basic, vital facts about health and sickness will receive only scant attention. The vast majority of death and disease today does not happen through an accident, nor is it unavoidable. For example, thirty million people die every year from starvation, simply because they are too poor to escape from a famine which itself is the result of the production of food as commodities rather than to meet human needs. Then there are the “industrial” diseases like asbestosis, which are a direct consequence of the way in which some workers get their living and which inflict a brutally slow, agonising death on their victims. More subtly, there is the sickness which can be written into the death certificate as due to other causes but which is in fact the result of the jobs their victims do or the places where they live.
The Working Group on Inequalities In Health recently reported that a labourer, a cleaner and a dock worker are twice as likely to die as is someone in the “professions”; they are twice as likely to suffer respiratory and infectious diseases, have trouble with their circulatory and digestive systems. The distinction is a false one, since both “labourers” and “professionals” are members of the same class but the point is made; it is the former who in many ways suffer the harsher degree of exploitation, the heavier weight of impoverishment. More evidence comes from Professor Harvey Bremner of John Hopkins University, who has spent some twenty years studying the subject. Bremner is convinced that economic stress on workers stimulates physical and mental illnesses; specifically he says that a rise of one million in unemployment over five years could cause an extra 50,000 people to die and 60,000 more cases of mental illness. He also says that Scottish workers are under a peculiar stress, due to a more severe competition between industries there and this is reflected in sickness striking quicker, and more harshly, when there is unemployment.
So it comes down to a matter of class. The working class—those people who need to sell their working abilities in order to live—include those who do the dirty, monotonous, dangerous work as well as those who do the stressful, ulcerative jobs in “management” and the “professions”. It includes the people who crowd into cramped, jerry-built homes under the pollution of industrial capitalism. The other social class, who do not have to work because they own and control the means of life, can afford to live away from all this; they experience no stress of insecurity, their homes are spacious and leisured, they have access to the best of diets. If they want it that way, their lives can be a continuous recreation. The medical care they can command was typified in Tudor Hart’s Inverse Care Law. which laid down that the availability of good medical care varies inversely with the needs of the people it serves. Simply, they can have the best of everything—the best homes, food, education, medicine.
This class do not need the National Health Service, which was designed for the workers, to patch them up and get them back to work as quickly and as productively as possible. Whatever medical care is available to the working class exists only because it contributes, in the short or the long run, to the production of profit and the accumulation of capital. One of the reasons for setting up the NHS, for example, was that it is cheaper to pay for the hospitals, GPs, health centres and the rest through taxation than through the complex process of means testing, claims and rebates which was operated in the private system. Doctors who have trained for years to relieve sickness are persistently faced with agonising choices, based on the demands of a balance sheet rather than human comfort and survival:
If I abandon or downgrade the patient with advanced cancer of the stomach in favour of two patients with hernia, how do I make a cost benefit analysis? How do I equate the loss of six months dyspepsia-free survival with the economic utility of the return of two breadwinners to work? (Garner, op. cit.)