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Book Review: ‘The NHS – A Picture of Health?’

Sick service

‘The NHS: A Picture of Health?’ by Steve Iliffe (Lawrence and Wishart 1983 p/b £3.95 224pp)

This book, written in a fluent, easily readable style, examines health politics from the industrial revolution to the present time.

The author, a general practitioner in North London, is already well known to readers interested in health politics as a regular contributor to medical and political magazines, as a member of the editorial committee of Medicine in Society and a pamphleteer for the Communist Party of Great Britain.

The first chapter deals briefly with the years leading up to the formation of the Health Service and describes how, in the 1830s, cholera, syndicalism and Chartism “emerged from the slums and threatened to harm the established order” and that although repressive measures followed, the government realised that some reforms had to be made to reduce the threat to established power.

The political motives underlying the 1911 National Health Insurance Act are examined with its attempts to undermine the influence of the new Labour party; placate labour agitation; provide a fitter fighting force for the impending war with Germany; make the working population believe that the war was worth fighting on the promise of substantial social change. The 1948 National Health Service was “to be a ‘jewel in Labour’s crown”, the greatest public institution in the new socialist Britain. Unfortunately, the reality did not conform to either fantasy” (p. 24).

The pay and conditions of Health Service workers in the next two decades are discussed in more detail. The author describes how manual workers in the National Health Service during the 1960s were among the lowest paid workers in the country and that the government, uninterested in providing adequate Health Service funds, exploited overseas workers who were recruited to fill the gaps. The low market value of manual and domestic work is seen as the major obstacle to better pay, outweighing the weakness of health workers’ unions. The last decade is examined in greater detail — the cuts in the level of services provided; discontent among health service unions; higher rates of disease and death among working class people.

The closure of mental hospitals without adequate alternative provision causes mentally ill people to drift into the “homeless, workless population that sleeps in cardboard boxes and derelict buildings, rummages through litter bins and provides police, courts and prisons with an unpunishable stratum of hopeless recidivists” (p. 103). Steve Iliffe describes how administrators

    “. . . were able to use loopholes in the regulations to accelerate change. “Temporary” closures could be announced, without recourse to consultation through the CHCs (Community Health Councils) and quietly be made permanent, later on (pp. 122/3)”

The author discusses the mixed economy of health and states: “Only the Communists and the far left advocate economic renewal aimed at a preserving and expanding public services”. No evidence is given to back this statement and, indeed, socialists are aware that only a socialist, moneyless society can resolve the contradictions of capitalism.

There are two very interesting chapters on commerce and professionalism, and class, consumerism and resources. The author describes how market forces have developed a health service which treats rather than prevents disease because of the profits to be made. Professionalism is seen as the setting up of “trade secrets” and is based “on the idea of service and the practice of trade” (p. 46), placing control in the hands of professionals.

In looking at attitudes to smoking the author makes some interesting comments about Russia;

    “The USSR faces a chronic labour shortage and has many reasons to pursue a health provision policy, but these appear to be offset by other economic and social considerations”


    “Only by denying that the USSR is socialist can we maintain the myth that socialism will solve our current problems, and then we have only hopes, dreams and the thoughts of assorted prophets, past and present (pp. 176/7).”

Also there are odd statements such as: “British ‘socialism’ is at its strongest when shaping the state, even when it shapes it in the interests of capital”. The book concludes:

    “The right has the market relationship as its basic form of social organisation. So far Labour has concentrated on a different relationship between state and citizen, that was designed to modify the market relationship In the future it may not be able to gain much advantage from this approach, and will have to think again about social organisation and the role of the state. The development of participatory democracy now, in experimental ways, could inspire that new thinking and shift the initiative in health politics further to the left than it has ever been before.”

The NHS: A Picture of Health? is a stimulating book for the arguments put forward, and for the brief, but interesting history of health services in this country. However, there are considerable areas of disagreement and it is the political tactics, opportunism, reformism and compromise embodied in the final paragraph which socialists entirely repudiate.

Carl Pinel

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