By Dr Julia Grace Patterson
The book is easy to read, also thanks to personal anecdotes from the times when the author still worked for the NHS. It provides some interesting general information, which I will summarise in this review. I found the perspective of how to fight against the deteriorating conditions in the NHS slightly limited: the book primarily suggests that we should inform the public about how bad things are, make alliances with friendly MPs, start petitions and so on. Privatisation is singled out as the main problem, but the internal issues within the NHS remain largely unmentioned, e.g. the repressive hierarchy which forces most of the staff to just repeat the same tasks over and over again.
Perhaps the book is written mainly for ‘the public’, which explains why it sometimes uses pretty scandalising language, such as ‘the NHS is close to collapse’. As NHS workers we know that the NHS is not collapsing, but that both our and our patients’ conditions are deteriorating, and that it will largely depend on day-to-day struggles, instead of some holy reform from above to improve things for us. The day-to-day struggle at work is unfortunately missing from ‘Critical’ and the focus is on the campaigns of organisations such as ‘Every Doctor’, an organisation that the author co-founded. Still, the book is an important contribution to the general discussion.
In the near future ‘Vital Signs’ will interview a doctors’ organisation from Germany which has existed since the 1980s. This organisation attacks the austerity measures and health ‘reforms’ of the government, but also criticises certain aspects of the medical apparatus itself which are to the detriment of working class patients. We have just finished interviewing a junior doctor about recent strikes. Both will be featured on the Vital Signs website.
The scenario
As mentioned above, the author manages to draw an alarming picture of the situation of the NHS by using useful statistical data, e.g. that between 2008/9 and 2020 32,000 overnight hospital beds were cut; that according to the ‘Crowding and its consequences’-study by the Royal College of Emergency Medicine, 4,519 people died in England in 2020/21 due to ‘less than ideal care while delayed in A&E’. Still, we also read that today there are ten times more doctors employed than in 1948, when the NHS was founded. We see an increase in spending for the NHS – or at least for certain sectors within the NHS! – while also witnessing pretty substantial austerity measures, such as the introduction of Universal Credit or the two-child benefit cap. What makes more of an impact on working class peoples’ health – the taking away of social safety nets or the spending on expert medicine? We raise this question not in order to tell what politicians should spend money on – we defend both the access to better medical provisions and welfare – but to understand the seemingly contradictory strategy of the state.
The origins of the NHS
The author portrays the origins of the NHS as both ‘patriotic’ in terms of being part of the national identity, and ‘socialist’ in principle. “It was the shared experience of the war itself – the cohesion, the mutual dependency, the horror and the national trauma – that eventually propelled the NHS into being”. We could question this and add that the experience of large-scale post-war discontent both after World War I and World War II forced the state to provide a basic health insurance in order to prevent a more general movement for socialism. At the same time the NHS also centralised a lot of the command over the health system in the hands of the state – taking it away from numerous smaller clinics which had been funded and run by mutual associations organised by workers in working class towns. While workers’ control diminished, the government made sure that doctors were allowed to keep their privileges, e.g. to have private clients on the side. You can read more on the origins of the NHS in ‘Sick Of It All’.
The reasons for the crisis
The main reasons for the crisis of the NHS is seen in the decisions by politicians who fail to adhere to the original principles of the NHS. But why are they making these decisions? The author claims that “the most obvious place to start is the politicians’ personal political ideologies.” She focuses then on individual politicians who pushed for NHS reforms and who often had an economic self-interest in doing so, e.g. Matt Hancock’s family who owns 20% of a private health company that secured NHS contracts or the 28 Tory MPs who have links to private health groups. While these individual ideologies and interests play a role, they cannot explain the general trend of a system. With the whole system in crisis the state tries to reduce the costs to reproduce the working class – and each government, regardless of their ideological position, finds itself driven to do the same thing. This doesn’t mean that there is no use in struggling against austerity cuts, the opposite is true. But we have to do it as a wider effort that defends general human needs against not only those people who want to make profits, but also those who promote GDP growth, a reduction in state debt or the maintenance of bureaucratic state structures.
The restructuring
The book provides many examples about how the NHS has changed and what drove these changes. In the 1980s the marketisation started and with the private financing initiative (PFI) system under Blair – a system that pushed to build hospitals with private investors and developers – things accelerated. There have been investments of 12.8 billion under PFI schemes into the NHS. According to the Guardian, the NHS had to pay 2.3 billion on legacy charges for these PFI investments in 2022, out of which £1 billion was to pay for maintenance of buildings and £457 million in interest payments. This is interesting for us in Bristol, as Southmead hospital was one of the prime PFI schemes. We should look closer at the actual accounts in future. The Royal London Hospital, for example, has to pay £116 million every year to the private PFI developer, which is 7.66% of the trusts annual income.
The author states: “The NHS trusts affected have become the worst victims of the NHS reforms”. There is a problem with this view, as it puts the trusts’ management and upper hierarchy in the same boat together with the workers and patients. We can be sure that the PFI companies keep the upper-level of the hierarchy sweet. There is a close link between upper-NHS hierarchy and private management, greased through £400 million that the NHS paid on private consultancy companies in 2021. For example, Simon Stevens, the former NHS head, previously worked for the United Health Group, a major US multi-national health corporation. You will find similar overlaps with a lot of the people who form the upper-level of trust management.
Another interesting aspect the author looks at are the volunteers. During Covid, 750,000 volunteers signed up – Sajid Javid called them the ‘NHS reservists’. Volunteers take over more and more positions that used to be paid jobs. Similarly, a lot of health services are now run by so-called charities, with close links to the private sector. For example, ‘NHS Charities Together’ claims that it “wants to build meaningful relationships with corporate partners”. Another big open door for cooperation with the private sector is data, as around 13% of NHS data actually goes to private firms which use it commercially. Still, the growth of private sector health care is a hype. As the author exemplifies, the NHS employs 159,100 doctors, in contrast to the private health companies’ 860. Here it would be interesting to see how many NHS doctors work for the private sector on temporary or short-contract basis – that number will most likely be way higher than the actually ‘employed’ 860.
The forms of resistance
The author helped set up the organisation EveryDoctor. In particular during Covid the organisation managed to create a network of doctors who communicated with each other and discussed the development of the pandemic: “The EveryDoctor community, rapidly growing at this point, pulled together in the face of the crisis. The information sharing and collective support between doctors was fast-flowing.” It would be good to know how that happened and how communication and decision-making was organised. In the book we then mainly read about the demands for better PPE for health workers – which is of course of major significance. We get to know little about the fact whether the actual medical and quarantine decisions of the government were debated and alternative proposals developed. This would have been an important step; to develop an alternative medical proposition in the interest of the general working class, rather than the ‘national interest’. But even if we had such an alternative proposition there would still be the issue of enforcing it against the power and economic self-interest of the state. Here it seems EveryDoctor sought its allies amongst ‘progressive MPs’, rather than the wider NHS and health sector workforce.
The network’s tasks are described as “hold the government to account”, “demonstrate to the public”, “raise public awareness”. “With the help of a large number of MPs from various political parties we were pivotal in securing some policy changes…” The network organised weekly parliamentary briefings with up to 40 MPs present and helped to construct questions for Prime Minister’s Questions. During the EveryDoctor campaign against Health and Care Bill 2021, 12,000 people wrote to MPs within a couple of days. Here we can see that a grassroots initiative can have influence, in particular when those who are supposed to represent and lead us are utterly clueless and seek both expert knowledge and a legitimate and respectable partner, such as doctors. But the problem lies deeper, as the author herself says when concluding her experiences with politicians: “If we can’t trust what the politicians are saying (…) where does that leave us?” Therefore it is surprising that the current campaign of Every Doctor addresses the politicians again. From their website: “We are hoping to launch a huge new campaign, to write a “manifesto for the NHS” and push the new [Labour] government into action, but we need your help to get the project off the ground! We’re launching a crowdfund in a little while…”. At the same time other campaigners currently criticise that ‘the new government’ helps cover up the corruption of the old government!
Where next?
We need to turn our hope away from the political caste, towards ourselves as health workers and as the wider working class in need of health care. This would mean that we also address the divisions that exist within the NHS workforce. What is the actual relationship between doctors, nurses and health support workers? Why was it that first the nurses went on strike alone and then the doctors? How can health workers and patients defend free health care together?
‘Critical’ provides us with good material for discussion, which we can use to engage in a series of interviews with doctors and other health workers both within the NHS, but also within private companies. Nowadays the fight for free access to care and for an increase in workers’ control has to be conducted in particular at those points where ‘public’ and ‘private’ health workers meet and cooperate. And we need forms of struggle that create actual economic pressure on the state, such as the recent struggles of health workers in Argentina. If you want to share your experience of working in health, please get in touch.
