IN THE HOSPITAL, AS IN THE FACTORY AND THE OFFICE, THE STRUGGLE FOR HEALTH IS A STRUGGLE FOR WAGES AGAINST THE BOSS-STATE
The situation
It’s nothing new that the balance sheets of numerous hospitals in Belgium are in deficit. In 2015 the Federal Minister of Public Health launched a reform plan to counter this, with the aim of making health services capable of “creating more value with the budgets available”. Seven years before, in 2007-2008, the growth norm for health care had already been decided on. The financial means allocated by the federal state to general hospitals count for less and less in their running costs compared to the sale of treatments and medicines (fees and pharmacy). The De Block plan was based on three great pillars:
The centralisation of the provision of care forces the reorganisation of the hospital landscape in the form of networks. Costly technologies, for example, will be given to a network rather than scattering them into various hospitals.
The resizing of the capacity of the care provided translates into: a reduction in the number of acute beds and the redeployment of chronic beds; reduction of length of hospital stays; orientation towards outpatient care. Since 2008, the average duration of stay has gone down by a day in acute services and maternity. At the same time, outpatient care is growing (18% in days of stay, 60% in admissions, in 2018).
Fixing the prices of services according to a fixed rate rather than payment per procedure. According to the government, payment per procedure leads to growth in the number of procedures in order to artificially create more appointments. In 2019, sum totals were capped for 57 procedures at a low level, independently of the process of real care for the individual patient. All the hospitals lost money and had to adapt their cost structure.
What does this mean?
The state, as an individual capital, as the main investor in private hospitals and even more as the representative of the collective capital owner of the public hospital system, is looking for ways to diminish its contribution to the financing of hospitals and to invest in entities which are more efficient – that is to say capable of generating profit. Contrary to the mystification peddled by the unions about a “non-commercial” sector, health has always been a commodity: the state buys services from the hospital which sells them; as for the person who is ill, their contribution only covers one part, certainly limited but growing, of the costs of production of services. What has changed today is that the health commodity must become profitable for the state.
Capital is not killing the hospital, but making it profitable
The care sector, ruled by distorted markets (prices fixed outside the market by the social security institutions, mutual insurance companies and trade unions; state financing of hospital companies), has evolved since the 1980s and even more since 2008, following the fiscal crisis resulting from the financial crisis, towards a “classic” industrial model spurred and stimulated by competition. This penetration of capital into the state market corresponds to its continuous extension into all spheres of economic activity and to the generalisation of the commodity as the only form of wealth. The hospital becomes progressively a capital generating profit, as has been the case for a long time for public transport, for example. The search for profit inexorably sucks in all “public services”.
The mechanism is simple. Hospitals receive from the state a minimal allocation equal and proportionate to their volume of treatments and their health specialities. The capacity of the hospital to make money depends then on its productivity, that is to say on its capacity to restrict the costs of production of services to below their standardised prices. Relative to the capital invested and the prices fixed initially, certain health procedures are more profitable than others, and that is why the boss-state disinvests from some specialist treatments and directs its investments towards others. The “public” hospitals are also more and more in competition with “private” hospitals which are often far ahead in the more profitable market segments. Private clinics are an irreplaceable incentive which accelerates the search for profits from the state sector hospitals.
This will be paid for by workers and patients
The transformation of working conditions in hospitals is comparable to what happened in manufacturing industry a century ago: Taylorisation and mechanisation. Like any workforce, as long as the capitalist mode of production dominates society, health workers are subjected to pressure for the bosses to cut wages, prolong working hours, increase productivity and intensify work. A growing division of labour inevitably leads to repetitive work. The deskilled worker must also show themselves to be flexible and potentially interchangeable. The time for adaptation and learning new skills is more and more reduced. The hospital management does all it can to compress to a minimum whatever is not part of the (chargeable) medical treatment itself so that the time at work for the staff is as near as possible to the time spent working. All moments of the day at work which are not dedicated directly to labour productive of surplus value are restricted (breaks, discussions etc.). Also, the tendency is to make the patient shoulder the costs of their care – including when they are declared “free” by virtue of the “social contract” in force.
Whether the hospital is private or public makes no difference for workers’ struggles
The hospital is an essential link in the cycle of reproduction of labour power. Its main “social rationale” is to repair and return to work the labour power worn out by its exploitation in the process of production. In all the advanced capitalist countries which have a health system run by the state, it is the undisputed actor and the great organiser of this reproductive function which is indispensable to capital. The state is at the same time the juridical owner of the public hospitals, the order giver to the hospitals, the hegemonic customer who fixes, in advance, the prices in the health market, which partly finances infrastructure and other constant capital, which pays the wages of the public health sector and which is the guarantor of the “social contract” around health with and through its intermediate bodies (unions, mutual insurance companies). The ideology of “public service”, always at the service of capital, only has the aim of making the state coincide with the general interest. Whether it is the state or private capitals (the two often strongly interlinked) should not concern workers. What must concern them are wages and conditions of work. And to defend them, the first step is to fight collectively against the divisions between workers created by the organisation of work.
Concessions made by the state hospital management following Covid-19 will be temporary in the absence of struggle
In spring the Belgian government promised a billion euros to hospital management to deal with the reduction in hospital capacity and the growth in purchases of drugs and protective equipment. This billion is an advance which has to be repaid in the form of adjustments made to subsidies in 2022-2023. This reinforces a deeper tendency: healthcare units must become more efficient.
In mid-June, 400 million euros were allotted to the “White Coats Fund” with the aim of recruiting additional staff (around 4,000 in full-time equivalents). At the beginning of July, an additional 600 million euros were put on the table by the federal state, for the 2021-2022 period, in the framework of a future social agreement of refinancing wages (application of the scale negotiated in 2018) and improvement of working conditions (hours, weeks of holiday). This involves 110,000 full-time equivalents and corresponds to an increase of 5% in the total mass of wages in this sector (general hospitals, psychiatric hospitals, care at home). This plan has the agreement of the unions and must still be accepted by parliament. While not negligible, these adjustments earned the hard way from the Covid-19 crisis will be in the end reabsorbed by higher productivity and can only be preserved at the expense of maintaining a maximum uninterrupted pressure on the wages and working conditions of health workers.
The fight is not to preserve the public hospital but to engage in class struggle against the conditions of exploitation
FIGHTING FOR HIGHER WAGES AND FOR BETTER WORKING CONDITIONS MEANS SHIFTING THE BALANCE OF FORCES AGAINST THE REAL ENEMY
This enemy does not come from outside the hospital, but is incarnated in the state and in the managements of hospitals. It is therefore necessary to abandon any demand for recognition of the social utility of caring activity which “save human lives”. In a capitalist world the defence of “public services” has always led to more exploitation.
HEALTH WORKERS WHO GO ON STRIKE LEAD A STRUGGLE FOR WAGES AND FOR WORKERS’ UNITY
Because a strike in a hospital is difficult to carry out and because the management try to isolate different departments which mobilise, the organisation of struggle must overcome tensions between categories of workers and exploit the fault lines in the labour process. Refusing additional hours beyond the legal limit; refusing to do work which is not in your job description; signalling every accident caused by the lack of staff, the bad way work is organised, bad equipment; refusing to work during breaks… these are the practices that have emerged recently. To paralyse production, work teams can make a deep investigation into the way services function and choose to act when the balance of forces allow it.
THE DEMAND FOR FREE HEALTHCARE IS ALSO A FIGHT FOR WAGES
Does fighting for their own interests mean forgetting the patients? Not as long as healthcare staff forcefully put forward the demand for totally free care for all workers. It’s an objective which corresponds to nothing more nor less than fighting to defend the indirect wage and particularly the part relating to access to health care.
Fighting the hospital business as a place of exploitation means abandoning illusions about the “general interest” and “public services”. This also means recognising in the state-boss an enemy of the workers. To do that it is necessary to take initiative on the terrain of class by organising ourselves collectively outside the co-management unions, against the bosses of the hospital and the hierarchy of services.
Mouvement Communiste/Kolektivně proti kapitálu,
12 September 2020
