England, Wales and Scotland section of International Socialist Alternative

Review – NHS Under Siege: The Fight to Save it in the Age of Covid

A record 6.6 million people now languish on NHS waiting lists. Staff, burnt out by the pandemic and abused by the government, are leaving in droves, adding to the 110,000 already existing vacancies. Hospitals and NHS properties are crumbling due to a lack of capital investment. A lack of NHS capacity is nurturing our health services’ dependence on the private sector, leading increasingly to a two-tier health service. The NHS had already been in crisis for many years. However, the pandemic has greatly accelerated this deterioration, elevating the crisis to a whole new level.

NHS Under Siege: The Fight to Save it in the Age of Covid is a timely and utterly devastating critique of the government’s handling of the Covid-19 pandemic, but also of the role of successive capitalist governments in paving the way for this catastrophic public health failure. Co-authored by John Lister, national organiser with Health Campaigns Together, and Jacky Davis, a consultant radiologist and founding member of Keep Our NHS Public, NHS Under Siege expertly catalogues the litany of poor decisions, deadly prevarications, confused messages and flagrant corruption that characterised the government’s response to the pandemic. It is an indictment of the very idea of a market-driven approach to health, where human need is constantly subordinated to the need of private profit, and a testimony to the many advantages of public ownership (even within the straitjacket of capitalism).

NHS Under Siege presents an overwhelming body of evidence against the government. This includes the decision to ignore the findings of not one, but two government operations to test the countries’ pandemic preparedness which both recommended the need to stockpile PPE (p. 48). It includes the consequent and criminal failure to protect frontline NHS and social care workers – the authors cite 1,500 as the approximate number of deaths in these groups (p. 51). The abysmal failure of the test, track and trace programme for which the government handed over £37 billion – one fifth of the annual NHS budget – to unqualified private corporations, and the constant and self-defeating attempts to prioritise the economy over public health also make for a damning indictment. 

They ignored basic science, refusing a ‘circuit breaker’ in the Autumn of 2020, and then launched the infamous ‘Eat Out to Help Out’ scheme, which contributed greatly to the second Covid wave. Finally, there was the decision to try and reopen schools in January 2021 when infections were peaking – something that was only prevented by the actions of trade unionists and education workers, saving thousands of lives. Taken as a whole, the government’s record stands as a grotesque monument to capitalist greed, with more than 185,000 (those being only the ‘recorded’ deaths) now lying dead in its shadow.

Wider political context of pandemic failures

NHS Under Siege is invaluable in how it provides a thorough backdrop to the country’s biggest public health failure in modern history. Much of this context is explored in Chapters 1 and 5, looking in particular at the policies of Margaret Thatcher and subsequent Tory-led governments. Thatcher, of course, is well known for introducing the destructive internal market system in the 1980s. The internal market, which forced different parts of the NHS, including different hospitals and different departments, to compete with each other for services and supplies, was completely exposed at the beginning of the pandemic, when orders for PPE and ventilators had to be centralised. The capitalist market was revealed to be totally incapable of meeting public needs. 

Thatcher is also known for moving long term care for the elderly – now called ‘social care’ – out of the NHS and into the control of local government. These services have now been almost completely privatised, with human need subverted to the needs of private profit. By the end of 2019 there were more than 120,00 vacancies in the care sector – hardly surprising given the prevalence of minimum wage and zero-hour contracts in what is an extremely complex and demanding job. After the government made the abhorrent decision to discharge Covid-positive patients into care homes, it was into these crowded, understaffed and under-resourced homes where 20,000 needless deaths were recorded in the first wave of the pandemic (representing 23.2% of deaths across the whole period). 

The NHS itself was woefully and criminally unprepared to cope with a pandemic due to years of underfunding and conscious decisions to drive down hospital capacity. With the election of the Con-Dem coalition government in 2010, and after more than a decade of funding growth, NHS funding was rolled back to its lowest levels in its history (0.1% in real terms between 2011 and 2014). Between 2010 and 2018, the population had grown by 4 million, but 8,000 frontline beds and 20% of mental health beds had closed. This resulted in persistent crises for our health services. 

Even before the pandemic, a “report for the 2018-19 winter showed only about 20 out of 131 acute trusts had managed to contain bed occupancy below 90% on 3 March. 36 trusts were running on or above 97%. Five were completely full at 100%” (p. 35). The NHS was increasingly providing ‘emergency only’ services, while relying on the private sector to take up more of the potentially profitable elective procedures (p. 161). 

When the pandemic hit in March 2020, NHS hospitals were quickly overwhelmed. The following years have represented a “bonanza” for private health corporations as waiting lists have exploded and the NHS has been overwhelmed with emergency treatment. Between April and June 2021, 65,000 patients resorted to self-pay operations, up 30% from the same period in 2019; research commissioned by the Financial Times shows that for the first time ever more people were getting hip and knee operations done privately rather than through the NHS (p. 110). 

As with social care, the NHS entered the pandemic with around 100,000 vacancies, including more than 40,000 for nurses. Not only did this lead to overwork and staff burnout, but it provided a hotbed for unsafe working practices – something that NHS workers had been gagged over but had been raising the alarm about for some time. It also meant that government initiatives to expand capacity, such as the creation of Nightingale Units at a cost of £500 million, fell flat because there were simply not enough staff to run them: “The Birmingham Nightingale Hospital, the most expensive one set up at £66.4 million, did not treat any patients throughout the pandemic” (p. 58). 

Similarly, the government wasted huge amounts of money on block-booking 8,000 private hospital beds, at an estimated cost of up to £400 million a month. On average there was just one patient per day in these beds! As Jacky Davis explains, “at a time when the NHS needed the private sector to step up, it underperformed to a shocking degree.” For Davis, this ‘investment’ only makes sense as an effective subsidy to the private sector, “which otherwise might not have survived the pandemic”. Had all this money been spent in consultation with frontline workers, it could have been used to solve critical issues relating to staffing and NHS beds and thus to avoid many needless deaths.

The Labour Party and the NHS

The book also provides an extremely useful history of the role of New Labour, especially under the leadership of Tony Blair then Gordon Brown, in deepening the role of the private sector in the NHS. This history is well-established with its legacy living on in the approach of Labour’s current right-wing leadership. Despite claims to be leading the “party of the NHS”, statements from Keir Starmer and Wes Streeting, Labour’s new Shadow Health Secretary, that they would continue to use the private sector in the NHS explodes this myth. Their odious funding links to private health corporations, are well documented. 

While it is true that funding for the NHS reached record highs under the Labour government between 1997 and 2010, it is also true that New Labour, as they were then known, played a decisive role in laying the foundations for the many problems our NHS faces today. New Labour is perhaps most infamous for its expansion of Private Finance Initiatives (PFIs), saddling the NHS with monumental levels of debt, much of which is still being paid off today. But less well documented is their role in developing a private sector alternative to ‘compete’ with the NHS. 

Upon election in 1997, one of Blair’s constant refrains when talking about the NHS was ‘patient choice’. Even when NHS budgets were expanding, this meant committing additional resources to developing the role of private provision of elective clinical care. This was not something that existed at the time, at least not on any large scale. John puts forward a strong case that rather than being based in practical realities, this decision was ideological in character, having to do with New Labour’s capitalist ”belief that the power of competition could improve quality and increase efficiency in healthcare”. This fetish for the private sector also extended to primary care: “In 2008, 14 giant private sector corporations were added to a list of firms pre-approved to bid for contracts in primary care” (p. 12). Today, the private sector share of NHS spending on clinical care has risen in cash terms from practically nothing in 1997, to £2billion in 2006, then to over £12billion in 2021 – something for which Blairite New Labour bears large responsibility (p. 153).

One of the most heinous crimes of the Blair administration was the abandonment of any principled opposition to the Tories. During his 1997 election campaign, Blair promised to do away with Thatcher’s destructive internal market system in the NHS. This turned out to be a lie, as did many of his pledges. Indeed, as John explains, “not only did he retain them, but he built on them making them more complex and bureaucratic” (p. 12). 

The same can be said of Thatcher’s trade union laws. Despite repeated appeals from the more militant sections of the labour movement, Blair went into the 1997 election having reassured the capitalist class that changes proposed by the New Labour government would “leave British law the most restrictive on trade unions in the Western world.” Having refused to roll back Thatcher’s anti-trade union laws, which prohibited solidarity strikes, for example, the Tories were eventually able to press ahead with the still more restrictive 2016 Trade Union Act, which raised the threshold for legitimate strike ballots to 50%, subjecting union democracy to a much higher standard than that of Parliament. Were it not for the maintenance of restrictive trade union legislation, the Tory government, fearing repercussions from organised labour and health workers in particular, would undoubtedly have been less able to press ahead with their cuts and privatisation agenda in the NHS throughout the 2010s onwards.

Finally, for those who rightly point to the record levels of funding provided for the NHS under New Labour, it is worth considering Labour’s response to the 2007-2008 financial crisis, which was to commission a report from management consultants at McKinsey to investigate how £20 billion could be squeezed out of the NHS’s budget by 2014 (p.14). In the years that followed the election of the Con-Dem government in 2010, Labour’s opposition to austerity was only that it was “too hard and too fast”, advocating instead a slower, but no less deadly, programme of cuts and privatisations. It is difficult to imagine that New Labour would have plotted a fundamentally different trajectory to that of the Tories if they were elected in 2010 or 2015.

The fight back

Part of the strength of NHS Under Siege is that it avoids the easy conclusion that the current aim of capitalist politicians is to replace the NHS wholesale with a US model of private health insurance. Even if this is what some of them may ultimately want, the truth, the authors argue, is far more insidious: 

“They [private health corporations and their political representatives] don’t want to replace the tax-funded system, but to exploit it more fully, to ensure the maximum flow of profitable activity to private providers, while also maximising the numbers who will opt to pay privately for elective treatment rather than face long delays.” 

In the specific context of the UK, it is clearly preferable for mega-corporations like Centene and Cygnet to milk the NHS of public funds, picking and choosing which services they would like to undertake, rather than to compete with it outright. 

This conclusion may be alarming for some because of the extent to which private corporations have already reached into our NHS. But it should also be empowering, because it clearly shows the points at which campaigners can, and often have, successfully pushed back against the interests of of the private companies and profiteers. The implications of this conclusion for socialists and health campaigners is important: it warns against waiting for some final moment of collapse and urges us to take up the fight now. The NHS is already collapsing, but it is far from irretrievable. In fact, the share of the NHS budget spent on private providers stood at 18.1bn (16%) in 2019 which, while high and growing since the pandemic, shows that there is still “a lot of NHS to fight for” (p.185).

One of the unanswered questions in NHS Under Siege is about the role played by the Labour Party in the period from 2016 to 2019 under Jeremy Corbyn’s leadership. Aside from a short comment on Labour’s 2017 election manifesto and its extreme limitations (p. 29), there is no discussion on the competing ideas which were taking place in Labour during this time – which to be fair, would expand the remit of this book.

Indeed, the ideas of ‘public vs. private ownership’ and ‘public investment vs. austerity’ were part of the backdrop against which factional wars within the party were being waged. Weaknesses in manifestos and policies often reflected a misguided approach from Corbyn’s leadership to compromise with the rabidly hostile Blairite wing – such was the opposition to socialist ideas within the Parliamentary Labour Party that they would rather see the Tories elected than Labour win on a socialist programme. However, it is not a coincidence that the biggest demonstration in support of the NHS ever, called by Health Campaigns Together, was in 2017, largely as a result of raised expectations and the idea that a fight-back was possible. 

Similarly, NHS Under Siege strikes a somewhat pessimistic note when, in a concluding chapter on ‘ways to get involved’, states that “the stock response from the left to any campaign is to call for trade union action. However, it is clear from experience over five decades that strikes, and the credible threat of strikes, are most likely to take place on trade union issues – pay and conditions; jobs; staffing and safety concerns; discrimination; victimisation of union reps; contracting out and the creation of wholly owned companies, rather than on broader defence of services, cuts, closures and reorganisation.” 

In many ways, John is absolutely right in this chapter. In too many campaigns trade union action has been a missing ingredient and that it has been left up to NHS campaigners to fight back. However, the reason that trade union action is considered so central is not because it is always the most likely arena of struggle, but because it is the place where the potential power of the workers’ movement is at its strongest. The ability of workers to withhold their labour in defence of, and to expand, our services is our best chance of winning fundamental change in the NHS.

Without this perspective, socialists and health campaigners not only dispose of their most dangerous weapon, they also leave it open to suffocation by right wing trade union leaders who see it as their role to simply negotiate between workers and the bosses, rather than clearly and boldly providing a lead on escalating action to win our demands. . 

To be clear, there are reasons to be optimistic today. In light of the huge uptick in workers’ struggle that has developed over the Summer, and looks set to continue to grow. We are entering a period when union action from health workers is more likely than ever. John is right, however, to point to the many existing campaigns, health and otherwise, that have a brilliant record of fighting and that should be supported by the workers’ movement and members of the public.

The conclusions drawn in this excellent book are profound and far reaching. We are in the fight of our lives to save the NHS, because successive governments have taken us down a path of privatisation, cuts and closures. This year’s battles around pay will be critical in mobilising the beginning of resistance amongst the NHS staff. Their battles have to be linked to the wider industrial struggles, being undertaken by the RMT, CWU, and hopefully soon, the NEU, UNISON, UNITE and GMB which are not just fighting to preserve living standards, but in reality, they are fighting to defend all public services. 

That is why we have confidence that the trade unions can and will take action to defend the NHS, and will be supported by the wider public and of course health campaigners up and down the country. The NHS is the jewel in the crown of our public services and its future lies in the hands of the working class which must rally to protect, support and improve it and all other public services.

Socialist Alternative fights for:

  • Proper public funding for the NHS now
  • Kick out the profiteers and private companies – bring all the NHS back into the public sector
  • An immediate inflation busting pay rise for all NHS and Social Care staff, with all future pay linked to the cost of living
  • A crash recruitment campaign to tackle staff shortages, overcoming waiting lists and cancelled appointments
  • Bring all Social Care back into the public sector
  • Nationalise the drug and pharmaceutical industries under workers control and management

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