From International Socialism (1st series), No.99, June 1977, pp.18-21.
Transcribed & marked up by Einde O’Callaghan for the Marxists’ Internet Archive.
When public spending cuts were first launched at the October 1975 Labour Party Conference, they were presented as merely slackening in the rate of growth of services although Wilson candidly admitted they were to be permanent,
‘In the reviews we have had to make, up to five years ahead, long after the present recession has ended, we shall make sure that our expenditure is strictly related to our priorities.’ 
In the first half of the Seventies health spending grew annually by about 4 per cent, but over the financial year that has just ended the equivalent estimated figure is 2.7 per cent and the projected figures for 1977-8 are 0.9 per cent and 0.7 per cent, respectively.  This ‘zero-growth’ has been only made possible by very stringent cuts in the hospital building programme which has cancelled the long promised and oft-postponed 300 bed ‘nucleus hospitals’ which were to be centre pieces on the re-organised service and of which Dr David Owen said:
‘It is my sad lot to inspect large holes in the ground where a new hospital was hoped to be built, and to write off very large sums of money in consulting fees and staff effort designing hospitals which will never leave the drawing board.’ 
But the sudden spending brake to nil growth greatly un-derstimates the real impact of the cuts. The figures are ‘inflation-budgeted’ to allow for the promised 10 per cent not the actual 17 per cent. Wage settlements, like those awarded to the junior doctors, have to be paid out of existing budgets as does the ever growing drug bill. The Department of Health (DHSS) has introduced strict ‘cash limits’ which force areas that can’t manage on their estimates into bankruptcy. Finally the Resources Allocation Working Party (RAWP) has put into action an internal re-distribution intent on equalising spending whose effect, like all social-democratic schemes in times of hardship, is a levelling do wn; a robbing of broke Peter to pay a pennyless Paul.
But the cuts are not simply economies forced by the fiscal crisis of the state. They mark the end of an era of welfare policy. The NHS, perhaps more than any other part of the service sector, has become relatively more expensive. Once it was a bargain, mainly due to the willingness of its staff, especially nurses, to put up with very low wages. Now it is seen as drawing resources and labour from the industrial sector (which is called ‘productive’ because it is productive of profit). Its also apparent that despite enormous spending on health care, because of the kind of medicine and the lack of real change in social conditions, health has improved very little and the class incidence of illness and death has scarcely altered.  Both pressures incline towards abandoning the comprehensive aims of the NHS, what Bevan called the ‘triumphant example of the superiority of collective action and public initiative.’  If all this spending is to no avail, why not trim it down to provide the minimum level to keep the working population working and a bare minimum service for the old, the disabled and the handicapped? Nurses and theatre porters would somehow reappear as fitters in Leyland and a private sector which will make Harley Street look like a back alley might earn some hard currency. ‘The Welfare State has flourished because the Growth State flourished’ : now in economic crisis, the welfare state goes into reverse gear and the social-democratic theorists have nothing better to do than wave a tearful goodbye, hope for oil-strikes and do some more research.
The cuts are not just saving money by lowering the standards of medical service but a systematic and permanent attempt to undermine existing work practices and introduce new methods of operation. It is the attempted solution, in health, to capitalism’s general problem of raising the level of productivity in the service sector. It required the 1974 NHS Re-organisation which replaced any estige of local control, even by consultants and dignitaries, with a national, top-down bureacracy. The managers, moved in from industry, are hardfaced and ruthless, without any sentimental loyaties. Efficiency is their God, they talk of patient turnover, bed usage and staff savings, just like factory owners.
This fundamental change comes to a service already suffering from prolonged underfinancing, with a backlog of untreated disease and a very poor record on infant mortality, perhaps the most basic index of health standards. Professor Donald Court’s mammoth report points out that ‘of every 1,000 births in England and Wales, 11 are still-born, of every 1,000 lives births 11 die in the first four weeks; 16 fail to survive the first year. Infant mortality is a holocaust equal to all the deaths of the succeeding 24 years of life’ and concludes ‘children still die in our lifetimes of ninteenth century reasons.’  The buildings are ninteenth century often too; hearly half were built before 1891 and one in four are over 100 years old. Only four mental hospitals have been built since 1915. New coats of paint and lower case signs can’t disguise poor law architecture and even they can’t be afforded now. The seediness of hospital premises make them health risks in their own right; the operating theatre in Queen Mary Hospital, Roehampton are so old that cross infection is a danger , the Rossendale Hospital in Lanes, 105 years old, where 9 women died of exposure in midwinter was described as having ‘one wall dripping with damp, with no curtains or carpets, the windows did not fit and the old people might as well have been in the open air.’  Even the brand new Liverpool Teaching Hospital is beset with fire risks, according to a confidential report leaked to Construction News.  It’s not surprising hospitals are exempt from the Health and Safety at Work Act, it is said that it would cost the London Hospital alone £1m to become legal.
THE FIRST, and best disguised cuts have been achieved by freezing existing, inadequate staffing levels. The negotiated establishment for a ward or department have been concealed or replaced with an ‘in post’ estimation. London advertised consultant posts, especially in the less popular and more socially useful specialities, have been quietly abandoned. Management, until the hospital unions started taking up the no-cover policy pioneered by the teachers, were generally successful at pressing people to cover up, even though the strain of being constantly understaffed and depending on poorly trained staff in any sort of hospital work is both nerve-wracking for the staff and dangerous for the patient. Further wage savings have been made by hastening the departure of staff, especially those over retirement age, by fair means or foul and seeking to cut back on the guaranteed overtime which alone makes hospital wages possible to live on. (Rota changes precipitated recent anti-cuts strike action at Epsom and St Barts). Further shedding of staff is achieved by centralisation of catering, laundry and laboratory, forced through despite the inevitable decline in efficiency.
This imprisoning of hospitals in over-worked and under-staffed levels has been worsened by the spate of closures of small hospital. As measured on the computer, these units are uneconomic. But they have provided a homely atmosphere, convenient access which is important for immobile out-patients and visitors and various specialist facilities (like the Elizabeth Garrett Anderson’s guarantee of ‘treatment of women by women’, The London Jewish’s traditional link with East London Jewry or St Faith, Edmonton’s unique epileptic centre). The pattern of care they have provided cannot easily be transfered to the already over-burdened larger units. Inevitably in the remaining hospitals it becomes harder to see a specialist; there are fewer sessions, longer waits, more pressure on beds. Increasingly Accident and Emergency Units come under medical siege from patients who are sent direct by GP’s who despair of getting a hospital appointment in reasonable time. More and more patients are shuttled about by the Ambulance Service and London acute admissions would be in open crisis if not for the referal work done by the privately funded Emergency Bed Service, itself under financial review. Despite creating a new grade of ‘Hospital Practioner’ described by the President of the Royal College of Radiologists as a bad grade.
‘When there is a shortage it is tempting to appoint a pair of hands. I find it difficult to understand why more people are not dismayed.’ 
The number of patients seen has declined markedly and the number of patients awaiting surgery for illness diagnosed for over a year lengthened by bwtween 10 and 25 per cent between September 1975 and March 1976.  And when it is hard to see a doctor, people just do without and preventable pathology worsens unattended.
Especially marked effect is being felt in obstetrics, geriatrics and psychiatry. The Royal College of Physicians, not usually a radical body, has warned explicitly against the reprecussions that the closure of obstetric beds, justified by the falling birth rate, will have on medical facilities for women in general:
‘Under the present plan the obstetric services are to suffer the most stringent cuts. It is likely, because of the effect that this will have on staffing and recruitment, that facilities for gynaecology will also be curtailed. If this is so the gynaecology waiting lists, already among the longest, will lengthen still further. Already nearly a quarter of all women admitted for perineal repair have waited six months or more.’ 
Leicester Age Concern compiled a dossier on a 77 year old widow, so ill ‘that all she could do is sit in a chair, not even feed herself but who had been refused hospital admission for 18 months. As the local Age Concern spokesman put it:
‘The social services departments and the hospitals just pass the buck backwards and forwards and its getting worse because of the cutbacks.’ 
There are thousands of Mrs Barletts who awaiting pneumonia, unvisited, ill-fed and unhappy, victims of a society which can keep them alive but not give them a life worth living. And even where elderly patients can get a place in geriatric ward there is little relief for their isolation and boredom. Geriatric patients in long-stay ward are clean and well-fed but often sit all day with nothing to do in high backed chairs. 
Even more marked is the decline in psychiatric care. The closure of the custodial asylums, fired by humanitarian motives, has resulted in more and more badly disturbed patients who are supposeed to be under ‘community care’ but who, in the absence of adequate hostels, sheltered homes, day hospitals and staff, exist between intramuscular injections of tranquillisers, industrial retraining units which are little better than workhouses and the mercies of the police. The ill-treatment and neglect which still regularly occurs in the under staffed, overcrowded wards of the large mental hospitals is hard to remedy. After the St Augustine’s scandal an emergency panel recommended changes which would have cost £1.4 million. In fact only £112.000 could be found and a year after the inquiry, conditions, had in some instances worsened.  Nor is the situation of the psychiatric wings of general hospitals which were meant to take over from the asylums much better. Psychiatrists in the Hackney Hospital, a wing of St Barts teaching unit reported:
‘The wards have no curtains around the beds, so there is no privacy for patients at all. Every type of patient is treated together – the young, aged dementing, violent, depressed. More than 50 families or individuals arrive every week in acute distress for first aid from the duty psychiatrist, who can only admit those in danger of killing themselves, or someone else. There are no services at all for accommodating severly disturbed children or adolescents, nor any hostels. Junior doctors are forced to see one out-patient every 10 minutes.’ 
The effect of the cuts can be seen in everything from research into blood diseases , cervical cancer and haemophilia to striking current decline in dental standards built up over decades. The DHSS have announced cuts in medical facilities if an H bomb explodes, in the event of nuclear war those merely suffering from radiation sickness will have to be treated at home! 
Faced with such a fundamental attack on the most important reform ever won by the Labour movement, we need to resist on two levels. Its essential to launch a public campaign to inform and arouse those whose health is at risk. But the bitter truth is that without firm trade union organisation inside the affected hospitals the public campaign is bound to end up controlled by the councillors and professionals who seem to have influence and who will steer the campaign back into their channels. The way to recover the initiative is for rank and file hospital workers themselves to take occupation and strike action and then call on other hospital workers, local industrial workers and the public in support. An all out, area wide strike over a particular cut is more realistic than repeated general stoppages over the general issue. The success of the joint Right to Work Campaign and Hospital Worker ‘Save our hospitals’ Conference in London on March 19th in attracting over 200 NHS trade union delegates, probably the biggest gathering of rank and file hospital delegates yet, shows the potential.
The epitaph on the moderate road was pronounced for us by the Hospital Secretary at the Metropolitan which had served Hackney since 1886:
‘The staff have been incredibly loyal and steadfastly refused to strike and now it is us who face the chop.’ 
The shine is very rapidly wearing of Alan Fisher’s halo too. But to get any action, given the decrepit state of unionism in many hospitals, will need help and encouragement from more experienced branches.  We should perhaps remember Poplar not in 1974 but in 1921 when a mass movement in East London refused to cut the unemployment benefit and its leaders went to jail for it. The threat of Poplarism forced the Government to back down in 1921, maybe the spirit of Poplarism will ride again and really stop the cuts not just protest about them.
1. Written Parliamentary reply Mr. Roland Moyle, Hansard, 30th Nov. 1976. (This quote seems to have been omitted from the published version. – ETOL)
2. Morning Star, Oct. 1st 1976, p.1.
3. NHS expenditure: turning figures into facts, Rudolph Klein, British Medical Journal, 26 March 1977, p.856.
4. Guardian, Dec 8th 1976, p.4.
5. See Peter Townshend’s speech to the Socialist Medical Association, 27 March 1977.
6. A Bevan, In Place of Fear, chapter 5.
7. Inflation and Priorities, Centre Studies in Social Policy, London 1975.
8. Fit for the Future, Committee on Child Wealth Services, London HMSO 1976.
9. Guardian, 8 Feb. 1977.
10. Committee of Inquiry, Rossendale Hospital, Chairman Mr Baird McNeill QC, April 1975.
11. Construction News, 17 Feb. 1977.
12. BMJ, 5 Feb. 1977, p.396.
13. Written Parliamentary, reply Ronald Moyle, Hansard, 6th Dec. 1976.
14. BMJ, 20th Nov 1976.
15. Guardian, 7th Feb 1977.
16. Hospital Advisory Service, Annual Report 1975.
17. St Augustine’s Hospital, Committee of Inquiry, Canterbury 1977.
18. Open letter to the City and East London Area Health Authority.
19. See report on thalassenia in North London Right to Work Campaign, Save Islington’s Hospitals pamphlet.
20. Guardian, 5th Feb 1977.
21. See East London Hospitals Worker, Feb 1977.
22. See the report of the Save Our Hospitals Conference, Hospital Worker and the Hospital Worker Almanac for very detailed discussion of the nuts and bolts of building hospital trade unionism.
Last updated on 23.3.2008