Dave Widgery

Crises in the NHS

(February 1988)

From Socialist Worker Review, No.106, February 1988, pp.16-20.
Transcribed & marked up by Einde O’Callaghan for the Marxists’ Internet Archive.

Dave Widgery is a GP and member of the SWP. His latest book The National Health: a radical perspective will be published by Hogarth Press in July. Here, he talks to Gareth Jenkins and Lee Humber on the state of the health service today.

SWR: WHY HAS the crisis in the health service come to a head now ?

DW: THE TORIES have a number of problems. The first is the sheer size of the NHS. Its the biggest employer west of the Red Army. You’re talking about three quarters of a million people working for it, plus a million citizens making contact with it every day through GPs or whatever.

Again and again good quality attitude surveys show that support for the NHS is growing not shrinking.

Thatcher realises that and knows she’s got to be a bit clever with something so popular, she want’s to get rid of it but its actually very difficult for her to do.

Let me first explain the economics of the health service.

The changing patterns of the British population mean quite simply that there is a growing group of the very old, the over 75s, and they are very heavy users of health care. Not that people ace living longer just that that proportion of the population is growing relative to the rest of the population.

Also interesting is that the birth rate is going up quite markedly in some inner city areas. That puts a pressure on the other end of the health service at the antenatal stage. So there are demographic factors.

Inflation is higher than average within the NHS both because of its high labour intensity and also because its costs – things like drugs and so on – have a higher rate of inflation than the general shopping bag. So the NHS’s costs rise more rapidly than other sections of the economy.

Also you’ve got medical innovation. Each year doctors come up with new schemes which they could use and widely apply. So its not just kidney machines and heart operations that we know about but other things like fetoscopy, which is a very good method of looking at the health of the foetus early on.

There are continuing expectations now to make things like that or, say, breast screening universal, and this is good. Obviously people’s expectations should rise but for the ruling class this is a fantastic problem.

Just to keep up with all that the NHS budget needs to grow by about two percent per year. But when you adjust what the government have done with then- fake figures you find that they are increasing NHS spending in real terms – it is increasing in real terms which is important for us to understand – by about half a percent.

So each year there’s a shortfall of about one and a half percent. Now if you do that for one year that’s bad, two years then it gets worse. You don’t have to be the President of the Royal College of Surgeons to work out that if your taking topside slices off a joint you get through the fat, you get through the meat, then you hit bone. And thats whats happening now, they’re really hitting bone.

The Tories talk about improving efficiency. In fact some doctors have really worked hard at tightening up on their efficiency and of course now they’re in trouble. Because these are the doctors that management come round and say, alright, you’ve improved your efficiency 10 percent, do it another 10 percent. But it can’t be done.

There’s a thing called Starling’s Law in physiology which shows that if you stimulate a bean it gets more and more efficient. You do it with a little frog’s heart. You can stimulate it on and on, and then it dies. You’ve made it too efficient and it just dies. Starlings Law is happening to the NHS in a way.

The staffing problem, the morale problem and the consistent low wages of nurses have also been creeping up for ages. People are leaving the profession.

Then there’s the changing attitude of doctors. They’re mainly Tories, of course. In the last survey I read, of 360 GPs only six were going to vote Labour. It’s that bad.

But they are members of the middle class, professionals who are in day to day contact with the working class. They know things are getting worse and they want an answer from the government that makes sense. They’re just getting total bullshit.

I think the fact that the doctors are very fed up is quite important in this crisis. They’re speaking out when they shouldn’t and providing a lot of ammunition for us to pick up. They’ve done four or five years work trying to improve efficiency and they’ve been rewarded for their efforts with, “Well you’re slackers anyway.” That’s what Thatcher came out with recently which really blew the gaffe.

SWR: What is the attitude of consultants to the health service?

DW: The BMA is notably pro-NHS on paper and has produced some remarkably strong material. For example the Board of Science published a follow up on the Black report about inequalities in health and it was an improvement on the Black Report. It actually went into great detail about the impact of unemployment on health. But if the line is pro-NHS, the reality is different.

The reality of the NHS is that you work very hard until you’re about forty, then you become a consultant. You’ve reached power, and you can start making serious money if you do private work.

So one of the major problems in London is absentee consultants – people who are supposed to be running a department, operating, planning services, encouraging morale, and the nurses don’t know who they are. They don’t come in from one year to the next. So their commitment to private medicine is a problem in that respect.

However, to counterbalance that, there are a lot of truly full-time NHS consultants who do little or no private work. They are often the working class grammar school kids of the forties and fifties who are now professors of medicine or heads of renal units or something like that. They’re quite anti-private practice because they don’t like the fact that their colleagues are always in Harley Street. I used to think that they were all ogres but I’ve been very impressed with some of them recently.

Because they can read figures they know the government’s lying and they know the NHS is being underfunded. So they are saying, you’ve got all this money, why not give us more? And what’s the government’s answer? We don’t want to give more money to the health service. You’ll just have to get more efficient and cost-effective.

But the problem is the NHS is so demand-led you can’t plan it like you were merchandising cassettes or videos. AIDS comes along or there is a meningitis outbreak. Things like this cost a lot of money if you’re going to deal with them properly. The demand comes at you, its unpredictable, and it changes.

We should take up these challenges, we should face them head on. But, for example, the AIDS doctors and the nurses are absolutely collapsing in exhaustion because it’s so underfunded.

SWR: About hospital specialisation, can you expand on the idea of the internal market in the health service?

DW: This is an invention of a doctor called Ken Grant. He’s the general manager for Hackney and City, which means he’s got Barts hospital in Spitafield, he’s got the Hackney hospital and he’s got a teaching hospital very much into research and obscure things. But his hinterland is the population of Hackney who need the general bread and butter medicine. So there’s a complete mismatch of resources.

Grant’s idea is, well we’ve got all these specialised and over specialised doctors, we’ve got brilliant people working on endocrines (hormones), say. There’s not enough endocrine work in the Hackney population to keep this high powered unit going so we’ll take referrals from all over – it happens already to an extent. So all the hormone problems come and keep his team in clover, plenty of work, plenty of referrals.

But then the question is, who’s going to look after the people in Hackney with heart attacks and chest problems and so on? Mr Endocrine Specialist doesn’t want to know about what they call “grot” in the medical profession, its not interesting for him.

So in a way Grant is trying to rationalise that by advocating replacement of the national system by a series of local systems in competition with each other. So someone will get good at doing, say, heart attacks. So all the Hackney people with heart attacks will go out to Basildon. What Grant thinks is, the Basildon set up will be cheap so it will be cost effective. It’s absolutely mad but it’s an internal market system so that people will be cross referred from district to district. What you should have is a hospital in the district attending to the problems of that district.

SWR: We’ve not talked about GPs. How is the crisis in the health service affecting them?

DW: The Tories have just published a white paper on primary health care which is incredibly pro-prevention, pro-community services and says it is pro many of the things we have argued for as GPs.

They’re not totally stupid. They’ve sussed that it’s much easier to stop people having heart attacks than to deal with them hi expensive hospitals. So they’re pushing that line. Their plans for primary care in general are still going on reasonably well in some areas.

GPs are very much the choreographers of health care on community levels, so if you’ve got a good GP the GP will be getting all the evening nurses, the physios, writing expensive referrals and getting you the best drugs. GPs are prodigious spenders, or at least could be. Most of them are Tories so they don’t like doing that sort of thing.

The Tories then have got another problem – how to control GP spending and how to put cash limits on them. They’ve got cash limits on the hospitals and the hospitals are crying out in public pain. They’re now trying to introduce cash limits into the GP service and there’ll be a heck of battle about that because the GPs have seen what the hospital people are up against.

The GPs, as a consequence of thirty years in the NHS, think NHS. There’s no private general practice. One was set up in Harrow, it was Thatcherite triumphalism at its best. The ministers personally went to this guy’s private practice and did everything to boost it. It’s been a financial disaster. The private sector doesn’t want to get involved in things like that.

SWR: Can BUPA and private medical health insurance take the place of the NHS?

DW: No, quite clearly, it’s a con. When you get BUPA you don’t get a lot of things. It’s not comprehensive. For example you don’t get psychiatric care, you don’t get maternity care. They can do cheap operations on basically fit people and they can advertise, you can get the choice of wine and all the luxury and all that. But in 1982 when the EETPU started negotiating for BUPA as part of the salary for electricians BUPA took on all these electricians and found that electricians get ill. It found that as you go down in social class you get more illness and BUPA doesn’t want its clients getting ill.

Unlike most insurance payments your premiums go up as you get older so you pay more as you get to retirement age if you want to keep on with BUPA. It’s very selective. It doesn’t, as people think, guarantee you the surgeon of your choice in the place of your choice.

In order to control doctors’ costs they have had to commit people, if they buy a certain kind of insurance, to a certain kind of hospital. They get the basic and all the frills are dispensed with.

So it’s not what it makes out to be and it can only exist because of the back up of the NHS. Like all parasites it depends on a healthy body to live on.

This is strikingly true even in the case of intensive care. Let’s say, purely hypothetically, that a businessman flies into the London Independent Hospital from Zurich for his heart operation because, say, it markets the cheapest coronary bypass heart operation.

So his firm will pay for the operation because he’s earning a lot of money for them. The company, being businesslike, telexes round all the hospitals in Europe for the cheapest price, flies the chap into the new city airport and he’s driven by limo into the hospital.

Now he has his operation and things go wrong. He gets cerebral clotting difficulty, for example, so all his blood starts clotting and he needs massive quantities of blood to be transfused. Problem, where do they get that from? They get all their blood from the NHS as it happens. He starts needing very complicated and very frequent blood tests which even a well equipped hospital like the London Independent can’t do on site. And then he starts dying and he goes into a coma. The London Independent will shunt him out the back door and dump him on a casualty department. He’ll start costing BUPA and he’ll go over the limit, because in the fine print they’ve said any costs over and above five grand and the policy is invalid. They’ve got all these little trip clauses. The logic of it is that they don’t pick up the pieces. They do it as long as it doesn’t go wrong, and if it goes really wrong they’ve got a body disposal problem. That’s shunted down the road to London Hospital’s casualty who have to take over the terminal care or whatever.

That’s the problem for them. They can’t match the NHS and they’re perfectly frank about it. All the best informed private health people don’t want the NHS cut so badly. They need a reasonable level of low cost blanket provision for the great unwashed, and don’t want to do it themselves because there’s no money in it for them.

What they want to do is quick, reasonably safe operations on basically healthy people who’ve got quite a lot of money. Now that’s not many people – 5, 10 percent of the population, no more than that. I’ve seen no evidence that the mass catering for health is their aim and they’re never going to have an interest in prevention because they want the operation. They want the hearts to go wrong so they can put them right. They’re not going to traipse around telling people to smoke less and eat healthy food.

They’re not interested in chronic psychiatric care or what is the bulk of GP work – mild but not life threatening conditions which make life a bit of a misery. The sort of things that capitalism generates all the time. They’re not really bothered about all that.

SWR: If private health care doesn’t want to expand beyond a certain limit, and doctors don’t want it, health workers don’t want it, workers in general don’t want it, why is Thatcher so keen on pushing it through?

DW: That’s the 64 million dollar question. She really doesn’t like the health service existing, it gets up her nose. She would crawl past a NHS hospital if she had a heart attack to get to a private hospital.

The reason she hates it is because it works. In a way, it’s not very marvellous – the working class has not achieved a revolution or anything – but it works a bit. It’s an example of a sort of semi-welfare socialism that actually works. And that sticks in her throat.

It’s not cash, you don’t pay for it, and she believes that anything that’s worth anything in this life has to be paid for. It’s an interesting problem for Marxist theory. I was with a bloke recently and I said I could prove that private health doesn’t work, and he said it doesn’t matter about that. You can show them all the figures in the world, you can show them countries where it’s been tried and hasn’t worked, it’s no use. They actually believe their own propaganda.

Then you read the people in the Times and so on and they’re saying to Thatcher, don’t do it, it’s not worth it, all that aggravation and what are you going to get out of it. Leave well alone. But Thatcher obviously doesn’t think like that.

She’s had plenty of chances to come up with some money over the last few months and if she’s going to tough it out and Currie and Moore and co are going to ride the tide of protest, you’ve got a very interesting situation. Because you will have a mass confrontation over an institution that involves millions and millions of people. And its at least as political as the miners’ strike because all the issues are raised right across Britain, not just in the mining areas.

Every town’s got a hospital, everyone’s got a GP, everyone’s got a friend who’s ill.

SWR: But there must be more than just ideology. Isn’t it a more global measure about driving down the living standards of working class people?

DW: Yes, I’m sure it is. As a manager of capitalism Thatcher sees a problem that has to be trodden on, contained and turned round. She wants to get back to the idea of a bare minimum standard of health for workers and proper health, care for the middle classes.

That’s a rational argument for capitalism actually because if there’s an old lady who has no more contribution to make to capitalism but needs a hip operation and good quality domiciliary care or decent psychiatric help, that little old lady is going to cost a bomb.

And there’s a lot of little old ladies and old men around. This over 75 group is growing and is a real worry for them. I think they’d like to shoot them all.

The other reason for the attack on the NHS is that the NHS represents a very substantial group of organised trade unionists. Now we know the level of organisation is low and usually pretty passive, but there have been some major contributions to post-war British industrial history made by hospital workers.

SWR: What is the tradition of industrial action in the NHS?

DW: If you look at strike days lost you had a big upsurge in the early seventies with the rank and file movement in the hospitals. If you compare that with the spending levels you find that actually, after industrial action, more money got spent on the NHS. It’s really as simple as that. If anyone asks you why you should go on strike, say strikes work.

The very big stoppages in the winter of discontent saw another rise in spending because they had to make good all the wage claims. Then came that great event in 1982 when the TUC was calling days of action and everyone was calling days of action. Again, spending went up the next year.

The problem is that because of the high turnover in the health service, industrial experience is lost very quickly. A nurse might be won to the idea of striking but leaves three years later, and there’s another young nurse who hasn’t been won to the idea. In fact, our comrades probably represent the continuity of the tradition of trade unionism in the hospital which is very young still. We’re among the few who go back to the big struggles of ’72.

It’s really weird having exactly the same argument as we used to have ten or twelve years ago, arguments for instance about the Royal College of Nursing.

The RCN’s an odd institution. It excludes a whole mass of nurses, the non-SRN types, the “lower orders”, and it deliberately doesn’t recruit them. Outrageous really. It also, of course, sells itself on the basis that it doesn’t strike. What kind of union sells itself on that basis?

I think it’s very important that we really take up the cudgels with the RCN. It’s not just a case of some steward from NUPE saying oh, we always knew it was a scabby union. You’ve got to argue the case.

The basic point is that the lessons of hospital trade unionism evaporate very quickly and we have a real responsibility to digest the experience of the big strike waves of the early 70s and the catastrophe of 1982. There was massive public solidarity with people stopping all over the place in support of the nurses and it all fizzled out because it wasn’t focused.

If you look at rates of unionisation they’re going down in some areas of the public sector, but it’s kept pretty firm in the NHS. Nothing spectacular, but it hasn’t fallen. My impression is that shop stewards are more confident and despite all the defeats they do actually represent a body of trade unionism that is quite intact.

So the Tories would like to humble these people. They’re a bit big for their boots, they argue, let’s kick NUPE out of hospitals all together. Why should we have shop stewards in hospitals? So that’s what they’d like to do. We must remember that there was a lot of victimisation in the early seventies because of the action.

But you get new people in all the time who haven’t been broken and humiliated and made fools of. They come in and they get stroppy.

And they’ve got very strong ideological commitments. They’ve gone into nursing, or any job in the hospital, because they’ve chosen not to be secretaries to yuppies. They want to do something. Then they find they are continually frustrated, they find they go on a ward and they’re the only one there.

Once that anger starts expressing itself life will get very difficult for the Tories because I think they would have liked to have sat on it. They would love a sort of half cocked Bickerstaff fiasco when there’s a non-event and they manage to lock out a few people and victimise a few stewards. They wouldn’t mind that at all.

As for this time round, the Labour Party has been terribly weak in parliament, and were terrible on the white paper. Kinnock’s not very bright, he doesn’t understand the arguments as well as Thatcher does.

He wrote a piece in the New Statesman recently which was diabolical, pompous and ill informed. He came out with stuff like, of course we all know that demand for health care is infinite. But everyone knows it’s not! You can show it by a graph.

It never ceases to amaze me because the NHS is their big trump card, but they don’t capitalise on it. It’s no good just shouting “NURSES, NURSES” at election time.

SWR: So it’s not just the attack on the NHS, which alone might appear a bit irrational but the broader attack on trade union rights and the wider needs to cut the social wage that the Tories are interested in?

DW: Yes, very much so. We should be asking why is it that we and our families are getting so little when the army and so on are getting a bigger and bigger share? We and our families need a decent health service. No one argues against that.

We shouldn’t be pulling our punches. We should really be rubbing their noses in it because they are in a tight corner and I really don’t quite see how they’re going to get themselves out of it this time.

Even if they came up with quite a large sum of money it still wouldn’t stop the general trend which is down towards the bone. And of course if they did come up with more money then it would be perceived as giving in to the nurses.

All the quality press were furious about Manchester. Even the Guardian headline was something like “Government caves in to strikers”. The old argument that action and militancy pays was really borne out by that.

And it’s obviously a relatively small number of people in Manchester who achieved that and started the ball rolling this time.

Doctors and nurses and anybody involved in the health service have been trained by the social democratic idea that you don’t treat the wallet you treat the illness. So if a poor destitute tramp comes in with a cancer of the stomach he gets exactly the same treatment as a company director.

Now Thatcher has got to crack that and say no, because you’re destitute you go to the destitutes’ hospital which is down the road. That’s an enormous thing to achieve. A lot of doctors would be quite happy with that idea, but a lot wouldn’t.

Most nurses would be quite horrified by the idea so the consequences of social democratic assumptions is that they actually generate their own momentum.

If people had never had an NHS then there wouldn’t be a problem. That’s the case in America. But people here have sampled it and they know its not too bad and they’re going to fight to prevent it being taken away.


Last updated on 29.11.2004