Healthcare under capitalism has always been a contest between the needs of workers and desires of capital, and now the National Health Service faces its biggest battle ever.
The appointment of Simon Stevens, a top executive from the largest US private healthcare firm, United Healthcare (and former health adviser to Tony Blair), to be the new chief executive of the National Health Service (NHS) will do more than send a shiver down the spine of all 50,000 campaigners who marched magnificently in Manchester in September.
Few in our movement doubt the scale of the massive attacks on the NHS. And the desire to defend it is strong. Staff are under attack. Pay has been frozen now for two years running, at a time when inflation is eroding real wages. NHS staff have been told they will forgo the meagre 1 percent pay rise promised last year, at the same time as senior NHS managers have had their pay increased by 13 percent since 2009.
Scarcely a week goes by without one group or other of NHS staff having their professionalism attacked by ministers or the papers. GPs are blamed for increasing A&E waits while nurses are blamed for ignoring sick and helpless patients.
All this aims to create an atmosphere where ministers can claim the NHS is not working as a public funded service and that reform is needed, which inevitably, after the passage of the Health and Social Care Act, means competitive tendering and privatisation. The privately owned Virgin Healthcare, for example, now runs over 200 contracts providing community health services for the NHS.
The scale of cuts in NHS funding is astounding. Having promised that NHS funding will be maintained, the government has embraced the "Nicholson challenge", named after the previous chief executive of the NHS, Sir David Nicholson, to achieve £20 billion in so-called efficiency savings out of a total NHS budget of £110 billion. This is unprecedented, coming to about 8 percent of NHS funding over the next few years, four times the 2 percent efficiency savings originally demanded by Margaret Thatcher. No NHS manager believes these levels of cash savings can be achieved without major attacks on frontline services and on the workforce.
Hospital trusts saddled with Private Finance Initiative (PFI) debts are particularly vulnerable, as the Lewisham Hospital fiasco demonstrated. Barts Health, in east London, is another example, drowning with £77 million savings to be made each year. It has had to freeze vacancies to cut 1,000 posts out of a workforce of about 15,000. Special administrators have been called in and staff, particularly at Whipps Cross Hospital, have been down-banded to lower salaries.
The NHS is moving from a public funded and provided comprehensive service, to a more partial, privatised service with a plethora of competing private providers frustrating attempts to deliver an integrated, efficient, comprehensive and equitable healthcare system.
This should not surprise us. The history of healthcare in Britain has always represented a compromise between the desire of our rulers to provide the bare minimum healthcare needed to maintain their workforce, and our fight for something more humane than that, something that comes closer to meeting human need in a much broader sense. And wars and revolutions have often been part of the motor of change in health provision.
The industrial revolution was a turning point for healthcare in England. Before that medicine offered little. Hospitals hardly existed and were dangerous places to be. The rich had physicians who visited them at home, surgery was done by barbers, and the poor saw quacks.
Life expectancy was low. In industrial Manchester in the 1840s average life expectancy for the gentry was 35 and for workers 15 years. These figures were so low because of high infant and child mortality. One in five upper class babies perished before the age of five and three out of five workers' children. Cholera spread through cities as a result of poor sanitation. Poor law hospitals were the only system of healthcare available to most workers, plus a few charitable hospitals like Barts.
Edwin Chadwick, one of the more farsighted reformers of capitalism, brought in the major Public Health Acts from 1848 onwards, arguing that "the sullen resentment of the neglected workers might organise itself behind the trade union leaders. If a Chartist revolution is to be averted, the governing classes must free the governed from the sharp spur of their misery, by improving the physical condition of their lives."
But reforms in healthcare and sanitation were not simply handed down from on high. Workers also fought for reforms. In mining towns with strong trade union organisation they banded together into "sick clubs" and friendly societies and hired their own doctors. Membership rose from 1 million in 1804 to 7 million by 1900. The father of Nye Bevan, who founded the NHS in 1948, was a founding member of the Tredegar Working Men's Medical Aid Society.
But it was all very patchy. The utter failure to treat TB, poor diet, and slum housing meant during the Boer War (1899-1902) only one recruit in three was fit for military service. The height requirement had to be gradually reduced from 5 foot 6 inches in 1883, down to 5 foot by 1902. Lord Rosebery, the Liberal peer and imperialist, asked in the House of Lords, "How can we get an efficient army out of the stunted denizens of the slum basements of our great cities?"
The German Chancellor, Bismarck, was facing the same problems, and started introducing the beginnings of a welfare state there too. Anticipating the First World War, Lloyd George, the future prime minister, had to respond, "I hope our competition with Germany will not be in armaments alone."
So in came Lloyd George's 1911 National Insurance Act. This brought in compulsory national insurance, paid for mainly by workers themselves. It gave free GP healthcare to working males, but nothing for wives, children or the elderly. It did not cover the unemployed and, importantly, it did not cover hospital care.
This was far from adequate. In the 1930s health was still appalling with large class differentials. The infant death rate was 42 deaths per thousand in the prosperous Home Counties, still enormously high by today's standards, but 114 per thousand in industrial Jarrow in the north east.
In 1937, 83 percent of children in County Durham had rickets. Yet no longer was there the excuse that medicine had little to offer. There was already a vaccine for whooping cough, but 2,000 deaths occurred in epidemic years because there was no mechanism to deliver mass immunisations.
Once again it was another war, this time the Second World War, which produced the next reorganisation of healthcare. Blueprints had been around for ages. The 1920 Dawson report had looked forward to the creation of a coordinated system of comprehensive health centres in garden city environments in the cities, something we don't still have today, but there had been no action.
It was the war that pushed the state to take some action, to overcome the narrow short-term interests of individual capitalists, to fund a major reform.
The 3,000 Poor Law hospitals were bankrupt. The 1,000 voluntary charitable hospitals were slightly better off, but could not afford to buy modern x-ray machines or even new boilers for their crumbling buildings. Most had been erected before 1891. The government was frightened the Germans would use poison gas, and casualties of at least 300,000 were expected in the air raids. The inertia was shattered. The Emergency Medical Service was put in place together with the Regional Blood Transfusion Service, and the Public Health Laboratory Service.
The question soon arose, "What would happen after the war?" The radicalisation of workers in the army provided another spur. A Liberal peer, Lord Beveridge, was charged with writing the report to provide a plan, and his report had a deep resonance with workers in uniform.
When it was published in 1945 there was a queue a mile long outside Her Majesty's Stationery Office to get a copy. A Gallup poll three weeks after publication showed that 19 people out of 20 were familiar with the report and the vast majority approved the findings. The Armed Forces Education Service was overwhelmed with requests for lecturers to debate the report.
It was the idea of an NHS that was among the things responsible for the post-war Labour victory. But it was the landslide nature of the victory that was responsible for the radical nature of the final outcome. Bevan went much further than Beveridge and nationalised the hospitals themselves rather than just going for an insurance model with the private hospitals remaining - the situation that exists in most European countries now. Bevan also insisted on including the voluntary hospitals as well as the municipal hospitals.
Yet it is important to realise that the NHS was not some enclave of socialism as Bevan insisted. It was a reform that was part of capitalism's post-war settlement with the working class, albeit a reform much more in our favour than the Tories would have liked had they been in power. But the burden of paying for the NHS fell mainly on workers' shoulders through national insurance contributions.
This was made explicit in the leaflet that fell onto everyone's doorstep, entitled The New National Health Service: "It will provide you with all medical dental and nursing care. Everyone - rich or poor, man woman or child - can use it or any part of it. There are no charges. There are no insurance qualifications. But it is not a charity. You are paying for it, mainly as taxpayers..."
The NHS was established at a time of austerity with national debt higher than it is now. But the fear of revolution made Britain's rulers willing to bring in the NHS and all the other welfare reforms of housing, education and social security. But attacks on the NHS were not long in coming.
The government had underestimated the amount of illness that needed treating and naively thought the NHS might cause illness to disappear. Costs rocketed from the paltry £150 million outlined in the NHS bill to £450 million by 1950. The health centre building programme was cancelled early on. We still live with the consequences with many GPs still working in terrible premises.
In April 1951 the Labour government took the dramatic decision to end the wholly free provision and bring in charges for dental and spectacle services. Bevan, together with Harold Wilson, resigned from the cabinet. Perceptively he explained why he was resigning over "such a triviality as spectacles and dentures", explaining that "avalanches start with the movement of a very small stone". The real driving force for the cuts was to fund the new arms race and Labour's involvement in the Korean War - both a reflection of the onset of the Cold War.
The second major attack on the NHS came with the Tory government in the 1970s. Three options were discussed in cabinet. First a straight opt in/opt out policy for the NHS. Either you stayed with the NHS or you got a tax rebate to insure with a private health company like BUPA. Second was a proposal for an employer-financed scheme, with legislation to compel employers to offer private healthcare like in Germany. The NHS would only exist for the unemployed. The third option was a supplementary top up insurance scheme that everyone could take out.
It never happened. And what drove it back was a wave of fightbacks. There was a spate of hospital occupations, although some of them lost their immediate demands. There were large TUC-organised demonstrations against the cuts. But it was the 1982 nurses' strike that really bowled the Tories over. Selective strikes started in May and a national strike took place in June. In Sheffield a dozen nurses and occupational therapists went on a tour of the local coal mines, and by lunchtime four pits were on sympathy strike.
By the summer there was support for all-out action at the NUPE and COHSE (now both part of Unison) union conferences. This culminated in a Day of Action. There were 120,000 on the London demonstration. One million workers went on strike in Scotland, 750,000 in Wales; 157 coal mines were on strike and 43 ports were closed.
It could not be ignored by the press. Indeed no national newspapers were published that day! Margaret Thatcher, the lady who was "not for turning", was forced to abandon her plans, and declare at the Tory party conference in October 1982, "The NHS is safe in our hands" - meaning there was to be no wholesale privatisation of the NHS. Once again the form that the NHS survived in depended on the balance of class forces at the time.
The new round of NHS cuts and privatisations today are different from those the Tories sought to achieve in the 1980s. Rather than bringing in a private healthcare system as an alternative to the NHS, both the last Labour government and now the coalition government with its Health and Social Care Act safely on the statute book are privatising from within.
They have produced a market where every operation, every blood test, every GP consultation or outpatient appointment or A&E attendance has a price, and competing firms vie against each other for NHS money to provide a service. Even the commissioning of this care by the NHS is being privatised, probably to the big four accountancy firms. GP Clinical Commissioning Groups are fig leaves hiding the true power of the markets being set up.
But just as in the 1880s, the 1940s and the 1980s, what happens depends very much on what we do. The demonstration of 50,000 in Manchester on 29 September was a great start, and was built on the campaigns at Lewisham Hospital when some 25,000 marched and gained a reprieve for their hospital, and Stafford where 30,000 marched to save a hospital ravaged by underfunding and poor care brought on by a management's determination to obtain foundation trust status at all cost.
In east London the attacks at Whipps Cross Hospital within the Barts Health Trust have started a fightback that unites hospital workers and a community campaign, the successful formula from Lewisham. It is a start in rebuilding the union strength we had in the 1980s.
This round of privatisation started under New Labour with the Private Finance Initiative that saw hospitals built privately at exorbitant interest rates from the banks. The effects of that were obscured because of the increased funding the NHS received under the Labour government. But now we are seeing a perfect storm of cuts and privatisation which is making clear to more and more people what had previously been hidden.
Ed Miliband has committed to the repeal of the Health and Social Care Act. But the shadow secretary of state for health, Andy Burnham, remains very silent on getting rid of the Private Finance Initiative. We cannot afford to wait for Labour to do it for us. What happens will depend on the battles in the hospitals, in the communities and on the streets.
What remains clear is that for the last 150 years healthcare has been determined by a battle between the minimum our rulers feel they can get away with to maintain a moderately healthy workforce to exploit and workers' struggle for something more than this.
This has given us an NHS that is worth defending. Most people are prepared to fight for a heathcare system where "poverty is not a disability, nor wealth an advantage". Where the balance falls in the future, and how Labour plays its cards, depends on our fightback now.