Wednesday, 16 February 2011

Why The NHS Cannot Protect Our Health - Part 2

In previous posts such asValue Theory, I have challenged the view put forward by some that the production of commodities such as Health and Education by the Capitalist State, is based upon the production of Use Values rather than Exchange Values.
The adoption of that position by the Fabians and Lassalleans, is merely an ideological reflection of the fact that they present the Capitalist State as being class neutral, acting in the interests of “society” not of the Capitalist Class.

“The Use Value “clean laundry” might be produced purely as a Use Value, by domestic Labour, but it is unlikely that the Exchange Value of “clean laundry” produced as a commodity will not be considered. That, after all, is why commercial Laundries arose, and why washing machines became commonplace, because workers measured the Exchange Value of those items in relation to the time spent on producing “clean laundry”, and related it to the Exchange Value that could be earned from wage labour as opposed to domestic labour during that same time.

The same is true in relation to the State. But, there are nuances. Firstly, it is clear that State production is determined by Exchange Value – for one thing nationalised industries were once required to set their prices equal to their Marginal Costs.
Capital did not nationalise or socialise production and distribution out of some desire to meet society's needs removed from its own need to maximise profits. Nor does it conversely seek then to privatise what it once nationalised purely out of ideological conviction. Capital is quite happy to nationalise where it is in its interests to do so. It seeks to privatise where it believes it will reduce its costs by doing so. Moreover, the goods and services produced by the State are themselves commodities. Certainly, the Labour-Power purchased by the State capitalist is sold as wage-labour, as a commodity. The goods and services produced by the State Capitalist and sold to workers collectively under conditions of State Monopoly Capitalism, are commodities. The fact that they are sold to the working-class collectively – though consumed individually – does not change that fact. Nor does the fact that they are sold under conditions of Monopoly. The existence of that Monopoly might mean that workers overpay for those goods and services, but that is merely a function of Monopoly, not of State production.”

In fact, what the above demonstrates is the point that Marx makes about the revolutionary function of Competition, which acted to break up the old Feudal State Monopolies, which State Capitalism now seeks to re-impose with all of its reactionary attributes of bureaucracy, paternalism, hierarchy and dependence.
But, as Marx points out Competition, which came out of this state of Monopoly, also leads to Monopoly via the centralisation and concentration of Capital, of which State Capitalism is the logical conclusion, but in turn this Monopoly itself leads to further Competition at a higher level.

“In practical life we find not only competition, monopoly and the antagonism between them, but also the synthesis of the two, which is not a formula, but a movement. Monopoly produces competition, competition produces monopoly. Monopolists are made from competition; competitors become monopolists. If the monopolists restrict their mutual competition by means of partial associations, competition increases among the workers; and the more the mass of the proletarians grows as against the monopolists of one nation, the more desperate competition becomes between the monopolists of different nations. The synthesis is of such a character that monopoly can only maintain itself by continually entering into the struggle of competition.”

The Poverty Of Philosophy.

This statement by Marx is very important. We can see it at play all the time. I've just been watching an item on the news this morning about Higher Education, where the Head Teacher of a school was commenting about the number of his students who were now looking at going to University in Europe or North America. The reason was that if UK Universities were now going to be charging up to £9,000 p.a. then students would look to where they could get a higher standard of degree elsewhere for the same or a lower cost to themselves. If UK Universities want to attract students then they will in a global market place have to raise the quality of the education they provide if they are to be able to charge the prices they now seek. The likely consequence of this based on Marx's analysis, and what we have discovered in relation to Monopolistic competition, is that Universities will increasingly have to go through the same kind of process that Capital in general has gone through.
That is there will have to be a concentration, and centralisation of Capital, a combining together in large Oligopolistic companies providing Higher Education so as to be able to compete on the basis of quality, whilst driving down the cost of that quality by greater efficiency deriving from the economies of scale. That is what we see from Monopolistic competition wherever it exits, such as in the production of cars, aeroplanes, electronics, chemicals and so on. It is a complete verification of Marx's analysis that, “The synthesis is of such a character that monopoly can only maintain itself by continually entering into the struggle of competition.”

But, Marx's analysis is one that emphasises that this process is not one that simply plays out in a smooth linear fashion, but is one in which the basic contradiction is resolved by periods of stagnation interrupted by sharp, violent breaks, crises, revolutions. These revolutions, the truly important ones that essentially occur behind men's backs, not the ones that are visible, the political revolutions that are merely there ultimate surface manifestation, are always a result of fundamental changes in the productive forces, which make the old ways of doing things redundant, and ultimately force a restructuring of both productive and social relations.
That essentially is what Michel Aglietta concluded in his analysis of Neo-Fordism, in which he recognised the truly revolutionising role that the microchip was bringing about in the form of the range of new productive techniques it made possible. It meant that the kind of techniques that had previously been capable only of application in manufacturing, now could be applied to service production, and white collar employment.
The initial manifestation of that came in the private service sector in banking and finance in the late 1980's, and more particularly in the 1990's. It became manifest in relation to white collar employment in the 1990's with the introduction of the word processor, and other digital innovations, for example in relation to communications.
It was, he concluded, inevitable that this would also have considerable implications for those main areas of service provision, such as Health and Education – where the inability to introduce the methods of mass production, and Fordism in the past had limited the ability of Capital to drive down costs without driving down quality, and which had, therefore, led Capital to socialise those costs i.e. to remove them from the backs of individual Capitals and place it on the backs of the Capitalist State, which could use its Monopoly power of taxation to make workers pay. The possibility opened up for private Capital to take on some of this activity, and to do it profitably, and at less cost than that incurred by the State, and at the same time to drive up quality. That is the material conditions upon which the drive for privatisation across Europe rested, and of which the policies of Thatcherism et al were merely the superficial manifestation.

This is related to the point I made in Part 1 that we really need to be told by the Government how much of our tax goes to pay for things such as the NHS so that we can make a fair comparison with how much alternatives cost. As a back of a fag packet calculation, for example, I have looked at the figure for Healthcare in the Government's 2012 Budget courtesy of UKPublicspending. It shows Healthcare at £126 billion out of a total Budget of £702 billion. In actual fact, this understates the actual proportion of the total budget due to healthcare, because a significant amount of the interest to be paid, will be interest on borrowing to cover Healthcare costs in previous years financed out of borrowing rather than taxation. Allocating that interest cost accordingly, a figure of £136 billion would be more accurate. That means that Healthcare amounts to 19.37% of the total budget. If we assume that the share of total tax take then going to cover Healthcare is the same we can make an approximation of how much the NHS costs the average worker in payments of tax. The Government calculates the average wage to be £25,000 p.a. It is also estimated that approximately 40% of income goes in taxes of one form or another – Income Tax, N.I. V.A.T. Excise Duty, Road Tax, and so on. So the Capitalist State deducts £10,000 p.a. from the average wage in Tax from each worker. Consequently, each worker on average pays around £1937 p.a. for the NHS. That, of course does not include the other amounts paid directly such as Prescription Charges, Dental Charges, Opticians Charges and so on. This is comparable to the figure of £1300 per person (which of course, is more than just workers) estimated by the Patients Association in 2007/8. By comparison when I was looking at how much it would cost to take out Private Medical Insurance if I went to live in Spain, the average cost was around £400, or about a fifth of how much the average worker currently pays for the NHS. It should be noted, as some LP comrades in Spain recently commented to me, the Health Service in Spain is markedly better than the NHS in Britain!

I don't make that point to advocate the privatisation of the NHS, far from it. Although, the system of socialised healthcare in Europe, which is based on a model of a single payer National Insurance scheme with actual provision of healthcare by private hospitals and clinics, provides a significantly more efficient, and higher quality service than the NHS in Britain, that is no reason for a Marxist to advocate the privatisation of the NHS. But, it IS a very good reason, especially given the reports into the NHS such as that released this week, for Marxists not to defend the expensive, oppressive, bureaucratic, and poor quality NHS that State Capitalism provides, and instead to argue for a socialist alternative, an alternative which is based on the idea that a large scale, single payer system has been shown to be the most efficient means of funding such a scheme, avoiding the unnecessary duplication and bureaucracy that accompanies the kind of private insurance schemes that dominate the US, which recognises that only a “National” Health Service can achieve the kinds of economies of scale that act to drive down costs effectively, and can also ensure that provision is maintained at a uniform level across the country, and that only if this service is taken out of the hands of private capitalists or their State, can workers both ensure that it is geared to meeting the needs of workers and not Capital, and can they exercise any measure of control over it.
And the reality is that socialists, and workers in the NHS need to consider this seriously, because unless they begin to think in terms of such an alternative quickly they may find they have missed the boat. As I have written previously, for many years socialists complained about the bureaucratic, oppressive nature of State Capitalist housing provision in the hands of local Councils.
But, they offered tenants no real solution to those problems. Tenants and Residents Committees were established, which acted like Trades Unions, bargaining within the system for crumbs off the table of the the local Capitalist State. Ritual calls were made for greater control to be granted by the Local Council, but for the reasons that Trotsky outlined,

“However, a bourgeoisie that feels it is firmly in the saddle will never tolerate dual power in its enterprises. workers’ control consequently, can be carried out only under the condition of an abrupt change in the relationship of forces unfavorable to the bourgeoisie and its state.”

those calls were simply pissing in the wind, revolutionary phrase mongering. Workers sought to provide their own solutions moving out of Council housing to buy their own homes when they could, and when the Tories latched on to that mood within the working-class, they seized it with both hands, introducing the Right to Buy legislation that saw workers buy their Council houses by the tens of thousands. Yet, it had already been shown that Co-operative Housing was the most efficient form of housing provision.

Nor should we delude ourselves about the potential for that to happen with Health. The Left, which is largely isolated from the real working-class, and in denial of its real fears and aspirations, deludes itself about how prized things such as the NHS are. But, the facts speak against it. A report done by the Patients Association - The NHS At 60 - showed a different picture of widespread concern at NHS provision, a willingness to look at alternative methods of funding, and an already significant number of people who were taking out Private Health Insurance, or financing their healthcare by alternative means.

It showed:

1. Over 90% of respondents had had to spend clinical time reassuring patients about the risks of infections such as MRSA

2. Considerable disquiet from patients about Out Of Hours GP provision

3. Considerable problems both from the point of view of both patients and dentists arising from the new contract arrangements

4. Despite a Government promise and assurance from Patricia Hewitt that mixed sex wards had been abolished, it found up to 30% of hospitals still had them, and 10 years after the promise had been given the Under Secretary of State, Lord Darzi, announced that it was an “aspiration that cannot be met”!

5. Concern at wide variations, and in some cases lack of service in relation to pain management

6. Too many hospitals not providing good food for patients, and this 2008 pre-empted the current report by highlighting the problem of the food being made available, particularly for the elderly, for patients to eat!

7. Concern that the Government had decided not to legislate in relation to cosmetic surgery – a problem highlighted recently by someone who died after having a botched butt-implant – but to leave it up to self-regulation by the industry.

8. Continued concern over Patients Rights within the NHS

9. 61.1% of people used the NHS exclusively, with 25.5% saying they used both the NHS and Private Healthcare, 1.7%, only used private healthcare, with no response from the rest..

10. Interestingly, and keying into the points made by Aglietta, although GP's were the first point of reference for information on Health Matters, the Internet was the first port of call for 22% of respondents.

11. 30% of respondents considered non-clinical staff i.e. bureaucracy to be the main source of waste within the NHS, whilst 24% thought that patients contributed to waste. The patients Association believes that this is in relation to patients demanding unnecessary medicines such as antibiotics, another area could be patients who fail to turn up to appointments.

12. Although it was the largest number of the various alternatives, only 40% wanted to retain the funding of the NHS out of taxation. Half that number (20.2%) favoured a tax deductible Insurance Payment, whilst 13% favoured Co-Payments, and 7% favoured vouchers for healthcare up to a specific limit. The Patients Association favours the status quo, and provided no information on alternative methods of payment, but it was forced to recognise that put together the alternative methods formed a majority for change from the current system of payment out of tax. It also admitted that this was despite very little information or advertising to inform patients about these potential other forms of funding.

13. A large number thought that the NHS should not provide cosmetic surgery (40.9%), but large numbers thought the same about Obesity (13.7%), IVF (18.4%), and self-induced illness (12.5%).

14. The vast majority believed that healthcare should be free at the point of need.

These findings should also be considered alongside the findings of the Social Trends Survey. It found that the percentage of those satisfied with the NHS stood at 55% in 1983, and fell steadily until 1994, when it stood at 44%. It then fell again sharply down to 34% in 1997. After Labour came to power satisfaction rose steadily rising to an all-time high of 64% in 2009. But, it has to remember that even to get to this figure, which is not even double the 1997 low, Labour had trebled the funding of the NHS! The figures also show that the highest degree of satisfaction (75%), was in the 65+ age range, with the level of satisfaction falling in each lower age range down to 61% in the 18-34 age range. This is understandable given that the NHS was created when the over 65's were in their formative years, and so most closely associate with it.

Next I want to look at the way in which the NHS fulfils its function for Capital in the way it produces and provides Health as a commodity.

Back To Part 1

Forward To Part 3


Jacob Richter said...

Re. the fourteen-point poll, are you suggesting there's a trend towards this:

He's suggesting an option in between private, employment-based insurance and single-payer.

Boffy said...

I'm suggesting that the idea that support for the NHS in its present State Capitalist form is unassailable is false. Now, what trend emerges from that I cannot say, I can only set out what I have set out previously, and will attempt to set out again. That is that workers should aspire to the kind of Health provision they were creating on their own voliiton in the 19th century. That is one in which workers make their own contributions into a Co-operative Insurance Fund, and that at a local level there are established Consumer based Co-operative Commissioning Panels, who then buy in Healthcare. I would prefer that workers begin to organise within the NHS, and take advantage of the opportunity the Tories are providing them as part of the Big Society Con, to turn it to their advantage and establish Workers Co-operatives that are able to provide the Healthcare Services that the Co-operative Commissioning Panels buy in.

The Trades Unions who currently object to such an approach, in favour of a defence of State Capitalism, are hypocritical, because Trades Unions have always run their own healthcare provision via, their own Convalescent Homes etc., as well as their own Funds to cover such things.

I recognise that obviously it is not possible to simply go from the present State capitalist set up to a socialist, co-operative system, but there are a number of possible strategies or routes via which the transition could be made. It could be that Worker Co-ops grow, as they are doing in Education, for instacne, and begin to link up into a large efficient, national Co-operative provider, which is commissioned by the existing arrangements. Or it could be that provision and commissioning on A Co-operative basis is developed in pockets, and linked together, for example. In every case, workers would have a strong incentive to ensure that any transition was as smooth, and painless as possible, in contrast to the changes being introduced by the Tories, which will only lead to chaos.