Both Britain and the US will need to move towards the model of France and Germany, if the cost and quality of healthcare is to be maintained let alone if the changes brought about by developing technology are to be accommodated. But, this provides a considerable adavantage for workers in the current climate. The efficient aspect of the current Health system in the UK, is precisely the collection of insurance premiums through the Tax, and National Insurance system i.e. the payment for healthcare out of State Funds. Moreover, moving to a Co-operative Healthcare system is not something that could be likely introduced overnight.
Provided, payment for services could be guaranteed from such a State scheme, however, then workers in existing Hospitals, Clinics, and other establishments could take them over as Co-operatives, in the knowledge that adequate funding would be available. Moreover, the greater efficiency of Co-operative production , would ensure that these funds went further, and could be used to both raise workers conditions, and to provide necessary investment in new equipment.
In short efficient large scale provision of medical care could be developed very quickly if the workers, and the trades unions in the NHS took that initiative. But, it would still mean that control of the purse strings remained with the Capitalist State, and how tightly it drew those strings would continue to be dictated by the year to year needs of Capital in relation to its needs for the reproduction of Labour-Power. However, once a Co-operative National Health System has been established in relation to medical care, it is a fairly simple matter from there to demand the right to establish Co-operative Health Care Insurance to cover the cost of that care, with the State paying the contributions of workers that Capitalism cannot provide employment for. The advantages of such a Co-operative Insurance Scheme, managed by local elected Commissioning Boards, is obvious. It means that it is workers who become the direct purchasers and providers of their own healthcare for the first time, taking that ownership and control out of the hands of Capital and its State. Rather than that healthcare being determine by the needs of Capital it becomes determined by the needs of workers, and those worekrs will have a direct incentive to ensure that their funds are used not only in the most effective way to meet their needs for healthcare, but in the most effective way to protect their health, including campaigns against unhealthy working environments, unhealthy food, unhealthy housing, and those campaigns as part of a class struggle against Capital open up wide vsitas for joint action with Trades Unions, Tenants and Residents Associations, Co-operative Housing, and the Co-op itself in relation to Consumer Rights.
The Ombudsman's report into the NHS spoke about an ingrained culture that led to the problems of lack of basic compassion etc. For the elderly patients left to lie in their own urine and faeces etc. That is partly to do with the phenomenon described by Marx known as “The Alienation Of Labour”. In other words, those producing the commodity, in this case healthcare, have no direct personal link with those who consume the product they produce. There is a lot of nonsense spoken about the idea that those who work in the state capitalist sector are driven by a commitment to the Public. Having worked in Local Government, and been a Councillor, as well as a customer of the State Capitalist Sector I have to say I've never noticed it. And, why would workers in the State Capitalist sector be expected to be different from their comrades working in the private capitalist sector? They have no more control ove their means of production, no more direct link with those who consume their product. In fact, in many ways they have less.
In the private sector, money plays an important role. At each stage of management and, indeed down into the workforce their tends to be a direct financial incentive to perform well, to sell more, to work more productively. No such imperative exists in the State Capitalist Sector. In its place has to come other forms of control, which is why additional tiers of management, bureaucracy and measurement have to be introduced, which in turn make control over the labour process less for the ordinary worker, make the relationship with management more paternalistic and oppressive. It means that whereas in private Capitalist businesses, much more freedom and possibility for initiative is granted to workers – that was particularly the case with the neo-Fordist, and the non-continuous flow systems introduced during the 1980's – in the State Capitalist sector, all such development is squashed. In fact, as was seen in Eastern Europe, this kind of oppressive managment control tends to have the oppsoite effect. Everyone does all they can to avoid initiative that might lead to criticism or hinder their promotion, or worse. And those at the bottom respond with sullen resignation, and find other means of expression, and revolt.
That's not to say that alienation does not exist in private Capitalism. In fact, all of the things said earlier about small Capital, make it similar in that respect to State Capitalism. It is Big Capital with its greater resources, its greater scale of operation that can introduce quality circles for workers and other such techniques to counter that alienation and promote and utilise the natural inventiveness of workers. It is Big Capital, which via Oliigopolistic competition, works on the basis of competition on the basis of quality not price, and which seeks to raise profits by ever new, more efficient means of production. Small Capital and State Capital in the end also responds, but its response takes place under different conditions, it is always lagging, and as a result never achieves the benefits of first-mover advantage when new methods of production are introduced.
By comparison, as Marx pointed out in relation to the Lancashire Textile Co-ops, and as James Connolly set out in relation to the Workers Co-op at Ralahine, workers have an even greater incentive to introduce new labour-saving machinery than even Big Capital.
“To those who fear that the institution of common property will be inimical to progress and invention, it must be reassuring to learn that this community of ‘ignorant’ Irish peasants introduced into Ralahine the first reaping machine used in Ireland, and hailed it as a blessing at a time when the gentleman farmers of England were still gravely debating the practicability of the invention. From an address to the agricultural labourers of the County Clare, issued by the community on the introduction of this machine, we take the following passages, illustrative of the difference of effect between invention under common ownership and capitalist ownership: –
“This machine of ours is one of the first machines ever given to the working classes to lighten their labour, and at the same time increase their comforts. It does not benefit any one person among us exclusively, nor throw any individual out of employment. Any kind of machinery used for shortening labour – except used in a co-operative society like ours – must tend to lessen wages, and to deprive working men of employment, and finally either to starve them, force them into some other employment (and then reduce wages in that also) or compel them to emigrate. Now, if the working classes would cordially and peacefully unite to adopt our system, no power or party could prevent their success.””
Even within the Capitalist Sector, the importance of a personal relationship between producer and consumer can be seen. In contrast with the report of the NHS Ombudsman, when my Mother was in a Private Nursing Home in the last few years of her life, our experience was quite different. But, hte home, which was within our Community, also employed local workers. Unlike, the NHS Report which commented on the fact that a patient would not often see the same nurse twice, due to the employment of agency staff etc., one of the nurses at the home lived in the same road as me, and one of the carers lived in the lane, just around the corner from me. It makes a clear difference when that day to day, more or less, personal human contact occurs, when it comes to those workers seeing the person in front of them as a human being, and not just a customer.
A Co-operative system of healthcare could ensure that those advantages were utilised by ensuring such local contact and control. Local democratically elected boards of Co-operative Health Commissioning, would ensure such personal contact between the workers sitting on those Boards, and the Workers in the co-operatives producing the healthcare. Locally elected Boards of Workers Inspection, visiting each establishemnt, would deepen that personal link, and undermine any tendency towards alienation of labour. In the meantime, a direct financial incentive, and the incentive described by the workers at Ralahine above, would ensure that where possible the producers of those services would introduce whatever new innovative means were available to lighten their load, improve the quality of provision, and reduce their costs in order to increase the profits of their Co-operative. In the meantime, the workers sitting on the Commissioning Co-ops would have an incentive in trying to ensure that such savings were also shared with the workers consuming those services, and in attempting to address those things, which led to workers needing to resort to healthcare in the first place.
Healthcare would then cease being a commodity provided to individual workers, apparently arising from their individual needs, but in reality determined by the needs of Capital, and would become absorbed inthe attempt to protect workers Health. The protection of workers health would itself cease to be seen in individualistic terms, but would be considered collectively by workers themsellves nd viewed in terms of their wider needs – Health & Safety in the workplace, and communities, decent housing, decent food, decent environments in which to live and work, decent education and so on. If workers want to protect their health, they should not expect that from the Capitalist State. They have to take ownership of the means of doing that for themselves, and they should do it now.
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