Capitalism & Care

The last few days have shown once again that Capitalism cannot be relied upon to provide even basic standards of Care for workers. Coming on top of the many revelations about appalling conditions and treatment of patients at Stafford Hospital and elsewhere, there have been further similar revelations about Redditch Hospital, and Panorama has produced film evidence of atrocious treatment of residents at a private Care Home, Winterbourne View, in Bristol.

On top of that, Southern Cross, the biggest provider of private residential Care in Britain, is facing a financial crisis, partly due to its model of selling its homes to Landlords and renting them back (a version of PFI), and because of limitations on payments by the State to cover costs.

The fact, that these problems extend to both private and State capitalism demonstrates that this is not a question of whether care is provided by private companies or by the State, but is a result of the fact this provision in both cases is CAPITALIST, i.e. it is ultimately determined by the needs of Capital, not of ordinary workers. In fact, even in the case of the private provision, the Capitalist State is also culpable. The reason that private companies such as Southern Cross and BUPA are resorted to by Local Authorities, is that the scale of operation of these companies means that they can achieve efficiencies that the Local Capitalist State cannot, and usually can do so whilst still providing higher quality facilities than the local Council is capable of.

But, although these private care homes do have a considerable number of residents who pay the full cost of their places, in order to meet their legal responsibilities, and to operate on a large enough scale, they also have to take residents sent by the Local Authority, and they are, therefore, at the mercy of what the Local Authority is prepared to pay, and as the Cuts imposed by the Liberal-Tories bite, that is passed on.

This shows the lunacy of attempting to provide something like Care on the basis of profit. At least in the case of Southern Cross, and BUPA and other large scale providers there is not a question about the quality of Care provided. In fact, this is really a mirror of what is seen elsewhere. Particularly, since WWII, we have seen the development of a small number of very large companies in most sectors of production. These companies compete, mostly not on price, but on quality, in order to expand their market share.

This has driven the marked improvement in the quality of most consumer goods seen during that period. At the same time, in order to increase their rate of profit, these companies have also been vigorous in finding new methods of production, new techniques etc. in order to raise productivity and reduce costs. This has acted ultimately, to ensure that higher quality has been accompanied by lower prices, as these new methods become standard. In Europe, where socialised healthcare is achieved via State run National Insurance schemes, which commission services from often large private or not-for profit companies, this has also acted in the same way to raise quality, and reduce costs.

But, this assumes that the care needs of the population will be met by the National Insurance funds collected by the State. In the event that does not happen, then the companies providing the services will make losses, and eventually withdraw provision or close down.

If workers had full control over this, then they would ensure that, if necessary, the insurance premiums required to meet the costs were increased. But, this is precisely the problem with Capitalist provision of Care, be it private or State Capitalist. Workers do not have any control over the provision, either in terms of how much of their wages are devoted to it (let alone how much of society's resources are devoted to it), or over what or how provision is made. In the case of Redditch Hospital, it had only recently been given a clean bill of health by the Care Quality Commission, the Capitalist State body set up to inspect such establishments.

In fact, as the Patients Association have reported in the past, it is not the first hospital that has been given such a clean bill of health, but been found to be wanting in its provision. Similarly, the CQC was responsible for the inspection of Winterbourne View, and despite having been warned by a former member of staff about what was going on there, failed to take any action.

But, anyone who has worked in the State capitalist sector can understand why this is. In reality, the whole culture breeds an attitude of complacency. Frequently, those doing the inspecting – this applies to external audits amongst other things – move in and out of doing the very functions they are inspecting. They belong to the same profession as those they are checking up on, and so on. In addition, the bureaucratic mindset developed is one of box ticking. You have a job to do like any other, for which you get a pay check at the end of the month, and like most other workers your attempt is to maximise the pay check, whilst minimising the effort you need to put in to get it. Again, any one who has worked in the State capitalist sector knows that not only do people who rock the boat not get promoted, but they are likely to face hostility from both superiors and peers alike. But, more than that there is no imperative for an Inspector sent in by the Capitalist State to have any immediate reason to make their own life more difficult. It is not their parents or children who are in the home after all.

When it comes to buying a new car, there is lots of information, including the information given by people you know, and your previous experience. That means you have a good chance of being able to make the right decision, and, if there is a problem with it, of complaining and getting it sorted out by the dealer. That is even true if you are going into a hospital yourself. But, it is largely not true about care for your children or parents. What is more, they are frequently not in a position to complain, or to tell you if there is a problem. You rely, on the State Inspectors to do their job properly in that regard. But, why should we be surprised that this does not happen.

Although, we have had Factory Acts for 150 years, and a Factory Inspectorate, and now a Health and Safety Executive, workers do not rely on them to ensure their safety, they know that these things provided by the Capitalist State are a facade, and that we have to continue to appoint our own Health and Safety Reps, and undertake our own direct Trade Union action to try to protect workers health and safety. If we really want to ensure that the existing provision of health, care and education even minimally goes to meet our needs, we cannot rely on the Capitalist State to do that. Just as we have our own Health and Safety Reps, we need our own Committees of Workers Inspection to go into hospitals, schools and care homes to ensure that our needs are being met.

But, just inspection alone is not enough. As a County Councillor, sitting on the Social Services Committee, both myself and the Chair of the committee, month after month complained about the terrible level of education provided to children in the Council's care. But, we found that we were effectively impotent to do anything about it. Real control rested with the Permanent State bureaucracy, and when eventually some action was taken by them, it was to appoint yet another high paid bureaucrat to be responsible for improving the situation.

Of course, month after month, despite that, the situation did not improve. My Mother spent the last three years of her life, bed-ridden in a Private Nursing Home, paid for by the Council. The quality of the home was good, better than the Council, Residential Home she had been in previously. Many of the staff, lived near to me, and so I knew them personally, which helps. A number of them came to my Mother's Funeral. Yet, if I had had any complaints, it would have been difficult to raise them individually, because, ultimately I was not paying for my Mother's stay there, and even if I was, it would still have left me relating to the Home on an individual basis.

If ordinary workers are to have any real power in such relationships they have to be able to act collectively, and that means that they must be responsible for Commissioning that Care themselves on a collective basis from within their Community, rather than the Commissioning being done by a Health Authority, Primary Care Trust, or Doctor's Collective. Only if workers through a Commissioning Co-operative, have control of the funds, and use it to buy in the care they need, will they have any hope of exercising any power in such relationships.

That would also mean that workers through such a process could also exercise direct supervision over the care provided to avoid the kind of problems seen at Winterbourne View, Stafford Hospital, and elsewhere. That could be done by workers, through such a Commissioning Co-op, placing one or more of its members into each establishment on a full-time basis, and providing regular reports back. This duty should be done on a rotational basis to prevent any relationship developing between the Monitor and the establishment, and like Jury Service, the time taken from their usual work to carry out this function should be met by their employer, and guaranteed in law.

That would be a start in ensuring some degree of democratic and workers control over provision. But, such control is only effective if the Commissioning Co-op, also has control of the purse strings in a wider sense. If the State continues to determine how much money shall be allocated to each activity, then workers will only exercise partial control. The quality and quantity of provision will remain under the control of the Capitalist State. In other words, workers will need to move to a situation, in which the taxes and other payments that are currently absorbed by the Capitalist State, and its bureaucracy, go directly to them to cover the commissioning of these services.

In that way, as Marx described we will also be better able to see how much of our taxes go to pay for these services, and how much is actually siphoned off by the Capitalist State for its own purposes, including the maintenance of its vast and controlling bureaucratic apparatus.

“Because indirect taxes conceal from an individual what he is paying to the state, whereas a direct tax is undisguised, unsophisticated, and not to be misunderstood by the meanest capacity. Direct taxation prompts therefore every individual to control the governing powers while indirect taxation destroys all tendency to self-government.”

(Marx - Programme of the First International)


Already in Britain, we have some move towards the establishment of worker co-operatives in health and social care provision. That is far more developed in Europe and other parts of the world. It is the rational extension of Worker Owned and controlled commissioning of services. In the first instance it is likely that such Co-operatives will continue to compete against each other, private Capitalist and State Capitalist providers.

We should not be afraid of that situation, but be confident that a Co-operative, socialistic model is more efficient, and will win out in the end, due to its superiority, even if there are inevitably some failures along the way. Even whilst they compete on quality, and, to begin with, price, we should encourage these Co-operatives to join together in a national Co-operative Federation, in order to obtain the benefits of economies of scale. As part of that Co-operative model we would expect a continual expansion of planned production in conjunction with the needs expressed by the Commissioning Co-ops, and a general sharing of best practice, new techniques and so on, so that the Worker Co-operative sector as a whole could rapidly develop at the expense of the private and State Capitalist sector.

In Left-Wing Communism, Lenin wrote,

"We must work to accomplish practical tasks, ever more varied and ever more closely connected with all branches of social life, winning branch after branch, and sphere after sphere from the bourgeoisie.”

Given that Lenin here recognised that bourgeois democracy was a sham, and that it was impossible to control the Capitalist State through it, it is clear that what he means is that these practical tasks, and this winning over of branch after branch means workers doing that outside Parliament, in their daily life. As Trotsky puts it,

“It would of course be a disastrous error, an outright deception, to assert that the road to socialism passes, not through the proletarian revolution, but through nationalization by the bourgeois state of various branches of industry and their transfer into the hands of the workers’ organizations.”

Nationalised Industry And Workers Control Of Production

It is a reatatement of the ideas of Marx and Engels who rejected the idea that workers should rely on or promote the development of the Capitalist State in all forms including Welfarism. Instead they argued that workers if they were to make themselves fit to become the ruling class had to increasingly establish their own forms of property, democracy, and state in opposition to the Capitalist State. Marx and the First International called this "self-Government". Engels himself remarked,

“It seems that the most advanced workers in Germany are demanding the emancipation of the workers from the capitalists by the transfer of state capital to associations of workers, so that production can be organised, without capitalists, for general account; and as a means to the achievement of this end: the conquest of political power by universal direct suffrage.”

If we want to avoid the kind of abuse, and catastrophes we have seen in the last few days, then workers have to begin to take control and ownership into their own hands, rather than simply expecting the Capitalist State to do it for us.