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Wednesday 27 March 2013

A Climate of Fear

Before the NHS can be opened up to the market, popular support must be undermined. This is problematic as the defence of established ways naturally appeals to the conservative temperament. To get conservatives on board, the ideological focus initially shifts towards external threats. In other words, the NHS is being battered by forces beyond its control, so we must change it to save it. These external threats include genuine secular trends, such as advances in medical science and demographic change, but with a relentlessly negative spin (too costly, too old). Other threats include the staple of all things "foreign", from incompetent locum doctors to "health tourists". Even government reform is shamelessly held up as a threat, as politicians decry the destabilising effect of yet another restructure before proposing their own bureaucratic cure.

As pessimism becomes entrenched, the narrative gradually shifts towards the claim that the NHS is intrinsically incompetent. A major trope is the idea that hospitals are a danger to our health. Popular anxiety has been fuelled both by legitimate concerns, such as infections and neglect, and by the irresponsible indulgence of quackery, which has an interest in promoting the risks of conventional treatments under the cover of "choice". When the language shifts up another gear, to imply that the NHS is comprehensively rotten (a culture based on the "normalisation of cruelty"), then you know we are fast approaching the end-game. This has been reinforced this week by Jeremy Hunt explicitly claiming that hospitals are "failing" and that they have "betrayed" patients. The rhetorical equivalence of the hospital and the charnel house can't be far off.

The Health Secretary's proposals in response to the Francis report include the usual managerialist mechanisms of ratings and sanctions. These will institutionalise failure as a feature of the health service, much as the same mechanisms have already done in education. Just as "failing" schools have been handed over to the private sector, so failing hospitals will be handed over to private providers. Health care staff are to be inspected as vigilantly as teachers, while professional status is to be eroded at the bottom end of the pay scale. Nurses are to be obliged to spend a year learning how to care (i.e. wash patients and change bedpans), though this appears to be considered unnecessary for doctors and hospital managers. Given that there will be no extra money, this could mean nurses displacing cheaper ancillary workers, leading to either lower wages or fewer staff. In tone, this sounds punitive: teach nurses their place in the class hierarchy of health.

Compare and contrast with the revelation that job centre staff are expected to meet targets for benefit sanctions, and that offices are being judged in league tables, with underachievers threatened with "performance management". Ian Duncan Smith has sought to deny that this is departmental policy, as it clearly shows that failure (i.e. the sanctioning of a set number of claimants) is being deliberately engineered. He doesn't appear to be trying too hard, and I don't get the feeling that Liam Byrne, his Labour shadow and fellow workfare enthusiast, is really as appalled as he claims to be. Before long, we'll simply accept that the arbitrary decimation of benefits is a necessary discipline for the jobless. Having it decided by the drawing of lots will probably be advocated as fairer.

It has been an interesting couple of weeks for Jeremy Hunt. Last Tuesday came the news that the three main political parties had agreed a deal to set up a new independent press watchdog. This brought to a close the political strand of the phone-hacking affair, which blew up on Hunt's watch as Culture and Media Secretary just as he was trying to facilitate News Corp's takeover of BSkyB. It is widely recognised that both the Leveson inquiry and the subsequent political response failed to address the key issue, namely the concentration of media power in the hands of Rupert Murdoch and a few other rich men. Alan Rusbridger, the editor of the Guardian, has produced many bland words advocating reasoned compromise between press and politicians over the issue of regulation, but even he couldn't avoid admitting the stark truth: "The most powerful newspaper group in the country was – on the kindest interpretation – out of control. The police and parliament were cowed". In the case of Jeremy Hunt, "enthusiastically supportive" would be more accurate.

Given the role that the press has played in denigrating and undermining the NHS over the years, it is distasteful to watch their hysterical over-reaction to the supposed threat to free speech represented by the new regulatory regime. Nick Cohen even went so far as to claim that "a great chill will descend on the free republic of online writing, which until now has been a liberating and democratic force in modern British life". While we should never underestimate the ability of the state to blunder into repression, the idea that any regulator would have the resources, let alone the inclination, to proactively monitor the citizens of "the free republic of online writing" (i.e. obscure bloggers) is laughable.

This is the hyperbole of fear. A weak press regulator is decried as the end of 300 years of press freedom, thus avoiding the need to address the odious privilege of newspaper barons, while the NHS is painted as if it were a murderous conspiracy, the better to justify its dismemberment.

11 comments:

  1. David,

    I think this approaches the question from the wrong direction. It assumes that the goal of Health Policy is privatisation without asking the question why that might be. The idea of a Welfare State was proposed by Liberals and Tories going back to the beginning of the last century. The proposals for the NHS brought forward by the Liberal Beveridge.

    During all the post-war period Tories never even considered privatisation of the NHS, and indeed developed it as much as Labour. Not even Thatcher proposed privatising it, and if anyone was going to be able to do it, it was she.

    So, the question is why would any Government want to privatise the NHS, and why now? Sure, this is an ideologically driven Government with no ideas of its own, and only able to copy as farce the ideas and solutions of Thatcher, in the changed conditions of today, but most of their proposals were also put forward in some form by Labour, which was not driven by such ideological considerations.

    Indeed, Labour could hardly be accused of that. They quickly trebled spending on the NHS, and raised public support for it from around 34% to about 60%. They started not by proposing privatisation, but rather the quite reasonable idea that if such huge amounts of money was to be pumped in, then some means of ensuring it resulted in some measurable outputs was required.

    It was the fact that this attempt floundered, rather like similar attempts to achieve such control under the Stalinist planned economies in Eastern Europe failed, because bureaucrats found means of gaming the plan targets, and workers suffered from alienation, that led to the idea that only competition could impose the necessary whip for efficiency.

    The Left should be careful about attacking Blair for that, as with other similar policies like PFI. Lenin proposed something pretty identical to PFI in Russia in the 1920's, as a means of quickly accumulating capital, and he saw that as well as the introduction of the market via NEP as a necessary means of providing the whip of competition to drive up efficiency. Trotsky proposed something similar in relation to Mexico.

    The real problem in all these instances is the lack of development of the working class to be able to exercise control over the means of production in its own name, and indeed its unwillingness in most cases to do so.

    The real reason the Tories and labour, and behind them the State and Capital seek to privatise the NHS, is because there are now more efficient means of delivering the commodities it produces. The low level of patient satisfaction at the NHS is not driven by some conspiracy at the top, but by ordinary workers actual experiences of it, and I can speak with personal experience.

    Yes, we can argue for more democratic control over it, but so long as it is in the hands of the State, that will never be granted this side of the revolution. Such a campaign is only then relevant as a means to an end of demonstrating to the mass of workers the need to remove it from the hands of the State, and bring it under workers ownership and control.

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  2. Privatisation (or the unwillingness to nationalise) has been a feature of the NHS since 1948, specifically with regard to surgeons, GPs, drug manufacturers etc. Nye Bevan's famous claim of the doctors, that he "stuffed their mouths with gold", shows that the system was compromised from day one. Thatcher may not have furthered privatisation significantly, but that was a tactical judgement about priorities. Her own oft-stated preference for going private is typical of the Tory long-game: the gradual expansion of "choice" and market provision, and the snide denigration of public provision.

    The New Labour twist (drop the internal market, introduce targets) differed from the Tory strategy not in its attitude to privatisation, as it continued the process of diverting an increasing amount of the NHS budget into the private sector, but in its choice of which private suppliers and professional classes should benefit. The Tories favour big healthcare companies and small capitalists (GP practices), while Labour favours big management consultancies and tiers of management apparatchiks.

    I don't think the move towards privatisation is driven by the belief that health commodities can be delivered more efficiently by other means, though that's not to say this isn't possible. I think it is driven by the relative attractiveness of healthcare as an investment sector. Demographic change (an ageing population in advanced economies) and the prospect of technology-biased change (i.e. addressing Baumol's cost disease), make it a sector with a guarantee of structural growth and a much larger potential for productivity growth than the norm.

    My point in this post, which is essentially about the use of language rather than the NHS per se, is that what has been "normalised" (in Jeremy Hunt's phrase) is the idea that the NHS is toxic. I am well aware of the real failings in the service (I use it too), but the popular description of it in government statements and press reports is black propaganda. I noticed a great example of this in today's Sun: "Migrants to bring drug-resistant TB superbug to UK". It only needed evidence of dilatory UK hospital management for a full house.

    http://www.thesun.co.uk/sol/homepage/features/4861619/Time-Bomb-immigrants-to-bring-drug-resistant-TB-superbug-to-UK.html

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  3. There are more efficient means of delivering the commmodities the NHS produces? Pull the other one, it's got bells on. Privatisation is about driving down wages for workers and increasing perks and remuneration for shareholders and senior management. What more efficient methods exist?

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  4. David,

    Yes, there has always been the element of private sector involvement in the NHS. The main aspect of that, of course, is the way drug companies, and other large providers - construction companies, IT companies etc) have been able to rip it off. The other aspect, that of the Consultants etc, was driven by their own individual economic interests rather than the interests of Capital as such.

    As with education, the rich always have an incentive for the retention of a private sector, for their own use. But, the existence of the NHS was also beneficial to them, in that its mass production, Fordist nature, provided the basis for reducing the cost of many drugs and treatments that could then be used in the private sector, and by the rich. It also meant that it could be used for experimentation of new treatments before they were used on the rich.

    The only reason that healthcare represented an attractive investment area in the past was precisely because it was limited in size, and limited to a niche market that could pay higher prices for a superior service in terms of what was provided. Its rather like with Rolls Royces. The production of them would not represent a good investment area if they continued to face the same costs, but were produced for the mass car market! The only reason that a mass health care market could now be attractive would be precisely because, as Aglietta predicted, the introduction of Neo-Fordist methods, based on new technology, would make all service industries go through the same kind of revolution that manufacturing went through during the 20th Century. That means that it is able to provide efficiently on the kind of large scale that Capital requires for the reproduction of labour-power, whilst creating Surplus value, for those that take on the production. Healthcare is only the latest service industry to go through that kind of transformation.

    As far as that private sector is concerned, in response to Guthrie's points, the NHS has always had a problem of nursing staff, in particular moving into the private sector because they were able to obtain higher wages and better conditions than in the NHS. The same is true, of course of teachers who go to work in Public Schools where wages and conditions also tend to be better. They have been able to do that in the past because of the higher prices charged in the private sector, but as with the experience of Fordism during the 20th century, the higher profits of such companies generally come from driving up productivity via more efficient methods, rather than through driving down wages and conditions.

    The classic example of that was Ford himself, who rather than driving down wages, doubled his workers wages to $5 a day, and yet increased his profits because productivity rose by a larger amount as a result.

    There is no shortage of more efficient production of healthcare. Most of Europe's healthcare is more efficient than the NHS. France has reputedly the best healthcare in the world, and yet its cost is no more per head than in Britain. The same is true of Germany, and Spain. The main difference is that whilst the countries have the same basic system of social insurance that exists in the UK (which is more efficient than individual private insurance as the US system demonstrates) the actual delivery of healthcare is provided by a combination of co-operatives, other mutuals, not-for profit companies, and capitalist providers. Anyone who has used the healthcare system in these European countries knows it is considerably better than the NHS.

    They have not suffered the same kind of problems of waiting lists, hospital infections and so on for a start.

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  5. Boffy,

    It obviously depends on how you define "efficient", but I think most people would agree that this is a combination of two dimensions: best outcomes (effectiveness) and lowest cost (resource efficiency), with the assumption that one trades-off against the other. This 2010 meta-analysis, from the US-based Commonwealth Fund, indicates that the NHS does well in both dimensions (second cheapest and second best in terms of outcomes), which must be a sign of overall efficiency/quality. I would suggest that this is the result of two structural features of the NHS: large economies of scale and enforceable rationing. Unfortunately, this comparison doesn't include France, however all the data I've seen indicate that it has a higher per capita cost than the UK, both in terms of government and total health expenditure. The GDP cost is 11.9% versus 9.6%.

    This World Health Organisation report from 2000 provides another insight, which you can see in the spider-web charts on page 6. France, in common with other EU countries, spends relatively highly on healthcare staff, bed capacity and drugs. In contrast, the UK spends modestly on these areas, and is notably sparing when it comes to expenditure on capital equipment, such as CT and MRI scanners. Contrast this to the high capital intensity and commodity costs of US healthcare. (It is interesting to note, than in respect of these resource allocation choices, the real polar opposite of the US system is not the UK but Germany).

    As I mentioned above, part of the attractiveness of the NHS as an investment opportunity is this atypically low use of capital goods (equipment and beds), as well as it's relatively restrained use of commodities (drugs). While it is possible that a "reformed" NHS could end up more like other continental systems, with a bias towards labour, I suspect the "preferred suppliers" being teed up by the Tories will be more interested in a bias towards capital.

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  6. David,

    I think the nature of those analyses show the problem with the sale of healthcare as a commodity. The metrics used are quantitative rather than qualitative. That has always been the problem, and has to be the problem with planning v market solutions. It is very hard to devise meaningful metrics for quality, and so all such systems end up measuring outcomes in terms of some measurable quantity such as number of operations performed. This simply emphasises the nature of healthcare provision, as the provision of a commodity rather than the provision of good health, which if anything could only be measured by the LACK of operations etc performed!

    Of course, these kinds of quantitative metrics always see mass production, Fordist providers do well, and they do well for the reasons you outline as regards the NHS. Precisely because they work on a mass production, essentially conveyor belt system of healthcare in large anonymous factory units, they enjoy economies of scale. But, it is precisely those conditions that mean the quality of the healthcare provided in terms of building human relationships etc. is poor, and why things such as MRSA become endemic.

    It is what allows somewhere like Stafford Hospital, or now the heart surgery unit at Leeds, to get away for year after year mistreating patients, up to and including killing them, and yet to show up as meeting their targets. What those targets measure is, has the hospital carried out X number of operations and so on, not did they do them well, not how many patients survived the experience, or the number who contracted some other illness during the process and so on.

    I cannot think of any similar experiences in the European socialised healthcare system, where the kinds of problems that have been shown to be rampant in the NHS exists.

    Moreover, I worked in Local Government, where every year similar statistical returns of functions carried out had to be sent to Government. I know very well that not only was it possible to massage the figures submitted, in order to paint a satisfactory if not rosy picture, but it was also quite easy to simply send in figures that were just totally made up!!!

    The problem with the NHS, is precisely the problem that it is a monopoly, and thereby encourages rent seeking activity. The kinds of problems it experiences tend not to exist in Europe, because the various healthcare providers have an incentive to provide quality as well as quantity, at the lowest price, because otherwise they do not get the business, and so go bust. A few years ago, my wife had a minor operation done under the NHS, but performed at a private clinic. Her experience there was completely different to that of my brother in law who at a similar time, had a similar operation performed at the main NHS hospital. My wife's experience was quite civilised, and everything was done for our convenience. My brother in law, despite being operated on by the hospital's leading doctor in that field, did not even get his head shaved around where the surgery was performed, was sent out without the proper medication and so on, and ended up with a huge infection on his head, that produced an abscess that burst a few days later!

    Had we had that experience we certainly would not have gone back to the clinic another time, but the NHS hospital could legitimately send in its report saying it had completed the operation on my brother in law. It is precisely the experience workers had in the 19th Century with this kind of monopolistic provision under the Truck System, and why they set up their own Co-ops as an alternative.

    Cont'd

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  7. It is precisely, for these reasons that what is now required is the provision of quality rather than simply quantity in healthcare provision that means neo-fordist, flexible solutions are more appropriate than Fordist mass production techniques. The same rent seeking in the NHS means that bureaucrats at the various levels and organisations have an incentive to focus spending on the big prestige projects rather than on Primary Care (where far more funding is focussed in Europe), and why a lot of money tends to go to funding large hospital buildings at the expense of staff. Hence the fact that we have seen huge amounts of money spent on building hospitals, with wards left empty because the hospital has then not let itself enough money to cover the wages of nursing staff!

    In Europe, because it focusses more on Primary Care through the use of Poly Clinics, more money tends to be spent on Capital equipment rather than expensive buildings, and that facilitates higher productivity, which in turn enables them to pay higher wages and provide better working conditions. In turn that facilitates better quality of provision, and every one at the different levels of the hospital has an incentive to ensure that is the case, particularly in the Co-op hospitals, where the workers own it, and have a vested interest in its success.

    As Marx pointed out, where wages are low the price of labour is nearly always high and vice versa. That is because where wages are low, as in the NHS, there is no incentive for capital to invest in capital equipment to raise productivity. I think you are right that, now that in certain areas, neo-fordist solutions mean that labour can be replaced, or made far more productive and effective in the NHS, this is a reason for Capital to become involved in those areas in particular. It is precisely, for these reasons that what is now required is the provision of quality rather than simply quantity in healthcare provision that means neo-fordist, flexible solutions are more appropriate than Fordist mass production techniques. The same rent seeking in the NHS means that bureaucrats at the various levels and organisations have an incentive to focus spending on the big prestige projects rather than on Primary Care (where far more funding is focussed in Europe), and why a lot of money tends to go to funding large hospital buildings at the expense of staff. Hence the fact that we have seen huge amounts of money spent on building hospitals, with wards left empty because the hospital has then not let itself enough money to cover the wages of nursing staff!

    In Europe, because it focusses more on Primary Care through the use of Poly Clinics, more money tends to be spent on Capital equipment rather than expensive buildings, and that facilitates higher productivity, which in turn enables them to pay higher wages and provide better working conditions. In turn that facilitates better quality of provision, and every one at the different levels of the hospital has an incentive to ensure that is the case, particularly in the Co-op hospitals, where the workers own it, and have a vested interest in its success.

    As Marx pointed out, where wages are low the price of labour is nearly always high and vice versa. That is because where wages are low, as in the NHS, there is no incentive for capital to invest in capital equipment to raise productivity. I think you are right that, now that in certain areas, neo-fordist solutions mean that labour can be replaced, or made far more productive and effective in the NHS, this is a reason for Capital to become involved in those areas in particular.

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  8. I would be careful about using Ford as a reference point - he raised the wages then kept them at the same level for so long that there was a massive series of strikes as workers attempted to get increases that actually paid for them to live.

    I'm afraid I don't understand the nurses moving into the private sector bit, since after all there used to be a limited number of private hospitals, and it isn't as if they were eating the nurses to keep going, therefore it isn't as if a major number would get removed from circulation every year.

    I note also that you say the French health system is as expensive per head as ours is. That didn't used to be the case; new labour threw money at the NHS, a great deal of it was wasted on massive salaries for managers and consultants (Financial and medical) and on the infamously wasteful and inefficient PFI.
    That aside they did need to throw money at it, to catch up with 20 years of relative neglect. The money has led to improvements in a great many areas, e.g. cancer care and treatment, but such improvements have occured at the same time as the waste and buggering about by politicians, not to mention the increased bureacracy that comes with an internal market, and so on.
    As a normal member of the populace, I am in no place to be able to weigh how much money has been wasted and how much spent well, but I think that your comparing expenditure now with France kind of misses the historical point.

    On that line, I vaguely recall lots of numbers and charts from a decade ago which showed that the NHS (At that point costing 2 or % GDP less than healthcare in France) was not necessairly the most efficient or modern in Europe, but was at least doing the most it could for the least cash. Which makes you wonder why the austerity condems don't go back to how the NHS was decades ago, which would be a damn sight more efficient and cheaper than wholesale privatisation.

    And yet, that aside, I do agree with the general thrust of your earlier comment:
    "The real problem in all these instances is the lack of development of the working class to be able to exercise control over the means of production in its own name, "
    I think a lot of instances like the Staffordshire tragedy/ disaster could be avoided with more personal involvement of the people living in the area. Unfortunately the 3 main partys are unlikely to suggest such a thing, since it flies in the face of their centrist control freakery.

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  9. And since we're on anecdotes, my sister works in the NHS, and switched to a different hospital a couple of years ago, but doing the same thing. She moved from a modern up to date department (albeit housed in a badly designed and bad to work in new building that may well have used PFI) to one which had a better building but the methods used were a bit behind the times. She's doing what she can to improve things, but ultimately it comes down to the managers in charge; unless you can change them, things aren't going to improve. And my experience of the private sector is that there are plenty of useless and dangerous managers out there - your company just has to be only as bad as your competitors to at least survive.

    I also had an operation last year, a fairly simple one although it did require a general, in an NHS hospital. Everything went fine, smoothly, effectively. The staff involved were fine and generally helpful.

    As for capital expenditure, my understanding is that simply the NHS is playing catchup. Successive governments have refused to spend what is required on capital, and catching back up with that takes years and years. Meanwhile, time, effort and billions of pound are being spent on a botched form of privatisation which will lead only to a healthcare system more like the USA, than like France.

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  10. Your point about Ford is historically inaccurate. The strikes at Ford plants came in the 1930's when the limits of productivity increases were starting to take effect, and so wages could not rise, and workers started to unionise. In fact, Fordist methods after WWII, worked up until the same roadblock occurred in the 1970's. That is real wages rose year on year, whilst profits also rose on the back of bigger rises in productivity. That is one reason as Marx noted that where wages are low, the price of labour is generally high.

    Big Capital already realised that by the end of the 19th century, as Engels described, which is why it generally stopped trying to make profits by cutting wages, and instead switched to making profits by steadily rising productivity. That can be seen in healthcare too. In Europe, where things such as the Working Time Directive apply, working conditions and in their non-state hospitals are generally better than in Britain, where instead the NHS demands that Junior Doctors work for 60 hours a week, and we then wonder why operations get botched! France is actually a prime example of Marx's analysis. In France working hours are relatively short, but productivity per man hour in France is higher than in the most productive state in the US, California.

    If the drive for privatisation were about reducing wages then the question that has to be asked is - Why now? The Tories were in power from 1951 to 1964. During that time the privatised a number of things that had been nationalised in 1945. Not only was the NHS not one of them - and that would have been easy given the hostility from many perhaps the majority of doctors, the extent to which private practice continued, and the fact that the NHS was only 3 years old when they came to power.

    They didn't. In fact they continued its expansion. Why? because at that time, as with education, these kinds of mass production, Fordist solutions to the provision of healthcare were the most efficient means of Capital obtaining the supply of healthy, educated workers it required. The same is true with Thatcher in the 1980's. Having defeated the Miners in 1984, Thatcher could easily have dismantled the NHS piece by piece. But, again, that didn't happen.

    So, the question is why now, but not then. The answer cannot be to cut wages, because that would have applied at least as much in the 1950's and 1980's as now. In fact, in the 1980's the possibility of cutting wages in the private sector would probably have been considerably more than today.

    The point about nurses going to the private sector, is that they did so because they could earn more money, and enjoy better conditions. I agree that there were very few such jobs - though many nurses did emigrate to work in the US - but that is not the point. The point is that for what jobs existed, the wages were higher and conditions better, so the idea that privatisation equals lower wages does not hold.

    The fact that much of the money that Labour threw at the NHS was wasted, I think rather proves the point I was making! As for PFI, without it many of the new hospitals would not have been built. It performed the same role as that Lenin sought to achieve in the NEP i.e. to overcome a lack of capital, by resort to private sector investment. Cont'd

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  11. On the historical point, we are now nearly 20 years after Labour started pumping huge amounts of money into the NHS, and yet outcomes in terms of quality seem to be deteriorating rather than improving. You can hardly claim today's inefficiencies are the result of inadequate spending 25 years ago.

    I doubt that Capital does seek "Wholesale" privatisation, because that would be an inefficient method of proceeding. Instead it will proceed first in those areas where Neo-Fordist methods offer the greatest advantages. Already 25% of the population use private as well as state healthcare, and a large majority favour some alternative funding model. Unless, the Left recognises that the population at large do not have to same love affair with the NHS as it stands that they do, it will go the same way as Council Housing.

    The US is seeking to convert its healthcare system to something more like that in Europe, so its unlikely the UK will move to something like the US. All the proposals so far are on the European model. There would be no point in privatising social insurance. Its inefficient and takes control out of the hands of the Capitalist State.

    Many problems would be resolved if workers themselves had control, but the Capitalist State is not going to allow that. That is why workers have to get on with the job of building their own alternative by taking over hospitals and other such facilities, linking up with other Co-op hospitals across Europe, with the Co-op Pharmacies, with the GP Co-ops and so on.
    On the historical point, we are now nearly 20 years after Labour started pumping huge amounts of money into the NHS, and yet outcomes in terms of quality seem to be deteriorating rather than improving. You can hardly claim today's inefficiencies are the result of inadequate spending 25 years ago.

    I doubt that Capital does seek "Wholesale" privatisation, because that would be an inefficient method of proceeding. Instead it will proceed first in those areas where Neo-Fordist methods offer the greatest advantages. Already 25% of the population use private as well as state healthcare, and a large majority favour some alternative funding model. Unless, the Left recognises that the population at large do not have to same love affair with the NHS as it stands that they do, it will go the same way as Council Housing.

    The US is seeking to convert its healthcare system to something more like that in Europe, so its unlikely the UK will move to something like the US. All the proposals so far are on the European model. There would be no point in privatising social insurance. Its inefficient and takes control out of the hands of the Capitalist State.

    Many problems would be resolved if workers themselves had control, but the Capitalist State is not going to allow that. That is why workers have to get on with the job of building their own alternative by taking over hospitals and other such facilities, linking up with other Co-op hospitals across Europe, with the Co-op Pharmacies, with the GP Co-ops and so on.

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