Can Welsh stronghold ensure continuance of free health care?

Julian Tudor Hart asks whether we can defend the NHS in Wales from increasing commercialisation outside our borders

In June negotiations will begin in Washington for a comprehensive new treaty on international trade between USA and the European Union. The delivery of health services will be among the areas affected, yet the Welsh NHS will have no independent voice in these talks. This is despite its increasingly anomalous and vulnerable status as a planned public service, protected by existing EU law from the transnational marketplace, and committed to co-operation rather than competition as its driving force for future progress.

As things stand, these negotiations are within the sole competence of the EU, with no independent representation from any individual EU governments. Apparently the only UK MEP present will be Peter Skinner, Labour MEP for South East England, and it is unclear whether even he will have any official voice.  He has an impressive academic CV, with expertise in transatlantic financial trade, but like most MPs today, “not much in the way of a normal job before entering the House of Commons” – to quote Rhodri Morgan.

It seems scarcely credible that we are asked to place our trust in a single MEP with no experience whatever either of the Welsh NHS, or of what remains of the NHS in England. Through its Health and Social Services Act of 2012, the coalition government at Westminster has shifted responsibility for the provision of healthcare in England from elected ministers to any willing and competent provider, within or outside the existing NHS, who can win a contract against market competitors.

I qualified in 1952, close to the birth of Bevan’s NHS, when most work in or out of hospitals was still in much the state it was before 1948. However, for the first time it was exposed to all the demands of poor people in need. Though more than 80 per cent of GPs had opposed it, an equal majority had accepted the huge increase in workload it entailed, as free healthcare became available to all.

At astonishing speed, GPs learned that a healthcare economy could work much more efficiently where care was no longer a traded commodity, produced and sold for profit. Instead, it had become a free public gift, available to all who needed it when they needed it, and paid for by everyone, whether in need or not.  Within the NHS economy, money almost ceased to influence clinical decisions. For healthcare, we had developed a cash-free economy, motivated by needs, not by profit, a space in which both patients and professionals could learn to think and act in a new way, beyond the marketplace.

Moreover, a Royal Commission appointed by a Conservative government proved conclusively that as an economy, it worked.(Committee of Enquiry into the cost of the National Health Service, 1956). Of course, we still had plenty of parasites, the people who sneeringly referred to the NHS as a “sacred cow”. They knew, because they were milking it.  I know well enough there was never a golden age for the NHS, but I also know, because I was in it, that we had a golden beginning, despite the worst possible economic circumstances.

Over the past 20 years, backed by the International Monetary Fund, the World Trade Organisation, and innumerable corporate lobbyists, media editors, and ‘expert’ think-tanks (their ‘expertise’ entirely managerial, utterly ignorant of battlefield conditions for both patients and staff), the European Commission has sought to open all EU health care services to global investment. It has promoted cross-border shopping around by patients for healthcare within the EU, and ‘harmonisation’ of healthcare policies in all member states to expand international trade.

In the early 1980s, the UK NHS was recognised as a special case, with less private sector healthcare than any other EU state. It was also seen as an exceptional opportunity for transnational investment, if public devotion to the NHS as a public service could somehow be overcome. As even the most ardent advocates of marketed care recognised, the NHS had almost become ‘a religion’ in the UK. It was a place where the humane aims of all religions had at last found material expression. Even today, with the legal framework of care as a public service virtually demolished in England, to stand any chance of re-election, all the agents of its destruction must proclaim their devotion to the NHS.

In the same way, as EU commissioners have opened national public services to transnational competition, they have had to deny that this will endanger existing public provision of care. Each step toward further commercialisation of public services has been legitimised by the proviso that harmonisation need not apply to free government services. It will apply only if direct patient charges create a normal provider-consumer relationship. Where the state remains sole provider, competition laws will not apply.

Since the 1990s, when they began to run out of customers who could afford their products, international healthcare and personal insurance companies, mostly from USA, have been competing aggressively in what they see as a world market. They have mainly targeted European care systems, hitherto organised as public service, with variable components of social insurance. If they can find any way to include our NHS in their negotiations, they will take it, and subordinate our public services to EU and international commercial law, making it answerable not to voters but to shareholders.

Though apparently no EU member state will be an official participant in these new trade talks, we may be sure that all ‘stakeholders’ (that is, everyone who might gain or lose money through their decisions) will make themselves well represented. This will not be a purely ceremonial event. Real decisions will be made, and everything possible will be done to open public services everywhere to transnational corporate investment for profit. This will include a readiness to operate at a loss for long enough to secure thin-end-of-the-wedge contracts. The smaller the print, the greater the risk to what nearly everyone has voted for, on the few occasions when any choice has been offered.

Why not trust those who certainly know more about all this than we do, who tell us these negotiations entail no risk to Wales NHS as public service, so we need no representation? The Labour Party’s Manifesto for the 1997 general election contained the following explicit promise:

“Our fundamental purpose is simple but hugely important: to restore the NHS as a public service working cooperatively for patients not a commercial business driven by competition.”

Labour won that election with 45 per cent of the vote, a majority of MPs even larger than after the landslide of 1945. It was free to implement that promise. Yet, with only two partial exceptions, Frank Dobson at the beginning and Andy Burnham at the end, New Labour health ministers pressed ahead with policies precisely opposite to those they had promised. Two of them (Alan Milburn and Patricia Hewitt) ended on the boards of directors of provider companies.

New Labour embraced deregulated capitalism with the blind fervour of calf-love. But this was just before its worldwide paper economy collapsed. The deregulated casino created by Margaret Thatcher’s ‘Big Bang’ got egg all over its face – but new billions of our taxpayers’ pounds into its pockets.

Labour in the National Assembly is not Labour in the House of Commons. There is still substantial support for creeping NHS privatisation among a powerful minority of New Labour MPs, just as there is significant support for solidarity from a few more socially responsible Conservative MPs. Principled support for the NHS as a public service exists in all parties, but so does ruthless and often covert and cowardly support for commercialisation. Speaking to the Royal College of Midwives’ annual conference in 2011, shadow minister Andy Burnham made this explicit and apparently sincere promise:

“And let me make it clear – if the Bill in parliament goes through, we will repeal it. We will return the NHS to a national system based on the principle of collaboration on which it was founded in 1948.”

Burnham’s pledge appeared on the Guardian website on 17 November 2011. It was never printed. Inquiries to the Guardian and to Denis Campbell, the Guardian’s health correspondent whose report it was, were ignored. It was never reported in any BBC radio or TV broadcasts. Burnham’s attempt to commit Labour to repeal of Lansley’s Act after the next general election was suppressed. New Labour thinking remains dominant among the Party’s full-time staff, who seem permanently nailed to their perches, and still have more power than any elected delegate conference.

Welsh Labour in the Assembly is a different animal. First Rhodri Morgan, then Carwyn Jones, took first steps to eliminate the purchase-provider split. They recognised that this was the legal foundation for creeping privatisation of the service. Furthermore, nobody could be more committed to this principle than the new Health and Social Services secretary, Mark Drakeford.

Welsh Labour Ministers restored free prescriptions for everyone, and frankly declared their intention to return NHS Wales to the course set out by Nye Bevan in 1948, however far this might take them from the ambiguous course still pursued by Labour in the House of Commons. In the National Assembly Welsh Labour was completing a social project first conceived in the late 19th Century by our organised miners, tinplate, copper and steel workers and slate-quarriers, and only later made law by Lloyd George.

Amazingly, but almost unremarked by our news media, that brave and independent course has been endorsed by the organised medical profession throughout the UK.  In face of the plans for NHS reform in England, a BMA Wales survey of more than 5,000 of its members showed that 86 per cent felt glad to be working in Wales. The BMA’s UK Annual Representative Meeting praised Wales for abolishing the purchaser-provider split and rejecting private sector involvement in the NHS, and commended the Welsh approach of planning healthcare as an integrated whole. Ministers win plaudits for ending internal market was how bma news put it in its edition of 2 July 2011.

In Wales we have a model to which both healthcare professionals and voters more generally in England may look when the time comes to rebuild NHS UK. Regardless of what historians may say, history is made by the common people, and shaped by whatever big ideas they come to embrace, and take into their everyday lives. Writing in 1867, soon after Disraeli’s extension of the franchise, William Bagehot wrote frankly and perceptively about how impending democracy would have to be managed by rulers, if they had to depend on election:

“As yet, the few rule by their hold, not over the reason of the multitude, but over their imagination and habits; over their fancies as to distant things they do not know at all, over their customs as to near things which they know very well” (The English Constitution, 1867).

As a practical expression of social solidarity, as a gift economy entirely different from the rest of the dog-eat-dog world in which we still live, Bevan’s NHS rapidly became incorporated into the imagination and habits of the multitude. It became a central part of their customs as to “near things” they knew very well.  They have come to take it for granted that in the UK, people faced with catastrophic illness are not simultaneously faced with catastrophic costs.

In contrast, in the USA, citadel of market-based healthcare, nearly two-thirds of bankruptcies in 2007 arose from illness and medical bills, a rise of 50 per cent over the figure in 2001. And this was despite more than three-quarters of those people being medically insured. Americans have no common experience of shared burdens and shared risk, so it is not yet within their common imagination and habits.

In UK however, we have experienced a higher civilisation in that respect. Assisted by a news media largely outside common experience, most people may not notice their loss until NHS England is well on the way to extinction. Meanwhile, in Wales we have a stronghold, from which a successful counter-attack can eventually emerge.

Success will depend on confidence in ourselves, and in our own experience. Polarisation of wealth and power has become too great for all but a very few professional politicians to resist. Those few rely not on their own fragile integrity, but on the common sense and experience of their voters. Their gut understanding of social solidarity is ultimately all that we have to defend us from the technologised barbarism of a state stripped of all conscience, where everything and everyone is for sale, and all of us are valued only from what we can consume, not from what we produce.

Voters have never been asked whether they wanted any of these NHS ‘reforms’. Bevan had confidence in the good sense of most ordinary people, most of the time: Above those ordinary people with shared common experience, Bevan learned to trust no one. Remembering that lesson, I think Wales must find some way to get into these international trade talks in June, and discover what the ‘experts’ are up to.

Dr Julian Tudor Hart is President of the Wales Socialist Health Association, and author of The Political Economy of Health Care: where the NHS came from and where it could lead (Policy Press, 2010).

4 thoughts on “Can Welsh stronghold ensure continuance of free health care?

  1. Thank you for this impressively argued rallying call. The fragility of our position is worrying but the commitment to collective ways of doing things does appear to be rock solid in Wales. In the face of almost complete silence from the UK media and our own local ‘democratic deficit’, the problem could come down to one of communication. How do we ensure that our politicians hear, and respond to, the voices of ‘ordinary people’?

    On 1st May, 250 of those ordinary people are sending an Open Letter to the Welsh Government asking that co-production principles of equality, mutuality and democracy are placed at the heart of public services in Wales. The Letter has drawn passionate support from USA, Canada, Australia, Scotland, and from increasingly beleaguered colleagues in England.

    Many of those supporters are looking to Wales to take a lead. I may be over-optimistic, but with Mark Drakeford as our Health Minister, I believe we have a real opportunity to return to the ‘gift economy’ of Bevan’s NHS, safeguarded through legislation and regulation.

  2. Ruth, In my heart I am with you, but my head is asking two things: Can the ‘gift economy’ survive infinite demand and finite resources? And, more prosaically, how do we ensure that co-production is not code for the over-influential producer interest?

  3. Dr. Tudor Hart has a long and distinguished history in working a in very disadvantaged area,and his views are worth listening to. However, given the weakness of the UK economy,and with possibly with no, or little growth, how will the NHS be funded? Its a little known fact that there is a thriving private health service operating in Wales, both within and without the NHS. It is inescapable that greater rationing is here,and this will increase in coming years. Major changes will not go down well with the Welsh people, but this is only the start of major changes/problems. What will be the attitude of people who have worked hard, played the game be when they see their services going down hill, whilst the NHS is still free to people who have never contributed to society in general. I’m not sure that the Welsh are any more altruistic than any one else when push comes to shove. But we’ll know in coming years.

  4. GTD poses the right question but too politely. The naked truth is GPs and surgeons are both ripping off the NHS getting overpaid for pleasing themselves when they work. Nurses and junior doctors are faced with taking up the slack, work in stressed conditions and take the flack for failure. I agree that the market mechanism is not always appropriate but some means needs to be found to maintain fairness and efficiency in a monopolistic organisation. Talk of the gift principle is a poor joke when producers fleece the taxpayer and patients are neglected. Our NHS works worse than some of the insurance-based systems in Europe.

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