The fundamental difference between the Labour and Conservative Parties lies in their opposite aims for future society, how our children and grandchildren will live. Socialists cannot believe that any society worth living in will be possible, without fundamental change toward an economy of co-operation and sharing, rather than an endless fight of every man against every man, with all condemned to be either heartless winners or miserable losers, with most talents and imaginations wasted.
In 1945, we thought we knew. From 1940 to 1945, centralised command economies in Britain, USA, and the USSR proved able to perform all sorts of miracles, which we had all been told were impossible before the war. We would use essentially the same means, the same defiance of economic laws devised by bankers in their own interest; the same determination to subordinate money, a human invention, to human ends; the same confidence that property is less important than life, and that nobody has a right to dispose of the jobs and futures of thousands of others, merely because this suits the ends of directors or shareholders. That high tide of economic democracy, demanded as a necessary sequel to political democracy, formed the NHS as its apparently unimportant by-product, far less significant to every contemporary observer than nationalisation of the coal industry, or other “commanding heights” of the economy.
Now even the memory of those high expectations has almost vanished. The NHS is virtually all we have left. Refounded on a new base of participative democracy, how could the NHS contribute to such wider social change?
To all who actually believe in society, even to “One Nation” Tories who realise that the war of every man against every man can only be sustained within some framework of shared human values, the NHS as a free and equal public service, not as a competitive business, is essential for social survival. Just as 19th Century society had to declare a truce on Sundays, when people who had thieved and swindled so far as the law allowed on weekdays, could re-establish some self-respect among their fellows, the NHS now provides an area in which we can still relate to each other as members of a single species, with equal rights to such life and health as blind providence allows us. Unlimited pursuit of profit leads to an intolerably divided society, hateful to socialists because they know it is unnecessary, but also dangerous and disturbing to conservatives with enough intelligence and sensitivity to understand that winners in their society differ from losers much less than they like to imagine.
We therefore have a huge base of popular support for any policy that moves the NHS back on course, away from competitive business and back to universal public service. And the evidence deployed in this book guarantees that, for once, the interests of social justice and of economic viability are the same. Medical science will continue to grow, but sustainable growth in the NHS sufficient to apply this science to all who need it will certainly not be possible, if health workers continue to be subordinated to managerial visions of efficient production of medical care as an industrial commodity, passively consumed by an increasingly demanding public. A re-socialised service will not necessarily be cheaper than what we now have, because years of systematic underinvestment must be corrected, but costs can certainly rise far more slowly in a co- operative than a competitive service, in which both staffs and patients are once again encouraged to help each other, and to understand the great complexity of even the simplest problems in human biology.
The fuller use of human intelligence, wider clinical autonomy and professionalisation for health workers of all grades, and far greater use of the intelligence and imagination of patients, carers, and parents in continuing management of chronic disorders, could bring huge economies to the service. This unused energy cannot be released quickly. It depends mainly on micro-economic changes at the level of personal consultation both in primary care and in hospitals. However, medical and nursing professionals are now generally ready for such changes, which could have large macro-economic effects within five years, mainly through more thoughtful prescribing and less translation of psycho-social problems into costly but futile somatization.
Above all, we must re-assert the human right to effective care in its widest sense, for all according to need. Everyone thought this was a permanent gain in 1948. This right has been steadily eroded since the Conservatives took office in 1979. In 1984, 30% of long- term nursing care was provided by the NHS; by 1994, this had fallen to 10%. The rest was and is provided by means-tested nursing homes, run either by Local Authorities as a public service, or by private entrepreneurs, who are now guaranteed at least 85% of the means-tested market. Without any public discussion or mandate, Conservative governments have steadily and stealthily shifted the NHS from its traditions of curing where possible, but caring always, to become so far as possible a repair service, without responsibility for continuing care. Which of the many exciting new innovations aimed at cure will actually work, time alone will tell; but we already know the effectiveness of long- term nursing care and support, relief of pain, and housing, dressing, feeding, washing, cleaning, and generally encouraging sick people, often near the end of their lives, services all of us want for ourselves if and when our time comes. Make no mistake, we want genuine advances in medical science to be applied as widely as possible, but this can only be done on a secure foundation of continuing care.
We fully realise the huge cost implications of such a commitment, the difficulties this will represent when a Labour government is elected to undo the damage inflicted on our economy and culture by almost two decades of every man for himself, and the consequent constraints on opposition policy. That’s why the Labour movement still needs the SHA today, as an independent socialist conscience, to remind all of us of the real purpose of all our efforts.
THE NHS AS MODEL FOR A FUTURE ECONOMY
For socialists, a democratised NHS has far greater potential significance. Many Conservatives honestly believed that remodelling this huge public service in the image of competitive manufacturing industry was bound to give taxpayers better value for money. Though the NHS was indeed the envy of the post-war world, the same could hardly be said for British manufacturing industry, but never mind. Predictably, the experiment has failed. Nobody likes it, except people well paid to do so. People are different from motor cars.
But not so different that the car industry has nothing to learn from the NHS. The NHS has a socially useful product, both personal and social, health gain for all. This can, with some difficulty and imagination, be measured. It must be measured, for us to avoid the fatal error of using easily counted clinical interventions as a convenient, but from all historical experience grossly misleading, proxy for health gain. Why should this not eventually be true also of the transport industry, that is, the entire ragbag of motor manufacturers, bicycle makers, their retailers, road and rail construction and maintenance, railway engine and rolling stock manufacture and maintenance, airports and aircraft, travel agents, road hauliers, town planners, removal vans, ferries, in fact every part of the economy mainly concerned with mobility? The socially useful product of this presently uncoordinated and unplanned concatenation of competing industries could be gains in mobility for all, personal and social. But this is not how the transport industry is either seen or organised. The common aim of all its uncoordinated parts is to maximise profit, often by driving some other part of the industry out of business, through sale of competing products. In the case of car sales, we have the nonsensical situation that in the absence of any overall transport policy, and with continued decline of all forms of public transport, each new car produced and sold actually reduces the overall mobility of the population, and every industrial success brings our cities closer to gridlock.
Manufacturing industry as presently conceived, in advancing Germany, Japan, and South-east Asia no less than decaying Britain, presents no useful model for reform of the NHS. But as a centrally co-ordinated nationalised industry serving social need rather than private greed, open to peripheral innovation at its community base with a growing element of participative democracy, the NHS will one day present a useful model for eventually socialised manufacturing industry.
When will that be? For serious politics, for the future of our children and grandchildren, the timetable of social change is relatively unimportant. What is supremely important is not the speed but the direction of change; forward to sharing, or backward to grabbing. In this battle the NHS has been driven to the very centre of serious politics, and there it will remain, a core of custom and practice around which a more dignified society will one day be built – starting not with the commanding heights of our economy, but the commanding depths of our culture.