Medicine’s private parts
At this time of queues to the Bankruptcy Court there is very little cheer in the boardrooms of Britain where, as we all know, they can clink a sherry glass or two in salute to a pleasing balance sheet. Yet here is one chairman who can report in terms of glowing optimism:
It is with pleasure I present the accounts for 1980 . . . most positive encouragement from the government . . . the service given to subscribers continues to be of the very highest standard . . .
The author of these self-satisfied, not to say smug, words is John Phillips, chairman of Private Patients Plan (PPP), one of the larger organisations providing insurance for medical treatment outside the National Health Service. Private treatment is currently a boom industry; PPP’s subscribers have risen from 10,000 in 1950 to 313,000 in 1980 and over the same period its “Excess of Income Over Expenditure” from £12,000 to £4,010,000. And PPP have only about 20 per cent of the market, which is dominated by the 75 per cent held by British United Provident Association (BUPA). Each week during 1980 an average of 15,000 people joined a private health insurance scheme and if this trend continues, by 1985 one in five of the population will be covered.
So if people are rushing in their thousands to be ill the private way, what of the National Health Service, once described by the author Alan Sillitoe as “ . . . probably the greatest single factor in this century in creating a new pride in the English working class”? The aims of the Service, when it was introduced in 1948, were set out in no less glowing terms by Aneurin Bevan, whose job as Minister of Health at the time made him a sort of midwife to its birth:
Society becomes more wholesome, more serene, and spiritually healthier, if it knows that its citizens have at the back of their consciousness the knowledge that not only themselves, but all their fellows, have access, when ill, to the best that medical skill can provide. (In Place of Fear).
What was Bevan talking about? Before the National Health Act 1946 hospitals were run in a number of different ways, by local authorities or by charities. They held flag days or sold their wall space to the advertisers of patent medicines in order to raise money. Their standards, relying on local initiatives, varied widely from place to place. It was by no means the kind of efficiency a capitalist state might demand from its medical services. The Act effectively nationalised the hospitals, grouping them under Regional Boards appointed by the Minister. The declared intention was to achieve an overall adequacy at the highest level which could be afforded.
Like all other hospital employees, consultants were to be paid a wage but they were also allowed to keep some private beds in NHS hospitals. In other words, the Act by no means killed off private practice and these seeds have subsequently flourished. At the time there was hostility to this from some sections of the Labour Party but more serious by far was the opposition Bevan encountered from the doctors. At the end of it all, even with the many compromises he had had to make, Bevan was satisfied with what he later called “. . . the most civilised achievement of modern government”.
The workers too were enthusiastic; believing that they had a genuinely free, all-embracing, super-efficient health service immediately available at need, they registered with it in their millions. By 1952 only a rich (or eccentric) 1.5 per cent of the population were still outside the Service.
Well it did not happen as Bevan promised. To describe the average experience of a National Health Hospital as civilised is sometimes to reshape the English language. In one of the newest hospitals, for example, people who have been referred to a consultant by their GP wait to be seen in an area which, as the morning wears on, comes to resemble a minor battlefield. Then the consultant has little time to treat the patient in a civilised manner; little time to discuss the problem, to give a prognosis, to present the options. Having pronounced on what should be done, the choice presented to the quivering mass of flesh and bones and blood under the probing hands is to take it or leave it.
If the consultant decides (it should be “advises” but let that pass) on some sort of in-patient treatment then there is the fearsome matter of the waiting list. For some operations this can run into months, even years, of discomfort, pain and disability. At the Congress of the British Medical Association last October a Glasgow doctor warned that the waiting list for psycho-geriatric patients is so long that “seventy-five per cent of (them) die before they are admitted.” (Among the wards, macabre jokers insist that that is a common method of cutting the waiting list.)
But for those who survive the wait the great day eventually dawns and the patient is, as they say, admitted. Already in some anxiety, they are at once submitted to a process of depersonalisation, rather like going into prison. To begin with, inmates are made immediately distinguishable from everyone else because they are only allowed to wear nightclothes. In fact—although only the paranoid would think this is to prevent them escaping—they are forbidden to keep their day clothes in the hospital. The patients’ day is pummelled into a shape to fit in with the hospital’s needs; the institution is far, far greater than the sum of the individuals it theoretically exists for. As the doctors sweep on their rounds though the wards, treatment is more or less imposed; there is no time for them to inform, still less to argue about it. It takes some courage for an inmate, half naked and supine, surrounded by white coats and silvered, spiky instruments, to insist on knowing what it is proposed to do with their body. And they might lose remission, if they don’t absorb those anonymous drugs regularly pumped into them.
Not all of this springs from any historical arrogance of the medical profession. The NHS does not directly make a profit but it is required to work within limits of cost and it is often under the axe of government economies. Hospitals are what is euphemistically called under-capitalised they often can’t afford the latest and the best equipment and have to rely on charitable efforts to buy civilised things like a body scanner. Staff levels are kept at a minimum, which means that nurses are worked to the limits of safety (and often beyond; it is common for a ward full of sick people to be overseen during the night by a single, unqualified nurse). A Professor of Geriatric Medicine told the BMA in October:
We have old people in accommodation which would have been useful for dogs, cats or race-horses twenty years ago. It is still fashionable to put the elderly into hospitals which have been discarded.
Such standards of civilised treatment do not apply to the private patient. The same consultant who is offensively off-hand to his wretched queue of NHS patients in the morning is courteous and gentle in the evening when he conducts his private clinic. Everything—the necessary tests, medication, surgery—is described, sometimes with helpful notes and diagrams and the patient is helped to make their own decision about their own body. They leave, feeling not at all wretched, with the great healer’s hand reassuringly on their shoulder.
Private in-patient treatment usually takes place in a separate room with its own bathroom, TV, radio and telephone and it is lubricated by the attention of plentiful, ever-attentive nursing staff. There is rarely any delay in admission: having chosen the specialist, the patient also names the day for admission and almost always the consultant can miraculously fit this in with other commitments. Organisations like BUPA spell this out as if it were miraculous when in fact it represents what should be the very minimum standard of care and treatment.
So why isn’t it the minimum? The NHS was designed for the working class — a sort of Tesco Stores in contrast to the discreet, exclusive shops of Belgravia which admit the superior class of capitalist society. The first object of the NHS is to repair workers to the point at which they can be got back into the exploitation process and for that the crowded out-patients clinic, the large boisterous ward and the casualness of the doctors will suffice. For the rich — for the exploiters — there have always been havens where the very best is available for those who can pay places like the Harley Street Clinic (where it costs between £560 and £1029 a week just to stay in bed); the London Clinic (£770 to £973) or the Wellington Hospital (£1225 to £1750).
Of course anyone paying that sort of money is not going to be handled with any discourtesy; no mere consultant surgeon will make decisions about them without fully discussing the matter. Medical care, like all other services in capitalism, is a commodity. It is produced — that is to say, doctors and nurses are trained, hospitals are built, equipment manufactured — to be sold and in the process to contribute to the overall driving force of capitalism — the realising of profit and the accumulation of capital.
There is a mass of evidence — recently the Brenner study and the Report of the Working Group on Inequalities in Health — to point to the conclusion that illness is a matter of how we get our living, of where we live, what stress we are subjected to in the act of survival in property society. In summary, the evidence says that avoidable illness is a problem for the working class, who are forced to live by selling their abilities to work for a wage. It hardly matters to the class who buy those abilities — to the owning, exploiting capitalists. For the workers, sickness brings additional despair as the bills mount up and perhaps their job is in jeopardy; a recent report from the Office of Health Economics states that the level of unemployment may now act as an incentive for workers not to go sick.
The failure of the NHS to ease that despair has left a gap which the private insurance schemes are trying to fill. They offer sick workers the prospect of a little comfort at a time when it is needed and that is no bad thing. But that is the limit; it is rather like shopping in Sainsburys instead of Tesco. As the NHS goes into further decline and private medicine picks up some of the pieces, there will be pressure on this sector too and there is no reason to think that it will cope any better with it than has the NHS. It will be operating under the same inhuman priorities which leave little room for civilised standards. To see the problem as one of sick people is to start at exactly the wrong end of the stethoscope, for it is the basis of society which needs attention.