The 2010 annual meeting of the Association of Surgeons of Great Britain and Ireland (ASGBI) was held at the BT convention centre in Liverpool, from 14 – 16 April. It was principally an event for the exchange of technical information and innovation and as such, one might assume, of limited interest to the readership of this journal.
In the present economic and political climate, however, the ASGBI’s Thursday afternoon ‘hot topic’ discussion, introduced by the association’s vice-president, Professor John MacFie, takes on more than usual interest.
Prof MacFie explained to the assembled delegates (Consultant Surgeons and their senior trainees) that while none of the major parties could be forthcoming about the nature and magnitude of impending cuts in government spending, given the election, the recession was acknowledged to be much deeper than superficial reports would suggest, and that unofficially, both the government (Labour) and opposition parties (Tories and Liberals) had been in communication with doctors’ leaders and made it clear that the NHS would be no exception.
He therefore proposed that the title of discussion would be “£20 billion in cuts to the NHS – How can we achieve these savings while maintaining clinical excellence?” This would be a period “of savage cuts, the like of which the profession has not known in a generation”, he said. He welcomed, however, the fact that the politicians were involving doctors’ leaders in the discussion early, whilst noting that the reason was their fear of taking full responsibility for these decisions themselves.
He had duly drawn up a framework of likely areas where savings, he thought, could potentially be made and invited brief contributions from each of the presidents of the Royal Colleges of Surgeons of England (John Black), Edinburgh (David Trolley) and Ireland (Frank Keane) followed by limited discussion from the floor.
Of the 92 billion spent on the NHS, said Prof. MacFie, roughly 20% went on buildings and equipment and 80% on staff. The most obvious place to make savings was therefore also on staff. He went on to introduce his discussion guidelines as follows:
1. Limit or decrease pay, or sack staff (nurses, and/or doctors)
Many trusts, strapped for cash, already have a total freeze on recruitment, and with increasing privatization of ‘peripheral’ and then medical services, the workforce of the NHS has fallen from over a million to about 300,000 over a decade.
The president of the royal college of surgeons of Ireland pointed out that there were fewer doctors, but more nurses per capita in Ireland, compared to England, and that there was “clearly room for manoeuvre there”. Irish nurses be warned.
The assembled consultants were generally of the view that consultant care was the most efficient health delivery model, and that doctors should not be threatened, but it did not prevent them floating the idea that doctors could be made to pay for their training.
John MacFie pointed out that government documents already explicitly state the necessity of introducing “planned oversupply” of medical professionals in order to manipulate their pay downwards. In fact this has already been implemented.
The necessity of unemployment under capitalism was long ago pointed out by Marx, who noted the growth of the industrial reserve army was proportional to the growth of capital itself.
The Royal Colleges of Surgeons will no doubt consider themselves above the concerns of the ‘common’ industrial labourer. As self-regulated bodies of professionals, more akin to medieval guilds (which, in fact, they formally remain) than a modern industry, surgeons have been used, with the wider medical profession, to regulating training and matching the supply of doctors to demand. A logical step, given the magnitude of investment needed to train doctors. But governmental domination of the profession by such regulatory mechanisms as the Post-Graduate Medical Education and Training Board (PMETB) is now well advanced, and with increasing medical school tuition fees, the expense of training can indeed be shifted to the individual, and the resulting unemployed become the ever-present threat to the working medics.
The recent drive to recruit doctors trained overseas, often to non-training grades, in conjunction with higher domestic graduate output will inevitably depress doctors pay and conditions and make unemployment a real issue for medical professionals.
At this time of increasing insecurity for British workers, an Irish consultant publically lamented, apparently without irony, the fact that “unions are the real problem”, as they make it “impossible to sack anyone”. Would that this were the case.
Met with the consequences of the capitalist crisis of overproduction and the bailing out of the Banks to the tune of £850 billion, some of the assembled surgeons sadly found no contradiction in calling for the “efficiency of the market” to come to their rescue. Even such a glaring and systemic market failure, responsible for the very problem they seek to address, has not helped them to grasp the contradiction between the dictates of market economics and the health needs of their patients. Such is the prevalence and frenzied pitch of the dogmatic propaganda of “economic realities”, that few have the presence of mind to notice, and fewer still the courage to point out that the financial oligarchs in the city of London are wearing no clothes.
With some limited share in the means of health provision by way of their private practice, Surgeons are undoubtedly petty-bourgeois in their outlook and real economic position, and to the extent that they recognize health care as a modern industry, surgical leaders very clearly assign themselves a managerial, rather than a proletarian role.
But facts are stubborn things. The majority of doctors have no such private practice and most remain predominantly, if not entirely the employees of the NHS. Even if they are receiving sizable earnings from GP and consultant contracts, they remain, in the last analysis, privileged sections of the working class. Few, much as they might like to be, are capitalists.
Politicians engaged in privatizing the NHS clearly see doctors as pawns in the game, and are making moves to cow any possible political resistance while reducing their wages, along with allied health professionals. In the mean time, they seek to enlist doctors, as the highest paid section of the medical workforce, to do their dirty work by championing the health cuts and spinning them as “efficiency savings”. Doctor’s must decide which side they stand on – for there is no avoiding the conflict of interest between the banking and political elite and the British working people. Ethically, there can be no doubt that our duties should lie with the health of our patients.
2. Closure of beds, wards, hospitals and/or services
Those familiar with the Whittington hospital campaign in North-East London will know that no fewer than 10 Accident and Emergency departments are currently threatened with closure in London alone. Anyone who works in a hospital near another that closes its A&E department’s doors, or has the misfortune to visit one as a patient, will know the knock-on effect that this has on increased workload, increased waiting times, increased admissions and decreased functional capacity of adjacent hospitals to perform elective procedures. All this in effect compromises care of the local population in both the emergency and elective setting and therefore effectively introduces rationing by decreasing the quality of service, inevitably decreasing patient safety and leading to loss of life. Those least able to utilize connections and demand privilege, the (economically and educationally) lowest ranks of the working class, will inevitably fare worst.
In this capacity, the old theme of decreasing duration of hospital admissions was also raised. As Prof. Allison Pollock points out in her excellent work NHS PLC, the shortening of admission times has already been pushed beyond the limit of reductions made possible by improved surgical techniques and admissions policies. Higher bed occupancy rates inevitably lead to poorer infection control, in itself extremely costly. Many Hospital private finance initiatives (PFI) also built in drastic reductions in bed capacity, in order to falsely present these cuts as “market efficiencies”.
As one consultant rightly pointed from the floor, however, ‘keyhole’ laparoscopic surgery actually makes it possible to offer operations to an older and more frail group of patients who would previously have been considered unfit. In the context of an ageing population this may in fact increase demand on health services and overall bed occupancy yet further.
Couple this with cuts in the provision of long term social care, hidden behind division of health budgets between local councils (long term care) and the NHS (acute care), that has given rise to a bureaucratic system of bed bouncing and fratricidal squabbling over responsibilities and eligibility for various rehabilitation, palliative and medium to long-term care packages that is both undignified and fiercely bureaucratic, and it will become clear that pressure on bed space is becoming overwhelming. Which leads neatly to the next proposal.
3. Rationing: Waiting lists? Paying for services?
Rationing, pointed out Prof. MacFie, could mean paying for services, or the reversal of the targets set for waiting times, which has been the single claim of the Labour Party to ‘improving’ the NHS over its three terms in office.
If patients waited for 18 months or 2 years for their operations, well, some would die, others decide they don’t need the operation, but could live with their condition, and others would find the means to have their operations performed privately. Effectively, it would give a massive boost to private provision – the underlying essence of all health reform over the last 30 years, as discussed in the CPGB-ML pamphlet on the NHS. 
One consultant explicitly lamented the fact that “under the NHS, there is no way to limit demand. Anyone who goes to their doctor with a bad knee ends up getting a knee replacement!” What a travesty! The sick get treated due to their actual health needs, rather than the effective economic demand at their disposal. Whether this individual realised it or not, he was in effect issuing the slogan “treat the rich!” The very structure of the debate, in fact, was designed to produce these ill thought out daily-mail reader, kilroy-silk style outbursts.
The panel was of the opinion, that no government would have the courage to announce the re-introduction of rationing openly. Rather, they would continue to introduce rationing by stealth, by all the above measures (1 and 2); resulting in an ever poorer service, decreased performance and reduced government funding (perhaps even justified by failure of cash-strapped trusts to meet ever stricter and less realistic targets), coupled with bad press to encourage all who can to find alternatives to NHS care, leaving a rudimentary public health system for basic and emergency care only.
Effectively, the assembled surgeons discussed, quite openly, the dismantling of what Prof MacFie described as “The last religion in Britain – The NHS.” The effects of removing such a safety net on the health of British workers would be profound, and amount to the greatest cut in wages since the second world war. Such a move will impact on the quality of life of all who live in Britain.
In reality, the financial crisis is adding extra impetus to a program long underway. Having introduced the internal market into the running of the health service, the entire gamut of health provision will be increasingly put out to private tender.
One lone delegate was left to point out that this sum could easily be saved by cancelling all the PFI (formerly PPP) contracts taken out by the NHS during Labour’s period in Government, noting that his own NHS trust spent some 25% of its annual revenues on renting its hospital premises, which after 30 years of being bled in this manner, it would not even own. In fact it has emerged that Labour’s accumulated PFI program would cost the NHS a staggering 63 Billon pounds – far more than the proposed cuts. He pointed out that the assembled surgical leaders were missing the chance to lead a campaign to protect public services, rather than falling over themselves to ‘lead’ the efforts to cut off the branch of the tree on which they were all sitting. 20 billion in NHS savings should be put into the context of the incredible 850 billion gifted to the banks from the public purse, he concluded. Sadly this contribution was met by the assembled delegates with little enthusiasm, with the chairman remarking blithely “that’s a point of view that many people will share,” before curtailing the debate.
From this two things emerge clearly.
First, that 20 billion pounds are due to be wiped off the budget of the NHS. Although Labour Minister’s propositions of making this cut over three years has recently been criticised by Prof Bernard Crump (CEO of the NHS institute for improvement and innovation), it is equally clear that real consideration is being made to cutting the NHS budget by 20 percent annually, ie 20 billion pounds each year. This will devastate the NHS and accelerate the slow cumulative changes into a sudden and total collapse in levels of NHS provision. Britain’s ‘last religion’ is itself threatened with closure. The social wage has only been a temporary and limited concession made by capitalism, under peculiar economic and political conditions that no longer pertain.
Second, that doctors existing petty-bourgeois leadership cannot be relied upon to lead the campaign to defend workers health interests, and that only strong pressure from the organised working class can play this role. Once workers take up the struggle, they will find their own champions – a new generation of Norman Bethunes, who will be prepared to make great sacrifices in the broader struggle. In the mean time, we must lend a hand with the rearguard actions to defend the NHS all along the line, as from this source will spring the beginning of a revolutionary understanding of the real nature of capitalism and the need to replace it with a revolutionary system of administration by the working class itself. Only such a socialist system can guarantee humane and just conditions of existence to all working people.
 End in sight for the NHS. CPGB-ML Pamphlet. London, 2007.
 ‘Efficiency targets will hurt health service, MPs told’ BMA News April 3 2010.