The New Serfdom

by Angela Eagle

  The problem is that it takes ten years to train a GP. You need a degree in medicine, which takes five years, then a two-year foundation course in general training, then a further three years of specialist training in general practice. So, even if we expanded the number of medical places today, it would still take a long time for that measure to bear fruit. In the interim, Britain has had to import general practitioners from overseas. Leaving aside the impact that has had on other countries’ health systems and the lost investment made by their education systems (which can be really problematic), this is complicated and expensive to implement. The NHS is currently planning to recruit 2,000–3,000 GPs from overseas and will pay £100 million to international recruitment agencies. A long-term plan to ease the stresses on British GPs, to encourage them to open their own practices in areas of need and to encourage medics into general practice is needed, but it is not clear the NHS currently has the resources to implement such an ambitious plan. And nor will sky-rocketing tuition fees or Brexit help either.

  The same pressures can be seen in our hospitals. The 2016 annual report on waiting times for non-essential surgery by the Patients Association, an independent health and social care charity, showed that the total number of patients waiting over eighteen weeks for operations in 2015 was 92,739, a huge increase over the 51,388 patients waiting the same time in 2014. Average waiting times for five procedures (hip replacement, knee replacement, hernia, adenoid and tonsillectomies) have risen above 100 days. This represents the highest average waiting time in the six years that data has been collected by the Patients Association. The report also found that hospitals cancelled an average of 753 patient surgeries ‘on the day’ in 2015. Shortages in equipment or beds were the most common reasons for cancellation. Again, the picture is one of a system under strain: of rising demand and an organisation that simply doesn’t have the resources it needs to meet that demand.

  The final part of the health system that is under critical stress is our adult social care system. Adult social care – and meeting the challenge of its future funding – was the principal cause of Theresa May’s extraordinary turn of fortunes in the 2017 election; her plan to have people fund their own social care through a wealth tax was deeply offensive to many Conservative voters – who believe in keeping as much of their wealth as possible – and was quickly dubbed a ‘dementia tax’ by her opponents. Unreformed, the adult social care system is going to collapse under the weight of the growing number of older people with health conditions that require some form of supervision or help, and there is a huge funding shortfall. The Conservatives’ reluctance to proceed with the Dilnot reforms to social care and their decision to sabotage Labour’s attempt to reach a cross-party consensus on this issue in the 2010 election had come back to bite them. The catastrophic Conservative campaign in 2017 seems to have put paid to the idea that the wealthiest older people should have to pay for social care through their assets, but it has not put paid to the ongoing need for new sources of finance for social care to be found. The can cannot be kicked down the road forever.

  In 1948, hospitals were brought under the control of the new NHS, but social care was left under the control of local authorities, which are legally required to meet the needs of their communities. The sort of care required varies by age. People over sixty-five are most likely to need physical help, but a substantial proportion require help with memory or cognition. For those younger than sixty-five, who make up a quarter of those getting local authority help, the most likely reason is either a learning disability or mental health problems. But enormous cuts in recent years to local authority funding – the most squeezed part of the public sector – have put the system under huge strain. The Local Government Association, health charities and the Association of Directors of Adult Social Services all estimate the shortfall in adult social care funding to be around £2.5 billion by 2020.

  This has meant unpaid ‘informal’ carers – mainly women – have had to take on a huge amount of the workload. According to a major National Audit Office (NAO) report in 2015, £19 billion was spent by local authorities in 2012/13, while the value of informal care and support was estimated at £55 billion. Around 2.1 million people in the UK received some form of informal care in 2014, according to the Office for National Statistics. The proportion receiving 24-hour care has increased considerably in the past decade. The NAO concluded:

  Pressures on the care system are increasing. Providing adequate adult social care poses a significant public service challenge and there are no easy answers. People are living longer and some have long-term and complex health conditions that require managing through care. Need for care is rising while public spending is falling, and there is unmet need. Departments do not know if we are approaching the limits of the capacity of the system to continue to absorb these pressures.

  All these problems – with A&E, GP services, elective hospital procedures and adult social care – are a reflection in great part of the chronic under-resourcing of the NHS. This is not a matter of debate between the political parties. Both Labour and the Conservatives accept that an ageing population, rising costs, rising public expectations – driven in part by technical advances that mean we are capable of dealing with more health problems – and rising obesity are driving up demand and the overall cost of healthcare.

  The NHS’s own Five Year Forward View, published in November 2014, identified a shortfall of £30 billion in England alone. That’s around 5 per cent of the total tax take in the UK; as much as the total amount of council taxes raised in the UK or one sixth of UK income tax returns.

  In terms of the number of doctors, the OECD found in 2017 that the UK has fewer doctors per head of population than most other member countries. They calculated the UK has 2.8 doctors for every 1,000 people. Austria has 5.1 and Germany, Italy, Lithuania, Norway and Switzerland all have more than four doctors for every 1,000 people.

  The OECD also found that in the UK we only had three hospital beds per 1,000 people in 2011. This was far behind the majority of other Europe countries. Germany has 8.3; Austria 7.7; Hungary 7.2; Czech Republic 6.8; Poland 6.6; Estonia 5.3; and Slovenia 4.6. Only Sweden had fewer, with 2.7 per 1,000 population.

  Other countries have allocated more resources to meet the demand in their countries and that is, in great part, because they raise more revenues from taxes than we do to spend on healthcare. That might sound surprising since we spend what sounds like an enormous sum of £140 billion a year on healthcare. But that is actually a smaller proportion of our total national income than is spent on health in many other developed countries. If we spent the same as, say, Germany, as a proportion of our Gross Domestic Product, we could bridge the gap between demand and supply.

  It would mean a serious conversation between politicians and the public on how to deal with the problems of underfunding in the NHS. These are not new problems, but they are undoubtedly being exacerbated by insufficient annual increases in the NHS’s budget and the inexorable and counter-productive cutting of council social care budgets.

  Democratic socialists must also look at how we can work together – as a nation – to alleviate the pressures on the NHS. The UK actually has serious health inequalities. In short, the poor are much more likely to get ill. They have worse nutrition, and have higher rates of obesity, cardiovascular disease and diabetes – all of which are huge burdens on the NHS. In 2008, the Labour government led by Gordon Brown asked Professor Sir Michael Marmot to review the link between socioeconomic status and health. In his report, published in 2010, he introduced his analysis in stark terms:

  People with higher socioeconomic position in society have a greater array of life chances and more opportunities to lead a flourishing life. They also have better health. The two are linked: the more favoured people are, socially and economically, the better their health. This link between social conditions and health is not a footnote to the ‘real’ concerns with health – health care and unhealthy behaviours – it should become th
e main focus.

  Professor Marmot updated his analysis in 2017, when he stated:

  The longest life expectancy in the country was in the richest borough, Kensington and Chelsea: eighty-three for men and eighty-six for women. By contrast, the lowest life expectancy was in the North: Blackpool, seventy-four for men; Manchester, seventy-nine for women.

  Even more dramatic than these regional inequalities are the inequalities within local areas. In Kensington and Chelsea, life expectancy was fourteen years shorter among the most disadvantaged compared to the best off. Alarming, but perhaps not surprising. Kensington and Chelsea may be the richest local area in the country, it is also the most unequal economically.

  In the Wirral, containing Angela’s constituency of Wallasey, life expectancy can vary by over ten years, even though communities are geographically close together. East of the M53 motorway, which runs down the peninsula, is where poorer health outcomes can be seen in Birkenhead and Seacombe, with the richer west side of the Wirral such as West Kirby and Heswall having much longer life expectancy.

  As in our analysis of inequality when it comes to the evil of want, inequality matters in healthcare. Both authors completely endorse Professor Marmot’s conclusions, in which he ‘identified six domains that cause health inequalities and where action is required to reduce them: early child development, education, employment and working conditions, minimum income for healthy living, healthy and sustainable places to live and work, and taking a social determinants approach to prevention’. Public health education – delivered by the NHS, local authorities, through education in school and beyond – is an essential component of bringing down demand for NHS services. If we can make ourselves healthier through voluntary modification of our consumption and behaviour, the cost of healthcare would of course come down.

  However, there is another problem that makes that task more difficult. In Britain and across the developed world, our diets contain too many calories – chemical energy – and thus make us fat. We drink too much alcohol and we smoke. All of these are human behaviours that bring us pleasure and are actively encouraged by private companies comprising what can only be considered an Obesity and Ill-Health Industry, profiting through making us ill, and encouraging us to consume as many of their products as possible. A rich array of product designers and scientists study the mechanisms of human pleasure and addiction in order to physically entice us into consuming more. Marketers cover up any potential harmful effects and use exceptional levels of mendacity and misleading imagery and statements to psychologically persuade us to consume more. There is now a positive correlation between poverty and obesity which would have been unimaginable only a few years ago. We need much more governmental intervention to correct this inaccurate food labelling and advertising to children. Misleading promotional material needs to be clamped down on and we need far better education on nutrition in schools. The Conservatives would dub this an expression of a ‘nanny state’ (which is ironic, considering half of them had nannies themselves). The truth is that we need to do this if we are to protect children and parents from an industry that spends vast amounts of money and time trying to deceive and cajole.

  The Obesity and Ill-Health Industry also attaches itself to sports, fashion, music and other forms of entertainment. What did smoking have to do with Formula 1, for example? What does alcohol have to do with football? Why do sugary cereals that tempt young taste buds all have cute comic characters on the front? There is a direct linkage between the increase in healthcare demand in the UK and the pernicious activities of the Obesity and Ill-Health Industry. Brits are today over three stones heavier than fifty years ago. As of 2015, according to the OECD, over a quarter of British adults are not just overweight but obese. Over 60 per cent of adults are overweight. A growing number of children are also obese. The rate has almost doubled in the past twenty years to one in eight children. A study by the American management consultancy, McKinsey, estimated costs to the British economy of over £15 billion in treating obesity-related medical conditions, including diabetes.

  A guide as to how we might take on this industry can be found in how we dealt with the huge and powerful global tobacco industry. Smoking rates in the UK have been cut drastically since we got serious, using a mixture of taxation to increase prices, legislation to cut the spaces in which people can smoke, health warnings on packaging and education in schools to reverse the tobacco industry’s decades of propaganda aimed at persuading our citizens that smoking was safe, cool and attractive.

  The owners of companies that profit from obesity will cry foul, of course, but to improve the lives of British people, the amount of time they spend in good health and therefore our productive capacity as a nation, to cut costs in the NHS and to ease the burden on our amazing healthcare staff, we need to take on the Obesity and Ill-Health Industry. We must use the power of the state and every bit of determination as individuals not to allow ourselves to be duped by fat cats who profit from making us overweight and unwell.

  CHAPTER EIGHT

  LONELINESS

  It was in an interview with Woman’s Own magazine, in 1987, that Margaret Thatcher first stated: ‘There is no such thing as society.’

  It’s a quote that is often used to contrast the atomised individualism of Margaret Thatcher’s politics with the communalism of the Labour Party and of democratic socialism. The intent of her words was somewhat more complex than that stark, memorable phrase might imply. As she herself opined in her autobiography: ‘They never quoted the rest.’ She explained:

  I went on to say: There are individual men and women, and there are families. And no government can do anything except through people, and people must look to themselves first. It’s our duty to look after ourselves and then to look after our neighbour. My meaning, clear at the time but subsequently distorted beyond recognition, was that society was not an abstraction, separate from the men and women who composed it, but a living structure of individuals, families, neighbours and voluntary associations.

  From that broader explanation it becomes clearer that Mrs Thatcher was in fact drawing, yet again, on the teachings of Friedrich Hayek. Hayek believed diffused market-based mechanisms were far superior to centralised planning when it came to making decisions. He said that the taking of innumerable decisions on prices in a free market better marshals scarce economic resources by aggregating the distributed knowledge of lots of people. He compared that favourably to the idea that a central government should set those prices and thereby control economic life. In his writings, Hayek also applied these ideas to society itself. He believed ‘spontaneous evolution’ was preferable to ‘intelligent design’ in ordering social infrastructure and relations too, so that people could live good lives based on a more natural order. This ignores the truth that human beings are natural co-operators who live in communities of mutual interest and thrive best in that context. We are not made to be atomised individuals.

  This idea has been used over the past four decades to tear down many of the aspects of our state that define a civilised society. Mrs Thatcher’s fundamental approach to policymaking was to end universality and state provision in favour of the so-called ‘free market’ and to encourage both volunteering and individual self-reliance to fill in any gaps and provide support for those who simply cannot thrive in a society without a safety net. Similarly, we see Hayek’s disdain for any form of central planning in David Cameron’s Big Society. Cameron himself stated in a muddled revision of Thatcher’s maxim: ‘There is such a thing as society, but it’s not the same as the state.’ He and George Osborne showed what this means in practice by stripping back funding for services such as libraries, SureStarts, youth centres and – significantly – adult social care across the country through huge cuts to local authority budgets, while suggesting that individuals might band together to provide those services under the ‘Big Society’ banner.

  The result of this activity has been the sustained degradation of the social infrastructure that
underpins communal relations in Britain. Many of the buildings that were the sites of social interaction and the institutions and programmes that encouraged people to come together, mingle and share their lives, have disappeared. This all happened at the same time as capital took the whip hand over labour and squeezed more hours and energy out of workers, limiting the ability of individuals to enter into voluntary co-operation when they weren’t at work. This pincer action – on institutions and individuals – has led to a continued loss of meaningful and satisfying social interaction in Britain and a substantial increase in loneliness, one of the most modern and most pernicious of the evils that Britain faces today.

  Loneliness is not being alone. In modern Britain, especially in our cities, few of us are truly alone. The Mental Health Foundation, who have studied this phenomenon, state:

  Loneliness, then, is not being alone but a subjective experience of isolation. It is inevitable that all of us will experience this feeling at one time or another, whether it’s a brief pang of being left out of a party or the painful sensation of lacking a close companion. Life-changing events, such as moving to a new town or a bereavement, can lead to acute loneliness. But it is the time factor that decides how harmful loneliness may be: research shows that ‘loneliness becomes an issue of serious concern only when it settles in long enough to create a persistent, self-reinforcing loop of negative thoughts, sensations and behaviours’. In other words, it is long-term, chronic loneliness that wears us down rather than loneliness that is ‘situational’ or passing.