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The following article is reprinted from Workers Hammer (No. 249, Spring 2023), newspaper of our comrades of the Spartacist League/Britain.

The NHS [National Health Service] has been gutted and bled dry. The entire system is collapsing and access to even the most basic care is on the line. For the working class in Britain, this is literally a life-and-death question. The strikes by the Royal College of Nursing (RCN), Unite and other NHS unions are certainly about wages, but also much more. The very survival of a publicly funded healthcare service is at stake.

This reality is widely recognised. The question is: what to do? Every single politician swears up and down that they are entirely committed to “saving the NHS.” To count on them is to count on an arsonist to put out a fire. The Tories have ground the NHS down and are now slamming the door on nurses’ modest wage demands. As for Labour, [party leader Keir] Starmer promises to go back to the legacy of…Tony Blair, the very man who opened the doors wide for the private sector in healthcare. The SNP [Scottish National Party], Lib Dems and Greens offer nothing better. Clearly the politicians don’t have the answer.

Social progress comes from one place in this reactionary kingdom: the struggles of the working class. Clearly the unions are central to “saving the NHS.” On the other hand, for 40 years the unions have utterly failed to put a stop to the destruction of the NHS and the erosion of living standards. The fault lies not with the unions themselves but with the disastrous course followed by the union leadership. Instead of building unions as tools of struggle which can defend the basic needs of workers, unions in this country have been hollowed out and are wielded as pathetic public relations tools.

This is apparent in the strategy currently being pursued by the RCN. After almost a century of opposing strikes, allowing its members to be worked to the bone and the state of the NHS to become disastrous, the RCN has called a few strike days. Their objective is to “force the government to stop and listen to what the health care workforce is asking for” (RCN Magazines, 16 October 2020). All well and good, but a few spread-out strike days will not “force” the government to do anything. In fact, while the government hasn’t budged, the RCN cut its pay demands in half, from 19 to 10 per cent after only two strike days.

The government will not be made to “recognise” the true worth of NHS workers through media attention. What has happened to the NHS is not some misguided policy but a decades-long campaign to destroy the greatest working-class gain in this country. This will not be reversed without a real fight and certainly not by having illusions in goodwill from Westminster.

Every nurse knows that to treat a patient one must first have a correct diagnosis of the ailment. The RCN correctly identifies low wages as an important factor in the crisis of the NHS. However, low wages are only a symptom of a broader problem. The real cause of the NHS crisis is the general degradation of social and economic conditions in Britain and Northern Ireland. In the last 40 years working conditions, public services and the condition of women have all been ground down by constant attacks. Nothing expresses this reality better than the collapsing NHS—a showcase of miserable working conditions, crumbling services and the brutal treatment of women in this country.

To save the NHS and reverse the general decline in living standards, it is necessary to broaden the struggle and get at the root of the crisis. Towards this Workers Hammer advocates that strikes in the NHS be organised around the struggle for: high wages, quality healthcare, women’s liberation. These questions cannot be divided into separate boxes but will either go forward or fall back together. To advance, they must all be fought for together by the entire working class. But none of the NHS unions are pursuing such a strategy, focusing instead on narrow demands divorced from the broader social questions at stake. The question of women’s oppression in particular is ignored or given token mention. This will not do. Yes, it is bread we fight for, but we must fight for roses too.

Women as Workers

What does women’s liberation have to do with the crisis in the NHS? Everything in fact. The question of women’s oppression is intertwined with every aspect of the NHS. First and most obviously, it relates to the status of women as workers. The NHS workforce is overwhelmingly female, and the NHS is by far the largest employer of women in Britain. It is no coincidence that NHS employees make generally much less than those in male-dominated jobs of similar qualification.

A large reason behind this pay gap is that the government exploits the social conditioning of women as “caregivers” to demand greater sacrifices than in male-dominated professions. In the name of “saving lives” and “caring for patients,” nurses and other NHS staff are asked to put their own well-being aside. This moral blackmail was ramped up to an extreme during the pandemic. Now, the same method is being used to try to discredit and demoralise the strikes. Nurses and ambulance workers are accused of killing people by striking for better working conditions. This demagogy must be decisively rejected if any progress is to be made in the NHS.

Far from doing this during the pandemic, the NHS unions totally submitted to the government’s blackmail, giving it free rein to press workers to the breaking point. In return they received nothing but clapping. In the current strike, the RCN has had to oppose some of the very arguments it peddled during the pandemic. It has argued that the nurses strikes are necessary to save the NHS and that it is the crumbling system which is killing working people. This is entirely correct. Why then is the struggle so minimal and halfhearted?

Clearly the NHS unions are still on the back foot, conciliating the argument that it is morally wrong for them to cause disruption. It is time to go on the offensive. The selflessness and social consciousness so strong among NHS workers—and women in particular—need to be unleashed in the fight for better healthcare and wages for all. The bottom line is that the NHS will collapse and many more working people will die if the working class as a whole doesn’t take a stand. The more determined and decisive the struggle, the more support will be won from working people and the more healthcare will be improved.

Public Services and the Family

Women’s oppression in the NHS goes deeper than inferior wages. Being an overwhelmingly female workforce means that most NHS workers face a second shift at home of childcare, housework and care for the elderly. These tasks fall disproportionately on women, making the question of public services all the more important for them. The provision of free healthcare, public education, care homes—these are all modest but very real steps towards taking “caring” out of the private sphere of the family and into the social sphere. Improving the quality and availability of public services directly alleviates the burden of domestic work on women. Conversely, cuts to public services and the absence of affordable childcare only increase the strain.

While the state of public services has a particular impact on working women, it profoundly impacts the well-being of working men as well. Far from dividing workers along sexual lines, making women’s emancipation a centrepiece of the struggle for the NHS has the potential to unite the working class on a much stronger basis than simple economic demands. For example, workers in male-dominated sectors like rail will be much more likely to ally with nurses for better healthcare and reducing the burden of household chores than over wage demands.

Indeed, the condition of women directly relates to the general level of social progress. The early socialist Charles Fourier explained back in 1808 how:

Social progress and changes of historical period are brought about as a result of the progress of women towards liberty; and the decline of social orders is brought about as a result of the diminution of the liberty of women.

“Other events influence these political vicissitudes, but there is no other cause which produces such rapid social progress or decline as a change in the condition of women.”

—The Theory of the Four Movements

The struggle for the advancement of women is not only an entirely just cause but also a lever that can lift all of society. The fight for a quality NHS and better public services demonstrates this clearly.

Healthcare and Capitalism

In order to obtain quality healthcare for all, it is essential to understand what obstacles stand in the way. At bottom it is the very nature of the capitalist economy which drags down and limits the quality of healthcare. When Britain was a manufacturing power, its ruling class had a certain interest in providing a rudimentary degree of education and healthcare. This was not out of charity but because of the pressure from a strong working class, as well as the need for an effective industrial workforce and able-bodied soldiers. As the economy was turned more and more towards purely speculative and parasitical activities in finance and high-end services and the working class was decimated, the need to maintain semi-decent healthcare and educational standards for the mass of the population has receded.

Today more and more of the economy relies on a thin layer of highly trained technocrats and specialists. This has meant that education, healthcare and social housing for the general public have all become “wasteful” expenses in the eyes of the capitalists. These services simply do not contribute enough to “productivity” to warrant meaningful investment. As public services receive less funding and the general welfare of the population is degraded, the strain on the public healthcare system becomes untenable. This is the reason for the NHS crisis. It is caused not by a heartless “ideology” or “greed” but by the fundamental interests of the ruling class. This understanding has to be at the centre of the struggle for better healthcare and better working conditions.

Lesson of the Pandemic: NHS Workers Should Call the Shots

Looking back at the pandemic through this lens leads to clear conclusions. It was criminal for the entire labour movement—the Labour Party, unions and left—to support the lockdowns. This meant leaving full control of health and working conditions in the hands of the demented Boris Johnson government, which obviously could not have cared less about protecting the working class in the pandemic.

Instead, what was needed was a determined struggle by the labour movement to take matters into its own hands. The working class should have fought for all social resources to be mobilised to respond to the emergency. New hospitals, care homes and other health facilities should have been built urgently. The housing stock should have been redistributed to ease overcrowding and unsanitary living conditions. NHS wages and staffing levels should have been doubled. These are only a few examples of basic measures which should and could have been taken to address the pandemic. They would also have had a beneficial long-term effect on the health of the population and the state of the healthcare system.

The obstacle to taking any of these measures is the fact that most resources are in the private hands of a small number of families. Requisitioning the assets of the capitalists (and royals) is obviously a big red line for a government whose entire purpose is to defend the interests of those very people. So instead, it shut everything down, pumped money into the pockets of Tory donors and squeezed NHS workers to the breaking point. The RCN and other NHS unions entirely bought into the national unity, “We’re all in this together” propaganda, submitting to the government. Rather than fighting for improved social and working conditions, they begged for more lockdowns. The outcome of these policies is clear. It was a catastrophe during the pandemic and it pushed the NHS into the shambles it is today.

The lesson should be just as clear. Leaving healthcare in the hands of a capitalist government can only lead to disaster. Healthcare workers should be in charge of running healthcare. A first basic step towards this would be for unions to push back against the ever-encroaching bureaucratic intrusions and fight for union control of health and safety. Ultimately the whole system should be run by workers from top to bottom.

The Road to Women’s Liberation

The fundamental problem with the strategy pursued by the RCN and other NHS unions is that it does not start from the understanding that quality healthcare for all and capitalism are incompatible. Of course, unions must start from today’s struggles and consciousness. But they must use the everyday battles to educate workers in the irreconcilable nature of the conflict. Far from doing this, the NHS unions peddle illusions that the capitalists and their government can be made to see the light and be reasonable. Such fairy tales undermine even the most minimal fights for better wages and working conditions. Instead of well-planned and determined struggles, they lead to half measures, compromise and capitulation.

Whether it is working conditions, public services or the status of women, it is crucial to understand that incremental and constant progress is impossible within capitalism. The NHS itself, while a crucial gain, was not a step towards socialism. It was part of the measures taken to shore up collapsing British imperialism after WWII. Attlee and arch-reactionary Churchill broadly agreed on such measures at the time. Since then, the NHS has been under constant attack. As the whole social fabric of the country is hollowed out by the ruling class, the only prospect for the future under capitalism is decline and misery.

In contrast, a workers government which would expropriate the capitalist class would be able to take immediate and long-term measures to increase the quantity and quality of public services. With productive forces used rationally and planned on an international level, more and more of the burden which today rests on the family can be taken on by society as a whole: cooking, cleaning, healthcare, education, child-rearing. As this progresses, the social role of the family will gradually wither away and with it the oppression of women.

Trade Unionism and Women’s Oppression

The crisis in this country is crushing working people in every aspect of their lives. The ruling class is in perpetual crisis and social stability is rapidly eroding. The biggest hurdle to the liberation of the working class and the emancipation of women is certainly not the stability of the system. The road to socialism is blocked first and foremost by the absence of a working-class party that fights for socialism.

The current leadership of the workers movement is composed of the utterly pro-capitalist Labour Party and an occasionally militant-talking pro-capitalist union bureaucracy. To break the stranglehold of these traitors, it is necessary to show how their actions undermine the working class at every point and show that another road is possible. This is the key task for socialists today. But far from doing this, the rest of the socialist left talks about Marxism and revolution only to then support various non-revolutionary leaderships of the working class.

This problem of leadership is highlighted very clearly in relation to the question of women’s oppression and the NHS strikes. Take Socialist Appeal [affiliated with Socialist Revolution in the U.S.] for example. They frequently write about women’s oppression. They recently wrote about the disgusting cover-up of a serial police rapist by the Met [Metropolitan Police]. They also write articles about the need for socialism to emancipate women. But when it comes to the NHS strikes—which impact women in every way—none of their articles so much as mention the question of women’s oppression, much less advocate that the unions fight for women’s liberation. The same could be said of any other socialist paper.

What explains this apparent contradiction? It comes from a disease identified by Lenin as economism. In Britain it is better known as trade unionism. At bottom this programme limits the aim of trade union struggle to improving the immediate economic conditions of the working class and preaches socialism for the future. When it comes to addressing the oppression of other groups—women, ethnic minorities, immigrants, Travellers, etc.—economism limits itself to denouncing injustice and again…preaching socialism for the future.

This programme in all its iterations is entirely compatible with the current trade union bureaucracy, whether right-wing or left-wing. What is rejected is the struggle for a socialist leadership today which not only champions the cause of all the oppressed but aims to put an end to their oppression by overthrowing capitalism. Economism does not lead to gradual improvement but to betrayal by the pro-capitalist bureaucracy and obviously no progress at all towards socialism.

For the trade union bureaucracy and fake socialists, advocating women’s liberation in the context of the NHS strikes would be “divisive” because some workers (and certainly the bureaucrats) think it is too radical. Fighting for black, Asian and immigrant liberation, which is also absolutely central in the NHS, would also for the same reason be considered “divisive.” Similarly, it was to avoid “division” that when the Queen died, avowedly “republican” union leaders cancelled strikes and the RCN suspended its strike ballot. In fact, it is economism which divides the workers movement.

The ruling class constantly bombards the working class with all sorts of prejudices with the specific purpose of setting workers against each other and keeping them loyal to the capitalists. For socialists to water down their programme in the face of backward consciousness means trampling on the interests of the most oppressed in society, presenting the fight for their liberation as “divisive.” This fosters identity politics among the oppressed, who rightly feel betrayed or left out, further drives reactionary social polarisations and divides workers. Only if the struggles of all the oppressed are united under a common socialist banner can the workers of the world overcome the myriad divisions fostered by the ruling class.

This perspective is antithetical to every other left organisation in Britain. However, we hope to be proven wrong in this regard and would be glad if other socialist groups join us in fighting for the NHS unions and the entire labour movement to inscribe on their banners: For women’s liberation!

To save the NHS, fight for women’s liberation!

  • One union for all healthcare workers! For a joint strike offensive.

  • 50 per cent pay rise, wages pegged to inflation.

  • No mandatory overtime. Mass hiring under union control. Scrap agency work and zero-hours contracts. Permanent jobs for temp workers.

  • Down with racist discrimination. Full citizenship rights for all immigrants.

  • Socialise household duties. For 24-hour childcare, dining rooms and laundry services paid for by the state — available in the workplace and neighbourhoods.

  • Scrap the NHS debt. Nationalise the private healthcare sector.

  • Build new healthcare infrastructure, schools and low-cost, quality housing. Seize the estates of the monarchy and the church to pay for it!

  • Establish a planned economy to reindustrialise Britain. Expropriate the City of London!

  • Dump the bureaucrats! For a class-struggle leadership of the unions and a revolutionary workers party.

  • For workers governments on both sides of the Irish Sea!