Friends from France have written a detailed paper on the question – read it <a href="https://mouvement-communiste.com/documents/MC/Booklets/BR6_Sant%C3%A9%20_EN_vF%20Site.pdf">here</a>.
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Debate on the current character of hospitals and their restructuring

This article was distributed as part of <a href="https://www.vitalsignsmag.org/posts/vital-signs-no-6">Vital Signs no.6</a> amongst our fellow workers at Southmead hospital and the BRI. Comments welcome!
In this article we want to summarise briefly the role of the health sector in a revolutionary change of society. By revolution we mean the break with the current system which is based on exploitation, competition, chaos of markets, increasingly arbitrary rule of the state apparatus and destruction of our natural surroundings. Revolution means to create a different social system, that we still want to call communism, which is based on the conscious application of resources and social labour to fulfil our needs, decided through a process that includes as many people as directly as possible.  
Why does it need a fundamental change?
It becomes increasingly clear that the current system has little to offer and that its crisis spins it out of control. Global competition drives more and more states into military conflicts, the scramble for markets and resources destroys social relationships and nature. What might be even more of a reason for a revolutionary change is that the current system doesn’t allow us to fulfil our human potentials: with the given degree of knowledge and technology we could create conditions where we have to work much less, live better and more equally  &#8211; and don’t leave major decisions to a detached cast of politicians. 
In the health sector we see the direct consequences of the crisis of this system. There is a close link between illness and poverty, stress, financial worries, lack of community, long working hours or unemployment, feeling depressed about a life that we have little control over. All these things push us towards quick rewards, from sugar to booze. Even if we have the most modern medical equipment and the newest scientific insights at hand, we only manage to patch people up, we can’t address the underlying causes for illness.
Our work itself makes us ill. We still work 12 &#8211; 13 hour shifts, we are still trapped in repetitive jobs, either handing out medication all day, pushing patients around or cleaning floors all day. We could double the amount of staff and/or have more time for learning new things if the social goal of labour was the satisfaction of social needs, not the creation of profits, which promotes the proliferation of unnecessary jobs.
The organisation of the NHS becomes increasingly wasteful and ineffective. With the introduction of the ‘internal market’ (where hospitals and departments have to ‘buy’ services from each other), up to 10% of all labour is wasted on tracing financial transactions. With privatisation we see how a health system that should be well coordinated becomes increasingly segregated and segmented, from charities to private care homes, to corporate laboratories. The Covid pandemic has shown that also the state is not able to hold all this together.
Knowledge that should be available for everyone is locked away in elite research departments or shielded by patent laws that only exist to guarantee big profits for the pharma or medical equipment industry. For example, there are no global data-banks that would tell us the rate of revisions a certain hip replacement required, despite the fact that such information could be readily available and improve outcome. Research goes into drugs that promise profits, not into those that are urgently needed, such as new types of antibiotics. All this needs changing and it could be changed fairly easily once we are in control.
Why is it not possible to change things ‘within the system’?
According to the rules of the system we could vote for a government that implements all these changes for us. History has shown us that this is pretty impossible, for various reasons. 
Governments that actually touch the interests of corporations or of other, stronger nation-states are dealt with fairly quickly. When Allende introduced land reforms and nationalised mines in Chile in 1973, he was ousted and killed by a US backed military coup. The left Syriza government in Greece in the 2010s promised to stop austerity measures, but under the pressure of the EU and the financial markets they broke this promise as soon as they were in government. Cooperatives, which started in the name of workers’ self-management, quickly turn into ‘normal businesses’ under the pressure of market forces
The process of revolutionary change itself is essential. Only by struggling against the basic pillars of this system &#8211; that politicians and bureaucrats decide our fate and that competition and profit is the basis for social relations &#8211; can we change ourselves and our social relationships. We need a movement of solidarity that confronts the existing power structures to appropriate the knowledge and resources that allow us to create a better life for everyone. 
Where do we want to get to?
The history of revolutions and attempts to create a new society can mainly teach us what to avoid. We don’t want to replace the current cast of politicians with a new cast of technocrats who wave a red flag, but otherwise continue to keep the control over society in their hands. This has given communism a bad name. We don’t want to replace the random dynamics of markets with top-down 5-year plans. We can’t and don’t want to go back to a village economy, where everyone might have a direct say, but where we can’t address global problems, such as larger-scale energy production or the unequal distribution of natural resources. 
We can develop a system of delegation and accountability, that allows smaller units, such as workforces in factories, hospitals or inhabitants of neighbourhoods, to participate in larger scale decisions and to organise the production and circulation of goods on an equal basis. We need open book-keeping that shows us the total amount of social labour time and resources available and we need decentralised means to establish what the social and individual needs are. Based on this we can decide where to focus time and energy and organise the satisfaction of social needs without the detour of jittery markets.
Based on such a truly democratic system we can address the many issues of the current health sector. Once labour time is not wasted on the financial or military sector, there will be more resources and woman power available. 
What are the phases of a revolutionary change?
The first phase of revolution is the struggle over control in the workplaces or over the allocation of social resources. Initially these can be small steps. For example, a corporation want to shut down a factory and sack all workers, but the workers refuse and occupy the plant; the police wants to arrest a migrant patient in a hospital, but the staff opposes the state force; management decides to shift production to parts used for re-armament, but workers go on strike against it; a multi-national corporation wants to open a new mine or build an unnecessary factory in a green-belt and the local population blockades the construction site; the state wants to draft in more young men into the army, but school kids protest against this plan. On a larger scale we can imagine that during the next pandemic, health workers don’t just follow the erratic plans of the government or the self-interested moves of the private health corporations, but develop an alternative plan to deal with the pandemic that incorporates the knowledge and interests of everyone, from scientists to health workers to patients. 
In all these examples, people oppose the interest in profits and power with their own social needs. As long as these remain individual struggles, the system can either integrate them or repress them. In the current social moment of global crisis, these struggles will necessarily intensify and spill over. Recently we have seen mass uprisings in Nepal, Indonesia, Tunisia or the Phillipines, where government buildings were attacked. Even these mass uprisings with tens of thousands of people involved can be dealt with if they don’t go to the heart of the system: the means of production. A revolutionary situation only arises when the struggle over the control in the main workplaces meets with a movement that challenges the state forces of repression. We can call this phase a phase of dual power. Historically, the outcome of this phase depends on many factors.
A crucial factor is the internal organisation of the revolutionary working class movement: do workers manage to establish a structure that connects each workplace and neighbourhood with each other and is able to come to coordinated decisions. This is a balance act, as a revolution only succeeds if it gives everyone a say in it, if people feel that something new is created, where they are actually involved in shaping the future. At the same time it needs quick and coordinated decisions in a moment when you are confronted with a centralised force, such as the capitalist state. Historically, workers created a council system that took on this role of coordinated decision making. As health workers we are at the centre of this, as hospitals are mass workplaces, with an already existing internal structure that can be adapted, which reach out far into communities and neighbourhoods. These structures can also be used to facilitate an immediate and just redistribution of wealth and resources: banks, useless office buildings and villas can be turned into clinics, nurseries and social centres.
Another crucial factor is the ability of the movement to confront the repressive response of the state. There is no successful revolution if the army (and to a lesser extent the police force) doesn’t split and a larger part of the soldiers change sides. Working class soldiers mainly change sides when they see that the revolution can provide a better life for everyone. But it also needs pressure. Here, again, health workers are at the centre. The army and the police force depend on health care provisions from the civilian health sector. Historically, the refusal to treat injured soldiers if they don’t desert the state forces has been a strong influence and the treatment of injured working class protestors an essential requirement of the struggle for a new society. A modern revolution doesn’t win militarily, but it has to be able to defend the working class control over factories, energy and transport infrastructure and hospitals. These workplaces can then be used strategically to weaken the repressive forces and other enemies of the revolution. Already during the revolutionary process, most bullshit-jobs that are unnecessary to society will disappear. This frees a lot of man and woman power to support workers in the essential sectors.
In the next part we look at the main tasks within the first 100 days after taking control away from the state apparatus and the distant board rooms and giving it to the working people. We look at how the health sector can change in order to meet the needs of people who care and are cared for.

Debate on the current character of hospitals and their restructuring

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