The health crisis and the forced return to work

Aus aktuellen Anlässen, wie der Aktion am Dachauer Klinikum und den Warnstreiks in Kliniken im öffentlichen Dienst, ein Text über Gesundheit während COVID-19, das Gesundheitssystem im Kapitalismus und wo Arbeiter*innen am besten ansetzen. Der Text behandelt die Situation in Frankreich.

Mouvement Communiste | Kolektivně proti kapitálu
14. Oktober 2020


The health crisis and the forced return to work

Covid is starting to hit hard again. But this time the state and the bosses have stopped spouting
the nonsense about how their absolute priority is to preserve the health of the population. They have
simply decided to place the economy (which means maintaining profits) at the top of their agenda.
This is why they are doing everything they can to get workers going to work, taking public transport in excessive numbers and beginning to go shopping again to relaunch internal consumption. From now on, health has become a dependant variable of work and not vice versa.

In these conditions, putting forward token barriers to hold back the epidemic is particularly hypocritical. And, as a logical consequence, intensive care services are seeing the number of patients grow, mostly people hit by Covid.

The material means at the disposal of hospitals have grown a bit since March, but it’s the
hospital staff using the stuff that there is a shortage of. An example? The 900 additional hires taken on by the APHP (1) are not enough because 450 health workers in Paris have resigned in the meantime, sickened by the impossible working conditions and by the deception regarding their wage increases.
And how did the APHP react? It postponed or abolished the All Saints’ Day holiday. Again, as in spring, we face the militarisation of labour. All this is in line with a health policy applied for more than 30 years, whose immense deficiencies for patients and staff have been amplified by the present health crisis. This policy comes down to the transformation of the hospital into a business like any other, dedicated to profit.

The state as an individual capital, as the principal investor in private hospitals and even more as the owner of the public hospital system, tries to diminish its contribution to the financing of hospitals and to invest in more efficient entities – that is to say ones which are capable of generating profit. Contrary to the mystification peddled by the unions about a so-called “non-market” sector, health has always been a commodity: the state buys services from the hospital which sells them to it. As for the patient, their contribution only covers part, certainly limited but growing, of the costs of producing the services. What is accelerating today is the need for the commodity “health” to become profitable for the state.

Capital is not killing the hospital, but making it profitable
The care sector, ruled by distorted markets (prices fixed outside the market by the social
security institutions, mutual insurance companies and trade unions; state financing of hospital
companies), has evolved since the 1980s and even more since 2008, following the fiscal crisis
resulting from the financial crisis, towards a “classic” industrial model spurred and stimulated by
competition. This penetration of capital into the state market corresponds to its continuous extension into all spheres of economic activity and to the generalisation of the commodity as the only form of wealth. The hospital becomes progressively a capital generating profit, as has been the case for a long time for public transport, for example. The search for profit inexorably sucks in all “public services”.

The mechanism is simple. Hospitals receive from the state a minimal allocation equal and
proportionate to their volume of treatments and their health specialities. The capacity of the hospital to make money depends then on its productivity, that is to say on its capacity to restrict the costs of
production of services to below their standardised prices. Relative to the capital invested and the prices fixed initially, certain health procedures are more profitable than others, and that is why the boss-state disinvests from some specialist treatments and directs its investments towards others. The “public” hospitals are also more and more in competition with “private” hospitals which are often far ahead inthe more profitable market segments. Private clinics are an irreplaceable incentive which accelerates the search for profits from the state sector hospitals.

This will be paid for by workers and patients
The transformation of working conditions in hospitals is comparable to what happened in manufacturing industry a century ago: Taylorisation and mechanisation. Like any workforce, as long as the capitalist mode of production dominates society, health workers are subjected to pressure for the bosses to cut wages, prolong working hours, increase productivity and intensify work. A growing division of labour inevitably leads to repetitive work. The deskilled worker must also show themselves to be flexible and potentially interchangeable. The time for adaptation and learning new skills is more and more reduced. The hospital management does all it can to compress to a minimum whatever is not part of the (chargeable) medical treatment itself so that the time at work for the staff is as near as possible to the time spent working. All moments of the day at work which are not dedicated directly to labour productive of surplus value are restricted (breaks, discussions etc.). Also, the tendency is to make the patient shoulder the costs of their care – including when they are declared “free” by virtue of the “social contract” in force.

Whether the hospital is private or public makes no difference for workers’

The hospital is an essential link in the cycle of reproduction of labour power. Its main “social rationale” is to repair and return to work the labour power worn out by its exploitation in the process of production. The state devotes an important part of its budget to managing the health of the population, if we understand by that the interventions necessary to the reproduction of labour power useful to capital, directly or indirectly (since children, the elderly and long-term disabled are also taken in hand by the healthcare system). In all the advanced capitalist countries which have a health system run by the state, it is the undisputed actor and the great organiser of this reproductive function which is indispensable to capital. The state is at the same time the juridical owner of the public hospitals, the order giver to the hospitals, the hegemonic customer who fixes, in advance, the prices in the health market, which partly finances infrastructure and other constant capital, which pays the wages of the public health sector and which is the guarantor of the “social contract” around health with and through its intermediate bodies (unions, mutual insurance companies). The ideology of “public service”, always at the service of capital, only has the aim of making the state coincide with the general interest. Whether it is the state or private capitals (the two often strongly interlinked) should not concern workers. What must concern them are wages and conditions of work. And to defend them, the first step is to fight collectively against the divisions between workers created by the organisation of work.

Concessions from the state and hospital management: at a heavy price
The Ségur de la santé (2) and its additional announcements have been presented as the realisation of the promises the government made at the height of the pandemic crisis. Here are the headlines. For staff incomes, a rise of €183 (in two stages) is certainly something, even if it’s far from the demand of €300 for all expressed by the medical staff, as during the demonstration on 16 June. The category promotions within the Public Hospital Profession (FPH) of 563,000 auxiliary nurses (from C to B) and 210,000 nurses (from B to A) (3) also translate, in the short term, into wage increases, and, in the medium term, into more rapid career progression and improved bonuses. In the long term, this will result in better pensions (on the present basis).

More or less, it’s a matter of an average increase of 10% of wages in a period of low inflation.
To put it in perspective, this is a similar percentage to the one obtained in May-June 1968, during a
period of significant inflation. Nevertheless, we must not forget that they excluded the 370,000 contract workers, temps and agency workers and the 58,000 classified as “various” representing respectively 18.2 and 7.1% of the total employed in the sector. This reinforces the division between the “statutory” workers and the casual workers in the hospital. It’s a strategy applied for a long time in other capitalist enterprises which are public services, such as the Post Office or French Railways.
These concessions from the state will not be without an impact on working conditions. Increasing the flexibility of the staff, their mobility between services (while respecting the health rules), optimising investments and better management of the mass of wages, will involve “loosening” the rules of the PHF. All while taking account of the experience of Covid which has almost transformed hospitals into military ones practicing “battlefield medicine”. The condition for the good functioning of a “field hospital” is the presence in sufficient numbers of a workforce which is qualified, supple, adaptable, available to operate care structures which are short-lived, mobile and adjustable according to the needs of the moment. This is the reason for which a fundamental objective of the reform of the French hospital system is to demand from the staff, in return for the wage increases and more rapid career progression, greater flexibility, mobility and versatility.

Returning to the transformation of the hospital into a business, the first stage is the transfer of
decisions to the local level, the hospital director becoming a company boss in their own right:

1) For negotiations over wages, working conditions and investments. Arbitration over investments will be on a department level by ARS (4) (when they are over 100 million euros) but their criteria (not defined in Ségur) will be based on performance objectives;

2) For work organisation, for shifts as for wages received individually. The individual part of the
wage will grow (according to management of additional hours); careers will also be individualised. The “improvement” in team working will involve competition between different teams within the same hospital, and competition will grow between hospitals to attract qualified staff.

This will allow the rationalisation of the territorial division of hospitals and services but also authorises, within each hospital structure, the temporary transfer of staff from one service to another and, to some extent, from one specialisation to another. The fall in the number of beds will continue but it will be planned on the basis of common criteria over the whole territory.

To summarise, these developments sanctioned by Ségur are going to be paid for by the health workers, in the
The fight is not to preserve the public hospital but to engage in class struggle against the conditions of exploitation form of a constant pressure on working conditions and wages.

Fighting for higher wages and for better working conditions means shifting the balance of forces against the real enemy
This enemy does not come from outside the hospital, but is incarnated in the state and in the
managements of hospitals. It is therefore necessary to abandon any demand for recognition of the
social utility of caring activity which “saves human lives”. In a capitalist world the defence of “public services” has always led to more exploitation.

Health workers who go on strike lead a struggle for wages and for workers’ unity
Because a strike in a hospital is difficult to carry out and because the management try to isolate different departments which mobilise, the organisation of struggle must overcome tensions between categories of workers and exploit the fault lines in the labour process. Refusing additional hours beyond the legal limit; refusing to do work which is not in your job description; signalling every accident caused by the lack of staff, the bad way work is organised, bad equipment; refusing to work
during breaks… these are the practices that have emerged recently. To paralyse production, work
teams can make a deep investigation into the way services function and choose to act when the
balance of forces allow it.

The demand for free healthcare is also a fight for wages
Does fighting for their own interests mean forgetting the patients? Not as long as healthcare staff
forcefully put forward the demand for totally free care for all workers. It’s an objective which corresponds to nothing more nor less than fighting to defend the indirect wage and particularly the part relating to access to health care.

Everyone who works in healthcare knows that a strike in a hospital or clinic is not the same as in other places of production. A complete stoppage of work would immediately lead to worsening outcomes for sick people. Hospital managements play on this to put pressure on workers tempted by more determined strike action. Hospital bosses never stop going on about how health employees must act in the name of the general interest by looking after patients. Nice words which hardly hide the fact that when it’s a matter of improving the everyday conditions at work of hospital staff or raising their wages, hospital directors and the government suddenly go deaf, completely impermeable to the demands of the workers.

What to do then? One example comes from the overloaded intensive care service staff in some hospitals before the Covid outbreak who refused to fill out the administrative forms for patients. Without going back as far as the nurses’ strike of spring 1988, more recent strikes like that of Ormeau Clinic in Tarbes, from November 2016 to January 2017, which won better wages and working conditions, could be an inspiring example. The reason for this victory was the high number of strikers, their strong involvement in the strike and their refusal to bend to legality. Other means consist in collectively applying internal rules to the letter (work-to-rule) every day against the unbelievable pace of work. We must also involve in the struggle the “pariahs” of the hospital, the contract workers, the interns, the medical and nursing students, the components of our camp who have become real pressure adjustment valves for public health institutions.

Fighting the hospital business as a place of exploitation means abandoning illusions about the “general interest” and “public services”. This also means recognising in the state-boss an enemy of the workers. To do that it is necessary to take initiative on the terrain of class by organising ourselves collectively outside the co-management unions, against the bosses of the hospital and the hierarchy of services.

(1) Assistance publique – Hôpitaux de Paris, the state-owned hospital trust operating in Paris and whole Île-de-France region
(2) This was a process of consultation with the main players in the health system announced by the French Ministry of Health on 17 May 2020. It was carried out between 25 May and 10 July. The name comes from the location of Health Ministry on avenue de Ségur in Paris.
(3) Out of 1,173,000 who work for PHF
(4) ARS (Agence régionale de Santé – Health Regional Agency) is a state agency depending on Ministry of Health