the relevance of marxism to the current transformation of the nhs

7/29/2019 The relevance of Marxism to the current transformation of the NHS

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The relevance of Marxism to the current transformationof the NHS

Sally Ruane

Introduction

The NHS is part way through a process of radical restructuring viawhich it will become much more an organisation for thecommissioning or contracting of health provision from others with lessinvolvement in direct provision and via which many activities whichhad been transferred to the public domain 60 years ago are revertingto the commercial sphere. Despite these radical changes to aninstitution considered until the past decade to be virtually

untouchable by political parties of any hue, there is limited publiclyvoiced criticism and political resistance to these dramaticdevelopments.

This paper attempts to revisit and apply a limited number of Marxistconcepts and analyses to inquire as to how this could have happened.It is selective in both the concepts it deploys and the policy areas itcovers so at best offers only the start of a critique of current healthpolicy from a Marxist point of view. I am not well-versed in theapplication of these concepts and you are welcome to tell me whereyou think Ive gone wrong.

First the paper identifies some key policy developments of the pastdecade. It considers the conditions in which the NHS was created inthe first place and then tries to account for the historic abandonmentof Labours commitment to a socialised health system. It examineshow best to understand what capital requires of a health system andfinally how to understand the absence of effective political resistanceto this major policy shift in a policy area thought to be of significantimportance to the electorate.

The recommodification of the NHS: Marketisation andprivatisation

A wide range of activities within the NHS is now carried out on amarketised or privatised basis. These processes should bedistinguished conceptually. Processes of marketisation (the separationof purchaser from provider, the introduction of competition, financialflows to allow money to follow patients and so forth) can occurwithout the involvement of commercial or independent sectorinstitutions. (The Conservative governments internal market in the

NHS is a case in point, although technically there was someinvolvement of the commercial sector, this was very limited and this


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involvement itself did not affect in a direct way the character of theNHS as an institution although the market processes did.)Privatisation, on the other hand, should be understood as the transferof activities, personnel, assets, duties or resources from the public toeither the sphere of the private individual or to the commercial sphere.

This may or may not entail the use of market processes andprinciples.

Aneurin Bevan, Minister for Health in the post war Labourgovernment and chief architect of the NHS, asserted on severaloccasions the superiority of a public arrangement for health care. Forexample,

A free Health Service is a triumphant example of thesuperiority of collective action and public initiative applied to a

segment of society where commercial principles are seen attheir worst.(Bevan, 1952:109)

He introduced the first system of universal, socialised medicine withhealth care free at the point of use in the world. This notion ofsocialised needs some elaboration since elements of the healthservice were not publicly owned or employed although they were to alarge extent publicly controlled through funding and planning. Thus,GPs were independent contractors and not salaried as were thepurveyors of spectacles, and pharmaceutical products and most itemsof equipment continued to be produced commercially. This distinction

has become important of late since recent Labour ministers havejustified current policy of involving private business in health care asa continuation of and in keeping with the original principles of theNHS as set down in 1948. However, Bevan was clear that he viewedthe NHS as establishing the transfer of a whole segment of activityfrom private enterprise and individualism to collective goodwill, publicenterprise and public administration. This state invasion of theprivate and individualistic was, for him, the practical expression ofnothing less than the articulation of a new society. He saw continuedprivate elements as raising points of conflict of interest and envisagedthat this would be resolved over time as these private elements everdiminished (Bevan, 1952). In the meantime, hospitals werenationalised and all their staff become state employees; primary andcommunity health care services outside GP practices were stateprovided; and funding and planning responsibilities were assumed bythe state. These two areas of responsibility had a decisive impact onshaping the character of health services available to the public evenwhere some personnel remained formally independent.

Private Finance InitiativeHowever, this transfer of a whole segment of activity to the public

domain is now in reverse and it has been reversed by the very partywhich created the NHS in the first place, the Labour Party. This was


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first evident in the reversal of the Partys opposition to the privatefinance initiative (PFI) in 1995 well before coming into office. PFIentails the use of commercial companies to design, finance and buildnew hospitals (or other amenities) and to lease these back to therelevant public body over the subsequent 30 or 40 years. In addition

to this, the private companies run the new hospital in terms ofmaintenance, estates management and other services such ascleaning, catering and portering. Thousands of workers who had untilthat point been the employees of the NHS were transferred to privatesector employment where terms and conditions were notably poorer(Lister, 2003; Unison, 2003; Ruane, 2007). The Retention ofEmployment agreement with Unison in 2002 permitted, in mostcircumstances, most workers in the five trades to remain theemployees of the NHS (albeit seconded to the private companies).However, this has not altered the transfer of ownership of NHS

hospital to pass to private hands. In exchange for the use of thesebuildings and these services, it has been calculated that in Englandalone, some 90 billion of the public NHS budget will be transferredfrom the public sector into private hands over the next 40 years or sosimply to meet PFI repayment obligations (Hellowell and Pollock,2007). As a result, services offered by local health communities havebeen dramatically altered both through the opportunity costrepresented by this astonishing transfer of resources from public toprivate but also by the interpolation of a contract into the process ofpublic service provision, a contract which is used by the privateconsortium to disrupt and interfere with public priorities in health

care.

Although the Retention of Employment deal permits some groups ofworkers to remain in-house in the PFI context, elsewhere budgetaryand ideological pressures are leading some senior NHS managers tooutsource other areas of so-called support or ancillary work. Forinstance, back-office functions such as payroll have been contractedout by some NHS bodies to private companies, sometimes withdisastrous consequences for quality.

Independent Sector Treatment CentresThe Labour governments of Blair and Brown have taken the use of thecommercial sector well beyond these policies which were, admittedly,originally Tory initiatives. For the first time since 1948, Labour haveintroduced the re-commercialisation of hospital care through theestablishment of Independent Sector Treatment Centres. Thesededicated private surgical centres offer, on a fast track basis, routinerelatively uncomplicated surgery plus some diagnostic tests for NHSpatients. They are paid by the sponsoring PCTs which divert flows offunding away from the NHS hospitals which previously conductedthose operations. ISTCs have been set up even where their extra

capacity is not required for the local health community; they are paidmore per procedure than an NHS unit; are guaranteed their income


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for five years regardless of the number of patients actually treatedwhere NHS hospitals are paid on strictly payment-by-results basis.The local NHS units which previously provided these services on aplanned and continuous basis are now thrown into a relationship ofunequal competition: unequal because they are paid less and on a per

procedure basis and unequal because they continue to haveresponsibility for complex and difficult cases whilst the private ISTCcherry picks the relatively easy, straightforward and thereforecheaper patients. All of the ISTCs in the first wave were contractedto overseas based companies such as Netcare (South African) andCapio (Swedish).

MarketisationWhat the ISTC example shows are the possibilities offered by therestructuring of the NHS as an open competitive market. The Labour

government spent much of its second term in office restructuring theNHS away from being a planned integrated publicly provided serviceinto an open competitive market. Unlike, the Conservative internalmarket, Labours market is equally welcoming of voluntary sector andcommercial providers alongside traditional public NHS providers.Health care is organised a contractual basis with PCTs representingthe single payer (In fact, each PCT is the single payer for itspopulation but across England there are around 150 PCTs.) Thefinancial infrastructure of the NHS was changed during this period toallow money to follow patient payment by results in which providersare paid a nationally fixed tariff per procedure regardless of the cost to

the provider of producing the procedure. Tariffs are fixed by theDepartment of Health supposedly on the basis of national averagecosts for the relevant procedures and are revised annually. Theindividualisation of payment flows supports a policy of patient choicein which patients are encouraged to choose from a range of providersfor secondary care.

Primary CarePrimary care, too, has been identified as in need of a market shake-up. The traditional NHS GP, funded through NHS money to care forNHS patients according to NHS priorities, faces competition from bigbusiness in the form of, for example, Virgin Healthcare (launched inJanuary 2007 as part of the Virgin suite of companies partly for thispurpose) and United Health Europe (the European subsidiary ofUnited Health Group, one of the largest multinational health careproviders in the world). GP surgeries are being destabilised throughthe establishment of new health centres and polyclinics which affecttheir patch and will potentially poach their patients. Some of thesecentres and polyclinics are being tendered out to these alternativeproviders and some existing GP surgeries are also being tendered outin this way. At present, more and more of this kind of contracting out

of primary care is envisaged. Some companies expect to employ GPs,nurses and other staff as their own salaried employees; others such as


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Virgin are suggesting practice management and clerical staff willtransfer but GPs and nurses will remain independent and NHSemployed, respectively.

A similar process is occurring in other parts of primary and

community care. Primary Care Trusts have come under pressure overthe past two years to divest themselves of their providing arm (as thisarea of health care is now bizarrely described). So health visitors,community and district nurses, some professionals allied to medicineare re-positioned as arms-length community health service providers.They are still in most instances (although not in Surrey and Sussexwhere a social enterprise was created instead) employees of the NHSbut the intention is that, within a year or two, these providerscompete with other providers to offer the services covered. Whetherthe staff remain NHS employees or then transfer to a status

independent of the NHS or transfer to a private employer which in duecourse wins the contract is yet to be seen.

Hospital ManagementRecently, the government announced its intention to transfer wholeNHS hospitals over to private management when they are failing.This idea of franchise is not new and was touted by Alan Milburnwhen Secretary of State for Health and one experiment in this at theGood Hope Hospital in Birmingham roundly failed and the hospitalwas eventually taken over by a local foundation trust hospital. Thehospital currently tipped for this form of privatisation is the

Hinchingbrooke in Cambridge, coincidentally the constituency of theshadow minister for health.

CommissioningThe last illustration I want to use concerns not the provision of healthcare services but their commissioning or purchasing in the first place.In the market structures which Labour retained and thenreinvigorated and reshaped, there is a formal separation between thefunctions of purchasing/contracting for/commissioning health careon the one hand and actually providing that health care on the other.Institutionally, this is less clear cut since GPs, for instance, and PCTs,both provide heath care andcommission it from others. But theprinciple of separation is important for the functioning of the market.The commissioning function is obviously an important one not merelybecause of the implications for the effective use of resources and valuefor money but also because it has a powerful influence in shaping thesorts of health care services available to the local population. Thisincludes range and location of providers, range of services availableand patient pathways and thus has a strong impact potentially on theexperience of NHS patients and on the reality of their entitlement.Despite the repeated message from ministers and the Department of

Health over the past few years that PCTs must become primarilycommissioning and not providing organisations within the NHS (the


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justification for putting community health service providers intoarms-length organisations), the commissioning function is nowslipping out of the PCTs hands into those of large global corporations(including UHE (again), Humana and Aetna) which have beenapproved as part of the Framework for the procurement of External

Support for Commissioning. This Framework, confirmed in February2007 but not announced to the public until October 2007, providesfor PCTs to contract with one of the approved companies forassistance in their commissioning function that is they cancontract out a greater or lesser portion of their commissioningresponsibilities to global corporations which will then decide whatkind of health care NHS patients should have access to in what sort ofinstitutional set-up. End-to-end commissioning (ie contracting outthe total commissioning function) has not been ruled out. Howconflicts of interest where corporations engage both in commissioning

and in providing health care services to NHS patients are regulatedremains to be seen.

The point of these examples is to illustrate that across diverse areas ofthe NHS, health services which have to date been provided on adevalorised basis are now being commercialised. Even the planningand commissioning of services are in the process of being privatised.

How can we use Marxist insights to make sense of this step by stepspread of the application of market principles and commercialisationand the substitution of a mixed economy of health care for a

socialised one?

Labours decision to abandon a socialised health service

The first question to address perhaps is how it is possible for theLabour Party to have abandoned its commitment to a public healthservice.

Although Marx himself did not strictly have any notion of adevalorisedsector, he did allow for the possibility of concessions wonfrom the state through working class action. Engels, who witnessedthe early stages of the developing labour movements, went evenfurther in the direction of envisaging the possibility of peacefultransitions to socialism in some societies. This peaceful approach inother words the use of parliamentary and legal means to securesocialist goals was embraced by many Marxists, especially theCommunist parties, in the middle and later decades of the twentiethcentury, before but particularly following the radical reforms ofClement Atlees post-war Labour government by which the NHS wascreated.

However, the real potential of reformist parties for bringing aboutsocialism has remained a point of debate and controversy amongst


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Marxists (see the Workers Liberty website for a debate on whetherLabours reforms were real as an example), particularly those of theTrotskyist left. The Communist parties in the UK have retained theirreformist stance and continue to support Labour even at this stage asa strategic alliance. Others warn of the tendency of reformist parties to

slide into ever cosier relationships with capital and to compromise bitby bit as principles are eroded in favour of pragmatism (Bottomore,1983). Even where the parliamentary route has been extolled, it hasbeen more a counsel of expediency (Laski, 1934:213) than a point ofprinciple, an acknowledgement as much of the lack of appetite for arevolution amongst the working classes as of the potential of areforming party. Further, from a Marxist stance, reformism islegitimate only where it forms part of a coherent strategy for thetransformation of society.

Explaining in Marxist terms the decision to abandon the socialistprinciple underpinning the NHS by the same party that originallycreated it as part of a programme of radical social reform must drawto some extent on that pro and anti-reformist debate.

Some writers (Marxist and non-Marxist) have suggested that Labourhas been captured. A number of key Cabinet members over the pastdecade or so are former members of Trotskyist groups. Instead ofcapturing the Labour Party in order to pursue a socialist programme,it is suggested, they have captured it and steered it in the direction ofneo-liberalism. Monbiot (2000) and Barratt Brown (2001) are amongst

those who have succeeded in amassing a degree of empirical evidenceof a business take-over, giving rise to what they describe, respectively,as the captive state and the captive party. Barratt Brown claims theLabour Party has shifted from social democratic cooperation withbusiness to a much closer relationship evident in the restructuring ofstate activities as commercial undertakings, often making senior civilservants rich in the process. This has significantly blurred thedistinction between the public and the private spheres. This has beenmost keenly felt in the NHS in the creation of the CommercialDirectorate, a section of the Department of Health devoted to settingup contracts with commercial organisations. This directorate wascomposed of 190 staff in 2007, 182 of whom had been recruited fromthe private sector, many on a consultancy basis, and only 8 of whomwere civil servants (Player and Leys, 2008). Both former DirectorGenerals were drawn from senior posts within companies which havebenefited from lucrative contracts with NHS organisations (Amey inthe case of Texan Ken Anderson; and United Health in the case ofChanning Wheeler).

Colin Crouchs (2000) work goes some way to explaining how the closelinks between business and Labour have been able to develop by

emphasising the class base of the reformist party. He has described inhis pamphlet, Coping with Post-Democracy, how deindustrialisation


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from the 1970s has fatally weakened the industrial electoral base ofthe Labour Party (and of other broadly social democratic partieselsewhere). In order to appeal to a broader swathe of the electorate,the Party has freed itself from its dependency on the trade unions andits traditional activists and has subverted the policy-making

machinery which had previously addressed the concerns of thattraditional base. The consequent vacuum, especially after the 1987third electoral defeat, was filled rapidly by corporate lobbyists. Asdeindustrialisation has proceeded in a global context, influentialbusinesses have increasingly pursued their interests in relation to theservice sector rather than traditional manufacturing and industry. Asa result, the Labour Party and subsequently government, have comeunder very strong pressure to open up public services to corporatepenetration.

Despite its publication in a Fabian pamphlet, this seems asconvincing a Marxist explanation of Labours about-turn on health asany although, despite the endeavours of Monbiot and Barratt Brown,the empirical evidence for corporate influence on social policy remainspatchy and under-researched (see Farnsworth, 2004). A Gramscianexplanation of Labours general shift in political position is presentedlater in the paper.

Going back to the beginning

The question is asked can we afford it? Supposing the

answer is No, what does this mean? It really means that thesum total of the goods produced and the services renderedby the people of this country is not sufficient to provide forall our people at all times, in sickness, in health, in youthand in age, the very modest standard of life that isrepresented [in this bill]. I cannot believe that our nationalproductivity is so slow, that our willingness to work is sofeeble or that we can submit to the world that the masses ofour people must be condemned to penury.Clement Atlee, 1944, cited by Hennessy, 1993:119

Broadly, there are two Marxist conceptions of the state. The firstadheres to and adapts the assertion of Marx and in the CommunistParty Manifesto (1847/8) that the executive of the modern state is buta committee for managing the common affairs of the wholebourgeoisie. Here the state is an instrument of the capitalist class asa whole and a myriad of networks and social connections sustainsocial relationships between capitalists and members of the politicalclass and state bureaucracy (e.g. Miliband, 1968). The second is aconception of the state as to some degree autonomous either on atemporary basis for instance where the state at certain high points of

class conflict acts as a mediator when neither the capitalist nor theworking class is strong enough to influence it or on a more


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continuous basis since, it is argued, it tends to support policies whichserve the interests of the capitalist class but can and sometimes doessupport policies which are contrary to those interests either becauseof effective pressure from the working class or in an attempt to headoff more radical demands by the working class by offering

concessions. This idea has been particularly developed by Poulantzas(1973). Here, the state serves the long term interests of capital butmay act against the shorter term interests of some elements of capital.

There is something unconvincing about these conceptions which areat odds with the notion that transition can come about peacefully inrelation to the post-war radical Labour government. This acted verymuch in the interests of creating institutions and processes ofredistribution which served the interests of the working class despitethe economic hardship of the time. It is not that Labour sought

entirely to overthrow capitalism in 1945, it did not, but that its focuswas on addressing the need of the mass of the population. It is truethat this was possible partly because of the weakness of capital at thetime.

When the NHS was created in the immediate post-war period, thesignificance of pressure from below has been emphasised. PeterHennessy (1993), author of one of the best historical accounts in printof that period, identifies the importance of shared experiences forforging a community spirit a spirit of hope and purpose. Not onlydid people from vastly different backgrounds gain an insight most

notably through evacuation - into and understanding of each otherslives, living conditions and life chances but they also shared theexperience of hardship and sacrifice in the interests of the commonendeavour. Derek Fraser points out that the war produced a commonexperience and universal treatment. He continues:

almost by way of aquid pro quothe nation acceptedlimitless sacrifices in the war effort in return for an impliedpromise of a more enlightened, more open post-war society.The nearer to a total war, the greater tends to be the degreeof social equality involved and so the Second World Wartended to reduce social distinctions. This flowed from thecharacter of the war as perhaps the first peoples war,wholly dependent on the efforts and support of the wholepopulation (Fraser, 1984:208).

The combination of shared experience and orientation towards acommon purpose was critical in the development of classconsciousness - the conviction that the society created after the warhad to be a radically different one from that which preceded it, that ithad to be a society which put its resources at the disposal of all to

meet the needs of all. In combination with this were the widely readproposals of Beveridge (1942) , the developing expertise of Labour


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ministers in the Cabinet and the practical experience of runningservices effectively on a planned and centralised basis by the stateconsidered essential to the organisation of the Home Front. Thesefactors contributed to a belief that society could and should beradically re-designed. This is the high point in class consciousness in

this country.

It is a class consciousness developed not entirely vis-a-vis the materialconditions of capitalist exploitation, although the experience ofcapitalist exploitation had radicalised many of the leaders such as NyeBevan and was the foundation of the institutions of the working class,principally the trade unions and Labour Party, through which socialchange would be organised. But the popular consciousness of 1945was forged in the context of unity in the face of a common enemy notcapital but Nazism. It was a consciousness orientated towards the

common good, orientated in fact towards philanthropy.

What gets relatively little mention in these accounts (e.g. Fraser, 1984;Gladstone, 1999; Webster, 2002) of this period (including Hennessysdespite its vast array of sources and attention to detail) is the role ofcapital. True, Whiteside (1999) does refer to the support for theabolition of the approved society system by the Association ofApproved Societies and opposition to it by the National Confederationof Friendly Societies and, yes, the Tories who could be considered thepolitical spokesmen for capital, opposed the 1946 NHS bill. On thewhole, though, the reader is struck by the absence of the capitalist

class or at least its relative silence and marginality in the process bothof welfare state construction and to a slightly lesser extent ofnationalisation. (There wasopposition to nationalisation of the steelindustry.) It is hard to believe that this is simply an oversight by thehistorians. Even accepting the ambivalent and underdevelopedapproach to nationalisation, it seems absurd to describe the post-warAtlee government as a committee (or part of a committee since Marxand Engels used this phrase in relation to the state as a whole) formanaging the affairs of the bourgeoisie or as part of a state apparatusreluctantly conceding reforms to the working class or engineeringnationalisation and costly state welfare structures when resourceswere scarce as the best way to facilitate accumulation for thecapitalist class. The amount of social and economic activity taken outof the hands of capitalists through nationalisation and the massiveredistribution of resources consequent upon the foundation of thewelfare state address labour not capitalist concerns.

Instead, it is more likely that the capitalist class of the time wasindeed less powerful and organised than it has since become. TheBritish based capitalist class had been severely disrupted by first therecession of the 1930s and then the war in which resources were

commandeered by the state for the war effort not for privateshareholders. Moreover, in the context of an industrial society, the for-


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profit sector in health care and social care was extremely small.Access to any hospital services was very circumscribed for themajority of the population with only a tiny market for privatehospitals, mad houses and private care homes. The service sectorrelated to social needs was itself very small during this period. As a

result, capitalist impact on social policy in the 1945-50 period appearsto have been limited, largely unrecorded and under-researched.

The resurgence of capital shaping Labours policy on health

The need of a constantly expanding market for its productschases the bourgeoisie over the whole surface of the globe. Itmust nestle everywhere, settle everywhere, establish

connections everywhere (Marx and Engels (1847/8)Manifesto of the Communist Party).

Once Labour ceded the principle of a socialised health service, theusual tendencies of capitalism come into play. A century and a halfago, Marx and Engels envisaged an industrial bourgeoisie striding theglobe subverting all relations in favour of brutal exploitation. Feudal,patriarchal and idyllic relations, unchartered freedoms, chivalrousenthusiasm, philistine sentimentalism, family relations andpersonal worth were all swept away to leave remaining no othernexus between man and man than naked self-interest, than callous

cash payment. In one word, for exploitation veiled by religious andpolitical illusions, it has substituted naked, shameless, direct, brutalexploitation (Manifesto).

The character of the relations institutionalised in the NHS in 1948was a long way from this cash nexus reductionism. On the contrary,the NHS eschewed financial payments and removed entirely the cashrelationship from access to health care. Although relationshipsbetween professionals and patients remained unequal, they werecomplex since they were overlaid by the fact of equality throughshared citizenship which itself was the basis of access). Entitlementwas not merely individual but collective: the entitlement of theindividual was intimately bound up with the entitlement of all others.

However, this institutionalisation of altruism (Hennessy, 1993: 132) isbeing eroded. Current policies not only reintroduce the profit motiveand re-commodify health care work but also but also undermine thecollectivist ethos of the service through emphasising notions ofindividual choice and personalisation. These policies tackle not onlycollectivist structures but also the collectivist ideology which hassurrounded the NHS, about which more below.


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The NHS represented a triumph of British working class action tochange its own society. Capital has regrouped, however. The drive toreplace all other relations with the simple relation of the cashpayment continues. In other words, the drive of the bourgeoisie toconvert all activities into opportunities for capital accumulation

continues. It is now better placed to do so. It has developed strongstructures and processes in the US where, unlike most otherdeveloped societies, health care is run on a market basis. In 2007, theU.S. spent an estimated US$2.26 trillion on health care, or $7,439 perperson and has facilitated the concentration of a huge mass of wealth.For example, individual companies are enormous United HealthGroup (UHG), for instance, has the largest net sales in health careinsurance achieves record net earnings in excess of $12 billionannually, according to its Annual Reports. This sector of capital hasdeveloped strong lobbying skills and close relationships with

legislators and other policy makers. It has organised itself to developsimilar links in the EU setting, particularly through the TransAtlanticBusiness Dialogue (TABD) which, for example, has organisedconferences to stimulate innovation and has redesigned the way itworks in recent years to create a more conducive environment toadvance transatlantic economic relations(http://www.whitehouse.gov/news/releases/2003/06/20030625-7.html) .Commercial health care organisations have consolidated a substantialpresence in the private UK health care market where the charitablestatus of independent hospitals has been progressively eroded infavour of commercial ownership over the past twenty or thirty years

(Higgins, 1988;http://www.privatehealth.co.uk/private-hospitals/hospitaltreatment-companies). It has helped develop (throughlobbying) and used the new trading infrastructure which has emergedover the past 15 or 20 years, particularly the World TradeOrganisation and the enlarged EU. It has succeeded in breaking intothe EU health care market, evident for instance in UHGs Europeansubsidiary (UHE).Although the process of recommodification has been under way acrossthe welfare state since the 1980s, it has reached the NHS only underLabour. Capital is penetrating the public sector both throughundertaking contracts to provide services, through the transfer ofassets out of public hands and increasingly through service planningdecisions. But it should be noted that the transfer of assets representsnot a concentration of wealth typically associated with advancingcapitalism but a dispersal of wealth which had previously beenconcentrated in public hands. Of course, once relocated to the privatesphere, that wealth will be subject to the same processes affectingother stocks of wealth in that sector particularly a tendency toconcentrate where unregulated. Similarly, the NHS represented (andstill does to a reducing extent) a concentration of the means of

production and the contracting out of services represents a process ofdispersal.


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What does capital want from the health service?

Our first premise is that the capitalist state must try to

fulfil two basic and often mutually contradictory functions accumulationand legitimization. This means that the statemust try to maintain or create the conditions in whichprofitable capital accumulation is possible. However, thestate also must try to maintain or create the conditions forsocial harmony (OConnor, 2002:6, emphasis in theoriginal).

Saville (1957) differed from Marxists who believed that the welfarestate arose either from concessions by the state to pre-empt more

radical demands or from working class struggle. He claimed that thecreation of the welfare state was due to a combinationof three factors.First were the economic and social needs of a complex industrialsociety. Second was class struggle or pressure from the workingclasses for social change. Third came the calculations of the capitalistclass in terms of what concessions were needed to maintain overallconditions for continued capital accumulation. I have referred alreadyto the second and third of these.

It is difficult to make a case for the notion that the social andeconomic requirements of advanced post-industrial societies either

require or preclude the provision of free and universal health care.Whether a capitalist society is deemed to need universal health caredepends entirely upon the model of development it is pursuing andthe sorts of popular pressures for services which need to be addressedfor the overall conditions of accumulation to be fulfilled. In otherwords, it is difficult to separate a technical assessment of objectivesocial and economic needs without at the same time assessingpolitical pressures and expectations. This includes both the ways inwhich needs and wants are construed and the organisational cloutof those demanding that they be responded to. From a functionalistpoint of view, some health care or at least public health measures areessential for the efficient performance of the workforce in acompetitive global context. This is therefore potentially a cost tocapital given capitals need to secure the reproduction of labourpower. Capital benefits enormously from the socialisation of thesecosts especially where the public funds for this health care are derivedfrom sources other than business itself and where health care isconfined to the kinds of care needed by employers. Although this isnot easy to define, it certainly does not imply the sort of socialisedhealth service we have had in the UK until the past decade or so. It isconceivable that lower levels of entitlement would suffice, that

inequality of access could predominate and that funding and provisioncould come from a mix of sources. The experiences of other European


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states and even the US (which has never had a universal healthsystem) confirm this. We should also note that a significant proportionof health spending is devoted to meeting the needs of the oldermembers of an ageing population that is, those who are,economistically speaking, no longer productive.

The sort of health service we have had has neverbeen a requirementstrictly speaking of an advanced and complex economy such as ours.It has far exceeded what could be described as necessary and itexceeded it because of the collective public pressures for social changein 1945. In other words, we got the health service we did because ofpopular pressure in a context of a weak capitalist class and a statewhose institutions had been taken over by a radical democraticsocialist party whose raison detre was the restructuring of society inthe interests of the working class. (And weve kept it until recently

partly because of popular resistance to changing it and the willingnessof leaders within the labour movement to articulate and act on thisresistance.) The Labour government of 1945 did not create the NHS inorder to legitimise capitalism but as one element in socialtransformation.

It is useful to take up James OConnors typology here. OConnor(1973/2002) suggests there are two types of state expenditure inmodern capitalist societies which principally relate to two necessaryfunctions the state must perform. One is social capital expenditurewhich facilitates accumulation; the other is social expenses

expenditure which fulfils the states legitimization function. OConnorsuggests the latter does not even indirectly facilitate accumulation butserves to keep social peace. I have already said that I do not believethe Labour governments policies of 1945-50 were motivated to keepthe peace but to transform society. However, as this socialtransformation imperative has been lost by later Labour governments(and was never shared by Conservative ones), OConnors approachhas some value.

There are two types of social capital expenditure which indirectlyexpand surplus value. Social consumption expenditure which, forOConnor (writing in a US context), includes medical and healthinsurance and hospital and medical facilities (2002:124) constitutesa socialisation of the costs of variable capital (the costs of reproducinglabour power) and tends to lower the level of money wages and, ceterisparibus, raise the rate of profit in the monopoly sector. The other typeof social capital expenditure is social investment and, in the humancapital part of this, OConnor does not include health care. This refersto investment in the growth of the productive forces (including labourpower and labour skills) and includes projects and services whichincrease the productivity of a given amount of labour power and,

ceteris paribus, increase the rate of profit.


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The analysis here suggests the contribution to reducing the costs ofreproducing labour power is a small element in the function of theNHS and instead its scope and relative generosity have persisted overtime mainly for legitimization rather than accumulation purposes. Infact, OConnor acknowledges that nearly every kind of state

expenditure to some extent fulfils both functions and has a two-foldcharacter rendering unambiguous classification difficult. However, themain purpose (function) of the expenditure can be identified bydiscerning the political-economic forces served.

The question is whether we can use OConnors typology of stateexpenditure in the context of a welfare service being turned over tocapital penetration. For, there is another dimension to therelationship between capitalism and the health system. From thestrengthened capitalist point of view, the health sector is viewed for its

potential for generating opportunities for the accumulation of capitalnot indirectly butdirectlyand in that sense is no different from anyother sector. This was not the case in 1945 but it is so now that thehealth and social care commercial sectors are so much more highlydeveloped in global terms. About 100 billion of public money is beingspent on the NHS this year and it is expected to increase by slightlymore than the rate of inflation over the next few years. This is a vastsum of money, an increasing proportion of which is to be madeaccessible to private companies for the purpose of capitalaccumulation. The Labour government has responded to the criticismof Bacon and Eltis (1978) and others from the right that state welfare

crowds out the private investment necessary for continued economicgrowth.

Generally, the pressure to open up the health service to capitalpenetration has come from transnational health corporations and notfrom the traditional UK private health sector. Because of the creationand dominance of the NHS, the private health care sector in the UKhas been small and under-developed relative to that in other advancedcountries. As a rapidly expanding pool of public money has been madeavailable to commercial providers of health care over the past decade(and especially the last 6 years), the UK private health sector hasbenefited to only a limited extent (eg through the GeneralSupplementary contracts) and generally has failed to expand andadapt fast enough to take advantage of this. This has created furtherspace for global or at least transnational commercial providers ofhealth care. In fact, the health service has not passed and will notpass through a phase of national privatisation at all: it has beenexposed directly to global capital both in the PFI which involves thetransfer of NHS assets to the private sector and in the privatisation ofprimary and secondary care.

In the case of contracting to provide services, capital has been able tosecure for itself a share of the national income and is working to


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expand this. Some major global corporations have responded rapidlyto evolving Labour health policy. There are gains to be made throughthe provision of health services but the amount of contracted outprovision has been modest to date (for example about 7 billion hasbeen set aside since 2003 for the provision of routine surgery and

diagnostics in independent sector treatment centres). On a muchmore significant scale, the provision of assets through PFI hasestablished an enormous and long-term public debt to the privatesector as mentioned earlier. In addition to this, the really big money isavailable through the commissioning policy. Not only does this put atheoretical 80 billion up for grabs, it allows those firms approvedunder the Framework for the procurement of External Support forCommissioning to shape the sorts of services available to patients the range of services, patient pathways, character of providers and soforth. In short this policy allows for the gradual restructuring of health

services along lines conducive to capitalist involvement and capitalaccumulation. Moreover, the single-payer system reduces the cost tocapital of billing (though in practice these companies are highly skilledat passing on to the state other transaction costs such as thoseassociated with negotiating contracts).

Despite its dramatically different character as a health system, it isthe American model which is tipped most to influence this process(e.g. Pollock, 2004). Its institutions have been positively evaluated bygovernment advisors (e.g. Professor Chris Ham), NHS bodies aredrawing heavily on US research or research in the US setting (for

instance, in relation to the transfer of services out of hospital and intothe community) and it is American companies whose presence is mostfelt in the external support for commissioning process.

OConnors work does suggest a way of thinking about this use ofstate expenditure to facilitate accumulation directly and we considerthis in the next section.

The publics response: the NHS as a terrain of conflict

The question is why the public have been prepared to go along withLabours policy of recommodification of the NHS and this raises theissue of class consciousness. There hasbeen some resistance to itamong trade unions and campaigners defending local health servicesand there have been efforts to develop a network of pro-NHScampaigners (e.g. Keep Our NHS Public and Community HospitalsActing Nationally Together) (Pollock, 2004; Ruane, 2000; 2004; 2007).But overall, resistance has been weak and disorganised. How can thisbe explained in Marxist terms? I shall start by considering elements ofresistance and then turn o the question of acquiescence in the next

section.


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We could return to OConnor here for some insight. OConnor arguesthat state expenditure is surrounded by intense lobbying by specialinterests a wide range of business interests keen to shape budgetand state expenditure decisions in ways conducive to their businessinterests. OConnor describes this as the private appropriation of

state power for particularistic ends (2002:9). At the same time,organised labour continues to make claims. Few of these claims arecoordinated by the market, he says, but instead are processed by thepolitical system and are resolved on the basis of political struggle. Itmay be possible to consider the NHS today in this vein: as a sphere ofpolitical contest and conflict in a way it wasnt even a decade ago(largely because, before the Blair administration, businessesconsidered the NHS off-limits). The way this is manifested in practiceis through local battles being fought out across England over thephysical reconfiguration of services and new patterns of expenditure

and new patters of service delivery.

OConnor suggests that the claims of business interests, associatedlobbying and expenditure and policy decisions which favour themmust be either legitimized or mystified. We can see this in tworespects in current health policy. One is in the presentation of policiesat a national level which are couched in the language of legitimization.The other is in the character of local health battles. In the latter, atthis comparatively early stage, the public may not be aware of theparticipation of business and the relationships they are fostering anddeveloping with local health decision makers. In Leicester where I live,

for instance, there was little public information about the impendingcontract between the hospital trust and the Birkdale Clinic to contractout some orthopaedic surgery; but instead this became publicknowledge only after the contract was signed. Although the swiftsuspension of that contract on what appear to be quality groundsafter, Im told, four short weeks was made public, little informationhas been disclosed since then concerning how this situation arose.Another example of the low profile of business in terms of localawareness comes from another East Midlands town where a pensionerreported attending the public meeting of the PCT board and decidedon whim to ask the other two members of the public present who theywere and was flabbergasted to discover they were from Humanaobserving proceedings. No information about the potential role ofHumana in local health care had been in the public domain at thatstage. (Humana is a large US-based corporation which has beenapproved by the department of Health to assist PCTs with theircommissioning responsibilities.)

Reconfiguration of services, including the transfer of services out ofhospitals into the community and the establishment of polyclinicswhich poach patients from existing GP practices, create opportunities

for private sector involvement but these policies are not presented inthese terms. A 2007 Q&A document found on a PCT website identified


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that part of the review of community hospitals in the county wouldinclude exploring the possibility of new models of ownership. Thisissue, however, has not found its way into any of the later publicinvolvement documents Ive seen so far and indeed this is notparticularly surprising as, despite its fundamental nature, models of

ownership is not seen as a public involvement and consultationmatter.

There are many factors shaping reconfiguration policies and eachproposed reconfiguration needs to be examined individually. However,apart from locality-specific factors, similar arguments are found indifferent reconfiguration documents (demographic changes, newpatterns of morbidity, ability to manage chronic conditions betteroutside hospital, the implications of the European Working TimeDirective and so forth). However, Boyle and Steer (2008) point out that

many of the reconfigurations are driven by cost considerations whereclinical issues are often finely balanced. The fact that health servicesrestructured into different sorts of institutions also createsopportunities for business (its much easier to own and run apolyclinic than a general hospital) is not mentioned. In fact, some ofthe reconfiguration proposals put forward, for example in Coventryand Warwickshire, arguably are themselves in part the outcome ofprevious privatisation policies such as a new PFI hospital development(which in this case costs the local health community more than 1mper week and has been followed by a controversial downsizing of otherhospital provision in the county Boyle and Steer (2008), who have

acted as expert advisors to local authority health overview andscrutiny committees on a number of reconfiguration proposals,identify various ways in which information is not properly presentedto the public (or not presented at all) and even suggest that publicconsultation may be a sham.

These consultation exercises themselves become a means throughwhich what is really happening is disguised the appearance is ofpublic involvement and public consent; the reality is of publicimpotence and the recent change in legal provision for challenginghealth service decisions locally illustrates this.

This obfuscation occurs nationally as well where all health policies arepresented as good for the patient. Even at the most basic level of cost ie the use to which resources are put and the associated opportunitycost the Department of Health has not been transparent. It isastonishing that we have no publicly available figures regarding thetransaction and overhead costs of running the NHS on market lineswith the associated contracting processes and handling of payment byresults. We do get glimpses of the high costs of negotiating contractswith the private sector. For instance, when the proposed hospital PFI

scheme for Leicester was abandoned last summer as the costs hadspiralled out of control (by that stage they stood at over 700m), the


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Trust admitted that it had spent 22m of local NHS funds on theprocess of negotiating alone. Bizarrely, even the Wanless Review of2008 ostensibly into funding and performance (Wanless et al, 2007),made no calculation as to the total bureaucratic costs of restructuringand then running the health service as a market. So we do not know

precisely what proportion of the NHS budget is not available forpatient care because it has been redirected into the additional costs ofoperating and managing a market. This is significant because of thecomparatively (in international terms) very low proportion of spendingon NHS administration before market systems came to be introducedand the rational character of this. There are other examples ofmystification and obfuscation also, including around the policy ofindependent sector treatment centres (e.g. see Player and Leys, 2008;Ruane, 2008).

So perhaps we should see the NHS now as a zone of conflict in whichpopular, professional, managerial and business interests struggle overthe direction of policy in different locales but where business interestsare rapidly ascendant and where the public doesnt necessarily knowit is in a conflict of this kind. OConnor points out that these conflictscan result in duplication, waste and policies which cancel one anotherout or are mutually contradictory in other ways. This is surely thecase in the NHS where resources are invested not in healthcare itselfbut in creating and sustaining a market per se.

The public response: acquiescence

..[0]ne becomes aware that ones own corporate interests, inthe present and future development, transcend thecorporate limits of the merely economic group, and mustbecome the interests of other subordinated groups. This isthe most purely political phase, and marks the decisivepassage from the structure to the sphere of the complexsuperstructures.until a single combination of [ideologies]tends to prevail, to gain the upper hand, to propagate itselfover the whole social area, bringing about not only a unisonof political and economic aims, but also intellectual andmoral unity, posing all the questions around which thestruggle rages not on a corporate but on a universal plane,and thus creating the hegemony of a fundamental socialgroup over a series of subordinate groups.

A further questionis whether fundamental historicalcrises are directly determined by economic crisesIt may benoted that immediate economic crises of themselves do notproduce fundamental historical events; they can simply

create a terrain more favourable to the dissemination ofcertain modes of thought, and certain ways of posing and


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resolving questions. Gramsci (1932-34) Selections fromPrison Notebooks Notebook number 13; paragraph 17 (inHoare and Nowell-Smith, 1971)

However, the discussion so far has examined some of the difficulties of

obfuscation and mystification where resistance is mounted and thisdoes not give full due to the general acquiescence to governmentpolicy. I have referred to the spirit of hope and purpose which wasdecisive in creating the radical policies of the 1940s. From theperspective of the Marxist who believes a peaceful transition tosocialism is possible, this should be perceived as the high point ofclass consciousness, understood as the perception of common plightand common identity accompanied by concerted action to create anduse the necessary institutions for self-emancipation. Awareness of thelives of others contributed to a sense of common interest and common

purpose. People interacted in ways and contexts which conferred asense of shared identity. People were able to relate to each other asfamiliars rather than strangers. Both efforts and costs were sharedand everyones lives were affected profoundly by common experience.By the end of the war, Britain was a highly self-confident nation. Bythis stage, the working class had created its institutions its politicalparty and trade unions; now it expected those institutions to createthe infrastructure through which societys resources would be put atthe disposal of all and a new society created.

The ideas of Gramsci (1971; Davidson, 1977; McLellan, 1998) are

useful here. We find a civil society, already fairly strong, whichdevelops rapidly during the period of the war and its immediateaftermath. Existing organisations within civil society werestrengthened and reinvigorated; new institutions especially at thelocal community level developed on an ad hocbasis in response toneeds and necessary tasks as they presented themselves. Civil societywas characterised by diversity and multiplicity, creativity andcooperation, but always orientated towards a common purpose. Thiscommon purpose might be served through local action for local needsbut always in relation to an overarching societal purpose. People onaverage were four times less well off than we are now andconsumerism was absent from popular culture. The civil societyinstitutions interacted with, shaped and were shaped by politicalinstitutions. Moreover, circulating in these institutions of civil society whether they were large or small, local or national, permanent orimprovised was not only the lived experience of economic crisis andits aftermath but also a steady accumulation of ideas about a differentsocial order. The Beveridge Report, for instance, sold 635,000 copiesand later when Labour were in power, its Party and associatedmembership (that of affiliated trade unions) was substantial andconstituted a mass movement with the development of services

characterised by local engagement and debate.


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In relation to social revolution, Gramsci emphasised the importance ofdeveloping an alternative set of ideas in diverse institutions of civilsociety. These ideas formed part of a counter-hegemonic project tochallenge the dominant and received wisdom. Gramsci argued againsteconomism and the notion that social change would come about

following an upsurge of revolutionary consciousness at the time of theinevitable economic crisis. Instead, Gramsci emphasised thesuperstructural and argued that history had to be made through theagency of political actors. Moreover, these actors needed to develop anideology which went beyond the economic and corporate to a higherplane, Gramsci believed that in relatively stable states in WesternEurope, the dominant interests were safeguarded not only by force orthe threat of force but also by dominant ideas diffused through civilsociety which could appear as common sense. For social revolution,these ideas had first to be challenged in the institutions of civil

society. Gramsci conceived of civil society in Western Europe as apowerful system of fortresses and earthworks behind the outer ditchof the state. The state could not be taken by a new dominant classwithout addressing civil societys fortresses and earthworks througheither a war of movement or manoeuvre (in which artillery could openup sudden gaps in defences and troops be rapidly switched from onepoint to another to storm through and capture fortresses) or a war ofposition (in which enemies were well balanced and had to settle downto long periods of trench warfare) (McLellan, 1998:207).

What we find in Britain at the end of the war is a burgeoning civil

society through which circulated very clear and practical ideas abouthow society should be changed. During the second world war, the setof dominant values and ideas altered. What had been a set of ideasjustifying the social arrangements of the 1930s (widespread poverty;high levels of unemployment; inequality; poor collective provision)gave way to an alternative set of ideas which justified collective actionthrough the state both to run key elements of the economy (in boththe productive and the finance sectors) and to organise generoussocial provision. The thinkable and the do-able shifted; there was anew common sense. Participation in the war, taking responsibility in ithad the effect of empowering the people. They became more skilled,more knowledgeable, more organised, maybe even more independent.Participation in the war empowered and transformed civil society vis avis the state and as a result it became easier to take control of thestate. This was always an interactive relationship between theinstitutions of civil society and those of the labour movement, eachacting upon and shaping the other. The peoples war was in fact awar of manoeuvre. The new dominant ideas attracted a reasonabledegree of consensus and certainly by 1951, the Conservativegovernment left more or less intact the dramatic changes instituted bythe preceding Labour governments.


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But what have we now? We have in some respects virtually theopposite of this. We do have flourishing institutions of civil society butthese are largely unshaped by the institutions of the labourmovement. Although many are altruistically orientated towardsassisting vulnerable members of the community or to contributing to

some local collective effort, the orientation of many is highlyindividualistic, often of a lifestyle character, relating to the worldthrough consumerism on behalf of self and family. Divisions aboundwith worsening levels of inequality fuelled by a regressive tax system.Spatial segregation predominates in housing and this has someimpact on segregation in schools and other amenities. Differencesbetween the in-country population and new arrivals, be they migrantworkers or asylum seekers are accentuated by politicians amongothers.

Andrew Pearmain (2006) has summarised the Gramscian analysisapplied by Stuart Hall and others to the collapse of the postwarideological and institutional settlement:

Stuart Hall and other prominent Gramscians have argued aconsistent and (I find) compelling narrative. The post-warsocial democratic consensus of Keynesian economics andwelfare statism was broken in Britain in the 1970s, becausethe trade-off between capitalism and the welfare state wasno longer sustainable. Thatcherism set about its dynamic,destructive/creative project of regressive modernization,

producing an entirely different political and economic, andabove all ideological climate. This culminated in thedomination of neo-liberal capitalism and its associatedpolitico-ethical framework in Britain and much of the restof the world.

Along the way, national-popular support was won for awhole range of measures, which would have previously beenanathema, such as the sale of council housing, privatizationof utilities, cutbacks in public services and benefits, andlimitations on trades union power. This approach has beencharacterized as authoritarian populism. Certain keyevents served as intimidatory/educative jolts (recallingGramscis pivotal couplet of coercion/consent) to publicfeeling, like the Falklands War and the 1984 miners strike,or the late-80s big bang of financial deregulation.Fundamental shifts took place in our social ethos - from thecollective to the individual, from the public to the private,from society to family, from we to I, from production toconsumption and congealed into a new, all-embracing andalmost incontrovertible (i.e. hegemonic) common sense.


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New Labour explicitly accepted this new settlement, and setitself the task of reshaping the people to suit the needs ofthe new global market economy, thus inverting the logic oforthodox social democracy.

This implicitly defines the moment of Labours reversal of position asin the years prior to assuming office.

The NHS has not escaped this trend towards individualisation. Whatwe find in health policy is not a denial of the central importance ofhealth services in peoples lives (and expenditure on the NHS hasincreased markedly from the end of Labours first term) but anattempt to reshape the relationship between the public and the NHS.The collectivist and institutional character of the NHS has beencriticised by ministers on a sustained basis in recent years as

monolithic and one-size-fits-all whilst, by contrast, patients are nowencouraged to expect a personalised service characterised by elementsof individual choice. This move to personalisation and choice has noton the whole come from patients and public but is largely a contrivedand top-down initiative, started by Alan Milburn and furtherdeveloped under John Reid and subsequent secretaries of state. Theexpressed wish of patients to spend longer with GPs to discussdifferent treatment options is not the model of choice being developedby government; instead patients are encouraged to select a providerfrom a menu of different providers in a supermarket model of patientchoice. Moreover, patients are encouraged to connect this

personalisation in the receipt of health services to the exercise ofconsumerist individual choice elsewhere in their lives. This attempt tofoster not only a consumerist discourse but also a consumeristrelationship between the patient and the service forms part of anideological attempt to re-form, in the mind of the patient, health careas a commodity. This can be seen as an essential component in theLabour leaderships attempt to break the ideological and emotionalbond between citizen and service and thereby to remove obstacles tofurther commodification. Reconfiguration of services contributes tothe effort to weaken this bond since attachment to the NHS is to someextent attachment to specific institutions ones local hospital, thelocal cottage hospital, even ones GP surgery (though that might bemore related to the person of the GP than to the premises themselves).

Looking at it from a Gramscian point of view, the supplanting of aconsumer model of public services in place of a citizenship one ishighly significant. Catherine Needham (2003) has examined how atransformation occurs in the articulation of the relationship of theindividual to the state. The individual ceases to be a citizen engaged inan ongoing relationship to the state in which considerations for thepresent and future needs of other citizens were paramount but now

becomes a consumer engaged in short-term, self-interested exchangeswith different agencies in which the individuals wants and


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preferences are paramount. Thus, consumerism goes beyondeconomic relations to infuse meaning throughout society moregenerally and forms part of an ideological bulwark against effectivechallenges to the governments health policies generally.

It is worth thinking about the institutional underpinning of this,especially the difficulties of organising and acting effectively in acontext of a highly disparate working class and of a well resourcedand well organised state and capitalist class. Offe and Wiesenthal(1980) identify the diversity of workers as a key impediment tocollective action particularly in terms of developing effectiveinstitutions. They argue that the institutions of capital and of thestate function more effectively on a hierarchical basis but that thisstructure is ill-suited to popular collectivism which requires anongoing dialogue between grassroots members and the leadership.

What is striking about the efforts to resist Labours rightward progressgenerally and not just in health is the absence of an institutionalframework in which a defence can be mounted and new ideas aboutpolicy alternatives generated. In the past, trade unions and politicalparty served this purpose but they do not do so now and thesetraditional institutions of the working class have been declining.

The trade unions mounted a modest and short-lived campaign againstprivatisation in 2001 but stood down after the events of September11th on the grounds that the media were preoccupied with whatbecame the war on terror. NHS Together was formed in 2006 bringing

together for the first time all the trade unions and associations in thehealth sector. It mounted one parliamentary lobby and one half-hearted national demonstration (of only 5,000 people!) and seems tohave collapsed virtually without trace.

More generally, trade unions are weak with little more than half theirmembership at their peak. We dont have the industrial trade unionsof old - or at least these are far less significant within the trade unionmovement as whole. Instead we have more service sector unions withan overwhelming preponderance of public sector members. These donot face the harshness of the capitalist worker relation to sharpentheir senses and their actions. Moreover, any industrial action, sinceit affects immediately a more or less vulnerable client group and thevery members of the public whose support they need to legitimisetheir action, is at best morally ambiguous. In addition to this, theretention in the UK of anti-trade union legislation along with variousopt-out from EU wide protection of workers rights prohibit the lawfulstaging of virtually any solidarity action. Lawful action involving thewithdrawing of labour eats into the limited resources of the tradeunions and unlawful action risks on top of this the sequestration ofassets. The state by contrast can spend hundreds of millions defeating

trade unionists if it so wishes.


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Party membership has declined across all the major parties andLabours rupture of the link between the motion passed at the localconstituency party and the policy ultimately adopted by the Partyleadership may have contributed to this. Engagement with formalpolitics is in decline and explanations draw variously on a range of

possible causes: the absence of real differences between the mainparties; the remoteness of politicians from the lives of ordinary people;ever more scientific approaches to electioneering so that smallpopulation categories are targeted instead of electoral approaches thatseek to persuade all voters; the treatment of policies as products to bemarketed; and excessive use of spin undermining confidence inpoliticians honesty (see, for instance, Todd and Taylor, 2004; McHughand Parvin, 2005).

Outside both trade union and political party, citizens and NHS

patients have attempted to organise independently. A myriad of localcampaigning groups have emerged set up to defend local healthservices under threat. These campaigns have varied enormously intheir size and capacity (although there is no systematic research onthem to date). There have been moves to draw this together intocampaigning networks (e.g. Keep our NHS Public) but theireffectiveness has been patchy. It is true that the full swathe ofreconfigurations predicted by the Chief Executive of the NHS inOctober 2006 to affect 60 hospitals has not yet occurred and thenumber of closures of hospital departments such as A&E has beenmore modest (and is unlikely to grow much before the next general

election). On the other hand, the Department of Healths strategy ofusing clinicians (most notably the heart surgeon, Sir Ara Darzi) topersuade the public that the reconfiguration of local services is intheir interests has developed significantly over the past 18 months orso and has focused on the vaguer concept of transferring services outof hospital into the community (rather than the stark proposal to closea particular hospital department).

Notably, the vast majority of the parliamentary party and trade unionleadership have acquiesced to the policies and direction of the Labourleadership. It is an extraordinary thing that despite the dramaticoverhaul of the health service, not a single Labour backbencher canbe found who will consistently articulate on public platforms andnational media the anti-privatisation case. The relationship betweenpopular Save our NHS type campaign groups and the trade unionshas been faltering and problematic. This is a crucial factor in thedemise of the NHS: were a Conservative government to attempt thesepolicies of privatisation and marketisation, they would face the moreor less united wrath and political action of the labour movement.When it is the political leadership of the labour movement itself whichpursues these policies, opposition is halting, compromised and

divided. Whats more, Labours leadership has itself been informed byMarxist analyses.


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Partly as a result of the decline of these institutions, their limitedengagement with wider groups in civil society and the diminished rolethey play in peoples lives, many have forgotten or never learnt therationale for collective provision and equity of access; they have

forgotten or never learnt the associated arguments, vocabulary andconcepts and they do not find these consistently articulated anywhere.

It should be pointed out that a degree of speculation arises since wedo not know what the public think about health policy in anysophisticated way. There is no depth research on broad publicattitudes towards health policy. There are patient satisfaction surveys,opinion polls which ask very general questions and reports fromdeliberation exercises but no broad sociological studies of public viewsof health policy and the meanings the public confer upon the NHS and

its restructuring. Similarly, we have no ethnography of health serviceworkers and their perceptions of current developments. Lay theoriesamong campaigning activists as to the lack of engagement of thepublic often focus on the role of the media: it is suggested that thelack of media coverage of privatisation in practice is to blame or themanner of media coverage is to blame or the manner of governmentspin is to blame or the powerlessness learnt through failed action is toblame.

One of the debilitating characteristics of the anti-privatisationmovement/anti-privatisation initiatives is precisely that they are

anti. In other words, the absence of a positive policy agenda and analternative vision of what the health service should look like leavecampaigners always defending astatus quoand unable to negotiateforanything from a position of principle. The reasons for this lacunain ideas and policy relate in part to the absence of left think-tanksdeveloping blue skies thinking and practical policy suggestions.However, if Gramsci is to be taken seriously, a successful challenge tothe new capitalist ascendancy in health requires not merely aconsideration of the political and economic but also the mounting of acounter-hegemonic project. This involves the development anddiffusion of a different set of ideas which can enable people toconceptualise their situation differently.

This takes us finally to the question of the intelligentsia and us. Policyacademics who might have been expected to speak out against therestructuring of the NHS in, say, the way they have from time to timein relation to questions of poverty, have in the main declined to do so.This is particularly the case in terms of collective interventions suchas multi-signatory letters to the newspapers. With one or two highprofile exceptions, health policy academics have tended to keep theirheads low. In Gramscian terms, the degree to which the academic

community now addresses the concerns of the powerful in the terms


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set by the powerful (eg via commissioned research) potentially rendersus the intelligentsia of the dominant class.

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Dr Sally [email protected]

the relevance of marxism to the current transformation of the nhs

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