We are very proud here in the UK of our National Health Service, established by the post-WW2 Labour government, that still, despite creeping privatisation, provides healthcare to all ‘free at the point of delivery’ paid out of general taxation. Unsurprisingly, therefore, it is major news that this week all hospital doctors-in-training in England (i.e. doctors not yet consultants pejoratively labelled ‘junior’ doctors), will be striking for the first time in over forty years after an amazing 98% of doctors who voted in the British Medical Association ballot approved of strike action.
The Conservative government, led by arch-villain Jeremy ‘Berkshire’ Hunt, claims that it seeks to modernise the pay and conditions of doctors and to end the supposed imbalance of treatment received by patients between weekdays and weekends.
It seems to me that the issue of weekend cover is legitimate. However, thanks to Jeremy Hunt’s fearmongering, he’s actually managed to jeopardise the health of many British people by scaring them away from taking themselves to hospital in a timely fashion if it happens to be the weekend. Indeed, there is now even a recognised ‘Hunt effect’ which has come to be understood as ‘inadvertent harms caused to patients by misstatements about the quality of healthcare’.
The government claims to be motivated purely by concerns for ‘patient safety’. In reality, the government’s proposed ‘reforms’ are overwhelmingly about drastically reducing the labour costs of doctors to the NHS and, crucially, ultimately to the private healthcare firms it wants to take it over. You can find much more detail about the conflict between the government and doctors elsewhere. Here, I simply want to make the case for what this conflict is really about – the hunt for ‘surplus-value’ as a necessary precondition for total NHS privatisation.
Why privatise the NHS?
The government wants to privatise the NHS for three main reasons. First, its friends and backers within the private healthcare sector, including the biggest US healthcare firms, are salivating at the prospect of running such a large and potentially lucrative service. Already, large areas of NHS services have been subcontracted to private firms, often with dystopian outcomes: Virgin Care now runs Surrey Sexual Health Services and Serco, a firm notorious for running private prisons and secure units, runs Cornwall’s childrens services! Second, the accompanying market ideology that most of our politicians espouse (either as active proponent or in fatalistic acceptance) means the government genuinely believes that a privatised NHS would work far better than the current model. This is despite the injustice and inefficiency of the US model and despite the glaring facts that all privatised sectors are not just far worse for consumers and taxpayers, they are not even remotely free markets at all (not that such a thing exists). Instead, they are oligopolies taking huge, endless subsidies from the state and getting the government and Parliament to legislate and regulate in their favour. Where I part from the ‘idealists’ (those who think the world is driven by ideas and that, therefore, for example, austerity or privatisation policies are simply irrational and ‘ideologically driven’) is that I see this ideology tied inextricably to underlying material interests. This leads me to reason number three: the privatisation of the NHS is, first and foremost, about the continued extension of capital into every area of human life. Consequently, in both ideological and material terms, the NHS presents a formidable obstacle to the capitalist class in the UK: it is a highly popular and relatively efficient and cost-effective institution that defies hegemonic capitalist ideology and it constitutes one of the few major economic sectors beyond the total control of capital. The NHS must be colonised.
Profit as ‘surplus-value’
In dominant ‘neo-classical’ economic theory, the profit from selling a good or service is produced derived purely through the market price. It is a matter of supply and demand.
What mainstream economists call ‘profit’ Marxist political economists call ‘surplus-value’. Workers work a given number of hours each day to reproduce themselves and their families. Karl Marx calls this the ‘necessary labour-time’. The additional hours they work is the time during which the surplus-value taken by the capitalist is produced. Two particular things are important to us here: First, that the production of surplus-value is not a mere economic relation, but a social relation of power and exploitation that binds the capitalist and working classes; Second, that this is a social relation of fundamental ‘contradictions and antagonisms’, as Marx puts it. Here, we can see the fundamental class contradiction: the boss wants us to work longer hours for less and we desire to work shorter hours for more. Check out this amazing quote from Marx’s Capital Vol I that powerfully summarises these contentions:
‘Capitalist production is not merely the production of commodities, it is, by its very essence, the production of surplus-value. The worker produces not for himself, but for capital. It is no longer sufficient, therefore, for him simply to produce. He must produce surplus-value. The only worker who is productive is the one who produces surplus-value for the capitalist, or in other words contributes towards the self-valorization of capital. If we may take an example from outside the sphere of material production, a schoolmaster is a productive worker when, inaddition to belabouring the heads of his pupils, he works himself into the ground to enrich the owner of the school. That the latter has laid out his capital in a teaching factory, instead of a sausage factory, makes no difference to the relation. The concept of the productive worker therefore implies not merely a relation between the activity of work and its useful effect, between the worker and the product of his work, but also a specifically social relation of production, a relation with a historical origin which stamps the worker as capital’s direct means of valorization. To be a productive worker is therefore not a piece of luck, but a misfortune.’
In Capital Vol I (Part V), Marx describes the historical expansion and consolidation of capitalism through the development of capitalist social relations or what he calls the ‘formal’ and subsequent ‘real’ ‘subsumption’ of labour under capital. He shows how, since really the 18th Century in Europe, the emergent capitalist class successfully extended the length of the working day, thereby greatly increasing what Marx calls ‘absolute surplus-value’, i.e. getting workers to produce more surplus-value for you simply by making them work more hours. After the biological limits of work were exceeded, causing widespread death and illness, the gradual unified resistance of the working class combined with the realisation of some influential sectors of the capitalist class themselves that they risked killing their golden goose to regulate and limit the length of the working day. The working class was, by this stage, fully formally subsumed under capitalism. Subsequently, the emphasis has been on their ‘real subsumption’, that is, the increase of ‘relative surplus value’ which concerns increasing the productivity of workers within the same work period.
So, what does all this mean for NHS workers today?…
The hunt for absolute surplus value: extending the working day
Since the NHS is not yet a capitalist sector, central to the process of its formal subsumption to capital will be a sustained push for absolute surplus value. Unsurprisingly, therefore, the government’s primary aims are to extend the ordinary working day of hospital doctors to a fifteen hour weekday (from 7am till 10pm!) and to make Saturdays from 7am till 7pm also a normal working day. This means that doctors would get no overtime pay during these hours. The government will, however, increase the amount the NHS pays for the remaining ‘unsocial hours’, i.e. late weekday nights, overnights, and Sundays. Even the BBC concludes that ‘the financial benefit of extending what constitutes “normal hours” to a Saturday is obvious.
The quest to reduce labour costs and increase surplus-value is the government’s fundamental objective. The King’s Fund (that self-proclaimed ‘independent charity’ which just coincidentally happens to be funded by private healthcare firms) tells us as much. It concludes that:
‘It is hard to predict the extent of further growth of non-NHS provision in the short to medium term. The appetite for such work, particularly among commercial organisations, may be limited given the degree of financial pressure within the system and more limited prospect of profit generation.’
The greatest single cost to any business is its labour costs. Put another way, the greatest single obstacle to ‘profit generation’ or surplus-value extraction is labour costs. In the NHS, these must be significant reduced to pave the way for privatisation.
It remains for me to demonstrate the political links between the UK’s political class and the private healthcare sector. Thankfully, this task has been done quite admirably by a number of others, most notably the ‘Social Investigations’ website team. Check out this link to see a list of over 100 British MPs and Lords with direct financial connections to private healthcare firms. Social Investigations also showed how a core elite network of lobbyists are pushing the privatisation agenda from without and within the government.
Finally, just to add that the previous Health Secretary, Andrew Lansley, now works for management consultants Bain & Co ‘advising corporate clients on healthcare reforms’ and serves as an adviser on health and social care for a ‘strategic communications consultancy’ set up by his wife! In addition, the current Secretary, Jeremy Hunt, has form. In 2012, he was transferred to the Department of Health from the Department of Culture, Media, and Sport after it was revealed that he was keeping Rupert Murdoch’s aide updated by text on the government’s ‘impartial’ decision regarding Murdoch’s NewsCorp’s aim to take total control of BSkyB!
The ‘Hunt’ for surplus-value: this is the government’s real objective
Forget patient safety, the government’s real goal is the privatisation of the NHS. A fundamental precondition of this is the drastic reduction of labour costs. The extension of the working day is a crucial element of this. This will have terrible effects on the lives of both doctors and, of course, the patients they diligently serve. Consultant hospital doctors and nurses know this and have been outspoken in their support for their ‘junior’ colleagues. So, don’t believe the media. The greatest threat to our health and livelihoods is not the ‘greed’ of ‘junior’ doctors, but the interests of capital that our political establishment ceaselessly promotes.