The relevance of Marxism to the current transformation of the NHS Sally Ruane

Introduction The NHS is part way through a process of radical restructuring via which it will become much more an organisation for the commissioning or contracting of health provision from others with less involvement in direct provision and via which many activities which had been transferred to the public domain 60 years ago are reverting to the commercial sphere. Despite these radical changes to an institution considered until the past decade to be virtually untouchable by political parties of any hue, there is limited publicly voiced criticism and political resistance to these dramatic developments. This paper attempts to revisit and apply a limited number of Marxist concepts and analyses to inquire as to how this could have happened. It is selective in both the concepts it deploys and the policy areas it covers so at best offers only the start of a critique of current health policy from a Marxist point of view. I am not well-versed in the application of these concepts and you are welcome to tell me where you think Ive gone wrong. First the paper identifies some key policy developments of the past decade. It considers the conditions in which the NHS was created in the first place and then tries to account for the historic abandonment of Labours commitment to a socialised health system. It examines how best to understand what capital requires of a health system and finally how to understand the absence of effective political resistance to this major policy shift in a policy area thought to be of significant importance to the electorate.

The recommodification of the NHS: Marketisation and privatisation A wide range of activities within the NHS is now carried out on a marketised or privatised basis. These processes should be distinguished conceptually. Processes of marketisation (the separation of purchaser from provider, the introduction of competition, financial flows to allow money to follow patients and so forth) can occur without the involvement of commercial or independent sector institutions. (The Conservative governments internal market in the NHS is a case in point, although technically there was some involvement of the commercial sector, this was very limited and this

involvement itself did not affect in a direct way the character of the NHS as an institution although the market processes did.) Privatisation, on the other hand, should be understood as the transfer of activities, personnel, assets, duties or resources from the public to either the sphere of the private individual or to the commercial sphere. This may or may not entail the use of market processes and principles. Aneurin Bevan, Minister for Health in the post war Labour government and chief architect of the NHS, asserted on several occasions the superiority of a public arrangement for health care. For example, A free Health Service is a triumphant example of the superiority of collective action and public initiative applied to a segment of society where commercial principles are seen at their worst. (Bevan, 1952:109) He introduced the first system of universal, socialised medicine with health care free at the point of use in the world. This notion of socialised needs some elaboration since elements of the health service were not publicly owned or employed although they were to a large extent publicly controlled through funding and planning. Thus, GPs were independent contractors and not salaried as were the purveyors of spectacles, and pharmaceutical products and most items of equipment continued to be produced commercially. This distinction has become important of late since recent Labour ministers have justified current policy of involving private business in health care as a continuation of and in keeping with the original principles of the NHS as set down in 1948. However, Bevan was clear that he viewed the NHS as establishing the transfer of a whole segment of activity from private enterprise and individualism to collective goodwill, public enterprise and public administration. This state invasion of the private and individualistic was, for him, the practical expression of nothing less than the articulation of a new society. He saw continued private elements as raising points of conflict of interest and envisaged that this would be resolved over time as these private elements ever diminished (Bevan, 1952). In the meantime, hospitals were nationalised and all their staff become state employees; primary and community health care services outside GP practices were state provided; and funding and planning responsibilities were assumed by the state. These two areas of responsibility had a decisive impact on shaping the character of health services available to the public even where some personnel remained formally independent. Private Finance Initiative However, this transfer of a whole segment of activity to the public domain is now in reverse and it has been reversed by the very party which created the NHS in the first place, the Labour Party. This was

first evident in the reversal of the Partys opposition to the private finance initiative (PFI) in 1995 well before coming into office. PFI entails the use of commercial companies to design, finance and build new hospitals (or other amenities) and to lease these back to the relevant public body over the subsequent 30 or 40 years. In addition to this, the private companies run the new hospital in terms of maintenance, estates management and other services such as cleaning, catering and portering. Thousands of workers who had until that point been the employees of the NHS were transferred to private sector employment where terms and conditions were notably poorer (Lister, 2003; Unison, 2003; Ruane, 2007). The Retention of Employment agreement with Unison in 2002 permitted, in most circumstances, most workers in the five trades to remain the employees 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 these buildings and these services, it has been calculated that in England alone, some 90 billion of the public NHS budget will be transferred from the public sector into private hands over the next 40 years or so simply to meet PFI repayment obligations (Hellowell and Pollock, 2007). As a result, services offered by local health communities have been dramatically altered both through the opportunity cost represented by this astonishing transfer of resources from public to private but also by the interpolation of a contract into the process of public service provision, a contract which is used by the private consortium to disrupt and interfere with public priorities in health care. Although the Retention of Employment deal permits some groups of workers to remain in-house in the PFI context, elsewhere budgetary and ideological pressures are leading some senior NHS managers to outsource other areas of so-called support or ancillary work. For instance, back-office functions such as payroll have been contracted out by some NHS bodies to private companies, sometimes with disastrous consequences for quality. Independent Sector Treatment Centres The Labour governments of Blair and Brown have taken the use of the commercial sector well beyond these policies which were, admittedly, originally Tory initiatives. For the first time since 1948, Labour have introduced the re-commercialisation of hospital care through the establishment of Independent Sector Treatment Centres. These dedicated private surgical centres offer, on a fast track basis, routine relatively uncomplicated surgery plus some diagnostic tests for NHS patients. They are paid by the sponsoring PCTs which divert flows of funding away from the NHS hospitals which previously conducted those operations. ISTCs have been set up even where their extra capacity is not required for the local health community; they are paid more per procedure than an NHS unit; are guaranteed their income

for five years regardless of the number of patients actually treated where NHS hospitals are paid on strictly payment-by-results basis. The local NHS units which previously provided these services on a planned and continuous basis are now thrown into a relationship of unequal competition: unequal because they are paid less and on a per procedure basis and unequal because they continue to have responsibility for complex and difficult cases whilst the private ISTC cherry picks the relatively easy, straightforward and therefore cheaper patients. All of the ISTCs in the first wave were contracted to overseas based companies such as Netcare (South African) and Capio (Swedish). Marketisation What the ISTC example shows are the possibilities offered by the restructuring of the NHS as an open competitive market. The Labour government spent much of its second term in office restructuring the NHS away from being a planned integrated publicly provided service into an open competitive market. Unlike, the Conservative internal market, Labours market is equally welcoming of voluntary sector and commercial providers alongside traditional public NHS providers. Health care is organised a contractual basis with PCTs representing the single payer (In fact, each PCT is the single payer for its population but across England there are around 150 PCTs.) The financial infrastructure of the NHS was changed during this period to allow money to follow patient payment by results in which providers are paid a nationally fixed tariff per procedure regardless of the cost to the provider of producing the procedure. Tariffs are fixed by the Department of Health supposedly on the basis of national average costs for the relevant procedures and are revised annually. The individualisation of payment flows supports a policy of patient choice in which patients are encouraged to choose from a range of providers for secondary care. Primary Care Primary care, too, has been identified as in need of a market shakeup. The traditional NHS GP, funded through NHS money to care for NHS patients according to NHS priorities, faces competition from big business in the form of, for example, Virgin Healthcare (launched in January 2007 as part of the Virgin suite of companies partly for this purpose) and United Health Europe (the European subsidiary of United Health Group, one of the largest multinational health care providers in the world). GP surgeries are being destabilised through the establishment of new health centres and polyclinics which affect their patch and will potentially poach their patients. Some of these centres and polyclinics are being tendered out to these alternative providers and some existing GP surgeries are also being tendered out in 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

Virgin are suggesting practice management and clerical staff will transfer but GPs and nurses will remain independent and NHS employed, respectively. A similar process is occurring in other parts of primary and community care. Primary Care Trusts have come under pressure over the past two years to divest themselves of their providing arm (as this area of health care is now bizarrely described). So health visitors, community and district nurses, some professionals allied to medicine are re-positioned as arms-length community health service providers. They are still in most instances (although not in Surrey and Sussex where a social enterprise was created instead) employees of the NHS but the intention is that, within a year or two, these providers compete with other providers to offer the services covered. Whether the staff remain NHS employees or then transfer to a status independent of the NHS or transfer to a private employer which in due course wins the contract is yet to be seen. Hospital Management Recently, the government announced its intention to transfer whole NHS hospitals over to private management when they are failing. This idea of franchise is not new and was touted by Alan Milburn when Secretary of State for Health and one experiment in this at the Good Hope Hospital in Birmingham roundly failed and the hospital was eventually taken over by a local foundation trust hospital. The hospital currently tipped for this form of privatisation is the Hinchingbrooke in Cambridge, coincidentally the constituency of the shadow minister for health. Commissioning The last illustration I want to use concerns not the provision of health care services but their commissioning or purchasing in the first place. In the market structures which Labour retained and then reinvigorated and reshaped, there is a formal separation between the functions of purchasing/contracting for/commissioning health care on 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 and commission it from others. But the principle of separation is important for the functioning of the market. The commissioning function is obviously an important one not merely because of the implications for the effective use of resources and value for money but also because it has a powerful influence in shaping the sorts of health care services available to the local population. This includes range and location of providers, range of services available and patient pathways and thus has a strong impact potentially on the experience 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 primarily commissioning and not providing organisations within the NHS (the

justification for putting community health service providers into arms-length organisations), the commissioning function is now slipping out of the PCTs hands into those of large global corporations (including UHE (again), Humana and Aetna) which have been approved as part of the Framework for the procurement of External Support for Commissioning. This Framework, confirmed in February 2007 but not announced to the public until October 2007, provides for PCTs to contract with one of the approved companies for assistance in their commissioning function that is they can contract out a greater or lesser portion of their commissioning responsibilities to global corporations which will then decide what kind of health care NHS patients should have access to in what sort of institutional set-up. End-to-end commissioning (ie contracting out the total commissioning function) has not been ruled out. How conflicts of interest where corporations engage both in commissioning and in providing health care services to NHS patients are regulated remains to be seen. The point of these examples is to illustrate that across diverse areas of the NHS, health services which have to date been provided on a devalorised basis are now being commercialised. Even the planning and commissioning of services are in the process of being privatised. How can we use Marxist insights to make sense of this step by step spread of the application of market principles and commercialisation and 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 the Labour Party to have abandoned its commitment to a public health service. Although Marx himself did not strictly have any notion of a devalorised sector, he did allow for the possibility of concessions won from the state through working class action. Engels, who witnessed the early stages of the developing labour movements, went even further in the direction of envisaging the possibility of peaceful transitions to socialism in some societies. This peaceful approach in other words the use of parliamentary and legal means to secure socialist goals was embraced by many Marxists, especially the Communist parties, in the middle and later decades of the twentieth century, before but particularly following the radical reforms of Clement Atlees post-war Labour government by which the NHS was created. However, the real potential of reformist parties for bringing about socialism has remained a point of debate and controversy amongst

Marxists (see the Workers Liberty website for a debate on whether Labours reforms were real as an example), particularly those of the Trotskyist left. The Communist parties in the UK have retained their reformist stance and continue to support Labour even at this stage as a strategic alliance. Others warn of the tendency of reformist parties to slide into ever cosier relationships with capital and to compromise bit by bit as principles are eroded in favour of pragmatism (Bottomore, 1983). Even where the parliamentary route has been extolled, it has been more a counsel of expediency (Laski, 1934:213) than a point of principle, an acknowledgement as much of the lack of appetite for a revolution amongst the working classes as of the potential of a reforming party. Further, from a Marxist stance, reformism is legitimate only where it forms part of a coherent strategy for the transformation of society. Explaining in Marxist terms the decision to abandon the socialist principle underpinning the NHS by the same party that originally created it as part of a programme of radical social reform must draw to some extent on that pro and anti-reformist debate. Some writers (Marxist and non-Marxist) have suggested that Labour has been captured. A number of key Cabinet members over the past decade or so are former members of Trotskyist groups. Instead of capturing the Labour Party in order to pursue a socialist programme, it is suggested, they have captured it and steered it in the direction of neo-liberalism. Monbiot (2000) and Barratt Brown (2001) are amongst those who have succeeded in amassing a degree of empirical evidence of a business take-over, giving rise to what they describe, respectively, as the captive state and the captive party. Barratt Brown claims the Labour Party has shifted from social democratic cooperation with business to a much closer relationship evident in the restructuring of state activities as commercial undertakings, often making senior civil servants rich in the process. This has significantly blurred the distinction between the public and the private spheres. This has been most keenly felt in the NHS in the creation of the Commercial Directorate, a section of the Department of Health devoted to setting up contracts with commercial organisations. This directorate was composed of 190 staff in 2007, 182 of whom had been recruited from the private sector, many on a consultancy basis, and only 8 of whom were civil servants (Player and Leys, 2008). Both former Director Generals were drawn from senior posts within companies which have benefited from lucrative contracts with NHS organisations (Amey in the case of Texan Ken Anderson; and United Health in the case of Channing Wheeler). Colin Crouchs (2000) work goes some way to explaining how the close links between business and Labour have been able to develop by emphasising the class base of the reformist party. He has described in his pamphlet, Coping with Post-Democracy, how deindustrialisation

from the 1970s has fatally weakened the industrial electoral base of the Labour Party (and of other broadly social democratic parties elsewhere). In order to appeal to a broader swathe of the electorate, the Party has freed itself from its dependency on the trade unions and its traditional activists and has subverted the policy-making machinery which had previously addressed the concerns of that traditional base. The consequent vacuum, especially after the 1987 third electoral defeat, was filled rapidly by corporate lobbyists. As deindustrialisation has proceeded in a global context, influential businesses have increasingly pursued their interests in relation to the service sector rather than traditional manufacturing and industry. As a result, the Labour Party and subsequently government, have come under very strong pressure to open up public services to corporate penetration. Despite its publication in a Fabian pamphlet, this seems as convincing a Marxist explanation of Labours about-turn on health as any although, despite the endeavours of Monbiot and Barratt Brown, the empirical evidence for corporate influence on social policy remains patchy and under-researched (see Farnsworth, 2004). A Gramscian explanation of Labours general shift in political position is presented later 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 the sum total of the goods produced and the services rendered by the people of this country is not sufficient to provide for all our people at all times, in sickness, in health, in youth and in age, the very modest standard of life that is represented [in this bill]. I cannot believe that our national productivity is so slow, that our willingness to work is so feeble or that we can submit to the world that the masses of our people must be condemned to penury. Clement Atlee, 1944, cited by Hennessy, 1993:119 Broadly, there are two Marxist conceptions of the state. The first adheres to and adapts the assertion of Marx and in the Communist Party Manifesto (1847/8) that the executive of the modern state is but a committee for managing the common affairs of the whole bourgeoisie. Here the state is an instrument of the capitalist class as a whole and a myriad of networks and social connections sustain social relationships between capitalists and members of the political class and state bureaucracy (e.g. Miliband, 1968). The second is a conception of the state as to some degree autonomous either on a temporary basis for instance where the state at certain high points of class conflict acts as a mediator when neither the capitalist nor the working class is strong enough to influence it or on a more

continuous basis since, it is argued, it tends to support policies which serve the interests of the capitalist class but can and sometimes does support policies which are contrary to those interests either because of effective pressure from the working class or in an attempt to head off 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 but may act against the shorter term interests of some elements of capital. There is something unconvincing about these conceptions which are at odds with the notion that transition can come about peacefully in relation to the post-war radical Labour government. This acted very much in the interests of creating institutions and processes of redistribution which served the interests of the working class despite the economic hardship of the time. It is not that Labour sought entirely to overthrow capitalism in 1945, it did not, but that its focus was on addressing the need of the mass of the population. It is true that this was possible partly because of the weakness of capital at the time. When the NHS was created in the immediate post-war period, the significance of pressure from below has been emphasised. Peter Hennessy (1993), author of one of the best historical accounts in print of that period, identifies the importance of shared experiences for forging a community spirit a spirit of hope and purpose. Not only did people from vastly different backgrounds gain an insight most notably through evacuation - into and understanding of each others lives, living conditions and life chances but they also shared the experience of hardship and sacrifice in the interests of the common endeavour. Derek Fraser points out that the war produced a common experience and universal treatment. He continues: almost by way of a quid pro quo the nation accepted limitless sacrifices in the war effort in return for an implied promise of a more enlightened, more open post-war society. The nearer to a total war, the greater tends to be the degree of social equality involved and so the Second World War tended to reduce social distinctions. This flowed from the character of the war as perhaps the first peoples war, wholly dependent on the efforts and support of the whole population (Fraser, 1984:208). The combination of shared experience and orientation towards a common purpose was critical in the development of class consciousness - the conviction that the society created after the war had to be a radically different one from that which preceded it, that it had 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 read proposals of Beveridge (1942) , the developing expertise of Labour

ministers in the Cabinet and the practical experience of running services effectively on a planned and centralised basis by the state considered essential to the organisation of the Home Front. These factors contributed to a belief that society could and should be radically 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 material conditions of capitalist exploitation, although the experience of capitalist exploitation had radicalised many of the leaders such as Nye Bevan and was the foundation of the institutions of the working class, principally the trade unions and Labour Party, through which social change would be organised. But the popular consciousness of 1945 was forged in the context of unity in the face of a common enemy not capital 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 Hennessys despite its vast array of sources and attention to detail) is the role of capital. True, Whiteside (1999) does refer to the support for the abolition of the approved society system by the Association of Approved Societies and opposition to it by the National Confederation of Friendly Societies and, yes, the Tories who could be considered the political spokesmen for capital, opposed the 1946 NHS bill. On the whole, though, the reader is struck by the absence of the capitalist class or at least its relative silence and marginality in the process both of welfare state construction and to a slightly lesser extent of nationalisation. (There was opposition to nationalisation of the steel industry.) It is hard to believe that this is simply an oversight by the historians. Even accepting the ambivalent and underdeveloped approach to nationalisation, it seems absurd to describe the post-war Atlee government as a committee (or part of a committee since Marx and Engels used this phrase in relation to the state as a whole) for managing the affairs of the bourgeoisie or as part of a state apparatus reluctantly conceding reforms to the working class or engineering nationalisation and costly state welfare structures when resources were scarce as the best way to facilitate accumulation for the capitalist class. The amount of social and economic activity taken out of the hands of capitalists through nationalisation and the massive redistribution of resources consequent upon the foundation of the welfare state address labour not capitalist concerns. Instead, it is more likely that the capitalist class of the time was indeed less powerful and organised than it has since become. The British based capitalist class had been severely disrupted by first the recession of the 1930s and then the war in which resources were commandeered by the state for the war effort not for private shareholders. Moreover, in the context of an industrial society, the for-

profit sector in health care and social care was extremely small. Access to any hospital services was very circumscribed for the majority of the population with only a tiny market for private hospitals, mad houses and private care homes. The service sector related to social needs was itself very small during this period. As a result, capitalist impact on social policy in the 1945-50 period appears to 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 products chases the bourgeoisie over the whole surface of the globe. It must 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, the usual tendencies of capitalism come into play. A century and a half ago, Marx and Engels envisaged an industrial bourgeoisie striding the globe subverting all relations in favour of brutal exploitation. Feudal, patriarchal and idyllic relations, unchartered freedoms, chivalrous enthusiasm, philistine sentimentalism, family relations and personal worth were all swept away to leave remaining no other nexus between man and man than naked self-interest, than callous cash payment. In one word, for exploitation veiled by religious and political illusions, it has substituted naked, shameless, direct, brutal exploitation (Manifesto). The character of the relations institutionalised in the NHS in 1948 was a long way from this cash nexus reductionism. On the contrary, the NHS eschewed financial payments and removed entirely the cash relationship from access to health care. Although relationships between professionals and patients remained unequal, they were complex since they were overlaid by the fact of equality through shared citizenship which itself was the basis of access). Entitlement was not merely individual but collective: the entitlement of the individual was intimately bound up with the entitlement of all others. However, this institutionalisation of altruism (Hennessy, 1993: 132) is being eroded. Current policies not only reintroduce the profit motive and re-commodify health care work but also but also undermine the collectivist ethos of the service through emphasising notions of individual choice and personalisation. These policies tackle not only collectivist structures but also the collectivist ideology which has surrounded the NHS, about which more below.

The NHS represented a triumph of British working class action to change its own society. Capital has regrouped, however. The drive to replace all other relations with the simple relation of the cash payment continues. In other words, the drive of the bourgeoisie to convert all activities into opportunities for capital accumulation continues. It is now better placed to do so. It has developed strong structures and processes in the US where, unlike most other developed societies, health care is run on a market basis. In 2007, the U.S. spent an estimated US$2.26 trillion on health care, or $7,439 per person and has facilitated the concentration of a huge mass of wealth. For example, individual companies are enormous United Health Group (UHG), for instance, has the largest net sales in health care insurance achieves record net earnings in excess of $12 billion annually, according to its Annual Reports. This sector of capital has developed strong lobbying skills and close relationships with legislators and other policy makers. It has organised itself to develop similar links in the EU setting, particularly through the TransAtlantic Business Dialogue (TABD) which, for example, has organised conferences to stimulate innovation and has redesigned the way it works in recent years to create a more conducive environment to advance transatlantic economic relations (http://www.whitehouse.gov/news/releases/2003/06/20030625-7.html). Commercial health care organisations have consolidated a substantial presence in the private UK health care market where the charitable status of independent hospitals has been progressively eroded in favour of commercial ownership over the past twenty or thirty years (Higgins, 1988; http://www.privatehealth.co.uk/privatehospitals/hospitaltreatment-companies). It has helped develop (through lobbying) and used the new trading infrastructure which has emerged over the past 15 or 20 years, particularly the World Trade Organisation and the enlarged EU. It has succeeded in breaking into the EU health care market, evident for instance in UHGs European subsidiary (UHE). Although the process of recommodification has been under way across the welfare state since the 1980s, it has reached the NHS only under Labour. Capital is penetrating the public sector both through undertaking contracts to provide services, through the transfer of assets out of public hands and increasingly through service planning decisions. But it should be noted that the transfer of assets represents not a concentration of wealth typically associated with advancing capitalism but a dispersal of wealth which had previously been concentrated in public hands. Of course, once relocated to the private sphere, that wealth will be subject to the same processes affecting other stocks of wealth in that sector particularly a tendency to concentrate where unregulated. Similarly, the NHS represented (and still does to a reducing extent) a concentration of the means of production and the contracting out of services represents a process of dispersal.

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 accumulation and legitimization. This means that the state must try to maintain or create the conditions in which profitable capital accumulation is possible. However, the state also must try to maintain or create the conditions for social harmony (OConnor, 2002:6, emphasis in the original). Saville (1957) differed from Marxists who believed that the welfare state arose either from concessions by the state to pre-empt more radical demands or from working class struggle. He claimed that the creation of the welfare state was due to a combination of three factors. First were the economic and social needs of a complex industrial society. Second was class struggle or pressure from the working classes for social change. Third came the calculations of the capitalist class in terms of what concessions were needed to maintain overall conditions for continued capital accumulation. I have referred already to the second and third of these. It is difficult to make a case for the notion that the social and economic 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 care depends entirely upon the model of development it is pursuing and the sorts of popular pressures for services which need to be addressed for the overall conditions of accumulation to be fulfilled. In other words, it is difficult to separate a technical assessment of objective social and economic needs without at the same time assessing political pressures and expectations. This includes both the ways in which needs and wants are construed and the organisational clout of those demanding that they be responded to. From a functionalist point of view, some health care or at least public health measures are essential for the efficient performance of the workforce in a competitive global context. This is therefore potentially a cost to capital given capitals need to secure the reproduction of labour power. Capital benefits enormously from the socialisation of these costs especially where the public funds for this health care are derived from sources other than business itself and where health care is confined to the kinds of care needed by employers. Although this is not easy to define, it certainly does not imply the sort of socialised health service we have had in the UK until the past decade or so. It is conceivable that lower levels of entitlement would suffice, that inequality of access could predominate and that funding and provision could come from a mix of sources. The experiences of other European

states and even the US (which has never had a universal health system) confirm this. We should also note that a significant proportion of health spending is devoted to meeting the needs of the older members of an ageing population that is, those who are, economistically speaking, no longer productive. The sort of health service we have had has never been a requirement strictly speaking of an advanced and complex economy such as ours. It has far exceeded what could be described as necessary and it exceeded it because of the collective public pressures for social change in 1945. In other words, we got the health service we did because of popular pressure in a context of a weak capitalist class and a state whose institutions had been taken over by a radical democratic socialist party whose raison detre was the restructuring of society in the interests of the working class. (And weve kept it until recently partly because of popular resistance to changing it and the willingness of leaders within the labour movement to articulate and act on this resistance.) The Labour government of 1945 did not create the NHS in order to legitimise capitalism but as one element in social transformation. It is useful to take up James OConnors typology here. OConnor (1973/2002) suggests there are two types of state expenditure in modern capitalist societies which principally relate to two necessary functions the state must perform. One is social capital expenditure which facilitates accumulation; the other is social expenses expenditure which fulfils the states legitimization function. OConnor suggests the latter does not even indirectly facilitate accumulation but serves to keep social peace. I have already said that I do not believe the Labour governments policies of 1945-50 were motivated to keep the peace but to transform society. However, as this social transformation imperative has been lost by later Labour governments (and was never shared by Conservative ones), OConnors approach has some value. There are two types of social capital expenditure which indirectly expand surplus value. Social consumption expenditure which, for OConnor (writing in a US context), includes medical and health insurance and hospital and medical facilities (2002:124) constitutes a socialisation of the costs of variable capital (the costs of reproducing labour power) and tends to lower the level of money wages and, ceteris paribus, raise the rate of profit in the monopoly sector. The other type of social capital expenditure is social investment and, in the human capital part of this, OConnor does not include health care. This refers to investment in the growth of the productive forces (including labour power and labour skills) and includes projects and services which increase the productivity of a given amount of labour power and, ceteris paribus, increase the rate of profit.

The analysis here suggests the contribution to reducing the costs of reproducing labour power is a small element in the function of the NHS and instead its scope and relative generosity have persisted over time mainly for legitimization rather than accumulation purposes. In fact, OConnor acknowledges that nearly every kind of state expenditure to some extent fulfils both functions and has a two-fold character rendering unambiguous classification difficult. However, the main purpose (function) of the expenditure can be identified by discerning the political-economic forces served. The question is whether we can use OConnors typology of state expenditure in the context of a welfare service being turned over to capital penetration. For, there is another dimension to the relationship between capitalism and the health system. From the strengthened capitalist point of view, the health sector is viewed for its potential for generating opportunities for the accumulation of capital not indirectly but directly and in that sense is no different from any other sector. This was not the case in 1945 but it is so now that the health and social care commercial sectors are so much more highly developed in global terms. About 100 billion of public money is being spent on the NHS this year and it is expected to increase by slightly more than the rate of inflation over the next few years. This is a vast sum of money, an increasing proportion of which is to be made accessible to private companies for the purpose of capital accumulation. The Labour government has responded to the criticism of Bacon and Eltis (1978) and others from the right that state welfare crowds out the private investment necessary for continued economic growth. Generally, the pressure to open up the health service to capital penetration has come from transnational health corporations and not from the traditional UK private health sector. Because of the creation and dominance of the NHS, the private health care sector in the UK has been small and under-developed relative to that in other advanced countries. As a rapidly expanding pool of public money has been made available to commercial providers of health care over the past decade (and especially the last 6 years), the UK private health sector has benefited to only a limited extent (eg through the General Supplementary contracts) and generally has failed to expand and adapt fast enough to take advantage of this. This has created further space for global or at least transnational commercial providers of health care. In fact, the health service has not passed and will not pass through a phase of national privatisation at all: it has been exposed directly to global capital both in the PFI which involves the transfer of NHS assets to the private sector and in the privatisation of primary and secondary care. In the case of contracting to provide services, capital has been able to secure for itself a share of the national income and is working to

expand this. Some major global corporations have responded rapidly to evolving Labour health policy. There are gains to be made through the provision of health services but the amount of contracted out provision has been modest to date (for example about 7 billion has been set aside since 2003 for the provision of routine surgery and diagnostics in independent sector treatment centres). On a much more significant scale, the provision of assets through PFI has established an enormous and long-term public debt to the private sector as mentioned earlier. In addition to this, the really big money is available through the commissioning policy. Not only does this put a theoretical 80 billion up for grabs, it allows those firms approved under the Framework for the procurement of External Support for Commissioning to shape the sorts of services available to patients the range of services, patient pathways, character of providers and so forth. In short this policy allows for the gradual restructuring of health services along lines conducive to capitalist involvement and capital accumulation. Moreover, the single-payer system reduces the cost to capital of billing (though in practice these companies are highly skilled at passing on to the state other transaction costs such as those associated with negotiating contracts). Despite its dramatically different character as a health system, it is the American model which is tipped most to influence this process (e.g. Pollock, 2004). Its institutions have been positively evaluated by government advisors (e.g. Professor Chris Ham), NHS bodies are drawing heavily on US research or research in the US setting (for instance, in relation to the transfer of services out of hospital and into the community) and it is American companies whose presence is most felt in the external support for commissioning process. OConnors work does suggest a way of thinking about this use of state expenditure to facilitate accumulation directly and we consider this 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 with Labours policy of recommodification of the NHS and this raises the issue of class consciousness. There has been some resistance to it among trade unions and campaigners defending local health services and there have been efforts to develop a network of pro-NHS campaigners (e.g. Keep Our NHS Public and Community Hospitals Acting Nationally Together) (Pollock, 2004; Ruane, 2000; 2004; 2007). But overall, resistance has been weak and disorganised. How can this be explained in Marxist terms? I shall start by considering elements of resistance and then turn o the question of acquiescence in the next section.

We could return to OConnor here for some insight. OConnor argues that state expenditure is surrounded by intense lobbying by special interests a wide range of business interests keen to shape budget and state expenditure decisions in ways conducive to their business interests. 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 are coordinated by the market, he says, but instead are processed by the political system and are resolved on the basis of political struggle. It may be possible to consider the NHS today in this vein: as a sphere of political contest and conflict in a way it wasnt even a decade ago (largely because, before the Blair administration, businesses considered the NHS off-limits). The way this is manifested in practice is through local battles being fought out across England over the physical reconfiguration of services and new patterns of expenditure and new patters of service delivery. OConnor suggests that the claims of business interests, associated lobbying and expenditure and policy decisions which favour them must be either legitimized or mystified. We can see this in two respects in current health policy. One is in the presentation of policies at a national level which are couched in the language of legitimization. The other is in the character of local health battles. In the latter, at this comparatively early stage, the public may not be aware of the participation of business and the relationships they are fostering and developing with local health decision makers. In Leicester where I live, for instance, there was little public information about the impending contract between the hospital trust and the Birkdale Clinic to contract out some orthopaedic surgery; but instead this became public knowledge only after the contract was signed. Although the swift suspension of that contract on what appear to be quality grounds after, Im told, four short weeks was made public, little information has been disclosed since then concerning how this situation arose. Another example of the low profile of business in terms of local awareness comes from another East Midlands town where a pensioner reported attending the public meeting of the PCT board and decided on whim to ask the other two members of the public present who they were and was flabbergasted to discover they were from Humana observing proceedings. No information about the potential role of Humana in local health care had been in the public domain at that stage. (Humana is a large US-based corporation which has been approved by the department of Health to assist PCTs with their commissioning responsibilities.) Reconfiguration of services, including the transfer of services out of hospitals into the community and the establishment of polyclinics which poach patients from existing GP practices, create opportunities for private sector involvement but these policies are not presented in these terms. A 2007 Q&A document found on a PCT website identified

that part of the review of community hospitals in the county would include exploring the possibility of new models of ownership. This issue, however, has not found its way into any of the later public involvement documents Ive seen so far and indeed this is not particularly surprising as, despite its fundamental nature, models of ownership is not seen as a public involvement and consultation matter. There are many factors shaping reconfiguration policies and each proposed reconfiguration needs to be examined individually. However, apart from locality-specific factors, similar arguments are found in different reconfiguration documents (demographic changes, new patterns of morbidity, ability to manage chronic conditions better outside hospital, the implications of the European Working Time Directive and so forth). However, Boyle and Steer (2008) point out that many of the reconfigurations are driven by cost considerations where clinical issues are often finely balanced. The fact that health services restructured into different sorts of institutions also creates opportunities for business (its much easier to own and run a polyclinic than a general hospital) is not mentioned. In fact, some of the reconfiguration proposals put forward, for example in Coventry and Warwickshire, arguably are themselves in part the outcome of previous privatisation policies such as a new PFI hospital development (which in this case costs the local health community more than 1m per week and has been followed by a controversial downsizing of other hospital provision in the county Boyle and Steer (2008), who have acted as expert advisors to local authority health overview and scrutiny committees on a number of reconfiguration proposals, identify various ways in which information is not properly presented to the public (or not presented at all) and even suggest that public consultation may be a sham. These consultation exercises themselves become a means through which what is really happening is disguised the appearance is of public involvement and public consent; the reality is of public impotence and the recent change in legal provision for challenging health service decisions locally illustrates this. This obfuscation occurs nationally as well where all health policies are presented as good for the patient. Even at the most basic level of cost ie the use to which resources are put and the associated opportunity cost the Department of Health has not been transparent. It is astonishing that we have no publicly available figures regarding the transaction and overhead costs of running the NHS on market lines with the associated contracting processes and handling of payment by results. We do get glimpses of the high costs of negotiating contracts with the private sector. For instance, when the proposed hospital PFI scheme for Leicester was abandoned last summer as the costs had spiralled out of control (by that stage they stood at over 700m), the

Trust admitted that it had spent 22m of local NHS funds on the process of negotiating alone. Bizarrely, even the Wanless Review of 2008 ostensibly into funding and performance (Wanless et al, 2007), made no calculation as to the total bureaucratic costs of restructuring and then running the health service as a market. So we do not know precisely what proportion of the NHS budget is not available for patient care because it has been redirected into the additional costs of operating and managing a market. This is significant because of the comparatively (in international terms) very low proportion of spending on NHS administration before market systems came to be introduced and the rational character of this. There are other examples of mystification and obfuscation also, including around the policy of independent 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 which popular, professional, managerial and business interests struggle over the direction of policy in different locales but where business interests are rapidly ascendant and where the public doesnt necessarily know it is in a conflict of this kind. OConnor points out that these conflicts can result in duplication, waste and policies which cancel one another out or are mutually contradictory in other ways. This is surely the case in the NHS where resources are invested not in healthcare itself but in creating and sustaining a market per se.

The public response: acquiescence ..[0]ne becomes aware that ones own corporate interests, in the present and future development, transcend the corporate limits of the merely economic group, and must become the interests of other subordinated groups. This is the most purely political phase, and marks the decisive passage from the structure to the sphere of the complex superstructures.until a single combination of [ideologies] tends to prevail, to gain the upper hand, to propagate itself over the whole social area, bringing about not only a unison of political and economic aims, but also intellectual and moral unity, posing all the questions around which the struggle rages not on a corporate but on a universal plane, and thus creating the hegemony of a fundamental social group over a series of subordinate groups. A further questionis whether fundamental historical crises are directly determined by economic crisesIt may be noted that immediate economic crises of themselves do not produce fundamental historical events; they can simply create a terrain more favourable to the dissemination of certain modes of thought, and certain ways of posing and

resolving questions. Gramsci (1932-34) Selections from Prison Notebooks Notebook number 13; paragraph 17 (in Hoare and Nowell-Smith, 1971) However, the discussion so far has examined some of the difficulties of obfuscation and mystification where resistance is mounted and this does not give full due to the general acquiescence to government policy. I have referred to the spirit of hope and purpose which was decisive in creating the radical policies of the 1940s. From the perspective of the Marxist who believes a peaceful transition to socialism is possible, this should be perceived as the high point of class consciousness, understood as the perception of common plight and common identity accompanied by concerted action to create and use the necessary institutions for self-emancipation. Awareness of the lives of others contributed to a sense of common interest and common purpose. People interacted in ways and contexts which conferred a sense of shared identity. People were able to relate to each other as familiars rather than strangers. Both efforts and costs were shared and everyones lives were affected profoundly by common experience. By the end of the war, Britain was a highly self-confident nation. By this stage, the working class had created its institutions its political party and trade unions; now it expected those institutions to create the infrastructure through which societys resources would be put at the 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, which develops rapidly during the period of the war and its immediate aftermath. Existing organisations within civil society were strengthened and reinvigorated; new institutions especially at the local community level developed on an ad hoc basis in response to needs and necessary tasks as they presented themselves. Civil society was characterised by diversity and multiplicity, creativity and cooperation, but always orientated towards a common purpose. This common purpose might be served through local action for local needs but always in relation to an overarching societal purpose. People on average were four times less well off than we are now and consumerism was absent from popular culture. The civil society institutions interacted with, shaped and were shaped by political institutions. Moreover, circulating in these institutions of civil society whether they were large or small, local or national, permanent or improvised was not only the lived experience of economic crisis and its aftermath but also a steady accumulation of ideas about a different social order. The Beveridge Report, for instance, sold 635,000 copies and later when Labour were in power, its Party and associated membership (that of affiliated trade unions) was substantial and constituted a mass movement with the development of services characterised by local engagement and debate.

In relation to social revolution, Gramsci emphasised the importance of developing an alternative set of ideas in diverse institutions of civil society. These ideas formed part of a counter-hegemonic project to challenge the dominant and received wisdom. Gramsci argued against economism and the notion that social change would come about following an upsurge of revolutionary consciousness at the time of the inevitable economic crisis. Instead, Gramsci emphasised the superstructural and argued that history had to be made through the agency of political actors. Moreover, these actors needed to develop an ideology which went beyond the economic and corporate to a higher plane, Gramsci believed that in relatively stable states in Western Europe, the dominant interests were safeguarded not only by force or the threat of force but also by dominant ideas diffused through civil society 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 a powerful system of fortresses and earthworks behind the outer ditch of the state. The state could not be taken by a new dominant class without addressing civil societys fortresses and earthworks through either a war of movement or manoeuvre (in which artillery could open up sudden gaps in defences and troops be rapidly switched from one point to another to storm through and capture fortresses) or a war of position (in which enemies were well balanced and had to settle down to 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 about how society should be changed. During the second world war, the set of dominant values and ideas altered. What had been a set of ideas justifying 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 action through the state both to run key elements of the economy (in both the productive and the finance sectors) and to organise generous social provision. The thinkable and the do-able shifted; there was a new common sense. Participation in the war, taking responsibility in it had 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 a vis the state and as a result it became easier to take control of the state. This was always an interactive relationship between the institutions of civil society and those of the labour movement, each acting upon and shaping the other. The peoples war was in fact a war of manoeuvre. The new dominant ideas attracted a reasonable degree of consensus and certainly by 1951, the Conservative government left more or less intact the dramatic changes instituted by the preceding Labour governments.

But what have we now? We have in some respects virtually the opposite of this. We do have flourishing institutions of civil society but these are largely unshaped by the institutions of the labour movement. Although many are altruistically orientated towards assisting vulnerable members of the community or to contributing to some local collective effort, the orientation of many is highly individualistic, often of a lifestyle character, relating to the world through consumerism on behalf of self and family. Divisions abound with worsening levels of inequality fuelled by a regressive tax system. Spatial segregation predominates in housing and this has some impact on segregation in schools and other amenities. Differences between the in-country population and new arrivals, be they migrant workers or asylum seekers are accentuated by politicians among others. Andrew Pearmain (2006) has summarised the Gramscian analysis applied by Stuart Hall and others to the collapse of the postwar ideological and institutional settlement: Stuart Hall and other prominent Gramscians have argued a consistent and (I find) compelling narrative. The post-war social democratic consensus of Keynesian economics and welfare statism was broken in Britain in the 1970s, because the trade-off between capitalism and the welfare state was no longer sustainable. Thatcherism set about its dynamic, destructive/creative project of regressive modernization, producing an entirely different political and economic, and above all ideological climate. This culminated in the domination of neo-liberal capitalism and its associated politico-ethical framework in Britain and much of the rest of the world. Along the way, national-popular support was won for a whole range of measures, which would have previously been anathema, such as the sale of council housing, privatization of utilities, cutbacks in public services and benefits, and limitations on trades union power. This approach has been characterized as authoritarian populism. Certain key events served as intimidatory/educative jolts (recalling Gramscis pivotal couplet of coercion/consent) to public feeling, 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 the collective to the individual, from the public to the private, from society to family, from we to I, from production to consumption and congealed into a new, all-embracing and almost incontrovertible (i.e. hegemonic) common sense.

New Labour explicitly accepted this new settlement, and set itself the task of reshaping the people to suit the needs of the new global market economy, thus inverting the logic of orthodox social democracy. This implicitly defines the moment of Labours reversal of position as in the years prior to assuming office. The NHS has not escaped this trend towards individualisation. What we find in health policy is not a denial of the central importance of health services in peoples lives (and expenditure on the NHS has increased markedly from the end of Labours first term) but an attempt to reshape the relationship between the public and the NHS. The collectivist and institutional character of the NHS has been criticised by ministers on a sustained basis in recent years as monolithic and one-size-fits-all whilst, by contrast, patients are now encouraged to expect a personalised service characterised by elements of individual choice. This move to personalisation and choice has not on the whole come from patients and public but is largely a contrived and top-down initiative, started by Alan Milburn and further developed under John Reid and subsequent secretaries of state. The expressed wish of patients to spend longer with GPs to discuss different treatment options is not the model of choice being developed by government; instead patients are encouraged to select a provider from a menu of different providers in a supermarket model of patient choice. Moreover, patients are encouraged to connect this personalisation in the receipt of health services to the exercise of consumerist individual choice elsewhere in their lives. This attempt to foster not only a consumerist discourse but also a consumerist relationship between the patient and the service forms part of an ideological attempt to re-form, in the mind of the patient, health care as a commodity. This can be seen as an essential component in the Labour leaderships attempt to break the ideological and emotional bond between citizen and service and thereby to remove obstacles to further commodification. Reconfiguration of services contributes to the effort to weaken this bond since attachment to the NHS is to some extent attachment to specific institutions ones local hospital, the local cottage hospital, even ones GP surgery (though that might be more related to the person of the GP than to the premises themselves). Looking at it from a Gramscian point of view, the supplanting of a consumer model of public services in place of a citizenship one is highly significant. Catherine Needham (2003) has examined how a transformation occurs in the articulation of the relationship of the individual to the state. The individual ceases to be a citizen engaged in an ongoing relationship to the state in which considerations for the present and future needs of other citizens were paramount but now becomes a consumer engaged in short-term, self-interested exchanges with different agencies in which the individuals wants and

preferences are paramount. Thus, consumerism goes beyond economic relations to infuse meaning throughout society more generally and forms part of an ideological bulwark against effective challenges 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 a context of a highly disparate working class and of a well resourced and well organised state and capitalist class. Offe and Wiesenthal (1980) identify the diversity of workers as a key impediment to collective action particularly in terms of developing effective institutions. They argue that the institutions of capital and of the state function more effectively on a hierarchical basis but that this structure is ill-suited to popular collectivism which requires an ongoing dialogue between grassroots members and the leadership. What is striking about the efforts to resist Labours rightward progress generally and not just in health is the absence of an institutional framework in which a defence can be mounted and new ideas about policy alternatives generated. In the past, trade unions and political party served this purpose but they do not do so now and these traditional institutions of the working class have been declining. The trade unions mounted a modest and short-lived campaign against privatisation in 2001 but stood down after the events of September 11th on the grounds that the media were preoccupied with what became the war on terror. NHS Together was formed in 2006 bringing together for the first time all the trade unions and associations in the health sector. It mounted one parliamentary lobby and one halfhearted national demonstration (of only 5,000 people!) and seems to have collapsed virtually without trace. More generally, trade unions are weak with little more than half their membership at their peak. We dont have the industrial trade unions of old - or at least these are far less significant within the trade union movement as whole. Instead we have more service sector unions with an overwhelming preponderance of public sector members. These do not face the harshness of the capitalist worker relation to sharpen their senses and their actions. Moreover, any industrial action, since it affects immediately a more or less vulnerable client group and the very members of the public whose support they need to legitimise their action, is at best morally ambiguous. In addition to this, the retention in the UK of anti-trade union legislation along with various opt-out from EU wide protection of workers rights prohibit the lawful staging of virtually any solidarity action. Lawful action involving the withdrawing of labour eats into the limited resources of the trade unions and unlawful action risks on top of this the sequestration of assets. The state by contrast can spend hundreds of millions defeating trade unionists if it so wishes.

Party membership has declined across all the major parties and Labours rupture of the link between the motion passed at the local constituency party and the policy ultimately adopted by the Party leadership may have contributed to this. Engagement with formal politics is in decline and explanations draw variously on a range of possible causes: the absence of real differences between the main parties; the remoteness of politicians from the lives of ordinary people; ever more scientific approaches to electioneering so that small population categories are targeted instead of electoral approaches that seek to persuade all voters; the treatment of policies as products to be marketed; and excessive use of spin undermining confidence in politicians honesty (see, for instance, Todd and Taylor, 2004; McHugh and Parvin, 2005). Outside both trade union and political party, citizens and NHS patients have attempted to organise independently. A myriad of local campaigning groups have emerged set up to defend local health services under threat. These campaigns have varied enormously in their size and capacity (although there is no systematic research on them to date). There have been moves to draw this together into campaigning networks (e.g. Keep our NHS Public) but their effectiveness has been patchy. It is true that the full swathe of reconfigurations predicted by the Chief Executive of the NHS in October 2006 to affect 60 hospitals has not yet occurred and the number of closures of hospital departments such as A&E has been more modest (and is unlikely to grow much before the next general election). On the other hand, the Department of Healths strategy of using clinicians (most notably the heart surgeon, Sir Ara Darzi) to persuade the public that the reconfiguration of local services is in their interests has developed significantly over the past 18 months or so and has focused on the vaguer concept of transferring services out of hospital into the community (rather than the stark proposal to close a particular hospital department). Notably, the vast majority of the parliamentary party and trade union leadership have acquiesced to the policies and direction of the Labour leadership. It is an extraordinary thing that despite the dramatic overhaul of the health service, not a single Labour backbencher can be found who will consistently articulate on public platforms and national media the anti-privatisation case. The relationship between popular Save our NHS type campaign groups and the trade unions has been faltering and problematic. This is a crucial factor in the demise of the NHS: were a Conservative government to attempt these policies of privatisation and marketisation, they would face the more or less united wrath and political action of the labour movement. When it is the political leadership of the labour movement itself which pursues these policies, opposition is halting, compromised and divided. Whats more, Labours leadership has itself been informed by Marxist analyses.

Partly as a result of the decline of these institutions, their limited engagement with wider groups in civil society and the diminished role they play in peoples lives, many have forgotten or never learnt the rationale for collective provision and equity of access; they have forgotten or never learnt the associated arguments, vocabulary and concepts and they do not find these consistently articulated anywhere. It should be pointed out that a degree of speculation arises since we do not know what the public think about health policy in any sophisticated way. There is no depth research on broad public attitudes towards health policy. There are patient satisfaction surveys, opinion polls which ask very general questions and reports from deliberation exercises but no broad sociological studies of public views of health policy and the meanings the public confer upon the NHS and its restructuring. Similarly, we have no ethnography of health service workers and their perceptions of current developments. Lay theories among campaigning activists as to the lack of engagement of the public often focus on the role of the media: it is suggested that the lack of media coverage of privatisation in practice is to blame or the manner of media coverage is to blame or the manner of government spin is to blame or the powerlessness learnt through failed action is to blame. One of the debilitating characteristics of the anti-privatisation movement/anti-privatisation initiatives is precisely that they are anti. In other words, the absence of a positive policy agenda and an alternative vision of what the health service should look like leave campaigners always defending a status quo and unable to negotiate for anything from a position of principle. The reasons for this lacuna in ideas and policy relate in part to the absence of left think-tanks developing blue skies thinking and practical policy suggestions. However, if Gramsci is to be taken seriously, a successful challenge to the new capitalist ascendancy in health requires not merely a consideration of the political and economic but also the mounting of a counter-hegemonic project. This involves the development and diffusion of a different set of ideas which can enable people to conceptualise their situation differently. This takes us finally to the question of the intelligentsia and us. Policy academics who might have been expected to speak out against the restructuring of the NHS in, say, the way they have from time to time in relation to questions of poverty, have in the main declined to do so. This is particularly the case in terms of collective interventions such as multi-signatory letters to the newspapers. With one or two high profile exceptions, health policy academics have tended to keep their heads low. In Gramscian terms, the degree to which the academic community now addresses the concerns of the powerful in the terms

set by the powerful (eg via commissioned research) potentially renders us the intelligentsia of the dominant class. References Avineri, S. (1970) The Social and Political Thought of Karl Marx, Cambridge: Cambridge University Press Bevan, A. (1952) In Place of Fear, London: Quartet Books Beveridge, W. (1942) Beveridge Report: Social Insurance and Allied Services Bottomore, T. (ed) (1983) A Dictionary of Marxist Thought, Blackwell Boyle, S and Steer, R. (2008) The sham of NHS consultation on service provision, Radical Statistics, Issue 96, pp60-76 Office of the Actuary in the Centers for Medicare & Medicaid Services (2008) National Health Expenditures: Forecast summary and selected tables. Crouch, C. (2000) Coping with Post-Democracy, Fabian Ideas No.598, London: Fabian Society Dunleavy, P. and OLeary, B. (1987) Theories of the State: The Politics of Liberal Democracy, Basingstoke: Macmillan Esler, J. (1986) An Introduction to Karl Marx, Cambridge: Cambridge University Press Farnsworth, K. (2004) Corporate Power and Social Policy in a Global Economy: British Welfare Under the Influence, Bristol: Policy Press Ferguson, I., Lavalette, M. and Mooney, G. (2002) Rethinking Welfare, London: Sage Fernbach, D. (1973) Introduction, in K Marx: The Revolutions of 1848, Harmondsworth: Penguin Fraser, D. (1984) Evolution of the British Welfare State, Basingstoke: Macmillan (2nd edn) George, V. and Wilding, P. (1989) Ideology and Social Welfare, Routledge and Kegan Paul Gladstone, D. (ed) (1999) Before Beveridge: Welfare before the Welfare State, London: Institute of Economic Affairs Gramsci, A. (1971) in Q Hoare and G Nowell Smith (eds) Selections from the Prison Notebooks, Harvard University Press M Hellowell and A Pollock (2007) Private Finance, Public Deficits: A Report on the cost of the PFI and its Impact on Health Services in England, Centre for International Public Health Policy, University of Edinburgh Hennessy, P. (1993) Never Again: Britain 1945-1951, London: Verso Hewitt, P. (2005) Even Nye Bevans NHS saw a role for the private sector, The Guardian, 2nd July Higgins, J. (1988) The Business of Medicine: Private Health Care in Britain, Basingstoke: Macmillan Laski, H (1934) The State in Theory and Practice, Allen and Unwin Lister, J. (2003) Not so Great: Voices from the Front-Line at the Great Western PFI Hospital in Swindon, London: Unison Marx, K. and Engels, F. (1847/8) The Manifesto of the Communist Party, in Karl Marx: The Revolutions of 1848 (op cit)

McHugh, D. and Parvin, P. (2005) Neglecting Democracy, Hansard Society McLellan, D. (1973) Karl Marx: His Life and Thought, Basingstoke: Macmillan McLellan, D. (1998) Marxism after Marx, Basingstoke: Macmillan OConnor, J. (2002) The Fiscal Crisis of the State, New Brunswick: Transaction Publishers Miliband, R. (1969) The State in Capitalist Society, Weidenfeld and Nicolson Needham, C. (2003) Citizens-Consumers: New Labours Marketplace Democracy, London: Catalyst Offe, C. and Wiesenthal, H. (1980) the two logics of collective action theoretical notes on social class and organisational form, in M Zeitlin (ed) Political Power and Social Theory, New York: JAI Press Pearmain, A. (2006) Gramsci and Us, Compass Online http://www.compassonline.org.uk/uploads/documents/GramsciforC ompass.doc Player, S. and Leys, C. (2008) Confuse and Conceal: The NHS and Independent Sector Treatment Centres, Monmouth: Merlin Press Pollock, A. (2004) NHS plc: The Privatisation of Our Health Care, Verso (2nd edn) Poulantzas, N. (1973) Political Power and Social Classes, London Ruane, S. (2000) Acquiescence and opposition: the private finance initiative in the National Health Service, Policy and Politics, Vol 28, No.3, July Ruane, S. (2004) Anti-privatisaiton politics, in M Todd and G Taylor (eds) Democracy and Participation, London: Merlin Ruane, S. (2007) Acts of distrust? Support workers experiences in PFI hospital schemes, in G Mooney and A Law (eds) New Labour / Hard Labour: Restructuring and Resistance inside the Welfare Industry, Bristol: Policy Press Ruane, S. (2008) One modest brick?: Independent Sector Treatment Centres and the Re-Commercialisation of the NHS, Radical Statistics, Issue 96, pp115-124 Saville, J. (1957) The welfare state: An historical approach, New Reasoner, Vol 3, No.1, pp5-25 Todd, M. and Taylor, G. (2004) Introduction, in Todd, M. and Taylor, G. (eds) Democracy and Participation: Popular Protests and New Social Movements, London: Merlin Unison (2003) The PFI Experience: Voices from the Front-Line, London: Unison Wanless, D. Appleby, J. Harrison, A. and Patel, D. (2008) Our Future Health Secured? A Review of NHS Funding and Performance, London: Kings Fund Webster, C. (2002) The National Health Service: A Political History, Oxford: Oxford University Press (2nd edn) Whiteside, N. (1999) Private provision and public welfare: National Health Insurance between the wars, in D Gladstone (ed) Before

Beveridge: Welfare before the Welfare State, London: Institute of Economic Affairs Dr Sally Ruane sruane@dmu.ac.uk