The United Kingdom’s National Health Service (NHS) is an institution which seems to uphold the remains of a British socialist welfare ideal. However, due to chronic underfunding, this care is severely under strain. At first glance, the NHS is a service that brings the public together. The NHS is an equaliser, providing care to Brits from all different backgrounds, lifestyles, and identities. Yet, digging a little deeper, it seems that not everyone must endure the long waiting times, lack of resources, and understaffed aspects of the NHS. Wealthy members of society like Rishi Sunak, Britain’s current Prime Minister, register with increasingly popular private health services. [1] These private clinics like the one Sunak utilises offer more availability, efficiency, and a price tag to match. Margaret Thatcher also utilised private healthcare, arguing that the availability of healthcare at any time was essential for her. [2] Thatcher’s use of private healthcare reflected a lack of faith in the capabilities of public services and her policies of increased healthcare privatisation. While Sunak has recommitted to promises of shorter waiting times and access to urgent care, his personal decisions reflect an underlying disinterest in the maintenance of public services. [3]
Marxist theory outlines public space and goods as, originally, land which was utilised and maintained collectively. [4] These public services are a modern manifestation of public space and working class collectivity, and parallel Marxist thought. This article explores this dispossession of public services through a Marxist lens.
The NHS has been around since 1948 when it universalized healthcare coverage, nationalised hospitals, and abolished direct payments. [5] It is funded by the federal government and national insurance contributions and began as a centralised health system. [6] However, Margaret Thatcher’s government introduced increased separation of patient and provider responsibilities, arguing that these policies would increase individual choice.Yet these policies, alongside the overall development of private services and insurance companies, served to further the privatisation of the NHS. Following Thatcher’s government, New Labour seemed to make a stand against this privatisation, yet their NHS Plan in the year 2000 further decentralised hospital leadership, agreed to use private facilities and resources within the NHS, and introduced even more consumer choice and market involvement. [7]
The gradual deterioration of the NHS is not simply due to directly liberalising policies. Policy drift, which characterises the process by which policies become less effective overtime, is another factor. Policy drift occurs as a result of a variety of societal changes including inflation, and increased needs. It essentially results in the previous policy which offered a certain amount of funding, provision, or other welfare becoming less relevant or less useful, creating, with no political effort, services which fall into disrepair. The NHS has been a victim of policy drift for many years, and the Coronavirus pandemic exacerbated the lack of staff, resources, and time that was already an issue. When public services become more ineffective in liberal economies where the market is empowered, private companies see an opportunity to make a profit.
Modern Marxist Theory
Applying Marx’s theory of ‘so-called primitive accumulation’ to the deterioration of the NHS can help offer critical analysis of modern structures and policies, as well as draw comparisons to historical phenomena. Primitive accumulation is the process by which public, shared spaces become enclosed, privatised, and monetizable for the wealthy elite. [8] The creation of these enclosed spaces separates the public from what was formerly seen as public goods. These public goods can take many forms, originally identified by Marx as the common land which, when enclosed, separated the producers from their original livelihood and means of production and created a reliance on waged labour. [9]
The notion of primitive accumulation when applied to contemporary enclosures must look beyond physical dispossession towards ideological and political dispossession. Common processes of contemporary dispossession include the privatisation of the public sector, gentrification, strategies of zoning and development which displace communities and uphold market and business interests, surveillance of public spaces, and creation of lawless private spaces for the elite, to name a few. [10] Further processes of accumulation include ‘stock promotions, Ponzi schemes, … asset stripping, … promotion of levels of debt’ which debilitate the working class. Stuart Hodkinson, author of The New Urban Enclosures argues that these policies and practices are rooted in a neoliberal, capitalist ideology, rationalising the privatisation of public spaces through the argument that private services offer purity, security, and peace for the public. [11] With this rationality, contemporary processes of enclosure seek out new spaces and networks that embody the commons of Marx’s original theory. [12] The essential aim, no matter the process, is to separate people from access to social wealth and connection, making producers and production oppositional and independent variables. [13]
A Marxist Perspective of NHS Privatisation
The NHS represents a space that both provides work and care. Welfare spaces often embody this dualistic nature of give and take. Whether it is the labour of individuals employed in public services or money paid through taxes to fund the service, all individuals in a society give to this public resource. And whether or not they choose to opt into the service itself, all individuals can also receive the benefits of this same service. The same logic applied to the common land which peasants relied on through their own labour and harvest; a common space through which members of society can be connected to the means of production and the product itself, requiring no more than is necessary to live.
Privatisation in the NHS reflects a profit-oriented view of these public spaces. The spaces necessary for society’s functioning can be commodified, with the benefits reaped becoming imbalanced. The benefits of the NHS, which can be identified as the variety of healthcare provisions an individual might need, turn instead to the potential profit when healthcare is instead privatised. This can be seen in the multitude of private healthcare, healthcare insurance, and a variety of other providers in the United States, which can, in their pursuit of profit rather than care, ‘artificially inflate’ insulin prices , charge thousands for ambulance rides, and pressure patients into unnecessary services. [14]
When wealthy individuals like Rishi Sunak turn away from the struggling public sector towards private options, they not only demonstrate their lack of faith in these services, but turn their investments towards private providers which undermine public services. What healthcare and other public services and unenclosed spaces require is maintenance and social investment; a trust in a system that will both give and take, and create a more enjoyable society by uplifting everyone. Those advocating for more and more private services don’t realise that as they empower these private companies, they themselves lose power as public citizens. As private providers gain a hold on the market through the accumulation of these wealthy supporters, they gain the power to control market values and are able to orient even more towards profit rather than provision.
There are many pervasive narratives in all areas of politics, with varying degrees of truth. One such story is that of stigmatisation. The separation of us and them, payers and receivers, circulates around and supports the continuation of liberal welfare states: states which focus on private welfare provision and market success. [15] These narratives of the US ‘welfare queen’, British tabloid stories of generational worklessness, and many more, create motivation for the public to turn towards private services, where they believe their investment is more fair. [16]
However, the fairness of welfare and healthcare in particular is not seen in the small scale, current state of one’s finances. The taxes one pays over the course of employment provides public services for oneself at birth, through the unemployed years of childhood, and into retirement and old age. Healthcare, and the NHS, are not stealing taxpayer funding for some unknown group of people reaping the benefits of one’s hard labour. They are providing social security over the course of an individual’s life, through ups and downs. The motto of public services could be understood as giving what you can, and taking what you need. The larger picture of what a well-funded NHS can provide for society includes one’s health over a lifetime, the public space which allows members of society to exist both collectively and freely as healthy individuals, and an equalisation of wealth to provide everyone with what they need.
Endnotes:
[1] Pippa Crerar, “Rishi Sunak Is Registered with Private GP Practice Offering £250 Consultations,” the Guardian, November 21, 2022,
[2] Ibid.
[3] Ibid.
[4] Marx, Karl. Capital: A Critique of Political Economy Volume I Book One: The Process of Production of Capital. 1st ed. Moscow: Progress Publishers., 1887.
[5] Cliff Alcock, Guy Daly, and Edwin Griggs. Introducing Social Policy. Harlow: Pearson Education Ltd, 2008. p. 243
[6] Ibid.
[7] Alcock, Daly, and Griggs
[8] Hodkinson, Stuart. “The New Urban Enclosures.” City 16, no. 5 (October 2012): 500–518. https://doi.org/10.1080/13604813.2012.709403.
[9] Marx.
[10] Hodkinson.
[11] Harvey, David. “The ‘New’ Imperialism: Accumulation by Dispossession.” Socialist Register 40 (2004): p. 74. https://socialistregister.com/index.php/srv/article/view/5811/2707. and Hodkinson.
[12] Hodkinson.
[13] De Angelis, Massimo. “Marx and Primitive Accumulation: The Continuous Character of Capital’s Enclosures.” The Commoner 2 (2001): 1–22. https://www.researchgate.net/publication/268411539_Marx_and_primitive_accumulation_The_continuous_character_of_capital’s_enclosures/citation/download
[14] Byrnes, Dave. “Illinois Attorney General Sues over Sky-High Insulin Prices.” www.courthousenews.com, December 2, 2022. https://www.courthousenews.com/illinois-attorney-general-sues-over-sky-high-insulin-prices/.
and Makary, Marty. The Price We Pay. Bloomsbury Publishing USA, 2019.
[15] Esping-Andersen, Gøsta. The Three Worlds of Welfare Capitalism. Cambridge: Polity Press, 1990.
[16] Hancock, A. M. “Contemporary Welfare Reform and the Public Identity of the ‘Welfare Queen.’” Race, Gender & Class 10, no. 1 (2003): 31–59. p.45
Bibliography
Byrnes, Dave. “Illinois Attorney General Sues over Sky-High Insulin Prices.” www.courthousenews.com, December 2, 2022. https://www.courthousenews.com/illinois-attorney-general-sues-over-sky-high-insulin-prices/.
and Makary, Marty. The Price We Pay. Bloomsbury Publishing USA, 2019.
Cliff Alcock, Guy Daly, and Edwin Griggs. Introducing Social Policy. Harlow: Pearson Education Ltd, 2008. p. 243
De Angelis, Massimo. “Marx and Primitive Accumulation: The Continuous Character of Capital’s Enclosures.” The Commoner 2 (2001): 1–22. https://www.researchgate.net/publication/268411539_Marx_and_primitive_accumulation_The_continuous_character_of_capital’s_enclosures/citation/download
Esping-Andersen, Gøsta. The Three Worlds of Welfare Capitalism. Cambridge: Polity Press, 1990.
Hancock, A. M. “Contemporary Welfare Reform and the Public Identity of the ‘Welfare Queen.’” Race, Gender & Class 10, no. 1 (2003): 31–59. p.45
Harvey, David. “The ‘New’ Imperialism: Accumulation by Dispossession.” Socialist Register 40 (2004): p. 74. https://socialistregister.com/index.php/srv/article/view/5811/2707.
Hodkinson, Stuart. “The New Urban Enclosures.” City 16, no. 5 (October 2012): 500–518. https://doi.org/10.1080/13604813.2012.709403.
Marx, Karl. Capital: A Critique of Political Economy Volume I Book One: The Process of Production of Capital. 1st ed. Moscow: Progress Publishers., 1887.
Pippa Crerar, “Rishi Sunak Is Registered with Private GP Practice Offering £250 Consultations,” the Guardian, November 21, 2022,
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