The cost of marketising Britain’s NHS

Twenty years ago, with Tony Blair still prime minister, I struck up a conversation with a stranger on a train. His eldest was about to enter infant school and he was bewildered by the choices – or as I would put it, the chimera of choice – confronting him and his wife.

We don’t want to have to choose from half a dozen different schools. We want there to be one school for our catchment area and for it to be good.

I speak often of neoliberalism  but while I take care to define other terms I see as vital – ruling class ¹ and imperialism  ² for instance – my use of the n-word has been impressionistic. I hope to put that right in a future post but for now what I mean is the reification/deification of market solutions for every problem; a corollary being the relentless search to shrink the state.

But markets aren’t all they’re cracked up to be. A national economy may indeed be energised by freeing up markets for the pursuit of private profit and capital accumulation but that energy is wayward and anarchic even on its own terms. Full of internal contradiction. Take Britain’s coal, rail and steel sectors prior to nationalisation by the 1945-51 Attlee government. Though hailed as a victory for socialism, this narrative obscures another: that coal, rail and steel were vital to a powerful, profit-led industrial capitalism – but were themselves running at a loss. The paradox was resolved by transferring them from private to public hands.

For the differences between on the one hand an industrial capitalism whose critical sectors are protected by a strong state – as in Britain 1840-1980 and in China today – and on the other the financialisation ³ of neoliberal economies, see Why read Michael Hudson? In it I wrote of:

… the state funding of infrastructure (roads, rail, ports) and education: burdens that must otherwise fall upon private capital, raising production costs. And as the growing complexity of industrialisation demanded a better trained and more experienced workforce, longevity became an issue. Workers dying in their thirties had not much mattered in the early days – provided they bred copiously first – but now the expenses of training argued for taking better care of them. Cue for Factory Acts, Food Adulteration Acts, public sanitation projects and curbs on child labour from the 1840s onwards ….

Here I’ll hand over once again to modern monetary pundit and tax specialist Richard Murphy. On his Funding the Future blogsite today, the professor has this to say of Britain’s NHS and education system, both on life support.

As the FT notes this morning:

The British government could save at least £20bn a year by modernising IT systems, tackling fraud and getting a grip on failing mega-projects such as the HS2 rail line, according to the head of the UK government’s independent spending watchdog.

To be candid, I really do not doubt it.

But imagine how much more it could save if it stopped pretending that so much of the public sector was made up of independent organisations competing with each other rather than cooperating to provide integrated services.

Take this on the NHS. There are:

• • 42 integrated care boards, which each have an integrated care partnerships
  • 229 total number of trusts, including 154 foundation trusts
  • 50 mental health trusts
  • 10 ambulance trusts
  • 124 acute trusts

Each of these will spend its life:

• • Creating duplicated policy
  • Accounting furiously to each other, billing like crazy and employing an army of accountants to reconcile the results
  • Have its own PR and comms teams
  • Spend a fortune on websites, glossy annual reports and more
  • Duplicate management structures

And all for no gain and a lot of cost. Regional strategic health authorities could solve that.

And then there is education, where in 2022 (I struggled to find more up-to-date information quickly), there were 2,539 multi-academy trusts operating in England, made up of nearly 10,000 schools. That still left 17,500 outside trusts, rather surprisingly, but all these trusts suffer all the problems noted above, and destroy the chance of integrated education provision in any area, which should be the goal.

What if we got rid of all this nonsense? What would that save?

* * *

1. Like most Marxists I define a ruling class by its monopoly ownership of some essential of wealth creation. All else flows from that.
2. Modern imperialism, whose major powers show high but not total overlap with those of the colonial era, is defined by the export from global north to south of monopoly capital, and south to north repatriation of profits – or more precisely, surplus value. (Another way of putting this is that the relations of production studied by Marx and Engels in mid 19th century Britain became increasingly globalised – north = capital; south = labour – after WW2.) Where the wealth transfers of European colonialism were enforced directly by armed might, those of imperialism are enforced by armed might mediated by debt and dollar rule. The threat to imperialism – from Eurasia rising … from the BRICS …  from a steady weakening of both petrodollar, and dollar as world reserve currency – and the inept but terrifying responses by Washington and its satellites to that threat are what now make the world so dangerous.
3. Financialisation of Western economies is a key aspect of neoliberalism, its limitations driven home by the West’s failure to defeat Russia in Ukraine. Mesmerised by her smaller GDP – an increasingly unreliable metric of productive capacity – Washington, London and Brussels massively underestimated Russia.