Tag: Neoliberalism

Neoliberalism: Rhetoric and Reality.

This paper was prepared as background to the 4th edition of ‘Communication and Interpersonal skills in nursing (Grant, A. and Goodman, B. forthcoming). In that book discourses of neoliberalism and their effects on health and health service delivery as well as the interpersonal communications nurses have with people will be explored and critiqued. An example is the discourse on ‘individual responsibility for health’ and ‘lifestyle drift’ responses to public health which draw upon the concept of ‘sovereign individual’ of neoliberal philosophy. This paper explores what neoliberalism might be to argue that it is more a discursive practice than a political action.

 

Neoliberalism is at once everywhere and nowhere. There is ‘appearance’ and ‘reality’, there is reification and fetishisation. Its name is spoken in certain circles and vilified (Springer 2016), it is an ‘imprecise exhortation’ (Thorsen and Lie 2007, Thorsen 2009), in others there is denial that it even exists (Talbot 2016). It might be best to understand neoliberalism as a ‘discourse’ (Foucault 1969) rather than an actuality of political practice, as a “rather radical set of ideas which nevertheless have had a certain influence on society and politics in recent times” (Thorsen 2009 p20).  It is a word used by the progressive and critical left, e.g. Saad-Filho and Johnson (2005), to counter what the right call the ‘free market’ in the context of the breakdown of the post war consensus around the social welfare democratic state.

 

I suggest that the discourse of the ‘Free Market’ was, and is, used to reshape the State, and civil relationships, away from ownership and control of the means of production, away from Keynesian state intervention in the economy and away from providing all social security (including housing, health, education, and transport). Free market rhetoric is used to mask the reshaping of State apparatus towards State intervention for wealthy landowners and corporates (financial and industrial). This is a bid by a capitalist class to (re)capture the State’s support for capital and property accumulation in their favour. This ‘support’ is referred to as a ‘framework’ in which ‘free’ markets are to operate. I also argue that there is nothing ‘neo’ or ‘new’ about the practical reality of this form of liberalism, tied as it is to the capitalist State.

 

The term ‘Free market’ is often preferred to ‘neoliberal’ by its supporters according to Talbot (2016) and Thorsen (2009) who argues that the term neoliberal is now most often used in a pejorative way by the left. We say ‘Neoliberal’ you say ‘Free Market’. ‘Free market’ or ‘neoliberal discourse’ is used as part of the Ideological State apparatus backed up by the Repressive State apparatus of the judicial system, police and ultimately, if needs be, the military.

 

An important idea of ‘Free Market/Neoliberalism’ is the espoused theory of a minimalist State. The theory in action is a State becoming minimal for social security but otherwise continuing the facilitation of capital accumulation and the ownership of wealth especially by the 0.01%. The ‘Nightwatchman’ minimal state of the 19th century is a goal of free market (or liberal) ideology, but this has not been achieved for all of the talk of the Reagan/Thatcher years of the 1980’s. This is possibly because the reduction of State spending down to 10% of GDP from the current 40% of GDP (per year, see figure 1 in the appendix) would be as disruptive for the capitalist class and the political power elites as it would for everyone else. This is also because key sectors of the economy such as agriculture, the military-industrial complex, and the nuclear power and fossil fuel industries, rely on government funds and subsidies without which their business models would have to be radically altered. Capitalism’s ‘creative destruction’ is a lauded dynamic feature, as long as its not your industry or business model that goes bust or, in the jargon; is ‘disrupted’.  It is also because in theory, liberalism is not a monolithic philosophy, ‘classic’ and ‘modern’ Liberalism (Ryan 1993) have different views of the State’s role.

 

The minimalist state (‘Nightwatchman’) ‘classic liberal’ solution to questions of political economy might still be the goal of some current thinking. This may include the Tea Party in the US, kicked into life by Rick Santelli’s comments on President Obama’s mortgage bail out plan (Pallasch 2010),  and perhaps in the UK by the Adam Smith Institute. Yet in current practice many of the Conservative capitalist class, and their political voices in the Tory party, seem as wedded to state intervention as they claim socialists to be.

 

Neoliberalism as a discursive practice, embedded and supported by an ideologically driven, highly funded ‘intellectual’ infrastructure, can also be linked to around 1,000 self conscious neoliberal intellectuals organised in the Mont Pelerin Society (Plewhe et al 2007). Its proponents fight for hegemony in research and development, and engage in political and communication efforts with well funded, well coordinated and highly effective new types of knowledge organisations: partisan think tanks such as the Cato Institute and the Heritage Foundation in the US, the Institute for Economic Affairs (IEA) and the Centre for Policy Studies (CPS) in the UK and the Institute of Public Affairs in Australia (IPA) (Beder 2001).

 

A Discursive Project.

 

This is an ongoing rhetorical project in the UK because as Desai (2007) argues, the values and principles of Thatcherism, which did not call itself neoliberal but did emphasis similar ‘free market, small state’ principles mixed with ‘Victorian values’,  were not wholly accepted by the British public. This is evidenced in surveys of public opinion in the 1980’s and 90’s and arguably even today if support for the socialist inspired NHS is an indicator.

 

Support in elections since 1979 have not won over majorities of the electorate, and it is only thanks to first past the post that Tories and clause 4 ditching ‘Tory lite’ New Labour, were able to win. See figure 1 (appendix) which shows what % of the electorate actually voted for the government of the day.

 

These figures show that at its peak only 33% of voters could be bothered to put an x next to free market rhetoric. This was down to 24% by 2015. Neoliberals/Thatcherites/ Conservatives have not won the hearts and minds of the British Electorate and neither has the goal of a small state in terms of GDP spend been achieved. Their success in the US and the UK, is to be measured not by the popular vote, but by their assaults on Trade Unions, by Privatisations, Tax breaks and Labour market and Financial deregulations.  And by the increasing share of wealth and high pay going to the 1% and 0.01% (Saez and Zucman 2014, Dorling 2014, Moshinsky 2016).

 

I argue here in accordance with Desai (2007) that:

 

“Market dogma may well be entrenched in capitals around the world, but its intellectual vacuity and practical failures have been documented in a vast literature. It would be truer to say that neoliberalism’s intellectual pretensions are designed to provide a fig leaf of intellectual respectability to the most naked pursuit of the interests of capital and property (my emphasis) than that neoliberalism has motivated this pursuit by intellectual force and political influence” (Desai 2007 p220).

 

In other words, powerful and rich individuals have used talk of free markets (and neoliberalism) to justify their ongoing grab of global wealth through using the levers of State power, rather than it being the case that the intellectual case motivates their actions.

 

Graham Scambler (2012) also points in this direction in his exposition of the ‘Greedy Bastards Hypothesis’ which is underpinned by the strategic actions of ‘focused autonomous reflexives’ in the capitalist class executive and the political power elite.

 

 

 

 

Discourse

 

 

In common understanding a ‘discourse’ is an exchange, perhaps of ideas, between two people involving language as the medium of transmission. This can be seen as a neutral exercise between two people of equal power and status using certain phrases, words, jargon and syntax to share understanding or to question the other’s statements. Consider the situation when two Tory MPs are talking to each other about a ‘flexible labour market’  or the need for people to be ‘taking responsibility for one’s health’. The first is an example of the neoliberal/free market discourse that favours weak labour regulations to make it easy to hire and fire staff making them ‘flexible’. The second brings in and joins the ‘Moral Underclass discourse’ (Carlisle 2001) to the free market’s central idea of ‘free sovereign individuals’ in charge of their own destiny in order to shift responsibility fully onto the shoulders of individuals. This discourse can then blame individuals for being obese, for smoking or for any other ‘moral failing’ such as catching an STI or binge drinking.

 

Discourse as a critical concept is associated with Michel Foucault. For Foucault (1969) discourses are institutionalised patterns of speech and knowledge seen and felt in ‘disciplinary’ structures, e.g. in the medical clinic or in the prison (Foucault 1963, 1975). Discourses connect knowledge to power. Knowledge is power. To oversimplify, the concept refers to the idea that a discourse shapes, or constructs what we know, what we can say and also reflects differences in power between people. Becoming a Tory MP introduces one to the institutionalised patterns of speech which might be very familiar to that experienced in public schools (e.g. Eton) and certain Oxbridge clubs (e.g. Bullingdon).

 

 

 

 

Discourses are more than mere words.  A discourse, Foucault (1969) suggested, actually brings into being that of which they speak.

 

“…discourses…are nota mere intersection of things and words….

 

The task of analysing discourses is to show that they are not just:

 

groups of signsbut as practices that systematically form the objects of which they speak.discourses are composed of signs; but what they do is more than use signs to designate things. It is this more that renders them irreducible to language and to speech. It is this morethat we must reveal and describe (1969 p 54)” (my emphasis).

 

By continually repeating the discourse, and getting it accepted by enough people, that “There is no money” or “There is no Alternative” or “Labour caused the public debt” or “Banks are too big to fail” or “Top cornflakes rise to the top” or “high pay rewards hard work and intelligence” or “Inequality is good for competition” or “Skivers v Strivers” or “In this together” or “we must balance the books and bring down the deficit” these things are brought into being. They are part of a larger, taken for granted, understanding of the ‘proper’ role of the state, the individual and the corporation.

 

 

What then is ‘Neoliberalism’ and what is formed by that of which it speaks?

 

 

Traditional Enlightenment ‘classical liberalism’ (Ryan 1993) emphasises:

 

  1. Individual Freedom (liberty) through limiting government and maximising capitalist market forces.
  2. Civil liberties under the rule of law and laissez faire economics.
  3. Free markets, utilitarianism, natural law (inherent rights which are universal, uncovered by reason) and progress.

 

Key thinkers: Adam Smith, John Locke, Thomas Hobbes, David Ricardo. Alexis de Tocqueville

 

Modern liberalism accepts a greater role for the State in the economy, manifested in regulation and the State supplying of goods and services (Ryan 1993). Laissez faire economics cannot in this interpretation meet the goals and purposes of liberalism. Thorsen (2009) argues that liberalism has many facets and has become in effect a contested concept particularly over the role of the State.

 

 

Neoliberalism is associated with ‘Austrian’ economists Ludwig Von Mises (1881-1973), Friedrich Hayek (1899-1992) and the American economist Milton Friedman (1912-2006). Around 1950, the classic liberal state had grown into, for some, a social democratic monster driven by Keynesian economic theory and the growth of Welfare States. In both the US and the UK, governments were beginning to spend more and more of GDP and intervening in many areas of the economy including social security programmes. Von Mises, Hayek and Friedman would have noted that the share of GDP spent by the State on welfare and public services had grown from about 10% in the middle of the 19th Century (figure 2 in the appendix) to around 40% by the 1970’s.  Today the share of GDP spent by the government in the UK is about 41% (figure 3 in the appendix).

 

In the context of the centrally planned Soviet Union and Hitler’s Germany, Hayek (1944) argued that any government control of economic decision making through central planning leads to tyranny and that civilisation requires liberty as a prerequisite for wealth and growth (1960). Hayek and Freidman (in the 1950’s) referred back to classical liberalism rather than ‘neoliberalism’ in their reaction to the amount of state intervention in the economy.  Yet, they accepted some aspects of welfare provision by the State although this provision in their view should be greatly reduced. Their status as fringe economists  in the 50’s was altered when their economic theory and political philosophy was then taken up by Reagan in the US and Thatcher in the UK around the late 1970’s. At this point there had been a sort of post WW2 consensus between Conservatives and Labour regarding the level of state intervention in the economy.

 

 

 

Margaret Thatcher was to change that cosy relationship.

 

At a Conservative Party policy meeting in the late 1970’s, Thatcher made it clear upon what her approach to the economy was based:

 

Another colleague had also prepared a paper arguing that the middle way was the pragmatic path for the Conservative party to take…the new Party Leader [Margaret Thatcher] reached into her briefcase and took out a book.  It was Friedrich von Hayek’s The Constitution of Liberty…..she held the book up for all of us to see.  ‘This’, she said sternly, ‘is what we believe’, and banged Hayek down on the table.” (Ranelagh 1991).

 

Neo simply means ‘new’ and refers us back to the earlier liberal small state. The ‘Nightwatchman’ state in the 19th century provided for property rights, contracts, markets and personal/national security. That was about it. No provision for schools, health, transport or subsidies for industries. Hence the relatively small % of GDP being spent by the government. Talbot (2016) argues that the 1950’s Neoliberalism was new in that it also embraced social as well as economic and political rights. Social protection, workers rights and public health would actually help the capitalist society, however following the Chilean coup of 1972 a theoretical inversion took place in which it now meant a reversion to 19th century free market liberalism.

 

Four Definitions

 

Stuart Hall (2011) argued that:

 

The term ‘neo-liberalism’ is not a satisfactory one. Intellectual critics say the term lumps together too many things to merit a single identity; it is reductive, sacrificing attention to internal complexities and geo-historical specificity. However, I think there are enough common features to warrant giving it a provisional conceptual identity, provided this is understood as a first approximation…..What, then, are the leading ideas of the neo-liberal model? ….neo-liberalism is grounded in the idea of the free, possessive individual. It sees the state as tyrannical and oppressive. The state must never govern society, dictate to free individuals how to dispose of their property, regulate a free-market economy or interfere with the God-given right to make profits and amass personal wealth”.

 

A ‘tyrannical and oppressive’ State was of course Hayek’s view.

 

George Monbiot (2016) outlined its main principles in this way:

 

“Neoliberalism sees competition as the defining characteristic of human relations. It redefines citizens as consumers, whose democratic choices are best exercised by buying and selling, a process that rewards merit and punishes inefficiency. It maintains that the marketdelivers benefits that could never be achieved by planning. Attempts to limit competition are treated as inimical to liberty. Tax and regulation should be minimised, public services should be privatised. The organisation of labour and collective bargaining by trade unions are portrayed as market distortions, that impede the formation of a natural hierarchy of winners and losers. Inequality is recast as virtuous: a reward for utility and a generator of wealth, which trickles down to enrich everyone. Efforts to create a more equal society are both counter-productive and morally corrosive. The market ensures that everyone gets what they deserve”.

 

David Harvey (2005) defines it thus:

 

Neoliberalism is in the first instance a theory of political economic practices that proposes that human well-being can best be advanced by liberating individual entrepreneurial freedoms and skills within an institutional framework characterized by strong private property rights, free markets, and free trade. The role of the state is to create and preserve an institutional framework appropriate to such practices. The state has to guarantee, for example, the quality and integrity of money. It must also set up those military, defence, police, and legal structures and function required to secure private property rights and to guarantee, by force if need be, the proper functioning of markets. Furthermore, if markets do not exist (in areas such as land, water, education, health care, social security, or environmental pollution) then they must be created, by state action if necessary. But beyond these tasks the state should not venture. State interventions in markets (once created) must be kept to a bare minimum because, according to the theory, the state cannot possibly possess enough information to second-guess market signals (prices) and because powerful interest groups will inevitably distort and bias state interventions (particularly in democracies) for their own benefit.

 

 

Thorsen (2009) after an examination of literature on liberalism including the critical literature argues:

 

“Neoliberalism is…a loosely demarcated set of political beliefs which most prominently and prototypically include the conviction that the only legitimate purpose of the state is to safeguard individual liberty, understood as a sort of mercantile liberty for individuals and corporations. This conviction usually issues, in turn, in a belief that the state ought to be minimal or at least drastically reduced in strength and size, and that any transgression by the state beyond its sole legitimate raison d’etre is unacceptable (cf, especially Mises 1962; Nozick 1974; Hayek 1979).

 

This latter two descriptions  are that of the ‘Nightwatchman State’. Remember at this time in the 19th century less than 10% of GDP was spent by the government on public activities. Is this the goal of current Conservatives? Or is neoliberal/free market discourse an ideological mask for something else?

 

A minimal state safeguarding individual mercantile liberty and that is it?

 

We have to question whether in action Tory ministers believe this and wish to cut public spending from around 40% to 10%. To see what that would mean, we would need to look at the current 2017 budget (approximately £800 billion which is 40% of GDP) and note that to get down to 10% of GDP the budget would have to be £200 billion. See the appendix figure 4 for the 2017 budget. This is not 10% of GDP. Social Protection (pensions in the main) is over 10% on its own.

 

This is not a ‘Nightwatchman’. Is it a socialist utopia? The State is spending a lot of money still. However, what is actually happening is that in each sector, privatisation means that more and more government money (taxpayer’s money) is subsiding private provision. This is an explicit aim of the Adam Smith Institute who explicitly call for private provision but public funding for health. In Rail the government is subsiding private train operating companies and in housing the government is subsidising landlords through housing benefit.  In employment the government is subsidising employers through tax credits.  Figure 5 in the appendix shows where the revenue comes from.

 

The UK government spending accounts for about 40% of GDP, leaving 60% going elsewhere. Spending on health, social care and social protection (pensions) accounts for £426 billion, that is over 50% of the total spend. Add £102 billion for education (total now is £528 Billion).

 

Who pays for that? Well, whoever pays Income Tax, National Insurance, VAT, Council Tax and excise duties. All of this accounts for £628 billion.

 

What we have is redistribution from the 99.9% to the 99%.

 

‘Neoliberalism’ as rhetoric actually works for 0.01% – the plutocrats, the global capitalist executive. Henry (2012) argues that anything between $21 to £31 trillion as of 2010, has been invested tax free in about 80 ‘offshore’ secrecy jurisdictions. That is trillion not billion.

 

What we don’t have is a minimal state focused solely on safeguarding liberties for markets.

 

This idea of a small state free market economy is of course patent nonsense as it has just not happened. The reduction of public spending and deficit reduction are two current policy goals (i.e. Austerity) but this is hardly neoliberalism.  Neoliberal purists have failed to get the Tory party to reduce spending to these ‘classic liberal state’ levels. So what was all that Thatcherite talk for?

 

The reduction of state spending down to 10%, I suggest is either a complete failure of the neoliberal project or it is deliberate policy failure in that this is not the neoliberal goal at all.

 

It could be the case that the free market discursive practice is a cover for capital and property accumulation through curbing what is seen as labour power but more importantly by capturing the levers of the State. Cutting state spending to 10% would be seen by the capitalist executive and the political power elite to be socially and politically dangerous to capital accumulation.

 

Marx once remarked in the Communist Manifesto:

 

the executive of the modern state is but a committee for managing the common affairs of the whole bourgeoisie”.

 

One does not have to be a communist to begin to see how executive power is being used to the advantage of Capital (deregulations, subsidies and offshore tax breaks) while at the same time weakening labour through strict union laws, wage freezes and labour market ‘flexibility’.

 

Prior to 1900, no state spent more than 3% of GDP on ‘social programmes’. Around 1870 the average public spending level of ‘advanced economies’ was 10% (Talbot 2016). The 1914-1918 war saw an increase to 20%, followed by a steady growth to the 40% of today. This leads Talbot to argue that the neoliberal state of the 1970’s with 40% spending is actually little different from liberal market/social democratic states. Therefore it is all talk and no action since that level of spending has not been reigned back to 19th century levels.

 

Does this mean that Thatcherism was not neoliberal in action? Yes, if by that we define a neoliberal state as that in which only 10% of GDP is spent. Was Thatcherism even ‘free market’ in action given the continuing level of state intervention in many sectors of society and economy? Both Thatcher and Reagan promised to ‘roll back the frontiers of the state’ or that ‘government was not the answer, it was the problem’. This was ‘New Right’ talk to distinguish it from post WW2 Conservatives who accepted the post war social democratic consensus based on around 40% GDP spending and intervention.

 

Talbot (2016) argues that neoliberalism exists only as a ‘bogeyman’ created on the left to oppose various conservative attempts to ‘rebalance’ government-market relations. Bruff (2017) however argues that ‘neoliberalism’ is not about a return to free markets and 10% spending levels but is an ideology to mask a coercive, non-democratic and unequal reorganisation of society. There is seeming agreement that this is not about cutting government spending per se down to 10% but about reshaping democratic social and political relationships in favour of Capital. To repeat Desai (2007):

 

neoliberalism’s intellectual pretensions are designed to provide a fig leaf of intellectual respectability to the most naked pursuit of the interests of capital and property”.

 

Bruff (2017) points out that many current governments are not neoliberal in that they actually oppose free markets in practice and instead are engaged in protectionist rhetoric and practice. A 40% GDP spend does not indicate much in the way of ‘cutting back the state’ except for the working classes as a result of austerity politics and social security spending decisions.

 

This results in socialism for the rich (state spending) and neoliberalism for the poor (welfare cuts).

 

If neoliberalism is narrowly defined as a political programme valorising free markets then indeed leaders such as Trump, Modi, Erdogan and Abi are not neoliberal. Instead ‘free market’ rhetoric is just that: rhetoric. Bruff goes on to suggest that actually Hayek et al constantly invoke ‘free markets’ as an abstract principle but then they have a preference for certain types of markets to prevail in actuality. Neoliberalism in this definition is the use of the State in a central role to maintain a certain kind of market:

 

“neoliberalism has nothing to do with markets as commonly conceived, and everything to do with the orchestration of social relations in the name of markets…it is about the coercive, non democratic and unequal reorganisation of society along particular lines…intensification and extensification of the differences, inequalities, hierarchies and divisions that pervade capitalist society as delivered by authoritarian states and global corporations…neoliberalism is a way of seeing the world that is carved from the empty words ‘free’ and ‘markets’ ”. Bruff calls this ‘Authoritarian Neoliberalism’

 


 

Some Free Market advocates get this too.

 

Jamie Whyte is a free market advocate and in the BBC radio programme Analysis ‘Keeping the Free Market faith’ (8th October 2012) thinks Conservatives are now losing that faith in the free market, implying neoliberalism has lost its grip. Of course, as figure 1 to 5 show, it never had one.

 

Three Conservatives said this about the state of politics in 2012:

 

An Unholy alliance between a free market ideology which took over a government and a process of social change in which fair dealing and trust were ditched in favour of get rich quick economic libertarianism”

 

“We have to challenge the assumptions of laissez faire economics…”

 

“…the left wing account (of a conspiracy of the rich against poor people) is much more believable (since the credit crunch) than in 1990, although I don’t believe it”.

 

(Jessie Norman, Matthew Hancock (Tory MPs) and journalist Charles Moore).

 

In the ‘Free Enterprise Group’ in the Tory party, Andrea Leadsom argued deregulation in the banking sector had caused major problems. Ferdinand Mount also queried deregulation and the big bang which ‘had its downside’. Matthew Hancock (Tory Minister for Skills) also of the Free Enterprise Group, argued free markets need strong frameworks. He argued we should not muddle up laissez faire economics with free markets, and that the banking sector is special, it is an exception where free market principles should not hold! The State also should have a view of what are sustainable business models for many industries.

 

Jamie Whyte interviewed Ferdinand Mount, who helped write Thatcher’s manifesto in 1983, argued in the radio programme that ‘bankers are the worse kind of oligarchs, immune to old standards of corporate governance, paying themselves whatever they like. Shareholders are sleeping and are not taking them to account’. Qualms about high pay, argued Mount, is about social justice and economic efficiency (rewards gained despite performance). He argues against total deregulation and against withdrawal of state support for the ‘too big to fail’ banks.

 

Whyte interviewed Lord Griffiths (advisor to Thatcher in 1986) who dents Thatcher’s image as a neoliberal or free market ideologue. He argues that Thatcher believed in a ‘moral market’ and the value of enterprise but was never a total free marketeer. Free markets yes, but within a boundary of social justice, including consumer protection. Thatcher he suggests was not a purist Hayekian. Despite the earlier Hayekian gesture in the 197o’s, Griffiths argued that Thatcher believed that the market economy had a moral basis in a Judeo-Christian ethic; a ‘moral market’ and this was the underpinning of the economy. Thatcher was free market enough to let the UK coal mines close and railed against support for ‘lame duck’ industries. She also began the wave of privatisation of nationalised industries.

 

What then now of Theresa May’s reintroduction of industrial policy, of explicit talk of government involvement in various sectors of the economy? Since 2010, there has been the  setting up of a British Business bank and the rebalancing of the economy as policy goals. Government should now have a view over the structure of the economy (Matthew Hancock MP), and support for successful business is a legitimate role. ‘Active and thoughtful’ government should support successful companies, and not be neutral between sectors. Hancock argued that there needs to be a strong framework around a market supporting successful industries, i.e. those that work well. An industry strategy must allow new challengers, but there must not be a planned economy. This must be done through looking at regulation and providing industry with the skills it needs.

 

Pro-Business rather than Free markets?

 

However, businesses are good at lobbying government (Zingales 2012), they ask for and get support rather than just asking for arm’s length regulation.  Zingales (2012) also argues that the US risks deteriorating into a pro-business rather than pro-market system. Jamie Whyte calls the relationship between business and government  ‘cosy and corrupt’.

 

Trump’s election and his appointees and advisors might indicate or vindicate Zingales’ point. His first big meeting in January 2017 (Feloni 2017) was with 12 CEO’s of the United States’ largest companies and he told them that he would ‘prioritize corporate tax cuts and decrease regulation’ (free market talk) and impose a ‘border tax’ on companies that move production outside the US (state interventionist).

 

Key appointments include:

 

Rex Tillerson (ex CEO of ExxonMobil), Steven Mnuchin (Goldman Sachs, Hedge Funder), Robert Lighthizer (Corporate and Trade Lawyer), Andrew Puzder (CEO of restaurant chains) and Wilbur Ross (Billionaire Investor). Well, who else would you want to run the capitalist executive but capitalist executives?  Smith (2016) suggests that ‘Trump’s billionaire cabinet could be the wealthiest administration ever’:

 

Todd Ricketts ($5.3 bn), Betsy DeVos ($5.1 bn), Wilbur Ross ($2.9 bn), and Steve Mnuchin ($46 m).

 

In the UK, May’s cabinet are pretty rich but look like paupers compared to Trump’s (Saner 2017).

 

As for business connections, in the UK, there are 50 official ministerial ‘business buddies’ for large firms in the Business Council. Glaxo Smith Kline had David Willetts while Vince Cable worked with Oil and Gas. Hancock in the Whyte radio programme argued they ‘listen’ to their companies and the government then does what they would like. This is not only a UK phenomenon. Angresano (2016) argues there is a ‘Corporate Welfare Economy’ in which the US government has increasingly been influenced by corporate lobbyists with regulation skewed in order to suit the interests of the privileged.

 

Other examples include the United States Department of Agriculture’s plan to buy 11 million pounds of cheese worth $20 million (USDA 2016) to support US dairy farmers. The Overseas Development Institute (ODI) and Oil Change International found that as a whole, G20 nations are responsible for $452bn (£297bn) a year in subsidies for fossil fuel production. Bergin (2016) reported that compensating carmakers in Britain for any post-Brexit tariffs on exports to Europe could see the government hand the companies more money than they need to pay the salaries of all their British workers. For decades British farmers have received subsidies under the EU’s Common Agricultural Policy (CAP). Full Fact (2016) report that the average farmer made £28,300 in subsidies in 2015 and £2,100 from agriculture. Wealthy land owners, such as the Daily Mail’s Paul Dacre, the Queen, a Saudi Prince, the Dukes of Westminster and Northumberland, the Earl of Moray also received subsidies from the CAP (Press Association 2016). Hinkley nuclear power station will have a subsidy worth £30 billion (Ward 2016). George Monbiot (2011) wrote:

 

the Guardian revealed that the government’s subsidy system for gas-burning power stations is being designed by an executive from the Dublin-based company ESB International, who has been seconded into the Department of Energy. What does ESB do? Oh, it builds gas-burning power stations. On the same day we learned that a government minister, Nick Boles, has privately assured the gambling company Ladbrokes that it needn’t worry about attempts by local authorities to stop the spread of betting shops. His new law will prevent councils from taking action”.

 

The Economist (2012), a free market paper, also reports on the US Chamber of Commerce and its lobbying and influence in US politics:

 

“Small firms can get a lot out of the Chamber—its annual small-business summit is well-regarded, for instance. But some feel under-represented: most of the firms represented on the board are large. Others worry that they are being used as pawns. In a letter to a Philip Morris executive just after he took over, Mr Donohue said that small firms provide the foot soldiers, and often the political cover, for issues big companies want pursued, because Congress listens more to them than to big business”.

 

Traynor et al (2014) similarly reported on corporate lobbying in the EU, claiming that there are over 30,000 lobbyists operating in Brussels while Drutman (2015) argues US lobbying is ‘America’s Business’ leading to ‘politics becoming more corporate’.

 

Jamie Whyte argues for a genuine free market, unregulated and free from government, even in the banking sector whereas Ferdinand Mount argued that it would be a ‘brave thing to do’, and it is  “rather terrifying”. Whyte argues however that the market is a mechanism for experiment and trial and thus there is no place for state regulation and subsidy. Banks should be allowed to fail. However, not bailing out the banks in 2008 would have been a brave thing to do, argued Mount, but he thinks ‘free market’ ideology will return.  Luigi Zingales (2012) supports Whyte in arguing that too much intervention creates perverse incentives. The State’s involvement in protecting money lent by the banks, means we have socialised the losses and privatised the gains. Free markets should apply to banks, they should not be bailed out, and government protection of their lending, subsidises the bank’s risks.

 

Neoliberalism, if defined as ‘small state’ and free markets, does not exist. If however ‘neoliberalism’ is understood as a discourse including ideas around individual liberty within free markets with minimal state intervention including cutting welfare programmes  aimed at the ordinary people, then it does. Its function is to reshape society by using the rhetoric of free markets while at the same time controlling certain markets though state intervention. Neoliberalism for the poor, socialism for the rich.

 

We have the data on wealth and income distribution, land ownership, offshore tax wealth, derivative values, corporate subsidies and the connections between the capitalist class executive and the political power elites which includes the military-industrial complex.  We know what money is, that it is not a physical commodity or has material existence in any form whatsoever (Harvey 2008, Pettifor 2017) and is therefore not in short supply. We know that it is now nothing more than a set of social relationships, ‘promises’, and thus is in infinite supply, but it is backed by judicial and ultimately military power. One reason we perhaps do not join the dots is too many of us have swallowed neoliberal ideology that argues ‘free markets and individual effort brings success’ while ignorant of its real effect to cover the actions of Capital which operate in rigged markets.

 

 

What should current neoliberalism look like?

 

The Adam Smith Institute (ASI) (https://www.adamsmith.org) is a free market think tank. It calls itself, “independent, non-profit and non-partisan…(to) promote neoliberal and free market ideas through research, publishing, media commentary and educational programmes”. Their priorities:

 

…are driven by a desire to rid the system of rent-seeking and inefficiencies that destroy wealth, and to create public services that are both innovative and in the hands of the people who use them, not the people who run them”.

 

The use of the word ‘neoliberal’ is interesting because it is not easily clear at first from the website that the ASI wants actually to be as neoliberal as Talbot’s ‘Nightwatchman’ state. It is not immediately obvious at first glance that they would wish to reduce public spending from 40% to 10% of GDP. However, the ASI published a blog on the level of public spending (as a % of GDP) that states that we are stuck with current levels “much as we ourselves would prefer the Hong Kong option”. Hong Kong’s spending ranges from 5.7% in 1960 to 10.9% and in 2015 was 9.15%. Therefore, buried in a blog an aim would be levels of spending equal to the ‘Nightwatchman’. The ASI believes in ‘market efficiency’:

 

  1. Low, simple, flat taxes that encourage investment and innovation, and hence economic growth (OK, need to read upon on that).

 

  1. A voucher-based education system that gives parents and schools complete freedom over how and where children are educated. (Hang on, vouchers, who is paying for that?)

 

  1. A privately-provided, publicly-funded healthcare system where patient outcomes, not NHS wages, are the focus. (what, publicly funded?)

 

  1. Freedom of trade with the world, and a liberal immigration system that is designed to work for migrants and natives alike.(open borders and requires ‘flexible’ labour markets?)

 

  1. A liberalised planning system that lets many more houses be built, so everyone can afford to own their own home. (so, environmental protection to go?)

 

  1. A simple welfare system based around a Negative Income Tax or Basic Income that tops up the wages of the poor and guarantees that work always pays. (basic Income…that’s more like it…something Marx would approve of)

 

  1. Free market money and an end to bailouts of private banks, in all their forms (Yes, nothing for a Marxist to disagree with).

 

 

 

 

The need to ‘rid the system of rent seeking’ echoes Thomas Picketty’s (2014) analysis of current capitalism and Marxist critiques of rentier forms of capitalism. The importance of wealth in attracting rent, is once again asserting itself as wealth grows faster than economic output. The ASI is sounding a bit marxist here.

 

Conclusion

 

If it is serious about a minimalist state and protection only for market transactions then free market/neoliberal ideology ought to be seeking to get private corporate and wealthy landowning snouts out of the State trough. In that, Marxists would agree. A free market should be just that. No bank bail outs, no subsidies for private schools in the form of charitable status; Oil, Gas and Nuclear power to stand on their own two feet; Farmers to earn from agriculture not government handouts; Aristocratic grouse moor owners likewise; Employers should pay what the market bears and not rely on working tax credits; Private health care companies should rely on what private individuals are willing to pay; Train operating companies should pay the full price of running the network and keep all of the profits from passengers while receiving no state funding; social care to be provided by charity, families or private individuals buying from care companies; private citizens should insure themselves for ill health and old age; Schools and Universities should compete in a market for students paid for by their parents or themselves with no state funding or through loans at market rates of interest; the road network sold off and motorists to pay to access; no housing benefit, no unemployment benefit, no sickness benefit, no pension unless paid for by private schemes, no business rates, no corporation tax; Free trade across borders with no tariffs, free movement of people, capital and services.  With the state off your back: “no income tax, no VAT, no money back, no guarantee…Good Bless Hooky Street” in a ‘Del Boy’ economy.  Libertarianism for all. Freedom from the State! Let the market decide!

 

A bit much?

 

The problem with neoliberalism and free market ideology is indeed a Hobbesian one: life could be ‘nasty, brutish and short’ as we compete one with another in a dog eat dog ‘ubermensch take the hindmost’ world.  And there’s the rub. Do they really mean it, or have they not only accepted a role for the state but embraced it for their own ends under the guise of ‘market efficiency’?

Appendix

 

  winning % Turn Out Total who did not vote

at all

Total Electorate

Who voted for

Thatcher 1979 44% 76% 24% 33%
1983 42% 72% 28% 30%
1987 42% 75% 25% 31%
Major 1992 42% 77% 23% 32%
Blair 1997 43% 71% 29% 30%
2001 41% 60% 40% 25%
2005 35% 61% 39% 21%
Cameron 2010 36% 65% 35% 23%
2015 37% 66% 34% 24%

 

 
Figure 1. Voter support for free market discourse. Increasingly it is the case that nearly a third (range 23% to 40%) or more of voters were either apathetic, disillusioned, disengaged or too distracted to bother to give their support for any political party.

 

 

Figure 2.     1900-2010 spending  as % of GDP

http://www.ukpublicspending.co.uk/past_spending

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 3. 1996-2017 spending as % of GDP.

 

 

The following two figures illustrates the degree of State involvement in the economy. The spending accounts for about 40% of GDP, leaving 60% going elsewhere. Spending on health, social care and social protection (pensions) accounts for £426 billion, that is over 50% of the total spend. Add £102 billion for education (total now is £528 Billion).

 

Who pays for that? Well, whoever pays Income tax, National Insurance, VAT, Council Tax and excise duties, accounts for £628 billion. What we have is redistribution from the 99.9% to the 99%.

 

‘Neoliberalism’ as rhetoric actually works for 0.01% – the plutocrats, the global capitalist executive, as Henry (2012) argues that anything between $21 to £31 trillion as of 2010 has been invested tax free in about 80 ‘offshore’ secrecy jurisdictions.

 

 

 

 

Figure 4. 2017 UK budget. Spending £802 billion

 

 

 

Figure 5 Revenues. £744 billion.

 

UK Budget:  https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/597467/spring_budget_2017_web.pdf accessed 22 march 2017

 

 

References

 

 

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Environmental Politics, 10(2), Summer 2001, 128-133.

 

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Bruff, I, (2017) Authoritarian Neoliberalism and the Myth of Free Markets.

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Carlisle, S. (2001) ‘Inequalities in health: Contested explanations, shifting discourses and ambiguous policies’, Critical Public Health, 11: 3, 267 — 281

 

 

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Dorling, D. (2014) Inequality and the 1%. London. Verso

 

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Harvey, D. (2005) A brief history of Neoliberalism. Oxford. Blackwell

 

Harvey, D. (2008) Reading Marx’s Capital vol 1. Class 3 Chapter 3. Money, or the circulation of commodities

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Hayek, F. (1944) The Road to Serfdom. London. Routledge.

 

Hayek, F. (1960) The Constitution of Liberty. University of Chicago Press. Chicago.

 

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Monbiot, G. (2011) Its business that really rules us now. The Guardian 11 November.

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Moshinsky, B. (2016) The global wealth pyramid is still topped by the 1% who own almost half of the world’s wealth. World Economic Forum. Online available at https://www.weforum.org/agenda/2016/11/the-distribution-of-global-wealth-has-stayed-just-as-skewed-as-last-year accessed 22 march 2017

 

Office for National Statistics (2015) The Effects of taxes and benefits on household income : financial year ending 2015. https://www.ons.gov.uk/peoplepopulationandcommunity/personalandhouseholdfinances/incomeandwealth/bulletins/theeffectsoftaxesandbenefitsonhouseholdincome/financialyearending2015 accessed 20 march 2017

 

Pallasch, A. (2010) ‘Best 5 Minutes of my life; His ’09 CNBC rant against mortgage bail outs for ‘losers’ ignited the Tea Party movement’ Chicago Sun-Times.

 

Pettifor, A. (2017) The Production of Money; how to break the power of the banks. Verso. London

 

Picketty, T. (2014) Capital in the Twenty-First century. Harvard. United States

 

Press Association (2016) The Queen, aristocrats, and Saudi prince among recipients of EU farm subsidies.

https://www.theguardian.com/environment/2016/sep/29/the-queen-aristocrats-and-saudi-prince-among-recipients-of-eu-farm-subsidies accessed 20 march 2017

 

Ranelagh, R. (1991) Thatcher’s People:  An Insider’s Account of the Politics, the Power, and the Personalities.  London:  HarperCollins.

 

Ryan, A. (1993) ‘Liberalism’ pp 291-311 in Goodin, R and Pettit, P. (eds) A companion to Contemporary Political Philosophy. Oxford. Blackwell.

 

Saad-Filho, A. and Johnson, D. (2005). Neoliberalism – a critical reader. London. Pluto Press

 

 

Saez, E. and Zucman, G. (2014) Wealth inequality in the United States since 1913: Evidence from capitalized income tax data National Bureau of Economics Research Working Paper, October 2014. Available at http://www.nber.org/papers/w20625 accessed 22 march 2017

 

 

Saner, E. (2017) ‘Theresa May’s cabinet: pretty rich, but nothing on Trump’s’. The Guardian online. Available at https://www.theguardian.com/business/shortcuts/2017/jan/17/theresa-mays-cabinet-pretty-rich-but-nothing-on-trumps accessed 22 march 2017

 

 

Scambler, G. (2012) GBH: Greedy Bastards and Health Inequalities. Available at:

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Hunt’s agenda

The ideology of health care provision.

 

 

Amid the junior doctors strike of 2016, the health secretary Jeremy Hunt was embroiled in a conflict with the BMA over doctors’ contracts designed to address a 7day NHS. This is the surface issue but sits upon a deeper ideological conflict, one that many of the doctors will be unaware of but will suspect, especially if they have read Alysson Pollock’s works on the privatisation and corporatisation of the NHS. Hunt argued he has a ‘mandate’ to introduce a 7 day NHS and perhaps realises that if this policy cannot be introduced, the balance of power over the future of the NHS will swing back towards the BMA and other health professional groups. The irony is that the BMA opposed the introduction of the NHS back in 1948 but now is one of the strongest supporters. Since 2012 however, the NHS has been dismantled and been replaced with privatised and corporatized service provision, with ‘patient choice’ and ‘patient safety’ being used as the ideological veil which masks the corporate face. People have not noticed this detail because so far ‘free at the point of delivery’ is still in place, but this principle, along with universal and comprehensive cover, is under threat. The government remain the almost monopoly purchaser of health services on our behalf but for how long? The care home crisis points in the direction of travel. This will be withdrawal of state funding and reliance on private provision which will not be ‘free at the point of delivery’.

 

 

 

In 2005 ‘Direct Democracy – an agenda for a new model party’ was published, the authors include the current health secretary Jeremy Hunt. It is not government policy and does not represent the full range of conservative views. The Tory party itself is home to those of a ‘one nation’ persuasion who mix ideas of ‘noblesse oblige’ with a modicum of a social welfare, safety net, public service ethos. It is also home to ‘neoliberalism’ rooted in anti State sentiment based on freedom of the individual and free market economics. This ideology can be clearly seen in the 2012 book ‘Britannia Unchained – Global lessons for growth and prosperity’ which argues for further free market economics based on a bonfire of employment laws. The book suggests:

 

“The British are among the worst idlers in the world. We work among the lowest hours, we retire early and our productivity is poor. Whereas Indian children aspire to be doctors or businessmen, the British are more interested in football and pop music.”

 

This one quote conveys the disdain neoliberals have in general for those less well paid, less “successful” and less powerful than themselves. Boris Johnson’s speech in 2013 on the impossibility of equality being based on differences in IQ, implied some people are too stupid to get ahead. This individualises issues, while ignoring structures of class, gender, ethnicity and privilege. He said:

 

And for one reason or another – boardroom greed or, as I am assured, the natural and god-given talent of boardroom inhabitants – the income gap between the top cornflakes and the bottom cornflakes is getting wider than ever. I stress: I don’t believe that economic equality is possible; indeed, some measure of inequality is essential for the spirit of envy and keeping up with the Joneses that is, like greed, a valuable spur to economic activity.”

 

Two ideas are core here: that the working class and the poor are so because they are more lazy and stupid than the ruling class, and that the answer to this is to increase competition and to use inequality as incentives for personal improvement. Of course said like that to the electorate, it would seriously threaten voter support. Instead the discourse of market efficiency, effectiveness and choice is used to justify privatization and corporatization of public services. The message to the public is clear: take responsibility for education, health, social care and housing. It is down to individuals and families to provide by working hard and being prudent.

 

The arguments over the NHS have to be seen within this wider context. At heart, many in the current Tory party viewed the state run NHS as anathema. As such they have succeeded in dismantling the post war structure of the NHS following the Health and Social Care Act 2012. This allowed for private providers to bid for the provision of health services but keeps in place, for now, principles such as ‘free at the point of delivery’.

 

According to Alysson Pollock, the Health and Social Care Act 2012:

 

  1. Removed the duty of the Secretary of State for health to secure and provide health care for all.
  2. Introduced US style insurance schemes.
  3. Gives the secretary of state legal powers to create a market, allows providers to pick and choose which patients will get care, services to be provided and what will be charged for.

 

A market has been introduced into health service delivery, and markets operate through risk selection and appraisal resulting in fragmentation of provision. That is to say a market provider needs to pick and choose which patients are profitable in competition with other providers. We now have clinical commissioning groups modelled on insurance based lines. Those with high risk or multiple needs will be expensive to provide care for.

 

The ‘NHS’ is now fragmented in which:

 

  1. Services are broken up and put out to tender to commercial companies.
  2. Commercial shareholders have new legal powers to decide who gets care, what the get and what they pay for.

 

This current state of affairs is not enough for neoliberal thought. So what is the vision of this group of neoliberal Tories? How did this happen?

 

Direct Democracy argues:

 

“Several other countries operate political systems based on localism and direct democracy. Two outstanding examples – one much smaller than the United Kingdom and one many times larger – are Switzerland and the United States. In their different ways, both states respect the principles of the dispersal of power, the direct election of public officials and the use of the referendum as a legislative tool. Our proposals for the devolution of power directly to the citizen – notably in the fields of education and health care – have also been successfully trialled abroad, often in unlikely places. No less corporatist a state than Sweden has introduced a form of school voucher, while almost every state in Europe, at least since the fall of the Berlin Wall, now provides for an element of health insurance”.

 

This goes to the heart of the matter, note how the US and the Swiss are held up as models. The principles of localism and direct democracy are invoked as justifications hiding their argument and belief about market mechanisms. The United States is a beacon for the dispersal of power? One cannot expect anything other than this nonsense from neoliberals, wilfully ignorant as they surely must be of the work of C Wright Mills, Herbert Marcuse, Jurgen Habermas, David Harvey, Thomas Picketty, Graham Scambler, and Yanis Varoufakis? This also ignores the literature on social inequalities and inequalities in health and the social and political determinants of health. At this point we must also point to the wealth of feminist and post-colonial literature on ‘power’. In short it is an invocation of bourgeois patriarchal perspective on the exercise of power which blinds them to actuality.

 

As for Switzerland, the OECD reports that compared to the UK’s 9.3 % of GDP, the Swiss pay 11.4%. The UK used to pay under 6% but has seen a rise, not totally due to actual health spending but to cater for administration and profit for private companies. The US spends 16.9% (OECD 2014) and has introduced ‘Obama care’ to address the plight of uninsured americans. Obama care is an outcome of class struggle which has been hotly contested in the ‘land of the free’.

 

 

 

‘Direct Democracy’ claims to hold to three principles:

 

  1. Decisions should be taken as closely to the people they affect.
  2. Law makers should be directly accountable.
  3. The citizen should enjoy maximum freedom from state control.

 

 

On the face of it who would argue with that? Certainly not anarchists, socialists or libertarians. The problem is that these principles exist within a social and historical context, one characterised by imbalances of power along class, gender and ethnic lines and this cannot deal with the reality on the ground. Hunt et al are blind to the context in which ‘men of wealth buy men of power’, a world in which the capitalist class executive and the political power elite exercise a new class/command dynamic which neoliberal ‘reforms’ ushered in since about the 1980’s especially in the US and UK.

 

Yanis Varoufakis (2016) clearly discusses the effects of such things as the “Nixon Shock’ on the post war global financial settlement, the outcome being that the ‘strong do what they can and the weak suffer what they must’. Global health corporations need new markets and looked to the UK’s NHS as a source of rich pickings. This is the context in which Hunt’s bourgeois democracy operates.

 

  • Decisions about who provides health care, what health care looks like and where it is provided are taken by unelected clinical commissioning groups operating within a profit driven market context.
  • Patients do not have an electable secretary of state who has a statutory obligation to provide health care services.
  • Freedom from state control for health service provision has morphed into control via corporate decision making.

 

 

Direct Democracy (2005) argues:

 

‘The problem with the NHS is not one of resources. Rather it is the system remains centrally run, state monopoly designed over half a century ago’ (p74).

 

Clearly this is a statement that ‘the system’ needs to go. The resource issue in the context of increasing demands and costs is brushed aside. This remark now looks questionable at best in 2016.

 

“We should fund patients either through the tax system or by way of universal insurance, to purchase health care from the provider of their choice. Those without means would have their contributions supplemented or paid for by the State.” (p74).

 

Holding on to a notion of ‘free at the point of delivery’ implied here, it is clear that private provision is to be introduced. The language is anodyne, context free, taking no notice of what private provision might look like, who would provide it and what the consequences of the inevitability of a market might be. The State at least has a role in providing for the poor. The writers of this document are part of the political power elite, or may wish to be, and the coherence of interests with the corporate/capitalist class executive are hidden. Those who sell insurance have not been lobbying for this change then? A bit of research into who benefits from this change might prove insightful. Are there links between corporate interest and the politicians who are driving the changes?

 

Hunt et al feared the NHS would only be second to the US in terms of % of GDP spent. This has not occurred. They report a study ranking the UK 18 of 19 countries. This is selective in the extreme, and is now way out of date.

 

Many of the critiques they evoke of the NHS are a result of the rise of new public management, or ‘managerialism, introduced into the system by previous governments both New Labour and Tory. For about three decades managerial control, targets and distrust of professionals have eroded the ability of the NHS to be the best in the world.  The judgment about the efficiency and effectiveness of health services partly depends on what criteria are being used to judge them. The % spend of GDP is a crude figure as it hides a plethora of costs and profits.

 

Other measures of success could include universality of access, comprehensiveness of cover, mortality and morbidity outcomes, and the publics’ safety and satisfaction.

 

Mark Britnall has written ‘In search of the Perfect Health System’ (2015) of the complexity of comparing health systems. Britnall is no Tory ideologue and describes his approach as more brown mud than blue sky thinking:

 

He also wrote in 2011 before the 2012 Act:

 

“[o]f course, the vast majority of care – quite rightly in the UK context – will always be provided by public sector organisations (currently, about 95% of it) and will be paid out of taxation” and “[t]he issue of competition, which now seems to be conflated with privatisation, is unhelpful and misleading and, at best, only a small part of reform. Competition can exist without privatisation and the NHS can maintain its historic role in funding care while dealing with a richer variety of providers – public sector, social enterprise and private organisations”.

 

This 2011 comment predated the 2012 Act and can be seen as a statement of intent than actuality on his part. In 2010 there was some controversy over his statements in the US about private provision.

 

One area in which private provision is facing severe challenges is the care home sector.

 

Roy Lilley, writes a daily blog, and has considerable experience in the health service and with private sector organisations. He is no left wing radical. He writes in ‘They don’t matter’ (3rd May 2016) that success in private provision in the community has been ‘patchy’, citing Circle’s loss of £5 million and the paying of another £2 million to get out of the Hinchinbrooke contract, while SERCO and Bupa ‘bailed out’ of provision leaving Virgin clinging on. He argues that the private sector can be nimble and quick to adapt, but of course needs to make a profit.

 

However, the largest care home provider, Four Seasons, is in talks to ‘restructure its debt’ as they face a 39% drop in profits. Most of their ‘customers’ have their fees paid by social services. This amounts to some local authorities paying £385 per week which is just not enough. The living wage is also an issue for them, they have over 30,000 staff but with no way of adjusting prices to pay for the increase and with no operating surplus. It has a debt of £510 million. If Four Seasons go broke they have 450 care homes at risk.

 

The bottom line is that health and social care costs money. There is not enough money in the system to pay for the care required. Some private families are paying £1,250 per week. Company Watch data which covers 20,000 homes, indicates that there is a funding black hole of half a billion pounds. This is market failure due to inadequate funding by design. It is almost as if the government is deliberately forcing people to find the money themselves either through savings, insurance or property while state funding through local authorities is slowly wound down.

 

Mark Britnall’s approach is scholarly, based in experience managing health care organisations and a deep knowledge and overview of many health systems. However, is Britnall sufficiently aware of the political economy of neoliberalism and its agenda for health?  Roy Lilley’s highlighting of the care home crisis clearly shows the political, austerity driven nature of the issue.

 

‘Direct Democracy’ and ‘Britannia Unchained’ are ideological approaches to health and social care. Whether Hunt has the temper for addressing Britnall’s insights or whether he still stands by the document he co-wrote is anyone’s guess. However, I know where the smart money would go. His face down of the doctors is more to do with power and who exercises it rather than the future of the health service as we knew it. If the neoliberals can get away with it, then free at the point of delivery will be severely challenged perhaps using spurious arguments stigmatising drug users, alcoholics, smokers, the obese, self harmers, self inflicted sports injuries, prostitutes, the promiscuous and Johnson’s ‘stupid’ as a wedge driven between the deserving and the undeserving ill. The care home crisis indicates that older people are ignored and the costs increasingly privatised as the state withdraws, or should we say abdicates, support. The NHS was to socialise risk, to spread its cost across the whole population. Instead we are rapidly moving towards individualising risk and private insurance based provision as the state withers away.

 

The neoliberal revolution and Health

Neoliberalism has various meanings, but many commonalities (Hall, 2011). Nurses in the UK’s NHS, alongside their colleagues elsewhere, may not be familiar with the term but they will be familiar with its effects on service delivery, patient care and of course their own working conditions (Abramovitz & Zelnick, 2010; Gonçalves et al., 2015; Horton, 2007; Reiger & Lane, 2013; Wright, 2014).  Stuart Hall outlines the main ideas underpinning what he calls the ‘neoliberal revolution’ (Hall, 2011). This is useful for nurses in order to first understand and then to act.

 

The main ideas according to Hall (2011) are:

  1. It is grounded in the idea of the ‘free, possessive, individual’; a concept understood in classical economics as ‘homo economicus’ – the rational actor in a market weighing up costs and benefits of consuming decisions according to price signals. Therefore:
  2. The State must not govern society or dictate to individuals how to dispose of their private property.
  3. The State must not regulate the free market.
  4. The State must not interfere with ‘God Given’ rights to make profits or to amass personal wealth.
  5. The State is tyrannical and oppressive.

 

In the health service it means:

 

  • The State should not really be running hospitals. Instead private sector companies, and health care professionals should offer their services for a fee. These providers should compete in a market
  • Patients are not really patients but consumers of health care services and so should decide what they want, when they want it and where they want it.
  • The State should not tax the public to pay for health services, instead there should be private health insurance or provision by family, charity and friends.
  • The NHS gets in the way pf private sector companies money making services by distorting the market.
  • There should not be any national pay and conditions for service providers, that should be decided by the market, so where demand outstrips supply the price (wages) should go up.

 

 

 

Abramovitz, M. & Zelnick, J. (2010) ‘Double jeopardy: the impact of neoliberalism on care workers in the United States and South Africa’. International journal of health services : planning, administration, evaluation, 40 (1). pp 97.

 

Gonçalves, F., Oliviera-Souza, S., Gollner-Zeitoune, R., Leite-Adame, G. & Pereira do Nascomento, S. (2015) ‘Impacts of neoliberalism on hospital nursing work’. Texto contexto – enferm., 24 (3). pp 646-653.

 

Hall, S. (2011) ‘The neoliberal revolution’. Cultural Studies, 25 (6).

 

Horton, E. (2007) ‘Neoliberalism and the Australian Healthcare System (factory)’. Proceedings 2007 Conference of the Philsophy of Education Society of Australasia. Wellington. Available at: http://eprints.qut.edu.au/14444/1/14444.pdf (Accessed: 7th December 2015).

 

Reiger, K. & Lane, K. (2013) ”How can we go on caring when nobody here cares about us?’ Australian public maternity units as contested care sites.(Report)’. Women and Birth, 26 (2). pp 133.

 

Wright, S. (2014) ‘Cash v compassion: underpaid care workers expose the battle between the profit and the service ethos, says Stephen Wright.(Reflections)’. Nursing Standard, 29 (1). pp 26.

 

How responsible am I for my health 2

How responsible am I for my health?

 

The answer to that question from the dominant discourse is an overwhelming “very”.

This response sits alongside more scholarly understandings of the social determinants of health.  This ‘upstream’ understanding is open to ‘Lifestyle Drift’ , ‘downstream’, responses to health. Lifestyle Drift is:

“the tendency for policy to start off recognizing the need for action on upstream social determinants of health inequalities only to drift downstream to focus largely on individual lifestyle factors” (Popay et al 2010)

McKenzie et al (2016) argue:

“Although policy documents may state that the causes of poor health or inequalities in health are to do with poverty and deprivation, the interventions which actually operate on the ground focus much less (if at all) on changing people’s material circumstances and rather more on trying to change behaviours (which are in fact heavily shaped by material circumstances)”.

Nurses might understand the concept of the social gradient in health inequalities but drift into advocating lifestyle changes for the individual, centring around smoking, diet, and exercise messages.

So why is this happening? Why resort to lifestyle approaches to health when we know health is largely socially and politically determined?

 

One answer is that lifestyle answers fit within the neoliberal social imaginary which individualises health and social problems and seeks market solutions to those problems. Neoliberalism is a doctrine well known to many scholars and academics but is hardly mentioned in popular discourse.  To understand responses to health inequalities and poverty , we need to understand the tenets of neoliberalism underpinning much of current thinking:

 

  • Neoliberalism sees competition as the defining characteristic of human relations. Therefore competition between service providers should be introduced into the NHS.
  • It redefines citizens as consumers, whose democratic choices are best exercised by buying and selling, a process that rewards merit and punishes inefficiency. So patients can and should choose between hospitals and GP practices as consumers of health care using their purchasing power (not yet realised in the NHS). This way, poor service providers should go out of business.
  • It maintains that “the market” delivers benefits that could never be achieved by planning. Therefore NHS = bad, US private health insurance = good; BBC = bad,  SKY/Fox = good;  British Rail = bad, Great Western/Virgin = good; Royal Mail (state owned) = bad, Royal Mail (privately owned) = good.
  • Attempts to limit competition are treated as inimical to liberty. Thus socialised NHS service provision must be broken up to allow freedom in the market. The BBC must be sold off because it is unfair competition for Sky.
  • Tax and regulation should be minimised, thus the use of offshore tax havens, reduction in top rate of tax, mistrust of EU environmental standards and hatred of health and safety regulations.
  • Public services should be privatised. The Health and Social Care Act 2012 facilitates this, there may well be more to come for the NHS.
  • The organisation of labour and collective bargaining by trade unions are portrayed as market distortions, that impede the formation of a natural hierarchy of winners and losers. Unison, RCN, BMA etc, must have their power curtailed. The Junior doctors cannot be allowed to win or else it will be a victory for organised labour.
  • Inequality is recast as virtuous: a reward for utility and a generator of wealth, which trickles down to enrich everyone. Those at the bottom require incentives to better themselves, therefore benefits need cutting, those in the middle will benefit from wealth creation.
  • Efforts to create a more equal society are both counter-productive and morally corrosive. The market ensures that everyone gets what they deserve. The arguments from books such as ‘The Spirit Level’ are therefore irrelevant. If there is a social gradient in health then this is the natural outcome of people’s decisions and choices and any attempt to change this invokes  ‘moral hazard’ arguments; that is if people know they have a safety net (someone else takes the risk) they will not try to avoid poor choices.

(Monbiot 2016 The Zombie Doctrine)

 

 

 

Tory Rituals on poverty:

 

 

·         Blame the individual for their illness and poverty.

·         Benefits cause dependency , repeat this ad nauseam.

·         Deny any political responsibility for ill health, emphasise culture as causative.

·         Divide population into:  skivers v strivers, deserving v undeserving poor, low achievers v high achievers.

·         Deny the ‘social’ exists, there are only individuals

·         Privilege wealth through tax breaks and preferential treatment.

·         Deny one’s own privilege as a white affluent male.

 

 

These attitudes underpin the ideology of neoliberalism.

 

For a statement about what the Conservative Party should be about see:Direct Democracy – an agenda for a new model party’ (2005) especially the chapter on health:

 

 

“The problem with the NHS is not one of resources. Rather, it is that the system remains a centrally run, state monopoly, designed over half a century ago”.

 

 

 

All of this results in the politics of blame and shifting responsibility for health fully onto individuals.

If material health assets are paramount, poverty and our response to it is a foundation for understanding health in society. Poverty can be defined as 60% of the median income or using the ‘consensual method’  it is “enforced lack of necessities determined by public opinion”.

However, the UK government’s position is that poverty is not caused by lack of income. Based on Charles Murray’s idea of the ‘Culture of Poverty’, poverty is a result of individual deficits, as Kitty Jones writes:

“the poor have earned their position in society, the poor deserve to be poor because this is a reflection of their lack of qualities, poor character and level of abilities”.

Kitty Jones has written clearly on this issue in 3 blogs, which can be found here.

The alternative view, expressed in for example the ‘Greedy Bastards Hypothesis’ is that poverty, and health inequalities, is caused by the rich, often through unintended consequences of their actions but also through design. It results from structural socio economic conditions that neoliberal governments encourage: for example, low wages, withdrawal of benefit provision and the use of offshore tax regimes. Osborne’s ‘living wage’ is a cynical political manoeuvre designed to woo middling swing voters rather than to address structural economic issues such as under and unemployment , lack of investment in a green economy, deficits in the housing stock and affordability and a zero hours, self employed precarious job structure.

 

Nurses offering health advice, are not immune to this dominant discourse. It suffuses health advice on such sites as NHS choices and is supported by health campaigns which focus on changing individual habits. Action on social inequalities as root causes for ill health sits within specialised public health literature, for example ‘Fair Society,  Healthy Lives’, and unless nurses are exposed to an alternative perspective they will naturally draw upon dominant explanations for health inequalities. These are often either biologically/hereditarian explanations* or a ‘moral underclass discourse’ (Ruth Levitas) or a mix of the two. The politics of neoliberalism encourages the latter perspective.

 

 

Benny Goodman 2016

 

*See Chapter 4 in Psychology and Sociology in Nursing  Goodman 2015 for explanations.

Watch Richard Wilkinson discuss inequalities at a TED talk.

https://www.facebook.com/groups/Sociologyhealthnursing/

 

 

 

 

 

 

NHS Dissatisfaction levels are perhaps not yet high enough to embolden the political power elite to further uncouple NHS principles from actual delivery, but they might be going in the right direction.

How satisfied with the NHS are we? The British Social Attitudes Survey has been tracking satisfaction levels since 1983. In 2011 it reached the highest it had been (64%), much higher than the 39% recorded in 2001. In 2000 there was a large rise in funding and according to John Appleby (Kings’ Fund) the change upwards might reflect that extra funding. In 2010 the rate had hit 70%, while in 2015, 65% stated they were quite or very satisfied, with dissatisfaction at a low of 15%. Now, in 2016, dissatisfaction rates have hit a 23% ‘actively dissatisfied’.

 

For trends see the graph at:  http://www.bbc.co.uk/news/health-35527318)

 

 

So, should we read anything into these figures? The “NHS’ is a complex set of organisations and services, and is affected by such external factors such as social care. It is probably foolish to peg changes in attitudes to any one factor (such as funding or waiting times). The survey does provide some information as to why those who are dissatisfied say so:

 

The stand out reason is taking too long to see a GP (60%). Interestingly only less than 5% state ‘stories on TV or radio’. However, 6 reasons above that are also gained by reading the press, watching TV as well as being supplemented by actual experience of friends and family.

See reasons at http://www.bbc.co.uk/news/health-35527318)

 

The figures cannot be directly tracked to funding or political party. The background of the Health and Social Care Act 2012 has not on the face of it made a difference to people’s attitudes. The high rate of satisfaction in 2010 of 70% has dropped to around 60% since, while dissatisfaction has only just started to rise again from the 2011 level.

 

If you want to change the way the NHS is funded, this survey is still an issue. Too many people like it the way it is, “free at the point of delivery” is a possible reason. Social Care (means tested) ranks the lowest on these satisfaction scores and might indicate that funding is a real issue for people.

 

 

The context for this includes 4 assumptions held by governments over the past 25 years: Neena Modi in the Guardian writes:

 

  • Personal responsibility for health supersedes government responsibility.
  • Markets drive efficiency.
  • Universal healthcare is unaffordable.
  • Healthcare is a business.

 

For example, Christopher Smallwood wrote ‘Free at the point of use’ has had its day and argues for private health insurance.

 

Each one of these assumptions are questionable and draw upon a certain view of the role of the state vis a vis the private individual (neoliberalism). Alongside that there are profit making health care organisations looking for new business opportunities that the relatively closed NHS used to block. Graham Scambler’s ‘Greedy Bastards Hypothesis’ suggests that health inequalities are the unintended consequences of the actions of a core cabal of the ‘capitalist executive’ who, aided by the ‘political power elite’ engage in business activities aimed at capital accumulation which includes commercialisation of health services for profit. The Health and Social Care Act 2012 provided an opportunity for just such private sector involvement. A problem for the private sector is that much demand for services comes from an increasingly ageing population whose needs are difficult to make a profit from.

 

 

There are very real discussions to be had about the sort of health service we want and the principles that should underpin it. There is now increasing argument for a rolling back on its founding principles of universal access, comprehensive coverage, equity of service and free at the point of delivery all in the name of ‘affordability’ underpinned by an ideology that deplores public sector provision. Dissatisfaction levels are perhaps not yet high enough to embolden the political power elite to further uncouple NHS principles from actual delivery, but they might be going in the right direction.

 

 

 

For discussion on health services globally see:

 

  1. Which country has the best healthcare system?
  2. Britnall, M (2015) In Search of the Perfect Health System. Palgrave macmillan .

 

 

 

 

 

Want to thank a War Veteran?

Most politicians in the established parties are merely the outward looking face of the 0.1% or, as Professor of Sociology Graham Scambler calls them, the “Capitalist Class Executive”. I prefer his other term for them: the “Greedy Bastards”. Politicians who currently support the activities of the GBs form part of the ‘Political Power Elite’ and are the public facing wing of the GBs. Obama et al in the US; Cameron, Clegg and Miliband in the UK; Abbott in Australia.  In the UK they form part of the ‘Establishment’ while the other parts of the Establishment merely acquiesce  and squabble among themselves about the size of the crumbs falling from the GBs’ table.

The real people to punch are the self satisfied, smug, post imperialist, authoritarian, narrowly educated but often from ‘elite’ universities, usually white and overwhelmingly male plutocrats and oligarchs, the ‘focused autonomous reflexives’ , embedded in globalised corporate networks who believe in their own propaganda about their innate superiority, achievements and right to rule over the underclasses, women, inferior ‘races’ and of course nature.

Their comic, and not so funny, face in the UK is Boris Johnson.

These men usually share an ‘autocratic father metaphor’ and base their politics around core beliefs:

1. The world is a dangerous place and always will be, because evil exists.

2. The world is hard and difficult because it is competitive.

3. There will always be winners and losers.

4. There are absolute right and wrongs.

5. Children are born bad, in that they only want to do that which feels good rather than that which is right.

6. Children therefore have to be made to do the right thing.

7. This world therefore needs a strong strict father who can: protect the family in a dangerous world; support the family in a dangerous world and teach children right from wrong.

Their wealth, they believe, gives them a superior position because they ‘earned’ it based on their own hard work and innate cleverness drawing often unconsciously from the assumptions above.  They are ready to defend it with other people’s lives and the desecration and destruction of the ecosystems on which the rest of us rely. Chapter 1 of Naomi Klein’s latest book is a chilling read and fleshes out some detail on the attitudes of many US CCE’s and their apologists, to climate change. Polly Toynbee and David Walker also illustrates their attitudes in a UK context.

These are the boys to make us think again. Their defence of their wealth and power is wrapped up in words about freedom and democracy and the “American way of life”. This acts as a smokescreen because in reality, as Klein shows, those who inhabit ‘Richistan’ are only concerned about themselves, their class, their privileges and are now actively protecting themselves against climate change, social unrest based in inequality and global jihad. They do so with the blood of others.

The soldiers you see above have been dragooned into this unholy class war.

Veterans are often the saps who, through necessity or through unexamined ideological traps, are the tools of the GB’s. Believing in higher motives such as camaraderie, or poorly thought through notions of democracy, they engage now in fighting the GB’s battles, suffering the costs at hourly pay rates the GB’s would not bother to raise their bloated carcasses out of bed to receive.

To add injury now to insult, we now have to face a medieval Caliphate, largely of our own making.

A young man near you may be sent to die for a cause he knows nothing about other than lies, distortions and false premises. Joining the British military always had its dark side, and apart from fighting Hitler has always been about establishing imperial power to allow extractive capital to freely go about its business. The UK now has a long established military culture, it’s loftier manifestation being the ‘heroes’ trope, and a more base manifestation is our infantile clinging to nuclear weapons.

I met two young boys on the Dover-Calais ferry who had just joined the army, what else is there for them? Without privileged networks, or education, or wealth, their chances of getting ahead in civilian occupations are greatly reduced as they metaphorically jostle with sharper elbowed upper middle classes and the children of the elite who have a stranglehold on plum careers. They also compete with the Precariat, ‘Gringo’s and ‘Endies’ who fill the employment figures making the recession seem better than it actually is.

These two had been sent on a tour of the WW1 battle fields and cemeteries. They were learning military history as part of their basic training. Writing up their notes, one commented on the virtues of discipline in the trenches. I don’t think he’d seen ‘Blackadder Goes Forth’. So, with the best of motives and the least of opportunities, we are preparing two very young men to face lunatics with scimitars, or “ten thousand Watutsi warriors armed to the teeth with kiwi fruit and dry guava halves at Umboto gorge”. Fresh faced and poorly educated they might become veterans relying on a non existent mental health service to sort out their PTSD while their Etonian educated ‘superiors’ worry about the stock market and the price of a bottle of Chateau Lafitte.

Want to thank a veteran? Give, not ‘loan’,  an education, provide some proper mental health services and an economy orientated to the needs of the many not the few.

NHS Funding – Calls to introduce charges

The Kings Fund have been looking at the future of the NHS and how it will be funded. One of those invited to discuss the issue with Kings is the right wing think tank ‘Reform‘.
Roy Lilley stated that Professor Alan Maynard tweeted about Reform’s message to King’s:
Alan Maynard (@ProfAlanMaynard)   25/08/2014 04:35 pm
NHS funding: “can we ignore pricing any longer” in KF weekly bulletin. Answer: YES! Taxation is fairer, easier to collect & opposed by cretins!!
King’s concern is about the issue of  demand for health services outstripping the country’s ability to pay. The suggestion is that the  NHS is facing a funding crisis so big that that the only solution is co-payments, top ups and insurance. This challenges the NHS principle of ‘free at the point of delivery’. I have argued in a previous post that care costs and so we have to consider who pays, but my view is that we should socialise the risk and spread the cost across society.
Roy Lilley asks: “Are top-up or insurance based systems with their overheads, actuarial hocus-pocus, running costs, surpluses, cost of collections, regulations, appeals systems and palaver cheaper and more efficient than a tax based system?”
He goes onto make the point that insurers “have to lay-off risk, reduce exposure and break even on their book. And, ten pounds to see a GP is £10 that has to be collected, administered, audited and in extremis, debt-collected. Taxes must be cheaper to administer and easier to collect”.
Kings,  in listening to Reform , are lending credence to the neoliberal dogma that wishes to shrink the state, individualise costs and encouraging private sector involvement.
The Tories used to say that the NHS is safe in their hands. The Kings bulletin will be music to their ears. Don’t expect Miliband’s Labour to challenge this.

Has anything changed? The malefactors of great wealth.

I came across a quote in Oreskes and Conway’s (2014) ‘The Collapse of Western Civilization’ from a speech made by a national leader. At this point, I will not name or date the speechmaker. I thought it interesting as a view on the relationship between a nation state and its wealthy individuals and thus on the nature of democracy. What follows are parts of the speech with some commentary in bold. I think it speaks to us today.

 

“National sovereignty is to be upheld in so far as it means the sovereignty of the people used for the real and ultimate good of the people; and state’s rights are to be upheld in so far as they mean the people’s rights. Especially is this true in dealing with the relations of the people as a whole to the great corporations which are the distinguishing feature of modern business conditions”.

The democratic deficit in both the USA and in Europe is that increasingly voters’ rights are being increasingly limited and bound by the rights of corporations and through the actions of corporate lobbying and political influence. The Transatlantic Trade and Investment Partnership  (TTIP) further threatens nation state and citizen democracy by allowing corporations to sue governments if they implement social and environmental protection legislation that the corporation deems a barrier to trade. Thus, national sovereignty is being eroded by such new legislation that does not recognise the sovereignty of people. Globalised capital flows are also eroding national sovereignty through capital mobility and a lack of a globalised governance in such issues as tax evasion and climate protection.

“Experience has shown that it is necessary to exercise a far more efficient control than at present over the business use of those vast fortunes, chiefly corporate, which are used in interstate business”.

More efficient control is now seen as anti-business and anti-democratic by the corporate class executive and the political power elites within a neoliberal idiocy that wants smaller and smaller state interference.

“But there is a growing determination that no man shall amass a great fortune by special privilege, by chicanery and wrong doing, so far that it is in the power of legislation to prevent; and that a fortune, however amassed shall not have a business use that is antisocial”.

This determination has been somewhat diluted as exemplified in Peter Mandelson’s famous quote that new labour is “Intensely relaxed about people getting filthy rich” and Boris Johnson’s eulogy to the rich as an ‘oppressed minority’. In addition we have Tax laws favouring the 1% and their offshore havens and finance capital that rewards fancy financial products while being socially useless. They argue as an article of faith that if taxes on the rich go up, job creation go down to justify their snouts in trough. Nick Hanauer debunks this idea in this short Ted talk. The rich are not job creators.

“Almost every big business is in engaged in interstate commerce and…must not be allowed…to escape thereby all responsibility either to state or to nation”.

Globalisation. If you don’t like our employment practices and wage structures then we will take our investments elsewhere; we will take advantage of the weakness of global labour and call it flexibility. You should be grateful you even have a job.

“The…people became firmly convinced of the need of control over these great aggregations of capital, especially where they had a monopolistic tendency…”

The people have become blind and disorganised, many have been persuaded to vote against their class interests. Many wish there was greater control, but are unsure of how to do it.

“There is unfortunately a certain number of our fellow countrymen who seem to accept the view that unless a man can be proved guilty of some particular crime he shall be counted a good citizen no matter how infamous a life he has led, no matter how pernicious his doctrines or his practices”.

CEO’s of certain banks, some hedge fund managers, asset strippers, CEO’s in the fossil fuel lobby and industry, climate change deniers…..many who form part of the corporate class executive who view corporate social responsibility either as marketing ploy and as a façade to mask their antisocial and anti-environmental business practices. Their rewards are knighthoods, huge salaries and bonuses, because their activities are legal and increase shareholder value.

“There is a world-wide financial disturbance, it is felt in Paris and Berlin…on the New York stock exchange the disturbance has been particularly severe…it may well be the determination of the government…to punish certain malefactors of great wealth…”

They are conspicuous by their absence in criminal courts and yet no common thief has ever cost the country so much.

“….who shall rule this country – the people through their governmental agents or a few ruthless and domineering men, whose wealth makes them particularly formidable, because they hide behind breastworks of corporate  organisation”.

We know the answer now. Government agents are discredited, lobbied or have become representatives of capital, not the people.

“I…hope that the legislation that deals with the regulation of corporations engaged in interstate business will also deal with the rights and interest of the wageworkers…it will be highly disastrous if we permit ourselves to be misled by the pleas of those who see in an unrestricted individualism the all sufficient panacea for social evils…”

Hayek, Friedman, Reagan, Thatcher, Bush, Blair, Cameron. The high priests of neoliberal individualism who first philosophised and then preside and encourage low wage, part time, zero hours economies and call this ‘labour flexibility’.

“The rich man who with hard arrogance declines to consider the rights and the needs of those who are less well off, and the poor man who excites or indulges in envy and hatred of those who are better off, are alien to the spirit of our national life. There exists no more sordid and unlovely type of social development than a plutocracy for there is a peculiar unwholesomeness on a social and governmental idea where wealth by and of itself is held up as the greatest good. The materialism of such a view finds its expression in the life of a man who accumulates a vast fortune in ways that are repugnant to every instinct of generosity and fair dealing or whether it finds expression in the vapidly useless and self-indulgent life of the inheritor of that fortune…”

We now have demonization of the working class, poverty porn on our TVs and victim blaming focusing on immigrants, welfare claimants and benefit cheats as a way of deflecting public anger on the state of public finances and the accumulation of wealth in fewer and fewer hands. The 1% now blame the poor for their fecklessness and lack of hard work resulting in the poor man increasingly turning to such ‘tools’ as jihadist ideology in reprisals. Meanwhile the middle classes in the UK bleat on about inheritance tax that is set at such a level that most of them will not pay it in any case. Turkeys voting for Christmas, Lemmings searching for cliffs, donkeys asking for whips.

 

This speech was given by President Roosevelt 1907  – the words in bold are mine. There is nothing new under the sun, the same issues regarding wealth and its influence and practices exercised Roosevelt over a hundred years ago. Between then and now various policies and legislation were put in place to deal with those worries. However, we have now reverted back to a time when we can again speak of the ‘Malefactors of Great Wealth’. This time around Obama is aware of inequality as a ‘defining challenge of our time’ but is wary of raising it for fear of being accused of class warfare. Roosevelt had no qualms about calling these people out for what they are.

The NHS in ruins: Small state private medical care is the future?

You would have to have been living on a desert island, celebrity obsessed or just plain ‘not interested’ to know there is an issue with NHS funding. The issue at stake is not that there is a funding gap between demand and provision, although that is certainly the case. The issue is the dismantling of the NHS as a publically funded service based on core principles. These principles are based on progressive, socialist/collectivist values rooted in social democracy. In short, the larger political project currently underway is the shrinking of the state by transferring its core functions of empowerment and protection of the public, to private, often global, corporations. The ‘moral mission’ of government is being eroded in favour of profit and individualising risk and responsibility.

 

Before we briefly examine this claim, it might be a good idea to remind ourselves of the current basis for the NHS:

 

The NHS was a political project founded in 1948 on the following guiding principles to address inequalities in access to medical services. The 3 core principles were:

1. that it meets everyone’s needs.

2. free at the point of delivery.

3. based on clinical need, not the ability to pay.

Since then these 3 have been developed into 7 principles underpinning the NHS constitution.

1. The NHS provides a comprehensive service available to all.

2. Access to NHS services is based on clinical need, not an individual’s ability to pay.

3. The NHS aspires to the highest standards of excellence and professionalism.

4. The NHS aspires to put patients at the heart of everything it does.

5. The NHS works across organisational boundaries and in partnership with other organisations in the interest of patients, local communities and the wider population.

6. The NHS is committed to providing best value for taxpayers’ money and the most effective, fair and sustainable use of finite resources.

7. The NHS is accountable to the public, communities and patients that it serves.

NHS Core principles

 

These principles derive from a social democratic root, instigated initially by the post war labour government under the guidance of Aneurin Bevan , Minister for Health in the Attlee government of 1945 to 1951 at a time when the UK owed far more as a % of GDP than it does now. Despite this national debt, the Attlee government still found the money to set up the NHS. So from the outset, this was a political project based on collectivist principles and for this reason is now seen by free market conservatives, neoliberals and small state conservatives, as undesirable. However, as the NHS has huge public support, these critics of collectivism use the language of ‘affordability in austere times’ to frame the debate rather than outright argue for the wholesale privateering of the NHS and a move to individual responsibility for health based on health insurance. As part of this process, there appears an almost deliberate softening up of the public for this privateering and abdication of government responsibility for the protection of the public’s health and medical services. As a result of government policy we are being exposed to stories about NHS funding such as:

The Royal College of General Practitioners asks patients to petition the government on the issue of funding cuts”. This was reported by Neil Roberts in May 2014, who writes that a poster showing queues outside a GP surgery, and a claim that up to 100 practices face closure, is being sent to GP practices. Roberts states:

“The poster and petition, which the college is asking patients to sign, are part of the Put Patients First: Back General Practice campaign, run with the National Association for Patient Participation. The campaign calls for an increase in general practice’s share of NHS funding to 11% by 2017”.

Is this a case of special pleading? I don’t think so, the health service is facing a funding issue, including the £20 billion Nicholson challenge. In the context of rising demand, and an increasing gap in the budget to meet that demand, the NHS requires some radical changes or faces a ‘productivity challenge too far’ (Appleby, J. (2013) A productivity challenge too far? BMJ 344 e2416). One report from the parliamentary Public Accounts Committee, suggested that 1 in 5  NHS Trusts were in financial trouble and bankruptcy was a real option, this despite the NHS having an overall surplus of £2.1 billion in 2012-13. This surplus may not last, and the seemingly disorganised, costly management and inspection schemes alongside the disintegration of the providers into an ‘any willing provider’ mix of public and private do not bode well for the financial future of the service. The Private Finance Initiative (PFI) schemes have also locked some NHS organisations into costly long term contractual agreements.

So, yes the NHS is facing many challenging issues that some argue require a solution not yet fully implemented, although started, by the Health and Social Care Act 2012. This solution is to reduce public provision and encourage private sector organizations to tender and compete for services, they would be known as ‘any willing provider’. In theory this means Tesco as well as small social enterprises.

To get to this position, the NHS has to be seen to be not working and the current pressure on reducing public spending assists this process. Lack of funding, allied to poor services, paves the way for further privateering. The argument is that the state cannot provide the funds and also should not provide the funds, but it is the former argument – ‘austerity’ that is being used as a shield for the latter.

David Cameron, in a speech at the Lord Mayor’s (of London) Banquet on November 11th 2013, outlined the strategic objective: ‘austerity is here to stay’, he said:

“The biggest threat to the cost of living in this country is if our budget deficit and debts get out of control again…we have a plan…it means building a leaner, more efficient state. We have to do more with less”.

Debt reduction as an imperative, masks the ideological position for a smaller state.

Let us not forget, for this government will have you do so, that the debt rose as a result of the bank bail out rather than out of control state spending. The successful narrative is that the debt is all Labour’s fault and that big state spending cannot go on. The global financial crash of 2007-8 is a very useful smokescreen hiding conservative wishes to reduce the state’s functions.

Health and medical services in this worldview is not a public good, it is a commodity to be bought and sold in the market. If the NHS can be seen to be failing, to be expensive, then you have a narrative which states that the answer is selling off the services to private companies and introducing competition. So, why not privatise the NHS?

We already have a model for this; it is childcare, the costs for which is seen primarily as the responsibility of the individual and the family, with just a little state support. The private sector is paying so little for so many families with children, and private sector landlords have private rents so high, that the state is subsidizing low pay with benefits. The idea that the whole of society benefits from well educated, healthy children, and thus has an interest in supporting their development, is sidelined when it comes to paying for that care. Childcare costs are largely picked up by individuals and families. The state supports families with tax credits, child allowance and is introducing some measure of support for childcare for parents who are working. This support derives from a collectivist, not an individualist, political philosophy, and as yet has not been fully withdrawn. This is partly meeting the government’s moral mission to empower and protect its citizens. Conservatives argue however that benefits should be cut, and wonder why those who choose to have children are not fully paying for them, after all it was their choice!

We do not know how far Cameron wants to push competition and more private provision for medical services, we don’t yet know how much of the more expensive US health insurance system he wants to copy. We do know that corporate lobbying for state contracts from companies such as Serco, Capita and GE occur for the more profitable services. See this short film on NHS lobbying .

The Free University argues:

The UK government is proposing to privatise yet more public services including Ministry of Defence procurement and the Fire Services. Other institutions such as the Met Office are also being considered for sale. Privatisation of NHS services has been underway for some time and will accelerate under the secret US/EU Free Trade Agreement currently in negotiation. These are all a manifestation of “Liberalisation“.

Linda Kaucher in 2013 stated:

“Liberalisation means offering investment opportunities transnationally and since the 1980’s, successive UK governments have prioritised liberalisation in both private and public sectors. Private sector liberalisation has resulted in overseas ownership of most UK enterprise. Privatisations in the public sector have been simultaneously liberalised, so overseas investors are involved in the public sector sell-offs (e.g. water, rail), private contracting (e.g. waste collection, hospital cleaning) and PFI schemes. Right now, it is the NHS that is at stake, as it is divided up, privatised and liberalised – potentially forever: once overseas companies are involved, it is very difficult to reverse liberalisations, and, inherently, also the privatisations underpinning them. This is even more the case as liberalisations are committed to international trade agreements –  which is precisely the purpose of trade agreements.”.

The drift is towards more privateering of medical services. Will we get a better health service with improved outcomes? Lets not confuse health with medical services; health is largely socially and politically determined, so even if the NHS is fully publically owned, health outcomes are determined elsewhere (socio-economic status, ethnicity, gender….). The NHS is providing medical services to treat illness and disease and to manage chronic long term conditions. So, will private provision improve medical outcomes, will it improve services for dementia, mental health, elderly care?

Nurses for Reform.

A free market nurse think tank:

“NFR has long argued that the NHS is an essentially Stalinist, nationalised abhorrence and that Britain can do much better without its so called ‘principles’ ”. (2008).

 

Health care is part of the ‘moral mission’ of government (Lakoff 2008 ‘The Political Mind p141) to empower and protect citizens. Lakoff argues that other forms of protection, such as the Police and the Fire services, don’t require insurance and health security likewise should be a function of government. Conservatives do not believe this, they feel that you should have health care only if you are willing and able to pay for it. If you are not making enough money then you probably do not deserve it. For conservatives, health is a commodity that should come with a price in the market. The post war consensus between conservatives and socialists in the UK held back this belief. This is now breaking down and conservatives are emboldened and empowered not only to make this argument, but to enact it.

 

Lakoff poses a simple question…will the privateering of the NHS serve the overall moral mission of protection and empowerment, will protection and empowerment be best served or undermined?

 

Those who argue it will not undermine this moral mission are also set to make a very large profit out of it.

 

 

 

The Corporate University, Health as commodity and the citizen as customer.

 “As universities mirror the increasingly unequal nature of English society … their role in advancing social equality, or minimising embedded disadvantage, will be traduced in a ‘meritocratic’ game of spotting talent and ensuring that it is slotted into the appropriate tier.” So writes Andrew McGettigan on the the discoversociety.org website in 2014. This comment on the ‘corporate university’ indicates that universities have functions that go beyond only meeting the needs of student consumers in their quest for a job, that indeed Universities should address aims beyond producing  ‘cognitive capitalism‘.

Should we care at all about this, or should we encourage even more market discipline?

For some, education is a commodity which should be bought and sold in a free market.  If a student wishes to borrow money to study literature or sociology then that is their choice, the State has no business in supporting study that has little direct economic benefit for individuals or society. So goes the free market apologists who places trust in the individual rational action of the student/consumer when buying the commodity of education. This is not new. Logan et al in 1989 argued in the context of the provision of health care that

“…services should be treated just like any other commodity that can be efficiently produced and consumed under market conditions”.

David  Willetts, Minister for Universities and Science, told a fringe event at the most recent Conservative party conference: unleashing the forces of consumerism is the single best means of improving the quality of undergraduate provision.

Student tuition fees have turned students into customers. This is seen as a ‘good thing’. Students will vote with their money and desert courses and institutions that they feel will not fulfill their hopes and aspirations. Competition for Elite universities will thus increase and only the best survive – a bit like the Premier League. Since its inception we have seen the loss of 50 football clubs as well as a sense of the club representing the local community values. Does that matter? Not if you are the winner – a Manchester City/Utd or a Chelsea – or a winner’s fans.

A clearer statement of the ideology of free market capitalism you will find hard to beat. Consider that this thinking has, not as yet, boldly reared its head for health. How would you feel upon hearing:

“unleashing the forces of consumerism is the single best means of improving the quality of health care provision”.

What do you think about  this:  Individuals should pay for their own health and social care needs at the point of delivery, as they are best placed to know what their needs are and how much they value health and social care. If they value beer and fags more, then that is their choice and the state should not intervene in that decision.  Individuals and families could pay for insurance for that ‘rainy day’ of dementia, cataracts or a broken leg. Hospitals and GP practices would be forced to compete for customers and those with poor reputations would have to close. Public Health England could be disbanded as a wasteful state cost base and instead individuals could be nudged to take responsibility for their health.

Well, if you have swallowed market ideology wholesale, that might sound like nirvana.

If universities are turning into warehouses for the production of cognitive capitalism in which education is a commodity to be bought and sold for instrumental purposes (“its the economy, stupid”), then their social role diminishes. Likewise, is health care a commodity to be bought and sold or does society also need a health sector that addresses the social and political determinants of health as well?

Individual rights and liberties balanced with social solidarity?

At root this is the difference between a social democratic political philosophy and a market driven neoliberal agenda. Its your choice, but remember ‘some animals are more equal than others‘ and they have the clout to ensure they stay ‘more equal’.

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