The past few years has seen the emergence of an NHS which appears unrecognisable from its original form as the jewel in the crown of the post-war social democratic welfare system.
We are beginning to see the NHS exerting colossal punitive power and fascism operating within hospital wards. With Theresa May’s NHS taking shape, we believe that now, a more critical history of the NHS is urgently needed to understand the breaks, junctures and, significantly, the consistencies with the social democratic institution. We need to understand what has brought us to a point where pregnant women unable to produce the appropriate documentation are denied entrance to maternity wards, smokers denied IVF treatment and the clinically obese hip and knee replacement surgery. We need to ask how it is possible that NHS managers are currently deliberating over whether to cut provision for all “non-emergency” treatments for smokers, alcoholics and the clinically obese.
This story of the NHS is not simply one of a glorious institution on its last legs after a sustained campaign of privatisation, chronically underfunded but desperately trying to do what is right. It is a complex unfolding of an institution that has, from its conception, served to manage and administrate the production of life in Britain, prioritising, as always, the ceaseless accumulation of capital.
The NHS is forecasted to undergo £22 billion worth of ‘efficiency’ cuts by 2020. Contained within this idea of efficiency is the image of a stripping away of that which is surplus to necessity. Its application always comes with a presumed distinction between what is necessary and unnecessary. This distinction is reinforced by the Conservative maxim that, as a nation, we must find a way to “live within our means”. Probing deeper into the statement, we can see how ideas of what is necessary and unnecessary map onto criteria for what is deserving and undeserving, whereby, a deserving core is isolated, and the lives and care of anybody that falls outside are framed as a luxury we cannot afford.
As the NHS is aggressively privatised, opposition to healthcare reforms have taken on a particular nostalgia for an imagined golden age of welfare provision. The Save our NHS campaign led by Unite the Union and Keep Our NHS Public, among other anti-cuts narratives, insistently argue that the NHS is a pure and beloved institution whose provisions must be conserved and preserved rather than reformatted. Why “our NHS?” The NHS is “public” insofar as the public in question is that of public order. It is public insofar as it serves the interests of capital-driven state power. As social theorist Nina Power so aptly puts it, “the police are the public and the public are the police.”
More often than not this idea of “public” is deployed to isolate a certain section of society and exclude a whole class of people – namely the non-hardworking British taxpayer – as a non-participant. The best example of this is the Public Order Act of 1986, a set of laws that have long been mobilised to criminalise protest and industrial action. Framing the rioters, the insurrectionists and the dispossessed not as of the public but as its enemies, it has long served to fabricate a mythological public good whose interests are actually the interests of capital. In the case of public order, it is the dispossessed and workers who are deemed public enemies. However, in the case of public healthcare, this role has fallen to those who are seen to put the most “strain” on the resources of the NHS: smokers, drinkers, addicts and the overweight. We must not reify these two categories of the dispossessed and the undeserving sick, for in reality they are largely the same people. Smoking, drinking, substance abuse and comfort eating are all coping mechanisms of those most impoverished in society. It makes sense therefore to call the NHS public, but it was certainly never ours.
We want to argue instead that the social democratic dream of welfare has in fact never not exerted a punitive and biopolitical power. In using the term “biopolitical” here we mean to refer to the state’s management of a population as a collection of living individuals, whose health and life processes are to be administrated and governed in the interests of a capitalist state. Biopower is a modern form of power that seeks control over life and death in a way that differs from the classical monarchical power to “let live and make die.” Biopower is not merely prohibitive, it is also productive, aiming at creating and enforcing on the population an obligation to conform to certain biological and health norms. In other words, the power to “make live and let die”. Instead of existing for “the health of the nation” the distribution of healthcare in Britain has existed primarily to preserve certain forms of life over others. Under this logic, the health that is mobilised is distinctly functional, simultaneous with the mobilisation of a working, productive population, working well enough only to effectively submit to waged and other forms of labour. What the popular opposition to healthcare reform lacks, therefore, is an agitation for health for its own sake.
Social theorist Michel Foucault notes the ways in which power exerts itself through institutions such as public healthcare along instrumental and biopolitical lines. This notion of making live and letting die sheds light on the more sinister aspects of healthcare. Health is not an uncomplicated and liberatory concept, but instead an enforced state of being for particular economic ends. This logic is traceable in the previous prohibition on suicide and the current prohibition on euthanasia. Whereas previously one’s right to health and life was deemed to be property of God, it has now entered the jurisdiction of a capital-oriented state. Welfare has always existed as a tool to shovel up the broken lives spat out by capital, rehabilitating them enough only to be re-inserted into a productive economy. Left-wing demands for a healthcare system have misguidedly championed the return to a halcyon NHS, but we argue instead for an overhaul of the disciplinary logics that have governed it since its conception.
The Social Democratic NHS and proletarian life production.
The formation of the modern National Health Service arose from the newly formed Labour administration in post-war Britain. Drawing on the 1942 Beveridge Report’s prescriptions to tackle the five great social ills of “squalor, ignorance, want, idleness and disease,” six years on Labour’s Health Secretary Aneurin Bevan pioneered the birth of a free NHS. In its beginnings, the NHS was emblematic of what neoliberal interventionists would later term the “paternalistic” British state, a structure that is held dearly in the hearts of many a social democrat today. This is one of the earliest examples of the state concerning itself with the notion of “health” – not simply reactively to epidemic emergencies, but rather a conscientious administration of the “health of the nation” and all the life processes therein. The seeming gift of universal free healthcare brings with it a shared social obligation towards a healthy national productivity, whereas under previous, pre-war forms of capitalism, the health of the worker – if considered at all – was at the disposal of their individual bosses, with no umbrella structure existing to ensure the health of those at the interstices of employment. Bevan registered these motivations in his 1952 essay “In Place of Fear”, acknowledging the limits to the individualised industrial health schemes that had previously been commonplace. He wrote of the need for “plan and central direction” to avoid an uncoordinated and unequitable constellation of industrial healthcare schemes that would create a “patch-quilt of local paternalisms.” At the centre of this plan was “the worker and his family,” who is drawn into a nationalised system of contribution and reward.
This landmark instance of state intervention reconstructs the idea of health as a social good. But as with all social goods, health becomes a channel for the more sinister machinations of state power and capital accumulation. The “health” of the National Health Service seems less about health for health’s sake, and more about health as the reproduction of labour power for a post-war social democratic society rebuilding itself after the population and resource losses of the Second World War. Social democracy is to be understood as a concession of capital to the demands of the workers, or proletariat. It is a tempering of the more violent tendencies internal to the logic of capital, but at the same time, a system of capture designed to recast capitalism in order to make these forced concessions work for it. What was needed for British capital to regain its profit margins and productivity levels after the war, was a vast programme of proletarian life production and population expansion. The NHS served as the primary channel for the state administration of this production of proletarian life and health, administrating capital’s post-war population expansion project, more commonly known as the “Baby Boom”. It also, for the first time, ensured not simply the health of those currently employed in productive labour, but also the so-called reserve army of labour – those unemployed, but kept in a constant state of readiness to take over labour when strikes broke out. Altogether, the citizen’s health, whether working or not, became a duty of and to the state.
What all this amounts to then, is a concerted effort to make a huge generation of healthy workers and reach new levels of productivity hitherto unseen in Britain – not a free gift of life and health to be autonomously enjoyed, but a project of “making live” and investing that life more exuberantly into the accumulation of capital. Contained within the beginnings of the NHS therefore, are the seeds of biopower recognisably at work in public healthcare today. “Making live” can never be without its counterpart of “letting die”: the dark side of biopolitical production will become exposed as the logic of the NHS develops through the introduction of neoliberal health reform. We must see neoliberalism not as a break with the social democratic consensus of the post-war years, but as a particular evolution of capital drawing on and learning from the methods deployed at this time.
NHS in crisis and its neoliberal transformations.
The critical turning point that bred the significant changes in the structure of the health service in the later 20th century is simultaneous with the global economic downturn of 1973. A crisis in profit rates and productivity set off the demise of the social democratic project of les trentes glorieuses– the thirty years from 1945 to 1975 following the end of the Second World War. 1974 saw the first major reorganisation of the National Health Service, which entailed the streamlining and collapsing of services and the introduction of heavy spending cuts for the purposes of efficiency. As capital enters crisis its techniques of biopolitical production are forced to adjust. No longer does it have the resources to invest as much into “making live”; it must recapture its losses through efficiency measures. The positive project of the production of health changes tack to a project of harm reduction, aiming at a slowing down of the wasting effects of increased efficiency upon labouring bodies and minds. As the “make live” field of the biopolitical equation is forced to economise, and eventually shrink, simultaneously, the field of “let die” begins to expand to fill its place.
The crux of this proportional shift begins with the crisis, but has only begun to be fully realised in the past few months. To understand how we arrived at this point, it is useful to examine the transformations in the discourse of diet and health under New Labour. Tony Blair’s administration is memorable for its careful curation of a new social relationship between education and health sectors, within which the punitive mechanics of the NHS can be seen to allocate blame and punishment for certain forms of life. The biopolitical dynamic duo of Tony Blair and Jamie Oliver gave us the innovation of “healthy” school meals that enforced the quota of “5 a day” on British school children. While we are not suggesting that turkey twizzlers contain the promise of liberation, we must remember that every assumed act of care by a capital-driven government has its own sinister motivations. Suddenly, fizzy drinks become impossible to procure in schools, but the milk that Thatcher snatched, is repackaged and sold back to us at a very reasonable price. The Jamie’s School Dinners programme was a preparatory exercise in the formation of disciplined subjects and healthy bodies whose net cost to the health system could be reasonably capped at a certain threshold. Those who strayed from this health ideal were now more easily identified, and their illness moralistically responsibilised as a product of their individual lifestyle choices.
This shift was actually, acutely and consciously registered in Blair’s public engagement. A speech from July 2006 meticulously historicises the particularities of New Labour transformations of public healthcare, theorising the end of the age of public health and the emergence of a new form of governance, labelled “the enabling state” – a middle way between between the paternalistic public sector of the post-war social democratic years, and full concession to market forces. In this framework, government and corporate powers are mobilised to entice desirable personal behaviours and lifestyles. Blair claims that the age of pathogenic disease is over with the control of environmental conditions, citing collective behaviours and lifestyles as producers of their own diseases: “Today, our main killers are circulatory and cardiovascular conditions which very few people in the Victorian and Edwardian eras would ever survive long enough to contract.” Now, the public is no longer a body which must be protected from external damage. Instead, it is re-imagined as a body groaning under its own weight, lacking the strength and discipline to achieve its goals by its own ingenuity. Blair pays homage to “the increasing strain unhealthy living will put on the NHS”. Try and remember a time when the NHS was not always already framed as bloated, impotent and under immense pressure from the needs of the populace. Rather than looking to ways the welfare state might be strengthened and supported through specialised and ring-fenced funding, the responsibility for reducing this strain falls to those in receipt of care.
From neoliberalism to neofascism: May’s NHS and drawing of borders.
This landmark moment relocates responsibility, re-imagining public health as “not, strictly speaking, public health questions at all… [but] questions of individual lifestyle – obesity, smoking, alcohol abuse, diabetes, sexually transmitted disease.” This transformation in the idea of public health lays the groundwork for the situation we find ourselves in today. In this New Labour imaginary, these lifestyles are seen abstractly as properties of the public body, rather than the outright moral failures of individuals. The move to actively demonise the individual comes later, with the renewed vigour of the austerity programme implemented by the coalition government of 2010. In 2012, doctors announced a commitment to campaigning for the right of NHS practitioners to refuse non-emergency treatment to smokers and the overweight. Such “non-emergency” treatments at this time included denying IVF treatment to women who smoked, breast reconstructions and hip and knee replacements for the clinically obese. This is only the tip of the iceberg; in some areas of the country, all non-emergency treatments are actually being withheld from these groups on the grounds of financial management. In practice, these treatments, of course, do mean the difference between life and death: their denial is the difference between “making live” and “letting die”. The intrusion of these restrictions into the field of family planning forecasts some of the disturbing eugenic potentials of withholding rights to assisted procreativity to those whose lifestyles betray them as unworthy. More recently, this apparent consensus among medical practitioners has made its way more concretely into law, when the Vale of York clinical commissioning group, an official NHS body, ruled that these supposed “non-emergency treatments” could be denied to patients for up to a year.
Here we see a continuation of the logic of Blair’s new health regime, but with the unsavoury taste of false compassion stripped away. The growing neoliberal consensus has mutated to a point where there is no longer any express sympathy for the bodies of smokers, alcoholics, the overweight, etc. Now we see a very particular demonization of bodies as objects, not only as unwitting “strains” on the NHS, but as actively antagonistic by virtue of their very being to “the nation”. As such, the very notion that these bodies could become the recipients of care is seen as a perversion of justice and personal insult to both the government and the taxpayer. Here, the other side of Foucault’s formation comes into play: we are seeing the isolation of a class of bodies that should be let die, as just repayment for their own “choices” and circumstances. The smoker’s body, the body of the obesity sufferer, the addict: these objects are distinguished as surplus to requirement.
We need only take a look at the tax mechanisms through which the NHS is funded, and who these taxes target, to see the full extent of the responsibilisation and demonization of these particular bodies and behaviours. Though classically it is drinkers, smokers, addicts and the overweight who are identified as the figures placing most “strain” on the NHS, the mathematics of this blame game literally do not add up. For example, taxation on cigarettes brings in roughly £12bn to the UK economy, which is around double the NHS’ expenditure on treatment for smoking related illnesses. Similarly, a report by the Institute for Economic Affairs estimates that British drinkers subsidise non-drinkers by £6.5bn. Even by the pay-your-way logic already presumed by studies such as these, the consumers of alcohol and cigarettes not only cover the cost of their own treatment and discipline by the justice system, but add more to the public purse than the “deserving” sick.
These statistics present us with the chilling reality that the exclusion of these people from public healthcare goes far beyond the neoliberal logic that dictates they pay-their-own-way, taking the financial responsibility for their own sicknesses. To this emerging logic, it is not enough to fund the healthcare of drinkers, smokers and the clinically obese through the taxation of products they consume; nor is it enough to force them to subsidise that care twice over, effectively shouldering twice the financial burden as their non-smoking, non-drinking, and average weight counterparts. They are seen as surplus even to the value of their material investment in the healthcare system. This goes beyond mere financial responsibility, and actively seeks to remove certain bodies from the population. Whether this be through the forcible changing of their bodies and behaviours, not assisting them to reproduce, or standing idle and watching them die. This is the “let die” of the biopolitical equation.
It is consistent with this logic of demonisation, exclusion and, ultimately extermination, that the celebrated so-called public spaces of the NHS have, alongside schools, workplaces and universities, become extensions of the British border system. Only last month, Theresa May vociferously defended a trial scheme currently running at a South London hospital that demands women present their passport upon admission to maternity wards to ensure that the undocumented do not make their way through the cracks of the free healthcare system. May spoke out against the supposed rise of “maternity tourism” in the UK, which presumes that “there are people who come to this country to use our health service – and who should be paying for it,” and introduces reforms to identify “those people and make sure it [the NHS] gets the money from them. I would have thought that would be an uncontroversial view.” Again the bodies of the undocumented and the undeserving are deemed surplus to the duties of a “straining” health service. This rhetorical veneer conceals the biopolitical motivations of reforms such as these: not only will the lives of babies and mothers be placed in genuine jeopardy, but the automatic registration of the child’s birth is taken away. This technique deftly obliterates any possibility of children born to undocumented migrants in the UK holding any tenuous claim to British citizenship, securing the state’s justification for later deportation.
Projections for Our NHS.
What this history can tell us about our present conditions is that our fight for an NHS that is truly ours is bound up with the necessity of a comprehensive and coordinated antifascist movement in the UK. Fascism isn’t always as brash, loud and controversial as Trump, nor does it have to be as overtly traumatic and violent as historical projects of extermination, with landmark events like Kristallnacht – a pogrom against Jews throughout Nazi Germany on 9-10 November 1938. Often fascism’s machinations take place in the negative, wielding the slow violence of neoliberal denial. Life is not directly ended, but denied the conditions under which it can exist. While there is a common tradition of antifascist and anti-cuts organising struggling on the back-foot and fighting a defensive battle against the tides of a eugenic project, we are now tasked with speculating a decolonised and liberated healthcare system that actually belongs to the people.
This demands that we wrest the concept of health back from the hands of capital. Any equation of health with both productivity and necessity must be actively opposed, meaning that there is no healthcare that can be thought unnecessary and no person undeserving. The parameters of “deserving” must be drawn in accordance with desire as opposed to an externally decided “need” or one’s ability to contribute, be it through taxation or work. Healthcare should never be the top-down administration of public health, nor reduced to the responsibility of individuals. Instead it must become a project of autonomous care – by people, for people. Doctors and bureaucrats must cease to be the gatekeepers of resources and care, and patients must be empowered in the restructuring of the NHS.
If the social democratic organisation of healthcare is understood as the paragon of healthcare systems on the contemporary left, then we will inevitably fail to liberate healthcare from the biopolitical conditions that have operated upon it in Britain. The everyday realism of life under capitalism deceives us into forgetting a time before the hegemony of its various structures and forecloses the possibility of imagining an alternative future. But history has produced healthcare systems that have adopted different models to that which we historicise in this essay. Though we make no pretence of being able to theorise a cohesive and comprehensive model of a liberated healthcare system, the total colonisation of our imaginations by capitalist relations gives us the duty to fantasise and imagine organisations of health that resist the biopolitical structures explored thus far.
What reorganisations of healthcare can be imagined within the technological capacities currently possessed and the prescriptions already drawn? We know that our demands for healthcare must be antifascist, and therefore we turn to the greatest antifascist movement in history, whose flag is still flown at antifascist demos worldwide. During the Spanish civil war, when the Spanish anarchists had control over the Catalonia region, they developed the Health Workers Union, which alongside simply unionising healthcare practitioners, became more of a self-organising syndicate for the provision of treatment. What this actually looked like was a horizontal organisation of health centres across Catalonia. The geography of the region was divided into nine sectors, within which twenty-six secondary sectors were then organised. This model ensured that even the smallest villages and zones could access the healthcare that was needed by their populations, avoiding a core-periphery model that would force patients to travel great lengths in order to access medical care. These community health centres were autonomously governed by their users and workers, rather than a centralised state body or technocratic system.
Of course we must recognise that this particular organisation of healthcare emerged at a time of war, and therefore was geared towards providing emergency treatment for physical injury. If we want to imagine a health system that seeks to provide long-term care for the disabled and the chronically ill, we must incorporate a broader set of influences. Given substantial funding paired with a free and effective medical education system, however, what this model does provide us with is a vision of healthcare liberated from top-down state power and the biopolitical management of health that comes with that. It therefore can legitimately provide us with a backbone for the organisational structure of a new healthcare system. Doctors, nurses and other healthcare professionals should not be a class of technocrats with the power to remove freedoms and dictate the expenditure of resources through the investment of power to draw a line between necessary and unnecessary. Imagine a psychiatric healthcare system in which one did not have to agonise over having to convince their doctor of their condition, and a trans healthcare system that did not demand a subscription to already socially entrenched delineations of gender. This model resists the instrumentalisation of healthcare to produce healthy and able workers – the medical-industrial complex if you like. In divesting doctors of the power to declare bodies fit or unfit for work, we propose a patient-centred approach in which self-diagnosis and self-referral are respected and the social conclusions of medical care should be formed non-hierarchically out of a negotiation between patient’s experiences and doctors’ technical expertise.
At this point we might want to address the nagging liberal whinge at the back of all of our minds: “but someone has to pay for it!” Our projections thus far demand an expansion of healthcare, but how can we expect this to happen when we are told repeatedly that resources are already under immense strain? Transitionally, there are a number of answers: the defunding of Trident and the imposition of higher taxation on corporations could provide us with a robustly funded healthcare system and replace the pay-your-way logic of exorbitant taxation on “luxury” and unhealthy items that comprise our only coping mechanisms in a violent austerity regime. However, these transitional options do not and should not represent the pinnacle of healthcare reform. Ultimately, we call for the communisation of everything, including the production of medical resources and their provisions. If we want to understand why the NHS is “strained”, we must look at the exorbitant profit margins of big pharma’s monopoly on pharmaceutical provision, where innovations in medical care will always be much more expensive than their older, less developed counterparts. Partnered with a communisation of resources, we must also abolish pharmaceutical intellectual property, meaning that the cost of medication must never rise above its use-value. In untethering medical innovation from the motives of profit, we can watch them develop at an exponential rate.
While the future of the NHS is uncertain, what is certain is that we cannot achieve a communised and antifascist healthcare system by simply returning to the models provided by social democracy. There is very little we want to “Save” of “Our NHS” but an awful lot left to create. With this in mind, we have drawn up the beginnings of a manifesto, speculating what our NHS could be. In the spirit of expanding our collective imaginations, we actively invite contributions and suggestions in the comment section below.
Manifesto: Principles for a liberated health system.
- Healthcare should be freely available to everyone regardless of their lifestyle or ability to work.
- There is no unnecessary healthcare, just as there are no unnecessary people.
- Healthcare must be antifascist. It should only ever be “national” in the sense that it provides healthcare within this region of the world. It must not reinforce borders or any distinction between citizen/non-citizen/undocumented.
- All diagnoses for neurodevelopmental and mental health conditions should centre the experiences of the patient. Self-diagnosis is diagnosis.
- There must be no state power to section or otherwise coerce patients into certain treatments.
- Resources such as medication must be communally owned and without profit-margin.
- Where possible and desirable, we should look to automation to take on the work of some surgeries, healthcare administration and pharmaceutical distribution.
- A greater level of medical training should be provided for non-professionals on the national curriculum.