Presentation at King’s College, Guy’s & St.Thomas’ Medical Schools Millennium Debate on health and justice, Southwark Cathedral, 13 January 2000.

For an opportunity occurring once in a thousand years, and in a setting reflecting the daring of human imagination, I’m grateful - chiefly to my old friend and sparring partner, Marshall Marinker.  At 72, I’m more interested in the direction than the speed of social change.  Since 1979, our society has hurtled forward on an accelerating cycle.  It makes things better, by making people act and feel worse.  Every aspect of life, everywhere in the world, is now subjected to this dual process.  Its root cause is that everything - goods, services, athletes, music, body repairs and now even scientific knowledge – has become a commodity traded for profit.

To understand this we must begin at the beginning.  Despite fundamental differences, Karl Marx and pre-Pauline Christians shared important common ground.[1] They assumed that we originally became human not as isolated self-sufficient predators, not as marooned Robinson Crusoes, but through joint work shared between co-operating equals.  Within groups of subsistence producers, inequalities were biological rather than social.  Such communities had robust ideas of internal justice, though most competed bloodily with neighbouring tribes at least some of the time.  Justice was normally maintained by custom, exceptionally enforced by expulsion from society to the wilderness. 

Marx and the Old Testament agree that advance beyond egalitarian subsistence depended on divisions of labour and property, necessarily creating socially constructed inequalities.  The collective social product ceased to be collectively planned or consumed.  Productivity rose through organisation and legitimation of social injustice.  This began with the first and most lasting of all injustices, the subordination of women to men so that women did the most onerous work, most necessary to sustain society.

The original prophet of capitalism, Adam Smith, spoke with a frankness impossible for his successors.. “Till there be property”, he wrote, “there can be no government, the very end of which is to secure wealth, and to defend the rich from the poor.”[2]  There have been many attempts to justify social inequalities as consequences of human biology rather than of divisions of labour, power and property, as natural order rather than social construct. Women’s biological fitness for child-bearing was interpreted as unfitness for anything else but drudgery.  Slavery was justified first by Aristotle’s theories of moral selection in his Politics, then by 19^th century imperial racism.  Herding of men, women and children into mines, mills and factories was justified first by social Darwinism,[3] later by mismeasures of intelligence[4] and the competitive rather than co-operative education they sustain.[5] [6]

Social Darwinism remains part of that justification, with a particular appeal to people on top of the heap.  An old friend of mine, with lifetime experience of general practice and an international reputation in research, was honestly convinced that the real distinction between rich and poor lay not in their wealth or power, but in their different capacities to cope with life.[7]  He saw that quality in the rich which so impressed F Scott Fitzgerald when musing with his fellow novelist Dashiel Hammet: “Y’know, Dash, the rich are different from us.”  “Yes”, said Hammett, “They have more money”.  My conclusion from 40 years’ experience of doctoring industrial working class communities was just the reverse of my friend’s.  Measuring the coping power of poor people against what I thought I might have managed myself, with the same history in the same circumstances, they rarely failed to amaze me.

A less pretentious but more important justification, with far wider appeal, is the claim that rising inequality was, is, and will always remain a reasonable price to pay for the colossal rise in productivity which market competition for profit can yield.  For production of material commodities, this argument has been persuasive.  Though capitalism produced 3000 pairs of shoes for Imelda Marcos while leaving thousands of Phillipino children unshod, barefoot children no longer exist in fully developed market economies.  Even so, production for the market always and inevitably subordinates satisfaction of human needs and long term sustainability, to short-term profit and capital accumulation.  As material abundance first becomes feasible, and then becomes an assumption for at least the top two-thirds of society, the misdirection and reckless acceleration of effort ensured by pursuit of profit becomes increasingly obscene. Production for profit ensures deliberate invention and promotion of hitherto unperceived wants for people who already have far more commodities than they need, but still have enough wealth to support further extension of luxury markets.  And production for capital expansion ensures growing investment in less labour-intensive but more globally destructive production, even when unemployment has re-appeared as a major problem, and the future of our planet is in mortal danger.

The marketeers promote our guts but addle our brains.  They then blame the consequences on collective human folly. Consumers are kings – but kings who’ve lost every means of expression except how, where and when they spend their money.  After 12,000 years of sweated and bloodstained human history, after generations of heroes, heroines and unsung martyrs who’ve imagined, suffered and fought for more intelligent futures, there must be better ways than this.

Inequality, and thus injustice, are necessarily created by all societies in which a few live from what they own or control, leaving everyone else to depend on these owners for employment.  In all fully developed industrial societies, market competition compels everyone to be either winner or loser, in a universal struggle of every man against every man. 

Some developing societies have tried to break out of this pattern.  They used the collapse of more or less feudal or colonial economies, when capitalist production and state machinery were still poorly developed, as opportunities to create socialist societies alternative to capitalism, rather than sequels to it.  The hopes they raised were intoxicating, but have all proved illusory.  All have ended in some version of industrial capitalism.[1] 

Their error lay not in Marx’s analysis of society, but in uncritical adoption of the young Marx of the 1848 Manifesto as a secular prophet of voluntarist social change.  They welcomed the passion but ignored the analysis.  By 1852 Marx and Engels both recognised that what they had celebrated as death throes of Capitalism in 1848, had actually been its birth pangs: a serious misdiagnosis,[8] repeated several times since, and with fatal consequences.  A new society can’t be created or sustained only by passionate rejection of injustice, or any other act of will.  It needs new social institutions, new modes of production, new customs, a majority of new people developed within and by the old society, but thinking and acting in a new way with a new common sense.  This full winning hand can probably be developed only in advanced, fully industrialised societies, with material abundance at least visible on the horizon.  If just one advanced, fully industrialised country were able to develop anything different, making a breach in the international army hitherto always available to enforce primacy of property rights over human rights; then enormous social energy might again be released in less developed economies - but we, not they, probably have the detonator.

A causal link between social inequality and rising productivity has always been recognised.  A central task of the main religions has been to explain this paradox by accounts of lost innocence and original sin, to attenuate it through charity in the life we have, and to evade it by letting God redress the wrongs of this world in hypothetical worlds after death.  In the tangible world we actually have, profit takes precedence over charity.  As Margaret Thatcher said, the Samaritan had first to get rich and stay rich, before he could even consider helping anyone but himself.

From 1948 to 1979 the NHS functioned as a State charity, an institution for the people but not of the people.  Its funding depended on wealth generated from commodity production, transferred through taxation.  Anyone may at any time fall among thieves, of their health as well as their property.  Premature death, disability and unhappiness are socially selective.  Misfortune grants miseries most generously to the poor,[9] [10] but doesn’t altogether forget the rich.  Experience shows that if enough poor people live miserably, there will be bad consequences for everyone else.[11]  My mother was crippled by a severe stroke at age 52, at the height of a well-paid career in the pharmaceutical industry.  This was a consequence of childhood rheumatic heart disease, now virtually unknown in the UK, but common in Bolton in 1916.  Today, young doctors wanting to study acute rheumatic fever must go to West Africa, Latin America, or India - or to the ghettos of Chicago or New York.[12]  Here in the UK we’ve not yet created new slums large enough to recreate endemic rheumatic fever, but we’re being pushed toward the same social model.

So, can we and should we try to create just institutions within an unjust society?  The standard answer seems to be “Yes, but don’t try too hard.”  So long as the NHS is seen as a State charity, a wealth-consuming rather than wealth-producing system supporting an unfortunate sick minority by taxes levied on a fortunate healthy majority, limits to how hard we try will be set by consent to taxation.  This can be measured in three ways. 

First, media editors get all the news about society, so they can tell us what everyone else thinks, and thus set the agenda for our own thinking.  All our mass circulation newspapers are owned by people rich enough to buy a large company, and media commentators are highly paid celebrities.  Try as they may, none of these can see things as they appear from below, even if they want to. However, papers must be sold and programs must be watched.  This sets limits to how far what they publish can differ from what their readers personally experience.  As most people do experience the NHS personally, the media pay at least some regard to truth.  It has proved easier to sell wars to the public, than to get their consent to privatisation of the NHS.

Secondly, we have rigorous scientific studies of public opinion, for example the series on British Social Attitudes conducted annually since the early 1980s by Social & Community Planning Research.[13]  These have consistently shown a large majority of people in favour of an NHS providing the entire range of effective care free for the whole population, funded from taxation.  Despite all doubts thrown at this by Thatcher’s New Conservatives and by Post-Modern thinkers of the unthinkable, this majority persists.  Despite powerful advocates for continued piecemeal privatisation of the NHS by stealth and a return to that fee-earning mentality which has always been the main enemy of rational medicine,[14] the pro-NHS lobby is probably still growing.  Defence of the NHS unites voters of all persuasions.  The majority in favour of a universal service provided free according to need is larger among Labour and Liberal-Democrat voters, but exists even among Conservatives.  This cultural commitment to a free and universal NHS is not unique to Britain, but seems stronger and deeper here than anywhere else in Europe, possibly excepting Italy.  It’s certainly much greater here than in USA.[15]

Finally, we’ve evidence from parliamentary elections.  These, we’re told, are the only valid measure of what people truly believe.  When they say that a richer nation must be able to afford an expanding and more generous NHS, and that even if society as a whole becomes increasingly unequal, they want a sector of our economy to work for human needs rather than for profit, we’re told this is meaningless.  In opinion polls, they say, people vote with their consciences, but at elections they vote with their wallets. The 1992 election is supposed to prove for all time, that no party proposing higher graduated income tax for the rich can ever again get elected. 

According to The Economist, Rupert Murdoch’s main UK holding company, Newscorp Investments, has paid no net corporation tax for the past 11 years, despite profits of £1.4bn over that period.[16] Some media experts even assert that no government has ever got elected on a platform of raised taxes.  Apparently they’ve never heard of Lloyd George.  Of course, his new taxes were on the very rich.  Taxes on the very rich are what we need now.  Were there a political will at the top, a way could and would be found.  Convergence of all major parties toward a common agenda of totally business-orientated economy and culture has created a huge gap in serious British politics - not the pseudopolitics of personal careers, but the real politics of choosing what sort of society our children and grandchildren will live in.  Despite an increasingly vacuous agenda for approved media discussion, this political vacuum is unsustainable.  It will soon fall apart, and no spin doctor will be able to save it.

Once freed from fear of any socialised alternative, without audible hammering on the gates, there are no limits to Neoliberal economic thinking.  Professor Milton Friedman is a Nobel Prize-winning economist who must be taken seriously. “Few trends”, he wrote, “could so thoroughly undermine the very foundations of our free society as the acceptance by corporate officials of a social responsibility other than to make as much money for their shareholders as possible.”[17]  Few economists now admit to agreeing with him, but regardless of what they believe, this is indeed how the capitalist system compels corporate leaders to behave, simply to survive in dog-eat-dog international markets. 

Capitalism cannot, from its own intellectual resources, set limits to greed, because subordination of human judgement to market forces is its mechanism, and greed is its fuel.  To defend and extend human dimensions in a dehumanising society, we have to find forces outside the market paradigm, a credible alternative base for a fundamentally different economy, providing secure foundations for a rehumanising culture, and a higher form of common sense.  Simply to sustain capitalism within a tolerable and stable social context, this will become a necessity.  When the State of California spends more on its penal system than on education, the writing’s on the wall.  The Golden Years of stable prosperity in Western Europe and North America were years of Keynesian compromise, when Capitalism feared for its future and conceded a social infrastructure and a social wage in its own interest.  Capitalism needs competition, not only within itself, but also between itself and a credible alternative.  The most obvious and compelling alternative is the economic and cultural system already evolving in publicly owned medical services everywhere, but most clearly in the NHS.

The NHS functions within a society geared to pursuit of profit and expansion of capital as its aims, with satisfaction of human needs as subordinate byproducts.  The seed for an alternative society lies in the fact that the NHS produces its wealth more efficiently, and in an entirely different way. Its outputs are just as real as the products of commodity production for profit, they have far more scope for useful and sustainable expansion, and an insatiable appetite for human labour no longer required for commodity production of material goods.  With imagination, NHS outputs can be measured,[18] but not in units interchangeable with those used for the commodity market, because they are personal and social, but not exchangeable. 

I must explain the word “commodity”, which even academic economists often use carelessly.  A commodity is not simply a thing, a good or a service.  Whether or not something is a commodity depends on whether it is produced simply for personal consumption or use on the one hand, or for sale in the market on the other.  A cobbler who makes a pair of shoes for his grandchild has not produced a commodity.  If the child’s mother then sells the shoes, perhaps for money to buy milk, the shoes do then become a commodity.  Does this matter?  It seems so.    Over 200,000 US citizens with end-stage kidney failure enter dialysis programs each year, about two-thirds in for-profit centres, the rest through non-profit public service units.  A recent 6-year follow-up study of more than 3,500 patients showed that those in for-profit centres were 20% more likely to die, and 26% less likely to be referred for kidney transplant.[19]  For-profit centres have incentives to minimise both costs (particularly for trained staff and time periods for dialysis sessions) and referral (because they make their money from dialysis, and lose money when dialysis is replaced by transplant).  Ends affect means.  Motivation does matter.

Shoes are certainly produced more efficiently as commodities than as gifts.  There’s growing evidence that this is not true of medical care,[20] nor probably of anything else that needs interacting human imaginations or decisions for its optimal production.  Gifts of health care consume labour and resources, and therefore require economic decisions about resource allocation and investment.  Health economists need to start from totally different assumptions, than those used in commodity markets.  Just as adding more wheels within wheels to the Ptolemaic model of the universe failed to make the sun circle the earth, more sophisticated modifications of already complex mathematicised marginal utility will still fail to make free, universal health care resemble any kind of commodity market.  The only way to make the NHS work like a market is to compel it to be one, and thereby destroy it as a comprehensive national service, forfeiting the huge gains in social efficiency we have made since 1948, compared with fee-paid systems.

During the1980s business attitudes and methods were imposed on the NHS.  These were influenced by health economists, notably Alain Enthoven.[21][22] By applying business attitudes and methods to the NHS, they promised large gains in productivity.  In general, these policies failed.[23]  There were indeed huge gains in productivity of process.  In the 15 years after 1982, NHS beds were reduced by 40%, while numbers of in-patients and day cases treated rose by two thirds,[24] and bed occupancy rates rose to over 90% in most hospitals.  But this was at colossal cost, and for the Treasury (prime mover for all these industrialising “reforms”) it solved nothing.  It forced hospitals to adopt more costly, more technology-intensive methods.  Business culture damaged staff morale, encouraged medical staff to increase primitive medical, suborned the integrity of independent university research, and set us all on a path where anything goes, so long as it’s profitable. True, medical science, basic and applied, has continued to advance; but this advance has been despite rather than because of business attitudes and methods.[25] [26]

Consumer rather than supplicant status has in many ways been an advance for patients, a liberation from the condescending charity of unaccountable professionals.  But it has also entailed social retreat. New Labour’s leaders have adopted medical consumerism uncritically, just as they have adopted competitive education.  Provider-consumer relationships in the market are always at least latently adversarial, despite their rhetoric of suffocating affection for customers – “Have a nice day!”.  Optimal development of professionals to serve the people rather than to serve themselves depends not on pressure from shopping around or malpractice litigation, but on escape from fee-earning and the provider-consumer paradigm.[27]  Optimal development of patients as co-producers of a healthier society, or of students as co-producers of a more educated society, both depend on developing new, co-operative, socialised relationships.  Evidence from both medical and educational science consistently supports this path of development as more efficient and effective than commodity-based trade in medical care or education.  Equally consistently, real progress in both is thwarted by market competition, commercial secrecy, and the ultimately absurd idea of intellectual property.

Medical science is science applied to human life – the whole of life, from cloned cells in experimental tissue culture to the lives of real people in society, in the ordinary chaos of their activity.  Doctors, nurses, and all other health workers are, whether or not they recognise and accept this role, ambassadors of Science to the people: and the people, whether or not they recognise and accept this role, are users of Science. All staff, all patients, and all potential patients in the community, are or soon will be involved in some way in creating new knowledge, and they are already involved in its application. Scientific knowledge needs human intelligence to create it truthfully, and human judgment to apply it safely and efficiently – not only professional judgments, but judgments by users.

To say “human intelligence” implies that there is some other sort.  Indeed there is – the crude intelligence of the market.  The market reflects only one component of collective human behaviour, of only one part of humanity.  It draws its data from people who buy, defining and ranking them by the money they spend. This is a systematically skewed sample, providing a dehumanised view of humanity.  It’s an impoverished source of data, leading to promotion of foods to the overfed while others starve, to promotion of two cars to people who already have one while public transport falls apart, and an endless list of other examples.  The market is stupid.  Market-driven health care in the United States ensures that rich people are more profitable than poor people, and that healthy people are more profitable than sick people.  So Health Maintenance Organisations run by giant insurance companies systematically recruit patients least likely to need help, while offloading those with the biggest problems, [28][29] and then take 15-20% of turnover for profit.[30]

The NHS is a wealth-producer.  Its product is health gain - healthier births, healthier lives, and healthier deaths (death being always inevitable, but not necessarily unhealthy).  This product is both an extremely personal gain, and a social gain.  It makes life better and easier for patients, while also relieving potential burdens on everyone else.  And properly organised, it can help to produce new knowledge and new skills, so that the more the NHS applies medical knowledge, the more new knowledge it creates.  If health care were a commodity, this exponential rise would present no problems for government.   If a new, costly, but effective treatment becomes available in the private commodity market, people who think they can be helped will buy it, the commodity economy will expand, and so will general prosperity.  But alas, the NHS is a nationalised, non-profit industry, where we do things not because they’re profitable, but because they’re needed.  In the NHS, every advance in medical science therefore presents new problems for governments claiming to act for society as a whole, but still acting in practice for those with most wealth and power. 

The answer is to recognise the NHS as a potentially independent economy and culture, operating within its own entirely new paradigm, with its staff and the populations it serves as its most dependable political army.   As the NHS grows out of its paternalist, charity-ridden past, owned by the people in law but by professional Establishments in reality, this independent economy and culture will begin to understand itself, to organise itself for political action, and to find allies in other parts of the public service, cultural and sporting economy, as well as among its original supporters, workers in commodity production.  Paternalism is crumbling, attacked from three sides: from government, continuing the anti-professional, consumerist agenda initiated by Margaret Thatcher; from the voting public, still emerging from deference; and from medical science, continuing to extend research to objective studies of the processes of care, destroying delusions of grandeur long typical of health care professionals, and replacing these by justified pride in useful work shared with patients.

Studies of how optimal clinical judgments are actually made[31] [32] [33] confirm a view first advanced by Margaret Stacey in 1976,[34] which I developed further in 1992.[35] Patients can be more usefully understood, and more effectively and efficiently developed, as co-producers than as consumers.  Together with their professional and other carers, they are joint producers of a product measurable as health gain.  This measurement is difficult, not because the gain isn’t real, but because its nature as use-values can’t be measured in the same way as commodity values.  Health gain through care is produced as both personal and social value, not as a transferable commodity for sale on the market.  For this fundamental reason units of output proposed by health economists, such as QALYs[36] or DALYs[37] may be useful for ranking the comparative efficiency of different interventions, but they cannot and must not be used as cash-equivalent currencies to integrate the NHS economy with surrounding commodity production. The NHS, and the knowledge it generates, produces not aids to life nor decorations for it, but expansions and extensions of life itself.  This can’t be expressed in the same terms as goods and services.  It’s a more advanced category of thought and practice, in a different paradigm.

If efficient production of health gain depends on developing patients toward co-producer roles, this has theoretical implications for health economics[38] and practical implications for NHS policy.  For the past twenty years at least, virtually all argument about NHS policy has centred on efficiency.  If NHS outputs are measured with tasks performed as numerators and resources consumed (mainly staff time) as denominators, we inevitably end up with more uteruses or gallbladders removed, more coronary arteries bypassed, or more hip joints replaced, by fewer health workers in less time.  And so, in the name of efficiency, we get fewer people and less time for reaching intelligent decisions jointly with intelligent patients, not only at times of referral for these procedures, but over lifetimes preceding them.  The commodity approach to NHS care naturally adopted by policy makers using business as their ultimate model is not just inappropriate, it’s destructive.  It reduces the space and time within which staff and patients can develop shared responsibilities through continuing anticipatory care.  This pushes the NHS further toward body repairs and crisis salvage, while making continuing anticipatory care and prevention more difficult and fragmented.   Of course we need better repair and replacement services, but not at the cost of less thoughtful continuing care.

To keep faith with the hopes of 1945, we can at least start to build justice within an unjust society, by developing the new forms of economy we already have in community-based health care, in schools, in universities and many other areas of social activity, independently from the economy and culture of business.  By doing this we can develop a rehumanising culture, restore faith in the feasibility of a just society, and turn our eyes toward recovering our lost human unity recognised by all great religions.  The NHS provides our most important, most defensible and persuasive material base for this rehumanising culture, a sacred area for social development. To deride the NHS as a sacred cow has always come naturally to those milking it to their own advantage, but the majority has never been fooled.  Since 1948, most people in Britain have learned to treat health care as a mutual gift, not a commodity.[39]  In this area if no other, we’ve learned a solidarity no amount of devilment or cowardice has yet been able to destroy.

Writing of Oliver Cromwell, Charles George asked: “What more is possible in life than defiance of known evil and the courage to create and fight for new illusions?”[40]  No truth is final.  As knowledge grows, less of it may prove illusory.  I think we must settle for that.