Medicine under capitalism.

For about ten years, I have carried out annual appraisals on doctors working in general practice. I do this on a freelance basis, not as part of my salaried work. When I started, I used to claim my fees from a man called Steve, in an office at the local primary care trust. Now Steve is no longer there. Nor is his job, nor his office, nor the trust. Nowadays, I send my invoices to an agency a couple of hundred miles away called ‘Shared Business Services Payables.’ When I write the invoices, I have to use a ‘supplier number’, identifying myself as a private business supplying services to the National Health Service (NHS). I also have to include my ‘purchase order number’, confirming that the NHS has agreed to purchase those services. My personal contribution as an appraiser has effectively been absorbed into the same system that deals with the supply of X-ray machines, hospital beds, or toilet rolls. This change of my identity—from an individual professional to a business—is no random event. It is one small part of an intentionally designed change in the public services in England. It reflects an ideological shift that has taken place over the last couple of decades, in the name of the political and economic movement known as neo-liberalism. A generation ago, anyone in the health service who used terms like supplier, purchasers, providers, competition, market, profit, efficiency or output would have been regarded as exceedingly strange. Now it has become our everyday language. In England, and in many other countries, medicine has moved from a welfare model to a capitalist one. Private companies are taking over an increasing proportion of services, even if these are still branded as part of a public system. In keeping with this, the language of the welfare state has been replaced by one of commerce and capitalism. In a book entitled ‘Capitalist Realism’, the cultural commentator Mark Fisher has examined how this process has taken place. He suggests that, since the fall of communist regimes in the 1980s, capitalism has successfully come to present itself around the whole world as the only feasible political and economic system. He demonstrates how politicians, bureaucracies, education, books and movies all now speak with a single voice. It is a voice that says that everything, including medicine and education, should be run like a business. ‘For most people under twenty in Europe and North America’, he writes, ‘the lack of alternatives to capitalism is no longer even an issue. Capitalism seamlessly occupies the horizons of the thinkable.’ As a result, things that seemed impossible in the past—like the privatisation of public services—are presented as natural and inevitable, while alternative models of society are rendered unimaginable. Alterations in language are a significant part of how this happens.