Photo: 'Surgery Building – remains of cupboard' by Morgennebel from Flickr Photostream

In his Greedy Bastards Hypothesis Scambler (2004) argues that a capitalist class (the greedy bastards) are centrally complicit in widening health inequalities due to their commitment to social and structural changes associated with disorganized capitalism – such as changes that weaken trade unions and employment protection laws. Much of the current NHS reform involves TUPE’ing, where workers are transferred from NHS contracts to private sector contracts – these new contracts usually offer less pension benefits and less union protection.

Underpinning these moves are rhetorics of wasteful public sector employees with gold-plated pensions and ‘cushy’ terms and conditions. Contrast this with the ‘greedy bastards’ who want to fragment labour markets in order to accumulate more profit. A purported crisis in the welfare state (e.g. an austerity argument that the cupboard is bare) allows the capitalist class to create new conditions of employment that facilitate the pursuit of profit. These reforms also weaken the NHS as an institution, and the prevailing political wisdom is that attacking the NHS is not something any government seeking re-election should do. The Coalition reforms mark a move to fragment working conditions in the NHS, to make it an appealing proposition for the ‘greedy bastards’, whilst simultaneously seeking to protect themselves from moral outrage at the privatisation of the NHS, through appeals to financial necessity, i.e. the ‘crisis’.

The ‘crisis’ has two faces. Firstly, – a crisis of efficiency paints the NHS as wasteful, overly bureaucratic, and economically unsustainable – reform is a financial necessity if the NHS is to survive.  Secondly a fiscal crisis of the state decries an unprecedented deficit in the public purse. This fiscal crisis means that the ‘cupboard is bare’ – the NHS now needs to find money from existing budgets in order to improve its effectiveness, efficiency and economic sustainability (which are necessary if the NHS is to survive – witness the vicious circle). All of this takes place in the context of the so-called Nicholson Challenge – £20 billion of NHS efficiency savings by 2014. This Nicholson challenge is a ‘turned-off tap’ argument that requires NHS personnel to find resources from the existing pool.

However, none of this reform is determined solely by economic necessity. Under the economic rubric, discussions of healthcare come to be dominated by economic logics and it is here that we see the utility of the ‘cupboard is bare’ argument. It enables the state to plead their hands are tied by the need for fiscal rectitude and restraint. The rhetoric goes that these changes are neither warranted nor desirable (everyone remembers Tory pledges of ‘no pointless re-organisation of the NHS’).

However, economic necessity only works as a partial explanation for this particular approach– it is more so that necessity arguments background ideological intent.  The crisis is an ideological convenience rather than economic ‘fact’. It is a position that frames the free universal provision of health and social care as an inherently wasteful economic activity. In truth, these reforms are underpinned by a desire to reduce the burden – on government – of providing free, universal health and social care. This is the crux of the matter. The logic of economic necessity legitimises changes to the organisation and structure of the NHS. Economic necessity presents a ‘hard’ baseline which it is much more difficult to argue against. The logic of the ‘turned-off tap’ argument coupled to the ‘cupboard is bare’ argument serve to create ‘crisis’ and to open the door to the ‘Greedy Bastards’ waiting to skim a tidy profit off the top of the provision of care.