Readers might be shocked, surprised, or even disgusted by this. I’m not. As an A&E consultant, I occupy the relative moral high ground here. Almost nobody moonlights in my specialty: there is very little private emergency medicine in the UK. In my 20-odd years of practice, I’ve never once had to weigh a patient’s care against my own bank balance. But I have spent two decades watching how normal it is for colleagues in more lucrative specialties to fund school fees and second homes by drawing supplementary salaries in private medicine while being paid to work for the NHS.

Ojutiku’s, subject of a Medical Practitioners Tribunal in June, is a case in point. Between April 2017 and May 2019, he undertook 44 private clinics on Friday afternoons for Ramsay Health Care, for which he was paid £24,000. The tail end of the working week also saw him paid £5,000 by the local NHS trust for “Supporting Professional Activities” (SPAs) — the block of contracted time set aside for teaching, audit, research and administration rather than direct patient care. The tribunal found the conduct dishonest and suspended him for 12 months. He had already retired from the NHS by the time the case concluded.

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That’s just the tip of the iceberg. Though the NHS doesn’t collect data on the work that doctors undertake outside the public sector, a 2022 health department report suggests that “90% of UK private practice specialists work in the NHS as consultants”. Yet it’s equally important to stress that consultants doing some private work alongside a full NHS commitment is not, in itself, the problem. It is normal, contractually permitted, and arguably part of what keeps many senior doctors in the NHS rather than emigrating or going fully private.

However, every pound a consultant pockets from a Friday afternoon meant for the NHS is a pound the taxpayer has paid for, but unwittingly forfeited. And every patient on that consultant’s NHS list who goes unseen because their doctor’s attention is divided — is unwittingly paying a price that nobody asked them to shoulder.

Crucial to understanding the problem at those SPAs, especially the way they’re seldom scrutinized systematically. Nobody walks the corridor at 4pm on a Friday asking to see a consultant’s audit report. Some colleagues treat their SPA sessions as a standing joke, free money that exists on paper and nowhere else. Ojutiku’s defense was that his SPA obligations were being completed elsewhere and at other times, so his Friday afternoons were his own. The tribunal didn’t buy it, not least because his trust had put explicit reminders in writing as far back as 2016 that no private work could happen during SPA or on-call time.

More than the money, that reaction is the part I recognize most. Whenever I’ve challenged a colleague for taking on private work, the response is never “fair enough, that does look bad, I’ll do better”. It’s always some shoulder-shrugging variation of not understanding what the problem is, followed by business as usual. That’s despite the fact that the rules being abused, bent and broken are hardly obscure. The department of health’s code of conduct on private practice, in place since 2004, makes clear that private practice should be declared and reflected through a consultant’s agreed job planning, and that it mustn’t prejudice NHS patients or NHS time.

What is unclear, though, is how often that gets enforced, because in every case I’ve dealt with personally, detection has depended on luck rather than any systemic check. I can think of two orthopedic consultants I’ve worked alongside in the NHS who maintained enormous private practices. I rarely saw them. Their registrars and senior registrars managed their NHS patients for them. Eventually, one of my colleagues confronted one of them about the fact he constantly went missing and left his juniors to do his job for him. There was an awkward silence — and then, nothing happened. Elsewhere, I once had to track down a registrar’s consultant over a deteriorating patient by working my way round the switchboard and assorted secretaries until I finally reached him mid-session at his private rooms. I was told, more or less, that it was my patient and thus my problem to manage.

One of the most notorious examples of an NHS consultant abusing his position right across the public-private healthcare spectrum is that of Ian Paterson. Paterson lied to hundreds of healthy patients, terrifying them into believing they had cancer so he could perform unnecessary, invasive, and deeply damaging surgeries. On actual cancer sufferers, he conducted “cleavage-sparing” procedures that left behind breast tissue, often resulting in the return of cancer and, in some cases, the deaths of his patients.

In April 2017, he was convicted of 17 counts of wounding with intent and is currently serving a 20-year prison sentence. Over his career, he performed unnecessary operations on more than 1,000 patients for the Heart of England NHS Trust and at private hospitals, Spire Parkway and Spire Little Aston. These included hernia repairs, varicocele operations, and needless mastectomies, leaving his victims violated, mutilated, and psychologically traumatised.

As the judge pointed out in Paterson’s case, he was driven by “greed, self-aggrandisement [and] power” — a trifecta that motivates a dangerous minority of rogue consultants.

There is a structural point buried in this that goes well beyond individual doctors behaving badly. Most independent hospitals in Britain do not employ consultants directly. Instead, they rely on NHS consultants, who hold practicing privileges to undertake work which is supposed to sit outside their NHS commitments. That matters more than it sounds, because it means the private sector isn’t adding new medical capacity to the country at all; it’s effectively renting the NHS’s own capacity back to whoever can pay for faster access to it.

Colleagues in the surgical specialties describe something they call the “conversion rate”: the proportion of patients seen in a private clinic — an outpatient consultation, distinct from the follow-up review of an existing case — who go on to be booked in for a paying procedure. A clinical examination or review earns very little, while a procedure earns a great deal, and I have heard more than one consultant admit that their threshold for operating is lower in the private sector than in the NHS clinic down the corridor, because that’s where the serious money is.

There’s no single authoritative, up-to-date figure for what moonlighting doctors earn. Private earnings aren’t centrally reported the way NHS pay is, while consultants bill privately as self-employed income or through a personal company and declare it via self-assessment. But we can make some educated guesses. According to April 2026 statistics, the basic salary in England for an NHS consultant runs from £113,565 to £150,570 depending on seniority. Including non-basic NHS pay elements, average annual total NHS earnings across all consultants are an estimated £161,600 for those with a full-time contract. That’s NHS income only.

When it comes to private income, meanwhile, estimates are much softer, since there are no equivalent national numbers to the ones cited above. But colleagues and industry intel suggest that additional private earnings come in at around £50,000 to £150,000 a year on top of NHS pay — if not even higher — concentrated heavily in a handful of specialties like ophthalmology, orthopedics, cardiology, dermatology and cosmetic-adjacent surgery.

As most private hospitals bill for the total package — hospital stay, anesthetist, theater, consumables — rather than what a consultant actually pockets, the surgeon’s own fee is usually a separate, smaller line within that package. The Private Healthcare Information Network (PHIN) publishes these prices broken down by procedure, which gives an idea of the package price versus the surgeon’s own cut. Orthopedics, by far the biggest “conversion rate” earner, prices a replacement package between £11,000 and £17,000, with a consultant’s fee typically running into a few thousand pounds within that. Cataract surgery, in ophthalmology, costs about £2,000 to £4,700 per eye per package, depending on provider and lens type, with premium London clinics charging over £4,000. In general surgery, gallbladder removals come in at £5,500 to £8,500 per package, while hernia repair is around £3,200 to £5,500.

The average NHS consultant is capable of knocking out dozens of moonlit procedures a year — so you can see where the temptation comes from. Many consultants I know opt for the private coin because, like everyone else, they suffer from status anxiety. As one colleague once remarked to me, “That Bentley isn’t going to pay for itself.” I know of a case in which a surgeon, working across an NHS trust while simultaneously working at a nearby private hospital, had his private caseload reviewed and was suspended. A substantial share of his procedures were deemed to have been unnecessary or requiring further scrutiny. Nothing was ever proven at tribunal, and the case remained a serious allegation rather than a finding of fact — but it again illustrated the conflict that exists between NHS and private practice.

The private sector’s ability to offer a patient an appointment within a matter of weeks or even days, when the NHS list for the same consultant runs to months, is not an independent achievement or an advertisement for free-market efficiency. With an NHS waiting list totaling 7.3 million, a significant number of patients in need of specialist procedures, and a median waiting time of 13.3 weeks, moonlighting consultants are having a field day. Remember: it’s a finite pool of around 107,000 NHS consultants potentially redirecting themselves toward whoever can pay to jump the queue, with medical demand far outstripping clinical supply.

Patients can easily spot this hypocrisy — and the British Medical Association’s own ethics guidance is candid enough to name it outright. A patient who pays for a private consultation can, on returning to the NHS, join the waiting list at the point their clinical need dictates, gaining a real head start over someone waiting for an NHS referral to the same specialist. I have sat with a patient on my own ward, admitted with a gallbladder problem, while the surgeon looking after her mentioned, in passing, that she could see him privately the following Tuesday and be operated on before the following weekend, saving months of waiting. He was doing his NHS ward round at the time. Nobody in the room seemed to think that was worth remarking on except me. Certainly, very few other professions can market their own side-hustle so shamelessly.

To be fair, the powers that be aren’t totally blind to these issues. In its latest report to Parliament, the Medical Practitioners Tribunal Service (MPTS) concluded 185 substantive hearings in 2024, down from 250 in 2023. Of those hearings, 77% resulted in suspension or erasure (permanent removal from the medical register), compared with 68% in 2023. The figures show that fewer cases are reaching tribunal, while a greater proportion of those that do result in the most serious sanctions. The statistics alone, however, do not establish whether tribunals have become more punitive, or whether less serious cases are increasingly being resolved before reaching a hearing. From 24 November 2025, the MPTS introduced new tribunal guidance with formal sanctions bandings, intended to improve consistency and transparency in decision-making.

To put this in context, at the end of 2023 there were 378,054 doctors on the UK medical register, 10,031 of which the General Medical Council (GMC) had concerns about, of which 814 met the statutory threshold for investigation. In other words, the overwhelming majority of concerns never get to tribunal for a plethora of reasons, including colleagues exercising their own form of omertà. Ojutiku’s case was only uncovered because a hospital in crisis happened to need him for something else on the wrong Friday. Much like police officers, lawyers, politicians and other professions built around trust and hierarchy, doctors quickly pull ranks to protect their own. Loyalty within the circle often trumps any ethical concern about what’s being protected.

That leaves one more question — to what extent does all this actually affect patients? As far back as the early Nineties, Parliament and the Commons Health Committee debated whether consultants’ private practice was affecting NHS waiting lists. Apologists argued that most consultants worked well beyond their contracted NHS hours and that chronic underfunding, rather than private practice itself, was the real driver of delays. Both claims were probably true then, and both are probably still true now. What has changed is the scale of the incentive. With the Government leaning further into private-sector capacity to hit its elective care targets, the pool of NHS-employed consultants with a foot in both systems, and a financial reason to blur the line between them, is only going to grow.

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It would be wrong to read one tribunal ruling — or a few consultants grumbling from the sidelines — as evidence that NHS doctors are, as a rule, taking the taxpayer for a ride. Most colleagues I know declare their private work properly, job-plan it as the rules require, and take the distinction between the two systems seriously. But the honesty-based framework that is supposed to police the boundary depends almost entirely on a colleague being willing to report what they’ve seen, and on nobody being unlucky enough to need the doctor in question when things go belly up. One only has to think of how a reluctance to speak out has led to multiple scandals — and tragedies — in maternity healthcare, for instance, to conclude that silence is often akin to complicity.

That silence has a cost that patients pay in full — and too many doctors capitalize on, sadly. It rears its ugly head as longer waiting times, a rushed clinic, a specialist going M.I.A. or a complication that might have been caught if the consultant treating you hadn’t been stretched across two systems at once.

That Ojutiku was, after all, not undone by an audit or a whistleblower, but simple bad timing, should worry patients more than it worries doctors. Every consultant quietly running a parallel private income on NHS-contracted time is a consultant whose clinical judgment carries a financial incentive their NHS patients never see and never consented to; and every patient who pays to skip a queue is skipping it in front of someone who cannot afford to. Most of my colleagues would never behave the way Ojutiku did. But the system has no reliable way of telling the honest ones from the ones who haven’t been caught yet, and until that changes, patients are right to wonder whether the doctor in front of them is treating them fairly, or fitting them in at a price.

I feel obliged to say that South Africa is a wonderful country, and a resilient one. For every horror story you see in the media — most recently the tragic blaze in Johannesburg — there are many things worthy of love. Nonetheless, three decades after the end of apartheid, it is obvious that the ruling African National Congress (ANC) has failed in its historic mission: to spread the living standards formerly enjoyed by the white minority to the broad mass of the population. It has, if anything, achieved the opposite, overseeing the dereliction of the infrastructure and human potential on which any such improvement would depend.

Metaphors for this failure are everywhere. Railways that took my parents to their summer holidays as children now lie rusting and abandoned. Supermarkets sell asphalt for drivers to fill in potholes for themselves (the product is marketed as gatvol, which means both “hole-full” and “fed-up”). Criminal gangs, their numbers buoyed by an unemployment rate above 30%, cut down traffic lights for scrap, steal transformers from power stations and collapse roads with illegal mining operations. Eskom, the national power monopoly, is so ravaged by corruption that daily blackouts now last as long as nine hours.

Especially since the reign of former president Jacob Zuma, politics has descended into a looting operation that extends from multinational businesses down to local mafias, even as the impoverished majority finds its taps running dry and its sewage systems spilling over. Anger is quelled with promises to expropriate farmland and wealth from white citizens. Crime is rampant and the police are widely regarded as useless. As I say, Brits are far removed from this. They were heavily involved in Southern Africa during the 19th and early-20th centuries, sending settlers, redcoats, and gold and diamond prospectors, but today they mainly send nervous tourists. The pathologies of South African society seem as exotic as the hot, dry climate and the wild animals on the veld.

But are they really? Lately I’ve been questioning if the gulf separating the two countries is as vast as I assumed. At first it was just small things, sotto voce echoes of South Africa protruding into British life. A man begging from cars stopped at the traffic lights. An epidemic of urban homelessness. Universities renaming buildings to repudiate links with the past. A steady trickle of stories about police no longer bothering to investigate crimes. Now, a prison escape in the capital and parents scared to send their children to crumbling schools. Once I started paying attention, though, the resonances grew ever deeper. The media loves to measure Britain against the GDP of American states, European healthcare and Australian quality of life. This is supposed to be self-deprecating, but maybe it is more flattering than we care to admit. Analogies to South Africa can expose things that comparisons with rich countries leave obscured.

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Consider the cloud of scandal and dysfunction which has settled over the UK’s privatised utilities, namely water, energy and railways. These services have increasingly been marked by cronyism, private gain, mismanagement and underinvestment, all familiar symptoms of corruption in South Africa. For years the water companies have been paying out huge dividends to shareholders, while racking up vast debt piles and spilling sewage on a daily basis. Last year, Govia Thameslink Railway was awarded a lucrative new contract, despite one of its subsidiaries, Southeastern, being caught defrauding the public purse of millions. Then again, bad trains may end up being the least of our problems, for the National Grid has warned that the UK may face power cuts in the coming winter, and is urging businesses to reduce their electricity use. There is a growing realisation that Britain does not have the grid capacity needed for the government’s decarbonisation plans.

It is becoming clear, in other words, that Britain’s post-Eighties regime of privatisation has led to a subtle form of the South African disease. The state fails to maintain and improve infrastructure, while allowing the asset-stripping of national wealth by private interests. Who needs criminal syndicates when you have hedge funds and private equity firms? There was something especially South African in ministers’ claims that Thames Water cannot be renationalised, despite its severe debt crisis, because doing so would scare away the foreign investors who prop up the UK’s economy.

Meanwhile, the Tory party does an increasingly passable impression of the ANC. Apparently convinced it will be in power forever, it has become little more than a vehicle for personal advancement and influence peddling, disguising its aimlessness with an occasional bout of populist rhetoric. This was especially evident during the Covid pandemic, when the genteel traditions of British corruption — peerages in exchange for political and financial support — gave way to the handing out of state contracts worth billions to politically connected companies, often lacking relevant experience.

The South African comparison also casts a revealing light on Britain’s social cleavages, though I am not talking about the kinds of ethnic tensions for which South Africa is infamous. It is true that the UK economy’s voracious appetite for immigration, an easy source of cheap labour and consumers, resembles South Africa’s habit of exploiting migrants from elsewhere in Africa. But one only has to look at the frequent anti-immigrant pogroms in South African townships to see that, for all the anxieties over integration, British society remains a relative picture of harmony.

The real issue is class. Brits often express shock that extreme inequality appears so normalised in South Africa, but an outsider to the UK could make a similar charge. In post-industrial Britain, working classes of all ethnicities are consigned to poverty wages in jobs such as cleaning, shelf-stacking and delivery driving, if they have not dropped out of the workforce altogether. London and its surrounding counties have become, like South Africa’s Western Cape, the luxurious facade Britain shows to the world; but other parts of the country are faring much worse, with healthy life expectancy trailing significantly in parts of Northern England, Scotland and Wales. Countless towns have fallen into abject poverty, regarded by polite society with little more concern than South African townships, their inhabitants ruled unfit for anything better by the very fact of remaining there. Social mobility, we are told this week, is at its worst in more than 50 years.

This wasted potential is tragic on its own terms, but it has wider ramifications, too. In South Africa, where 29 million people receive state welfare grants and only 7.4 million pay tax, the state is trapped in a doom-loop, with spending on social programmes hampering investment that could benefit the economy. But to look at projections for the British state’s ever-growing benefits, health care and social care bills, it seems we may be heading for a similar scenario. These parallels will doubtless seem absurd to many Brits, and doubly so to South Africans. Earlier this year, when I mentioned to some friends over there that the UK has its own problems with government incompetence, they literally laughed in my face.

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After the Cold War, the rubric of “developed” and “developing” countries implied that the Western model was the endpoint of economic progress across the world. Three decades later, the distinctive features of that model — nation-states with strong civic cultures, meaningful democratic conflict, economic growth and a commitment to broad-based prosperity — have themselves been eroded by globalisation. Hence developing countries provide an increasingly plausible model for the future of developed ones, rather than vice-versa. In this sense, at least, Britain remains at the vanguard of global capitalism. And making this explicit ought to help in countering complacency. For all their gallows humour, the British are used to counting themselves among the world’s most advanced and admired nations, and so struggle to grasp the possibility that, in 50 years’ time, this may no longer be the case. Which brings me to the most disturbing echo of South Africa I’ve noticed in recent years.

This is something more amorphous: a matter of mood and mentality. South Africans have come to regard their chaotic and inept state with a weary resignation that borders on ridicule. It is a burden to be negotiated when necessary, and fended off where possible. For some time now, Britain’s attitude to its own governing class has been moving in the same direction. New Labour alienated large parts of the traditional Left, and now Tory incompetence has led to similar cynicism among conservatives. With each perceived betrayal, more people enter the reservoir of citizens who have given up believing that Westminster can do anything remotely useful.

These feelings have real consequences for a country’s prospects. Why do so many people stubbornly resist house-building and planning reform? Why do they see it as common sense to reject society’s claims on their resources? Part of the reason is surely that, once we lose faith in the nation’s political authorities, appeals to compromise for the greater good ring hollow. Or to put it in terms a South African would understand: the British are gatvol.

Last year, the Ukrainian government essentially outsourced the entire post-war “reconstruction” process to BlackRock, the world’s largest asset management firm. They signed an agreement to “provide advisory support for designing an investment framework, with a goal of creating opportunities for both public and private investors to participate in the future reconstruction and recovery of the Ukrainian economy”. In February, J.P. Morgan was brought on board as well.

The two banks will run the Ukraine Development Fund, which aims to raise private investment in projects potentially worth hundreds of billions of dollars across sectors including tech, natural resources, agriculture and health. BlackRock and J.P. Morgan are donating their services, but, as the Financial Times noted, “the work will give them an early look at possible investments in the country”. The opportunities are significant, particularly in the agricultural sector: Ukraine is home to a quarter of the world’s chernozem (“black earth”), an extraordinarily fertile soil, and before the war it was world’s top producer of sunflower meal, oil and seed, and one of the biggest exporters of corn and wheat.

From certain perspectives, the war is clearly good for business: indeed, the greater the destruction, the greater the opportunities for reconstruction. At Davos this year, Larry Fink, CEO of BlackRock, said he hoped the initiative would turn the country into a “beacon of capitalism”. David Solomon, CEO of Goldman Sachs, also spoke cheerily of Ukraine’s post-war future. “There is no question,” he said, “that as you rebuild, there will be good economic incentives for real return and real investment.”

Seeing opportunity amid the tragedy, 500 global businesses from 42 countries have already signed the Ukraine Business Compact “to help realise its huge potential” — or secure their slice of the Ukrainian pie. “Most are standing on the sidelines for now, given the security threat,” the FT reported. “But there are already companies on the cusp of moving in — especially in the low-hanging-fruit industries of construction and materials, agricultural processing and logistics.”

Over the years, across a series of similar events, Western governments and corporate leaders have made no secret of their enthusiasm to use the post-Maidan regime — and now the war — to radically alter Ukraine’s political economy. The agenda: to open up the country and make it safe for Western capital by transforming it into a special economic zone. This neoliberal shock therapy should, in their view, include “strengthening the market economy”, “decentralisation, privatisation, reform of state-owned enterprises, land reform, state administration reform”, and “Euro-Atlantic integration”, as well as widespread “deregulation” and the slashing of “outdated labour legislation leading to complicated hiring and firing process, regulation of overtime, etc”. In short, the Washington Consensus on steroids.

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This programme has, arguably, been underway since the mid-Nineties, when the West used IMF loans-cum-conditionalities to impose on Ukraine, just as it did on Russia, a series of radical free-market-minded reforms that crippled the economy. As the Indian economist Prabhat Patnaik has pointed out, the IMF played a key role in precipitating the 2014 crisis: Ukraine’s then-President, Viktor Yanukovych, refused to accept IMF demands that he cut wages, slash social spending and end gas subsidies in order to integrate with the EU, and turned instead to Russia for an alternative economic agreement. This was the backdrop for the Western-backed Euromaidan protests and, eventually, the 2014 regime change.

After 2014, the West’s economic agenda was stepped up once again. Western multinationals had long had their eyes on Ukraine’s vast agricultural wealth, but a 2001 moratorium on the sale of land to foreigners had always represented an obstacle to unrestrained privatisation. As post-Maidan governments turned again to the IMF for financing, aid was conditioned on a series of land reforms that would finally allow foreign corporations to acquire vast tracts of the country’s farmland. In the 2015 TV series, Servant of the People — which starred Zelenskyy as the fictional president, Goloborodko — the conditions required by the IMF for a new loan are rejected and the Western delegation is expelled. But in reality, things went rather differently. In 2020, Zelenskyy gave in to the IMF’s demands and finally repealed the moratorium.

“Agribusiness interests and oligarchs will be the primary beneficiaries of such reform,” said Olena Borodina of the Ukrainian Rural Development Network. “This will only further marginalise smallholder farmers and risks severing them from their most valuable resource.” But the World Bank could barely contain its excitement, gushing: “This is, without exaggeration, a historic event.” Even though the new law isn’t set to come into force until next year, US and Western European agrobusinesses have already bought up millions of hectares of Ukraine’s farmland — with 10 private companies reportedly controlling most of it.

As war has raged, the West’s calls for “structural reforms” in Ukraine have only intensified. In mid-2022, the Center for Economic Policy Research (CEPR), an influential European think tank, published a report, Macroeconomic Policies for Wartime Ukraine, which argued that Ukraine’s aim should be “to pursue extensive radical deregulation of economic activity”. Even more troublingly, according to the Oakland Institute economic observatory, Western financial aid “is being used as a leverage by the financial institutions to drive post-war reconstruction towards further privatisation and liberalisation reforms”. The European Union, for example, made it clear that the bloc’s decision to suspend interest payments on Ukraine’s loans would only be activated if there were “compliance with political prerequisites” with regard to labour reforms, for example, and the privatisation of state assets.

It came as no surprise, then, when last year the Ukrainian government adopted wartime legislation to severely curtail the ability of trade unions to represent their members. It gave employers the right to unilaterally suspend collective agreements and effectively exempted the vast majority of employees from Ukrainian labour law — a dramatic rollback for workers but a boon for global capital. Western governments have silently consented to the reforms and, in fact, leaked documents from 2021 indicate that the UK, via its development aid arm, UK Aid, and its embassy in Kyiv, was funding consultants to assist the Ukrainian government in selling the labour market reforms to the people.

As the Ukrainian government has simplified and accelerated the privatisation of state-owned enterprises, Zelenskyy would seem to have gone out of his way to similarly express the country’s “openness” to Western capital. Last September, he virtually opened the New York Stock Exchange, symbolically ringing the bell via video stream. He used the occasion to present “Advantage Ukraine”, his government’s new investment initiative (which relies on another British firm, WPP, for its marketing side). Zelenskyy said that his country was “open for business” — that is, for foreign corporations to come and exploit its resources and cheap labour. “I committed my administration to creating a favourable environment for investment that would make Ukraine the greatest growth opportunity in Europe since the end of the Second World War,” he wrote in the Wall Street Journal. Predictably, the president of the NYSE Group, Lynn Martin, wholeheartedly welcomed Ukraine’s decision to offer “unfettered access to capital”.

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In January this year, addressing the participants of the meeting of the National Association of State Chambers, Zelenskyy described American business as the “locomotive that will once again push forward global economic growth”. No one would blame Zelenskyy for choosing the lesser of two evils here: Western banks over Russian tanks. Yet, the grim fact remains that even if his nation succeeds in repealing the Russian invasion, the future in store for Ukraine is not necessarily one of sovereignty and self-determination but, most likely, one of Western economic tutelage.

It’s just before 8am on Monday morning, and my A&E department is heaving. I’ve been on-call all weekend — I’m shattered — but I don’t have time to dwell on it. Our traffic light system is a sea of red: red for staffing, meaning we’re low on doctors and nurses; red for capacity, meaning we have far too many patients; and red for acuity, meaning a terrifying number of those patients are severely ill. Some of them are dependent on a ventilator. Some won’t make it to the end of the day, let alone the end of the week.

And I can understand why: we’re on the brink of disaster. As a consultant, I am alerted every day to cases in my hospital and beyond that suggest the service, not just A&E, is at breaking point. Breast cancer sufferers had critical mammograms cancelled due to the pandemic. Nine out of ten NHS dental practices are not accepting new adult patients. GPs are quitting in droves. An unwell father-of-two waits 20 hours in A&E, refusing to leave until he gets a blood test, which ultimately reveals he is suffering from terminal leukaemia. A patient who, during lockdown, had his blood pressure managed remotely finally discovers his problem isn’t high blood pressure: he’s got a brain tumour.

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It’s not just the problems within the healthcare system that have caused this crisis. The terrible failures of Britain’s social care system also have knock-on effects. In a medium-sized hospital like mine, there are between 60 and 80 patients who don’t need to be there. But there’s nowhere else for them to go. Just as mental health patients wind up in jail for want of psychiatric care, the elderly wind up languishing on hospital beds in corridors because social care is in an even worse state than the healthcare system. On one recent Saturday night, for instance, a psychiatric patient came in for treatment. When I asked how he was doing the following Tuesday, I was told he was still on the ward, occupying a bed, because there wasn’t a psychiatric bed available in the region.

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An array of functions that were once the recognised duty of elected representatives have been progressively handed over to people from business and technocrats with no democratic mandate. Is it because our politicians are so bedevilled by a lack of confidence in their own abilities? Perhaps.

But it is also undoubtedly a consequence of the theory, embedded deeply in the psyche of the political class over the last 40 years, that governments shouldn’t meddle because ultimately the market and experts know best.

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Take the running of the economy – arguably the most crucial function any government can perform and one pivotal to the prosperity of a nation and the wellbeing of its citizens. Conventional wisdom has it that the decision by the New Labour government to grant ‘independence’ to the Bank of England in 1997 was a wise and far-sighted one. Few now question the merits of relinquishing control of the money supply – a cornerstone of the management of any economy – to unelected technocrats.

Yet, given the value of monetary policy in the armoury of any government – for example, by giving it the power to influence levels of investment and stimulate demand through the control of interest rates and quantitative easing – it beggars belief that a Labour government should wish to give it away. And it was given away to career bankers who, far from being ‘independent’, have been inclined to direct policy according to the interests of fellow bankers and asset holders, rather than those whose lives are rooted in the real economy.

In his autobiography, Tony Blair admits that, when it comes to the economy, he sees the role of government as nothing greater than “to stabilise and then get out of the way”. It is a striking departure from the attitude of previous Labour governments who understood only too well the need to use every available economic lever at their disposal to create jobs, build homes and fund public services.

That Corbyn’s Labour – which rails unremittingly against austerity and the rapacious power of finance – has not committed to restoring democratic control over the Bank of England is an indication of how deeply the ‘hands off’ philosophy has infected political thought.

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As with economic policy, so it has been for the public sector, with politicians of all colours eager to divest themselves of responsibility and control. The ideological drive to roll back the frontiers of the state pervades the public sphere at all levels, with few local institutions or services having escaped the onward march of outsourcing. Even modest, yet crucial, jobs that keeps our communities ticking over – the bus driver, the hospital porter, the town hall cleaner, the dinner lady – have often been contracted out.

There was a time when a shared civic pride existed between the communities running these services and the workers who delivered them. But with a diminished public ethos has come a diminished sense of public duty. These community-facing jobs are now seen as purely transactional, a commodified source of profit for an impersonal market. Little wonder that this new, abstract relationship between communities and their public servants has served to intensify the sense of loss and deracination felt in so many of our towns and cities.

The consequence of government disengagement from public provision is most apparent in the area of housing. We don’t build council homes anymore, and the government has no serious plan for addressing the chronic housing shortage. The result has been catastrophic. Try telling a young couple attempting to get on today’s property ladder, but faced with crippling costs due to inadequate supply, that the ‘market knows best’.

And perhaps the most indefensible shirking of responsibility by politicians has been in handing over so much of our justice system, including the running of prisons, to private companies. The punishment of crime, and such matters of moral right and wrong, ought surely to be the responsibility of the State alone, not of commercial entities seeking to extract a profit. Politicians who agreed to put the delivery of justice into the hands of multinational companies should hang their heads in shame.

More from this author

The fake patriotism of the liberal Left

By Paul Embery

This ‘hands off’ approach sits neatly with the attitude of most parliamentarians to the European Union over the last 40 years. Our relationship with that institution has been one of increasing surrender of powers from Westminster to Brussels. We can see the result of that now: our MPs are petrified of control coming back. They are rabbits caught in the headlights. A parliament atrophied by decades of having its legislation dictated by someone else has given its members a mindset similar to that of the average parish councillor. No wonder MPs are reluctant to assume responsibility over laws governing every area of public life.

The ceding of control over large parts of the economy and public services to business and technocrats has profound implications for democracy. It weakens accountability and reduces the status and power of politicians. As the functions of government, national and local, have been outsourced, so has responsibility – and ultimately the blame when things go wrong.

This isn’t a crude argument about privatisation versus public ownership. Any economy, if it is to be successful, needs a flourishing private sector, and God knows politicians have often done more harm than good when it comes to establishing the conditions for one. No, this is a debate about the nature of our society and the health of our democracy, about the proper role of our elected representatives and how much we value a sense of national and civic pride.

In 2008, we saw where a ‘light touch’ government philosophy and misplaced faith in the ‘expertise’ of bankers and technocrats led us. Now, the frontiers of the state must be rolled forward just a bit, and the role of government and elected representatives as a force for good reasserted. But to achieve that, we need a new class of politician who actually believes it.

It’s a clever, multi-layered put-down, painting socialism as not only profligate, but also confiscatory and unsustainable.

However, as George Eaton explains in the New Statesman, the line has been modified and turned back against the Lady’s latter-day followers:

“The problem with Thatcherism is that you eventually run out of other people’s assets.”

The “assets” referred to here are the nationalised industries that the Thatcher governments privatised and the social housing that was sold to its tenants:

“In the 1980s Margaret Thatcher and her allies championed what they called ‘popular capitalism’. According to this theory, voters would be given a permanent stake in the market through the sale of council housing and shares in privatised utilities.

“And, for a period, it worked. The sale of more than a million council homes helped transform Labour voters into Tory loyalists. In 1984, shares in the privatised BT were 10 times oversubscribed, gifted a windfall to the government and voters. The sale of British Gas (exemplified by the populist ‘Tell Sid’ campaign), British Airways and the water companies followed. By the end of the 1980s, share ownership among the public had risen from seven per cent to a quarter.”

And yet, as Eaton points out, “‘popular capitalism’ has become unpopular capitalism” – with the companies running some of these privatised industries held in contempt by the public:

“By an overwhelming majority, voters favour the renationalisation of of the UK’s water (83 per cent), electricity (77 per cent), gas (77 per cent) and railways (76 per cent)”

I totally understand the public’s anger. As a regular user of Southern Railway’s train ‘service’, I feel it myself. However, we shouldn’t forget how badly run these businesses were before they were privatised. Their asset would be ruins without the investment they’ve received since privatisation – investment they were starved of when owned by the state. They may now be ‘cash cows’ for shareholders, but at least cash cows get looked after.

Further reading

Test article

By Charlotte Pickles

However, Eaton’s core argument is irrefutable: there’s nothing much left to privatise, therefore, in that key respect, a return to Thatcherism is impossible.

Arguably the most popular bit of popular capitalism – the right of council house tenants to buy their homes – wasn’t capitalist at all. What really made the Right to Buy fly was the hefty discount on the full market value of the property. The policy, therefore, was distributist not capitalist. Anti-statists might also like to note that the houses couldn’t have been sold if they hadn’t been built by previous governments.

If Margaret Thatcher’s heirs want to revive popular capitalism – or, more accurately, the ideal of a property-owning democracy, then their first priority must be the creation of new assets – and especially housing assets.

Government has the power to buy land cheaply, grant itself planning permission quickly, and have it developed beautifully. And, as I explain here, it can sell the houses through a Community Land Trust to help ordinary people become homeowners affordably.

Further reading

More community land trusts could transform the housing debate

By Peter Franklin

Unlike, say, a pledge to increase funding for the NHS, this would be a policy on which the Conservatives can’t be outflanked by Labour.

The last thing that a socialist party needs is millions more people getting the chance to own their homes. To win power, the Left needs voters to be gratefully dependent on the state or resentfully dependent on private landlords. The re-democratisation of property ownership would be Margaret Thatcher’s dream and Jeremy Corbyn’s nightmare.

“The most common way people give up their power is by thinking they don’t have any.”

― Alice Walker 

Today, the world is confronted by globe-spanning, tax-dodging corporate behemoths; monopolies based on advanced, intrusive as well as seductive technologies. Some are armour-plated cartels with ever-stronger (and longer) intellectual property protection. They include not only the FANGS – that bundle of high-tech platform utilities – but also Big Pharma, Big Agrobusiness, Big Media and Megabanks. The rise of these new monopolies has coincided with the lowering of real wages, especially in the UK and US, for many workers, and to a reduction in the labour share of the economy.

The process of monopoly (or giant oligopoly) creation has accelerated at a reckless pace.

As economic power has become more concentrated, so levels of corporate crime have risen. Perhaps the most egregious of these was the conspiracy involving Barclays, a 300-year-old British bank, in rigging the interest rate that people and corporations around the world pay for loans or receive for their savings. LIBOR – the London Interbank Offer Rate –was used as a benchmark to set payments on about $350 trillion worth of financial instruments.

The process of monopoly (or giant oligopoly) creation has accelerated at a reckless pace. But can this late-capitalist model survive populist uprisings across the world?  Can it survive the political instability caused by the gross inequality in wealth fostered by increased monopolisation?

For many decades, the USA operated a strong anti-monopoly (or “anti-trust”) policy.  Beginning with the Sherman (1892) and Clayton (1914) Acts, the federal government oversaw an era of active interventionism to regulate, prevent or break up monopolies, reaching a new peak with FDR’s New Deal in the 1930s. It is no accident that the strongest steps to control big finance and Wall Street ran in tandem with anti-trust laws – first with the creation of the Federal Reserve in 1913, and then with the Glass-Steagall Act of 1933.

In Britain, the home of ultra-laissez-faire ideology, action against monopolies was more restrained. Indeed, the common law doctrine of unlawful “restraint of trade” was traditionally used more against trade unionists than against any corporate’s “conspiracy against the public, or… some contrivance to raise prices” in Adam Smith’s famous phrase. True, from 1948, legislation was passed to give some limited powers over monopolies and mergers, but they were used more modestly than in the anti-trust heyday in the States.

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Global monopolies were not created thanks to technology, or to entrepreneurial genius – but because we citizens let them happen

The big change in ethos came with the era of financial liberalisation, notably the Nixon-Reagan-Thatcher years, effectively endorsed in the Clinton-Blair period. First, the creation of a private monopoly was no longer seen as a bad thing (recall for example how at its peak Microsoft avoided break-up). Glass-Steagall was repealed in 1999, with support from Bill Clinton and the economist Larry Summers, symbolising the bi-partisan policy of support for hyper-financialisation.

The Reagan-Thatcher era also gave birth to the privatisation boom, with an ambiguous policy towards monopoly, leaving telecom giants in place, while also (in the UK) illogically fragmenting the rail network.

The myth propounded by recent governments is that the answer is more competition, with the public constantly checking prices (usually unfathomably expressed) from ever more new entrants to each utility. Everyone understands that this is a farce, since it relies on the inertia of the majority for a minority of customers to benefit. The attempts by regulators to police the system have likewise failed, so that customers have become victims of “regulatory capture”.

The EU runs a different competition and monopolies model, still (contrary to Brexiter mythology) from a strongly capitalist perspective. If the Anglo-Saxon model is founded on laissez-faire, the continental model has strong roots in German ordoliberalism, with its emphasis on rules and their enforcement. The European Commission takes its role more seriously in taking on cartels and harmful private sector monopoly acts. It was the Commission that forced the telecom oligarchs to abandon roaming charges. Its Commissioner Ms Margrethe Vestager (a staunch economic liberal) has taken on Google in ways not yet seen in the UK.

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The great British public is supremely unconvinced by the past decades of privatisation

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After decades of experience of privatised utility monopolies, in water, gas and electricity as well as rail, the great British public is supremely unconvinced. Polling by Populus and Legatum Institute showed that 86% said favoured public ownership of water, 77% gas and electricity, and 76% rail.  50% supported public ownership of banks.

The next step is for the British public to understand that it has the power to hold these companies accountable.

• This can be done by Parliament enacting tough anti-monopoly laws.
• Secondly, a democratic government can use its powers more effectively to break up companies that do not act in the public interest.
• Third, companies that have a strong public interest dimension should be required by law to fulfil public service obligations. Those obligations have already been imposed on the liberalised network industries in the EU, but public service obligations need now to be extended to companies in the gig economy.

Global monopolies were not created thanks to technology, or to entrepreneurial genius. They happened because we, as citizens let them happen. We must not give up our power to change this monopolistic system, by thinking that we don’t have the power. As citizens of democracies, we most certainly do.