Understanding Privatisation of Mental Health Services: Insights From Karl Marx's <i>Capital</i>

Considerable attention is being focused on the role, nature and consequences of privatised, or capitalist, health care in many countries and the role of nurses, doctors and other healthcare professionals in it. This is also the case in relation to the privatisation of mental health services (Guardian 2022; Silver-Greenberg and Thomas 2024). For instance in the UK, it was noted in the early 2020s that the NHS—the leading international example of universal healthcare provision—was spending billions on private health care for mental health patients (Campbell and Bawden 2022). Karl Marx's book Capital (1867) provides ideas that are worth considering by mental health nurses who are interested in understanding the nature of privatised health care. This essay provides an overview of Marx's key concepts in Capital and how they can be used to interpret and make sense of privatised health care, mental and otherwise, and its risks. The 21st century is a time of extreme economic inequality and wealth concentration across the world, where capital is becoming increasingly dominant and embedded (McKeown 2024; Varoufakis 2023). This is a century where the interests of capital and capitalists are often taken as the interests of the wider public, health systems and states, and are increasingly coming to colonise these institutions. It is a time of increasing healthcare commodification and threats to universalist health care. It is a time that, increasingly, has features of Marx's time. Capitalism is now the dominant socioeconomic system in the world, so it can be useful for mental health professionals to understand it and how it can potentially impact their practice and working conditions. The structure of this article is as follows. The first section discusses private health care as a form of what Marx refers to as a commodity. The article then discusses surplus value, which is the profit that is extracted from each commodity. After this, the idea of primitive accumulation is referenced, which refers to capitalistic colonisation of previously public entities. This is followed by a section on the impacts of capitalism on patients and mental and other health professionals. Two further concepts from Capital vol. 1 are then discussed. One is the concept of circulation, which describes the constant transformation of capital into money and commodities, and the other is constant and variable capital. The article concludes with some lessons that Capital vol. 1 might offer us in the 21st century, inheritors of this dying capitalistic world, where surplus value extraction has eclipsed all other ideals. Marx argues in Capital that capitalist systems are commodity producing systems. A commodity is anything that is sold to satisfy some human want or need. Private health insurance, private health care, are examples; so would any other mental health care or medical service that is sold for profit. Healthcare commodities can therefore be goods or services. Actors who produce healthcare commodities say that they produce them for what Marx calls their use values (i.e., as a good in themselves) but they really produce them for their exchange value (i.e., for profit, or surplus value). Once the healthcare commodity is exchanged it is converted into its money form, where it stays or where it is reconverted back into another commodity. Money and commodities are, for Marx, different forms of the same thing, and all commodities are ready at any moment to escape their bodily form and assume their money form (Marx 1867, 33). So every private mental health service, from the perspective of capital, Marx says, is ‘in faith and truth money’ (Marx 1867, 107). He noted that if a commodity, including a healthcare commodity, could speak, it would say ‘our use value may be a thing that interests men. It is no part of us…in the eyes of each other we are nothing but exchange value’ (Marx 1867, 52). This constant transformation of money into healthcare commodities and back again is described by Marx using the formula M-C-M, or Money-Commodities-Money. Circulation is an end in itself in this system, has ‘a life process of its own’ (Marx 1867, 108). The individuals who control the production of mental healthcare commodities in privatised systems are called healthcare capitalists. They employ healthcare workers such as mental health nurses, psychiatrists and allied mental health and psy- professionals. Capitalists own the means of healthcare production, the tools, infrastructure and technology that are needed to produce health care. Healthcare workers in privatised or semi-privatised health systems use the means of production to generate medical commodities for capitalists that are then sold to patients, to other capitalists or to the state to generate surplus value, or profit. Marx would say that healthcare capitalists should never be seen to produce use values as an end in themselves; ‘the real aims of a capitalist is the never-ending process of profit-making’ (Marx 1867, 107). Healthcare capitalists generally employ significant numbers of mental health workers. There can be an intermediate group between healthcare employees and capitalists, which Marx called ‘small masters’, who might own a small number of small healthcare institutions that sell mental health services or commodities and then begin to expand as a result of patient demand or an inability to the state to provide core services. Capitalism for Marx is a system of biological and mental exploitation. It depends upon, feeds upon, the life force of workers, including healthcare workers, their ‘muscles, nerves, bones, and brains’ (Marx 1867, 121) and also the life force of patients who must purchase the healthcare commodities that those healthcare workers produce. Marx said that a capitalist institution, such as a private healthcare company, has one single life impulse, and that is the need to create surplus value. To do this it will, if it is allowed, make mental health nurses and other healthcare workers work longer (what Marx calls increasing absolute surplus value) and more intensively (what he calls increasing relative surplus value). Capitalism's need to do this is fundamental; it has a ‘werewolf's hunger for surplus value’ (Marx 1867, 179). It will seek to regulate what Marx called the socially necessary labour time that goes into the production of each healthcare commodity. Socially necessary labour time describes that average time that the average health professional of average ability would need to provide a medical or nursing service. If this time can be shortened, then more healthcare services can be produced and more surplus value extracted from the nurse's work. Healthcare work can also be outsourced to workers whose socially necessary labour time is cheaper than that of nurses (Moth 2020). This can enable relatively more surplus value to be extracted from those workers and put into circulation by the entity that employs them. Capital will seek, where it is permitted, to privatise public health services and systems. This is what Marx refers to as primitive accumulation, a term that he uses to describe the capitalist colonisation of formerly public resources. Health care is attractive to capital because it is an example of a high-profit sector with the ability to continually generate new commodities and where demand is inelastic (Braverman 1998/1974). It is also a sector with a high turnover time, which means that there is often not much time between supplying a service (a commodity) and receiving money for it. Basically capital does not stay long in the commodity form/production stage in healthcare; it goes through metamorphosis quickly. Once primitive accumulation has begun, capital will begin to produce the privatised medical commodities that are needed for life, and then over time begin to charge more and more money for them. Healthcare capitalists are bound by the laws of competition, as real to them as the laws of evolution, and must be pitiless in their pursuit of surplus value; otherwise, they themselves will be devoured by more aggressive life forms. Some health systems are universalist in nature, which means in Marx's terms that health care is provided basically for free at the point of access, or at least for a low cost (i.e., health care is basically a use value), and the system has not been subjected to primitive accumulation on a mass scale. Other systems are fully privatised, which means that they have been successfully subjected to primitive accumulation. Others are a mix between public and private health care, which means that they have been partly subjected to primitive accumulation. The state has a crucial role in controlling or enabling primitive accumulation. Capitalists will tend to seek primitive accumulation and privatisation. However, the state can, in theory, restrict this process. In the absence of state intervention, capitalism tends towards uncontrolled exploitation of the public (Galbraith 1963). A feature of many states over the past 40 years, however, is that many political and healthcare elites have to of or their own the perspective of capitalist elites and the of capitalism health systems (Moth 2022). Marx noted that the to regulate the between and its are the (Marx 1867, of this is an and in many Capitalism as a system the of public healthcare systems so in some privatisation of public health care is a to an of It is more a from the more universal health and systems that After capitalist states to a to the socioeconomic that to the of and in the and They a form of capitalism that refers to as embedded capitalism was to a at by the part of this capitalist states focused on universal health care to their in to and political In the part of the century, however, this form of capitalism was across the by a more socially form of capitalism called This form of capitalism that all public such as health care, should be to capitalist and should be fully and exploitation of the public would be in or so the by capitalist entities. The role of the state in this system was to the interests of and and including healthcare from to it this system it is as as to money from the state to private and it is at least to money from public services such as health care. In this system of often to for the and capitalism for Once it has begun, primitive accumulation can itself in in a previously universalist health health formerly provided by the might now be fully provided by private institutions. the state might not as a but as a of health services from capitalist institutions (Moth 2022). health services might themselves fully or (Moth 2020). who work these public health systems might themselves to on the ideas of capitalist health care in their practice (Moth 2020). primitive accumulation can be to universalist health systems. It can money towards private and from the public time, this will those to generate more and more surplus value, which will them to often at the of the public capitalist health care more more and more will it and to it as healthcare institutions themselves as high and in to the and public and might to this of the health system as the Marx would that the of and doctors and nurses a thing with in its (Marx 1867, Marx would say that private health care is good for capitalists but it at the potentially for other including For us to the point that all commodities have socially necessary labour time into them. If a health professional or in a privatised system longer to a for an to and to each they would the socially necessary labour time that is being which would the of surplus value. The capitalist that employs them would not be patients value these of with healthcare professionals who have such will often say their health professionals that as a such patients are is that as a use value, not an exchange value. if a public health system has been of for example as a result of and subjected to primitive accumulation, patients may that they need to to health professionals who will them as a use value. This is one of the in patients in some countries for private health they can to to to escape capitalist of health care in public systems. In some in the 21st century those with money can mental health services. Capitalists can be interested in the mental health of their workers, such as mental healthcare nurses, but also the mental health of patients who are themselves workers. The for this is that mental health can which can to commodities being produced and therefore surplus value being Marx noted that in time capitalists workers to that was high in of as that their an would be workers to their mental health and on their not the that are mental health and in the first A for workers and patients, which Marx noted that capitalists do not care (Marx 1867, is that if the of life of (Marx 1867, then over time, as of these commodities will often have to work and longer to be to them. This will in generate significant and at and which in will generate more mental health of capitalist health care is often as and care to patients, working to make money to it the time necessary for the of the the (Marx 1867, Marx would also say that this system is also for the health of nurses and other healthcare workers. In pursuit of absolute and relative surplus value capitalist healthcare institutions can healthcare workers their biological to and mental It can force them to patients as commodities, there for the of surplus value not as real in need of This will create in professionals who are not fully by capitalistic have to any nursing or medical to the of on and healthcare workers of all and 2024). Marx that this was a system It is that the biological life forms that he as being to in this system Marx that if it was not human healthcare workers, and patients, to a state of of systems that they often do not fully an nurses and allied health professionals and patients generate surplus value their life force over the of their from them. in and life for many is to a an for where they work more and more intensively to produce healthcare commodities or work to the money to them. The surplus value that is from the of healthcare commodities, including mental healthcare commodities, is used for key One is to and of healthcare The other is to and expand the means of production by surplus value, and more private healthcare commodities to be or to new means of healthcare For example the surplus value that is by the of private health may be used to purchase a private which is used to then used to produce privatised mental healthcare services that are sold for profit, time, if the of this process will that healthcare capitalists will begin to more and more of the means of healthcare One thing that is worth of in health systems that are subjected to primitive accumulation is previously healthcare begin to be and of or this is a that surplus value has been and has been to more of the means of healthcare It can the or of capitalist Marx noted that in any including mental health care, capitalist circulation will from a to an Marx described the surplus value by this process of circulation as the of the (Marx 1867, Marx that this system was to absolute and relative surplus value, to and the means of He noted that capitalists are, as a interested in and He noted that technology is the key of capitalism as it biological on production to be The means of production are into constant capital instance the and infrastructure of mental health and variable capital instance nurses and other individuals who make health Capitalists seek to constant capital in to their on variable capital (i.e., to their need for nursing labour (Braverman or to more surplus value from for by the of socially necessary labour time that each healthcare commodity for it is that capitalists would be interested in using to private mental health services as it would their need to employ variable capital, that mental health professionals. permitted, such will be used to control and nurses in their so that their work can be more (i.e., they can process more patients more and they can produce more surplus value. This is a core of technology capitalism (Braverman health professionals who the capitalist of production because they in a universal health system, or if for example they previously been an who was by a or but who are then into it what Marx refers to as means that their work by capitalism and they from their work means that they have no control over their they are subjected to absolute and surplus value and the of their is to produce surplus value, they would say that their is to This is what Marx called also and means that a previously health subjected to by a capitalist The health might in this, for instance they might that the capitalist entity can do work and the health to more with However, the relation of and the need to produce surplus value are now a point if the capitalist it can make healthcare workers what Marx called real This refers to a transformation in the nature of the health work. For the healthcare might from being who to whose practice is and by and increasingly Marx would say that in many the is more human than the for many health professionals can an of and control over their work. Health systems can also and real A health system that has been privatised will that is and different from the entity that it was privatisation. and other healthcare workers are on the more in constant capital than other workers in other does not that they are from such that they are more from them. It is to that a key of capitalism is to make workers, including healthcare workers, real in much the same that workers it in the However, nurses are by these for the they do not make nurses themselves For if constant capital is in an and work is a of the what Marx calls the human biological will be then a surplus for If it is that such surplus will to the of the human where they will mental health that nurses will then have to such as and so on 2022). Health in such are not a that capitalism is working are a that it has Capital no longer the In are useful for They as a to those in work what will to them if they do not work long or work long or the in capitalism means that, for will be the They also as a that can the value of labour (Marx 1867, This has the of healthcare commodities more for those in work. lessons should we in the 21st century from Marx's that is that he would the of public health systems that provide universal mental health care the of the mental healthcare systems that in the of Marx's ideas are also capitalist health care, need to be Private health care he would as being more to say the if that are producing private mental health care to a use value) Marx would say that are really it exchange value). If a patient could not would is that The other is that health care is the to surplus value from it is to the and the service over time. If this process with there will a time many patients, those relatively will be to such health care. This will in the not the Marx that at a point the of commodities, including mental healthcare commodities, will to value’ (Marx 1867, If the health system has been subjected to primitive accumulation by that privatised to a many patients, not the or the socially will themselves in health nurses who work in privatised medical or semi-privatised must make sense of Health care for many nurses is a for its own means that is a use value. health care is produced for exchange value. are in the increasing of health care, for has been to as a in 2024). This might not if are a private sector healthcare who is with patients who can to but it will, or at least it if they have noted that many healthcare professionals are or or capitalist in health care (McKeown This is not Capitalism is 2023). there is no to capitalist is a that has been for Healthcare workers now into a where capitalism has for the moment at (Braverman 1998/1974). Marx that who was by capitalism to do anything it was in a of (Marx 1867, However, capitalism itself as a system might not itself be might not be to fully control to be there are different ideas what to control capitalism or there might be no to it at this point in time, have that it can be in relation to health care (Moth and control regulate its in health systems so that the of care is provided to patients free or at low cost at the point of and patients are to such care such as long or Health care then would be basically provided to patients as a use value. that there are this can be One is the that if healthcare workers are subjected to there will be part of at least some of them that healthcare workers for This part of them will be to capitalist if this part is them. The other is that that across the and across time the public have an understanding that health care is different from other in privatised healthcare and are to be of the and the have to be by such and by their to of towards privatised health care. professionals and patients are the in health care supplying the service and the for from Marx's on their surplus value), there will be at least the of and a towards more universalist health care in privatised systems. So what can be health and nurses need to health institutions that provide universal care. This must be and and to the public and professionals the of universal and public Health professionals must be to in an is a that will never be demand public health care for They must this as part of their core professional There is a and for the public that health professionals can use in this and have a can health care, mental or that is provided by and nurses and doctors who are who do not care how much money which is or at least low at the point of will be to be can for that health care, the cost will every the to understand the of the private system will be on and if are a or will to it are or and need it. Healthcare professionals need to and with one another that are to public systems that are the of They need to with and political that seek to control privatised health care. are as to primitive accumulation will in some at generate by privatised healthcare institutions and by those or to privatised health care. one should be what is on there is a of money at For their to the that they can, health professionals should their practice the concept of use value and not exchange value, which is said than but crucial to public for their need to doctors and nurses by supplying them with and where they are and so that they do not that they need to into privatised health care, or to privatised health care to patient demand or to that such as need to be as they are they should not be to If a healthcare company, such as a private or private health company, is private health care, then nurses need to by the of the commodity that is being in health need to be privatised health care. need to be and it should not be seen as the or the of health care. can be in for by to health or health professionals who work for the state from working for that work or in private health care, or health nurses and other professionals need to for themselves what they as of privatisation health and and they that privatisation should and what its nature should be (i.e., provide of services or for Private healthcare services can have However, as private health care will be by the need to generate surplus value. is its Health care is to Health professionals should not into where they are that of the health care in a system is now by private the point that privatisation is then of professional practice will be subjected to real In health systems that have been subjected to high of primitive accumulation, health professionals need to for themselves as a group the to which they want to and to back that accumulation and how they would in and health care in a capitalist system will be through by health patients and key such as who are to to the idea of universal health care (McKeown is as capitalist health are themselves in in of through and with the and and so health professional will not on their own be to the of money and that is by those entities. It is as a and a to universal health care, to a to all of the public, not those with money and with the of care and that healthcare professionals will be to privatisation and into being a different world, a world, a that is not on the economic exploitation and commodification of the the and the as a first Marx would say that Health in capitalist systems who are the commodification of health care in the 21st century need to the nature of the system that they are and that this system may be to to their patients, to who to the of surplus value. Health care, including mental health care, privatisation is in many states in the 21st an or healthcare might not be to do anything this Marx would say that as a first should be with the nature of the system that are and what it is to and if it time for them to seek mental health care, what it will do to The first therefore is is noted on Marx's understanding the is the The point of understanding the is to it. The no of not to this article as no or the