It’s official. A two-tier health system, that long feared prospect that rings the death knell of the NHS, has arrived. Trusts with long waiting lists are offering and promoting “quick and easy” private services in their hospitals. It’s not a choice anyone would relish, but increasingly those who can are giving up and paying up. If you’re after a hip replacement, £12,000 can make the difference between a two-year and a two-week wait. You can get an MRI for £379 in 48 hours, and with it a diagnosis that could save a limb or a life.
The story is the same across England’s public infrastructure. Those who can, after standing on a packed train platform, the clock ticking down to an important appointment, will decamp above ground and take a taxi. Those who can will work several jobs to pay exorbitant and rising rent because they have no access to social housing. Those who can will take the hit, and those who can’t will be stranded, on the streets and in the wards.
Every time you have taken that hit, and no one can blame you for trying to move or heal, you have paid a ransom in a transaction where the government had held you hostage to your needs. By failing to provide public services, by privatising them, or by refusing to engage with striking workers, the government effectively withholds your rights, for which you have already paid through taxes and national insurance, and dares you to blink first. Whether you can afford to blink has little to do with your real wealth, because loans, credit cards and, if you are lucky, family are there to help you cope.
The result is a poorly regulated monopoly of exploitative private interests that mops up unmet demand or “helps” satisfy it: private health practices that charge an eye-watering amount just for a remote consultation, and ride-hailing companies whose prices surge when public transport is down or the weather is severe and yet still cannot keep up with demand. There are the instalment payment finance bolt-ons that appear when you check out online with items that you cannot afford. This network, emerging and dystopian as it feels in England’s specific economic climate at the moment and Britain’s in general, is not unique. It is part of a global pattern that exists in every country where the state has withdrawn, or was never present in the first place.
It rises from the dust of disintegrating public amenities. As a child, I remember my father driving me, curled up in the back of the car in the middle of the night, through the streets of Khartoum to find an emergency room that would treat sudden crippling back pain. We returned at dawn, still unseen. All public hospitals were either deserted or overrun with patients. Today, in the same city, things are different. You have the option of treatment in a number of shiny private clinics and hospitals, but only if you have the money for a down payment that is required before you are even allowed to take a seat.
You also, as you do in many similar African economies, have options for almost everything that the state does not, or cannot provide. In Lagos, Nairobi, even more relatively affluent cities such as Cairo and Johannesburg, you have the choice to rent a private vehicle, from a motorcycle to beat traffic to an air-conditioned Uber, that can take you to your destination as you drive past rickety and unsafe public transport minibuses. There are electric generator providers who will sell you a wide range of devices to keep your lights on when the power goes out. There are sellers of water pumps to tease out the water from the mains, and another set of contractors to build you giant water containers to store that water when even the pumps don’t work any more.
Policing is patchy and unreliable, so you can pay someone to guard your home in the night. If you need to deal with state bureaucracy, which is slow, unpredictable and extractive, there is a private army of fixers that will help you, for a fee of course. Think of them as that expensive “fast track” you take to renew your British passport for urgent travel.
You still pay tax. Whenever the state can get its hands on your cash, it will take a chunk and you will pay it knowing that it is not going anywhere from which you will benefit.
This is the endgame – fast approaching here, in localised form – when the state stops performing its primary function, which is to provide basic human rights to health, shelter, energy, water and transport. Beyond the very wealthy who float above everyone else, the world becomes bifurcated into two classes, the same two that we are also beginning to see emerge in the UK. On the one hand, a class that may perish or starve, and another with disposable income diverted from self-improvement, leisure and savings to fund the creation and maintenance of a makeshift system of self-funded utilities.
The danger in this is less about the deliberate defunding of the public realm by the government – serious though that is. It lies more in the divestment from the public realm by the people. The withdrawal of the state creates not a physical place, but a mental place, where you give up on the government altogether. This is a place where you perceive what were rights before as luxuries: where each self-providing home or community becomes a mini-state.
Politicians feed this psychological reshaping. The most chilling aspect of Rishi Sunak’s premiership so far is a studied remoteness that seems to ask: “What does this have to do with me?” We told you there would be challenges, he says, in the face of a crisis of historic proportions. How about more maths in schools and fewer migrant boats in the Channel? Keir Starmer finally finds some fire in his belly to tell us there will be devolution of decision-making (a good thing, local politicians may be more minded to protect and invest in public infrastructure), but no extra spending under Labour. So that’s the future for communities: penniless autonomy.
At some point, poor countries and very rich capitalist countries end up in the same place – hoarding resources and leaning on the private sector to keep the lights on, and passing on the cost of that to the citizen.
But poverty hasn’t brought us to a place where our transport, housing market and healthcare system are buckling; we are here thanks to conscious political choices disguised as a fact of nature. The spirit of public service can only be kept alive through constantly combating this swindle of scarcity; through maintaining anger and holding on to a sacred definition of what rights and expectations we have – and seek to retain. Pay up if you have to, but don’t give up. Because they are counting on you to do just that.
Nesrine Malik is a Guardian columnist