Production systems may be owned by health professional entrepreneurs (singly or collectively), by senior managers and shareholders, by cooperative collectives or by the state (with varying degrees of public accountability or participation). All except a few idiosyncratic single-handed practitioners now have office staff, nursing staff, and land, buildings, equipment and so on – a team essential to effective work. For each of these players, ownership is always a centrally important question. For each of them, ownership is differently conceived and defined.

Because patients are increasingly compelled to accept roles either as consumers (for whom the ownership of a providing agency is a matter of indifference: what matters is the commodity they provide), or as co-producers of health gain (for whom ownership must be important, because this determines the motivation of their professional partners in the production process), so the ideas of patients about ownership of the service, and of its subordinate parts, have become as important as those of all other players.

Ownership relates not only to the buildings, equipment and other requirements for effective work in health care, but to the work itself. Adam Smith recognised that people work more productively for their own gain than to help others. This was his justification for the profit motive, which in itself he did not admire, referring to it as ‘self-love’. This explained the higher productivity of capitalism than the feudal agriculture it replaced as foundation and legal framework for commodity production. It also explained the higher productivity of serfdom than slavery. However onerous their tithes, taxes and tribute to landowners, sharecroppers worked more productively than slaves because they could, to at least some extent, work for themselves. With transition from craft skills to machine minding, we see both a huge rise in productivity from human labour plus the labour of machines, and declining craft skills and a fall in their value, as their productivity compared with machines declines. In industrialised labour, people themselves become tools, to be hired or discarded as market requirements and the progress of machinery dictate. Ownership of one's own work in imagination is as important as, and potentially distinct from, ownership of the material requirements for participation in work.