A bit of a long post. On holiday the other week I was diverted
by the hullaballoo over Stephen Hawking laying into Health Secretary Jeremy
Hunt's plans for a seven-day NHS and creeping privatisation. The intellectual
no contest between the world-renowned physicist and the political hatchet man
is a noisy propaganda event; more interesting is the underlying clash of
ideological* spectrum positions on the role of markets and privatisation.
The Conservative Party is always vulnerable to attack over
the NHS, firstly it exposes core differences between rank and file. Secondly,
it's a subject many blundering front line Conservatives lack sensitivity for,
and thirdly, the spotlight often crosses the sleazier edges of the party. My opinion
based on years spent as an activist, is that the bulk of Conservative members
support the NHS as a state funded, state run and primarily state provided
institution. However, this often coincides with an ideological antipathy
towards big government, and tacit support for commerce and entrepreneurship.
There are also legitimate concerns about getting value for money and a
sustainable financial settlement for the NHS.
This means Conservatives are more open minded about the
potential efficiencies from private sector involvement, things others see as
taboo. They're not blind to potential dis-benefits, nor risks from rent seeking
crony capitalism, but they're pragmatic about cost benefits. The upper echelons
and therefore policy direction tends to be disproportionately influenced by the
free market wing. They genuinely believe markets deliver benefits to the public
(a.k.a. consumer) and offer arguments (of admittedly variable quality) in
support. Finally, there is the tiny grubby fringe who associate with free
markets, but are better understood as 'freebooters' whose espousal of public interest
tends to be mere gloss for crony capitalism.
Nobody is against the idea the NHS should be properly
resourced seven days a week, but the concept of a seven-day NHS is more than about
having enough staff. At brief glance it’s clear current policies on NHS funding,
local government/social care funding, Brexit/ immigration, and healthcare
training are incredibly not consistent with sustainable resourcing. The idea of
a seven-day NHS seems tied to the free market concept of healthcare as consumer
service, and it’s hardly a great leap to see this as swaying towards private
provision. However, the much-loathed Mr Hunt has been at great pains to claim
the NHS should not be viewed as a typical consumer service (at least not for
the consumer). Is this just more evidence of confused policy? The undertones of
the freebooters and their clients are hard to ignore.
All this sets up the conflict with those, often on the left,
with more statist ideological positions, who see the NHS as something that
should be state owned, run and provided. As with Conservatives there are many
positions, some strong arguments, some very weak arguments, and there are
sectional interests (trade unions and professional associations may pitch
themselves as ‘guardians’ of public interest but their members come first).
They may be uncomfortable with cost benefit analysis when it comes to rationing
emotive treatments. There is also the category error of mistaking virtuous
intentions of healthcare workers with achieving the best use resources for
patients.
Some opposition is based on misunderstanding of economic
forces, be it confusion over the difference between markets and capitalism, or
viewing inefficiency through the prism of the broken window fallacy i.e.
defending unproductive practices because 'it's someone's job', or perhaps
failing to understand healthcare wages are more constrained by monopsony than by
competition. Emotive pleading is used to obscure the the tragedy of the commons
style problem caused by breaking the link between consuming resources and paying
for them. It's too easy to push responsibility for paying to abstract 'taxpayers',
especially the conveniently nebulous 'rich', but ultimately shunning potential benefits
on ideological grounds means someone else has to put in an extra shift.
I can see legitimate concerns in opposition to private
sector involvement, I just happen to think they can be mitigated without
throwing away potential benefits. I am aware efficiency destroys low
productivity jobs (it's not clinical professionals who are really threatened),
and I am aware those workers may face greater risks. But, there are better ways
of mitigating this than wasting finite resources. The private sector is not
guaranteed to be better, cheaper or more efficient than the public sector, but
restricting provision to a monopoly ends any chance of reaping potential
benefits and locks in the dis-benefits of public monopolies. Concerns about
private providers cutting corners are moot, if commissioning bodies cannot
manage contractual service levels there's no reason to believe they can manage internal
ones. Conflicts over how commissioning bodies decide to spend their funds exist
regardless of the profit motive.
Public monopoly also enables political meddling, this may welcome
for favoured specific political objectives. But enabling meddling is risky, it
leaves the door open to populists and pork barrel deals. Such objectives are
better managed through legislation or other governance. Some simply object on
principle, they despise the idea of private organisations profiting from public
funds, but this is naïve sentimentalism, there is no guarantee resources are distributed
more justly under public provision, taxpayers still pay and in the absence of
totalitarian revolution the fundamental basis of our economy and society
remains unchallenged.
I subscribe to the view that organisations should stick to
their core competencies, things they are good at, and let others handle the
other stuff. From personal experience the NHS is good at providing essential
clinical care, that's where its comparative advantage lies. If other
organisations have comparative advantage in peripheral services that can
benefit us all. We don’t expect the NHS to maintain its own private postal
service because we recognise greater benefit comes from letting specialist
postal services do it, so why not allow certain types of non-core medical services
be handled by private specialists?
Strangely enough this whole conflict tends to overlook that
privatisation and marketisation have always been a feature of the NHS. The bulk
of GP services and dentists are provided by privately owned practices that
contract to the NHS. Many hospital consultants combine public and private work.
There doesn't appear to be a groundswell against these examples of
privatisation, nor demand for clinicians to become indentured to the NHS. The
nomenclature of provision seems to matter as much as the taxonomy; profits for
Healthcare.PLC equals bad, profits for Dr X and Dr Y LLP goes unremarked.
Personally, I support the idea of an NHS funded by taxation,
where clinical services are generally free at point of consumption to those who
eligible (I don't support free treatment for illegal immigrants or health
tourists beyond emergency medicine, because there is no such thing as free
treatment and they bear no responsibility for costs). I don't believe private
insurance is better or more efficient, the state is able to provide comprehensive
society wide risk pooling in a way the private sector cannot. But healthcare will
always be a finite resource and sustainability is a moral as well as practical
necessity. That’s why private provision should be judged pragmatically on the objective
cost benefits, not on subjective principles.
* I find the term 'ideological' uncomfortable as it's
commonly deployed as a vacuous and unintentionally ironic pejorative to label
those who hold opposite or contrary ideologies.
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