Thursday, 31 August 2017

Hawking, Hunt and the NHS

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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