Wednesday, August 12, 2009

Privatise the NHS? Ah yes, our social Darwinians are among us again...

The argument raging in the US about President Obama's plans for a scheme to ensure that all Americans have health insurance appears to have spread over here via a 'hashtag war' - #privatisetheNHS versus #WeLovetheNHS, or some such thing.

I will say this, for trite comments, Sara Scarlett and Charlotte Gore have set an astonishingly high standard. 'We love the NHS... Like hostage victims love their hostage takers." is slightly more patronising than "If you love the NHS so much - marry it!", but as neither of them will be using the system any time soon (that would be far too hypocritical, wouldn't it?), perhaps one shouldn't be too hard on them.

Most people who have taken sides seem to have opted for the 'save the NHS' option, with the ever controversial Sara and Charlotte batting for the opposition. With the greatest respect for Sara and Charlotte, if not the manner in which they express themselves, I'm obliged to add to the weight of opposition to their stance. And not because I have a fixation for public provision over private, but mostly because I remain unconvinced that the private sector has the means or the will to provide universal healthcare.

It is an almost universally accepted viewpoint amongst the American right that state provision of things that they disapprove of is bad, and that anything that might increase the expenditure levels of the Federal Government is worse - except interfering in other people's countries, subsidising large chunks of their economy and anything that might come to their home district in the way of 'pork'.

In terms of healthcare, they are so determined to keep the state out of provision that they are apparently happy to condemn the poor to lower life expectancy and the rest of society to spending a higher proportion of GDP on healthcare than virtually any country on earth. And Sara wants us to go the same way. Bless...

There is little doubt that general levels of health and of life expectancy in this country have increased substantially as social provision has improved, be it through the NHS, social security payments or old age pensions. None of these things are, in themselves, a universal panacea, but by providing innoculations for children, medication at affordable prices (and free for the poor and the elderly) and modern surgical techniques free at the point of access, one cannot doubt that the NHS has achieved much.

It is, however, legitimate to question whether the NHS, in its current form, is best designed to deal with our future societal challenges. If inflation within the healthcare sector continues to run above that in the wider economy, is state provision capable of keeping up, especially in a time of shrinking government revenues? Can the private sector meet public aspirations and maintain its current standards?

So, perhaps, could we have the debate?


Charlotte Gore said...

Hi Mark,

With all due respect you've somewhat misrepresented the tone of my post on this subject, I think.

My post was about the fact that the UK is no stranger to holding up the US as an example to fear, and yet now we're complaining when the US begins doing the same.

The point is that you can't really have a debate in this kind of atmosphere of fear.

Mark Valladares said...


And your opening remark was supportive of a real debate? Or just a way of provoking exactly the type of response that takes us precisely nowhere?

Now it just happens that, having fisked young Irfan with the blogging equivalent of a horse whip, I can turn my mind to the very questions I ended this piece with...

Tristan said...

Social Darwinism is great! It means the evolution of social institutions, the survival of the fittest means the survival of the most suitable.

Unfortunately, those with power think they know better and are superhuman to boot. They think they can design social institutions to function better, with often disastrous results.

Tristan said...

Oh and further to that - the NHS and government action increases the costs of healthcare. In the US this is obvious thanks to large amounts of private purchase, in the UK its hidden through taxation and borrowing.

Drug costs would be far lower if patents weren't enforced, and there's be more incentive to develop new drugs as opposed to minor iterations of existing drugs.

The numbers of medical professionals is also artificially restricted to raise prices. Even when we need more doctors training is restricted.

And how anyone can support a system which rations health care I don't know. Especially when its done on the basis of the bureaucratic measures of QUALYs (so much for universal health care).

The non-state sector is perfectly capable of providing health care, unfortunately its not allowed to anywhere that I know of - because there are power games at play.

Charlotte Gore said...

But did you actually read beyond that first line, because it sort of looks like you didn't.

Caron said...

Mark, when I saw you say Sara and Charlotte, I thought for a minute you meant that other Lib Dem blogger Sara Bedford who I know is a great supporter of the NHS. I eventually rumbled that you meant Sara Scarlett on Liberal Vision. As we now have two high profile Sara's it might be a good idea to be more specific about which one you mean when you talk about them.

Does that make sense or is it just me being stupid?

Jock Coats said...

Way back as early as last Sunday I posted on this, together with a whole list of solutions suggested by the Centre for a Stateless Society just to show that being in opposition to the heavy hand of government delivering healthcare does not mean for libertarians that they want to see it remain exclusive an dunattainable.

Sara Scarlett said...

Ahh, my trite comments were largely in response to the equally trite raw emoting @ replies on Twitter. Blogging's meant to be fun, right? I supposed the way I express myself has always been my problem!!

Also I have never said anywhere that I want the UK's health system to look anything like the US's. The link I've been using a lot is:

There's too much wrong with the US's health system and in my humble opinion Obama's health reforms are going the wrong way. So no Sara does not "want us to go the same way. Ah bless."

I don't actually use the NHS to be honest. I wait until I visit my parents in Dubai and then go private for dentistry. I have never been to see an NHS dentist in my entire life.

Unfortunately a lot of my views stem from the treatment I've seen my grandparents receive on the NHS. My grandfather needs 24 hr care at home now. In no other countries I've visited have the hospitals matched sheer grubbiness, filth and indignity of NHS wards. So if there's any other way to do this I'll happily take my chances.

Also the NHS wasn't started from scratch. Where do you think all the hospitals before 1944 came from? They were private hospitals - you seem to think there was no health care for "the poor" before WWII - all the NHS has done has centralised them and bureaucratised them.

So yeah I'm still going to stand my ground.

Mark Valladares said...


Quite right. I suspect that Sara B would be fairly horrified to be associated with the views of Sara S, so I've made that explicit.

There are so many of you out there, and you share names. How is an old man to cope? :)

Mark Valladares said...


As ever, erudite and to the point. What is it with the practical libertarianism? If you keep that up, you'll start to convert a few of us!

But seriously, addressing the point that you want to liberate the healthcare 'industry' from the shackles of bureaucracy whilst ensuring access to all is the obvious way to deliver change and bring the fearful with you (Charlotte, you're absolutely right there...). What I fear is that the theory is elegant but the implementation is difficult to envisage.

Jock Coats said...

As ever, erudite and to the point.

I suspect you might want to retract that when you see the verbiose comment I've just left on the "How much are you willing to pay" thread!

Mark Valladares said...


It's the quality of the argument that stands up, laden with context and comprehension. I might not agree with you in terms of viability or deliverability, but one is obliged to admire the style with which you argue...

Mark Valladares said...


Have you been kidnapped by some alien life force? Whatever it is, it's not as good as you usually are.

The figures I quote for healthcare are as a percentage of GDP, so I'm not sure where the hidden sums are (the percentages add up to 100 everywhere).

And as for the notion that rationing can be avoided, there is no system, short of one which gives all the treatment you might want without charge or limitation. The price tag on that would be ruinous, as all the evidence indicates that take-up of healthcare increases proprtionate to availability (Jock, does that make sense?). Are you suggesting that this is possible, in which case I'd like to see an exposition of how it would function.

Mark Valladares said...


My apologies for taking so long to get back to you, but you know how this work malarkey tends to get in the way...

You are right about fear. Politicians seem awfully keen to 'defend the NHS' whether or not they believe in it, and preserving it in aspic is a safer electoral bet than delivering real, efficency-improving, life-saving change.

Perhaps I should not allow the personal to impact on my response to the political...

Jock Coats said...

What I fear is that the theory is elegant but the implementation is difficult to envisage.

Sorry, I didn't address this. You are right to be cautious in this. There is certainly a very real danger that any move to free up medical care would turn out to be the biggest rent seeking opportunity in history - like the railways so-called "privatization" only bigger - with well capitalized corporations buying up lots of facilities - again, a similar problem as with EU tendering. The government could well demand "guarantees" that only the biggest could reasonably provide.

In terms of whether even in the right circumstances my suggested model is feasible, I would say that if little old me can envisage the various incentives the network supply model would bring, then someone with a bit of real business acumen and an eye for an opportunity and perhaps a bit of speciality in the medical field would surely do so.

And it is as you pointed out (elsewhere?) an expaning market. I found an IPPR presentation the other day suggesting that we might even decide we want to spend three or four times what we do on healthcare in a couple of decades time. I am skeptical about such claims because whilst it might be true in an inflexible monopolistic system I imagine that in a dynamic system there would also be greater incentives to both find cures rather than treatments and that technological breakthroughs will reduce costs over time.

Some thought needs to be given to how such change could be kicked off - what I might suggest, since we are paying anyway for these big assets, is that we might decide to distribute shares to everyone in a particular hospital's catchment area so that the big ticket assets are initially at least held as broadly as possible and everyone has a right to a say in the direction of "their" hospital etc. The first job of the newly liberated hospital might then be to decide to split those shares in the hosptial as a whole into several creating different firms with different functions which could then be a manageable size say for even local speciality businesses to take over.

But overall, the message as a liberal is that we cannot plan the outcomes as minutely as we might want. We have to have confidence that dispersing power, decision making and investment brings in so many more human brains not tied to a Whitehall desk that they will always be able to find a way around problems.

PS - as I said in my Sunday blog post, I think it is a really good thing that this US debate has caused not a few of us here to have the debate. The age and venerability of the NHS cannot be the reason for its continued monopoly status (as the "I love the NHS because it's been around for sixty years, is part of our social fabric" and so on arguments seem often to suggest). It cannot be sustained on the basis of such nostalgia.