Tuesday, 3 July 2018

Knee-jerk ideology makes any sensible debate on the NHS virtually impossible

The NHS needs to improve. Most people agree with that. But when it comes to what specific policies or actions will deliver improvement there is far less agreement. So sensible debate about what to do would be useful. Sadly we are unlikely to ever have that debate when the response to any suggestion consists of a storm of ideological name calling.

A recent opinion piece on the BBC's Newsnight programme about the NHS has led to a storm of protest and abuse. The piece consisted of a short video by Kate Andrews of the IEA (a free market think tank whose funding is not very transparent). The response mostly consisted of arguments like this:
  1. The BBC should not provide a vehicle for right wing propaganda
  2. Kate Andrews doesn't understand the NHS because she is an American
  3. The IEA is an evil propagandist for an insurance based system and NHS privatisation
  4. The USA's health system is evil
  5. The BBC is biased
And more on the same lines.

Before I watched the video I assumed that she must have argued that the NHS needed to be financed by user charges and broken up into an american style mess run by the private sector for profit. Then I watched it. And my reaction was "what the holy fuck are those commentators talking about?"

The key arguments in the video are this:
  1. The NHS is in a state of perpetual crisis
  2. There is little appetite for radical reform
  3. Campaigners often pretend that there are only two alternatives: the NHS or the US "system"
  4. The NHS isn't on reasonable metrics "the envy of the world": outcomes are better in many other health systems
  5. The USA is a crap system but is also an extreme outlier and a meaningless comparison
  6. Many other countries (Australia, Singapore, The Netherlands, Germany, Sweden…) have universal healthcare with better outcomes than the UK
  7. Competition between a variety of providers (both profit and non-profit) is a common factor in other universal care systems
  8. Market reform in the NHS would be good
And that is it. No calls for abolishing "free at the point of use". No calls for privatisation. No praise at all for the US system.

The only contentious call is for more market reform in the NHS. The most left-wing pro-NHS campaigners agree with point 1. Point 2 is arguable but not controversial (unless you think that abolishing the Lansley act is radical which it isn't as returning the NHS to previous legal and structural model is a big change, but a conservative one). Point 3 is simply a summary of what the majority of commentators and campaigners seem to argue. Point 4 is solidly based on facts. Point 5 is also uncontroversial (though the fact that someone from the IEA has just said it ought to be interesting and pro-NHS campaigners might like to quote it a few more times in their arguments). 6 is also true but, annoyingly, rarely mentioned in the debate about what we should do to improve the NHS. Also 7, which probably explains why left-wing campaigners rarely mention 6 as it undermines the simplistic idea that provider competition is the root cause of everything wrong with the NHS. 8 is admittedly contentious and worth arguing about, though not for the reasons campaigners would normally use.

On that last point it is worth a quick diversion to see what good arguments against it would look like. The best argument isn't that competition doesn't work: it does, even in the NHS as respected and non-ideological health economists like Carol Propper have shown. But those studies showed that the benefits to quality were, likely, small (though the NHS's experiments with competition for elective procedures were not very radical). More importantly, more competition would do little to address the immediate short-term problems in the NHS even if they improved quality in the long term. We have more important things we need to tackle right now like gross underfunding, especially of capital and improvement projects.

So I can take Kate Andrew's argument and deal with it like an adult, specifically looking at what she argues for and rebutting it with logic. A disturbing amount of comment, however, looks less like a fight in a primary school playground and more like a shit throwing contest between two opposing tribes of agitated chimpanzees (seriously, read the twitter thread on the Newsnight post).

It is hard to judge whether any of the shit-throwing commentators even watched the video. I thought more might have latched onto her criticism of the US model ("even the IEA think healthcare in the USA is rubbish!"). What we actually got as a typical response was a series of ad-hominem attacks on Andrews and the IEA coupled with damning criticism of BBC bias for daring to allow such dangerous views to be broadcast (despite them clearly being labelled as an opinion piece to provoke debate and comment). Yes, the opaque funding of the IEA should make us suspicious of what they say and forensic in examining the facts and arguments they make, but it doesn't automatically render what they say as mendacious nonsense.

Much of the comment validates a point I have made before: it is impossible to discuss the NHS in ways that might help improve it because the "debate" is is conducted in clich├ęd shibboleths where all that matters is proving which side you are on. Identifying real problems and fixing them is utterly irrelevant.

If we really want to fix the NHS (and spend the government's new found largesse well) we need to dispassionately analyse what the real problems are and apply the new money to solving them. We need to look objectively at the facts and not just ignore the ones that don't entirely match whichever ideological agenda we have. The intemperate shit-throwing of the pro-NHS commentariat does not exactly encourage that debate. And the likelihood of finding good ways to make the NHS better is substantially lower as a result.