Saturday, 30 November 2013

Balkanising National Health: Another Argument Against NHS Privatisation

The NHS is undergoing privatisation. There are strong, well-worn arguments against this, based in moral philosophy, institutional logics, economics, and politics. While many arguments against privatisation either draw upon a number of these categories, or essay thoughts which overlap a number of these, it is worth being aware of the basic form of each. I will outline each here, but I do so not so as to proceed to judge the merits of each; I believe that as arguments against privatisation, they all have merit and pretty-much put to bed any rationally defensible basis for the privatisation of health provision. I outline each here, prefatory to proposing another argument against privatisation, which I’ll call the Public Health Argument (one might call it the Balkanisation argument). Here the thought is that if our clinical provisions are market-led or consumer-focussed the essential connection with public health will break down, leading to a state of health balkanisation: where public health agencies and clinical agencies pull in different directions because they operate according to different logics.

So, let us consider the argument categories I introduced above.

Moral philosophy.

Health provision is ultimately based, even if only implicitly, on a foundational moral commitment to the moral worth of good health for all. Privatisation undermines this commitment because it promotes a health service founded on a commitment to economic efficiency, based in the logic of profit maximisation and consumer choice rather than good health provision.

Here there are many possible arguments. But one might emerge from a consideration of human dignity: healthcare provided only to those who can pay for it is immoral because it violates the principle of the dignity of each individual, which is a foundational moral principle. But the moral philosophy defence is not exclusively dependent on arguments from human dignity. The point is rather that any society that has conceptions of universalism as a fundamental or essential part of its moral traditions will find it somewhat difficult to justify a non-universal provision of health while remaining consistent. What next, a justice system that provides justice only for those with the means to purchase it? Oh, wait on… Or, only those children whose families who can afford to pay for their education can be educated? Whether one’s morality is expressed in terms of human dignity or rights, maximising health for the greatest number or being in the service of providing the conditions for human flourishing, one will find it difficult to align this with a consumer model of health.

Economics or The Argument from Efficiencies

The argument from efficiencies, as that argument is advanced to justify privatisation, is based in orthodox economics, and is founded in a commitment to the thought that privatisation leads to greater efficiency. However, even if we accept the desirability of the argument from efficiencies (i.e. greater efficiency is good), privatisation of healthcare provision does not achieve that by any respectable measure.

The extraction of profit, the demise of the bargaining power that comes from being a monopsony buyer, where being one large purchaser of goods and services brings greater power to the purchaser, and the introduction of private insurance companies, who also take profits from the system, all lead to  greater inefficiencies. The economic argument is therefore not really based in an argument from efficiency, as it claims to be, but in an ideological argument regarding the desirability of a market system and the right to profit or capital accumulation. It is actually, therefore, a (flawed right-libertarian) moral argument masquerading as an argument based in the “science of economics”. The money spent on health as a proportion of GDP is, according to every serious study, greater in countries that operate some form of privatised and/or private insurance based health provision. Compare the health spending as a proportion of GDP for the USA and the UK, for example. The argument from economic efficiency is a lie and demonstrably so.


Here the proponents of privatisation argue that state provision of healthcare through taxation is increasingly unsustainable. This idea rests on a combination of confusions about efficiencies and assumptions about the difficulty of communicating arguments which clarify those confusions to taxpayers.

As medical science advances, medical provision becomes more complex and expensive. As people live longer they require more health support for a greater length of time. The proportion of the state budget healthcare takes becomes larger and larger, and in a context where citizens demand a lower tax burden this is politically unsustainable. But this could and should (cf. the argument from efficiencies) be addressed by more public provision, not less. State provision of drug research and manufacture, for example, would cut-out much of the current fiscal exodus to the profits of drug companies. The argument from politics is actually an argument about good communication. Politicians need to make the case persuasively for the best kind of health provision: universal provision financed through taxation. Lay it out for the voting public: private health provision costs double that of state provision of healthcare and it lets those without insurance or the means to pay die. Isn’t that a powerful argument? It doesn’t even need “sexing up”.

Institutional Logics.

Those advocating increased privatisation believe that all institutions are enhanced by the introduction of the logic of the market (supply and demand, market forces, the profit motive, and so on). However, the logic of health provision is of a specific kind that does not undergo enhancement through privatisation, but rather destruction.

The logic of an institution is to a large extent read-off the purpose of the institution. The purpose of the NHS is the health of the nation. The idea underpinning privatisation of public services is that the introduction of the profit motive (and market forces) will instil a purpose which will lead to the most efficient institution possible. I would suggest that it is significant that this is a general argument from efficiency and as such it is indifferent to the specifics of particular types of institution. This argument is, therefore, often based in certain foundational dogmas of classical economics, such as the myth of the individual as essentially a rational egoist: individuals are always self-interested and this is their only motivation to act. But we need not become preoccupied with this here. The point is that better healthcare comes from identifying the purpose of healthcare institutions: e.g. as Rupert Read and I have argued, the purpose of healthcare institutions should be understood as being one of medically contributing to the pursuit of human flourishing.  Should our healthcare institutions operate guided by their purpose as institutions that facilitate, through clinical and public health routes, human flourishing or should they operate as institutions whose purpose is to generate profits for shareholders? Now, if you are tempted to think there is no inherent tension between the logic of healthcare and the logic of supply and demand, I suggest you visit a branch of Boots, a pharmacy, or your local “Health Food” shop and ask yourself why they sell Homeopathic remedies and Bach Flower remedies; i.e. why do institutions which claim to provide you we products beneficial to your health, hand-over shelf space to products that are, as a matter of fact, medically inert? Of course, having a section of shelves instead labelled as “PLACEBOS” would be self-defeating. But, then that’s hardly a justification.

Yes, we could put in place legislation and checks and balances to ward-off the worst excesses of supply and demand logic, but proposing such legislation and checks and balances doesn’t just kind of miss the point, but actually sort of demonstrates the point: marketisation and privatisation, we are told by the advocates, are promoted because the law of supply and demand is supposed to enhance provision. If at the outset you need to talk about checks and balances then you already concede that provision will not be enhanced by the implementation of this institutional logic.

In the case of a complex, science-led and flourishing-directed domain such as healthcare what is demanded by individual consumers is often at odds with what those same individuals require in illness and for their good health. Consider the market for alternative remedies, consider the anti-vaccine movement, consider the tension between herd immunity and individual healthcare preferences.

Another Argument:

The Public Health Argument or the Balkanisation of Healthcare: National Health, Illness Treatment and Consumer Choice

So, I’ve gone through what I take to be the four paradigmatic argument forms with which one might operate when critically engaging arguments for private healthcare provision. I have not here sought to make these arguments, only to say enough about them so you might recognise them when you meet them. As I said at the outset, I think that when they are well-made they are each pretty devastating for advocates of healthcare privatisation. Taken together they are even more so. However, I believe there is another argument which complements these, and that is the Public Health Argument.

The nation’s health is served through an integrated approach, founded in clinical research and provision (in the UK: the National Health Service with support from university departments of Medicine) and Public Health research and policy initiatives (in the UK: Public Health England (formally the Health Protection Agency) with support from university departments). Instil a different purpose through privatisation and the NHS and PHE shared purpose—the health of the nation—becomes a goal only for PHE and not for a re-oriented NHS, which now becomes shareholder and consumer focussed.

I’ve touched on the problem of institutional logics, above, and this provides the resources for what I here want to say about this fifth argument against the privatisation of healthcare. At the moment, the National Health Service in the UK is complemented and guided by the work of the Public Health England (formally the Health Protection Agency). The idea is that the nation’s health is served by informed public health initiatives, which are integrated with clinical healthcare practice. The two bodies operate roughly within the same logical framework, provided by a shared purpose: the nation’s good health. I suppose that’s why we call the collection of clinicians, hospitals, and general practices the National Health Service. It is a service designed to ensure and maintain the good health of the nation. Public Health England, as a government agency, shares this purpose. But what if we restructure the institutional logic of one of these? Will they continue to be integrated? Will they even be able to, or want to, speak with each other in the same shared language?  One will continue to operate in accordance with the logic of the good health of the nation, while the other will operate according to the logic of supply and demand and consumer choice.

So, here we see another argument against the privatisation of the NHS, one anticipated to an extent in Allyson Pollock’s writings. Government recognises, implicitly at least, that public health, the health of the nation, is something which is not merely read-off individual preferences: we don’t do surveys on what individuals most want when they feel a little peaky, we do research into what are the public health needs. Yet, while, implicitly at least, PHE and its continued existence is testimony to this, the privatising of the NHS pulls in the opposite direction. Privatisation will instil the logic of the market, which in addition to posing the problems summarised in the section above, on institutional logic, will also lead to a break-a-way from, and de-integration of, what we call our National Health Service from the government agency tasked with better understanding the nation’s health needs: Public Health England. I believe it safe to think of the National Health Service as the clinical component of society’s contribution to public health. Yet, through privatisation, and through reconstruction, the logic of that service will transform into one founded in the logic of consumer choice. At best we will have an illness treatment service; at worst, an illness response service, with no guarantee that the response is founded in an overarching framework of good public health (or even, in the very worst case scenario, even founded in good medical science).

A political approach to our National Health Service might be measured in this way: does it bring the NHS into closer alignment and even integration with good public health, or decouple it from notions of good public health and thereby commit it to being no more than an illness treatment service?

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