Thursday, 26 June 2014

The Kafka-Light Re-Enactment Society

Recently, I visited my GP because my knee is painful when standing up from a sitting position and when cycling. After a brief discussion and examination my doctor decided to refer me to the orthopaedic clinic, which is held in the same surgery. Now, like me you probably think that the easiest and most cost effective way for this to go is that my GP makes the appointment on her PC while I sit there, or failing that, one of the receptionists does so as I pass by reception on my way out.

Nope. I was told to go home and wait...

Five days later I received a letter in the mail signed (per pro) by my GP and on my surgery’s headed notepaper. This letter does not offer me an appointment, but is rather a covering letter stapled to a set of instructions, printed over three further pages of A4 (one of which contains a solitary twelve-word line which seems to be instructing me that the otherwise blank page is confidential). The contents instruct me on how to make an appointment through the NHS “choose and book” online booking system.

Choice is important, we all know that. I might think I would prefer a quick appointment and a fixed knee, but management theory tells those who design the systems otherwise. I want choice, and failing that the illusion of choice, whether I know it or not. This is what keeps us happy. So, I can revel in the ‘choices’ I’ve been given and the consequent increase in personal freedom I’ve gained as a consumer as I grimace in pain cycling to work over the next two months.

Back to the instructions. Those instructions included a password that they (who? what?) have allocated to me for logging on: "Transvestite", which is highlighted on the page by liberal use of pink highlighter pen:

2014-06-26 11.28.37

Superb! as my friend and occasional drag artist Nick Sutcliffe remarked, “clearly they have attributed your knee pain to your penchant for wearing heels.”


So, I dutifully followed the instructions to make the online booking, only to be told by the online system that there was no available appointment. Having then telephoned the number printed on the letter only to get an automated message which told me that the system was very busy and that I should use the online booking system, I finally decided to give up.

I then telephoned my surgery to be told by the receptionist to simply phone the number on the letter as the appointments service is nothing to do with them. Having already tired of being in the automated telephone message—online booking system loop: one doesn’t work, the other refers you to the one that doesn’t work, I am not keen to re-enter. So, with a hint of incredulity, I remarked "so you're telling me that my GP, based at your surgery, refers me to an orthopaedic clinic, based at your surgery, and that is nothing to do with you, despite you also having sent the letter on surgery headed notepaper?"

"Yes", she replied. "Call the number on the letter. The letters are computer generated, they come from us but we don't write them". I said "oh, that might explain the password. Tell me does the computer also make liberal use of pink highlighter pen? Or do you contract-out that task?"

A few hours later I received a call from the Practice Manager who proceeded to pursue the same line of argument the receptionist had employed earlier. Apparently, the one sheet of letter headed note paper and the three sheets of NHS "Choose and Book" instructions it is stapled to should be seen as unrelated. Any issues I have with the Choose and Book system are simply not related to the surgery despite them stapling a signed letter on headed paper to the instructions, which they had printed off, highlighted in pink, and mailed to me with the covering letter. Seriously. That was the defence.

On a more positive note the manager was happy (I believe her) to inform me that on this occasion one of her receptionists had made an appointment for me at the orthopaedic clinic: August 22nd. Two months from now!

I should also add here that I had already waited 18 days for the initial GP appointment, because it was deemed non-urgent.

Progress my friends. Progress. Seriously, who designs these systems, some secret Kafka-light re-enactment society, whose members infiltrate large institutions such as the NHS and universities just to have fun with the rest of us? No, this is management theory in practice.

This isn’t about health, or clinicians. I have nothing but admiration for many of the clinicians I have come to know over the years both when I have been in need of their expertise and when I have undertaken collaborative work with them. This experience is the result of the contemporary cult of managerialism. Every time one is confronted by systems such as these one is often struck by how much they seem to have in common with the bureaucratic systems which were once the stock in trade of political satire, which poked fun, or elicited deep unease, at the bureaucratic perversities of some of the Twentieth Century’s centrally planned economies. Thirty years of NHS systems being subject to management theory-led design and re-design cycles, and here we are.

57 comments :

  1. It ain't management theory, which is just a by-product of organizations in action. It's what happens when you're served by bureaucracy.

    Free medical care is great, in principle, but it's not really free, of course. Someone's paying. In this case, it's the taxpayer. Organizations without a bottom line (the measure of success in the private sphere where you tell if you're succeeding or failing by whether or not you're covering expenses and generating profits) must find other ways to improve their servicing capacity. They must find gauges of success or failure to report to their bosses, the government which funds them with tax your dollars.

    So it's not the patients who really matter (because they are part of the general pool of taxpayers, a pool of people who don't feel the direct impact of poor service except in an attenuated, general way) unless and until they have the equivalent of your knee complaint. It's pleasing the government overseeing them that counts! You, as individual voter and taxpayer, have only minimal impact on the bureaucracy because you rare embedded in a much larger pool of folks, nearly all of whom aren't concerned with your care at the time you are receiving it -- or should be!

    So the bureaucracy's managers come up with ways to incentivize staff to do better work -- or they fiddle with stats to pretend things are better than they, in fact, are (see the current Veterans Affairs hospitals and clinics scandal in the U.S.). On the other hand, in the States where we still have some degree of private health care (though it is being brought more and more under government's thumb!), if you have a problem with your knee you go to your GP who can generally see you right off and then bills your insurance (which you pay for monthly) while taking your co-pay at the time of service delivery. (This helps insure that you, as the patient, still have some skin in the game.)

    He or she then assesses and refers you to an appropriate specialist (say an orthopedist or an orthopedic surgeon -- been there, done that myself) and you make an appointment with his or her office, generally for within the week (if it's an emergency, they can generally see you right away or, in a real clinch you can go directly to a local hospital emergency room). The kinds of wait times you describe are unheard of in the private U.S. medical market although not at all uncommon (and much too much so, we are now discovering) in our clinical venues (such as the scandal ridden V.A.).

    So is national health care really the better solution?

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  2. Erm... yes it is management theory.

    ...But fine, comfort yourself with the tired old profit motive crap. I mean what pitiless selfish creatures human beings are on this view, motivated only by profit. Next you'll be banging on about how we should simply allow the market to take care of everything. I suppose you think Obamacare was a communist plot too.

    Do I still think national health care is the better solution?

    No, I think I'd rather a health service that costs twice as much as the one we in the UK have, as a measure of GDP, while leaving people who cannot pay and who are without insurance to suffer and die. And if anyone suggests any sort of minimal state provision as a safety net to prevent those who cannot pay from suffering and dying I would depict them as part of an anti-American, sorry, I mean anti-British, communist plot to take away our freedom to be selfish heartless brutes... Oh wait on. No. That's obviously a stupid idea.

    Yes, I passionately believe in universal healthcare free at point of use and funded from taxation. I also believe that human beings have no problem with motivating themselves, in the right socio-political conditions, to facilitate and make such provisions effective.

    Finally, the various government interventions dating back over 30 years have been driven by this misguided faith in profit incentives and marketisation, whether that be full-on privatisation that is being undertaken right now or whether it be fund-holding and internal markets introduced in the 1980s (hence the reference to 30 years in the post). It is the attempt to introduce the logic of market into the system that has brought us here and to the sort of madness I report in the post. That's my point. It is the repeated attempts to introduce market incentives where they are simply not required and which have been shown not to work (unless you are a shareholder of a health insurance company) that have generated this problem.

    Why do you presume a General Practitioner needs incentivising by the profit motive to give me an orthopaedic appointment while I sit there before her as opposed to letting me leave and send me a letter with instructions to book my own appointment? She has no choice but to operate within the structures. These are structures that bind both me and my doctor, which have been designed by managers in accordance with management theories that go hand in hand with neo-liberal ideology, that see human beings as little more than one dimensional egoistic consumers. I reject this view of the person and I reject its politics.

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  3. I spent my career in government so I know a bit about this. I was there at a low level and at the top by the time I stepped down and have seen it from both sides (as a union member and high level management). You're welcome to exercise your own anti-capitalist bias. Much of what gets said about these kinds of issues tends to reflect speaker biases rather than facts in any event. (For the record I went from liberal as a young man to conservative, the more I saw of government in operation.)

    As to Obamacare, it's an effort by government to dictate to the insurance industry, medical providers and the general public. The early returns are in and it's been highly disruptive to the medical system, increased costs and forced people out of healthcare plans they'd chosen and wished to keep into more expensive plans less suitable for their needs. Hopefully American voters will wake up soon enough to prevent us from going down the route your country took since I doubt most Americans will want the kind of healthcare you describe.

    By the way, our pre-Obamacare healthcare system didn't leave anyone to "suffer and die." That's a canard. There are advantages for the very poor who no longer have to rely on free clinics and hospital emergency rooms for their primary care (which was their previous option) thanks to government subsidies, but that could have been accomplished without taking a wrecking ball to the old system which was working quite nicely, thank you.

    It's fine that you believe "human beings have no problem with motivating themselves, in the right socio-political conditions, to facilitate and make such provisions effective." But believing don't make it so and your own experience as well as my years in various government agencies (including our municipal health department) say otherwise.

    A GP in a private system makes money on the basis of how many patients he/she sees and so they work hard to see more. Since they mostly run their own shops, they hire people to run their offices efficiently to enable them to see more. If they deliver poor quality care, or fail to do what's needed to refer you to another provider, the patients can and often do simply take their business somewhere else. There are always other doctors within a reasonable radius in our major municipal areas. (Rural areas wrestle with other problems which Obamacare has made worse, e.g., in New Hampshire the rules have all but eliminated competition among insurance providers, leaving only one in the state and that provider only covers one hospital so patients there now find themselves without hospital access in large parts of that state.)

    In our system you wouldn't have had to wait for your GP to "give you an appointment" with the specialist because, if the specialist was in the same office (as with my provider), you just go to the reception desk and they're more than happy to oblige (more patients, more dollars). If the specialist is elsewhere, you either get a few names of trusted specialists from your provider OR you simply look up one in a phone book or ask your friends and family who they'd recommend. And then all you'd have to do is call and they'd give you an appointment pronto.

    If their guy or gal is overbooked (highly unlikely) or out of town, they'd have another colleague or two or three to refer you to if you didn't want to wait. Your GP can't do that because it's "not her job" and besides, she's 9-5er or whatever hours they work. She draws a salary and doesn't do any better by being more efficient or stepping outside her job description. The reason "they" can't "introduce market incentives" (as you put it) in your system is because your system is not amenable to markets. Yours is a monopoly system. All the artificial goal setting and incentivizing can't change that. The way to have markets is to have markets.

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  4. I find it difficult to motivate myself to take the time to respond to such patent nonsense, but here goes:

    1. You clearly know nothing or at least nothing relevant to this discussion about the way the UK NHS is structured. For over thirty years the service has been structured and restructured according to various market models, where different provisions (e.g. general practice, specialist services such as orthopaedics, sexual health etc) hold their own budgets and purchase services from each other. My GP can buy orthopaedic services from where they see fit, even including private providers. This thirty year period has seen a massive increase in managers with no clinical or even health-related backgrounds being in positions where they are in control of commissioning services and designing and redesigning the systems. This is the problem, it is this this which leads to the Kafka-light experiences like that I document above.
    2. Why do I feel sure that this is about managers implementing neo-liberal ideas, which draw on precisely the sort of nonsense you spout? Well one reason, in addition to seeing how this correlates with the introduction of internal markets, is that it is also identical to the sort of Kafka-light experience one has when one deals with wholly privatised large scale service-providing organisations. I work in a university which introduced internal markets and budget holding and I have seen the changes this brought. I have also had have to deal with insurance companies, mobile/cell phone providers, privatised utility companies, credit card and bank account providers, gyms/healthclubs. All of these are private companies subject to the logic of the market, where maximising profit for shareholders is a legal requirement and dealing with all of them is always like that I describe above. Sure, I can change my mobile/cell carrier, or my bank, but they're all as bad as each other. They put lots of effort into recruiting new customers and then set about trying to screw you, because they know most people haven't time to switch each year and because their competitors in the market are doing the same thing, so there is little reason to switch.

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  5. 3. You talk of those who are critical of the market being biassed but provide no evidence for this claim. On the other hand, you spout market dogma without bothering to know anything about the UK NHS and the way it is structured. Who, I wonder, is biassed, or being led by ideological commitment? You, perhaps?
    4. Even if market logic does provide the sort of generalisable universally applicable motivational force you assume (Profit motive) (and there are so many observable and documented reasons for rejecting this, but let's just assume for sake of argument)) there is still a problem when you talk about public goods such as health and education. What about sparsely populated areas, where demand for certain treatments are few and far between. It's not profitable to provide sexual health or orthopaedic services there. So, do we just leave people who are in need of those services to go without the services they need because they do not gain the critical mass for a profitable service? And what about the health centre that collapses financially because of factors out of their control (a serious outbreak or epidemic or natural disaster which draws heavily on the service with little or no profit return)? Do all those relying on the service now go without treatment because of the market failure of their surgery? You can apply the same argument to schooling. A kind of survival of the fittest in a market system might seem to you to work and after years produce more efficient schools but what about those kids who were in the school that went bust and had nowhere else to go? And if you want to cite a state or federal safety net here, then you simply undermine your own argument right from the off: markets work you say, but only when they do and when they don't that's nto a problem because the state intervenes. That is not an argument in defence of the marketisation of health. It is an argument against it.
    5. Finally, you say that my claim that people without insurance in the US system can suffer and die is canard, but you are a. factually incorrect about this and b. where you are not, because the state or federal government intervenes, you can hardly claim that as support for you stance. Is it really a defence of a privatised health provision that people don't die because the state intervenes to make sure they don't when the logic of the market has failed those people? That is perverse.
    But let's look at one example: HIV. A person who receives an HIV diagnosis without insurance has to rely on state or federally-funded provision. But there are well-documented gaps, where people out of work or without insurance for various reasons do not get free HIV meds. Yet these are some of the most expensive drugs on the market and simply unaffordable for most to purchase. This is immoral, as regards the way the world's richest country supports its citizens, and it also makes absolutely NO sense from a public health perspective: An HIV positive person on the right anti-retrovirals (ARVs) can not only live a full, healthy and productive life but the virus is suppressed to such a degree that it is, as much recent evidence is demonstrating, practically non-transmissible. So here the market operates counter to the good health of ill individuals, counter productivity and counter public health (there will be more HIV infections). Furthermore, even in the case of the insured, the insurance companies often dictate what meds they are allowed, which means that an individual that would get the right meds to fully suppress their viral load and minimise any possible side-effects under the UK system might well be restricted to meds that don't fully suppress their viral load and give them debilitating side-effects under the US system, even though they are insured. This is a direct result of the market forces: insurance companies are driven by the goal of maximising profits to their shareholders.

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  6. What you describe are typical problems in bureaucratic organizations. The UK may have some unique elements but the case you present is one of bureaucrats on the clock, doing what they do until it's time not to, staying within the narrowest confines of their job description, etc. But you can have your anti-capitalist bias if you want and continue in the fantasy that all would work beautifully if only people were properly motivated by correctly engineered social forces. The problem you describe is clearly one of trying to have the advantages that come with markets and competitions within a system that is built for neither.

    You call my views "nonsense" but the larger U.S. healthcare system has few of the problems you describe (ex our free clinics, the V. A. Administration and the like which, as of now, are still anomalous to our system) even with Obamacare's massive disruptions to the health insurance market. We may end up where you are at some point, which would be a shame, given the picture you've painted of your system. But I expect you won't get very far by clinging to ideology over empirical evidence, except maybe to reinforce your pre-existing biases.

    Of course, bureaucratic inertia and inefficiency is certainly not the sole province of government operations. Plenty of big, for-profit corporations are also capable of stumbling into that kind of organizational behavior. Nothing about markets guarantees otherwise. But the advantage of markets is competitiveness and those who stumble fail get left behind when the markets are operating as they're supposed to. So there are incentives to do better in such a system, to be more efficient, more responsive, etc. But big companies which succeed in achieving monopoly or semi-monopoly status, or which operate as government sanctioned monopolies (like utilities and phone companies in some venues), evidence the same kinds of deficiencies one finds in government operations.

    Some things are best done by governments, of course. But not everything and, I would argue, not most things -- and so one should either privatize those things or strive to introduce competitive mechanisms into such operations. However, the latter is a somewhat weak and frequently unsatisfactory approach. Better to have markets than pseudo market mechanisms.

    I spent time running a government system intended to build into the operation competitive practices. It was a disaster -- the workers faked the outputs and the analysts, charged with gauging them, played along. In the end it was nothing but a PR exercise while real efficiency and productivity deteriorated. If that's what you're complaining about, you're right (as I pointed out above). But you don't solve that by simply reverting to straight, unadulterated non-competitive bureaucratic behaviors.

    I would say, by the way, that either your experiences of the private sector, that you describe above, indicate either a dyspeptic attitude on your part toward the whole shebang or else the UK's private sector is remarkably incompetent.

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  7. By the way, the evidence (which you say I don't offer) is that when I go to my GP I don't have to wait for an appointment and when he refers me to a specialist it doesn't take 18 weeks, etc. (indeed, it typically takes a week, at worst two). In the system I use, doctors WANT to see patients. They don't want their patients moving to other providers. The evidence is that my experiences on this side of the Atlantic, which are hardly anomalous, are completely different from yours and way more satisfactory.

    Other evidence consists of my testimony that the "profit center" system I was once charged with ensuring in a government agency in which I worked was a fraud (though my higher-ups at the time refused to accept that because they had their own reasons for wanting to believe it was real). And when I worked in our municipal health department at a very high level I witnessed bureaucrats routinely lying to city management about outcomes and needs in order to obtain more resources and directing those resources to inappropriate places (given what they were earmarked for) while ignoring citizen cries for service which the agency was charged with providing.

    You are right that in sparsely populated areas different solutions are often required. Similarly in impoverished areas, and we have government run and private non-profit health clinics that often move into those areas to provide needed services. Sometimes it's enough, sometimes not. What's needed are tailored solutions. The market place alone isn't always adequate for that. But because markets sometimes are insufficient hardly means that government bureaucracies are always the best alternatives, especially given the unique issues with government operations, i.e., they insulate the work force AND management from any but political accountability which is exactly the wrong kind of accountability needed when the issue is service levels and efficiency.

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  8. You write:

    "Finally, you say that my claim that people without insurance in the US system can suffer and die is canard, but you are a. factually incorrect about this and b. where you are not, because the state or federal government intervenes, you can hardly claim that as support for you stance. Is it really a defence of a privatised health provision that people don't die because the state intervenes to make sure they don't when the logic of the market has failed those people? That is perverse."

    The HIV problem stemming from the high cost of medicines is mostly addressed in our system so, on balance, I am not factually incorrect. When I was in our local health department we ran free AIDS and HIV clinics. High cost medicines are generally available via insurance although those lacking insurance (and before Obamacare there were certainly some) did suffer financially though hardly as seriously as they did healthwise. As I said earlier, I do not claim our system was perfect, only that we could have fixed the problems without blowing up and reconstituting our entire health insurance industry -- a move that has had severely deleterious effects on people's coverage across the board, has kicked up, rather than reduced, overall costs and is putting a serious drag on our economic recovery.

    More importantly, it is likely to eventually lead us to a system of health care rationing such as you experience in the UK (hence your experiencing incredibly long wait times to see specialists, get needed treatments, etc.). Here in the U.S. you only see that sort of thing (so far anyway) within government run health care providers like our V. A. system where people have literally died while waiting years for appointments to be scheduled.

    As to insurance companies limiting the spectrum of meds they will cover, that is an issue made worse by Obamacare because that legislation essentially regulates insurance coverage, increasing costs and so reducing company profits. (Those profits are what drive the companies to innovate by doing the research to create new drugs.)

    Thus, under Obamacare, the companies are becoming more restrictive, not less, in terms of the meds they will cover. Your solution, to nationalize the whole system would only shove us into your world of interminable waits for services and rationed care. It's certain that there are no perfect solutions but we can do a hell of a lot better by fixing the holes in a mainly successful private system than blowing it up in favor of government management of insurance providers or, worse, of the whole damned healthcare system as you describe!

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  9. You think mobile/cell phone companies are not genuinely private corporations? They operate precisely this way. And UK corporate law is pretty much the same as US corporate law. I've had 14 years of experiences like those I describe in the blog post with various mobile phone companies.This is not bias it is experience. And this is an experience which is not unique to me or the mobile phone companies I have dealt with. One can find forum after forum full of people describing experiences like I describe in the post above only in the context of dealing with private service providing corporations. Many of these people will not share my political views, yet they have the same experience as me with the same private companies. Hence the point. It is about managerialism. It is a fact of contemporary life. One has this experience when dealing with car insurance companies (private). Breakdown service providers (private). Fitness gyms (private), Internet Service Providers (private). Cable and Satellite TV companies (private). Need I go on?
    Is it just the UK? No. My son and his mother have lived in Norway, France and Belgium. All these countries throw-up the same experiences when one deals with large service providing corporations.
    Maybe it's a Europe thing? Yeah, 'cause I never talk to people from the US or Canada. I have absolutely no US or Canadian friends who can tell me how wonderful their corporations are. Obviously.
    You simply cannot accept this because of your dogma. Yet again you lazily and emptily accuse me of bias without any argument in support of that claim. You dismiss the examples I provide as the product of some kind of cognitive disorder. I guess everyone who documents these examples has such cognitive disorders. I guess the many documentaries and the consumer programmes on television that document such practices are fictions too. I guess the countless books are all made up by commies.

    Furthermore, you simply ignore points I make about the expense (i.e. inefficiency) of the US system (2 x as expensive as the UK system as a proportion of GDP while also needing state bailouts), and you ignore those state bailouts of the US system's failures. That excellent private system requires state intervention to stop people being left to die and suffer. And the point about people dying and suffering; I even took time to give you a concrete example of how this happens despite the state interventions and in a way that is simply not possible in the UK. But you fail to respond to this and just repeat the tired old Cato Institute-style bullshit.
    Feel free to continue to embarrass yourself.

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  10. Phone companies, especially mobile cell phone companies, are government regulated as you know. There are good and bad aspects to that but, on balance, I suppose I would prefer they be regulated to some degree. At least the amount of regulation in the U.S. has not adversely affected the service levels or costs (at least not to a significant degree). To some extent, in a modern society, we must accept government regulatory involvement, indeed it is preferable to an everyone for himself free-for-all.

    "Managerialism" is an interesting neologism and perhaps it means something useful though I tend to doubt it. Managers are human beings and have human failings and drives, usually to augment their own power and resources at the expense of others around them. Imagining we could structure a society that eliminates these human elements is most likely fantasy -- or at least it has been so wherever and whenever it's actually been tried in the real world so far.

    I'm sure your friends overseas mostly share your political views so it's unrealistic to suppose that their testimony in favor of your own feelings is reliable evidence for your views. I have many leftist friends on this side of the Atlantic and we rarely agree about the kinds of issues you've raised here but I also have friends on the right (some of whom I agree with and some I don't) and neither side's agreement with my views matters for their truth or falsity.

    The issue is not to take account of what our friends and acquaintances say alone but to actually look for ourselves and see what's going on. To the extent that your experience with your National Healthcare Service is as you describe above, it is not replicated here. We certainly do have other problems which need solving, in various walks of American life, and we do have the awful dislocations Obamacare has wrought on our health care system (mainly the medical insurance industry but also direct providers, who are paid by that industry's companies in large part). But I would argue that these problems are not evidence that a socialized solution of the sort you seem to be advocating is the answer.

    Socialism per se has not been demonstrated to be effective and there is ample evidence that governmentalism (if you can coin a term like "managerialism" I guess I can coin one, too) is not a source of better solutions.

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  11. You suggest that I am being "dogmatic," "lazy" and "empty" though perhaps this sort of argument (the ad hom sort) is not your most effective strategy if you actually think about it. You also accuse me of presenting no evidence yet you disregard the evidence I do present. No doubt, people who share your biases will be inclined to accept your claims and disparage mine but that isn't evidence, either, that your argument is actually correct.

    At the end of the day it comes down to your own description of the experience you underwent in your own healthcare system. if you want to pretend the solution is more of the same (removing the apparently weak efforts your system has put in place to try to introduce competitive forces) I can't stop you. But the fact that we don't have the waits you do, that we have generally high quality service and ready access to hospitals and clinics in most parts of our country, is evidence that your system is systemically flawed in a way that ours isn't.

    You argue that our medical care costs are high and they are. They are high in terms of costs for health insurance, among other things, and they are going higher thanks to Obamacare. Our system is highly litigious so doctors and facilities are obliged to carry very high malpractice insurance costs, and setting up practices requires a lot of investment. The cost of a medical education is also substantial and many doctors spend years earning their way out of the debt their studies incurred. Aside from the fact that most doctors do like to live well, they have very high costs to cover.

    Could medical care be cheaper here? I'm not sure how unless we simply mandate that all doctors become salaried government workers like yours but then we get a system like the one you are complaining about, where you get lousy service, care rationing and exorbitant waits to see your specialists. It would be ever so nice if everything were paid for by others, by those richer than us or those down the street and we never have to reach into our own pocket to pay our doctor bills or the monthly insurance costs we carry to defray such expenses. It would be wonderful, that is, if it was all free (which means paid by others) but the fact is someone always has to pay. Money and economic exchanges are a fact of human life in the societies we live in. I imagine you want to mandate that kind of society be changed but that hasn't worked so far, in any part of the world or any era, while those of us living in this era can thank our lucky stars for having been born into a time (and in many cases a place) where modern science and technology makes our lives so much more liveable.

    I'm sorry you're so defensive about your views or think anyone disagreeing with your obvious anti-capitalist bias must think you a "commie." Frankly, in today's world, I don't really know what that is. Communism is so passe these days. Indeed, there are far worse bugaboos to worry about so rest assured I do not think of you as a "commie." But I do think you are dogmatically leftist and I guess that's all there is left to say here.

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  12. Seriously, you think 'managerialism' is a neologism? What is it, do you let Microsoft spell checker decide such things for you?
    You continue to demonstrate ignorance.

    Your argument demonstrates laziness and dogmatism because you continue on your path without any thought to the evidence which counts against you. Someone gives you an example and you dismiss it as a product of their bias, as if my bias is so all-encompassing that it makes me misread the world in fundamental ways. You suggest that all those with whom I communicate share my political views. That is false. You couldn't know, but it serves you purposes to assume such because it enables you to dismiss examples which are counter you position.
    So, you proceed to suggest that my experiences with my mobile phone company must be because of government regulation or non-existent and figment of my imagination, because my political views lead to some kind of as yet undiscovered cognitive impairment that leads me to see inefficiencies and bad practice where there is only efficiency and good.

    Respect is earned and nothing you have written is worthy of respect. Calling you dogmatic and lazy is not ad hominem because it is not meant as an argument. Indeed, if you look at what i write you will see my points do not rest on these depictions of you at all. Those depictions of you are observations borne of deep frustration at your dogmatism and the paucity of your argument. Insults if you like.
    I'm not defensive. I am angry.

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  13. There's really no use continuing. I give you evidence and you say I don't. I respond to your evidentiary claims and you say I'm ignoring them. You call me names and hurl accusations by way of responding while mischaracterizing my responses I to you. You defend your right to call me names and claim they have nothing to do with your counter arguments even when you run them all together while asserting, falsely, that I haven't responded to your counter arguments. This is really not a prescription for discussion or dialogue (not even if filled at your own National Health Service).

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    1. I don't think that the question of private vs. national healthcare can be settled with reference to efficiency. Efficiency is great, but a) it's not everything, and b) there are always ways to improve efficiency that don't depend on whether the system is privately or nationally run.

      Personally, I think that the debate boils down to the question of which is the fairest way to run a health service; and to me it simply seems obvious that a system which discriminates both directly and indirectly against people with less money cannot be fair no matter how efficient it is.

      For example, I met an American girl at university who fell over and broke her wrist shortly after arriving in the UK. Even as a foreign citizen, she was taken to an NHS hospital which treated her free of charge including providing ongoing physiotherapy (it was a complex break). She told me that if she had broken her wrist a few months earlier while in America, she would have had to drop out of university and take out a loan of thousands of pounds in order to pay for her treatment. Surely you don't think that's ok.

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    2. Seems to me she was guilty of hyperbole to say the least. I have never seen anything like that here. Assuming you have no insurance, you can go to an emergency room at any hospital and they are required by law to treat you. Yes they bill afterwards but they can't just collect. It is a pain in the ass afterwards dealing with their billing department but there's always an accommodation. They adjust their charges based on ability to pay. KMoreover, if you are indigent you are entitled to Medicaid which is national health INSURANCE for the poor. Not all doctors take Medicaid because the reimbursement rates are lower than market level but hospitals which provide emergency medical care will, though they may not be willing to admit a patient with only that coverage and will redirect such patients to the closest hospital that will. But no one turns emergency cases away. Admittedly the American system is more uneven in this regard than the British system and it's obvious why some will prefer free national care. But free isn't really since providers have to make a living, too, so someone's paying in every case. The question is whether the tradeoff of "free" medical care for poorer service, slower appointments and rationing is worth it. The idea that you can have a bureaucracy serving those needs and get the kind of services you can get in a RELATIVELY free market system is a pipedream in light of the actual record.

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    3. Ok well I can't fact-check on that particular case. But it does seem to me from what you say that it is more difficult for poorer people to get good quality emergency care in the US - and I suppose things are even more difficult if you are poor and you happen to develop a chronic condition that requires ongoing care.

      As regards quality and value for money, does your faith in the American private system mean that you deny the findings of this recent study?:

      http://www.independent.co.uk/news/uk/uks-healthcare-ranked-the-best-out-of-11-western-countries-with-us-coming-last-9542833.html

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    4. I'll have to look at it when I'm at my computer again instead of on the road with a tablet. I certainly have not said the American system is perfect or ideal, but then what system is? It's always a matter of tradeoffs but it seems to me that folks here have a very wrong notion about the American system, perhaps because of a deepseated prejudice against the capitalist ethos. Faced with that kind of motivation, it's unlikely we can come to a meeting of minds. I just want to make it clear that 1) we don't have the problems Phil is complaining about in your system and 2) our system is not the cold hearted, screw the poor operation you and some others are making it out to be. Whether we agree as to the advantages of free enterprise capitalism either generally or in terms of healthcare is a different question.

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    5. Okay, I read the report on the study you cite at the link you provided. It certainly makes your case and, from reading it, I'd conclude that the U.S. system must really suck. The only problem is that that doesn't accord with my direct experience of it, or with anyone in my family or circle of acquaintances' experience of it. On the other hand, we have Phil's own indictment of the British system based on his anecdotal tale kicking off this discussion. So is his experience representative or anomalous? Is mine? I followed your approach and googled up a report that tells a different story: http://www.nationalreview.com/critical-condition/231045/why-americans-dislike-britain-s-nhs/avik-roy

      I'll transcribe a bit of it below.

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    6. ". . . Britons are frustrated by the indifference and inhumanity of the National Health Service. Its problems are covered widely in the British press. Here are some examples (and readers are welcome to provide others):

      "NHS doctors routinely conceal from patients information about innovative new therapies that the NHS doesn’t pay for, so as to not “distress, upset or confuse” them.
      Terminally ill patients are incorrectly classified as “close to death” so as to allow the withdrawal of expensive life support.

      "NHS expert guidelines on the management of high cholesterol are intentionally out of date, putting patients at serious risk, in order to save money.

      "When the government approved an innovative new treatment for elderly blindness, the NHS initially decided to reimburse for the treatment only after patients were already blind in one eye — using the logic that a person blind in one eye can still see, and is therefore not that badly off.

      "While most NHS patients expect to wait five months for a hip operation or knee surgery, leaving them immobile and disabled in the meantime, the actual waiting times are even worse: 11 months for hips and 12 months for knees. (This compares to a wait of 3 to 4 weeks for such procedures in the United States.)

      "One in four Britons with cancer is denied treatment with the latest drugs proven to extend life.

      "Those who seek to pay for such drugs on their own are expelled from the NHS system, for making the government look bad, and are forced to pay for the entirety of their own care for the rest of their lives.

      "Britons diagnosed with cancer or heart attacks are more likely to die, and more quickly, than those of most other developed nations. Britain’s survival rates for these diseases are 'little better than [those] of former Communist countries.'

      "These problems are not an accidental side effect of socialized medicine — they are inherent to socialized medicine."

      So dueling sources here. Do either have the advantage? Perhaps there's some truth on both sides. But that certainly isn't an argument for trashing the American system or praising the British despite Phil's own clearly stated complaints.

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    7. Yes there are problems - obviously - as with any system.

      However the point was not that the NHS is perfect, but that it is a fairer system than private healthcare because it provides for everyone regardless of wealth; and also that it's good value for money according to that rigorous study I cited which looked at a number of different factors using an extensive amount of evidence and data.

      You say that you used the same approach as me - but whereas I cited an article about an independent report compiled by an independent US organisation based on surveys of thousands of people, what you cited was a newspaper article that cited some anecdotal comments from other newspaper articles. Hardly a reliable source.

      Personal experience is important, but you can't generalise from one person's (or a handful of people's) experience of a health service to draw overall conclusions about how good it is.

      If you want to see the methodology and data used by The Commonwealth Fund to produce the report I cited, you can look at the original document here: www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror

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    8. Also, by the way, it is simply false that cancer patients who pay for the latest drugs are 'expelled' from the NHS system. Actually, we do have some private healthcare providers in the UK too, and people are allowed to pay for it if they want to - or go abroad. It's up to them.

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    9. Yes, and some go to the U.S. I didn't say the reports were equivalent, only that both could be found by googling the internet. You're right that the study you cited would have to be looked at in more depth with attention to its methodology, the criteria used, etc. And my cite was not of an equivalent study but of an article (as was the link you provided re: that study by the way). My point was that there are surely two sides here and perhaps more and that there is much anecdotal evidence that challenges some of the general claims being made here. For the record, during my years in government I was involved both with writing and reviewing such studies and I don't suppose I need to tell you that manipulating data, shaping the findings to what we needed, was not at all uncommon. Many of us became quite good at it, souring me forever after on the usefulness, if not the veracity, of such efforts.

      Nor are merely anecdotal evidence or direct experience of things without value in making such assessments. Studies certainly DO play an important role in assessing situations, a role which merely anecdotal information and one's own direct experience cannot replace. But the latter are important reality checks on the former, especially given the ability to shape conclusions by manipulating data.

      So here's the thing. Phil raised certain concerns, based on HIS experience with the NHS and I replied by noting that, based on MY experience THESE are not a problem in the American system. Phil asserted that the cause of the problems HE encountered was "managerialism" which sought to introduce capitalist competitiveness into a system which did not need it and which was made worse by its introduction, hence the problems he encountered.

      I replied by noting that the MORE capitalist American system didn't have the very problems Phil blamed on capitalist "managerialism" at which point, more or less, the argument shifted to who has the better system and you cited a report of a study asserting NHS superiority. I can certainly agree that a system that charges the user nothing at point of service yet still delivers timely, top flight service is better for users. But whether it's better overall for a society or whether it really DOES deliver timely, top flight services seem to be the real questions here.

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    10. Yes I did see what the discussion had been about, but I also noted, as you did, that it had shifted to discussion of which health service was better. It was at this point that I entered the debate.

      Let's just take this:

      "I can certainly agree that a system that charges the user nothing at point of service yet still delivers timely, top flight service is better for users."

      Great - that's brilliant that we agree on that point.

      What I disagree with is your attempt to link 'timely, top flight service' exclusively with private healthcare models; and to suggest that nationalised systems might be inherently worse at this.

      The study I cited was to try to break down your dogmatic assumption that nationalised health systems are inherently less capable, by showing that real-life nationalised systems are not necessarily worse than real-life privatised systems - and in fact, may even be better.

      When I said at the start that nationalised health systems were better, I meant that they are better *in principle* because they embody humanitarian principles of equality and compassion for those in need.

      While I think that nationalised health systems are better in principle than privatised ones for this reason, I agree that there can be various problems with implementation and efficiency - and Phil's story exemplifies one of these problems. But as I see it, this is not a problem created by the very fact of the NHS being a national system - but as you say, a particular problem generated by certain techniques and processes being introduced into the system.

      Such problems, as I see it, are therefore practical ones to be solved by changing the system of administration for a more appropriate one - given the organisational structure etc. These solutions can be carried out while retaining the 'in principle' better model of nationally-funded healthcare.

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    11. "What I disagree with is your attempt to link 'timely, top flight service' exclusively with private healthcare models; and to suggest that nationalised systems might be inherently worse at this."

      The point I made is that it's inherently problematic to try to replicate a market system in one that's non-market. I've seen it attempted before and even been part of such attempts and they have always failed. Now it's possible that my personal experience is not a reliable measure overall but it's also possible it is.

      I do think that, in principle, one could add such features to a non-market system and see them have a positive impact. But my experience suggests that is rare, at best, and that the impact is not likely to be long lasting. The study you invoked asserting that the U.S. healthcare system ranks at the bottom while the UK's is at or near the top strikes me as quite odd in that general conclusion to say the least, given my 66 years of experience of our system in the U.S. (both directly and in relation to friends and family). And if its conclusion were correct, why would so many come from elsewhere in the world to get U.S. medical care? And why do complaints like Philip's occur so often among users of the British system (see that article I cited)? Is the British system as strong an attractant to outsiders in need of medical care as the American then?

      I haven't claimed that the American system is perfect or that it's cheap at point of service (though in general it's not that costly -- the real costs to consumers are in insurance premiums and drugs). What I've said is that: 1) we don't experience the kinds of problems in our private care system (the bulk of our medical system) that Philip cited in his; and 2) we don't leave people, even if indigent, to suffer and die because they can't afford health care in our system, despite allegations to the contrary. There are mechanisms in place to accommodate such folks, and even more now, with Obamacare, despite the dislocations it's wrought and which are reasons to regret its implementation and make changes to it.

      I don't disagree that it's possible to improve bureaucratic organizations or that some services are not better provided by governments than the private sector (police, military, infrastructure and, to a lesser extent education and public health services come to mind). But I would say that it's difficult and probably less cost-effective to try to make such improvements stick when a better option in the form of private delivery is available.

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  15. Thanks for the debate!
    I reckon its a Phil win, clearly,on points.

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  16. There is no evidence to suggest that UK approval of new drugs through the National Institute of Health and Clinical Excellence (NICE) works in a significantly more restrictive way than the US system, through the FDA. Indeed, there are clear cases where the opposite is the case. If NICE approves a drug then it is available on the NHS, where there is a clinical case for it. Where the FDA approve a drug, an insurance company can still refuse to pay for it in favour of cheaper and less suitable drugs.

    Moreover, if it were true that drugs were withheld in the UK, owing to their cost, then many HIV meds would not be available (until the very recent generics came on line in the past few months). But this is not the case. Individuals in the UK, via the NHS, have had better access to the full range of HIV ARVs than even many of those who have insurance cover in the USA. This is not an anecdote. Do some reading.

    While health insurance companies are governed by the requirement to maximise annual shareholder dividends, which very expensive HIV ARVs eat into significantly, the NHS is tasked with providing good healthcare to those in need of it.

    When I used this example of HIV treatment, above, it was to make this point. It was ignored. The US private provision relies on state bail-outs so that it might even passably function as a health service, worthy of that label. This clearly demonstrates that purely private provision is unfit for the purpose of providing healthcare to the nation. It cannot reasonably be depicted as a health service (a service for those who require healthcare), but is rather a service to those who have insurance and even then the obligation to provide good service to policyholders is second in the order of priority to the duty to maximise shareholder dividends. So, because of these wholly predictable failings the US system becomes a hybrid system, where corporations make their profits and the state compensates for their failings as health service-providers.

    But then, even with those government bail-outs in place, the service often falls short, while at the same time being twice as expensive as the UK system. So, the purely private provision doesn't work without needing to be underwritten and bailed-out by the state.

    So then, what of the hybrid system of private insurance plus state bail-outs and state underwriting? Well, it transpires that this still works less well than the UK system on many counts (care for those with long-term chronic illness and no insurance, but a requirement for expensive meds), is unfair/immoral (it still gives better provision based on financial wealth not need), and costs twice as much (is less efficient).

    I find it rather felicitous that these products of my bias, as you would have it, also transpire to be true. What precisely in what I here write is incorrect? That the US system requires state bailouts (to, for example, provide HIV meds to people living with HIV who are uninsured)? That insurance companies are bound by law, as corporate entities, to maximise shareholder dividends but not bound by law to provide approved drugs where, for profit-related reasons, they want to provide less well-suited cheaper drugs? That the US system is twice as expensive as the UK system as a proportion of GDP?

    Which of these do you reject and why?

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    1. Yes, the U.S. most certainly has a hybrid system. As with most things in the world, absoluteness is hard to come by. The questions are whether a hybrid system tilted toward capitalism and free enterprise is better than one tilted toward single payer/government managed state healthcare. (Even the UK has some private providers as another writer here noted so it, too, is something of a hybrid -- the old Soviet Union was certainly purer but in that case it's not a good example of better.)

      Here's something from the British magazine The Economist, reporting on the study that has been mentioned here:

      http://www.economist.com/blogs/economist-explains/2014/06/economist-explains-16

      "The Commonwealth Fund makes quality, access, value for money and equity the leading criteria for judging which countries perform well. Its emphasis on access and per-capita spending mean that America, struggling to extend its insurance coverage, while committing a large amount to overall health-care spending, regularly comes bottom of the Commonwealth Fund table. But that judgment overlooks what American health care delivers well: it scores highly on preventative health measures, patient-centred care and innovation, for instance. It has led the way in reducing avoidable harm to patients, with Seattle’s Virginia Mason hospital delivering 'near zero harm', something many systems, including England’s, are seeking to emulate.

      "What the NHS is good at is providing cost-efficient care. It spends $3,405 per person per annum, less than half America's outlay of $8,508. Alas, that does not mean the NHS is financially secure: a £2 billion ($3.4 billion) shortfall looms from 2015 and NHS England is struggling to implement £20 billion in savings. And some outcomes for serious conditions do not commend the English model, which does worse on serious cancer treatment than Canada, Australia and Sweden, according to data from the King’s Fund, a health-care think-tank based in London. American women have higher survival rates for breast cancer. Mortality rates following strokes also let down the English system. Not everyone agrees with the Commonwealth Fund about what should be measured, and how the results should be weighted. A survey on health-care efficiency by Bloomberg recently chose Hong Kong, Singapore and Japan as the best performers, based on their efficiency. Adding greater weight to patient choice, for example, might reshuffle the rankings. The Commonwealth Fund most values equity and access, and so rewards the systems where it finds these. But change the weighting given to each category and you can quickly change the outcome. When it comes to judging the world’s health systems, preferences and values guide conclusions, as well as raw data."

      I'll answer the rest separately since this format limits word length as you know.

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    2. I don' know that there is "no evidence that UK approval of new drugs through the National Institute of Health and Clinical Excellence (NICE) works in a significantly more restrictive way than the US system. . . " There are certainly claims by often reliable sources so presumably there must be some though I haven't, myself, made a study of it. Your reference to "clear cases" for the opposite to the above claim is fine and no better or worse than our competing anecdotal reports of our respective experiences with our nations' health care systems.

      It's true that the U.S. system is more heterogeneous and complex than the U.K.'s but then the U.S. is a significantly larger country in terms of population size, population diversity and geography. So it stands to reason that we will have different systems across the different national parameters, from variations due to geography to variations in population locations (where the economic and cultural factors will differ and produce different demands on the local systems). It's also true that our three-tiered governmental structure means that responsibilities are divided between local (city, town and county), state and federal levels. A national healthcare system in the U.S. a la the U.K.'s would be a more massive undertaking by significant orders of magnitude along a variety of parameters as already discussed.

      Like you and like any other normal human being I'd favor a system where I could walk in the door, get my care at the time of need and walk out without paying a penny for it. That is certainly an ideal situation. But it's just the way of things that someone always has to pay because people need to feed and shelter themselves (and quite a few other things besides) and that means they have to earn to pay for that. So medical providers have to get paid like everyone else.

      The question then is whether it's better to have them on the government payroll or competing in the marketplace. If one starts with a predilection against marketplaces (and the kind of transactions that go with that) then I suppose one is going to plunk for putting them on government payroll. But then you get the kinds of service you started this discussion out with by your complaints.

      I responded by suggesting that what you were experiencing is a not uncommon feature of government control of service delivery and you replied that it was what you termed "managerialism," the effort to introduce market-type features to the NHS, that caused all the trouble and that if only these were done away with all would be well or at least much better. I noted that I have been involved in government service for most of my adult career and can say from my own experience that human nature makes government monopoly of service provision inherently problematic. I further suggested that a marketplace for services tends to enable those same human traits to produce better results, i.e., health providers strive to do more and think out of the box when there's something in it for them.

      I have no wish to insult your NHS or advise you that the U.K. should dump it and adopt a more American type system. Indeed, I have no idea whether that even makes sense for your country. I have concluded, however, that a national single payer health care system would be highly problematic for my country even if, all other things being equal, I would prefer to get my health care when and where I needed without paying at the door.

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  17. Finally,
    Your initial comment on the post above, suggested that what I claimed in the post was a result of managerialism, was in your view a result of the absence of the profit motive and market forces in the British NHS. I rejected this for various reasons, which I stated in the comments above. But let me summarise them:

    a. Your suggestion that the issues I related in my post are the results of the absence of the profit motive in state provision rests on a basic misrepresentation of the British NHS. The British NHS has undergone various processes of marketisation since the early 1980s. This might not amount to full-on privatisation (though that is happening as I write) but it does amount to a good reason to reject your alternative depiction of the problem. The market has been there in the NHS, with fund-holders holding budgets and purchasing services from each other (and from private providers) for 30 years. (NHS doctors can also undertake private work too.) These changes have brought with them rampant managerialism and this is, as I noted in the post and has been documented by many, the problem.

    b. The sorts of experience I depict in the blog post are neither unique to the NHS, nor even most commonly associated with it. Indeed, the incident was of note because it was unusual. I have pointed out that these sorts of Kafka-light experiences are familiar to people (of various political allegiances and from many parts of the world) and they are as often, if not more often, associated with service-providing corporations as they are with state provision. Dealing with mobile/cell phone companies, satellite/cable TV providers, insurance companies and so on, is a thoroughly maddening experience. These are all governed by the profit motive. So, in addition to misrepresenting the NHS, you also turn a blind eye to the well-documented cases of such managerialism in corporations wholly or largely governed by the profit motive.

    c. In a comment above, I mentioned in passing that there is a wealth of literature on managerialism in both the public and private sector. This literature goes back at least a couple of decades and is authored by individuals with wide-ranging political allegiances. This literature often draws attention to a paradox of management theory: that the rhetoric of effectiveness and efficiency often goes hand in hand with the sort of bureaucratic inertia and Kafka-light craziness which is more readily associated with the last days of Stalinism. I will reference here one book, which focusses in the main on healthcare management: Ethics, Management and Mythology by Michael Loughlin (2002).

    Critiques of managerialism do not only come from those on the traditional left. Many libertarians also find themselves critical (see some of Bruce Charlton's work, for example), I also have a good long-standing friend who is a traditional, old school, conservative and he is just as critical of this stuff as am I.

    As for discussions of private versus publicly-funded healthcare, I actually addressed this in a post published late last year, which can be found here:

    http://viewfromthehutch.blogspot.co.uk/2013/11/balkanising-national-health-another.html

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    1. "Managerialism" is a new term to me. Perhaps it's a Britishism? My response to your use of it, however, was not to deny its existence (the existence of whatever it names that is) which seems to be how you took my words, but to say that the problem you were raising was not a product of what you were calling "managerialism" but of human nature inserted into government controlled monopolistic or near-monopolistic situations. You apparently don't want to hear that. I took from your agitated reaction to my point that you were hostile to the idea of capitalism, profit making, etc., and subsequent things you've said in this debate have borne that out.

      Whatever the problems with your NHS, they are hardly unique and can be seen in many areas in which government service delivery is controlling. As a high level official at one point in the New York City Health Department, I was appalled at the ways in which my agency routinely failed to serve its users, not to mention the slothfulness of government workers, who had assurance of job security, short of committing serious felonies, and no reason to expect to earn more for any effort of their own (since pay increases entirely depended on union-negotiated raises and length of time in service). I was also deeply troubled by the ways in which management at that agency (and others I had been in) routinely misled our city government and misused funding, while hiding behind rules and regulations to avoid achieving better outcomes. I did what I could in my time to combat that but I was generally in the minority among my colleagues and superiors.

      Your complaint about dealing with private corporations and your assignment of the blame to the desire of these entities to generate profits strikes me as deeply mistaken. The problem lies with human nature and is exacerbated any time a system is so structured as to insulate its members from accountability.

      Profits are one very important measure of accountability and, given human nature, one of the most important. To the extent individual self-interest is removed as a factor in performance, performance invariably falters. I'm sympathetic with your dislike of greed but wanting to earn well (and so live well) is not, in and of itself, greed. Too often people fail to make that important distinction.

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  18. There are many points it is tempting to make, and re-make, but i continue to feel it somewhat fruitless. However, one correction, one point about sources, and one question will suffice:

    1. Correction.
    In one of your comments above you talk of an 18 _week_ wait. I have not had to wait 18 weeks for anything from the NHS, in my life, and certainly not on this occasion. Moreover, such a wait was never suggested on this occasion. I waited 18 _days_ for my initial GP appointment because when I telephoned them for an appointment I told them it was non-urgent, and I had intervening commitments. Moreover, while they initially offered me the follow-up orthopaedic appointment in late August, they phoned me the following morning, as they had said they would, to offer me an appointment on Friday that same week (e.g. a matter of days after my GP appointment). This appointment I could not take because I was in London that day. I now have an appointment in ten days' time. This all happened after the blog post had gone live. However, there was never a suggestion of me waiting 18 weeks, either at the time of writing the blog post or after.

    2. Sources.
    You cite The Economist (also mentioning that it is British) as if this is an authoritative and neutral source. The Economist is the most prominent pro-market publication available on UK news-stands. One might be tempted to say that it is akin to citing an article from the British Daily Telegraph (a well known newspaper of the right) but this would be to understate matters. The Telegraph is conservative but not as overtly and clearly pro-market as is The Economist. And as I noted above, many conservatives are similarly critical of managerialism. Next you'll be citing reports published by The Institute of Economic Affairs as authoritative and impartial! This odd for someone so concerned with bias.

    3. A Question. (And I would like to hear your answer to this)
    Do you believe human nature to be innate and immutable?

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    1. I'm glad to hear it was only 18 days. Thanks for the correction. So am I to take it you no longer feel aggrieved about your experience at the hands of the NHS then? Perhaps you just jumped the proverbial gun with the initial complaint?


      I obviously don't share your deep antipathy for all things capitalist so The Economist strikes me as a quite reliable source. Moreover the text I cited was certainly even handed (unless, I suppose, one comes to this thinking THERE IS NOTHING TO BE SAID FOR THE OTHER SIDE, in which case even a nod toward such an opinion, as The Economist article offered, is like to give one apoplexy). I would just note that my own instinctive aversion to a British media organ would most be like to kick in by an allusion to The Guardian, whose sheer leftwing bias strikes me was outrageous. But to each his own, as they say.

      As to what I believe about human nature -- an odd question to say the least -- I happen to be of the opinion that we humans are something of a mixed bag. There certainly are instincts and competencies that come with the territory of being the kinds of creatures we are. There are also capacities we have to change ourselves by our choices, our actions. And, of course, there are the societal norms we take on from the cultures within which we stand, some of which are contingently constructed by the exigencies of our cultures' histories, and some of which are built-in reflecting a certain consistency in human cultures generally.

      How it all shakes out is a function of our particular experiences and what we decide to do with our lives. I hope this answers your question.

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    2. 1.
      My criticism now is just the same as it was when I published the post and as it has been throughout our exchange. So, once again: my criticism is of managerialism. In this case in the NHS, but I believe the argument holds in many contexts, both public and private. You demonstrate ignorance of a wealth of academic literature on this and I have provided you with a reference to an academic text on managerialism in the health context. I can provide you with more if you wish. Moreover, and I am repeating this again too, because you seem determined to ignore it: critiques of managerialism come from many sources, sources with divergent political and economic predilections: traditional conservatives, libertarians and those of the left.

      2.
      You repeatedly accuse those who disagree with you of bias, yet in response to points made you do not cite academic, peer reviewed studies, but quote journalism, and journalism which wears its pro-market predilections on its sleeve at that! When this is pointed out to you, you do not then cite an academic study but rather decide to take pot shots at the Guardian newspaper. The relevance of this is beyond me. The Guardian is a news paper I very rarely read, even more rarely cite and have not mentioned once, much less cited as an authoritative source, in this exchange or in the blog post that prompted the exchange.

      3.
      You remark that my question to you about human nature is odd, yet it is you that has on numerous occasions used a conception of human nature as the foundation for your commitment to the profit motive. If you cannot remember doing so, please refer back to your contributions above (e.g. 04/07 at 18:07). Yet, if you and I agree that human nature is not innate and immutable, but is, rather, adaptive to both the natural and socio-political environment I see no grounds for constructing a whole economic system on a contingent manifestation of human nature. Human nature can only work as you want it to, as a foundation for a commitment to the market, if you can show that human nature is a. as a matter of fact the way you claim and b. this is a matter of non-contingent fact, as it were. (i.e. that human nature is non-adaptive). You have written above that you do not hold human nature to be innate and immutable, and thereby agree with me that in significant ways our nature is adaptive. Movable foundations are unstable foundations. Your argument falls.

      So, I see no reason to accept your view of human nature, arrived at it seems from observing those you worked alongside in New York, as a stable foundation for your claims about the profit motive. .

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    3. Your criticism of what you call "managerialism" -- which I take from your use to be the practice of trying to introduce features that emulate market dynamics into organizations lacking a market basis (such as government bureaucracies) -- is precisely what I have been responding to here. Yet, oddly, you seem not to notice.

      My point is that such efforts largely fail because they lack a real basis for market mechanisms. The mechanisms created for the purpose of tweaking greater efficiency and responsiveness from non-market based organizations tend to fail because they are superimposed on a system that lacks the underlying incentives which make such mechanisms effective. However, your responses make clear that it is less such an artificial attempt to infuse non-market type entities with market mechanisms that you object to than it is the idea of markets (and their profit-driven mechanisms) themselves. Given that, it's plain both why you object to "managerialism," as you call it, and why you and I cannot seem to find any common ground. Your continued ad homs ("you demonstrate ignorance of", etc., etc.) only serve to sully the responses you offer to my comments because they show your animus rather than addressing the content of what I have actually said here, i.e., that the policy of trying to create market mechanisms in non-market driven entities generally fails because non-market type organizations are not amenable to such mechanisms.

      As it happens, and you seem not to notice, my response to you involved "criticism" of what you call "managerialism" (I've repeatedly said here that one cannot hope to improve non-market type organizations by trying to shoehorn market mechanisms into them). Thus your continued responses to me have repreatedly missed a key point of my comments, namely that I am not defending so-called "managerialism" but pointing out why it fails.

      My explanation of why it fails, however, clearly gets under your skin, i.e., I've said that it fails because market driven entities work better in most (but not all) cases than non-market driven entities. Apparently you have other fish to fry in this matter than just the theoretical question of the possibility of successfully using market type features to improve non-market type organizations. (I'll address your other points below.)

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    4. Once again because you seem to really struggle here: 'managerialism' is not reducible to "the introduction of market dynamics in to organisations lacking a market basis". I have repeatedly rejected that depiction of managerialism and given you examples of corporations which have a market basis which are subject to the same kinds of managerialism. I have also cited academic literature which supports this argument.
      You are admittedly ignorant of this literature (you thought managerialism was a neologism) and yet you proceed to pronounce on it without consulting the literature I have cited for you.

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    5. Okay, I'll accept that. I did say that "managerialism" was a new term for me. However your points about it still remain, namely that you equate it with the introduction of market-like mechanisms into the NIH which you oppose.

      Note that my reference to it has been accompanied by a definition which I presented as being what you are equating it with. I did that because, unfamiliar with the term itself, I wanted to address YOUR use, not some use which the word is generally put to and with which I am not familiar. And plainly YOUR use revolves around your opposition to the "managerialist" inclination to introduce market-type mechanisms into the NIH (you've made this point several times here yourself).

      Anyway, the issue isn't "managerialism" but YOUR claim that markets aren't an answer to the perceived inefficiencies of the NIH which you started out by assailing but now wish to retract. Well, okay, but then your original complaint against your local NIH office no longer seems sensible since you have told us that, in fact, you are quite happy with its service to you.

      My original response to you was just to point out that the problem wasn't with the effort to use management indicators or mechanisms to create market-type forces to drive NIH performance but with the very nature of an entity like the NIH itself. Since you have now disavowed your earlier complaint against it, then there would seem to be nothing more to say about that. On your view the NIH is fine. Since I don't deal with them and have no experience of them, I can neither dispute or affirm your new claim.

      I do, however, have experience of the American system and, as I have said here repeatedly, it is not the caricature you have tried to make of it.

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  19. "You repeatedly accuse those who disagree with you of bias,"

    No, I accuse you of that because you have demonstrated it in your knee-jerk responses to my comments supportive of markets, your obvious distaste for the profit motive, your ad homs directed at me for presenting such views, etc., etc.

    "yet in response to points made you do not cite academic, peer reviewed studies, but quote journalism, and journalism which wears its pro-market predilections on its sleeve at that!"

    The study presented was offered here via a link to an article that reported it. I responded with some other articles, including one from The Economist which takes a very evenhanded view of the matter. Your response was to assert that The Economist is conservative/capitalistic in its orientation & so not to be trusted. Yet it's a highly trusted media organ on both sides of the Atlantic except, perhaps, by those who are ideologically opposed to the idea that there might be a case for conservatism or capitalism at any level of consideration. Your reaction to my reference of impugning the source was also ad hominem, needless to say.

    "When this is pointed out to you, you do not then cite an academic study but rather decide to take pot shots at the Guardian newspaper. The relevance of this is beyond me."

    Here it is: You dismiss The Economist for its politics. I put that in the same boat as dismissing the Guardian which is one of the media organs that gets my dander up. Still, I would never dismiss its arguments per se as you do with The Economist. So in that we are quite different.

    (continued below)

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    1. Great, so The Economist is highly trusted by those who agree with it. Good argument Stuart. Keep going. This is fun.

      The Guardian gets your "dander up". You know what The Guardian often irritates the hell out of me, too. But then this is, as I have already pointed out, irrelevant. Because I had not, either in the blog post or the comments, mentioned, much less cited, The Guardian! What next? Are you going to litter your comments with your thoughts on the latest Game of Thrones episode?

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    2. Apparently The Economist is not highly trusted by those who don't agree with it though, like you. So do you think your argument in favor of discounting it's assessment of the report in question, because you don't agree with its conservative, pro-capitalist orientation, is better than a judgment in favor of considering what it has to say?

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    3. I favour academic, peer reviewed, research over journalism. I don't cite journalism as an authoritative source, and I certainly would not expect you to be persuaded by me citing a known journalist of the left is if they obviously carried the argument. It's basic stuff. I find it difficult to believe I need to even spell this out.

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    4. Every review, every study is subject to interpretation. The Economist's article did not purport to present an alternative study with different data but to point out the biases built into the study in question. And that is a perfectly legitimate exercise in analysis.

      It's nice that you want to focus on the study exclusively though I suspect that, given a study produced by a conservative group with findings contrary to your pre-existing beliefs, you would simply discount it as coming from an unacceptable source. In that one could be right, depending on the source and the quality of analysis of course, but not merely because the source holds a world view different from one's own.

      All that was at issue vis a vis the article was how we should think about the study's reported findings. The Economist made a strong case for why there were reasons to consider the study's findings inadequate. What I can't believe is that you think interpretations and assessments of studies don't matter (or else why discount the review by The Economist?). I guess you think only a study's reported findings count (when these echo and affirm your pre-existing beliefs, of course).

      Well, this is clearly not going anywhere. As I noted somewhat earlier you want to discount anything that challenges your world view and seem prepared to do so by intellectually illicit means (invoking ad hominems, discounting information provided by sources whose belief systems are not in accord with your own and denying the importance of considering the parameters and biases of any given study). So I won't post further on this unless you post something that indicates a seriousness about the issues that go beyond a desire to preserve your existing set of beliefs.

      Thanks for the debate.

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    5. Do you not understand the distinction between peer reviewed, academic writing and journalism? Do you know what peer review is, or do you think that is a neologism or a "Britishism"?

      In fact, I have never, as you suggested I did, focussed on that study, indeed it was not I who introduced it into the discussion if you look back. It was another commenter.

      My comments on your use of The Economist were merely to point out that while you continued to accuse others of bias, you were happy to cite a piece of journalism from an overtly pro-market publication in response to someone else citing a serious academic study, and you did so as if The Economist were neutral and authoritative.

      What next? Are you going off to comment on someone else's blog and respond to the citing of an academic study on climate change by citing the Cato Institute on global warming?

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  20. "if you and I agree that human nature is not innate and immutable, but is, rather, adaptive to both the natural and socio-political environment I see no grounds for constructing a whole economic system on a contingent manifestation of human nature."

    Capitalism is not a system we "construct" through social engineering and so forth. It reflects the way things are, the way we are. That I happen to view mankind as a mixed bag includes the obvious fact that some of our nature is built into us. Moreover, that aspect of our nature reflects our evolutionary history dealing with the world we find ourselves in (as a species). The world is competitive and so are we. We, as a species, have developed mechanisms for survival in that world. It's probably not the case that any mechanism of that sort is fixed and immutable in our species. Survival competencies can change as the environment does, as the competitive mix in which we find ourselves with other species change, etc., so it's certainly conceivable that we can social engineer a better society for ourselves. But the evidence thus far, that we can do this by socialism, has not been good. Whether our natures are fixed in whole or part, or in which part, is still perhaps to be discovered. But there are some basic elements of human nature which cannot be rationally denied, including the importance in human motivation of self-interest. An engineered system that takes no, or inadequate, account of that is not likely to succeed.

    "Human nature can only work as you want it to, as a foundation for a commitment to the market, if you can show that human nature is a. as a matter of fact the way you claim and b. this is a matter of non-contingent fact, as it were. (i.e. that human nature is non-adaptive)."

    That's false. As I've pointed out, recognizing that we humans are a mixed bag does not require that we hold a picture of human nature that it is immutably fixed for all time and in all instances. One only has to show that self-interest is a fundamental motivating force in human behaviors and that it is more prevalent and more significant in most instances of human behavior than altruism, selflessness, etc. Do I have a study to that effect? No. But is one needed? I would say no, too, because one can, by simply considering the things we do and the reasons we give for doing them, discover that self-interest is the primary reason we act when we do act. I don't think it's the only reason or that it's a simple thing (we may see our self-interest in many different ways, as regards many different things and at many different levels). But self-interest is generally to be found behind the reasons we give for most of the things we do in the world.

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    1. You write:
      "Capitalism is not a system we "construct" through social engineering and so forth. It reflects the way things are, the way we are."

      But if the way we are is not fixed, as you agreed, then the reflection is not fixed either. It's that straightforward. But then of course you then need to get out of the bind you've got into. So, you decide that self-interest needs to be prioritised and treated as an innate and immutable aspect of our nature. You then write:

      "One only has to show that self-interest is a fundamental motivating force in human behaviors and that it is more prevalent and more significant in most instances of human behavior than altruism, selflessness, etc. Do I have a study to that effect? No. But is one needed? I would say no, too, because one can, by simply considering the things we do and the reasons we give for doing them, discover that self-interest is the primary reason we act when we do act."

      Well I do want to see that study. Because I reject this argument. That's the point Stuart!
      Are you familiar with "The Hobbesian Problem", for example, Stuart? Or are you going to make reference again to your time working in public service in New York?

      If true self-interest was the fundamental motivating force then even markets would not work. Yes, we have interests, but those interests are varied, and change over time and across cultures. Interests can be short term gratifications, or long term planned projects. Interests are often shared. Humans often devote themselves to the gratification of the interests of others. One could continue.

      What you see as obvious and fundamental about human beings, and on which your dogma is founded, is actually far from obvious. Social order is also everywhere to be observed, yet that, and what enables such order, is deemed less relevant to you. To reduce everything to a vague notion of self interest is to render the very fact of human society (that humans are social beings) at the best deeply puzzling.

      So, having answered that human nature was not innate and immutable, you now want to say that it isn't and it is; that is, it is in the one way which serves your purposes in this exchange, and that to you this is so obvious as to need no support. Well there is a whole world of discussion out there dating back centuries, which counters what you here depict as obvious. But hey, we don't need that 'cause this is obvious to Stuart and because he observed this behaviour in his New York colleagues.

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    2. ". . . if the way we are is not fixed, as you agreed, then the reflection is not fixed either. It's that straightforward. But then of course you then need to get out of the bind you've got into. So, you decide that self-interest needs to be prioritised and treated as an innate and immutable aspect of our nature."

      I said "mixed bag," no? Indeed, numerous times. That means some things are fixed and some aren't. Moreover, to be "fixed" is not one thing only but merely fixedness relative to this or that. Think of Wittgenstein's notion of the relationship of a river to its bed. The bed is fixed relative to the flow of water that counts as the river but is, itself, subject to change both from the flow of the water, itself, and various external factors (earthquakes, settlement, etc.).

      "Well I do want to see that study. Because I reject this argument. That's the point Stuart! Are you familiar with 'The Hobbesian Problem', for example, Stuart? Or are you going to make reference again to your time working in public service in New York?"

      If you think you need a "study" to ascertain the role of self-interest in human behavior then you are in an academic fantasy land. Moreover, reference to one's actual experience is hardly irrelevant in a debate concerning how things, which one has experience with, work. It seems to me that you are looking to hide behind a theoretical structure here, insofar as you think that only studies answer questions. You want to disregard all experiential reference in favor of theoretical claims and "studies" supporting them.

      "es, we have interests, but those interests are varied, and change over time and across cultures. Interests can be short term gratifications, or long term planned projects. Interests are often shared. Humans often devote themselves to the gratification of the interests of others. One could continue."

      One need not since I already said as much: "I don't think it's the only reason or that it's a simple thing (we may see our self-interest in many different ways, as regards many different things and at many different levels)."

      "What you see as obvious and fundamental about human beings, and on which your dogma is founded, is actually far from obvious."

      My view is "dogma" but yours, which rejects opposing opinions like The Economist's out of hand because you disagree with their orientation, is not? Interesting.

      "To reduce everything to a vague notion of self interest is to render the very fact of human society (that humans are social beings) at the best deeply puzzling."

      It would be more puzzling to try to explain most human behavior altruistically as in why most of us look to advance ourselves, increase our possessions, earn better salaries, obtain pleasing experiences, fill our stomachs, sate our appetites, compete for more recognition, and so forth and we we find it so striking as to warrant special notice when we encounter people who behave in certain situations in apparently selfless ways. Why we honor the hero or the person who, surprisingly, gives away his or her wealth and devotes him or herself to others.

      "So, having answered that human nature was not innate and immutable, you now want to say that it isn't and it is"

      Actually that's what I said from the start. Apparently you misread my initial response to that question.

      "there is a whole world of discussion out there dating back centuries, which counters what you here depict as obvious. But hey, we don't need that 'cause this is obvious to Stuart and because he observed this behaviour in his New York colleagues."

      It's the idea that we need a "study" to let us know whether or not self-interest is a fundamental motivation of people that is remarkable here. It's as if you have closed yourself off in a bubble remote from real life and real things in order to buttress your preferred belief system.

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    3. So, you're not familiar with the Hobbsian Problem then? OK, good. Just so we're clear.

      Thanks for citing Wittgenstein. So, self interest, on your understanding, is fixed relative to what precisely? Don't leave the analogy hanging Stuart. Cash it out. And what is it that makes you so certain that the relative fixedness is enough to serve as a foundation for your defence of the profit motive?

      And please point out where I tried to "explain all human behaviour altruistically"? Or where criticising your fundamental appeal to self-interest entails that I am committed to some form for foundational altruism? I have not even used the term altruism, much less appealed to it.

      And finally, why is self-interest fundamental for you, yet our sociality and capacity for social order not fundamental? Is it because of your excellent observational study of late 20th/early 21st century New York public sector employees? What does Wittgenstein say about a one-sided diet of examples? Or about the urge to generalise from particulars?
      Or am I being unfair? Was it actually that you read about it in The Economist?

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    4. I didn't say anything about the Hobbesian issue because I don't see the point you mean to make with it. If you do make one I'll respond. So far you have merely made the reference as if the reference alone were the point.

      "Relative fixedness" refers to the notion that being fixed is not, itself, fixed, i.e., it's a matter of fixed relative to what? Our self-interest is similarly described as relative to different levels of operation, to different objectives we may have, etc. Thus "self-interest" is not a term that denotes some single phenomenon or feature in ourselves but a general way we relate, behaviorally, to the world around us, a way that may look quite different in different venues. We look to sustain ourselves, protect ourselves, enhance ourselves, survive, accumulate goods, etc., etc., but doing that involves many levels of operation, e.g.,how we stand within a give group relative to other group members, say, and how we stand in terms of the group's standing relative to other groups, and so forth. Thus we may be self-interested in one sense within the group and self-interested in a different sense in seeking to advance the standing of the group.

      I'm glad you don't wish to explain human behavior in entirely altruistic terms (or even make reference to it apparently though that is an omission in any full account of human behaviors and motivation). The issue here is whether self-interest as a core human motivation (which I take you now to be agreeing to) tends to undermine organizational efficacy and efficiency, when its relevance is not built into the organization's system, as I maintain, or whether it is merely irrelevant or only minimally relevant in systems that are designed to exclude its dynamic (e.g., a government provided healthcare system such as your NIH), which I take you to be claiming. (If you think I have you wrong again please feel free to clarify.)

      As to your continued tone here, I can only say that it is unbecoming in a serious debate but then that's clearly not what's going on here, is it? You don't want a serious debate lest it challenge your most closely held beliefs. You want, rather, to proclaim those beliefs and shout down, or try to shame into silence, anyone who seems to challenge them. Well, have no worries. While I am perfectly willing to continue to respond to you, I don't plan on adopting your tone or insinuations.

      Just as I find them unbecoming in an interlocutor, I would find them equally so in myself. So I will try to keep to the higher road so long as we are continuing to discuss anything here.

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    5. Whereas your tone has been exemplary throughout. Give me a break Stuart.

      I spend my life having serious debates on these issues with people who at the very least would go to the trouble of Googling a term before declaring it a neologism. Apparently that just didn't occur to you.

      Seriously, do you think that your paragraph above, which begins by explaining the meaning of the word "relative", actually says anything which supports you claim that human nature is what makes the profit motive the best system? You have singularly failed to make a case for the self-interest that your whole argument rests upon.

      If you bothered to even glance at the Hobbsian Problem (Google is your friend Stuart) you would see why it is relevant. The problem is so named because when one assumes atomised, self-interested individuals, as do you, and as did Hobbes (admittedly he was a little more articulate and well-read than you) nearly 350 years ago you have serious problems accounting for even the most basic forms of co-operation, even things as basic and fundamental to market economies as the honouring of contracts. This problem is still worked over by rational choice and game theorists today. It is also one of the central problems which animated much of the significant debates in US sociology in the 20th century.

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    6. ...I should also add, as it rounds things off nicely, it is also why markets often tend to produce rampant managerialism and not to produce genuinely free markets. Because, the idea is, that a Leviathan (Hobbes's proposed solution to the problem) is required to ensure co-operation where self-interest will mitigate against it.

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    7. Your condescending attitude is what I find offensive, needless to say. ("Google is your friend" is a tiresome and obviously condescending platitude, in case you need an example of what I mean.)

      In a discussion one doesn't need to look up every word before raising it as an issue. Sometimes it helps and sometimes a civil answer from the other side is enough -- when civil answers are on offer, of course. Anyway, it is not me who has cast aspersions on your credibility, intellectual capacities, scholarly attainments or what not. Nor is it me who has resorted to ad hom remarks in order to sustain my argument. For that you must look closer to home.

      As to your apparent failure to follow my point about "relative," I would suggest that is your problem, not mine. However, one easy way to deal with something one's interlocutor has said, which one finds opaque, is to ask what was meant, to seek clarification. And you don't need a friend in Google for that. We also have your reference to Hobbes as in "admittedly he was a little more articulate and well-read than you." Do you seriously think you are not indulging in ad hominem behavior in these discussions, not resorting to put-downs rather than arguing on the merits, when you say something like that? (Well, given all that's gone before, I suppose you do. Ah well.)

      As to making a case for "self-interest" I have noted that "self-interest" is a ubiquitous element in human behaviors and that we don't need studies to see that. The extent of self-interest and whether it's involved in particular circumstances may be of interest to research but when speaking of how human beings behave generally, there's no need to prove they act with self-interest most of the time. If you think otherwise, it's on you to disprove the obvious, not me to prove it.

      Nor have I ever said anything about "atomised, self-interested individuals." That is another canard of yours. You are arguing against a view I have neither advanced nor subscribe to. Hence your reference to Hobbes, absent a clearer connection than you've made so far, is irrelevant.

      I cannot help it if you read my references to "self-interest" in individuals as one of atomization of the individual. You could, of course, have just asked me outright if that was how I see human beings, i.e., as standing outside any and all cultural contexts, but instead you simply presumed to impute that view to me. Of course we don't need to have atomized individuals to have self-interested behaviors and the fact there are cultural groups in which we stand does not abrogate the idea that we have individual interests and generally behave accordingly.

      At any rate, the idea of free markets is not abrogated by the existence of states and institutions which govern them. Indeed, one could not have markets at all without some rules of governance and some means of enforcing. But we have wandered far afield here from the case you had made, namely that the NIH, as a government entity providing healthcare to citizens, can provide better (as in more reliable, less costly and fairer) medical services to its clientele without the kinds of organizational features and gauges available to free market healthcare systems.

      To the extent that you have sought to redirect this discussion to my qualifications to even talk with you about this, you have certainly managed to blow some smoke here. But even that cannot mask your obvious bias in the matter, namely your dislike of free market systems, of the idea of profits and the notion that people generally act in their own interests. Well, as I said, I can keep this up even if you do try to muddy the waters by making this debate about me rather than about the issues. But it's still an ad hominem strategy which you ought to know better than to employ.

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  21. Stuart, you are clearly confusing me with someone else. I really don't care what you think about my tone and attitude. If you want to keep posting comments telling me how I should behave, fine. Just be clear, you are wasting your time if your hope is that I will change my attitude and tone in light of your comments.

    As for atomism, that really is of little bearing here. If you are not an atomist, that is fine. I'm glad to hear it. However, the point is that if you want to claim that self-interest is a determinant factor, that leads inevitably to the superiority of a market economy and the profit motive, then you are open to the Hobbes Problem. If you try to avoid this by conceding ground and retreating from a kind of Hobbesian self-interest, then you don't see self-interest as fundamental after all, but as a trait that is subject to adaptation. If culture does precede our individual natures, then that individual human nature can be subject to change according to cultures which promote values in which self-interest is much less central, if not marginalised.

    But this is really by-the-by, because as I have repeatedly noted, your stance relies on giving self-interest a status above other traits that are readily and obviously central to human existence, such as our capacity for the production of social order and and our sociality. Why not see these as determinant factors when thinking of economic systems?

    So please, continue for as long as you want to talk of my alleged bias (while citing articles from The Economist etc), feel free to continue to lecture me on the etiquette of argumentation, and feel free to talk of ad hominem arguments, when i have already corrected you on this some time ago.

    To reiterate: to commit argument ad hominem, is to attack the person in place of the production of argument; it is to attempt to discredit a person's argument in the eyes of the audience by discrediting the person. This is not what has gone on here. I believe your arguments are terrible and I believe there is ample evidence for my having met your arguments in the comments above. If you do not see this, that really concerns me very little; I trust others will see it. I have little care as to what you think.

    However, I also think your propensity to proclaim that certain terms are neologisms because you cannot be bothered to look them up is worthy of criticism. I think your insistence on continuing to depict the term as such, or as a 'Britishism', despite me citing literature on managerialism and despite easily found online discussions of the history of the term, is worthy of criticism too. I think your insistence on The Economist being an authoritative source, that is worthy of citing in response to someone having cited an academic study, is worthy of criticism. I think your repeated attempts to defend yourself on these issues is further worthy of criticism.

    So, continue in this vein, if you wish. Continue to take time to lecture me on how you think I should conduct myself. Just don't fool yourself into thinking this is a good use of your time. It isn't.

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    1. ". . . If you are not an atomist, that is fine. . . . However, the point is that if you want to claim that self-interest is a determinant factor, that leads inevitably to the superiority of a market economy and the profit motive, then you are open to the Hobbes Problem. If you try to avoid this by conceding ground and retreating from a kind of Hobbesian self-interest, then you don't see self-interest as fundamental . . . but as a trait that is subject to adaptation. If culture does precede our individual natures, then that individual human nature can be subject to change according to cultures which promote values in which self-interest is much less central, if not marginalised."

      Note that I never made a claim that self-interest is the only motivator. I said it's a primary one. I certainly don't argue that we can't do social engineering, only that a certain kind that disregards the core role of self-interest in human behaviors has persistently failed and, insofar as we aim to replicate in a non-market system the elements that depend on self-interest in a market system, we can expect to continue to see such failures. If one wants such motivators as depend on self-interest, then, I have said, one is better off turning to markets, not trying to reverse engineer them into non-market models.

      I do give self-interest in human interaction "a status above" other motivating traits in the sense that I take it to be more basic and more frequent in its occurrence than some others, e.g., altruism. Unlike you, however, I do not bear any antipathy to the notion itself. I simply take it as one of the givens concerning human nature and proceed accordingly in assessing what is possible, what we can reasonably anticipate from interventions, etc. Of course, this is NOT to disregard other motivating traits such as love for our fellows, affinity for close relations, etc. It's only to suggest that the idea that these others can be commandeered to replace self-interest in large organizations via some kind of cultural indoctrination, etc., is on my view a pipedream.

      As to etiquette, so long as you prefer to hide behind certain kinds of ad hominem remarks I shall feel obliged to mention them to the extent they get out of hand. But there's no reason this discussion should continue on that level. (As to whether you have done that, in light of your denials, I will leave that to you to think about by simply looking back at the things you've said here in response to my comments and criticisms.)

      I'll continue below:

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    2. As to "managerialism" I find it interesting how much you hang on the term. This began with your complaints about service you received at your NIH and your claim that it was due to "Thirty years of NHS systems being subject to management theory-led design and re-design cycles." To that I responded that it wasn't management theory but human nature because people act in their own interests. As I said, the term "managerialism" was new to me but it seems to carry a lot of the load for you. You took me to be somehow denying management theory:

      "Erm... yes it is management theory" and added "comfort yourself with the tired old profit motive crap. I mean what pitiless selfish creatures human beings are on this view, motivated only by profit. Next you'll be banging on about how we should simply allow the market to take care of everything."

      Of course, I had raised no such issue. My point was that it's not the efforts of managers or managerialists (or whatever you're calling them) that caused the problem you were on about but human nature itself because people are most motivated to act in their own interests. This led to your claim that "a General Practitioner" should not need "incentivising by the profit motive to give me an orthopedic appointment while I sit there before her as opposed to letting me leave and send me a letter with instructions to book my own appointment." I replied that your GP was on the clock and obviously had no incentive to operate outside her job description (assuming the system even allowed her to, which your complaint indicates you believe it does).

      You have since all but retracted that complaint in favor of an all out defense of the NHS against the prospect of some kind of privatization which, apparently, you take my view to support. For my part, I don't really care about the NHS. It's not my system. But I do care about the American system. To the extent this is about the relative benefits or deficiencies of free market capitalism, I care as well. But that's more of a theoretical concern since I think there's a good case to be made for such a system over and above a more socialist one. However, there are few pure examples of any of these to be found in the world as everything tends to be mixed in real life. Just as my level of comfort with self-interest as a human motivator (something you are plainly uncomfortable with) is high, so, too is my comfort with the relatively free market system as opposed to a more fully state dominated one.

      What happens in Britain is not my concern so I really don't care whether you hate or love free enterprise, capitalism, markets or the like. I've made my points here about the kinds of things we can expect of government enterprises and similar monopolies and why. If you still think you can engineer different behaviors and motivations in people, I'd say you're wrong and that the available real world evidence is against you. But you're welcome to your views and to fight for them in your country. It's no skin off my nose.

      As to The Economist, I will just say again, since you don't seem to be getting my point, that every study needs analysis and interpreting and The Economist article, which tells a story you apparently don't want to hear, does that well enough, albeit succinctly. That's not the same as citing The Economist as a source to counter the study cited earlier. It's merely to put that study in some perspective which I should think all of us here would welcome.

      As to my using my time, I happen to have had a little of it these past few days, hence these exchanges. To the extent I continue to have it and there is anything interesting to be said, I'll still wade in. But given the rather unproductive nature of these discussions and the rapidly ratcheted up incivility, it's unlikely I'll continue much longer. I'm sure you won't miss my input, either.

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  22. Stuart, I am hiding behind nothing. I am here. If you want to discuss these things in person you can easily find my place of work through the use of a search engine. We can have coffee and chew the fat. As I said, I discuss and argue about these matters all the time. I have no reason to hide from anyone, but certainly not you!
    I have dealt with your claims from the outset. I could have ignored you (I do not reply to all comments on my blog) and I could have switched off comments under this post and even deleted yours had I wished to do so. I did neither. I have responded to you, despite being exasperated by your willingness to criticise positions that you patently know nothing about (managerialism) and refuse to go and familiarise yourself with.
    To say the least, if I wanted to hide this is a peculiar way to to do it.

    Furthermore, I have retracted nothing.

    You now want to return to the beginning. Fine.
    I wrote a blog post based on a rather bizarre experience I'd had. I wrote it not because I wanted to provide a knock-down argument against managerialism, because there is lots of academic work dating back decades which documents the problems with managerialism: its tendency to produce authoritarian working environments, its attack on professionals in the workplace and its tendency to increase levels of bureaucracy in direct relationship to its rhetoric about efficiency (i.e. it achieves the opposite of its stated aims). My post referred to managerialism because I assumed most readers would either a. know something of the decades of work, or b. if they did not, they would do a bit of Googling and find some of the literature on it. Of course, you came along, and knowing nothing you decided not to find out something but to repeatedly post comments containing misfiring criticisms etc.

    I wrote the post by and large because I thought the whole episode rather amusing. If I wanted to write something detailed on managerialism it would not be a short blog post which only introduces the term right at the end.

    You opened your comments by asserting that I was mistaken in identifying the problem as managerialism and further asserting that the problem was with state provision and the absence of the profit motive. This demonstrated that in addition to your ignorance of managerialism, you were also ignorant of the business model of General Practice in the UK. Where each General Practice is run as a small business, in which the doctors (general practitioners) are partners. They can buy services from whomever they wish. Their salaries are not paid and set by the state. They are paid in the same way as directors of a ltd company. So, their salaries can and do vary by a range of over £100,000.00. The practice can purchase services from NHS providers from different regions and from private providers. The doctors can work for as many or as few hours as they wish and can provide private paid-for consultations. You seemed completely unaware of this.

    Yet, while being ignorant of the wealth of literature on managerialism and while being ignorant of the actual system operative in UK general practice, you went ahead and tried to correct me all the same. You now say that you "don't really care about the NHS". Good for you Stuart. Why waste so much time boring us with you ill-informed ramblings then?

    So, you read a short blog post on an experience someone has had at the GP's surgery, which at the end refers to the problem being rampant managerialism that has been in the system for the past thirty years (on which there is a wealth of academic literature. I have even cited a book on the subject for you). While knowing nothing of managerialism, while knowing nothing of the business model of British General Practice and while not really caring about the NHS, you then spend days offering your views on these things of which you know nothing...

    And you then complain that my tone is condescending (as if I hadn't noticed and needed this pointing out to me!). Too right my tone is condescending.

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    1. Yes, you've been condescending though I gather that's not of concern to you since you believe yourself entirely justified. I didn't mean you were literally hiding from me, only that you are using ad hominem rhetoric to shield your beliefs. Anyway, my interest is not in what you call "managerialism" (as I've said repeatedly, the term is new to me) but in the kind of problem you flagged. Having "been there" and seen it, and even, at times, been part of it, I have some experience with the phenomenon. More, I have served in an analytical capacity in developing and assessing interventions intended to make organizations work better so, in a sense, we are not on opposite sides vis a vis your pet bugaboo, "managerialism." I have done the stuff you call by that name and have found it wanting myself.

      Your description of the NHS business model suggests it's a system seeking to achieve a more business-oriented dynamic. I think that's commendable though perhaps it hasn't yet achieved its aims fully, if your complaints are any measure. Certainly, if your GP's group is a stand-alone medical enterprise as mine is, I would expect your experience with them to have been better. But as you say, there are all sorts of factors to which I am not privy and you are closer to than I am. The thing to recall, even given my non-experience with your NHS, is that the health care system that I use does not have the kinds of problem you complained about at the outset. Therefore, something is different. My guess is it's that mine is more of a free market system than the jury-rigged national health care system you describe. Perhaps, though, your case merely reflects a lousy GP or a poorly implemented operation. You have said in these discussions that you think the incident was, on balance, an anomaly, so perhaps that's all that's at work.

      My initial reply to your post dealt with the assumption that one can make a silk purse (a responsive market-driven operation) from a sow's ear (a non-market oriented bureaucratic monopoly). When I said the problem wasn't "management theory" but the nature of the operation itself that the theory was being applied to it was to that that I was referring.

      You immediately took umbrage at my comments, apparently, because you took me to be attacking your healthcare system itself and as extolling the virtues of free markets and the profit motive. Well they were certainly doing the latter, if not the former. When we got into a set-to over that question, we seem to have found ourselves at increasing loggerheads. At that point, I think, emotions took over (and, from the tone of your last comments, continue to dominate on your side).

      I know many who share your views on capitalism, markets and so forth who simply can't abide even the suggestion that such an approach could be right (or more right than some idealized socialist mechanisms they admire and desire). When we get to this stage in a discussion there really isn't a lot of reason to go on. We have hit bedrock, the place where our competing values come to rest and at that level facts no longer matter for drawing conclusions but only rhetorically, as a way to bolster pre-existing presumptions.

      Our discussion on this topic grew exponentially out of what seems to me, on consideration, to have been your deeply held belief system and your apparent emotional commitment to its "truth". Well, okay. There isn't much room to debate things when that is the underlying dynamic. As it happens, my free time to debate this has come to an end for most of the rest of this week anyway and since we haven't really had a constructive dialogue on these questions I'll step back for now. This is YOUR blog, after all, and I shouldn't be intruding on it so pervasively as I have been doing. Apologies and sorry to have troubled you!

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    2. OK, bye Stuart.
      I guess if at some point in the future I feel the need for some speculative distance psychoanalysis communicated in blog comments I know where to come.

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