-“Typical free-market dogmatism. Private providers are not better than the NHS.”
-“Assume this one is. Just as a thought experiment.”
-“But private providers just cherry-pick the easy patients, and snatch up the profitable services.”
-“Assume they are paid according to a well-defined risk-adjusted formula, which renders cherry-picking pointless.”
-“But it fragments the service.”
-“Assume the payment formula also encourages cooperation.”
-“Still, private providers are not better.”
-“Assume this one is.”
-“But they’re not.”
-“Assume it is.”
-“BUT THEY’RE NOT!!!”
-“Assume it is.”
-“Sigh! Alright. Er… well, if… but… um… but surely the real point is…”
Does this sound familiar? Have you had arguments like this? If you support a more pluralistic and competitive healthcare system, of course you have. Arguments about the NHS can look a lot like those weird interviews in Jonathan Haidt’s book The Righteous Mind. Haidt constructs scenarios in which fictional characters act in ways that repulse most people, but that do not cause harm to anybody, and that are not, in an obvious way, ‘immoral’. When Haidt presents these stories to his interview participants, they rush to condemn those actions, but when asked to defend that judgement, they struggle. This is how Haidt begins to develop a broader theory about moral reasoning, which he summarises as ‘intuitions come first, strategic reasoning comes second’: When forming an opinion, we often start with a strong gut feeling, and then seek out arguments to justify that gut feeling in hindsight. Arguments, then, cannot always be taken at face value, because they are often just post-hoc rationalisations.
If somebody tells you that their opinion is X, and that their reasons for holding that opinion are A, B and C, chances are that it is exactly the other way round: They held opinion X first, and then looked out for a justification, which is how they found A, B and C. If so, you cannot change that person’s mind by refuting A, B and C. They will still hold on to X, and just change the way they justify it.
Potentially, Haidt’s approach could tell us quite a bit about the state of the British NHS debate. Haidt’s theory is that moral intuitions (and by extensions, political intuitions) can be traced back to six core building blocks (the ‘moral foundations’):
Most people’s moral beliefs rest on most, or all of these foundations, but with large differences in degree, and in different combinations. This is what differences between political camps ultimately come down to.
But what does this mean for the NHS debate? Implicitly, advocates of pro-market reform seem to assume that the strong feelings which the health service arouses are based exclusively on the care/harm foundation: People are so passionate about the NHS, because they care so much about healthcare for the poor. Therefore, reformers have gone out of their way to drive home the point that the distribution of healthcare resources, and the provision of the services, are entirely different subjects. If you want everybody to have access to something, you don’t need to nationalise the provision. All you need to achieve this is targeted demand-side subsidies. Provision can be partly, or even entirely, private. Yet somehow, the reformers do not seem to be getting very far. Why is that?
Maybe we need to take that oft-repeated (I won’t repeat it again) Nigel Lawson quote a bit more literally, and accept that NHS purism does not primarily rest on the care/harm foundation, but on the sanctity/degradation foundation. That is the only way to make sense of the absolutism of NHS purists. Of course, these people also believe that there is a fundamental conflict between the desire to heal people and the desire to turn a profit. But they cannot possibly believe that no for-profit provider could ever, under any circumstances, outperform a public provider. If you believe that healthcare is generally best provided by a public sector organisation, and if your moral arguments rest on the care/harm foundation, you will end up favouring a setup not unlike the current commissioning system. At the moment, Clinical Commissioning Groups (CCGs) are able to contract with a private provider, but that is entirely optional. If they choose not to do so, then that’s that.
What’s not to like? A lot, apparently. In large parts of the media, any small increase in the share of contracts going to private providers (aka ‘NHS privatisation’) is presented as an unequivocally and self-evidently bad thing. You cannot explain that with reference to the care/harm foundation, but it starts to make a lot of sense once you start using the sanctity/degradation foundation.
To NHS worshippers, the health service is like a serene little church in the middle of a red light district: it is a sanctuary of higher, nobler, purer moral principles. Tendering out some bits to private companies would defile and besmirch the service, regardless of whether it would, according some petty efficiency measure, ‘work’. It would be like replacing the church’s vicar with a paid actor who does not have the slightest interest in religion. ‘But he does a good job’ would not be a convincing argument to regular churchgoers, to whom perceived motives and intentions matter more than observable outcomes.
The implication would be that pro-market reformers cannot hide behind phrases that start with “I love the NHS, but…”. They have to broaden their attack, and explicitly play out the care/harm foundation against the sanctity/degradation foundation. That should not be too hard. There is nothing noble about the NHS. For a long time, producer interests within the NHS have resisted every measure aimed at increasing transparency and patient choice, or simply at raising expectations. It is a system which shields self-interested producers from competition and accountability to patients, and people only put up with it because they are prepared to project onto the NHS what they would like it to be. If reformers want to succeed, they need to make this self-deception that much harder.
 The Guardian newspaper recently illustrated this mechanism, albeit, as usually, unwittingly. Until recently, the paper had promoted the view that there is an ‘obesity crisis’ in the UK, and that it is a crisis of capitalism: Corporations sell us high-calorie food. In the meantime, it has emerged that the point beyond which body fat levels become a danger to our health are far higher than previously assumed. The Guardian immediately integrated this new fact into its anti-capitalist worldview: “Thin privilege is rampant […] many people believe there’s something virtuous in consuming low-calorie food and going to the gym, and refuse to recognise that that’s a culturally constructed myth that props up the diet industry, patriarchy and oppressive beauty standards.”
 There also seems to be at least a weak element of authority/subversion, and a strong element of loyalty/betrayal. Just remember the reactions when Daniel Hannan, a Conservative MEP, criticised the NHS on American TV. (Incidentally, criticising one’s own country on foreign radio is one of the examples Haidt uses to explain the loyalty/betrayal foundation.)