What the proponents of the complexity-argument fail to appreciate is that we cannot escape making decisions on healthcare issues anyway. When we nationalise healthcare, we merely transfer decision-making from the private sphere to the political arena. We largely cease to make decisions in our roles as patients, medicine consumers and policyholders, but we now make decisions in our roles as voters, protesters, survey respondents or members of a patient group instead. In these latter roles, we are still the same people – rational or irrational, foresighted or myopic, cool-headed or emotional.
Anyone believing in the general superiority of public over private decision-making in healthcare should take a good look at how the Liberal-Conservative coalition’s recent NHS reform project has failed. Originally, the idea was that GP-led consortia would purchase healthcare services from the most cost-effective providers, which could potentially include private companies. Underperformers would lose funding and could even face closure.
But then a series of protests by NHS staff raised public suspicions about the intent of the reforms. The coalition got nervous and put its plans on hold. The reform debate was no longer about the actual content of the reform. Rather, opponents tried to label the plans as creeping privatisation, and reeled off the conventional anti-market phrases. Meanwhile, the prime minister tried to convince the public that his oft-professed love for the NHS really was heart-felt.
When the smaller coalition partner then lost a referendum on a totally unrelated topic (electoral reform), they suddenly U-turned on the reform which they had co-authored themselves. They were, to use John Redwood’s words, ‘trying to stop their own manifesto being implemented’, and sold this to the electorate as proof of their integrity. Subsequently, the larger coalition partner agreed to strip the bill of its controversial elements. One need not be especially critical of the government to suspect that this manoeuvre has more to do with the internal dynamics of the coalition than with spectacular ‘new insights’ that have become available in the meantime.
In this reform story, we have a neat summary of nearly everything that can go wrong with public decision-making. Decisions on an important topic like health are being dictated by the rules of the coalition poker game. Vested interests successfully portray their aversion to competition as concern for the public good. Entrenched opinions are being formed on the basis of a low level of knowledge: a YouGov poll shows that only 20% of respondents express support for the reform package – but when asked about its individual components (without being told that these are components of the reform plan), support is considerably higher. (The YouGov poll is not explicitly a poll about the level of public awareness. However, if somebody told me they enjoyed pizza, pasta, pesto and Chianti, but strongly disliked Italian cuisine, my interpretation would be that they don’t know what ‘Italian cuisine’ is.)
Healthcare is a complex issue indeed. But there is no escape from that. If we are really unable to make sensible decisions concerning our own healthcare, then how on earth are we supposed to make sensible decisions concerning everybody else’s healthcare?