“Managers Bad, Doctors Good”: Why even Adam Smith opposes the Con Dem overhaul of the NHS

This post was written by Reuben Bard-Rosenberg on July 13, 2010
Posted Under: Health Care,Liberal Democrats,Tories

The Coalition’s plans to overhaul the NHS are idiotic, but they are also the culmination of a decade of stupid thinking about the National Health Service. The Conservatives plan to get rid of all 10 strategic health authorities and the 152 management bodies known as primary care trusts. In their place, GPs will be asked to group together to form “social enterprises” that will take on the management of hospitals and other health services.

These plans do not just reflect the market fundamentalism of many in the coalition – after all Thatcher attempted no such such thing. They also draw upon a decade of idiotic rhetoric about the NHS which has heroised doctors and demonised managers. For years NHS management has been treated as a byword for waste. Statistics about the number of non-frontline staff in the NHS  have been bandied about as though they self-evidently demonstrate a lack of prudence, without reference to what those in the back rooms actually do – which as Owen noted some time ago is often actually quite a lot. This kind of thinking, meanwhile, has not simply been restricted to the right. All three parties gushed over  the importance of protecting “frontline” staff at the election. Similarly the BBC’s Casaulty – perpetually characterised by cliched, unsophisticated liberal leftism – constantly juxtaposes good doctors, who, you know, actually want to save people’s lives, against those involved in the dirty business of resource allocation.

Quite simply – and to treat all this rhetoric with the contempt that it deserves – doctors and nurses are seen as virtuous because we can physically imagine them patching people up, and anyone else can go to hell. And this is why Lansley hopes to achieve a level of popular support as he begins to dismantle the NHS, and in doing so cuts out a whole load of managers (he aims to halve management costs) and puts the good doctors in charge.

The idea that GPs could do a better job than people who specialise in management is an appealing falsehood. As Imran Ahmed notes:

The idea that creating a market of GPs, most of whom would be cluelessly stumbling through epidemiology, health economics, procurement and other features of health system management that they are completely unprepared for, would create an optimal system is simply ludicrous…

GP practices are clinical enterprises, not businesses, nor sophisticated Government bodies with the complex range of skills and expertise to use tax payers money sensibly to get the best for less.

Quite simply, specialisation matters. The capacity of an organisation to achieve its goals, and to deploy its resources effectively is greatly enhanced when people are able to focus on specific tasks, for which they can enjoy utilise specialist training and experience. This principle was noted (by no means exclusively) by Adam smith nearly 250 years ago when he hypothesised that instituting a division of labour in a pin factory could increase production 78 fold. In a case of the NHS, it is bleeding obvious that mammoth task of allocating resources and of delivering such an important service to so many necessitates a specific set of skills, and the full attention of individuals with relevant experience. And GPs cannot simply be expected to replace this – however virtuous their direct contact with patients might make them appear.

Yet perhaps the most serious issue with the Coalition’s proposals is a political one. The consortia of GPs that take on the management of much of the health service will be answerable not to the ministry of health – i.e. our elected government – but to an “independent NHS board”, which will set standards and will, in theory, be “free from political interference”. This is all well and good unless, like me, you think the provision of healthcare to us all is a political issue. It is all well and good unless you think that there should be some kind of democratic control over the means to keep all of us alive, and that the buck should stop with somebody who governs by our consent.

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Reader Comments

I’m not altogether convinced that you can argue that specialisation means that making GPs the gatekeepers is the wrong way to go. You may be right, but there again you may be wrong. I just don’t know. Surely what we need is some way of letting different systems operate and seeing which ones work best? We could call it a ‘competition’, or something like that, maybe!

Written By Philip Walker on July 14th, 2010 @ 12:39 pm

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