Last night, watching Question Time on the BBC, I was struck once again by the repetition of the public good/private bad dichotomy that so easily trips off the tongue when discussing the NHS. Today is the 65th anniversary of the NHS, so I thought I’d blog about the claim that private involvement in it is bad.
How many times have we heard the line that private involvement in the NHS is a bad thing? To many times to count. But what do people mean when they say that? The problem is that consistent and coherent reasons are rarely given in support of the ‘private bad’ claim, and that’s problematic; you’ll see why in a moment. So, what reasons might support the claim that private involvement in the NHS is bad? Here are some possibilities.
1. Private involvement in public services is intrinsically bad.
Underlying the ‘private bad’ claim is, I think, often the reason that it’s somehow wrong to profit from the provision of a public service. What would make profiting from public services wrong? One thought is that it feels wrong to profit from someone’s need rather than their mere desire. Certain goods are non-contingent, we need them regardless of our desires, and our need for them is strong enough to generate a right to them. If we have a right to something, then others are under a duty to provide it to us, which might make withholding it unless we pay wrong. Perhaps this is what makes the NHS different and which makes it more morally wrong to profit from it than other public services like, for example, town planning? The problem is that this argument doesn’t really work.
Public services provide goods that require collective action to deliver and coordinate, and for this reason we delegate responsibility for fulfilling our duties to the state. In the case of health provision, when the state pays a private company, it’s distributing some of the resources it’s raised through taxation to fulfil our duties. What matters here is that the duties are fulfilled and not how they are fulfilled. The duties met through public services are imperfect duties – they do not fall upon particular individuals. If I’m sick there’s no particular individual I can identify as the duty-bearer who must aid me: I do not get to decide the who fulfils the duty and how it is fulfilled. Rather, it falls upon society as a whole to fulfil the duty and determine the manner in which it is met. To put it another way: if I’m drowning I don’t get to choose who saves me and what stroke they use to do so, what matters is that I am saved.
What’s more, if we were to accept 1. then we would be forced to conclude that the NHS should not purchase anything which is sold for profit. Just think for a moment how the NHS would look if it were forced to manufacture the uniforms, medical equipment, computer systems, pens, clipboards, badges, etc, etc, etc. that it uses! In fact, if profit were ruled out it’d have to make the machines and factories to make that equipment too. I think we can all probably agree that that would be absurd.
Perhaps then the claim that private involvement in the NHS is bad can rest upon different reasons.
2. Private involvement in public services does not/cannot work.
Many people claim, citing numerous examples, that the private provision of services just doesn’t work. Often, the perfectly plausible claim is made that the profit motive distorts priorities and so leads to bad outcomes. It could be the case that the NHS is simply unable to meet its duties if it uses private companies to deliver services. The problem is that the evidence people cite doesn’t show that private companies are by necessity unable to deliver services – very often they do provide the services asked of them even if they do so badly in many cases. Instead, the evidence can at best be used to support the much weaker claim below.
3. Private involvement in public services is inefficient.
Given that we have limited resources, finding the most efficient way to provide services is very important. Perhaps there is something necessarily inefficient in using private companies to deliver public services? This looks like a plausible claim since it’s clear that because private companies seek profit they do not use all of the resources given to them to provide the services required. What’s more, they have a motive to use the minimum amount of resources to fulfil their duties, which might lead to increased risk of failure and a poorer quality service. This means that the state may have to give them more resources to provide the same level of service as a public sector organisation: if the resources were instead used by a public sector organisation then all of them would go on duty fulfilment. However, the counter-argument can be made that perhaps the public sector organisation, because it lacks the profit motive, is contrastingly prone to over-use of resources and waste: lack of competition and cumbersome bureaucracy leads the public sector to spend more than is necessary to achieve its outcomes.
It strikes me that both arguments are plausible: private involvement can lead to poorer services and greater risk, and public services can lead to waste. What I don’t think it’s easy to show is that private provision is always going to be less efficient than purely public provision.
Where does that leave us then? First, we should be sceptical of arguments based on claims 1 and 2. The debate about private sector involvement in the NHS should first be about whether we prefer higher risk and poorer services to waste and and the problems associated with bureaucracy. The answer to this will depend upon how much risk, how much poorer services might be, how much waste, and how much money we have to spend at any given time. Second, we should be asking whether both private provision can be provided in ways which minimise the negative aspects outlined. Perhaps restricting private provision to less risky procedures, or setting constraints on the amount of profit it’s permitted to generate might work. And, perhaps there are more efficient models or structures of public provision, such as social insurance or limited public competition, that we should consider. I happen to think that this is the area in which policy-makers tend to operate, it’s just a shame that the NHS is so fetishised that public debate is almost never conducted in these terms. Rather, we get endless versions of argument 1. and 2. So, let’s celebrate the 65th anniversary of the wonderful NHS, but let’s also be honest and reasonable in our consideration of how best to meet our collective duties.