Inequality & healthcare reform

“People with money can get friendly with their local GP at a dinner party, maybe see them out of hours if there’s an emergency” says Cameron.
Paul is critical of this, and rightly so; GPs don’t want to socialize with people whose piles they saw that morning.
This, though, misses the point - that there are other channels through which the middle class can get a better deal from the NHS than the poor:
1. The middle class tend to be better at moaning - God knows, they get enough practice. As Julian Le Grand has written:

Insofar as complaining works at all, it favours the self-confident and articulate middle classes, thus tending to steer services in their direction. (The Other Invisible Hand, p98)

We might add to this that it’s human nature to more or less subtly sympathize more with like-minded folk, and so some doctors might give the middle class a longer hearing than poorer patients.
2. Public information campaigns tend to reach the rich more than the poor, and so exacerbate health inequality.
3. Doctors tend to prefer to work in “nice” areas, and so poor areas are under-provided with GPs. Back in 1971, this led Julian Tudor Hart to propose the inverse care law: “The availability of good medical care tends to vary inversely with the need for it.”
Now, inequality in access to healthcare is not the main cause of health inequalities (pdf). But nevertheless it does seem to exist. One survey (pdf) in 2003 found:

There is strong evidence that lower socio-economic groups use services less in relation to need than higher ones from many studies of specific NHS services.

Equally, though, there is some evidence that this inequality has narrowed in recent years. One study found that waiting times for some non-urgent operations in 1997 were longer for poorer patients than richer ones and yet by 2007 this difference had disappeared. What’s more, this increased equality coincided with the introduction of more patient choice.
Now, this is not decisive. But it is suggestive of a possibility - that competition and choice in public services, regardless of its impact on overall standards, might be egalitarian. Introducing “exit” might redress the inequality caused by “voice” alone.
Which brings me to a sad fact. Debate about public service reform has crystallized along boring left-right lines. Rightists who don‘t give a toss about equality, be they Blairites or Tories, have promoted reform whilst the conservative statist left has opposed it. This, though, has led to neglect of a more interesting idea - that perhaps public services might be reformed in genuinely egalitarian directions.

Comments

[CharlieMcMenamin]

"Introducing “exit” might redress the inequality caused by “voice” alone."

Even the Wikipedia article you link too notes that there are circumstances where a 'tight monopoly' might be preferable to exit. Schools are quoted as the example given by theory's developer, but surely health falls into a similar category?

To believe that increased 'exit' opportunities might decrease health inequalities implies that this might occur via potential unplanned service closures. Yeah, right.

[Keith]

It is worth stating for posterity that I have not seen any convincing ideas from left or right about how you improve public services compared to the old fashioned methods of investment, and high quality training of staff. All the methods that work are well known but no one wants to admit it as that requires more spending. Combined with some long term planning. All we get from politicians including Cameron yesterday is recycling of right wing privatisation and LCD stuff that has been sold by the ruling class for decades. The collapse of soutern cross thanks to financial engineering by spivs seems to have no impact on the campaign for evan more public service sell offs to the same spivs ,that will produce more collapses when the shit hits the fan.

[CharlieMcMenamin]

&, right on cue, a defector from a competitive Health system with lots of 'exit' opportunities speaks:

"Competition sounds good in theory – but in practice, especially among hospitals, it has fuelled rather than contained medical inflation. US hospitals spend billions of dollars needlessly to obtain the latest technology and equipment just so they can compete with other hospitals in the same market.

This has led to a costly duplication of services and a kind of healthcare "arms race". It has not led to better outcomes or equal access to care. "

http://tinyurl.com/6hnsbpr

[chris]

@ Charlie - I'm not arguing blindly for competition. What matters here is the detail, of precisely how institutions shape incentives, not ideology.
I'm just worried that the left's hostility to competition and privatization might be distracting it from the fact that public health and (maybe more so) education have not been as fully egalitarian as they should be.

[Charles Wheeler]

"Which brings me to a sad fact. Debate about public service reform has crystallized along boring left-right lines. Rightists who don‘t give a toss about equality, be they Blairites or Tories, have promoted reform whilst the conservative statist left has opposed it."

I love the way you always stand above the iniquities of ideology.

Sadly, the current reforms are primarily driven by the ideology of market fundamentalism - and markets (without state intervention) will always act in the interest of those with more 'votes' in the marketplace.

To pretend that privatising services will benefit the poor is simply disinegenuous.

[Churm Rincewind]

@ Chris Wheeler: I think Chris is right - any real debate about public service reform tends to be precluded by unthinking kneejerks from both left and right. Thus, although there was much merit in the main thrust of Andrew Lansley's proposals for NHS reform (admittedly alongside a whole range of ill-considered suggestions) there was never any real debate, just a series of wild assertions including, I'm sorry to say, your all-encompassing view that "current reforms are primarily driven by the ideology of market fundamentalism."

In the case of the NHS, for example, there is considerable evidence-based research to show that choice and competition actually does improve healthcare outcomes in a fixed price market, and that it is irrelevant whether that choice and competition is provided within the NHS or by private healthcare companies.

[Metatone]

@Churm Rincewind - care to cite some of that research?
Many pieces about the performance of fixed price markets in the NHS have been discredited because of bad statistical practice.

@Chris - You say "What’s more, this increased equality coincided with the introduction of more patient choice." but of course this is a deeply ideological statement, because you neglect to mention that it also coincided with increased healthcare spending (or investment as some prefer to term it).

The largest reason for the improvement in waiting times for poorer patients by 2007 was the overall large reduction in waiting times for elective surgery. When no-one is waiting that long, the inequality automatically reduces.

Choice and competition were not big factors in the reduction in waiting times, contra the propaganda. The largest factor was the money put into increasing capacity:

1) Money spent on new facilities.
2) Money spent on coaxing consultants away from private practice and onto working on NHS waiting lists.
3) Money spent on independent treatment centres which turned out not to generate lasting competition, but did help with the backlog of cases.

Choice certainly helped even out some geographical disparities, but competition was not present to a degree that backs up people who claim it as causal beyond overall capacity increase.

[Churm Rincewind]

@Chris Wheeler: You ask me to cite relevant research. Certainly. The two key studies are from the University of Bristol under the title "Death by Market Power: Reform, Competition and Patient Outcomes in the NHS", and the LSE study "Does Hospital Competition Save Lives?". Both are available online.

As far as I'm aware, no-one of repute (including even Ben Goldacre) is seriously questioning these reports, especially as there is no evidence to the contrary. The issue with Lansley was the level of his commitment to the precondition of a fixed price market.

I pretty much disagree with the rest of your post, but that would involve a much longer answer...

[Dipper]

"The middle class tend to be better at moaning"

Don't get me started. The amount of time I have to spend moaning and complaining just to get anything out of any bureaucracy. I hate it, but oif you don't do it, you don't get anything.