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July 12, 2011



"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.


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.


&, 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. "



@ 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.


@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...


"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.

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