Episode 80 – 15th April 2011



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You wait ages for a philosopher, and then three come along at once. Following Rebecca Goldstein and AC Grayling last week, this week we speak to Sam Harris about his new book ‘The Moral Landscape’… and much, much more.

The Moral Landscape (2:42) by James O’Malley & Liz Lutgendorff (ft Sam Harris)
Koran Burning (16:04) by Pete Hague
Lansley’s Tenets (22:16) by Simon Howard
Free Markets & Fish (31:25) by Adam Jacobs
Copyright Extension (37:28) by Salim Fadhley (ft Peter Bradwell)
Humanist Schools in Uganda (44:34) by James O’Malley (ft Andrew West)
The Ancestor’s Trail (49:56) by Liz Lutgendorff (ft Chris Jenord)

Follow-Up Links

Full Interview With Sam Harris

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15 thoughts on “Episode 80 – 15th April 2011

  1. Simon,

    We do not ‘know’ that private sector organisations are more efficient and deliver more value for money. I consider that a myth myself, and you’ve assumed this as an ideological point (its therefore ironic that you accuse people who are skeptical of the notion that the private sector will really provide value-for-money as needing to restructure *their* arguments).

    Generally public sector organisations take on harder problems, and are more accountable so can’t cut corners so easily, whilst private sector organisations performing the same functions do cut corners (on things like hospital cleanliness, and in another case on rail safety) and can exteranlise their costs on the the public sector.

    ‘Value for money’ for the private sector often means figuring out what metric the buyer is using to value the product and slicing out things you don’t think he will notice until its too late. This is why the insides of most supermarket sausage rolls is more air than meat. When part of the NHS goes from public (and having the objective of providing the best service) to private (and having the objective of making money) this is bound to happen with health services.

    This seems to have been a theme in your reporting; a completely rose-tinted view of the private sector, from favouring regulatory take-over by the fast food industry to the continuing privatisation of the NHS.

    Please don’t assume other skeptics will accept your basically unquestioning support of all things market-based. And don’t accuse everyone in the NHS who disagrees with your right-wing views on this of being ruthlessly out for their own interests, or plain ignorant.

  2. Pete,

    Thanks for your comment.

    You’re absolutely right re: the flawed assumption that the private sector is more efficient, and in all honesty I thought the same thing myself as I listened back to the final edit. In the original, this was couched in terms of “if you accept that the private sector is more efficient”, and actually had examples of where this appeared to be true and where it didn’t. This was clearly an edit too far.

    This report wasn’t ever intended to give full-throated support to further private-sector involvement in the NHS – it was intended to flesh out some of the complexity of the decisions that need to be made, and point out that the issues aren’t black and white. I wasn’t trying to set out my own stall this time round.

    For what it’s worth, I’m not certain that the NHS should engage in further privatisation. I struggle to see how parts of the NHS can ever be truly market-based, particularly in my own area of Public Health. See also the Outcomes report from the other week where I pointed out that the market is doomed to fail in hard-to-reach areas due to a lack of competition, which in a market-based system leaves the most needy with a terrible service or no service.

    Without wanting to re-open our previous debate, I don’t favour “regulatory take-over by the fast-food industry”, but I do favour talking to them to see what they can offer. I have never argued that closer regulation of the fast-food industry should be taken off the table.

    I don’t think I’ve ever assumed that others will agree with my point of view. And I don’t think I’ve ever accused anyone of being “plain ignorant”, or “ruthlessly out for their own interests” – though I did point out that for employees of the NHS (myself included) their response to the proposals will naturally be coloured by their own future career prospects, and I still hold that to be true.

  3. The clarification is appreciated, although if you admit that its not a universally acknowledged fact that the private sector is better than the public sector at providing services, then you must surely also acknowledge that a distrust of the ability of the private sector to deliver services might be a motivation behind opposition to the reforms, and it isn’t just mushy-idealism versus hard-headed-realism as you seem to imply in your report.

  4. @Pete – You seem to have completely misunderstood the premise of Simon’s report. He’s saying that these are the ways to influence Lansley given these views. Lansley thinks opposition is mushy idealism, not Simon.

    @Simon – I think Lansley’s convinced in his position, and isnt going to change based on rational argument. The sheer weight of objection is more likely to convince him than nuance and will certainly convince the media, the masses and Cameron.

  5. Pete – Yep, I think you’re right. There are very real practical concerns about private-sector involvement, not just idealistic concerns. I actually think the limitations of private sector involvement in healthcare would make quite a good report in itself.

    That’s not to say I’m inherently “distrustful” of private providers in healthcare – I think there’s a role for some private sector involvement – but I’m not sure there’s a strong argument for increasing private sector involvement.

    Sebb – Perhaps you’re right. My concern is that non-specific concerns are more easily brushed-aside than detailed critique, but it’s probably true that there’s less likely to be mass engagement with that. Maybe it’s a bit of both that’s needed.

  6. Completely unrelated to the previous comments:
    Quite some time ago I came to the conclusion that the derogative use of douche bag by Americans is an indicator of a lack of communicative skill (and possibly of intelligence). For me, it’s a huge turn off when I see this used.

  7. @Pete It doesn’t, I was generalising. The term is often used as a put-down by Americans, “So there. What’r you gonna say to that, buddy?”. No offence intended. More of a comment on the insidious Americanisation of the English language. I’d hate for this particular term to enter common usage.

  8. A thought provoking report by Simon. I certainly agree that a lot of the opposition to the NHS reforms is easier to dismiss for being fragmented and ideologically opposed rather than logically opposed.

    I think that the problem is two-fold:
    1) The ideological position that competition will result in value-for-money. This only works if the only value is efficiency, AND if there are few externalities AND with good information. A lot of things meet this test, but not health care.

    2) A consistent push that GPs should be making trade-off decisions between patients. I don’t understand this one, and I don’t think it can be defended.

    I think the solution is not to have a unified objection, but to have a few key quetsions such as “why should GPs have to make trade-offs between their patients – or are you planning to give them infinite budgets?” and to hit the government with those questions at every opportunity.

  9. Drew – Isn’t the obvious response to point out that the budget would always be limited, GPs know patients best, and hence are better placed to make decisions about them than “faceless bureaucrats”?

    It’s a completely fallacious argument, but has great “soundbite logic”.

  10. OK, my thoughts on GPs making trade-offs between patients. I think we can all agree that, given they won’t be given infinite budgets, they will have to make trade-offs, yes?

    So, what does a GP do when having to decide whether, say, patient A gets kidney dialysis for end-stage renal disease or patient B gets some expensive drug for multiple sclerosis?

    I see 2 really big problems with that, which are not solved by the fact that the GP knows the patients best

    The first problem is that to make that sort of decision rationally and fairly (rather than on the basis that the GP never really liked the kidney patient anyway), you need to have a certain amount of expertise in health economics. How many GPs would have that expertise? Not many, would be my guess. Without the tools of health economics, how are you supposed to make that sort of decision fairly?

    The second problem is that it puts GPs in a really unpleasant ethical position. A GP’s ethical duty is to care for the individual patient in his or her surgery. That duty could then conflict with the duty to manage the budget for the benefit of all the other patients. It seems unfair to expect GPs to shoulder the burden of that conflict. Far better, surely, if the budgetary constraints are imposed externally, so if the GP can’t afford to prescribe the drug for the MS patient, he or she is still safe in the knowledge of having done the best possible for the patient given the available constraints.

    In some ways, knowing the patients best could be a disadvantage, as that allows the possibility for arbitrary and unfair criteria to affect decision making. What if the GP never really liked the kidney patient but has always been rather fond of the MS patient?

    If you’re interested in some more of my thoughts on this, I did a piece in episode 69.

  11. Adam – As you might expect from a Public Health Reg, I’m right behind you on this: these decisions need a wide view not a narrow focus..But I think there’s a big challenge in communicating that concisely to a public primed with the opinion that doctors are good and everything else is bureaucracy. Though that’s not today we shouldn’t try to overcome that challenge.

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