Margaret Thatcher almost completely succeeded in imposing her consumerist agenda on an entire political generation, across its whole spectrum from Left to Right. She succeeded not through any exceptional talent or imagination, but because her rediscovery of primitive 19th century laissez-faire economics coincided with the world- wide collapse of the only full scale socialist economies (real or imagined) history has so far produced. For the past decade at least, the market has swept the board.

In this view of the world, the large majority of ordinary people have either ceased to exist as producers, or will shortly do so. Whatever creative capacity they retain after 150 years of factory work will soon be replaced by machines, taking what were once fallible human decisions, more efficiently and therefore more profitably for managers and shareholders. Making money is the social justification for existence. Unless you can either employ others, or be employed yourself, with a profitable outcome, you are a burden on those who can.

Whereas your dignity and usefulness as a producer is therefore questionable and limited, your status as a consumer is assured, always assuming you have some money to spend. As a consumer, you are wooed day and night by half-naked ladies asking you to buy cars, dogs walking on the ceiling to sell you beer, and by housewives still wide- eyed and amazed after 50 years of beholding white getting whiter. As a voter, it seems less and less possible to change anything, but as a consumer, you can change anything for sale (that is, apparently everything) simply by purchasing one commodity rather than another. As a consumer, you have as many votes on how you will live, as you have money to spend on your choices. All you need is money, and all you need to get this is to forget about any other human objective, and concentrate on this single purpose. Then, legally or otherwise, you will almost certainly succeed, because even today few people are able to subordinate all other interests. To the extent that you get money, you become more of a winner and less of a loser, and thus edge your way nearer to the top of this great dung heap they have made of world history.

To see the alternative requires some imagination, and a lot of confidence that we are as yet using only a small fraction of human intelligence for any useful purpose. People acquire dignity and self-respect not as consumers, but as creative producers. Nowhere is this more true than in health care, and this truth is the key to the future of a socialist NHS.

When treatment seemed to depend largely on faith, medical care had the same immunity from serious criticism as religion. It was self-evidently good, and impious to suggest that its claims should be supported by serious evidence, so long as it remained doubtful whether much evidence existed. As reality displaced illusion in clinical interventions, and as State and corporate bulk purchasers replaced individual customers in medical trade, the processes of medical care began to be evaluated by the same criteria as other modes of production.

Socialists believe they can find better ways to organise society than to subordinate everyone and everything to pursuit of profit by a minority. To convince even ourselves, let alone others, we must accept evaluation of our ideas not in sentimental, romantic or religious terms of what should happen, but by rigorous measurement of what actually does happen. After a long experience of promises unfulfilled or contradicted, before anyone will risk losing what they already have, they want good evidence that change will be for the better. After 75 years of authoritarian communism, and almost a hundred years of largely supine social democracy, no conspiracy is needed to discredit the very idea of socialism (though such conspiracies do, of course, exist). The results of rigorous measurements will not always support our expectations. In any important activity, rigorous audit of what is actually going on virtually always produces initially disquieting results, showing that real performance falls below expected minimum standards. As socialists are critical of things as they are and demand fundamental change, they should be confident that measured evidence will generally help them far more than their enemies.

For socialists, it should therefore be easy to understand that it is a historic step forward to stop thinking of health care as an unverifiable (and therefore unfalsifiable) art, and begin thinking of it as a mode of production of value, whose objectives can be defined and efficiency in reaching them can be quantified. We can then begin to make medical practice as rational as the medical science on which it claims to be based.

In practice, many socialists, and more so other progressives with less specific loyalties, do not welcome either the concept of medical care as a mode of production, or the convergence and eventual identity of medical practice with medical science. Previous generations of socialists generally identified their own interests both with the progress of science, and the decline of superstition, in which they included most if not all religious belief. This is not true today, when science as a whole is seen as a more doubtful category, and religions are seen as something more than superstition. The relation of science to religion, and of both to socialist ideas, is an important question we cannot develop here, but its resolution probably depends at least partly on a redefinition of what we mean by science, how knowledge relates to doubt, how science relates to art (an antithesis between these two previously almost synonymous words began only in the early 19th century), how reason relates to faith, and how scientists themselves see their own social role.

In medical care in particular, both science and economics are mistrusted. Many progressive people are reluctant to abandon what was originally a strong cultural and political defence expressed in sentimental or religious terms, and prefer to exclude words like “production” and “efficiency” from any medical context, as a kind of blasphemy, accelerating the dehumanisation of medicine. The languages of science and health economics seem to them intrinsically dangerous, helping people to reach conclusions which were rightly unthinkable in the years of consensus.

Though no thinking person could fail to sympathise to some extent with these views, they are fundamentally wrong . We shall make no serious headway against the marketing of medical care until we recognise that if we insist on using a pre-scientific language to discuss it, we limit ourselves to deploring a world we are no longer seriously trying to change. Of course, figures can lie, because liars can figure, but if we refuse to define our terms, to count or to measure, liars have the field to themselves. As the evidence already quoted has shown, a socialist economy in the NHS, even of a most primitive kind, underfunded and hobbled by medical autonomy, was more cost-effective than marketed care in comparable societies, not marginally but by an order of magnitude. Providing all social costs and benefits are taken into account, not simply those agreeable to the accountants who now pass for health economists, and providing we make full allowance for the large but measurable uncertainties surrounding all calculations in human biology and sociology, we have nothing to fear and everything to gain from the most rigorous evaluation of all processes in the NHS, on essentially the same lines as other parts of the economy.

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