This is an example of what I was talking about here. What should I write about the NHS?
At the moment, Tories and Lib Dems have legislated to destroy large, geographically located primary care trusts and to replace them with small, non-geographically based GP consortia. These will register and treat patients but will have the option to have a large degree of administration carried out by private sector contractors. More details are not forthcoming in the maelstrom of amendments the Liberal Democrats are sticking over the Bill.
My priors tell me that:
- Large bureaucracies are inefficient – this means the NHS is probably fairly inefficient, it being one of the largest bureaucracies in the world.
- They are inefficient because hierarchy dull high-powered incentives to hard work – they insulate people from making loads of money from individual effort and reduce the chances of losing your job if you screw up vis a vis self-employment.
- They are inefficient because hierarchies aren’t very good at experimenting and dissemination the practices which are subsequently found to be effective. In fact, most efficiency gains come not from reorganising old firms and facilities but from the exit of worse ones and the entry of better ones.
- Large reorganisations are very difficult. So if you want a large reorganisation, 4% annual efficiency savings and to maintain the current level of service you’re probably just mad.
- The NHS is in fact a fairly efficient bureaucracy with internationally competitive health outcomes.
- Private sector involvement is all but inevitable given that GPs are not managers or accountants and would rather not be involved in that because it isn’t an ambition they’ve ever had, being GPs and all not administrators. GP Consortia would not be bound geographically so we would then find ourselves only one step from a national two tier (or more) health service. Were top up payments to be made legal some consortia could specialise in treating those with money and others would be left with the rest of us. This is a summary of an argument I first saw put forward by Ben Goldacre. As something of an egalitarian this bothers me.
Finally, there is other things militate against my adoption of Conservative and Liberal Democrat and reforms.
- They are being run by nincompoops like Andrew Lansley who don’t know quite what they’re doing, why they’re doing it and hence how to explain what they’re doing and why they’re doing it to people who don’t know what they’re doing even if they might potentially be supportive of what they’re doing were what they’re doing to be constructive. 
So with respect to yesterday’s post, I still find myself in stage two, struggling to understand what is going on in the world, aware of my own ignorance merely sketching out ideas. I hope that these sketches are illuminating to my readers.
To sum up, my primary worry is that any long term benefits of the reform – assuming it leads to a productivity miracle which is widely shared and not merely a cover for privatisation – is swamped by the short term disruption such as the cost and waste of GPs spending four out of five days setting up Consortia rather than treating patients. In the long run the reforms may destroy the NHS, but it can be rebuilt – in the short run, these reforms are going to kill people, and those lives cannot later be rebuilt.
 Confused? Good. That sentence was an allegory for the confusing nature of the reforms. Don’t say you don’t get more than one level of meaning from this blog.