Lordy but the man can be dim:
There is a problem: integration is not the opposite of competition. Collaboration is the opposite of competition.
Integration implies a disparate selection of independent bodies have to be meshed as well as possible one with another, with at any time there being risk of one component being replaced with an alternative. Relationships will be defined contractually: trust will be low because at any time the risk of a component being rejected and a replacement being sought is high. Defensive behaviour will be prevalent, focussing on the need for survival of the constituent parts, not the behaviour of the system as a whole. The patient will have low priority in that case.
Collaboration means people working together towards a common goal. If collaboration is the target the aim is to achieve a common goal. The risk of component failure is covered by seeking high standards of behaviour universally: the result is risk can be taken to achieve that aim. The relationships are built on trust, not contract. It is maximum and not minimum performance criteria that matter.
Which model is likely to produce the best health outcomes? Clearly a collaborative one.
Now, I admit we have not got such a model now. That is the fault of governments past, both Tory and Labour. So we need reform. But not the reform we are getting, which will undoubtedly increase fragmentation in the NHS (that is its purpose) and so make integration hard and collaboration impossible.
We do instead need to create a collaborative model. This is possible. Instead of breaking the NHS up we need to re-centralise it.
Markets are the way that human beings collaborate.
So, think about this for a moment. We need someone to be the person who gets weird metals into the lighting industry so that everyone can have those lovely metal halide bulbs with which to adorn their kitchens. Someone who occasionally goes out and finds some terbium to make those compact fluorescents work.
We also need someone to wibble inconsequentially on the internet about taxation: about how everything really should be paid to the taxman and we should be thankful for the pocket money we get back.
Excellent, we\’ve our division of labour and our specialisation. This is, as Adam Smith pointed out (yes, the pin factory again) one of the ways in which we can increase wealth.
Just for funsies we\’ll call our two people Mr. Worstall, who will deal with the weird metals, and Mr. Murphy, who will supply the wibble.
Now, how are we going to organise the collaboration between these two people? We\’ve products being made and they need to be exchanged. Ah, yes, we call that trade. And where does trade take place? Yes, in a market.
Good, excellent, so when Mr. Murphy requires light bulbs to make his wife\’s cooking visible from those little down lighter things he will purchase them. And Mr. Worstall, when he wants a good laugh, will purchase a newspaper or magazine that contains Mr. Murphy\’s dribbles. Or perhaps even, in this modern day and age, receive such for no money down, in what can be called the reputation market of the internet.
But we have collaboration here, cooperation. And the market is the method by which this happens.
Now, we can in fact go further than this and say that at times markets are not the correct method of such collaboration, cooperation. At times we\’d rather not have a web of contracts, at times we\’d rather have the more authoritarian \”do as I tell you\” style of organisation. When and where we would prefer this is dealt with by Ronald Coase in his Theory of the Firm. You know, that thing that gained him the Nobel Prize? There\’s been a number of decades of work done on where these dividing lines are: which is the best method of organisation for what purpose under what circumstances?
Few come up with the answer that 5% of the workforce and 10% of the GDP should be so centrally managed. But then of course Ritchie wouldn\’t be interested in such subtleties, for this is the \”blackboard economics\” which he rejects.
What amuses greatly is that Mr. Coase is the originator of the phrase \”blackboard economics\”, that thing which should be rejected, and his Theory of the Firm is entirely a rejection of the purely theoretical approaches that were taken before he advanced it.