Eoin Clarke gets confused buying a cup of coffee

Therefore there should be no choice in the NHS.

You\’ve got to admit the logic is delightfully pure and simple.

63 thoughts on “Eoin Clarke gets confused buying a cup of coffee”

  1. According to someone’s logic bumblebees can not fly.

    I think that looking at theory choice can be argued to be a bad thing. Normally however we look to see how this plays out in the real world.
    Are there any places where experiments have tried to see if this see if this is true? Like for example Russia 1917 -1989?

  2. Aye, this argument is increasingly common on the left, particularly American “liberals” and their copyists (i.e. the Left everyone else, a couple of years later). There has been a book written on it which is very popular with such types, called either The Paradox Of Choice or Liberty Makes My Brain Hurt, I can’t remember which.

    There are too many books anyway, I can never decide which one to read. It would be much better if there were just one book, wouldn’t it?

  3. Someone wrote on his blog
    “Anonymous said…

    It is a shame that you are not a woman in Saudi Arabia – your father would control your life 100% – heaven for you I guess.

  4. There is a serious point hidden in there about search costs and reliability of and access to information. Ultimately a properly functioning market deals with that by recognising that a low effort option is valued by some consumers so that it is also provided – eg one of the sofa companies now advertising on the basis that it doesn’t do sales or promotional pricing, Direct Line and Aviva insurance making a point of not being on price comparison sites. They reassure that quality is good and that you can trust them not to overcharge without making any claim that they are the cheapest.

    http://wp.me/p1kusD-4w
    Or, me going and searching for what I wanted out of a holiday and booking direct rather than trying to get the best deal out of all of the available holidays from all the comparison sites.

  5. When the left oppose choice they are tacitly admitting that most people wouldn’t choose what the left is offering. If leftists really believed that the masses would rush to embrace statism and socialism if only they had a free choice then they’d be all for it.

  6. Tell you what, lets pack in this whole democracy thing while we’re at it. It’s far too hard to choose a representative on such a wide range of issues (welfare, NHS, defence, Policing, the economy), and it would allow our glorious leaders to get on with things without all that dreary campaigning.

    Who is this tit?

  7. They used to have the Times. It is ironic that a business that had its foundations in lefty Seattle coffee culture and would therefore align naturally with the Guardian is hated by all good Guardianistas for being too big and successful.

  8. Brian, follower of Deornoth

    So let me get this right: someone self-confessedly unable to decide what coffee they want is to decide what healthcare I must have?

  9. Truly one of the most stupid things I’ve read on the Internet.

    Eoin Clarke walks into a bookshop.

    Eoin: “I’d like to buy a book please.”

    Staff member: “Certainly sir. What book would you like?”

    Eoin: “I just want a book. Nothing fancy.”

    Staff member: “Well sir, you might need to be a bit more specific as we have books about history, gardening, politics, science fiction, romance, literature, art, history and architecture, nuclear physics, philosophy, mathematics, sculpture, true crime and thousands of other categories.”.

    Eoin: “Oh, for goodness sake! Forget it. I just wanted a book.”

  10. There are now several books and magazines devoted to what is called the “voluntary simplicity” movement. Its core idea is that we have too many choices, too many decisions, too little time to do what is really important.”

    Shouldn’t there only be one?

  11. Not only all that, but he calls Paris the “home of coffee”.

    NOOOO. My Mother’s birthplace, Vienna, owns that claim to fame, for the Turks left coffee behind after they lifted the siege several hundred years ago.

    Or, failing that, anywhere in Italy.

    Alan Douglas

  12. But there’s a free market solution! I will agree to make all her choices for her, and guarantee not to diminish her bank account- in return for , say, half her income. Of course she’ll be so happy dressed from oxfam and living in a basement because she won’t have to chose. and a mere trebling of my income will be enough for me.

  13. It would be equally stupid to pretend that seeking prompt treatment for an acute MI or bowel obstruction is just like popping down the shops for some cleaning products.

  14. lost_nurse – Nah.

    The true stupidity would be pretending that “you’ll get what you’re given” by a State monopoly leads to better outcomes than when people are able to choose.

  15. It’s not even a defence of State provision, ffs. It’s recognition of the simple fact that acute care is not – and never will be – like going to the supermarket.

  16. lost_nurse – I’ve seen House MD plenty of times, Nurse. Does that count?

    Is there something I don’t know about that goes on during emergency operations that negates the sum of human experience re: the benefits of having choices as opposed to not having any?

  17. I’m not arguing against the benefits of having choices – but platitudes about choice are pretty meaningless when you are rapidly exsanguinating.

  18. Nurse, you seem to think you are making some sort of important point, but I can’t see that it is.

    Not even the most dyed-in-the-wool libertarian would claim that when you are bleeding to death is a good time to weigh up one’s options in healthcare providers.

  19. @lost_nurse: so because choice is (as you rightly point out) a bit pointless when your leg is hanging off and your guts are hanging out after a car crash (the general choice at that point being get something done ASAP or die), you decree that no other parts of the NHS can be exposed to choice, ie all the other bits of health care that don’t include emergency care (which I’d hazard is the vast majority of it)?

    Can you not see that the current system has zero incentive to improve within it, other than some superhuman effort of personal decency by every single person in the NHS? That if we had a system whereby the money followed the patient (the money coming from either the patients own pocket or insurance or the State) then there would be a much greater incentive for ALL parts (even A&E) to make sure patients got good treatment?

    The other Saturday I cut my finger badly playing cricket. It probably needed stitches. But as it was a Saturday I couldn’t face God knows how many hours in A&E sitting a a room of drunks waiting to be seen to. So I bandaged it up and let nature do the rest. Fortunately it healed OK. But what if there was a smaller private A&E clinic in town that was set up for just such small emergencies? The sort of thing when you need treatment right away, but aren’t dying? And perhaps one that didn’t have to take drunks either? I’d have been there like a shot. And my money would have come along too.

    Once you free the provision of healthcare from the money paying for it, a thousand flowers can bloom. Small clinics specialising in all sorts of niches will spring up, because the patients and their money will flow to them (if they are any good) , and away from the monolithic NHS hospitals. Who will then have to up their acts to make sure they don’t lose out entirely.

    The private sector manages to supply most towns with numerous shops and supermarkets supplying all the food needs you could imagine, at varying price levels and qualities. Poor people are given money by the State to buy whatever they need wherever they want. Why cannot healthcare be the same?

  20. The whole point about Starbucks specifically is utter shite into the bargain. So I walk into the Starbucks on La Jolla Boulevard in San Diego and say, “a medium size black coffee and a maple-glazed doughnut, please,” and lo and behold, thirty seconds later I am holding a cup of black coffee and a doughnut. It was like magic.

    God this Eoin Clarke guy is so far up himself he must be able to see his tonsils.

  21. Lost nurse – indeed. But there are similiarities. If the fact that occasionally there are emergencies where there is no time to make a choice, means that choice is bad, why have a democracy at all? After all, if a tsunami is bearing down on your home town, there’s no time to make a choice about the government of the day.

    Of course, there are a number of people on the left who have indeed been against democracy.

  22. The guy is just totally, utterly, irredeemably stupid, to say nothing of his appalling ignorance of grammar and punctuation. I’m actually astonished that anyone so moronic is prepared to publish his mindless witterings for the world to see.

    He’s almost as bad as Murphy.

  23. I love the fact that he ended up in Starbucks in Paris because he was too timid to go into a regular French cafe where the staff might actually speak French. This suggests that he lacks the ability to carry out the following exchange.

    “Un café?”
    “Oui monsieur”

    “merci”. (You will succeed in buying a cup of coffee in France without this, but it is good to be polite).

    No wonder Starbucks was too hard for him.

  24. Just look at the website – then rapidly look away.

    Actually, I think Eoin Clarke makes a good point, in a roundabout way. He is a professional politician. He is self-evidently incapable of making a satisfactory decision over the purchase of a cup of coffee. Therefore all politicians should be prevented from making any decisions more important than buying a cup of coffee.
    The rest of us can then run our lives without their incessant meddling.

  25. you seem to think you are making some sort of important point, but I can’t see that it is

    I’m willing to bet that the coming reforms will be accompanied by a whole lot of bullshit rhetoric about competition – with little corresponding improvement in outcomes. It will be like a healthcare version of the railways.

    The other Saturday I cut my finger badly playing cricket. It probably needed stitches.

    Jesus wept. Try being an elderly patient with a fractured neck-of-femur and long-standing history of cardiac problems. The multi-specialty capacity you need for that kind of patient isn’t going to be provided by a one-stop-stitch-shop. The general trend in acute care is consolidate it into a smaller number of major centres – now, why do you think that would be?

  26. Why are you talking about acute care when someone was making a point about non-acute care?

    Because the bullshit rhetoric du jour is being used to dress up reforms that will have a direct effect on the frontline. And it’s not as if we are moving towards either continental levels of investment or a rigorous (i.e. non-refusal) social-insurance model.

  27. “Jesus wept. Try being an elderly patient with a fractured neck-of-femur and long-standing history of cardiac problems. The multi-specialty capacity you need for that kind of patient isn’t going to be provided by a one-stop-stitch-shop. The general trend in acute care is consolidate it into a smaller number of major centres – now, why do you think that would be?”

    The point I was making was that the one size fits all A&E system we have thanks to the NHS makes me have to decide whether to brave the scrum of human flotsam & jetsam that is the A&E department of my local NHS hospital on Saturday night or go without treatment. There is no alternative. My NHS GP won’t do anything either. He’s too busy spending his £150K per annum down the golf club bar at 7pm on Saturdays.

    I suggest under a free (or freer) market in health care I would be in a position to choose someone else other than A&E to deal with my split finger at 7pm on a Saturday night.

    I can’t see how this is so radical. In fact it would probably improve things for those with life and death emergencies by taking the urgent (but non-life threatening) cases away from the critical ones.

  28. Try being an elderly patient with a fractured neck-of-femur and long-standing history of cardiac problems.

    Would you take the vote away from that elderly patient, on the basis that they can’t make decisions?

  29. lost_nurse. Your railway comparison misfires, the two are so totally different that no meaningful conclusions can be drawn from the post privatisation rail network about how the NHS will look in future. Not that the railways are anywhere near as bad as popular myth would have us believe anyway.
    Your argument that the reforms will impact on frontline services may be true but isn’t that always the case whenever large bureaucratic organisations are reformed ? The management barons always protect themselves first. The anti-choice argument is essentially conservative and deeply pessimistic, it implies that change will always be for the worse and attempts at reform always doomed. I have some sympathy with that viewpoint but the hypocrisy of self styled progressives using this kind of argument sticks in the craw.

  30. I can’t see how this is so radical. In fact it would probably improve things for those with life and death emergencies

    I have no problem with a mixed economy in healthcare, if we were to match continental investment & attitudes – but the fact remains, there is a big difference between walk-in type care (your stitches) and the capacity required for the majority of hospital-based activity. And whilst you could probably run [very] minor injuries a la Starbucks, you can’t simply separate front-of-house emergency/acute care from the bread n’ butter routine stuff – it’s a continuum: of staff, skills, kit, support services, infrastructure…. everything. But that is what is being fragmented (most obviously via cherry-picking of easy/profitable stuff, which is what Cinven, Care, Circle etc are bargaining on – with lashings of gravy for the likes of McKinsey). I apologise if I come across as overly-confrontational, but I know full well how overstretched things are in acute care – and I am not inclined to believe that the ConDem reforms will improve things. IMO, the political rhetoric of choice and competition is disingenuous waffle – it’s just cover for a yard sale.

    As for GPs on saturdays, NuLab were bloody stupid to lose the weekend OOH service – they did so partly because they believed they could have it done cheaper & better. More fool them.

    Would you take the vote away from that elderly patient, on the basis that they can’t make decisions?

    Nope, but I would want them in a large, well-equipped trauma centre – with a whole bunch of other specialties on tap. Enough, in other words, to deal with every possibility covered by Murphy’s Law.

  31. Is it just me, or am I right in thinking that the sort of people who don’t like consumer choice in the provision of government services are quite relaxed about market forces when applied to the pay and rations of senior public sector workers?

  32. Nope, but I would want them in a large, well-equipped trauma centre – with a whole bunch of other specialties on tap. Enough, in other words, to deal with every possibility covered by Murphy’s Law.

    You forget that the trauma centre needs to be well-run. All the equipment in the world won’t help if it’s not actually gotten to the patient when needed. What people are struggling with is how to provide the incentives to the people who run the hospitals.

    IMO, the political rhetoric of choice and competition is disingenuous waffle – it’s just cover for a yard sale.

    I’m rather surprised to hear this. Would you call democracy disingenuous waffle, and just cover for a yard sale? If you think there’s something in democracy, why do you think competition and choice works somewhat better than the alternatives in running a country, but couldn’t in running a hospital system?

  33. You forget that the trauma centre needs to be well-run

    Is that so? Well, knock me down with a feather.

    Would you call democracy disingenuous waffle

    Erm, no. My comment was about the language of the ConDem reforms – you are simply twisting my words. For the last time, I’m not saying “choice is bad, m’kay” – just that pithy coffee shop notions of competition tend to fall down in complex care.

  34. lost_nurse. Politicians all tend to use dumbed down language when explaining policies to the electorate, I wish they didn’t but it doesn’t necessarily make the policies wrong and you’re not above using the same sort of rhetoric yourself, talking about yard sales and coffee shop notions of competition. As someone who uses the NHS a lot I welcome the idea of opening up the provision of services, it may not work but if it does it won’t be before time, the take it or leave it attitude of too many parts of the NHS is a disgrace. I would particularly like my elderly and frail mother to get a bit of respect and proper treatment instead of being fobbed off by indifferent GPs and an attitude at the local eye clinic which makes it obvious that they’d rather she either went blind or died and stopped bothering them.

  35. lost_nurse: So you agree that a trauma center needs more than good equipment, the management matters too? That’s good to know. So, now we are agreed that management is essential, the question becomes how to induce good management all across a complex system. Competition and choice are the ways we know to do this.

    My comment was about the language of the ConDem reforms – you are simply twisting my words.

    No, I’m trying to make you realise how daft your opposition to choice is, by pointing out that your arguments imply that democracy should be performing badly.

    For the last time, I’m not saying “choice is bad, m’kay” – just that pithy coffee shop notions of competition tend to fall down in complex care.

    Do you think that running a government, or conducting a war, is vastly more simple than running a trauma center? If you think those sorts of matters are complex, by your logic, then democracies should be doing worse at this than dictatorships. So why aren’t you opposed to choice and voting generally? If you think that choice can work at a country-wide level, why shouldn’t it be able to work for medical services? (If you think that runnning a government, or conducting a war is simple, please tell me what evidence could convince you otherwise).

    I notice that you’re not engaging with this argument at all, instead you’re trying to avoid it, resorting to attacking strawmen like “pithy coffee shop notions”. It’s rather ironic that you criticise others for “pithy coffee shop notions”, or “disingenous waffle”, while trying to use the same tactic, when you ignore my actual arguments and falsely assert that it’s “simply twisting my words”. Are you possibly projecting your own behaviours onto others?

  36. Do you think that running a government, or conducting a war, is vastly more simple than running a trauma center?….So why aren’t you opposed to choice and voting generally?

    You are spinning this out to an absurd degree. I notice we recently managed to go to war in Iraq despite widespread public opposition. And how does choice and competition define our standing military capacity, for pity’s sake? Please, do tell – coming from an Army family, I’d be most interested in how I can vote on the deployment of ground troops or air power. Running a trauma centre is never going to be like running a supermarket – if you are unable to grasp why, then you are living in a mollycoddled fantasy world. Good multi-speciality acute care means having it all on base and in one place. For serious stuff, that’s true of any developed healthcare system – including the admired (and better funded) French/German systems. In other words, having choice about providers does not remove from the logistical requirements of provision.

    People always churn out platitudes about supermarkets – and then seem unable to explain why having sudden abdominal pain of unknown cause is just like buying fruit n’ veg. Supermarkets work because of repeated switching behaviour by consumers who are making planned purchases of specific items – again, what would be the equivalent of a episode of acute illness? A sudden & violent need to visit Tecos at 3 am, possibly confused, losing copious amounts of bodily fluids & with no specific idea of what you wanted – but it might (or might not) require lots of expensive stuff (with no guarantee of a profit)? And the supermarket best suited to acommodating such a varied shopping list – will there be several per high street? Or – dare I say – will they be like a single megastore?

    the take it or leave it attitude of too many parts of the NHS is a disgrace

    As for the rest, I’m not excusing indifferent GPs or slack eye-clinics – though, IMO, the need for a sea-change in attitudes towards elderly patients transcends any debate about the NHS (where elderly care has long been an underfunded Cinderella service). I’m not defending the NHS per se, but I’m suggesting that – for many acute/chronic patients – the ConDem reforms will not be leading us into some happy sunny uplands, whatever the rhetoric. The paradox might be that they have even less choice than they do now – with big consortia pushing ’em down preferred treatment pathways.

  37. lost_nurse. Sorry but you’ve constructed a bit of a strawman there, is anyone seriously suggesting that running a trauma centre is like running a supermarket ? The question is, will introducing more choice in the provision of services lead to an improvement in those services ? Since we can say yes to that in just about any other area we care to think of there is surely no reason to think it can’t work in the NHS. A better analogy would be with the number of supermarkets, I doubt if anyone would think that closing them all down except Tesco would be a good idea.

  38. is anyone seriously suggesting that running a trauma centre is like running a supermarket

    Believe me, it’s a recurring theme – elevated to a near-mantra.

    The question is, will introducing more choice in the provision of services lead to an improvement in those services ?

    On the simple face of it, yes – but I’m willing to bet that’s not what will be happening. If the benefits of choice and competition followed some kind of natural law, the care home industry should be gleaming – instead of being excellent in places, often merely adequate and sometimes downright criminal (and let’s not get started on Southern Cross…). In the meantime, all kinds of interests are queuing up to make hay. Take Circle – why would a bunch of ex-Goldman Sachs choose this particular moment in time to launch their oh-so-hotel style brand? Look at the issues surrounding their takeover of Hinchingbrooke – which will probably end up re-opening with a reduced level of service. Simply put: hiving off profitable elective procedures in the generally fit n’ healthy will do nothing for the kind of vulnerable patients who suffered at Mid.Staffs. That is what I mean about the rhetoric of choice being used to dress up a yard sale.

  39. lost_nurse: You are spinning this out to an absurd degree.

    Projecting again, are you? The reason this is taking a long time is that you keep trying to ignore the basic point and make fusses about rhetoric instead.

    And how does choice and competition define our standing military capacity, for pity’s sake?

    Well, in a democracy with a free press, the British government has more of an incentive to take care of the military because they are exposed to criticism, and because of the interests of voters who are in, or have loved ones in, the military. The efforts the modern democracies put into treating their wounded, for example, seem to be driven more by democracy, than by any great natural desire on the part of politicians to worry about the well-being of military men who are already out of action. (Consider, during WWII, if you were a soldier shot in the leg, would you rather be in the British army, or the Russian army?)

    I’d be most interested in how I can vote on the deployment of ground troops or air power.

    Hmm, so you think that more choice might have some value in military matters, but oddly think that this is a bad idea for healthcare?

    People always churn out platitudes about supermarkets – and then seem unable to explain why having sudden abdominal pain of unknown cause is just like buying fruit n’ veg.

    This is of course why I’m having to spin this out to an absurd degree, you keep introducing straw men. No one claims that the two are just like each other. Just that choice can work in both areas, as it does in running a government.

    Supermarkets work because of repeated switching behaviour by consumers who are making planned purchases of specific items

    And they also work for people rushing in to get emergency supplies of things like toilet paper, milk, toothpaste, panadol, cough syrups, etc. And non-repeat behaviour too, I’ve purchased things from supermarkets in tourist towns while on a brief visit.

    again, what would be the equivalent of a episode of acute illness?

    Let me see, the 7/7 simultaneous 4 bombings on London travel systems? A major earthquake in the country’s second-largest city? A flood breaking the levees in New Orleans (that I understand led to quite a few changes in local government based on their massive failures).

    And, also, quite a few people who show up at hospital suffering an episode of an acute illness, don’t then either drop dead or recover instantly and live in perfect health there-on. Often recovery takes a long time, with decisions to be made about where to get more treatments. And even once recovered, someone can then go on to acquire other, not-so-acute illnesses/injuries in the future where they may well have time to consider their options a bit further. Furthermore, many people have family and friends, who are likely to hear about their experiences, and draw conclusions which they use in making their own decisions.

  40. Hmm, so you think that more choice might have some value in military matters, but oddly think that this is a bad idea for healthcare?

    Your irony-meter is obviously way off… I expect those who are tasked with our defence to do their job professionally, without needing my input. Unless you think military tactics are best decided via a phone vote, or something?

    And they also work for people rushing in to get emergency supplies of things like toilet paper

    If we are going to argue about the minutiae of shopping lists, perhaps we should save on bandwidth & simply agree to disagree. I stand by my original point: much of the “choice” that is presented to the public during these reforms will be pseudo-choice.

    No one claims that the two are just like each other

    They do – ad nauseum. The rallying cry for the TPA is pretty much ‘why can’t everything be like Tescos?’ – which reminds me, I wish Wat Tyler would start blogging again.

  41. I posted a wee critique on the comments thread – which certainly appeared when I posted it. Five minutes, literally, after that my comment was gone, and the whole comment thread closed. Must have double-tapped him in his centre of mass.

  42. Lost_nurse: Your irony-meter is obviously way off…

    Again, you are trying to avoid engaging with the actual argument. What is ironic is that you after complaining about this argument being spun out, are now back to trying rhetorical tricks to spin out the argument even more.

    I expect those who are tasked with our defence to do their job professionally, without needing my input. Unless you think military tactics are best decided via a phone vote, or something?

    Actually I note that military tactics are driven by competitive pressures – by their very nature. Military tactics that the enemy figures out a way to beat have their own consequences, although many generals have managed to deny those for a while, at a high cost, but eventually reality forces its way in.

    Anyway, you are free to expect those tasked with our defence to do their job properly, the question is what should be done if they’re not doing their job properly, as has been known to happen from time to time. How it works in a democracy is that we elect politicians, who then direct the military. I have stated some of my reasons for believing that democracies do this better than the military.

    Finally, one can make individual choices about medical treatment, as about supermarket shopping, in a way that we can’t about military defence (as current military technology means I can’t have my home defended in a way sharply different to that of my next-door neighbour, while it’s perfectly possible for me to go to a different hospital, or GP).

    If we are going to argue about the minutiae of shopping lists, perhaps we should save on bandwidth & simply agree to disagree.

    Strawman again. My observation was that supermarkets work for people rushing in to get emergency supplies, and where there’s non-repeat behaviour too, eg in tourist towns.

    I stand by my original point: much of the “choice” that is presented to the public during these reforms will be pseudo-choice.

    And do you have any basis for why you are standing by this point, beyond your projection of your own debating techniques onto others?
    (This is ignoring the detail that this wasn’t your original point.)

    They do – ad nauseum. The rallying cry for the TPA is pretty much ‘why can’t everything be like Tescos?’

    Yeah right. You can’t provide a real quote, or a link. You’re arguing against a strawman.

  43. Yeah right

    http://burningourmoney.blogspot.com/

    Start here, read at your leisure.

    You’re arguing against a strawman.

    Oh, really? If you believe that competition is some kind of magic panacea for the serious issues facing the NHS, then I suspect you will be sorely disappointed by what happens over the next few years. In other words, those strawmen do indeed have substance. Toodle-pip!

  44. Lostnurse, I just did a search on the link you posted for “why can’t everything be like Tescos?’
    And it came up with zero.

    As I said, you’re arguing against a strawman. You can’t find a single case of a person saying this. (And what on earth were you thinking? Did you really believe I wouldn’t bother checking the link you gave?)

    f you believe that competition is some kind of magic panacea for the serious issues facing the NHS,

    Strawman again. The way that competition works isn’t magic, Adam Smith spelled it out over 200 years ago. If you are at all interested in me explaining to you how it works, let me know.

    In other words, those strawmen do indeed have substance.

    So now you’re claiming that imaginary people have substance? Unusual definition of substance you’ve got there.

  45. And it came up with zero.

    Didn’t look very hard then, did you? The site even has a tag for ‘Tesco Government’ – lookee here:

    http://burningourmoney.blogspot.com/search/label/tesco%20government

    Now, I disagreed with much of Wat said – but he was always incisive & interesting. Come back Wat!

    As for Adam Smith – how interesting that you presume I have never read him. Now, as a forfeit for being unable to do proper internet searches, please walk into the nearest busy acute hospital environment and lecture them about pin factories. Oh, and why the service will be so much better once we are all competing against each other, instead of – gasp! -co-operating.

    Tim adds: Erm, Smith’s point about the pin factory is that if you divide the labour, allow the labour to specialise, and then cooperate by trading the production, then you get a lot more done than if everyone tried to do it all themselves.

    In medicine we’d suggest that, umm, maybe, acute trauma was dealt with by the acute trauma experts over there, that vaccinations are done by ickle nursies over that way, that teaching new mothers how to get their baps out is done by maternity specialists, scraping babies out of wombs done by the murderers over there and that we wouldn’t in fact have a general sawbones doctor who tried to do it all on his lonesome.

    Smith’s pin factory is all about cooperation: are you sure you’ve read him?

  46. PS. nobody said, verbatim, ‘Why can’t everything be like Tescos?’ – but that is the inference. Describing something as being pretty much a rallying cry doesn’t mean I was ascribing a direct quote! It’s purely shorthand for the views of those who believe in the healing powers of the supermarket.

    Given that we are (again) arguing over minutiae, I think we should allow this thread to die a peaceful death…

  47. Smith’s pin factory is all about cooperation: are you sure you’ve read him?

    I have, Tim. The pin factory thing (being a famous AS example) was intended as a light-hearted jest, though I guess it didn’t come across that way. The division of labour in a decent A+E unit is a pin factory extraordinaire – with the obvious qualification that patients are not pins.

    Besides: I say your point illustrates – exactly – the pitfalls of competition rhetoric. Acute care only functions when all those different specialties are co-operating – and, generally speaking, when they are all in one place (or within easy reach). Patients in ITU, for example, might require the input of god-knows-how-many-different-bods. Now, that kind of capacity is increasingly concentrated in larger centres. Point blank, it’s safer – and it’s why (IMO) supermarkets make for a poor comparison. It also makes for difficult political decisions (see, for example, the reconfiguration of paediatric cardiac services). My beef is not with ‘competition’ per se – it’s with reforms that threaten to damage co-operation between specialities, thereby fragmenting services. And with the political rhetoric that gets used to justify ’em.

  48. Lost_nurse: The link you pointed me to is the author of the blog explaining, very patiently, to you, that they do not think that. To quote: “Look, we all accept that in healthcare there is no magic bullet. We all accept that. ” You even commented on this very blog post.

    Again, did you really think I wouldn’t check your link?

    As for Adam Smith – how interesting that you presume I have never read him.

    Another strawman. I never made any such presumption. I just offered to explain how competition works to you. I certainly would not presume that, just because you read Adam Smith, you therefore learnt anything from him.

    Now, as a forfeit for being unable to do proper internet searches, please walk into the nearest busy acute hospital environment and lecture them about pin factories.

    So, in other words, you don’t want to learn how competition actually works. You prefer to believe that it works by magic.
    Or, possibly you do know, and, like the claim about people thinking everythign should be like Tesco’s, you just chose to lie and pretend that you don’t.

    Oh, and why the service will be so much better once we are all competing against each other, instead of – gasp! -co-operating.

    Okay, so not content with lying yourself, you want me to lie. Nope, sorry. Unlike you, I try to base my view of life on reality. In reality, I see people both competing and co-operating, sometimes at the same time (for example, every sports team.)

    PS. nobody said, verbatim, ‘Why can’t everything be like Tescos?’ – but that is the inference. Describing something as being pretty much a rallying cry doesn’t mean I was ascribing a direct quote! It’s purely shorthand for the views of those who believe in the healing powers of the supermarket.

    Lost_nurse, you pointed me at a whole blog as support for your claim, you did not pick out any particular post or comment. Doing a search for the phrase you described and providing you with the link was the simplest way of saying how much I disbelieved your claim, and I did it with the intention of trying to provoke you into being more specific, which worked, you specifically pointed me towards a blog post where the author contradicted your assertion about what they believe.

    And I also note that you are now claiming that there are people who “believe in the healing powers of the supermarket”, a claim noticeably different to your earlier one. I think this is another strawman, and you can’t find a single person to support that one either.

    Given that we are (again) arguing over minutiae, I think we should allow this thread to die a peaceful death…

    Hmmm, if the question of whether “The rallying cry for the TPA is pretty much ‘why can’t everything be like Tescos?’” or not, is minutae, then why did you mention it in the first place? Indeed, if it’s minutae, then why are you opposed to introducing more choice into the NHS at all? Your thinking seems to be entirely unclear here.

    As for dying a peaceful death, yeah right. If you really wanted that, you’d stop aruging. What you mean by “a peaceful death” is for me to stop pointing out the strawmen you keep introducing. What logic you have for believing I’d agree with that is a question I am not qualified to speculate on.

  49. The link you pointed me to is the author of the blog explaining, very patiently, to you, that they do not think that.

    Erm, except that this was after a number of posts in which the public sector (inc NHS) was repeatedly compared to the beloved Tescos – a point to which several commentators objected strongly. Hence his reply, and the admission (‘no magic bullet’, above) that ok… it isn’t quite that simple. Surely it’s not that difficult to grasp why/how the supermarket is being used as a metaphor for private sector provision versus a state monopoly. In other words, “why can’t everything be like Tescos ?”(though Wat would probably exclude both Defence and the Justice System). As for the healing power of supermarkets: I was being sarcastic – IME, free-marketeers can be just as dogmatic as anybody else. We are arguing on the internet – you are allowed occasional recourse to imagery and jokes.

    In reality, I see people both competing and co-operating

    Jolly good – because that is how things get done, not least in the very messy & unpredictable world of acute care. And if people are going to evangelise about choice and competition (in your own words: “So you agree that a trauma center needs more than good equipment, the management matters too?..Competition and choice are the ways we know to do this. “), then it is also beholden upon them to recognise the importance of co-operation – and how easily such working relationships can be damaged, not least by the ConDem reforms.

  50. Lost_nurse:except that this was after a number of posts in which the public sector (inc NHS) was repeatedly compared to the beloved Tesco

    And in none of those posts did anyone say that hospitals were just like Tescos. Which was after all your claim.

    Hence his reply,

    So you agree with me that he was not making that point you attributed to him, when you pointed me to his post.

    I have to say that your chutzpah is quite amazing. Having directed me to a blog that did not support your claim, and then having directed me to a post that directly contradicted it, you’re now trying to pretend that you weren’t originally claiming that people believied that hospitals were just like Tescos.

    As for the healing power of supermarkets: I was being sarcastic

    This does not surprise me. You appear to be determined to avoid actually engaging with any real argument. I suppose you were “being sarcastic” when you pointed me at the burningourmoney blog as supporting your original assertions about what other people believed.

    We are arguing on the internet – you are allowed occasional recourse to imagery and jokes.

    Another strawman. I have never disputed your right to make imagery and jokes. Nor do I dispute your right to make your arguments based on strawmen. All I am doing is exercising my equal right to point out that you are making up strawmen.

    Jolly good – because that is how things get done, not least in the very messy & unpredictable world of acute care.

    My god! Did you make an argument based on reality, for once?

    then it is also beholden upon them to recognise the importance of co-operation – and how easily such working relationships can be damaged, not least by the ConDem reforms.

    Indeed, and the evidence is that these working relationships aren’t damaged that easily by introducing competition. Indeed, they seem to be even improved. See http://www.guardian.co.uk/commentisfree/2011/jun/26/research-competition-improves-nhs (link from this very blog, at the comment: https://www.timworstall.com/2011/06/27/competition-does-improve-the-nhs/)

    Of course we haven’t seen the ConDem reforms in effect, but given that you, as their attacker, base your arguments almost entirely on strawmen, and sarcasm, rather than anything substantive, my Bayesian probability is that the answer to how easily working relationships could be damaged by them is “not much”. After all, if there were any decent arguments, you’d’ve made them (unless you’re too stupid to see the decent arguments, which I doubt is the case).

  51. you’re now trying to pretend that you weren’t originally claiming that people believied that hospitals were just like Tescos.

    Nope – a clear line of attack in Wat’s blog (scroll thru his posts) is that public sector provision should be far more like Tescos (eg. http://burningourmoney.blogspot.com/2007/01/giving-customers-what-they-want.html). This extends to his view of the NHS (“Anyway, Tesco is just our shorthand for the power of the market. Nobody is literally suggesting Tesco is going to take over our hospitals. But BUPA and the like could. And having personally sampled both NHS and private hospitals, Tyler is very sure which he prefers”http://burningourmoney.blogspot.com/search/label/tesco%20government). It’s as if BUPA and the NHS are being compared as rival supermarkets – which is a gross over-simplification of how both private & public healthcare sectors operate in this country (not least given workforce training, critical care capacity, infrastructure, etc).

    my Bayesian probability is that the answer to how easily working relationships could be damaged by them is “not much”.

    How ironic that you should invoke Bayesian stat theory & then quote Cooper’s paper on competition. There are some pretty serious flaws in his approach – most notably the use of AMI (Acute Myocardial Infarction) mortality data to support the idea that things like the introduction of ISTCs drove up standards (for a very brief summary of the debate, see here: http://fullfact.org/blog/NHS_competition_Telegraph_heart_attack_mortality_rates-2857). Besides, patient mortality can be a notoriously tricky measure of ‘quality’ & outcome – given how acuity/complexity of the patient casemix varies between settings (put bluntly, there will be a lot of death in ITU or A+E, no matter how fantastic they are – but the same will not be true for a walk-in centre). I don’t think Cooper is measuring what he thinks he is measuring, but his conclusions are now being used to support all kinds of ill-thought-out reforms. Indeed, both incumbent ConDems and ye olde Blairites love to quote it – without apparently questioning why AMI mortality has declined in recent years (not least due to treatment advances & lifestyle changes). In simple terms, it ain’t just because a one-stop-stitch-shop has set up in the neighbourhood of an NHS hospital to do the easy elective stuff (and such cherry picking bloc contracts never really represented ‘competition’, anyway). And hiving off profitable ‘easy’ routine elective lists does indeed represent a threat to co-operation at the sharp end – besides having significant consequences for workforce training, emergency cover, etc. I worked for a fair number of years in emergency surgical admissions – I know what happens on the ground, and it ain’t how Cooper et al paint it. The most you could say of his paper is that proximity to more hospitals = better outcomes. Wow, what an incredible insight!

    FWIW, I do not dispute that competition & choice can drive up quality or improve outcomes – even if it operates at the marginal level. Anything, in other words, that forces hospitals to up their game is to be welcomed. But… the concept is grossly misapplied – especially when people wave their arms and simply chant that ‘the market will solve it’. Privatisation and competition will not solve many of the issues facing the NHS (see here for an excellent discussion – though I guess it will probably be dismissed as ‘producer interest’: http://abetternhs.wordpress.com/2011/06/29/competition/) and it is bullshit of the first order to pretend otherwise.

    But it’s friday, so enough of this. Shake hands & call a truce, eh? 🙂

  52. Lost_nurse: Nope – a clear line of attack in Wat’s blog (scroll thru his posts) is that public sector provision should be far more like Tescos

    Which is distinctly different from your claim that he was asserting that the health care sector was just like running Tescos. You were very specific about this. To quote again:

    Me: “No one claims that the two are just like each other”
    You: “They do – ad nauseum. ”
    (see comment 49).

    As I said, strawman.

    As for the question of the effects of competition and choice on working relationships, as you wind up with “FWIW, I do not dispute that competition & choice can drive up quality or improve outcomes”, then I continue with my belief that these working relationships aren’t damaged that easily. In the article you pointed me to, there’s a link to another article that says “More broadly, however, there is some evidence to back up claims that competition could lead to improved quality of care, particularly if competition occurs in a fixed-price system.” (see http://fullfact.org/factchecks/NHS_reforms_Milburn_Dobson_competition-2786)

    I’ve been wrong in the past, I’ll probably be wrong again, so it strikes me as entirely possible that I’m wrong this time, but at the moment the best evidence I can see is that these working relationships aren’t damaged that easily by choice and competition. And you yourself say: “I do not dispute that competition & choice can drive up quality or improve outcomes…”, so heaven knows why you were earlier telling people to recognise that it did.

    But… the concept is grossly misapplied – especially when people wave their arms and simply chant that ‘the market will solve it’.

    Strawman again.

    Shake hands & call a truce, eh?

    Truce on two conditions:
    1. You stop introducing strawmen.
    2. You stop saying that people should recognise things that you can’t support, such as “how easily such working relationships can be damaged, not least by the ConDem reforms”.

  53. Which is distinctly different from your claim that he was asserting that the health care sector was just like running Tescos

    I think this is an issue of semantics, not straw. Many people, including Wat, have made the (to my mind, rather uncritical) comment that healthcare would sooo much better if run in supermarket fashion. It’s a recurring theme in raging arguments about healthcare everywhere on the internet – most commonly expressed as something like ‘do we depend on one agency to supply our food?!’ & the observation that the market does indeed bring us solutions in a whole range of risk-critical situations (getting on a plane… crossing a bridge… ordering, like, really hot coffee). Now, as far as I’m concerned, that line of argument does equal the supposition that a hospital can be treated just like a supermarket. It’s just supply & demand, right? Dissolve the big bad monopoly and a thousand flowers (or choices) will bloom. Now, press ’em a little further and they will admit that, no, it isn’t quite that simple – BUT the comparison is certainly made. As for people waving their arms and claiming that the market will solve everything – they do, not least in these ‘ere parts.

    And you yourself say: “I do not dispute that competition & choice can drive up quality or improve outcomes…”, so heaven knows why you were earlier telling people to recognise that it did

    All kinds of things can drive up outcomes in healthcare – the colour of the paint can influence patients’ sense of wellbeing (though it won’t necessarily have an effect on the quality of their care). What I am saying is that choice & competition is not driving up outcomes (the AMI data) in the way that Cooper etc think it is. As for fixed-price competition improving quality – fine, but note how there was something of a storm recently (e.g. http://www.thebureauinvestigates.com/2011/06/08/analysis-price-competition-in-the-nhs/), with soothing proclaimations from Lansley’s minions at DoH that no, we are not going to have a race to the bottom (i.e. whilst competing on price – which was arguably the result of pseudo-market reform in the 90s – see http://www.efm.bris.ac.uk/ecsb/papers/deaths.pdf. I’m not entirely inclined to believe them.

    You stop saying that people should recognise things that you can’t support, such as “how easily such working relationships can be damaged, not least by the ConDem reforms”

    No, I can’t agree to this – simply because of what I see on the shopfloor in a large teaching hospital. Besides, much of the ConDem reforms are simply an extension of NuLab’s policies (which prefigured them nicely). Plenty of damage has already been done.

    I think we should settle on a stalemate.

  54. Many people, including Wat, have made the (to my mind, rather uncritical) comment that healthcare would sooo much better if run in supermarket fashion.

    I would like to see a link to exactly what they said.

    Now, as far as I’m concerned, that line of argument does equal the supposition that a hospital can be treated just like a supermarket.

    And as far as the people who are making the argument are concerned, it doesn’t. Indeed, you yourself linked to a post where the author directly told you that they weren’t making that supposition. And you tried to cite this denial as an example of that argument. That’s why you’re making a strawman argument. I don’t know whether your continual repeating of this strawman is due to being unable or unwilling to recognise the difference, but it’s still a strawman.

    As for people waving their arms and claiming that the market will solve everything – they do, not least in these ‘ere parts.

    And you can’t cite a single example of someone doing this. This is just yet another of your strawmen.

    On the competition issue, I am now totally confused as to what you think, you were in your previous comment telling me that: “I do not dispute that competition & choice can drive up quality or improve outcomes…”, now you’re saying that you can’t agree to this statement. Which is it?

    No, I can’t agree to this – simply because of what I see on the shopfloor in a large teaching hospital.

    Um, you’re the person who can’t see the difference between saying that competition can improve the quality of healthcare, similiar to how it improves the quality of supermarkets, and saying that “why can’t everything be like Tescos?’ You’re now trying to tell me that, as far as you’re concerned, “that line of argument does equal the supposition that a hospital can be treated just like a supermarket”. Your observational and logical skills do not impress me. (I am not saying that your conclusion is definitely wrong, just that I don’t trust your report.)

    Plenty of damage has already been done.

    Then why do the studies that you linked to conclude that “More broadly, however, there is some evidence to back up claims that competition could lead to improved quality of care, particularly if competition occurs in a fixed-price system.”? I just don’t see that damage, and I don’t think you should be telling people to “recognise this” on such weak grounds.

    I think we should settle on a stalemate.

    You are free to stop the debate whenever you like, by not replying. What you are trying to do here is to get in the last word.

  55. I am now totally confused as to what you think, you were in your previous comment telling me that: “I do not dispute that competition & choice can drive up quality or improve outcomes…”

    Yes, where stuff is amenable to competition – which often isn’t the case in complex, multi-specialty care. In simple terms, & in the context of services provided by (say) a large teaching hospital, I don’t necessarily want a choice of five hospitals/supermarkets – just ready access to dependable services, run by battle-hardened staff who know what the hell they are doing. If you can’t (or won’t) see the distinction, that’s your business.

    I just don’t see that damage

    Lucky you.

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