Junior doctors: asking the right question

A government source (anonymous of course) has told the BBC that junior doctors, in their long running dispute, are really trying to topple the government. It appears some in this government really think that this dispute is their version of the 1984 miners’ strike. A compromise to trial the new contract, which would have almost certainly led to the strike being called off, was rejected by Jeremy Hunt as ‘political opportunism’.

It is natural when this kind of standoff happens to choose sides. The government is trying to introduce a 7 day week culture into the NHS: are they trying to do this ‘on the cheap’ by suppressing pay (and safeguards against excessive hours), or are the doctors being unreasonable and putting lives at risk?

I think that is the wrong question. A much better question is to ask how this dispute came about in the first place. The mine workers had a long history of strike action, but this strike by doctors is unprecedented. Unlike coal miners, doctors are not in a declining industry, and they are not led by the likes of Arthur Scargill. Instead they are a key part of a sector where demand continues to rise, and technology (for the moment at least) tends to add rather than reduce costs.

In this context, this government and its predecessor have tried to do something pretty radical, which is to reduce the share of NHS spending in GDP (for a chart from the Kings Fund, see here, and for details of the NHS squeeze see here). It is part of their attempts to reduce public spending, initially under the pretext of deficit reduction but in reality to allow tax cuts. In their typically Orwellian way, they call this ‘protecting the NHS’. Their hope is that this squeeze on resources will reveal and end inefficiencies which until now vested interests, lethargy and bad management have maintained.

An alternative way of achieving the same goal is to embark on a top down reorganisation that you believe will make the system more efficient.

The 2010 coalition government tried to do both at the same time. You do not need to be an expert on the health service to guess that trying both at once would be a disaster. Any kind of successful wholesale reorganisation of a large organisation costs resources in the short term, even if it brings benefits in the longer term. Predictably, according to the experts, this reorganisation was “distracting and damaging”.

Did the new (2015) government learn the lesson? Silly question. Introducing a 7 day week culture into the NHS may well be a good idea in principle, although the evidence is not nearly as clear as Hunt suggests (which is why trials are a good idea). Using dodgy statistics to suggest to the public that going into hospital at weekends rather than a weekday was dangerous was an extremely irresponsible thing to do. To the extent that there is a problem it is unclear whether doctors are critical to it. But even if the reform itself is justified, it is another reorganisation that requires resources in the short term.

Aneurin Bevan, who set up the NHS, said that to persuade reluctant doctors to accept the idea he had “stuffed their mouths with gold”. Reorganising doctors’ contracts was bound to create winners and losers, and in a profession with considerable solidarity that would not be agreed to without extra money to compensate the losers. To try and do it while starving the system of resources was just crazy, and allows doctors to tell themselves that they are striking to save the NHS rather than to protect their pay.

The only similarity with the miners strike is that the doctors also cannot force the government’s hand. The more they escalate the dispute, the more their solidarity and public support will fragment. Jeremy Hunt has already got away with putting party interest above public probity once in a previous job, with Cameron’s active assistance, and he may profit this time as well. If he does demoralised UK doctors will leave in increasing numbers for more congenial working conditions overseas, and gaps will be filled by doctors trained overseas (if the home secretary lets them in).

The question to ask is not which side is right, or whether the strike is justified. The critical question is how did we get to this situation, and what that tells you about this government’s competence. The NHS works on relatively meagre resources because of the goodwill of those that work within it. Do we really think that facing down UK doctors is the way to get a better NHS? If the government does not compromise, the only losers in this dispute will be you and me.

Postscript (29/4/16) This by Ben Dean in the Telegraph makes similar points, and even questions whether the new contracts are better than the old in achieving a true 7 day week goal. 

Understanding the austerity obsession

It has often been argued, loosely following Keynes, that economists should be like doctors

Martin Wolf writes “The austerity obsession, even [sic] when borrowing costs are so low, is lunatic”. The IMF, the OECD and pretty much the whole of informed opinion agree. Yet those subject to this austerity obsession are in charge of levels of public investment in the the US, Germany and the UK. One interesting question that arises is whether they are all suffering from the same disease?

The diagnosis in the case of the Republican party in the US is reasonably clear. Judging from the remaining presidential candidates and the actions of Congress the main economic goal is to cut taxes, particularly for the very rich. That requires, sooner or later, less public spending. What about evidence that more public investment would help everyone in the economy, including the rich? The problem is that this group suffers from the delusion that the only way to help the economy is to tax the rich less and starve the beast that is the state. It is a clear case of the patient being infected by the neoliberal ideology virus.

The condition of the ruling class in Germany, however, is much more difficult to diagnose. Some local doctors have labelled it the Swabian syndrome: a belief that the economy is just like a household, and the imperative is to balance the books. This seems like a case of labelling rather than explaining a disease. There may be an allergy involved: an aversion to Keynesian economics, and anything that sounds vaguely Keynesian. But the microeconomic case for additional public investment in Germany is also strong: although German roads are not in such a bad state of repair as those in the US, the German public capital stock has been shrinking for over a decade. One possibility is that Swabian syndrome is being encouraged by an ageing population that worry about their pensions. It will be interesting to see how this is influenced by recent injections of the refugee vaccine.

The nature of the illness in Germany is therefore more of a mystery than in the US. Unfortunately as contacts between German officials and those in the rest of Europe are frequent, we have seen numerous cases of this disease - whatever it is - spreading elsewhere, and in one particular case (Greece) the patient remains in a critical condition. The disease also produces complications after accidents: here Finland - currently in intensive care - is a case in point.

The Conservative Party in the UK also seem to have the symptoms associated with Swabian syndrome. As with Germany, the outbreak reached a peak around 2010/11. For a time it was thought that UK cases might be in decline, but last year saw a renewed outbreak. There are some, however, who argue that in reality the party are feigning the symptoms as a means of winning elections, while still others claim that tests have revealed clear traces of the ideology virus.

What has become clear is that the traditional way of treating the austerity obsession, which involves occasional counselling with well trained economists, is having little effect. We also now know that the financial crisis shock treatment only makes the neoliberal virus more virulent. Extended therapy is the only known cure for this virus. As for Swabian syndrome, our best hope may be that the public gradually develop an immunity to the disease as its consequences become clear.  

Encouraging dialogue between economists and social scientists

In a way this is a rather trivial post, about language and attitudes as much as anything, that follows from some of the reaction to this post and related debates. One big difference between most (not all) mainstream economists compared to their heterodox or other social science colleagues is insularity. Political scientists will talk to sociologists who in turn talk to international relations people as a matter of routine. Economists by and large talk to each other. This is not because their subject matter is narrow - economists are notorious for applying their tools way beyond economics.

Most of the time I think that is fine, but sometimes it is not. How do we deal with the times that are not? I want you - as either an economist or social scientist or interested spectator - to think about a visit to your doctor. Why? Because economists should really think of themselves like doctors. (I know some want to think of themselves as physicists, but what can we do.) They are trying to understand highly complex and erratic systems based on a small number of principles, where most of the time they have very little idea of what is going on. But they have data, and some of the time they can make a lot of difference to people’s lives.

Now supposing your doctor prescribes you a course of treatment. It involves drugs that you have read a little about, and you have some concerns. If you were a social scientist would you say to your GP something like the following:

“I’m a little worried about this. I feel that you may not have adequately addressed the ontological and epistemological issues that are raised here. What exactly is ‘treatment’, and when is it necessary? Have you thought about the complex social and economic interrelationships that lay behind your prescription? Is the nature of what you call ‘illness’ really independent of the nexus of interactions that could be loosely called the medical profession?”

I kind of hope you wouldn’t, because I do not think you would get very far if you did. You might be much better off asking something like the following.

“I’m a little worried about this. Have you thought about whether this treatment is appropriate to my particular circumstances (HT Ben Goldacre), or are you reacting to pressure from the drug company or someone else? Has that company published all its trial data, or only the trials that were successful, and how was success defined in this case. Is this really going to make me better, or just increase someone’s profits?”

It is a simple and obvious (I did say trivial) point - you will get much further if you talk specifics in a language your doctor will understand, rather than in generalities and terminology they will not. Economists want (or need) to know why their approach is missing key issues or linkages which compromise their analysis, just as the doctor needs to know why they might be recommending the wrong treatment. You would not insist that your doctor needed to have studied economics before they can be a good doctor.

But if you were an economist, would you think it legitimate for your GP to respond like this.

“How inappropriate of you to ask me these questions. I’m a doctor, and I know from my years of knowledge and experience what is the right treatment for you. As you cannot know what I know, then you should not get involved in these issues. Some of the things you mention are really none of my business, and I do not see why I should worry about them.”

Now as an economist you know that such a response from your doctor would be both arrogant and naive. The doctor should ask about the quality and objectivity of the information they receive, and know full well that drug companies exist to make money. But might your response to a social scientist be as arrogant and naive?

Let me take a real world economic problem: the response to the financial crisis. Some have suggested that banks have become too large and need to be broken up, or that the activities of high street banking need to be separated from the activities of the casino. Your economic analysis tells you that networks of many small entities can be as subject to crises as networks involving a few large banks. You are also able to devise a system of Chinese walls that mean that the activities of the casino can be separated from those of the high street even within the same company, and your political masters seem to prefer this approach. You recognise that different assets differ in their liquidity, and so you devise complex weighting algorithms for computing capital ratios. Your suggestions form the basis of negotiations between officials and bankers, and a set of rules and regulations are agreed.

Over the next few years you watch in dismay as your complex system begins to unravel. The CEOs of the large banks seem to constantly have the ear of politicians, who in turn gradually compromise your elaborate controls to render them less and less effective. Those in charge of administering the rules find it much more lucrative to work for the banks, and so regulators gradually lose expertise and resolve.

And you realise that right from the start you made the wrong choice. You decided to focus on what you knew, which was how to design systems that worked well as long as those systems remained unchanged, but which were not robust to intervention by self-interested parties. In short, they were too open to rent-seeking. You realise that actually the best thing to have done was to break up the banks so that their political power was forever diminished. And you recall a conversation with your social science colleague when this all started, who might have been trying to tell you this if only you had understood the words he was using.