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This is the fifth of six related articles, commencing with a piece by Professor Marsland in MSN Volume 14, Issue 2 in April 1989, and concluding with his report in MSN Volume 19, Issue 1 in December 1993, which are published here, together, for the first time.

Research into Health Care - Partisanship or Scientific Inquiry

A Reply to David Marsland

Robert Dingwall
School of Social Studies
University of Nottingham, UK

Originally published in MSN Volume 16, Issue 1, December 1990

Professor Marsland’s contribution to the last issue of Medical Sociology News (August 1990, pp. 12-15) raises a number of serious matters. Some of his criticisms should be well-taken by medical sociologists. Others, however, reveal a considerable ignorance of the literature produced over the last twenty-five years, while a few reveal an aspiration to intellectual autocracy which seems inconsistent with Professor Marsland’s own philosophical roots.

Where does Professor Marsland have a point? There is some justice in his charge that sociologists have been unduly neglectful of efficiency questions, although this may not necessarily be the highest priority in a health care system that spends a proportion of GNP comparable to other Western countries (looking at purchasing power parties), but which incurs much lower administrative costs. Although there may be specific distributional problems, the NHS has, by international standards, been a relatively efficient provider of health care. However, as current thinking in the management schools reminds us, direct money costs are not everything. We also need to be concerned with effectiveness, with staff morale and with consumer satisfaction. The optimal solution to the problems of delivering any personal service will be found only by a complex balancing act between costs, quality, user-friendliness and employee welfare. There is little virtue in delivering a cheap service which is ineffective, hostile to consumers and indifferent to staff. It may well be worth paying a premium over the cheapest solution to construct an organization which provides a quality service, attracts customers, satisfies employees and has some prospect of long term survival. The ‘fourth generation’ evaluation studies which are now being conducted in the US have recognised the subtlety of the judgements involved in the inappropriateness of the kind of preoccupation with cost reflected in Professor Marsland’s contribution.
1 When it comes to issues of quality, consumer satisfaction and staff morale, one is dealing with areas where sociologists have long made a distinctive contribution.

Professor Marsland is on stronger ground with his suggestion that medical sociologists have romanticized the role of trades unions in health care, although not, surely, to the extent of David Green’s lyrical account of their role before 1911.
2 It seems bizarre, however, to accuse sociologists of an excessive sympathy for professional associations. If there has been a dominant obsession in medical sociology for the last twenty-five years, it has surely been ‘doctor-bashing’, even where this has involved a Procrustean treatment of the empirical evidence. The BMA, the GMC and the Royal Colleges have been repeatedly depicted as villains, whose power needs to be broken in precisely the sort of consumer interest advocated by Professor Marsland. What is more noteworthy is the absence of any serious attempt to understand their problems and internal dynamics in the way that, for example, Halliday has done for the Chicago Bar Association.3 Likewise, far from neglecting consumerism, this must be seen as one of the major influences on the field, despite Margaret Stacey’s powerful caution against its limitations as a model.4 In avoiding the language of the market, Sixties libertarianism may differ in its justifications from Thatcherism but its practical effects may sometimes be little different. Besides, Professor Marsland’s consumerist solutions raise their own empirical difficulties: why has it been so difficult for American women to influence obstetric care when they were theoretically its direct purchasers, at least until the spread of HMOs? Might this not suggest that there are real problems with simple application of consumer sovereignty? Can markets always regulate supplier-induced demand?

The point is, as health economists generally recognize, that health care is not a good case for market solutions. Even Adam Smith acknowledged this in exempting physicians from his general critique of occupational monopolies.
5 The unavoidable informational asymmetry between doctor and patient, coupled with the highly consequential nature of the decisions being made, create serious problems in equalizing the position of buyers and sellers in the way assumed by neo-classical economics. When this is coupled with the difficulties of creating a satisfactory system of insurance because of the problems of the increasing certainty of risk of uptake of the service as a result of the ageing process, of adverse selection and of moral hazard, the market provision of health care involves such torturing of logic as to appear unworthy of much expenditure of intellectual energy.

This becomes evident when one looks at the present Government’s proposals. Professor Marsland criticises the reluctance of scholars to come on board and it is remarkable how isolated the Department of Health’s position has become even among health economists who might have been expected to be the greatest enthusiasts for the internal market. Indeed, its alleged inspirer, Alain Enthoven, has professed himself unhappy with many aspects of the proposals and called for limited and carefully evaluated pilots to establish that there will indeed be a change for the better.
6 The problems of these proposals, however, have nothing to do with the ill-will of scholars and everything to do with their sheer intellectual incoherence. Even for those of us who share the view that financial and management information in the NHS is inadequate, there are still plausible reasons to see the reforms as an expensive charade which depends upon a massive centralisation of power in the Department of Health and an extension of costly and unproductive regulation, financed by a transfer of resources from patient care to administration, which will aggravate rather than relieve the funding problems of the service. In the circumstances, the reaction of many in the academic community may be more comparable to the reluctance of seamen to enlist on a leaky tub than any fundamental ideological animus.

Professor Marsland’s response, however, lacks the seriousness he finds wanting in others. If the community of scholars will not come on board, he will reintroduce the press gang. This response has already disconcerted a number of other libertarians like Professor Kedourie, who recognize that the logic of their own position calls for the sustenance of free thought and inquiry and that these are threatened by the demand for political commitment as the price of public support. As Hayek rightly observed, we cannot foresee the future in detail and part of the policy of any state must be the deliberate fostering of a diversity of perspectives offering politicians and public a variety of options for conduct under whatever environmental conditions prevail. If the market fails to provide this choice, because of its emphasis on the here-and-now rather than on the medium and long term, then this failure may legitimately provoke Government action.
7 Some part of this is undeniably the latter-day equivalent of the servant retained by the Roman Senate to whisper in the ears of triumphal Caesars that they too are mortal. Professor Marsland may choose to disregard the message but in shooting the messenger he is trampling on the very democracy he claims to represent.

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1 Guba, E.G. and Lincoln, Y.S. Fourth Generation Evaluation, Newbury Park, CA: Sage, 1989.
2 Green, D. Working Class Patients and the Medical Establishment, Aldershot: Gower, 1985.
3 Halliday, T.C. Beyond Monopoly: Lawyers, State Crises and Professional Empowerment, Chicago: University of Chicago Press, 1987.
4 Stacey, M. ‘The Health Service Consumer: A Sociological Misconception’. In Stacey, M. (ed) The Sociology of the NHS, Sociological Review Monograph 22, Keele, Staffs: University of Keele.
5 See the discussion in Dingwall, R. and Fenn, P. “A Respectable Profession?” ‘Sociological and Economic Perspectives on the Regulation of Professional Services’ International Review of Law and Economics, 7, 1987: 51-64.
6 Smith, R. ‘NHS Review: words from the Source: An Interview with Alain Enthoven’, British Medical Journal, 298, 1989: 1166-8.
7 See The Constitution of Liberty, London: Routledge and Kegan Paul, 1960, especially Part 1.

Next: 'Implementing Health Care Reform: From Policy To Practice' by Professor David Marsland