All in this together: the corporate capture of public healthBMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e8082 (Published 17 December 2012) Cite this as: BMJ 2012;345:e8082
All rapid responses
It is not uncommon to see anti-capitalist, anti-business and anti-private-sector arguments, but it is unusual to see them appear in what claims to be peer-reviewed work. The peer review process has missed several fundamental issues of logic and evidence. The work also offers a depressing view of human nature which few would accept if stated openly.
I should point out, before critiquing Mindell et. al., that, by the authors standards, I am not a valid source of criticism because I work for the private sector and might gain from advisory work to the NHS. In previous threads in BMJ responses with at least one of the authors this was a major part of their responses to my criticism.
But truth should depend on the strength of your logic and evidence not on your employer. Ad Hominem arguments should not be the primary material of the debate. Otherwise we would have to throw away, for example, Student's T-test because the inventor worked for Guinness.
The essential argument the authors make is that there is a conspiracy theory to shrink the state so private firms can make more money. In support of this they list examples of corporate malfeasance and quote their own interpretation of the Companies Act to suggest that profit at all cost is the prime directive of all private enterprise. Government, on the other hand, is "charged with advancing the welfare of its citizens."
But listing specific evils doesn't prove that all enterprise is evil. Yes the tobacco industry behaved criminally, but that doesn't prove that John Lewis or Apple Computer are evil. Besides only by omission is there a case for this sort of behaviour being unique to the private sector. Most readers will be reading about the scandal of Mid Staffordshire hospital (perpetuated by public sector employees) or the Bristol Heart Scandal (perpetrated, sustained by and covered up by public employees untainted by the pursuit of profit). Besides, if the whole private sector is tainted as they imply, we will have to stop believing anything our GPs tell us, since they are mostly profit-making private sector partnerships.
And the idea that private firms must pursue shareholder interests above all others is neither self-consistent not correct in UK case law (here is the reference I gave last time this argument came up: John Kay, The Business of Economics, Oxford University Press, 1996 p111–112). It is a little like an old communist slur that has somehow persisted despite the last 50 years of history.
And while I might share the author's concerns about civil servants leaving to work for, for example, management consulting firms they previously employed, others travel in the opposite direction foregoing the vast riches of, for example, Mckinsey to work on civil service salaries. Perhaps they are prepared to work for less because they want to put something back as public spirited individuals.
But perhaps the most worrying argument in the study is that people are merely passive pawns easily swayed by industry's aggressive marketing. Nobody would smoke if smoking were not advertised; obesity is the fault of aggressive advertising of energy-dense foods. This is a pretty depressing view of people. But it is also a ridiculous one. Advertising has some impact, but it can't make us do things we don't want to do. People will continue to smoke long after everyone has agreed it will kill them; nearly as many smoke cannabis as tobacco despite all the advertising saying it is bad for you; the obesity epidemic is a consequence of our choices as much as the industry which will rapidly switch what it advertises with every change in public opinion; lower constraints on the availability of alcohol has led to lower levels of consumption in England. It may be frustrating for public health experts, but people sometimes don't follow your advice. And it isn't mostly because some evil capitalist has brainwashed them.
In conclusion, people are sometimes good and sometimes bad as are governments and private firms. The only way to sustain the argument that the public sector has a monopoly on virtue is to ignore all the cases where it clearly doesn't.
PS I missed this article on its original pre-Christmas publication only to notice it when John Appleby tweeted his displeasure about the slurs on the Kings Fund and the Health Foundation who the authors seem to regard as no better than industry lobbyists on the grounds that nothing associated with the private sector in any way can possibly be independent.
Competing interests: I have worked for PA Consulting for more than a decade. Clients of this global management consulting firm, headquartered in the UK, have included the Department of Health, NHS providers and NHS commissioners. The views expressed here are personal opinions and not those of PA Consulting.