Intended for healthcare professionals


Competition in a publicly funded healthcare system

BMJ 2007; 335 doi: (Published 29 November 2007) Cite this as: BMJ 2007;335:1126

resistance to evidence

I find it ironic that Neville Goodman quotes Steven Jay Gould to
illustrate the point that people often find it hard to see evidence
contrary to their world-view. While Gould’s book “Wonderful Life” (Stephen
Jay Gould, Paperback edition published by Penguin in 1991) is one of the
best pieces of writing about science in the last 3 decades, it is also a
superb example of ideology-driven interpretation of evidence and one where
further evidence completely undermined the basic argument.

For those unfamiliar with the arguments they go a bit like this.
Gould argued that evolution is driven by contingent chance and, if a
different set of creatures had accidentally become extinct in the
cambrian, the world today would look very different (this fits with his
world view—his critics allege this was driven by his Marxist leanings
though this is probably unfair). His argument was that the fossils of the
Burgess shale—a rare fossiliferous deposit in Canada where traces of the
soft parts of fossils are often preserved in exquisite detail—contained
many whole categories (phyla) of animals quite unlike anything known
today. The world today depends on the chance survival of only a handful of
those categories. Unfortunately for his view, further probing of the
fossils revealed that most could be fitted into existing phyla and many of
the interpretations Gould relied on were just wrong. The story is best
told by Simon Conway-Morris whose book “Life’s Solution” (Cambridge
University Press, 2003) argues that evolution will tend to produce similar
results if rerun as there are tight constraints on what works. His book
The Crucible of Creation (Oxford University Press, 1998) is, essentially,
a criticism of the Gould interpretation based on his own later evidence.
And it is worth noting that Conway-Morris was one of the key players whose
incorrect reconstructions originally looked so good in the light of
Gould’s theory. Gould’s book is a perfect illustration of how better
evidence can refute a strongly held ideology.

Goodman argues that views such as mine cannot be readily debated as
it is “impossible to separate evidence from prejudice.” This is not only a
council of despair but a serious retreat from the debate we ought to be
having. It is one of the most unfortunate characteristics of the debate
about health reform that few seem to want to conduct it on the basis of
evidence. Allyson Pollock, for example, starts many of her arguments with
the assumption that profit is evil (she probably believes this as a
universal truth, but certainly believes it in health). She then adds the
additional assumption that significantly improved efficiency in healthcare
delivery is impossible (a belief of staggering naivety she shares with the
BMA. See Pollock et. Al. “NHS plc,” Verso, 2004 where she writes on page
37 “Given that healthcare is by its nature labour intensive, the scope for
achieving savings through greater efficiency was limited.” Or the BMA’s
discussion paper “A rational way forward for the NHS in England”, BMA, May
2007 where in paragraph 9 on page 10 they assert “Given that efficiencies
can only account for relatively small savings…”). She then uses these
assumptions to demonstrate why no private involvement can be good (profit
can only come from reduced patient care). This is an axiom of her
position. The thing is, we live in a world where the majority of goods an
services are provided by profit making companies in mostly well regulated
competitive markets and they have brought big collective benefits to us
all (we get cheaper stuff, a wider variety of stuff and better stuff than
we did 20 years ago or 50 years ago). So there is pretty good case for
rejecting her thesis as a general one (I don’t see much support for the
idea that we should nationalise food distribution or car manufacturing to
make them better). IF her case depended on the specific characteristics of
health then we could bring some evidence into play and have a proper
debate, but she chooses to beg the question.

Now I’m not saying that everything she says is wrong: she has made
very good criticisms of PFI deals (though she entirely misses the
underlying source of the problem which is that central planners’
assumptions underestimate risk especially when they are spending someone
else’s money: no sane independent provider operating in a market would
plan PFIs like the typical NHS trust).

Its not that I couldn’t be bothered to read the anti case, its just
that I don’t put much weight in arguments that assume what they try to

Moreover, if everyone sticks with their ideological positions and
fails to engage properly in the search for evidence, they won’t be able to
influence the current system which is far from being perfect. For example,
Pollock’s solution to PFI is just don’t do it and her solution to market
incentives in provision is to abandon them and revert to central planning.
Government policy in both areas has serious flaws but they won’t be
corrected if the criticism is pure vitriol. Future PFI schemes desperately
need to be based on more realistic and risk-aware planning assumptions,
and the market for provision is crying out for effective regulation.

Competing interests:
None declared

Competing interests: No competing interests

15 January 2008
stephen black
management consultant
london sw1w 9sr