Nudge, nudge, Daddy Cameron’s coming

Civitas, 14 January 2010

You can tell the Tories are being advised by Richard Thaler, the famed ‘nudge’ economist.  It’s now, apparently,  part of their life and blood.  Public health, after the latest health policy announcement yesterday, may just as well be called ‘nudge’ health.  Here’s the idea.  Point one.  Cash for public health initiatives will be separately identified (not necessarily a bad thing in itself).  Point two, local directors of public health, who will be joint appointments between the NHS and local authorities, will be ‘paid by results for achieving goals such as reducing teenage pregnancy, infant mortality, childhood obesity and alcohol-related hospital admissions’.

Oh.  Dear.  First, let’s deal with the practical issues.  One, how reliable is the data that this money will be tied to?  Two, it should be noted that every single one of these targeted areas ultimately lie outside the power of the state.  Or at least they should be.  Someone being admitted to hospital because they’ve gone out on a Friday night and got plastered is the result of that individual’s decision to drink so much, not of a local authority’s decision to pump them full of beer.  A girl getting pregnant at a young age may reflect declining societal values, but ultimately is the result of a decision an individual takes at a particular moment in time.

You can only imagine the how much figures are going to be buffed, then, if Primary Care Trusts and local authorities have payment tied to things that, when push comes to shove, are out of their control.  What, no, this fat kid’s only just moved here, it’s not our fault.  Worse, measures that seem ridiculous might just start to seem reasonable. Need to reduce alcohol admissions?  Hey, why not just have alcohol police patrolling the pubs looking for anyone who might look just slightly tipsy?  Time to go home, sonny.

Here’s the crunch.  Targets produce perverse effects where things are easily measured and under the control of organisations (such as waiting times), but it gets infinitely worse when they are not.  Most pernicious of all, trust goes out the window – yes, that very same ‘trust’ that the Tories are otherwise pandering to the medical profession that they will restore by scrapping targets.  Spot the inconsistency.

But second, and far more importantly, let’s look at the underlying principles here.  All this ‘nudging’ implies one fundamental thing: the state knows best.  Daddy knows what’s good for you.  You shouldn’t get fat, you shouldn’t drink too much, you shouldn’t smoke.  This is a very dangerous route to me travelling in.  As de Tocqueville warned long ago:

‘Above this race of men stands an immense and tutelary power, which takes upon itself alone to secure their gratifications and to watch over their fate. That power is absolute, minute, regular, provident, and mild… The will of man is not shattered, but softened, bent, and guided; men are seldom forced by it to act, but they are constantly restrained from acting. Such a power does not destroy, but it prevents existence; it does not tyrannize, but it compresses, enervates, extinguishes, and stupefies a people, till each nation is reduced to nothing better than a flock of timid and industrious animals, of which the government is the shepherd.’

In other words, those who wish to preserve liberty must take people’s actions as they find them, not substitute for them “better” or more “rational” actions, based on an assessment of what people “really” want.  What I might consider completely ‘irrational’ reasoning may make sense to another person facing different circumstances and I would not want to take this reasoning away from them (unless, of course, it involved the use of force against others).

And let’s get down to the nitty gritty.  Why are the Tories really so keen on this?  Might it just have something to do with fear of spiralling health care costs?  As Danny Finkelstein wittily put it, the NHS means ‘I have a big stake in your big steak.’  If you’re fat, you’ll more than likely cost the NHS, and me, and others, more.  So, for the greater good, why not ‘nudge’ everyone into healthy lifestyles, as Andrew Lansley put it?  Seem reasonable?  But then consider this:  just about any form of activity has an impact on health. So there is nothing that is immune to the NHS cost argument.  Do nothing.  Eat little.  Don’t smoke.  Don’t drink.  And heaven forbid, don’t do any exercise that might get you hospitalised.

And I’m not even mentioning the kind of ‘nudging’ that the proposed ‘independent’ NHS board might do at the top of the tree on the non-public health side of things.