British Health Bureaucracy Deploys the Washington Monument Strategy

Threatened with budget cuts it doesn’t like and wants to stave off, the British National Health Service is proposing economies to create the most visible increases in suffering and death:

Some of the most common operations — including hip replacements and cataract surgery — will be rationed as part of attempts to save billions of pounds, [says the NHS], despite government promises that front-line services would be protected. Patients’ groups have described the measures as “astonishingly brutal.”

Faced with budget cuts, skilled bureaucrats invariably threaten to save money by cutting their most important and visible programs. This gambit is called the “Washington Monument Strategy” by those who study political behavior. The name honors the U.S. Park Service for its skill in deflecting proposed budget cuts by declaring that the only economy possible in such a tightly run operation was the closure of the Washington Monument, its most popular and visible tourist operation, in July and August.

In health care, the most popular and visible operations are those that save people’s lives, dramatically reduce suffering, and visibly improve individual functioning. According to The Telegraph, NHS cost cutting proposals include threats to:

1. Restrict knee and hip replacements and cataract surgery. This condemns elderly people to blindness and immobility.
2. Cut palliative care for the terminally ill.
3. Close nursing homes for the elderly.
4. Further ration hospital acute care. Rather than improving access, the goal will be to keep primary care physicians from sending people to the hospital.
5. Cut hospital staff.

Privately run health care systems facing budget cuts seldom eliminate popular services because they add to profits. By the early 1990s, for example, hip replacements were so desirable that Britons were willing to pay cash for them. About 20 percent of British hip replacements were done by the for-profit private sector rather than by the NHS.

Profits act as a signaling mechanism. They help people who want health care to communicate their preferences about what to cut to those who provide it. Politically run health care services do away with profit. Patients have no way to signal their preference intensities. They end up at the mercy of the officials who run the health service, and those officials may prefer to deploy resources in ways that satisfy employees, meet trendy political demands, or defray budget cuts.

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