Peter Davies

There is currently an unrecognised conflict between the utilitarian nature of the overall NHS and the basic deontology of the doctor-patient interaction. This conflict leads to mistrust and misunderstanding between managers and clinicians. This misunderstanding is bad for both doctors and managers, and also leads to waste of time and resources, and poorer services to patients. The utilitarian thinkers tend to value finite, short term, evidence based technical interventions, delivered according to specifications and contracts. They appear happy to break care up into smaller pieces, which can then be commissioned from multiple providers. The deontological thinkers tend to think about care delivered through a long term continuous relationship, and regard that relationship as therapeutic and salutogenic in itself. To them breaking care up into smaller fragments is a denial of what caring is really about. Very rarely are either or both sides of this debate fully aware of where their powerfully felt and often well argued positions start from. In this paper we offer an appraisal of the strengths and weaknesses of both moral viewpoints as applied in the UK NHS context and we suggest a way in which they can be reconciled, provided neither is pushed too far or too hard against the other. We believe this reconciliation would be good for patients, doctors, managers and improve the service as a whole.

Analyses of market-based reforms of state schooling have occasionally acknowledged positional elements in parental demand, but none has fully examined their nature and implications. Contrary to the normal predictions of orthodox economic analysis, competition in positional markets can result in inefficient outcomes. Predominantly relying upon recent British experience, we examine the extent to which compulsory schooling can be viewed as a positional good and explore its implications for policy. In particular, we consider whether policies targeting increases in parental choice assist a rise in the overall level of educational attainment.