Monday, March 31, 2008

NHS Blog Doctor: setting out his stall against "fascist hyenas"

There is something of a spat developing between NHS Blog Doctor and the Taxpayer's Alliance. Last week, the TPA published their Town Hall Rich List, and the good Dr Crippen took exception to this; the TPA have now responded. The TPA are big boys and more than capable of defending their ethos and working practices, but I must take exception to one of Crippen's lines.
That is it. No exemptions. No explanation. No penumbra. No analysis other than that in which the conclusions have been pre-defined. Tax is a bad thing. Surprising they have not joined up with the Libertarian Party amongst whose avowed aims is the abolition of income tax. Come to think of it, maybe they have.

No, Crippen, they haven't; and believe me, much of the rest of the post seems to be based on a similar lack of evidence. For the record, employees of the TPA are specifically forbidden from being members of political parties and, as such, there is absolutely no affiliation with the Libertarian Party at all.

It may come as a surprise to Dr Crippen, but there are, believe it or not, people outside of the TPA who also think that taxes are too high and who are more than capable of coming up with their own policies.

For the good Doctor to link LPUK in with the TPA and then go on to say that the TPA "only attract fascist hyenas" displays a severe ignorance of what fascism is, and is also deeply insulting to the TPA and, by the baseless extension that Crippen has drawn, to the Libertarian Party.

As someone who is a member of both of these organisations, I consider myself vaguely insulted: apparently your humble Devil is, in fact, a "fascist hyena" and not someone who feels that his liberties—both financial and civil (for they are inextricably linked*)—are being eroded on a daily basis.

Well, thanks a bundle, Crippen.

On Friday, the good Doctor decided to attack the Libertarian Party's Health Policy. As you can see for yourselves, the policy is little more than a placeholder at present. There is a simple reason for this: health is a very difficult subject and, before committing ourselves to any specific policy, we want to spend the time researching the other available systems.
It is early days for the Libertarian Party. Funding healthcare is the single biggest problem facing the western world and so the party must be allowed time to formulate detailed policies. But the portends are not good. Already they make some fundamental errors.

And what might these be? I can't wait to hear them...
You cannot apply market economics to the provision of universal health care. Universal health care is not an economic proposition. It is an indulgence. An expensive indulgence which has to be funded by taxpayers.

Really? So, it has to be funded by taxpayers through government, or could it be, in fact, that it could be funded by taxpayers through insurance (the question of whether you make this insurance compulsory or not is one of those questions which we are discussing).

Almost everything else in this country is delivered via the market. Essential items such as bread, or milk, or tax services or... well... anything is delivered via the mechanism of the market. So, what makes health provision so very special?

What makes healthcare provision special in his country is the fact that it is an effective monopoly. The government takes the money to pay for it (or you go to prison), it then decides how much of that money is spent on health. Then it pays that money to government-sponsored QUANGOs (the Primary Care Trusts) who then disburse that money to government-run hospitals, in which the staff are paid by the government (in National Pay Deals that kill patients).

If there is one thing that even most on the Left agree on, it is that monopolies are a bad thing; where those of us on the Right disagree with the Left is that we believe that government monopolies are just as bad (or, actually, worse) than private monopolies.

Healthcare in this country is, effectively, a state near-monopoly. And so much faith does Dr Crippen, an NHS GP, have in the NHS, that he has opted out by buying private health insurance (as has your humble Devil: it costs less than £50 per month currently).
You can make a profit by selling sophisticated health care to the rich but you can only make a loss by providing the same health care for the poor. Successful entrepreneurs are driven by the profit motive.

This is perfectly true, but also extraordinarily disingenuous. There are always companies who can find a way to make their services affordable; one that springs to mind is Direct Line Insurance. They decided to offer cheaper car insurance. They were able to do this by cutting the cost of delivery (making ample use of the internet) and by taking a smaller profit on each policy but getting more people on board.

There was a report a few months ago, on supermarket ready food lines. Essentially, the ready meals came in two different lines: the low priced "value" and the high-priced "luxury". However, they were both the same product, except with different packaging.

The rich bought the "luxury" product and the poor bought the "value" product. The supermarkets make a profit on both products but the rich effectively subsidised the poor. Surely, this should appeal to Crippen's egalitarian mindset?

Why should the same not apply to medicine. The treatment would be exactly the same, but the rich might get silk sheets on their beds whilst the poor make do with linen. In this way, the rich—feeling that they are getting a better service (although the actual procedure is exactly the same)—will be willing to pay more and thus subsidise the treatment of the poor.

If you believed people like Doctor Crippen, the picture that you might have of the time before the NHS is of the poor dying like flies for the want of a quid. But charities took up much of the slack.

These days we are used to pointless charities like Greenpeace, which we are forced to fund through their massive government subsidies. But, before the Welfare State, charities fulfilled a rather more practical function: the care of those who could not (or would not) care for themselves.

Sure, these days we have lost the art of charitable giving but, when you are already losing 45% of your income, it makes one somewhat disinclined to give more. It is no accident that charitable giving in (relatively) low-taxed America dwarves that of high-tax Europe.

But, in the Victorian era, big businessmen tended to give large amounts of money to charity. Many of them did so out of what was ultimately a profit motive—those entrepreneurs who built housing for their workers in order to maintain a tied workforce, for instance, or just for the pleasure of seeing a plaque above a ward that they had built—but is there any quintessential reason why should this not happen again?

Just think of all those colossal City bonuses being put to use to built and run new hospitals (many individuals could do this many times over). And whilst some people will sneer and say that that will never happen, well, to you I say, "it did in the past. Has the nature of man fundamentally changed from that time?" The answer, of course, is not that man has changed, but that the state has changed the attitude that men have to their fellow man.

In this way, the state has allowed people to be insulated from their fellow man. Now when we see poverty we don't ask what we might do to alleviate it: we say, "why isn't the government doing anything about this?" Far from uniting us with our less fortunate fellows, the state has allowed us to isolate ourselves; it is no longer our problem, you see, but that of the state.

There were many mechanisms that allowed the poor access to medical care, such as the Friendly Societies, private philanthropists and charities.

Would I prefer to return to such a system, one that does not need coercion? Yes. Am I naive enough to believe that it would happen overnight? No. But, we do wish to have an orderly transition and this is why we need to think very carefully about how that might be brought about.
An independent “not-for-profit” organisation will not survive unless it is government subsidised and thus insulated from the realities of the market. And if it is so insulated, no private company can compete against it.

This is, of course, absolute crap. A "not-for-profit" organisation is allowed to make a profit (see almost all private schools and the vast majority of charities) but that profit is not allowed to be disbursed to the directors (above and beyond their agreed renumeration). The profit must be ploughed back into the organisation. This absolutely does not mean that every "not-for-profit" organisation has to be government-funded.

However, it is true that government-funding does provide a barrier to private enterprise.
An insurance based system merely substitutes a private, profit driven company for a government run organisation.

This is a particularly flippant line; yes, a private health insurance system replaces the government one, that is the entire point.

Now, Dr Crippen who has, as I have mentioned before, private health insurance for himself and his family, obviously believes that he gains from that insurance. He gains a better service than that which he himself works for.

So, why is he slamming a private insurance system that he himself is taking advantage of? Two-tier health-system? We already have it, John; and you have happily ensconced yourself in the upper tier of that system.

I don't blame you for doing so, at all. However, it is rather hypocritical of you to criticise a particular system when you believe that that system is going to provide you and your family with a better standard of healthcare and then deny access to that system for everyone else.
Doctrinally motivated health care economists will argue for one or the other, but there is no moral, or economic, absolute.

Well, I quite agree. What we should look for is the way that best delivers care to the customers who require it, as we do in any other area. A national monopoly doesn't do that.

It doesn't even terribly matter as to whether or not our spending as a proportion of GDP rises as long as there is a commensurate return in terms of productivity. What has been so irritating about the money poured into the NHS is that productivity has dropped.

But no system is perfect so what we want is a proliferation of many systems and a state monopoly does not help that at all.
Take a look at this article in Fortune magazine which describes the anomalies thrown up by a private insurance based system.

Indeed it does. But what that article also makes clear is how much government interference in free markets has led to the less than satisfactory state of the US healthcare industry. It is, for instance, the fault of the government that most healthcare plans are tied, not to individuals, but to jobs. Here's a taster:
McCain's main pillar is the elimination of a tax break that employees receive if their employer provides their health care. That may not sound like a shocker, but it is. The exclusion dates from World War II, when the federal government imposed controls on wages, but allowed companies to compete for workers by offering tax-free health benefits in lieu of pay. The law is largely responsible for the nightmarish patchwork of corporate-provided medical plans we enjoy so much today. Employees and their unions demanded richer and richer packages, and employers complied, since they could buy far more benefits for their employees than workers could buy with after-tax dollars on their own. Americans have paid a steep price, however, by sacrificing their raises as corporate insurance bills exploded, never more so than now.

Inevitably, this has also cut the choice of insurers and the flexibility of the consumer. Not an ideal situation and certainly not one that LPUK would endorse. But, let us return to the good Dr Crippen's piece...
We need a fresh start, free of doctrinal absolutes.

Well, OK. And your suggestion is...? Oh, you don't have one. Fine.

What, in any case, are "doctrinal absolutes"? Do i believe that the free market works best because that is my doctrine? Or, do I believe that free markets work best because all of the evidence that is available shows that they do?

In my case, it is the latter. Free markets are not perfect, but they are the best option. We have tried most combinations of the other options and they simply do not work anywhere near as well.

I have never really understood the UK medical profession's hostility to trying another system; after all, they as much as anyone, are shafted by the government's monopoly.

Nurses in London are substantially worse of than nurses in the middle of Yorkshire, for instance.

Junior doctors are churned out of medical schools only to find that, due to the state's incompetence, there are no training places or jobs for them.

The state's inability to plan has meant that we have been forced actively to import foreign agency prfessionals; and this not only denudes poor countries of much-needed trained staff, but linguistic misunderstandings lead to an overall diminshing of the reputation of all medical staff in the country.
Above all, we need to admit the fact that no country can afford to provide the full range of modern health care for all its citizens. Health care has to be rationed. We need a front end charge, appropriately safety netted, to stop the worst of the abuse.

Well, OK. But who is going to abuse the system the most: those who get it for free or those who pay for it?
We need to find a politically acceptable way to explain to the citizens that they can no longer have it all “for free”. Free health care was always an illusion, buttressed by the NHS with its ludicrous "free at the point of entry" mantra. The illusion has had dire consequences. It has fuelled the demand for health care to unsustainable levels.

Well, yes, Doc; that's fine. And the relevance to the LPUK policy is...? We would abolish the NHS; that is no secret. Do we think that we should look into feasible alternatives? Yes. That is why we decided to develop policy in our forums. Amongst other things, we have a few medical doctors and medical managers in there who can give us their opinion from the front lines.

You are welcome to join in and contribute, my dear Crippen; you do not have to sell us your soul, nor even join the party in order to join in the discussion: we will happily accept advice from anyone.
The choice is simple. Acknowledge the inevitable and take control or bury your head in the sand, pretending all is well, as stealth rationing and the surreptitious erosion of health care standards allow the NHS to lapse into a two tier system in which only the rich can access good medical care.

Now, this is a slightly bizarre finishing paragraph; the good Doctor appears to be contradicting everything that he has said previously.

Crippen has acknowledged that we need to ration healthcare, and that we need to charge for it. Presumably, he would also not object if people paid for additional treatments. But surely this would "allow the NHS to lapse into a two tier system in which only the rich can access good medical care".

What is "good medical care"? Presumably, we want everyone to access adequate medical care; as I outlined above, if the rich are happy to pay more for silk sheets, thus allowing the hospitals to subsidise the care for the poor, is this not a god thing?

But the main point is that if people are actively paying for their health insurance, then they are going to take more care of themselves. As Crippen correctly points out, the "free at the point of use mantra" is completely stupid because it makes people think that it is, in fact, free.

Of course, for those who don't work and will never work, the health system is free. For the rest of us, however, it is very expensive.

Is it right that someone who has paid 11% of their salary for the last thirty years should get the same treatment as someone who has paid absolutely fuck all for the same time? Of course it isn't. We wouldn't think that was fair with any other system, so why with health.

At the same time, is it right to leave people dying in the streets because they have never paid a penny towards any medical facilities? No.

And that is the difficult tightrope that one has to walk and, as far as I am personally concerned, the solution is private charity. Let those who care about our fellow man (and, yes, I would give money voluntarily were I not losing vast amounts in tax, just as I have given to various bloggers who have appealed for cash (and other bloggers have shown the same courtesy to me, at times)).

Because I believe that all of this rubbish that Cameron comes out with, about the "broken society", has been caused by the state, and the state cannot fix it. Take away that monolith that has allowed us all to retreat from our fellow man and I think that you will find people to be unexpectedly generous.


* This is a theme that I have amplified before. However, the gist of it is that the reason that the government feels that it can dictate what we eat, smoke, drink or otherwise put into our bodies is because the state "pays" for our wanton lifestyles through the NHS.

Actually, it is we taxpayers who pay for the NHS and that applies even if you have private insurance. I have private health insurance, but I am still not allowed to opt out of the NHS completely, so the state still feels that it can tell me what to do.

In this way, the financial lever that the government holds also leads to their hold over the civil liberties lever too.

20 comments:

Anonymous said...

Dr Sweeney will see you now....

Anonymous said...

DK, you said:

"For the record, employees of the TPA are specifically forbidden from being members of political parties and, as such, there is absolutely no affiliation with the Libertarian Party at all."

And then you said:

"As someone who is a member of both of these organisations, I consider myself vaguely insulted: apparently your humble Devil is, in fact, a "fascist hyena" "

So are you in TPA and LPUK and if so, how can you say TPA members can't be in any political party?

Devil's Kitchen said...

The clue is in the difference in meaning between "member" and "employee".

I have signed up as a supporter, i.e. member, but I am not an employee...

DK

Steve_Roberts said...

Dr Crippen doesn't seem to be aware that 'the market' is not a means of dividing the spoils, it is a social phenomenon which arises whenever human beings make voluntary exchanges of scarce things. The government monopoly healthcare system still exists in a market which affects the availability and costs of staff, equipment, facilities, drugs and other supplies etc, and can no more be legislated away than the rising of the sun can.

cornsighant said...

The more I think about it, I don't think we need to stop the NHS being funded by the governmant through taxes.

We have to stop the government controlling how the money is spent and making political milage out of it for thier own gain.

Seperate the 2 as a first step and see what you get,,,

Dr John Crippen said...

NHS Blog Doctor: setting out his stall against "fascist hyenas"

I don’t know whether to be flattered or intimidated that the DK should devote so much time and space to demolishing two of my posts. For starters, I think the expression “facist hyenas” was a through away hyperbole somewhere in the comments under the TPA article. Tame stuff compared to the DK’s output, I rather thought.

There is something of a spat developing between NHS Blog Doctor and the Taxpayer's Alliance. Last week, the TPA published their Town Hall Rich List, and the good Dr Crippen took exception to this; the TPA have now responded. The TPA are big boys and more than capable of defending their ethos and working practices...

Yes, I did take exception to it. It was a tabloid (some of it purloined from The Sun newspaper) ad hominen attack on named local authority officers who had only one thing in common. They earn more than £100,000 a year.

...but I must take exception to one of Crippen's lines.

That is it. No exemptions. No explanation. No penumbra. No analysis other than that in which the conclusions have been pre-defined. Tax is a bad thing. Surprising they have not joined up with the Libertarian Party amongst whose avowed aims is the abolition of income tax. Come to think of it, maybe they have.

No, Crippen, they haven't; and believe me...


DK, you are taking yourself too seriously there. The Libertarian Party has published a poster on the DK’s site itself suggesting the abolition of income tax. The TPA has said it is against all tax rises. Which is where my statement “That is it...” started from. So you have naughtily taken the quote out of context.

Both propositions are, in my view, unworldly, hence the gentle suggestion of an association between the two of you. Indeed, I believe you are yourself a member of both.







...much of the rest of the post seems to be based on a similar lack of evidence. For the record, employees of the TPA are specifically forbidden from being members of political parties and, as such, there is absolutely no affiliation with the Libertarian Party at all.

I did not discuss the political allegience of the TPA employees. I do however believe that most of their “prominent supporters” are both rich and right wing. Do you dispute that?


It may come as a surprise to Dr Crippen, but there are, believe it or not, people outside of the TPA who also think that taxes are too high and who are more than capable of coming up with their own policies.

No surprise. I am one of the ones who thinks taxes are too high.

For the good Doctor to link LPUK in with the TPA and then go on to say that the TPA "only attract fascist hyenas" displays a severe ignorance of what fascism is, and is also deeply insulting to the TPA and, by the baseless extension that Crippen has drawn, to the Libertarian Party.

You are taking a throw away remark in the comments to literally too far. Heavens, as the internets leading hyperbolist, I would have thought you would be a little less reactive. But, for the record, I do not think that the Libertarian Party is composed of fascist hyenas.

As someone who is a member of both of these organisations, I consider myself vaguely insulted: apparently your humble Devil is, in fact, a "fascist hyena" and not someone who feels that his liberties—both financial and civil (for they are inextricably linked*)—are being eroded on a daily basis.

Well, thanks a bundle, Crippen.

Oh poo to you too, DK. I didn’t call you a “facist hyena” but, compared to how you routinely describe dear sweet Polly Toynbee, this is but mere flummery.

On Friday, the good Doctor decided to attack the Libertarian Party's Health Policy. As you can see for yourselves, the policy is little more than a placeholder at present. There is a simple reason for this: health is a very difficult subject and, before committing ourselves to any specific policy, we want to spend the time researching the other available systems.

It is early days for the Libertarian Party. Funding healthcare is the single biggest problem facing the western world and so the party must be allowed time to formulate detailed policies. But the portends are not good. Already they make some fundamental errors.

For goodness sake, if you enter the political arena with a health care policy, you must expect it to be held up to the microscope


And what might these be? I can't wait to hear them...

You cannot apply market economics to the provision of universal health care. Universal health care is not an economic proposition. It is an indulgence. An expensive indulgence which has to be funded by taxpayers.

Really? So, it has to be funded by taxpayers through government, or could it be, in fact, that it could be funded by taxpayers through insurance (the question of whether you make this insurance compulsory or not is one of those questions which we are discussing).

I take back not one word of that. If you really want a high standard of health care available to all, independent of means, than absolutely, yes, some of it has to be funded by the tax payer. There is no alternative.

Almost everything else in this country is delivered via the market. Essential items such as bread, or milk, or tax services or... well... anything is delivered via the mechanism of the market. So, what makes health provision so very special?

I have frequently argued on NHS BLOG DOCTOR that logically food, which is more important even than health, should be “free at the point of entry into the supermarket”. I make the arugment as a reductio ad absurdum. I do NOT believe that health care should be “free at the point of entry”. In fact, it isn’t, and never was really.

What makes healthcare provision special in his country is the fact that it is an effective monopoly. The government takes the money to pay for it (or you go to prison), it then decides how much of that money is spent on health. Then it pays that money to government-sponsored QUANGOs (the Primary Care Trusts) who then disburse that money to government-run hospitals, in which the staff are paid by the government (in National Pay Deals that kill patients).

I agree

If there is one thing that even most on the Left agree on, it is that monopolies are a bad thing; where those of us on the Right disagree with the Left is that we believe that government monopolies are just as bad (or, actually, worse) than private monopolies.

I agree

Healthcare in this country is, effectively, a state near-monopoly. And so much faith does Dr Crippen, an NHS GP, have in the NHS, that he has opted out by buying private health insurance (as has your humble Devil: it costs less than £50 per month currently).

I agree. I have very little faith in the modern NHS to provide a decent standard of health care, so I have private health insurance. I feel the same about education, and do not use the state system for my children. BUT I bitterly resent that this should be so. It makes me ashamed of both the health and education systems.

You can make a profit by selling sophisticated health care to the rich but you can only make a loss by providing the same health care for the poor. Successful entrepreneurs are driven by the profit motive.

This is perfectly true, but also extraordinarily disingenuous.

Yes, but Chris, you are not being fair. You have taken an edited selected quote out of context. What I actually said was:

“You cannot apply market economics to the provision of  universal health care. Universal health care is not an economic proposition. It is an indulgence. An expensive indulgence which has to be funded by taxpayers. You can make a profit by selling sophisticated health care to the rich but you can only make a loss by providing the same health care for the poor. Successful entrepreneurs are driven by the profit motive. An independent “not-for-profit” organisation will not survive unless it is government subsidised and thus insulated from the realities of the market. And if it is so insulated, no private company can compete against it.”


And I stand by that.



There are always companies who can find a way to make their services affordable; one that springs to mind is Direct Line Insurance. They decided to offer cheaper car insurance. They were able to do this by cutting the cost of delivery (making ample use of the internet) and by taking a smaller profit on each policy but getting more people on board.

There is no profit to be made from schizophrenia and dementia, however you structure it.

There was a report a few months ago, on supermarket ready food lines. Essentially, the ready meals came in two different lines: the low priced "value" and the high-priced "luxury". However, they were both the same product, except with different packaging.

The rich bought the "luxury" product and the poor bought the "value" product. The supermarkets make a profit on both products but the rich effectively subsidised the poor. Surely, this should appeal to Crippen's egalitarian mindset?

Why should the same not apply to medicine. The treatment would be exactly the same, but the rich might get silk sheets on their beds whilst the poor make do with linen. In this way, the rich—feeling that they are getting a better service (although the actual procedure is exactly the same)—will be willing to pay more and thus subsidise the treatment of the poor.

But that is happening already. The so called “free at the point of entry” NHS is like an iron country food shop. The shelves are empty. To get real choice, you have to pay. And DK, come on, where is this going? Silk sheets for the DK and Polly Toynbee and linen sheets for hoi poloi?


If you believed people like Doctor Crippen, the picture that you might have of the time before the NHS is of the poor dying like flies for the want of a quid. But charities took up much of the slack.
Ah.... you want the poor to be “charity cases”, to be dependent on the begging bowel. Shall we have work houses as well?


These days we are used to pointless charities like Greenpeace, which we are forced to fund through their massive government subsidies. But, before the Welfare State, charities fulfilled a rather more practical function: the care of those who could not (or would not) care for themselves.

DK, I have read James Bartholomew too. There is merit in some of his arguments. But it is not as easy as that now. Medical care is infinitely more sophisticated than it was in 1948 and infinitely more expensive.

Sure, these days we have lost the art of charitable giving but, when you are already losing 45% of your income, it makes one somewhat disinclined to give more. It is no accident that charitable giving in (relatively) low-taxed America dwarves that of high-tax Europe.

There are 49 million Americans who are uninsured. There are diabetics dying of lack of medical care in the USA. I worked on the south side of Chicago (the wrong side of the tracks, believe me) and have seen it. The USA has pockets of good health care. We spread it more evenly, albeit more thinly

But, in the Victorian era, big businessmen tended to give large amounts of money to charity. Many of them did so out of what was ultimately a profit motive—those entrepreneurs who built housing for their workers in order to maintain a tied workforce, for instance, or just for the pleasure of seeing a plaque above a ward that they had built—but is there any quintessential reason why should this not happen again?

DK you accused me of not knowing what “fascist” means. I now accuse you of knowing nothing about medical and social care for the poor in Victorian England. Start by reading some Dickens.

(cut a bit there)

An independent “not-for-profit” organisation will not survive unless it is government subsidised and thus insulated from the realities of the market. And if it is so insulated, no private company can compete against it.

This is, of course, absolute crap. A "not-for-profit" organisation is allowed to make a profit (see almost all private schools and the vast majority of charities) but that profit is not allowed to be disbursed to the directors (above and beyond their agreed renumeration). The profit must be ploughed back into the organisation. This absolutely does not mean that every "not-for-profit" organisation has to be government-funded.

No no no, DK, you are being over pedantic. We are talking about “markets”. You cannot survive in the market if you are competing against organisations that have an inbuilt unfair advantage. I don’t agree with your economic analysis.

However, it is true that government-funding does provide a barrier to private enterprise.

An insurance based system merely substitutes a private, profit driven company for a government run organisation.

This is a particularly flippant line; yes, a private health insurance system replaces the government one, that is the entire point.

You may take it as flippant. I don’t. You are making the fundamental error of assuming that which is to be proved. There is no hard evidence that an insurance based system is ipso facto the best. It has advantages and disadvantages.

Now, Dr Crippen who has, as I have mentioned before, private health insurance for himself and his family, obviously believes that he gains from that insurance. He gains a better service than that which he himself works for.

Oh cheep, cheep. I have private health insurance be caseu the NHS is crap. But I can afford it. Many can’t. And that is wrong.

So, why is he slamming a private insurance system that he himself is taking advantage of? Two-tier health-system? We already have it, John; and you have happily ensconced yourself in the upper tier of that system.

True, true, true - in both health and education. It did not use to be like this. It does not need to be like this. Successive Labour governemnts destroyed the best state education system in the world and are now destroying what used to be the best health system in the world. I suspect we are in agreement there.

I don't blame you for doing so, at all. However, it is rather hypocritical of you to criticise a particular system when you believe that that system is going to provide you and your family with a better standard of healthcare and then deny access to that system for everyone else.

Doctrinally motivated health care economists will argue for one or the other, but there is no moral, or economic, absolute.

Well, I quite agree. What we should look for is the way that best delivers care to the customers who require it, as we do in any other area. A national monopoly doesn't do that.

I agree. Which is why I was so disappointed by the Libertarian new policy which, although only in outline, starts from the wrong place.


It doesn't even terribly matter as to whether or not our spending as a proportion of GDP rises as long as there is a commensurate return in terms of productivity. What has been so irritating about the money poured into the NHS is that productivity has dropped.

But no system is perfect so what we want is a proliferation of many systems and a state monopoly does not help that at all.

Take a look at this article in Fortune magazine which describes the anomalies thrown up by a private insurance based system.

Indeed it does. But what that article also makes clear is how much government interference in free markets has led to the less than satisfactory state of the US healthcare industry. It is, for instance, the fault of the government that most healthcare plans are tied, not to individuals, but to jobs. Here's a taster:

McCain's main pillar is the elimination of a tax break that employees receive if their employer provides their health care. That may not sound like a shocker, but it is. The exclusion dates from World War II, when the federal government imposed controls on wages, but allowed companies to compete for workers by offering tax-free health benefits in lieu of pay. The law is largely responsible for the nightmarish patchwork of corporate-provided medical plans we enjoy so much today. Employees and their unions demanded richer and richer packages, and employers complied, since they could buy far more benefits for their employees than workers could buy with after-tax dollars on their own. Americans have paid a steep price, however, by sacrificing their raises as corporate insurance bills exploded, never more so than now.

Well, that is interpretation. You can read that article in several ways and, don’t forget, it was written by a Republican supporter

Inevitably, this has also cut the choice of insurers and the flexibility of the consumer. Not an ideal situation and certainly not one that LPUK would endorse. But, let us return to the good Dr Crippen's piece...

We need a fresh start, free of doctrinal absolutes.

Well, OK. And your suggestion is...? Oh, you don't have one. Fine.

Bollocks. I have lots, and have written about them frequently. See below.

What, in any case, are "doctrinal absolutes"? Do i believe that the free market works best because that is my doctrine? Or, do I believe that free markets work best because all of the evidence that is available shows that they do?

In my case, it is the latter. Free markets are not perfect, but they are the best option. We have tried most combinations of the other options and they simply do not work anywhere near as well.

I have never really understood the UK medical profession's hostility to trying another system; after all, they as much as anyone, are shafted by the government's monopoly.

Nurses in London are substantially worse of than nurses in the middle of Yorkshire, for instance.

Junior doctors are churned out of medical schools only to find that, due to the state's incompetence, there are no training places or jobs for them.

The state's inability to plan has meant that we have been forced actively to import foreign agency prfessionals; and this not only denudes poor countries of much-needed trained staff, but linguistic misunderstandings lead to an overall diminshing of the reputation of all medical staff in the country.

Above all, we need to admit the fact that no country can afford to provide the full range of modern health care for all its citizens. Health care has to be rationed. We need a front end charge, appropriately safety netted, to stop the worst of the abuse.

Well, OK. But who is going to abuse the system the most: those who get it for free or those who pay for it?

We need to find a politically acceptable way to explain to the citizens that they can no longer have it all “for free”. Free health care was always an illusion, buttressed by the NHS with its ludicrous "free at the point of entry" mantra. The illusion has had dire consequences. It has fuelled the demand for health care to unsustainable levels.

Well, yes, Doc; that's fine. And the relevance to the LPUK policy is...? We would abolish the NHS; that is no secret. Do we think that we should look into feasible alternatives? Yes. That is why we decided to develop policy in our forums. Amongst other things, we have a few medical doctors and medical managers in there who can give us their opinion from the front lines.

Wow. I missed that in the LPUK statement. Your platform will include “the abolition of the NHS”. Politics is usually defined as “the art of the possible”. A political party without power is only a talking shop. However well meaning you are, a policy of abolishing the NHS is likely to be as electorally successful as abolition of the monarchy.

You are welcome to join in and contribute, my dear Crippen; you do not have to sell us your soul, nor even join the party in order to join in the discussion: we will happily accept advice from anyone.

The choice is simple. Acknowledge the inevitable and take control or bury your head in the sand, pretending all is well, as stealth rationing and the surreptitious erosion of health care standards allow the NHS to lapse into a two tier system in which only the rich can access good medical care.

Now, this is a slightly bizarre finishing paragraph; the good Doctor appears to be contradicting everything that he has said previously.
Well, that would not be the first time!! But, actually, I don’t see how that contradicts anything.

Crippen has acknowledged that we need to ration healthcare, and that we need to charge for it. Presumably, he would also not object if people paid for additional treatments. But surely this would "allow the NHS to lapse into a two tier system in which only the rich can access good medical care".

What is "good medical care"? Presumably, we want everyone to access adequate medical care; as I outlined above, if the rich are happy to pay more for silk sheets, thus allowing the hospitals to subsidise the care for the poor, is this not a god thing?

But the main point is that if people are actively paying for their health insurance, then they are going to take more care of themselves. As Crippen correctly points out, the "free at the point of use mantra" is completely stupid because it makes people think that it is, in fact, free.

Of course, for those who don't work and will never work, the health system is free. For the rest of us, however, it is very expensive.

Is it right that someone who has paid 11% of their salary for the last thirty years should get the same treatment as someone who has paid absolutely fuck all for the same time? Of course it isn't. We wouldn't think that was fair with any other system, so why with health.

At the same time, is it right to leave people dying in the streets because they have never paid a penny towards any medical facilities? No.

And that is the difficult tightrope that one has to walk and, as far as I am personally concerned, the solution is private charity. Let those who care about our fellow man (and, yes, I would give money voluntarily were I not losing vast amounts in tax, just as I have given to various bloggers who have appealed for cash (and other bloggers have shown the same courtesy to me, at times)).

Because I believe that all of this rubbish that Cameron comes out with, about the "broken society", has been caused by the state, and the state cannot fix it. Take away that monolith that has allowed us all to retreat from our fellow man and I think that you will find people to be unexpectedly generous.


* This is a theme that I have amplified before. However, the gist of it is that the reason that the government feels that it can dictate what we eat, smoke, drink or otherwise put into our bodies is because the state "pays" for our wanton lifestyles through the NHS.

Actually, it is we taxpayers who pay for the NHS and that applies even if you have private insurance. I have private health insurance, but I am still not allowed to opt out of the NHS completely, so the state still feels that it can tell me what to do.

In this way, the financial lever that the government holds also leads to their hold over the civil liberties lever too.



Gosh, this is all far too long for a comment. Should be a post, really. Let’s not get side tracked by a couple of bon mots like “fascist hyena” - the important thing is health care.

Any new health care policy must first define what it is trying to achieve. That is where the Libertarian Policy was disappointing. Straight into “process” without first defining objectives. Am I to infer that the Libertarian Party is going to abolish the NHS, charge the economic rate for health care, provide it for those who can afford it (with or without insurance) and let the charities pick up the slack? You cannot be serious.

I would suggest the following:

A reasonable standard of health care shall be available for all UK citizens without regard to status or income.

Then we can move on to decide how we provide it, and we must approach the problem without the shackles of old fashioned political mantras. We certainly need to charge for health care, on the front end, with safety netting. I suspect we need a hybrid government funded/insurance based system. We have to grasp the nettle of rationing health care and I don’t know how we do that. Can’t see the Queen eating her rations with the common folk.



Phew



John

Trixy said...

Didn't realise the market had nothing to do with health care. I wish someone had told me that when I was studying economics as I could have had even more time off.

Merit good anyone? anyone? laffer curve? anyone?

Steve_Roberts said...

Trixy:"Didn't realise the market had nothing to do with health care."

Nor did I. All those people who chose to train as doctors had no other choices ? All those doctors who chose to work for the NHS had no other choices ? Medical skills not intrinsically scarce ? The only way to organise healthcare by conscription ?

Dr Crippen is good at defining the problem, but he refuses to see the nature of the solutions

sjm said...

'A reasonable standard of care should be available for all UK citizens without regard to status or income' says Dr C.

And who will define reasonable standards? How would you get overwhelming agreement on the following:

Elective plastic surgery for cosmetic reasons?

IVF?

Abortions for social reasons?

Liver transplants for active alcoholics?

Free contraception?

Treatment for ME?

etc, etc.

Bishop Brennan said...

'I have never really understood the UK medical profession's hostility to trying another system; after all, they as much as anyone, are shafted by the government's monopoly.'

Actually, doctors (specifically, consultants), as anyone else who works in the NHS will tell you, are often the chief beneficiaries of the NHS. As are GPs, who earn a lot more in the UK than in other European countries...

But let's leave that aside - I, for one, would welcome the Good Doctor to the LPUK's discussion on health.

And yes, I think that the 1st step is a Government-funded market - supply-side reform. But when we get there, the sheer costs of modern medicine will mean that risk-adjusted insurance will be a necessity...

Richard said...

So an NHS employee admits that "tax is a bad thing".

Excellent; that's a start - one down, 1,299,999 to go.

Rory Meakin said...

John Crippen needs to work out what exactly it is he is for.

“A reasonable standard of health care shall be available for all UK citizens without regard to status or income…. We have to grasp the nettle of rationing health care and I don’t know how we do that.”

I mean – which is it?

“The Libertarian Party has published a poster on the DK’s site itself suggesting the abolition of income tax. The TPA has said it is against all tax rises. Both propositions are, in my view, unworldly”

To an extent this is true. Cutting tax by so much that income tax could be abolished is completely outside mainstream current political agendas. But why? Perhaps because those people who might actually agree with the propositions ridicule them because they do not yet have mainstream political support?

Crippen also needs to work out whether he’s in favour of charity or not.

Sometimes he disparages it: “Ah.... you want the poor to be “charity cases”, to be dependent on the begging bowel. Shall we have work houses as well?”

Sometimes he’s all in favour: “If you really want a high standard of health care available to all, independent of means, than absolutely, yes, some of it has to be funded by the tax payer. There is no alternative.”

After all, what is state-funded help for the poor if not compulsory charity according to the moral sensibility of the largest party in parliament?

Is there really ‘no alternative’ to compulsory state charity? Without the drain of higher taxes on the economy and people’s prosperity, not to mention their post-tax incomes, might not there be an alternative in voluntary charity? Might voluntary charities not be more effective at getting help to those in need than the compulsory charity we currently have?

Savonarola said...

"Compulsory charity"?? there is not such thing. Charity is giving out of the goodness of your heart with no thought of what you will get in return.
When you are taxed, you are, whether you choose to avail of them or not, getting certain services as a citizen of your country for free. Possibly an education, unemployment benefit till you find work again, free healthcare, a (mediocre) state pension, possibly a fuel allowance etc etc. You are, like everyone else who is taxed, getting something out of it. It just might not be something you want right then. I would not depend on the "charity" of other people to fund medical care, social housing etc etc. People do not, as a rule, give a lot when they have the option of keeping it all for themselves. There are exceptions, of course.
But would you give to charity what you are being taxed now? Despite some probable financial mismanagement, it is barely enough to keep services going as it is. The decrease in available funds for "charitable cases" would cause the "charity" system to collapse altogether.

lettersfromatory said...

"You cannot apply market economics to the provision of universal health care"

Absolute rubbish. The failure to apply market economics is precisely why we have ended up in this mess in the first place.

Anonymous said...

Dr Crippen

Can I just point out that most commentators put the quoted text in italics and their own additions in standard text. I understand that there's no hard & fast rule but conventions make things easier for everyone.

Rory Meakin said...

"People do not, as a rule, give a lot when they have the option of keeping it all for themselves. There are exceptions, of course.
But would you give to charity what you are being taxed now?"


Of course not. You're absolutely right. People are much more generous when spending someone else's money. Other people are much more keen to spend my money on things they want to spend it on than I am. That's the nature of these things.

cookie said...

Bravo, Devil.

The blogdoc criticises both the NHS and the private sector alternatives, in the same sense that the BBC criticised the last Tory government and the previous Labour one of Blair - both considered insufficently Statist.

That the blogdoc is so heavily linked by conservative and libertarian bloggers suggests that great numbers have been fooled into thinking he sees the inherent systemic faults of the NHS and the need for radical change. No such luck, of course. Is there a blogdoc out there who does?

david said...

The big flaw in blogdoc's argument for "up front charging" for GP appointments is that under the NHS system the charges will, like prescription charges, be just another tax. Unless he envisages GPs being able to pocket these charges as additional income?

The reason why GPs rail at the idea of a continental-style insurance based system because, historically, medics in continental Europe have been paid less than their British counterparts. This is their prime motivator for retaining the current system - it has served them very well financially for the past 60 years. Shame that the rest of us as patients have had to suffer the consequences of a health system which has never been fit for purpose.

Rory Meakin said...

Generally, we should be just as highly suspicious of the doctors when they get together in the form of the BMA as we are with other trade unions.

As david (above) highlighted, their conversation ends in a conspiracy against the public, or in some contrivance to raise prices.

Θεμις Μαντζαβινος said...

Hi

It is a very nice and good post and I like it.