Friday, 20 June 2014

Bracken's Law and the NHS

Everyone knows Godwin's law:

"As an online discussion grows longer, the probability of a comparison involving Nazis or Hitler approaches 1". 
Some then suggest the law says 
"and whoever does so, has lost the argument".
In discussing healthcare, I propose this law: 
"The longer any discussion about the NHS goes on, the closer the probability a spurious invocation of the US system of healthcare gets to one, and whoever does so has lost the argument".
If you are reading this post, there is a good chance you've been sent this way, by me, during an exchange on Twitter. Before we go further, let's be clear what I actually believe on the subject. 
  1. I am in favour of free(ish) at the point of delivery services.  By Free(ish) I don't rule out the likes of Prescription charges and nominal charges to see a GP or charges for missed appointments, which seem like reasonable demand-management to me.
  2. I am in favour of Tax Payer funding of healthcare. I cannot see any practical difference between compulsory insurance and tax-payer funding. Insurance is just risk-pooling. Taxpayer funding is a bigger risk pool. 
  3. The NHS isn't very good. And it isn't very good principally because of its vastness and consequent bureaucracy, not because of its funding mechanism.
  4. More competition is necessary. And competition isn't about firms competing for government monopolies, that's mere crony capitalism, a kind of cargo-cult market that achieves nothing a market should do, and simply allows firms to profit from state monopolies. Competition means the funds following the patient, with the GP as gatekeeper and advisor to the patient.
So, if you accuse me of favouring insurance companies, or wanting companies profiteering, you're arguing against a straw man. 

In international comparisons, the NHS often comes out well. The recent study by the commonwealth fund, whose report led the Guardian to proclaim the "NHS is the World's Best Healthcare System". However that is using patient-satisfaction survey data, and measures of cost. The Guardian's own report contains the remarkable passage: 
The only serious black mark against the NHS was its poor record on keeping people alive. On a composite "healthy lives" score, which includes deaths among infants and patients who would have survived had they received timely and effective healthcare, the UK came 10th.
Basically, the commonwealth fund finds the UK healthcare system cheap. This is because private-sector, insurance-based provision is effectively banned in the UK as co-payments are not allowed. You cannot top-up your healthcare. We spend about the same as most of Europe on state healthcare, without asking people to top up through insurance, as most of Europe do. Thus we have barely adequate healthcare, but which is very inexpensive. This is why the UK scores well on "efficiency".

Ease of access and equality are based on Patient-reported surveys. And as the NHS is healthcare in the mind of most Britons, and such surveys are skewed towards patients who, ahem, survived, then I can't see such data's all that reliable. It's just a reflection of the almost mythical, religious support Britons have been brainwashed into giving what politicians STILL call "the envy of the World".

Where the data does stack up is the NHS's excellence in dealing with Chronic conditions. Here the ability to marshall resources and the bureaucracy to back it up helps. The problem in the NHS is the customer facing bit - particularly diagnosis and A&E. This is where patient choice and a functioning market with competing providers would make all the difference. Once in the machine, the NHS functions as a first-world healthcare system. Getting into the machine requires sharp elbows, luck and knowledge. Delays in getting into the machine are behind the NHS's poor record in combating cancer in particular. There is very little immediate punishment for failure, which is too easily covered up; South Stafford Hospital for example.

The sooner the NHS starts treating its patients as customers for whose business they compete, not an irritating cost to be borne by the long-suffering nurses, the sooner the NHS will warrant the plaudits lefties so desperately want to give it.

But in prioritising "efficiency" over "keeping people alive" in order to give your pre-chosen answer (a state-run system) a big gold star is a bit desperate, and nothing short of policy-based evidence making. Or as I prefer to put it, immoderately, LYING.



Thursday, 5 June 2014

On the Right of Recall

I'm not a fundamentalist on this issue. We have a right of recall, it's just we might have to wait a few years to exercise it. Neil Hamilton was booted out by the electorate in Tatton in 1997 and now pathetically plods along, embarrassing UKIP rather than the Tories. Tatton was the fourth safest Tory seat.

The problem is how to deal with politically-motivated, opportunistic attempts at recall. It's easy to see a situation where an MP in a marginal constituency could face a recall petition simply at the behest of a (and it probably would be Labour) party in order to discomfit the Government and take advantage of mid-term unpopularity.

So while I like, in principle, a right of recall, In practice, I'm comfortable with a committee of MPs as a filter for vexatious recall petitions.

I expect lots of "How can you call yourself 'Libertarian'?" rants from the perma-outraaged in the comments. Democracy doesn't mean giving the people what they want, all the time. Nor does 'freedom and the rule of law' mean pandering to every whim of the mob. Indeed quite the opposite. We have a responsive democracy in the UK. It ain't broken, so doesn't need much fixing.




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