The coalition’s plan now is to dismantle the NHS


11:20 am - July 12th 2010

by Imran Ahmed    


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The Coalition, now in its most confident phase, is starting the process of changing the fabric of Britain to reflect its shared beliefs.

This morning a close friend, chair of a Northern Primary Care Trust, contacted me for help with an article he was writing on the Health Secretary, Andrew Lansley’s, plans to shift “power” to GPs.

My friend, a former GP with 30 years experience, was flummoxed by the decision to ask primary care clinicians to become the key actors in the NHS’s economic and disease management alongside their current role as patient need managers.

The thinking behind this is predicated so clearly on the free market fundamentalism that both Cameron and Clegg so dearly share: that many decisions, taken at an individual level, will eventually create the right pricing of consumables and equipment, the right mix of services and the right outcomes for patients.

This seems a grotesque idiocy for a number of reasons. After all, we live in a time in which market failures have led to a worldwide recession. But also in a time in which the world’s most privatised healthcare system, the United States, is desperately trying to dial back the damage done by micro- and macro-market failures on people’s health.

Indeed, no-one that deals with markets on a daily basis (as I once did in my early career) thinks that markets come out with rational and unimpeachable equilibria. Markets are wonderfully erratic, complex and ridden with human frailties like herd behaviour, irrationality and manipulation through covert action.

So the idea that creating a market of GPs, most of whom would be cluelessly stumbling through epidemiology, health economics, procurement and other features of health system management that they are completely unprepared for, would create an optimal system is simply ludicrous.

The next step might be the eradication of NICE, a health economics body that is unparalleled anywhere in the world despite the covetous eyes which health ministers direct towards it.

Surely doctors can, the LibConTricksters would argue, decide through market mechanisms what the price of a drug should be and the relative efficacy of that drug vis-a-vis competing therapies. GPs simply do not have either the specialist knowledge, the time or the inclination to carry out the detailed comparative studies and economic analyses required to make a go of this initiative. It will place intolerable pressures on clinicians to vitiate the purity of their need-led approach to patient care and instead consider all manner of economic and other factors.

GP practices are clinical enterprises, not businesses, nor sophisticated Government bodies with the complex range of skills and expertise to use tax payers money sensibly to get the best for less.

It will end up costing billions, in the short-term eviscerating the quality of patient care, and eventually setting us up for the wholesale privatisation of the NHS. Hyperbole? Not at all. The necessary next step after diversifying purchasers is to increase competition among suppliers of secondary care; hospitals, etc.

This will, and we can look to the Orange Book for the answer, be provided by wholesale privatisation of the NHS as a supplier of healthcare into a plurality of atomised healthcare suppliers.

We are inexorably going to be moved away from our traditional NHS approach to one ruled by the false idols of choice, competition and diversity of suppliers. Idols that would prove disastrous for the equity, efficacy and efficiency of Britain’s healthcare.

Remind me, how many Lib Dem voters voted for this: the eradication of the most progressive institution of the 20th Century?

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About the author
Imran is an occasional contributor and Labour party activist. He blogs here and is on Twitter here.
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Reader comments


Stop moaning, and start working out how to pay off debt whilst never ever raising taxes or cutting spending. See?

@roberto, the point is that this scheme *isn’t* a money-saver, it’s ideologically-driven stupidity which will end up costing us more. Read the piece.

3. Rowan Davies

Bang on. This White Paper is shaping up to be absolutely terrifying. And, as Allyson Pollock has pointed out, it seems that the statutory duty to provide healthcare free at the point of use – which the Conservatives made proposals to abolish in 2007 – is not mentioned anywhere in this new legislation.

Well, I suppose running this country into the ground and removing the light that attracts so many continental moths is one way to reverse the population/immigration growth.

I think the consensus still shows that most Brits believe a certain South American dictator could run the country better than Cameron … http://bit.ly/chvza

Indeed, no-one that deals with markets on a daily basis (as I once did in my early career) thinks that markets come out with rational and unimpeachable equilibria. Markets are wonderfully erratic, complex and ridden with human frailties like herd behaviour, irrationality and manipulation through covert action.

Centralised state control is so much better at this sort of thing. The dropped bedpan in the cottage hospital must echo through the corridors of Whitehall.

There may or may not be a covert coalition plan to dismantled the NHS but, for the present:

(a) “The National Health Service can make the £15bn to £20bn of savings needed during the next three years without damaging the quantity or quality of care – indeed while even improving the latter – according to David Nicholson, the NHS chief executive.”
http://www.ft.com/cms/s/0/6fba7dfe-e683-11de-98b1-00144feab49a.html

(b) “The NHS has seen a year-on-year fall in productivity despite the billions of pounds of investment in the service, latest figures show. The data from the Office for National Statistics showed a fall of 2% a year from 2001 to 2005 across the UK.”
http://news.bbc.co.uk/1/hi/health/7610103.stm

(c) Several independent commentators are highly critical of Lansley’s planned upheaval of NHS management:

“Chris Ham, chief executive of the Kings Fund health think-tank, said: ‘There is a real risk that people will be distracted and preoccupied with this huge organisational change, just at the point where they need to be increasingly focused on productivity and efficiency.’”
http://www.ft.com/cms/s/0/dc1eee7c-7a25-11df-aa69-00144feabdc0.html

“Moves to transfer commissioning responsibility to GPs could cost the NHS its £20 billion efficiency savings target, and worse.

“The coalition government’s White Paper on the NHS is due to be published next week. It is widely expected to outline plans to hand control of as much as £80 billion of resources in the NHS from Primary Care Trusts (PCTs) to consortia of GPs.

“Analysis by the independent think tank Civitas suggests such moves are likely to:
– Lead to at least a one year dip in performance in the NHS in absolute terms.
– Set the NHS back at least three years relative to what could be achieved without any structural change.”
http://www.civitas.org.uk/press/prcs_GPcommissioning.php

Neither the King’s Fund nor Civitas are ordinarily regarded as “leftist”, which makes their criticism all the more worrying.

7. Flowerpower

I’ve just come back from my doctor’s surgery and I don’t think Lansley is going far enough. The first and most prominent sign in reception told me that the car park was absolutely out of bounds for patients and for use only by doctors and health centre staff.

That’s the NHS all over: everything run for the convenience of the NHS staff, no thought given to the convenience of patients. Any chance of my follow-up appointment being outside normal working hours, so I don’t have to take a second morning off work? Ah well, they are thinking about having an evening surgery, but it won’t happen ’til the autumn.

After 60 years they’re “thinking about it”.

I suspect things would sharpen up if money followed the patient and the patient had choice upon which practice to bestow his/her custom.

Outside in the carpark BTW, 11 bays out of 16 were empty. Of those being used two were occupied by Porsches FFS.

I wonder which idiot bureaucrat directed 100 grand of NHS money into a sub-optimally utilized private carpark for playboy clinicians?

As reported, under Lansley’s announced proposals for restructuring NHS management, GPs will become responsible for commissioning c. £70 billion of annual NHS spending. The Primary Care Trusts (PCTs), hitherto charged with commissioning, will be wound down and strategic health authorities abolished.
http://news.bbc.co.uk/1/hi/uk/10565668.stm

Reported critical comments say some GPs lack the range of specialist knowledge and skills for commissioning treatments.

Another huge concern is financial control – suppose the rate of GP commissioning starts outrunning the (? reduced) budgetary provision for England or for London for the current quarter or the year. What happens then? Presumably, official alerts to GPs will be issued but will that lead to many GPs clamping down on commissioning regardless of clinical need?

I stopped reading when you called US healthcare a free market system.

#6 Bob B

“The NHS has seen a year-on-year fall in productivity”

The ONS who produce the figures say that productivity in the NHS is very difficult to measure, and they include capital spending in their measure, since the Thatcher/Major years were 18 years of under investment it means that a large amount of that capital expenditure is what should have been done during their regime.

A much better way of looking at the NHS is the outputs compared to the number of employees. In the period 1997-2007 the NHS workforce increased by 28% yet the outputs increased by 53%. See that is a HUGE increase in productivity.

This sort of rambling drivel is never going to win any argument about anything. It just reminds me how glad I am that we’ve got a government that’s going to stop paying people like this to tell me how to live life.

@11 spot on

#7. Flowerpower

I’ve just come back from my doctor’s surgery and I don’t think Lansley is going far enough. The first and most prominent sign in reception told me that the car park was absolutely out of bounds for patients and for use only by doctors and health centre staff.

Oh FFS. This is nothing to do with the NHS. If you are talking about your GP then you are talking about a private business and Lansley’s plans will give you more of this. GPs are contracted to the NHS but they are NOT publicly owned. In the past, in England, some GP services could be owned by PCTs (public bodies). From April this year PCTs have not been allowed to provide any service s(they have had to divest their “provider arms”).

So basically you are complaining about the private business (unaccountable, but funded by the taxpayer) and saying that you want more of this unaccountability and more funding by the taxpayer? This sort of nonsense is what the 30 spin doctors at the DoH are paid to spread.

[moderated out]

Probably the least coherent and plain wrong post on LC this year.

many decisions, taken at an individual level, will eventually create the right pricing of consumables and equipment, the right mix of services and the right outcomes for patients.

That’s correct.

This seems a grotesque idiocy for a number of reasons. After all, we live in a time in which market failures have led to a worldwide recession.

False, but irrelevant if it were true.

But also in a time in which the world’s most privatised healthcare system, the United States, is desperately trying to dial back the damage done by micro- and macro-market failures on people’s health.

False, but irrelevant if it were true.

Indeed, no-one that deals with markets on a daily basis (as I once did in my early career) thinks that markets come out with rational and unimpeachable equilibria.

Where’s Tim Worstall?

The next step might be the eradication of NICE

Not before time.

GPs simply do not have either the specialist knowledge, the time or the inclination to carry out the detailed comparative studies and economic analyses required to make a go of this initiative.

Oh FFS, everyone knows they only dole out anti-biotics, anti-depressants and look at the occasional rash. Lets get back to the days when they doled out the stuff from the guy who offered them their last golf holiday.

It will place intolerable pressures on clinicians to vitiate the purity of their need-led approach to patient care and instead consider all manner of economic and other factors.

Have you considered that “the purity of their need-led approach to patient care” is wasteful and may no longer be affordable?

GP practices are clinical enterprises, not businesses

False.

sophisticated Government bodies with the complex range of skills and expertise to use tax payers money sensibly to get the best for less.

This is satire, right?

the wholesale privatisation of the NHS as a supplier of healthcare into a plurality of atomised healthcare suppliers.

Yep, that’s what we need.

That’s exactly what we need.

Have a read of this http://www.healthpolicyinsight.com/?q=node/530

Here’s somethings to think about:

1. If your GP commissions patients to go to a hospital where you do not want to go, can you demand your choice?
2. If your GP commissions themselves rather than a specialist to treat you, can you demand the specialist instead?
3. If your GP is running a deficit, will your treatment suffer? Do you have the right to move to another GP?
4. Will all GP commissioning decisions be made public and accountable?
5. Will GPs be allowed to ignore the “commissioning guidelines” that will be created by the “independent” NHS Board?
6. Will clinical decisions ALWAYS override funding decisions?

This plan is fraught with problems and it is a huge experiment. The last time it was tried (GP fundholding 1991-1997) it was voluntary and resulted in 7% fewer patients being referred for specialist treatment from fundholding GPs than non-fundholding GPs. That means that 7% fewer patients got the treatment they needed from specialists. It also meant a similar cut in the funding of hospitals.

This final point is the most important. I think that the real reason behind GP commissioning is that Lansley wants GPs to close NHS hospitals. Such “local decisions” will mean that he will have no blood on his hands.

17. Flowerpower

Richard blogger @ 13

It isn’t a ‘private business’, it’s an NHS community health centre with NHS on the sign and all sorts of other stuff as well as the GP practice.

“the wholesale privatisation of the NHS as a supplier of healthcare into a plurality of atomised healthcare suppliers”

You are aware that (the generally admired) healthcare in Europe is provided by such a plurality, aren’t you?

Mysteriously such systems do seem to work at least as well, indeed better, than the NHS.

These reforms may do good or they may not.
But to claim *a priori* that they will not is simply wrong.

19. Alisdair Cameron

It was (New) Labour’s ‘direction of travel’ too. From the purchaser/provider split to FTs, the drive was all about marketisation, and allowing entry to the private sector.Fragmentation, competition ahead of cooperation or a joined-up NHS, and cherry-picking by those private sector entryists didn’t seem to both New labour. They undermined the foundations, which is what is making is so bloody easy for the Tories to demolish.

#15 pagar

Nonsense. There are 152 PCTs. The earlier this year in response to the need to make “efficiency savings” SHAs decided to create PCT clusters, so four or five PCTs would work together and share management as a cost cutting exercise. This is economies of scale. So what is Lansley intending to do? He wants 500 “commissioning consortia”. So there will be ten times more organisations doing commissioning, and in any locality on consortium will be replicating the work of the neighbouring consortium. Since there will be so much duplication, the management of these consortia will cost MORE not less than the PCTs.

Let’s look at the spin shall we? The Nuffield Foundation says that this plan will cost £1.6bn. The reason for this is that GPs will be allowed to keep surpluses (at the moment we do not know what proportion will be profits – sorry, incentives – and what proportion has to be re-invested in more services). However, studies have shown that for every GP practice that makes a surplus another makes a similar sized deficit, and under the current funding arrangement these even out within a PCT. But under Lansley’s plan there will be no surplus from the more efficient GPs to pay for the deficits from the less efficient ones. This is the “free market”, the GPs making the deficit will have to cut treatments or go out of business. Tough shit if they happen to be in an area with a localised healthcare issue like asbestos or coal dust, or in an area with a higher than average proportion of the elderly. Or maybe the Department of Health will pay these deficits? Well it is estimated that these will be £1.6bn.

Now we hear from the Department of Health that they expect this plan to cut commissioning management costs by £1.6bn (interesting that it is the same as the Nuffield figure, eh?), but when you look closer into it, this is the cost of management of PCTs at the moment, so basically the spin doctors are saying that GP commissioning consortia will do the work for free. Since there will not be the economies of scale, and that many consortia will be duplicating the work of others the likelihood is that management costs will go up. More management, less healthcare.

Imran Ahmed: “Surely doctors can, the LibConTricksters would argue, decide through market mechanisms what the price of a drug should be and the relative efficacy of that drug vis-a-vis competing therapies.”

I think you’ll find that in power, the “LabourTricksters” were largely of the same opinion. They were very keen on internal markets, and indeed went far further than the previous Tory government on the subject. They tried to implement schemes for GP commissioning of NHS services at least twice (in 1998 and 2005). To suddenly oppose it in opposition because it’s unpopular is just cynical.

I agree it is a stupid idea, though, for the reasons you state, plus the fact that it’s also a method of covert diversion of funds to private healthcare. I can imagine practices in wealthier areas will tend to spend their allocation on part-subsidising their patients’ private healthcare (which previously the patients would have voluntarily paid for). I would also not be at all surprised if practices in poor urban areas find themselves ending up with less money to spend per head, since fewer of their patients go private.

Also one consequence of GPs lacking time and expertise to do this commissioning will be healthcare corporations offering services to do it for them, introducing middlemen (sometimes with large conflicts of interest) at considerable extra cost.

Of course, all that makes it obvious why all parties are in favour of it, when in government. They will receive immense corporate lobbying (directly and via subsidised think-tank research) for it to be implemented.

@7: “Outside in the carpark BTW, 11 bays out of 16 were empty. Of those being used two were occupied by Porsches FFS.”

According to this survey in 2005, British doctors are among the best paid in Europe:
http://www.timesonline.co.uk/tol/news/uk/health/article758105.ece

Check out the league tables of an independent Swedish think-tank – Health Powerhouse – for healthcare systems in other west European countries:
http://www.healthpowerhouse.com/files/canadaIndex03.pdf

The NHS rates as mediocre compared with healthcare systems in most other west European countries.

Credit for starting a national welfare state funded out of tax revenues must surely go to Count von Bismarck, first Chancellor of the German empire (1871-90), who launched not only state pensions for the aged but, in 1883, a social insurance scheme to cover personal healthcare costs:
http://en.wikipedia.org/wiki/Otto_von_Bismarck#Chancellor_of_the_German_Empire

Whatever else, Bismarck was not renown for his socialist inclinations.

Comparative data showing public spending on healthcare services in affluenent countries as a percentage of national GDP is accessible in the OECD Factbook:
http://puck.sourceoecd.org/vl=3625314/cl=13/nw=1/rpsv/factbook2009/10/02/01/index.htm

My thoughts?

Doctors won’t have time to do all this nonsense, so will subcontract it out to some ‘efficient’ private company like, god forbid, Craprica.

This is privatisation through the back door plain and simple.

I hate this whole choice argument in the NHS, it’s a total misdirection. Nobody gives a crap about ‘choice’, they just want to receive a good standard of care quickly and efficiently at their local hospital/GPs/clinic.

Somehow if you give patients more ‘choice’ (to do what, drive 100 miles to another hospital to get the same procedure done for the same cost on the off chance it might be slightly ‘better’) the problems with the NHS i.e. lack of funding and masses of bureaucracy, suddenly bugger off.

I can’t roll my eyes in a large enough manner.

24. Rowan Davies

agree @19

What is the objection to NICE? Is it that it occasionally offers a pipsqueak’s-worth of objection to wholesale profiteering by Big Pharma? Or is it just that it’s tremendously successful?

@10: “A much better way of looking at the NHS is the outputs compared to the number of employees. In the period 1997-2007 the NHS workforce increased by 28% yet the outputs increased by 53%. See that is a HUGE increase in productivity.”

“The NHS inparticular has experienced substantial growth, with average annualised real increases of 3.2 per cent under the Conservative governments from 1979 to 1997, and 6.3 per cent under Labour from 1997 to 2008.” [IFS Survey of Public Spending – p.15]
http://www.ifs.org.uk/bns/bn43.pdf

I’ll need a lot of convincing that patient outputs have risen in proportion.

From what I read online, 5-year cancer survivial rates in Britain are still lagging those in most other west European countries.

Hey, look over there, a “free market fundamentalist” is trying to sell off the NHS! Quickly, everybody panic! We might end up with something like the Swedish model where the state provides the money, not the services, and healthcare might be immeasurably improved (as it was over there). Such a thing cannot be permitted!

I am staggered by the amount of waste in the NHS, and foremost in that waste are the primary care trusts. New Labour could have built new hospitals with the extra money it invested in the NHS. Instead, it *closed* hospitals and set up the PCTs, which have never done anything useful.

27. Rowan Davies

Swedish healthcare is comissioned by elected county councils or municipalities, not profit-making bodies. Seems a fairly salient difference from the Lansley plans. These councils have a statutory duty to provide good-quality healthcare to all citizens – still waiting to hear which statutory duties will fall where in the Lansley plans, if they are spelled out at all.

Health care is also not entirely free at the point of use in Sweden (although it is largely).

Swedish spending on healthcare as a proportion of GNP has been around about the 10% mark for decades; only since 1997 have UK levels of spending started to approach this figure. If you’re looking for explanations of Swedish excellence in health, that might be a place to start.

I didn’t see you give any source for the comment about NICE. Of course, unsourced claims that someone might do something are the bread and butter of dodgy fear stories, so I’m sure you’ve got a good source 🙂 So would be interested to know what it is?

Richard @ 20

But under Lansley’s plan there will be no surplus from the more efficient GPs to pay for the deficits from the less efficient ones. This is the “free market”, the GPs making the deficit will have to cut treatments or go out of business.

Or become more efficient.

The problem we have is that demand for healthcare services, provided free at the point of delivery, is effectively infinite and it is impossible to provide for unlimited demand with finite resources other than by, as we have now, a complex and expensive system of rationing that is inherently wasteful.

Assuming that it is politically impossible to introduce some kind of charging process that would constrain demand to some extent (my preference) the next best option is to devolve the decision making process on rationing and commissioning to the lowest possible level- the point of interaction between doctor and patient.

Much of the waste that occurs currently results from GP’s being influenced by the level of hypochondria and persistence of the patient rather than empirical clinical evidence of need. So, the person with a painful stomach who pesters the GP every few days will be sent for expensive tests, whether required or not, because there is no disincentive for the GP to solve his problem by doing so.

What we need is not a centrally planned and administered health service but a system that responds by having funding follow real need.

Or, to put it more poetically, “a plurality of atomised healthcare suppliers.”.

All this within the first year of a five-year government. It is indeed worrying.

About NICE:

The continuing survival of the Federal Drug Administration (FDA) in America, even through Republican administrations there, is testimony to the public regard for it. It stopped the prescription of Thalidomide in America so there was no Thalidomide tragedy there on the scale we had in Britain:
http://en.wikipedia.org/wiki/Thalidomide

I’m very apt to check out FDA advice on drug side-effects now, over the internet, ever since learning some years back from FDA warnings that I was being prescribed a drug (by my GP) which was identified as associated with higher cardiac risks. A consultant at the local hospital wrote to my GP advising that the particular drug wasn’t appropriate.

If NICE is abolished, we shall need something very much like it for protection. The healthcare market is rife with what economists call “information asymmetries”.

I think you’ll find the MRHA is the equivalent of the FDA.

MHRA I mean…

@29: “The problem we have is that demand for healthcare services, provided free at the point of delivery, is effectively infinite and it is impossible to provide for unlimited demand with finite resources other than by, as we have now, a complex and expensive system of rationing that is inherently wasteful.”

Other west European countries have social insurance schemes to cover personal healthcare costs where patients recover some or all treatment costs from the government or from occupational schemes.

The substantive difference with what we have in Britain, is that the NHS amounts to a verging on state-owned monopoly supply of healthcare services. The NHS employs 1.4 million – it’s the largest employer in western Europe. Other countries don’t have such state-owned monopoly suppliers of healthcare.

In an asseessment by WHO and now in regular annual assessments by an independent Swedish think-tank – Health Powerhouse – the NHS emerges with mostly mediocre ratings.
http://www.healthpowerhouse.com/files/Index%20matrix%20EHCI%202009%20091001%20final%20A3%20sheet.pdf

“GPs want to spend more time with sicker patients while those with minor ailments see a nurse, ring a helpline or go online for a video consultation.

“The Royal College of GPs (RCGP) is calling for appointments for standard patients to be increased from 10 to 15 minutes so doctors can spend more time with the growing number of people with long-term conditions such as diabetes, cancer and obesity.”
http://www.guardian.co.uk/society/2010/mar/23/gps-consultations-ill-patients

The predictable outcome of the 10 minute appointment regime is that GPs mostly just hand out pills.

“Britons are increasingly turning to prescription drugs to cure every ailment, a new study found. The average number of prescriptions dispensed per person rose from eight a year to more than 16 over the past two decades, according to the paper, titled A Pill for Every Ill.”
http://www.independent.co.uk/life-style/health-and-families/health-news/britain-turning-to-prescription-drugs-1930212.html

What motivated the Obama administration to press for legislation for more-or-less universal insurance cover for personal healthcare costs is that an estimated 46 million Americans otherwise have no cover for healthcare costs and “The leading cause of personal bankruptcy in the United States is unpaid medical bills.”
http://www.newyorker.com/archive/2005/08/29/050829fa_fact

The first thing that needs to be said is that public-sector bodies that buy and sell from one another are NOT “markets”. They are bureaucratic hierarchies pretending to behave like markets, and they do it because they believe it’ll make them more effective, or more accountable, or because they believe it will make the public trust them, or be more forgiving of the money they spend.

The ideological pose of encouraging pseudo-market behaviour in the NHS was something Blair and Brown embraced all through their term in office.The Coalition has decided to dismantle some of Labour’s pseudo-market arrangements and replace them with something different. I don’t whether it’s going to be an improvement: Bob B has posted links to evidence which suggests it might not be. But this isn’t a change of ideology. Look at that quote:

“My friend was flummoxed by the decision to ask primary care clinicians to become the key actors in the NHS’s economic and disease management alongside their current role as patient need managers.”

These are the words of someone whose brain is so surrendered to management jargon and the politics of administration that he no longer understands the link between doctors treating patients and doctors treating disesases. Seriously!

A GP’s practice is not a market, but it is a place where doctors see the health and sickness of a community and can intervene in positive ways. But you’re telling me my GP can’t be trusted, because the bankers caused a recession, therefore anything privately owned cannot be trusted? That really is a nasty idelogy.

37. Rowan Davies

@36: it’s the inclusion of a layer of profit – ahem, exuse me, I mean incentive – that bothers me. NHS budget ring-fencing still = a substantial cut in real terms over the next few years (not a party political point – Labour would have had to do the same). So allowing these new consortia to cream off however much will represent further cuts.

That’s before the concerns about free-at-the-point-of-delivery, postcode lottery etc (as outlined by Richard).

The tories have always wanted to destroy the NHS. Its simply central to their world view. What’s changed?

Thanks for the comments.

For those that seem bent to the ideological embrace of free-market fundamentalism, I’d point them to the Gulf states for an illustration of what can go wrong. Over the last few years a number of Gulf states have tried to shift the burden of healthcare expenditure from the state to individuals and employers. The CCHI in Saudi, Daman in Abu Dhabi, abortive schemes in Qatar and Kuwait. I was sent to provide specialist advice to the health ministries by my firm when their McKinsey neoliberal-inspired schemes led to a virtual collapse in healthcare coverage. In short, the poor suffered. Atrociously. Imagine countries adopting the US pre-Obama model apart from even greater income and wealth inequalities. Not for them the mere 47 million citizens without healthcare that the US boasted. It was far worse (and made more difficult because of the lack of effective epidemiological or data-gathering bodies). Eventually after playing around Abu Dhabi settled on a hybrid Bismarckian/private model which seems to have done OK. But the overall proportion of GDP spent on healthcare has increased drastically. This was entirely predictable; every single study shows that as you move from Beveridgean (NHS) to Bismarckian (German/ French) to hybrid (Swiss/ Obamacare) to fully privatised models the overall cost of healthcare to the nation increases, borne either by the state or out-of-pocket. That, to me, is the most compelling statistic explaining why a centrally-planned single-purchaser model is so effective. It’s efficient. It’s equitable in that all get access to healthcare (even if some precious little flowers can’t park their cars because the “playboy clinicians” (HA!) have a parking space in the building they work in every single day (I’m sure in the US they make their destitute clinicians park a mile away from the hospital)). And it’s efficient in that it uses less money. Tinkering is fine. It’s good. Go ahead. Tinker. Institute better disease-planning. Shift the mechanisms for deciding drug purchasing to use better and more intelligent or compassionate health economic models. But change it from a good system to a shitty one?

Give me a break.

Sorry, quick edit:

It’s EFFECTIVE and gives us some of the best health outcomes in the world. It’s equitable in that all get access to healthcare (even if some precious little flowers can’t park their cars because the “playboy clinicians” (HA!) have a parking space in the building they work in every single day (I’m sure in the US they make their destitute clinicians park a mile away from the hospital)). And it’s efficient in that it uses less money.

Imran Ahmed: “Surely doctors can, the LibConTricksters would argue, decide through market mechanisms what the price of a drug should be and the relative efficacy of that drug vis-a-vis competing therapies.”

I think you’ll find that in power, the “LabourTricksters” were largely of the same opinion. They were very keen on internal markets, and indeed went far further than the previous Tory government on the subject. They tried to implement schemes for GP commissioning of NHS services at least twice (in 1998 and 2005). To suddenly oppose it in opposition because it’s unpopular is just cynical.

I agree. I’m a vehement opponent of Labour’s schemes with internal markets. Foundation trusts, more recently and perhaps most odiously of all to my mind, has been an abortive scheme and so badly designed it’s now tremendously difficult to dial back the damage they did. Reading MONITOR’s website is just depressing.

@38: “The tories have always wanted to destroy the NHS. Its simply central to their world view. What’s changed?”

As mentioned above, other west European countries have social insurance schemes to cover personal healthcare costs – with thematic origins going back to Bismarck, who was hardly leftist. Social insurance for health is a regular part of the European social market model so there’s nothing especially leftist or radical about it.

The characteristic feature of the NHS is that it combines a social insurance mechanism along with a verging on state-owned monopoly supply of healthcare services which employ 1.4 million people – there is nothing approaching that in other west European countries.

There’s no evidence to show the monopoly supply element of healthcare services provides superior healthcare outcomes for patients, as compared with healthcare systems in other west European countries. If anything, the evidence points in the opposite direction.

Civitas briefs on other national healthcare systems can be accessed via this link:
http://www.civitas.org.uk/nhs/health_systems.php

“We are inexorably going to be moved away from our traditional NHS approach to one ruled by the false idols of choice, competition and diversity of suppliers.”

How appalling! Like, erm, the French, Swedish, Singapore, German and yes, even the US, health care systems. In fact, just like every system except the UK (and possibly Canadian) one.

“Idols that would prove disastrous for the equity, efficacy and efficiency of Britain’s healthcare.”

Some of them fail on the equity part, this is true. That’s a function of how the system is financed. Almost all are more effective and efficient.

“The necessary next step after diversifying purchasers is to increase competition among suppliers of secondary care; hospitals, etc.”

Yup, that’s the point all right. And an excellent idea too. Markets do many wonderful things.

“Indeed, no-one that deals with markets on a daily basis (as I once did in my early career) thinks that markets come out with rational and unimpeachable equilibria.”

Oooh, dear, a little economics is a dangerous thing. No one actually believes that equilibria exist. Sorry, they don’t: that’s Econ 101 there. When you get to 201 (and 301 etc) you find out that it’s a lovely way to build a model but that’s about all, it doesn’t reflect the real world.

For technology is always changing, d’ye see? Even if we did reach equilibrium in the treatment of, say, gastric ulcers (which we thought we had done in say the mid-80s) there’s always some cocky Australian who thinks he knows better and points out that actually they’re caused by a bacterial infection you cure with antibiotics. As they were and as was recognised when he won the Nobel.

So if technology is always changing, knowledge advances, then we don’t actually get to an equilibrium. We might tend towards one at the current state of knowledge under either planning or a market, this is true, but by the time we get where it was it’s moved on.

And that’s what markets are extremely good at. Processing new factors….these change relative prices….which means that knowledge of teh change flows through the system more quickly. Thaqt new knowledge then changes behaviour faster than under any other system.

No, this isn’t just some neo-liberal talking his own book. The major economist on invention and innovation is William Baumol. Invention (creating new things, new treatments in this case perhaps) can happen under any system. Innovation, the actual use of those new things, happens best in a market system.

“Markets are wonderfully erratic, complex and ridden with human frailties like herd behaviour, irrationality and manipulation through covert action.”

Indeed, all things human are riddled with the same things. It would be a very strange accusation that bureaucracies are not subject to either ingroup delusions or her behaviour. Our question is, rather, what’s the best way to deal with such frailties? Markets seems to the be the answer.

“the most progressive institution of the 20th Century?”

“Progressive” is not a synonym for “best”.

http://www.who.int/whr/2000/media_centre/press_release/en/index.html

Some 62.5% of the composition of that ranking is based upon equity of access, equity of finance, equity of treatment and so on. Only 10% (I think that’s right, might be 15% or so) is on the actual excellence of treatment.

Yet even with that bias in favour of a free at the point of use system like the NHS it still only comes 18 th (old figures, I know).

I have to admit, I really, really, do not understand these fits of vapours when someone starts to discuss markets. You can still have equity of provision inside a market you know.

44. gwenhwyfaer

So, Bob B says that there’s no correlation between state-owned healthcare and patient outcomes, and that other Western European countries, with Bismarckian models, do better on that score. Imran Ahmed contends that the Bismarckian model costs measurably more than the NHS.

Call me naive, radical or just plain mad, but doesn’t this suggest that spend per capita is likely to have the greatest association with patient outcomes – and to have a far greater correlation than the system under which it is spent? And once we’ve got that correlation out of the way, once we can remove that figure, surely that is the appropriate point to compare the relative per-capita costs of different models for a given patient outcome?

Until then, anyone trying to say anything about different models is merely shedding light on their own personal ideology. Let’s have some decent evidence – and in particular, a demonstration that a different system can improve patient outcomes for the same per-capita spend – before fucking about with the system, and especially before fucking about with it for reasons of blind faith (which is all ideology is).

45. gwenhwyfaer

Markets do many wonderful things.

Markets do many hideous things too. That’s pretty much the nature of markets. By all means argue that those hideous things are a price worth paying for the wonderful things, but I am sick to death of the rank intellectual dishonesty of market fundamentalists who pretend that markets are all wonderful, all the time.

gwenhwyfaer – most of us who deal with markets on an everyday basis – unlike the writer of this article who seems to be living in some state-planned asylum somewhere (those Gulags were wonderful places you know…as much food and medicine as we could ever need) – would rather pay a little more and get effective health care than just be attended to by a doctor with a stopwatch, hell-bent on meeting some arbitrary waiting-list target, just itching to get going on the prescription and on to the next “claimant”. The NHS has made claimants of us. We are no longer patients.

47. Charlie 2

42. Bob b. Do you know anything about the Austrian healthcare system? An Austrian friend living in the UK used too return home for healthcare which appeared far better than that in the UK. The Austrian systm appears to include compulsory health insurance. When looking at national healthcare, I think it is important to consider how people consider their own health. Austrians, French and Italians on the whole appear far more health conscious than many British; they are far more careful with regard to the the food they eat, how much they drink and the exercise they take.

Surely what is important is improving the health of the nation and this means people taking responsibility for what they consume and the exercise they take. In the Far East, one sees elderly people practising Tai’ Chi or ballroom dancing in order to maintain health. There is Chinese saying ” Our food is our medicine and our medicine is our food”. Basically there is 6,000 years of Indian and Chinese tradition regarding exercise, diet and taking herbs to achieve and maintain good health. Perhaps the British should learn from the Chinese and Indians?

48. Matt Munro

@ 47 “Austrians, French and Italians on the whole appear far more health conscious than many British; they are far more careful with regard to the the food they eat, how much they drink and the exercise they take.”

You are kidding. They haven’t even implemented the smoking ban (Italians/French) and contrary to popular belief they drink more than we do, on average. You don’t see gyms everywhere, or middle class wankers jogging in all the parks. Austrains eat much more meat than we do.

zomgz the Tories want to dismantle the NHS?!?

Has anyone enquired about the toilet habits of bears, or indeed the religious persuasion of that Pope chappie? I think we should be told.

50. gwenhwyfaer

bonkers, what is certain is that if you get your way and are able to “pay a little more” to upgrade your service (as opposed to the current system, where you can pay a lot more and go private, which will get you faster treatment of exactly the same standard), those who can’t afford to (like me) will get exactly the NHS you describe and disdain. Whereas at the moment, whilst it isn’t perfect, the odds of a poor person getting a decent level of care are a good way higher than zero, and more importantly, no lower than those of a rich person.

51. gwenhwyfaer

Oh, and as for your “the NHS has made claimants of us. We are no longer patients” canard, I have that disproved every time I walk into a doctor’s surgery and am just seen, as a patient, with no discussion of eligibility and no forms to fill in. Whereas the system you appear to prefer would make us all claimants, in a very literal sense, by requiring us to reclaim the cost of our treatment.

I have to question, if you can come out with absolute bollocks like that statement, whether you have ever had anything at all to do with the NHS – or whether, true to your pseudonym, you are incapable of distinguishing between reality and your own imagination.

52. Richard W

@ 43. Tim Worstall

A bit of an oversight for you to cite Baumol and not mention Baumol’s Cost Disease in the context of a discussion on the NHS, Tim.

http://en.wikipedia.org/wiki/Baumol%27s_cost_disease

http://prescriptions.blogs.nytimes.com/2010/01/17/an-economist-who-sees-no-way-to-slow-rising-costs/

Anyone who is selling the idea we can reduce costs and at the same produce better outcomes through the magic of markets being brought to bear on health spending is selling snake oil. The NHS is not perfect and is far from being the best in the world. How could it be when we spend so little on it? Considering we spend around the OECD average and are near the bottom for spending in the G7 nations does not suggest there is this great waste and inefficiency that many people talk about. If the intention is to get better outcomes, well we should certainly reform how the NHS operates by learning and copying others who get the better outcomes. However, we should not expect the reforms to be a great money saver especially in an ageing society.

“A bit of an oversight for you to cite Baumol and not mention Baumol’s Cost Disease in the context of a discussion on the NHS, Tim.”

No, not an oversight. As I’ve said elsewhere, it actually works the other way around.

Baumol on cost disease says that services are going to become more expensive in relation to manufactures as it is easier to improve productivity in manufactures than services.

Baumol on innovation says that the way to improve productivity is to have more markets. Planned systems tend not to improve productivity, market systems do.

Baumol on the system as a whole says that therefore we need more markets in services so as to overcome the difficulty of improving productivity in services.

Yes, I have been in email contact with Professor Baumol on exactly this point.

Have you?

54. the a&e charge nurse

[43] “Markets do many wonderful things” – yet not one country in the developed world entrusts it’s health care to markets alone, curious, given how “wonderful” they are meant to be.

Then we have the usual eulogizing about the French German & Swiss systems – all three far more expensive than the NHS.

Perhaps somebody clever than me could add up the cost differential over the last 50 years – given that the cumulative spend puts these 3 countries miles ahead of the NHS in financial terms.
Perhaps the truly amazing thing is that the NHS performs just as well (much of the time), unless anybody wants to argue specifics rather than vague generalisations about Europe having better outcomes.

By the way, Tim, sizable chunks of the NHS have already been hived off to the profiteers – can you tell us, specifically, which of these outperform comparable services offered within the state sector?

http://www.dailymail.co.uk/health/article-1288832/NHS-rated-efficient-health-care-study-ranked-life-expectancy-age-60.html

(This report was given virtually zero coverage in the media – perhaps surprising that the Daily Mail decided to mention it).

Completely support the other comments that point out that, whilst we continue to spend significantly less than other countries on healthcare, it is far from clear that the answer to improving outcomes is to reorganise the NHS and introduce market style reforms.

Markets work well in some places and not in others. This is because the conditions necessary for markets to function well are not always present. Ideologues, in their black and white view of the world do not, of course, choose to recognise/accept this – but then nor presumably did central planners in the Soviet Union.

Lansley’s plan could well improve healthcare outcomes.

After all the public/private models used in much of western Europe score higher on most indicators than the NHS does. The system Lansley is proposing and the place it might lead looks to me rather like the system they have in countries like France, Switzerland and the Netherland’s. There the lines between public and private provision are so blurred as to no longer be really visible. All of those countries are supposedly “better” than Britain when it comes to health.

The real problem which this article and many posters have touched upon isn’t that Lansley’s scheme will lead to increased inequality, rather that it will require expensive slack capacity so as to enable “choice” and will push up the costs of administration and the supplies bill as money is pushed between providers and funding bodies, each of whom takes their cut, and doctors demand branded goods and unnecessary treatments for their patients.

Loser financial constraints are in patients interests because their care will improve as waiting lists vanish and treatment rationing becomes a thing of the past. However, Lansley is left in an odd position because health costs will rise dramatically. Just look at how much most European health systems cost relative to ours. We spend <9% of our GDP on healthcare in most western European nations (even once Belgium and Germany with their legions of pensioners are stripped out) appear to spend around 13% of their GDP on health. Such an increase would wipe out most of Osbourne's savings. If we did adopt an American style healthcare system then we'd have the worst of all worlds, that is to say a massive bureaucracy, poor outcomes and we'd be spending about 20% of the national income on healthcare.

As such Lansley's scheme has its merits. But the NHS also has one massive advantage especially ATM.

57. gwenhwyfaer

After all the public/private models used in much of western Europe score higher on most indicators than the NHS does.

Consistently 60% higher? Because that’s the increase we’d be looking at, assuming that GPD per capita is comparable.

58. gwenhwyfaer

(or even GDP)

59. gwenhwyfaer

Baumol on cost disease says that services are going to become more expensive in relation to manufactures as it is easier to improve productivity in manufactures than services.

How so? Manufacturing has an absolute floor on base costs; you can never make something for less than the cost of its base materials. Services have no such floor – indeed, the fate of computer programming is an illustration of what happens to a service market once the perception of value vanishes from it. Therefore, the scope for productivity improvements is actually far greater in services than in manufacturing.

Since you made a point of boasting that you have this from the horse’s mouth, I have to suggest that the horse in question is dead, and your continuing to flog it will only tan its hide…

“Therefore, the scope for productivity improvements is actually far greater in services than in manufacturing.”

Nice try, overturning a basic economic concept in just a few sentences. But no, it doesn’t work. Try this:

http://en.wikipedia.org/wiki/Baumol%27s_cost_disease

It is more difficult to increase labour productivity in services than it is in manufacturing. Yet average wages are determined by average productivity across an economy: thus services will become more expensive relative to manufactures over time.

BTW, we all implicitly grasp this when we talk about the NHS: everyone knows that NHS inflation is above the general inflation rate, yes? This is one of the reasons why.

“By the way, Tim, sizable chunks of the NHS have already been hived off to the profiteers – can you tell us, specifically, which of these outperform comparable services offered within the state sector?”

Yes, actually I can. NHS England has had rather more “marketisation” than NHS Scotland or NHS Wales. Productivity (no, not labour productivity but total factor productivity, output against all inputs) has increased in NHS England and not in NHS Wales or NHS Scotland.

This is a reasonably general finding in economics. Planned systems can increase output through an increase in inputs. But they very rarely can produce an increase in total factor productivity. Market systems can also increase output through increased resource use: but they also can and do increase output through increases in productivity.

In the long run this is one of the strongest arguments for markets. Some Paul Krugman for you:

http://web.mit.edu/krugman/www/myth.html

“But what they actually found was that Soviet growth was based on rapid growth inputs–end of story. The rate of efficiency growth was not only unspectacular, it was well below the rates achieved in Western economies. Indeed, by some estimates, it was virtually nonexistent.”

That essay explains it all very well. And as Krugman has said eslewhere, productivity isn’t everything but in the long run it’s almost everything.

61. the a&e charge nurse

[60] “Productivity (no, not labour productivity but total factor productivity, output against all inputs) has increased in NHS England and not in NHS Wales or NHS Scotland” – so now you are comparing oranges and apples?

Let’s try comparing like with like, shall we?
Within the NHS profiteers have been drawn to activity dominated by two key elements;
[1] its profitability (natch) – so we get those attracted to PFI finance, or those able to fleece the pockets of predominantly middle class worried well (via, walk in centres) and;
[2] uncomplicated procedures (usually with a single pathology) that can be set up like a production line, so patients are offered hernia repair, joint replacement, MRI scans, etc but NOT palliative surgery for cancer, for example.

Needless to say the profiteers are conspicuous by their absence when it comes to those health groups with little cash, or those suffering with a chronic condition that does not have a sexy drug to cure it (schizophrenia, multiple sclerosis, etc).

So I ask again, despite the fact that the profiteers have amply demonstrated their predilection for cherry picking already – which service currently offered by them outperform COMPARABLE services provided by the state, because as far as I can tell ISTCs (to take one example) have been pretty woeful so far;
http://www.guardian.co.uk/commentisfree/2009/oct/21/scotland-nhs-profit-treatment-centres

I notice you duck the question as to why NO developed country actually trusts the market sufficiently to hand over ALL its health care to them but I guess anybody with half a brain can already guess the answer to that one?

62. the a&e charge nurse

Incidentally Pollock states (same link as 61)
“There is a growing body of research evidence to show that ISTCs are not good value for money; that they fragment care of patients and training of staff; that they are not associated with better patient outcomes; that they reduce equity by selecting healthier and richer patients; and that they undermine fairness of funding by diverting money away from patients’ services to shareholders and bankers”.

She concludes;
“The ISTC programme provides a good case study of what happens when the private sector is introduced into clinical services”.

Common sense dictates that if large chunks of cash are being diverted to the shareholder it is not being spent on clinical services (as patients who use PFI hospitals are learning to their cost).

You want a system that benefits the fat cats – I’d prefer one that benefits patients, and the NHS despite its various weaknesses should not be undermined by nonsensical claims about ‘competition’.

“so now you are comparing oranges and apples?”

No. My argument is that markets improve productivity. So, I then show that a system which has more markets than another improves productivity with markets more than the system with no markets. This is known as offering real world evidence in favour of my theoretical supposition.

For my theoretical supposition to be correct it is not necessary for any new participant to be more efficient than what went before. It is necessary only that there is a market, competition within it, which then drives the long process of improving productivity.

“I notice you duck the question as to why NO developed country actually trusts the market sufficiently to hand over ALL its health care to them but I guess anybody with half a brain can already guess the answer to that one?”

Sure. I’m not arguing that the health care system should be solely left to the market either. Just as I don’t say that housing, food supply or wages should be entirely left to the market.

What I do argue is that compared to the current system we are often (although not always) better off in the long run with more market based mechanisms inside such systems than fewer.

To change the subject entirely but to make the same point. Yes, we’ve a climate change problem. We could use all sorts of non market means to deal with it: pass laws that you cannot do this or that, regulations, bureaucracy (as an example, insist that all green glass is recycled. But as even WRAP has admitted, this probably produces more greenhouse gasses than simply landfilling it.). Or we can adopt market based solutions like carbon taxes or cap and trade. They are of course not pure free market solutions: we are intervening in markets after all. But they are solutions using the maximum amount of market that we can within the constraints of trying to solve the problem.

And just about everyone, from Lord Stern through Greenpeace to the IPCC agrees that these interventions into markets, these attempts to bend markets to our will, rather than dispensing with markets and using command and control, will work better.

Back to health care: I’ve no problem at all with the government being the financier of the majority of health care in the country. It’s just that over time we’ll get more health care for a given level of financing by using market mechanisms than command and control ones.

Perhaps not this year, perhaps not next, but over time, as that market stuff does its wonders on total factor productivity, yes, we will.

64. Mike Killingworth

A nurse who saves a life does not add to the national wealth.

A con artist who sells quack medicines does.

The Government’s priority is to increase the national wealth. End of.

65. the a&e charge nurse

Maybe your comparison with different parts of the UK is apposite, but not on the grounds originally suggested by you?

“In England, the parliamentary health select committee has expressed its frustration at the lack of data on the value for money and efficiency of a policy that is diverting £5bn of NHS funds to private for-profit healthcare companies, describing it as an “evidence-free zone”. It’s time the minister for England’s healthcare took a leaf from his counterparts in Scotland and Wales, to see how public and parliamentary scrutiny of public funds and their use can be improved by making data publicly available and ensuring collection of data on all patients treated”.
http://www.guardian.co.uk/commentisfree/2009/oct/21/scotland-nhs-profit-treatment-centres

Admit it Tim you are an ideologue without one shred of EVIDENCE to back up your claims when like with like is compared?

http://www.nuffieldtrust.org.uk/pressarea/?id=777

“A unique analysis published today of the performance of the NHS across the four countries of the UK before and after devolution has found striking differences in performance with some countries spending more on health care and employing greater numbers of health staff but performing worse when it comes to a range of indicators, such as waiting times and crude productivity of staff.

The report by the independent health charity the Nuffield Trust examines the performance of the health services in England, Scotland, Wales and Northern Ireland across three time points – 1996/7, 2002/3 and 2006/7. It also examines the performance of the ten English regions and compares them with the NHS in England as a whole and the NHS in each of the devolved countries in 2006/7. This is the first time such an analysis has been conducted. Performance was tracked against a number of key indicators, including expenditure, staffing levels, activity (outpatient appointments, inpatient admissions and day cases), crude productivity of staff and waiting times.

The main findings are:

* Historically Scotland, Wales and Northern Ireland have had higher levels of funding per capita for NHS care than England. However, the research suggests the NHS in England spends less and has fewer doctors, nurses and managers per head of population than the health services in the devolved countries, but that it is making better use of the resources it has in terms of delivering higher levels of activity, crude productivity of its staff and lower waiting times.”

No proof eh?

53. Tim Worstall

“A bit of an oversight for you to cite Baumol and not mention Baumol’s Cost Disease in the context of a discussion on the NHS, Tim.”

No, not an oversight. As I’ve said elsewhere, it actually works the other way around.

Baumol on cost disease says that services are going to become more expensive in relation to manufactures as it is easier to improve productivity in manufactures than services.

Baumol on innovation says that the way to improve productivity is to have more markets. Planned systems tend not to improve productivity, market systems do.

Baumol on the system as a whole says that therefore we need more markets in services so as to overcome the difficulty of improving productivity in services.

Yes, I have been in email contact with Professor Baumol on exactly this point.

Have you? ‘

I think reading your comments you would concede that health care is not just like any other market. I am sure you have read this old Arrow paper but I will provide the link anyway.
http://www.who.int/bulletin/volumes/82/2/PHCBP.pdf

However, the NHS could be improved in some areas with markets. I fully agree. My point is that it will not reduce costs for reasons that are well known. You know that the health insurance market has elements of The Market for Lemons about it. You know that wages are not just determined by productivity in one sector but are largely determined by earnings of similar workers in other industries. You know that much of the NHS is labour-intensive so can’t make the same productivity gains that other industries have made. Robots can build cars but they can’t wipe the butt of geriatrics. Therefore, we will have Baumol’s Cost Disease in the NHS. Although reforms could slow the growth of costs they will not reduce the costs.

Only an ideologue who thinks the NHS has reached a state of perfection would be opposed to introducing changes learnt from other nations who achieve better outcomes. Therefore, we should reform it. However, we would have to believe those other cited systems were grossly inefficient if we thought we could make those changes and save on costs when we currently spend less than they do. By all means introduce more markets but we should be realistic as to what they can achieve when it comes to health care.

68. the a&e charge nurse

[67] “Therefore, we should reform it (the NHS)” – OK, let’s have yet MORE health reform (since this has been a fairly continuous process for decades) but is it too much to ask to ask for a bit of evidence first?

Tim cites the performance of entire countries then claims any difference must be attributed to the market – sorry, I just don’t buy it, neither do I think we should be framing the reform question in these terms when there are complex independent variables.

Let’s narrow it down to particular services (such as GP out-of-hours care) so that we can judge if the market brings any real benefits rather than disasters like this;
http://www.guardian.co.uk/society/2010/feb/04/doctor-daniel-ubani-unlawfully-killed-patient

69. Simon Adams

I’m a libertarian and strongly believe in free markets, and I just thought I’d say that, from the description on this website, this seems like an incredibly stupid idea. This doesn’t, as far as I can see, have much to do with markets, though. An ultra free-market approach (as advocated by, e.g., Robin Hanson) would be to set up prediction markets to try and predict the effectiveness of drugs based on available data, not try and have every GP across the country be an analyst.

Try this extensive, useful brief by Nicholas Timmins, public policy editor of the FT, on the proposed new management of the NHS:

How power and accountability will transfer
http://www.ft.com/cms/s/0/5b0d90ce-8df1-11df-9153-00144feab49a.html

FT columnists and the editorial on 13 July are generally sceptical about how this upheaval will work out. For example: Political squalls before the cuts get serious, by Philip Stephens, Associate Editor

“The health service is to be spared the worst of the spending cuts. But even with a notional real increase in its budget over coming years, the NHS will not keep up with medical inflation and the rising demands of an ageing population.

“Yet the government now proposes to throw everything into the air in the fourth big organisational shake-up in less than two decades by turning local doctors into financial managers. The predictable effect will be to divert resources from front-line medical care and to replace large numbers of public sector bureaucrats with even more private sector ones. As I said, I am baffled.”
http://www.ft.com/cms/s/0/d3ffca50-8de3-11df-9153-00144feab49a.html

Imran: any chance of an answer to my question about what the basis of your comment about NICE was? Especially as the White Paper talks about extending NICE’s role (see http://www.guardian.co.uk/society/joepublic/2010/jul/13/will-health-swallow-social-care )

Latest news about new management for the NHS:

“The health secretary, Andrew Lansley, has hired two NHS managers from regional quangos, which he said he would abolish, on salaries of £200,000, as part of his drive to modernise the health service.

“While former colleagues face an uncertain future, Ian Dalton, chief executive of the North East Strategic Health Authority, and Dame Barbara Hakin, head of the East Midlands Strategic Health Authority, will be given powerful roles at the heart of the new NHS.

“They will also be allowed to keep their salaries, which are about £60,000 more than the prime minister is paid.

“The revelations will be embarrassing for Lansley, who on Monday called for a tier of management to be stripped out of the NHS. In his white paper, there are plans for the 10 strategic health authorities to be abolished by 2012 and the 150 primary care trusts to be scrapped by 2013. Up to 30,000 managers face being cut or redeployed.”
http://www.guardian.co.uk/politics/2010/jul/13/nhs-quango-heads-new-roles?&amp;

73. gwenhwyfaer

It is more difficult to increase labour productivity in services than it is in manufacturing.

Ah, yes, argument by repeated assertion and reference to authority. Always classic signs that someone has been called on something they don’t actually understand.

“Ah, yes, argument by repeated assertion and reference to authority. Always classic signs that someone has been called on something they don’t actually understand.”

Forgive me but please, don’t so alarmingly stupid.

There really are some things which economists have managed to find out about the strange universe we inhabit.

http://en.wikipedia.org/wiki/Baumol%27s_cost_disease

The obvious example is a symphony orchestra. You can’t ask them to increase productivity by simply playing faster now, can you?

However, you can increase the productivity of providing music for people to listen to: recording, CDs, iPods, records.

To do which you need a market in alternative methods of providing music to people.

75. caroline dunn

There is a tangible difference between a free market and a highly regulated market. In an imperfect world a compromise maximizing the potential of the entrepreneurial competitive approach with a system based on the principles of equality has its merits. Erraticism does lead to that innovative moment but this shouldn’t be at all costs.

The commissioning approach has led the UK to have a variety of service models tailored to the needs specific patients groups. It is not perfect equality but not everyone’s needs are the same. Localizing the approach at the GP would surely better mirror the idiosyncrasies of different parts of the UK (or perhaps it is more precise to say England). You can ask if the same innovation and local tailoring is promoted by countries with a social insurance system.

nternational benchmark shows that nothing focuses the mind of the primary care practitioner on cost than having to choose between re-carpeting the surgery and providing medicines. The Vardval (care choice) model in Sweden has improved access and focused clinician on outcome and quality. Quality and outcome both measured by the patient’s choice not to visit poor performing GPs and not key performance indicators.

A truly free market approach would introduce a level of risk in system that would not be acceptable to the consumer (electorate). No rational governor would suggest a wholly free market approach. Not even uncle Sam. Lets get sensible, healthcare is a conspiracy of the middle ground.

As for the bureaucrat and the health economist at NICE, if rationing is where we are – all analysis points to this then they need to take second place to the politician. Why isn’t health care part of the county council budget?

Though provoking – cheers Imran.


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  1. Liberal Conspiracy

    The coalition’s plan now is to dismantle the NHS http://bit.ly/dxtR1i

  2. Liberal Conspiracy

    The coalition’s plan now is to dismantle the NHS http://bit.ly/dxtR1i

  3. Kristofer Keane

    RT @libcon: The coalition’s plan now is to dismantle the NHS http://bit.ly/dxtR1i

  4. Kristofer Keane

    RT @libcon: The coalition’s plan now is to dismantle the NHS http://bit.ly/dxtR1i

  5. Jonathan Calder

    RT @libcon The coalition’s plan now is to dismantle the NHS http://bit.ly/dxtR1i <<And then eat some babies, no doubt

  6. Daisy Benson

    RT @libcon The coalition’s plan now is to dismantle the NHS http://bit.ly/dxtR1i <<And then eat some babies, no doubt (via @lordbonkers)

  7. sim89

    RT @libcon: The coalition’s plan now is to dismantle the NHS http://bit.ly/dxtR1i

  8. Eleanor Sharman, 15

    RT @lordbonkers: RT @libcon The coalition’s plan now is to dismantle the NHS http://bit.ly/dxtR1i <<And then eat some babies, no doubt

  9. Leischa

    RT @libcon: The coalition’s plan now is to dismantle the NHS http://bit.ly/dxtR1i

  10. Mind In Flux

    RT @SocialWorkerDan: RT @libcon: The coalition’s plan now is to dismantle the NHS http://bit.ly/dxtR1i < we can't let this happen #proudoftheNHS

  11. Mind In Flux

    RT @lordbonkers: RT @libcon The coalition’s plan now is to dismantle the NHS http://bit.ly/dxtR1i <<And then eat some babies, no doubt

  12. Little Metamorphic O

    This is very worrying:libcon ideology's impact on health RT@libcon The coalition’s plan now is to dismantle the NHS http://bit.ly/dxtR1i

  13. Victoria Lambert

    This breaks my heart #NHSunderthreat RT @libcon: The coalition’s plan now is to dismantle the NHS http://bit.ly/dxtR1i

  14. peterdcox

    #ConDems' plans to dismantle NHS http://ow.ly/2a5s3 England first, then Wales? Over my, undoubtably by then, dead body!

  15. hilary

    RT @libcon: The coalition’s plan now is to dismantle the NHS http://bit.ly/dxtR1i

  16. earwicga

    RT @libcon The coalition’s plan now is to dismantle the NHS http://bit.ly/cSUtoM

  17. Katrina Forrester

    RT @libcon: The coalition’s plan now is to dismantle the NHS http://bit.ly/dxtR1i

  18. Yasir Hassan

    The Coalition's plan is now to dismantle the NHS: http://lnkd.in/FTCsSE
    Thoughts?

  19. Teresa Cairns

    RT @libcon: The coalition’s plan now is to dismantle the NHS http://bit.ly/dxtR1i

  20. rowan davies

    Bored with me banging on about the #NHS yet? RT @libcon The coalition’s plan now is to dismantle the NHS http://bit.ly/dxtR1i

  21. Sarah Ditum

    RT @rowandavies: Bored with me banging on about the #NHS yet? RT @libcon The coalition’s plan now is to dismantle the NHS http://bit.ly/dxtR1i

  22. David Ritter

    #conlib attack on #NHS on the way http://tinyurl.com/2ab7mmo

  23. Tim Beadle

    RT @rowandavies: Bored with me banging on about the #NHS yet? RT @libcon The coalition’s plan now is to dismantle the NHS http://bit.ly/dxtR1i

  24. Ben Coleman

    RT @libcon The coalition’s plan now is to dismantle the NHS http://bit.ly/cSUtoM

  25. keith flett

    RT@ rowandavies Latest on the LibCon Tricksters- The coalition’s plan now is to dismantle the NHS http://bit.ly/dxtR1i

  26. David Marsden

    The coalition’s plan now is to dismantle the #NHS: http://bit.ly/dxtR1i ? @sim89 @libcon

  27. Stuart Vallantine

    RT @kmflett: RT@ rowandavies Latest on the LibCon Tricksters- The coalition’s plan now is to dismantle the NHS http://bit.ly/dxtR1i

  28. mariecx99

    RT @kmflett: RT@ rowandavies Latest on the LibCon Tricksters- The coalition’s plan now is to dismantle the NHS http://bit.ly/dxtR1i

  29. Joseph Bush

    Despite the hyperbole I wholeheartedly agree RT @kmflett: RT@ rowandavies Coalition’s plan now is to dismantle the NHS http://bit.ly/dxtR1i

  30. KeithGabby

    RT @josephbush Despite the hyperbole I wholeheartedly agree RT @kmflett @ rowandavies Coalition’s plan: dismantle NHS http://bit.ly/dxtR1i

  31. Naadir Jeewa

    Reading: The coalition’s plan now is to dismantle the NHS: contribution by Imran Ahmed
    The Coalition, now in its m… http://bit.ly/cVCKaL

  32. Elinor O'Neill

    RT @lordbonkers: RT @libcon The coalition’s plan now is to dismantle the NHS http://bit.ly/dxtR1i <<And then eat some babies, no doubt

  33. Black Triangle / The Coalition NHS White Paper

    […] an example of the latter from the Liberal Conspiracy website: The coalition’s plan now is to dismantle the NHS. The article sets out the Conservative-Liberal plans as the death of the NHS. I’m not going […]

  34. Andrew Roche

    The coalition’s plan now is to dismantle the NHS http://ff.im/-nCNb1

  35. Coalition plans for the NHS « Care in the UK

    […] from Liberal Conspiracy […]

  36. Hazico_Jo

    The coalition’s plan now is to dismantle the NHS | Liberal Conspiracy http://t.co/BnB17Si via @libcon





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