How Milton Friedman inspired coalition NHS reforms


by Dave Osler    
12:30 pm - January 18th 2013

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When you trust someone to wield a scalpel on the most sensitive parts of your anatomy – and such, dear reader, was my painful lot some 18 months ago  – you cross your fingers and hope they are a properly trained surgeon.

But according to the libertarian right, regressive attitudes like that hold back the development of a free market in health services.

The requirement for licensure both prevents all and sundry who wish to practice medicine from doing so, and deprives the rest of us of the opportunity to purchase their services, and so should be scrapped.

In case you suspect that I am making this stuff up, it is all there in black and white in the work of Milton Friedman, a thinker whose impact on the policies of governments of all parties since the 1970s has been incalculable.

On a range of issues from monetarism and exchange controls to the clear ideological animus against public housing, the emasculation of trade unionism and explicit tolerance of tax avoidance, Friedman’s ‘Capitalism and Freedom’ has been the de facto blueprint for successive administrations.

His stipulations often have had to be watered down, simply because they are too extreme for public taste. But Friedman’s work is nonetheless crucial to understand neoliberal thinking, largely because it provides the intellectual underpinnings for what Thatcherism, the Third Way and now the coalition have tried to do.

That brings me to the present government’s decision to hand over the National Health Service to the private sector, which will effectively result in the transformation of hospitals into what Friedman called ‘department stores of health’, acting as intermediaries between patients and service providers.

Such a change is necessary, the late economist maintained, because bodies like the British Medical Association, which licences doctors to practice, are monopolists who purposely restrict entry to the profession in order to boost members’ wages.

Instead, Friedman suggested an alternative based on untrained practice, including practice by ‘people who have no professional qualifications at all’. And of course, when it comes to routine matters such as scans, it would be foolish to argue that doctors should undertake tasks that technicians can carry out perfectly well. But Friedman wouldn’t stop there.

‘I conclude that licensure should be eliminated as a requirement for the practice of medicine,’ he writes, and anyone should be ‘free to practice medicine without restriction except for legal and financial responsibility for any harm done to others through fraud and negligence’.

Individual GPs and hospitals should be replaced by the medical equivalents of John Lewis and Selfridges, with consumers able to judge between them on the basis of reputation. That having surgery is an act in no way akin to purchasing a pop-up toaster is in no way considered an obstacle to such a vision.

Here we have the inspiration for the Clinical Commissioning Groups and the ‘any willing provider’ clauses contained in the Health and Social Care Act, which is the strongest medicine the Tory and Lib Dem right feels it can get away with forcing down the electorate’s throat right now.

Naturally, it would be hyperbolic to maintain that the legislation is the full Friedmanite Monty. But it takes us more than half way there, and its impact on the standards of practitioners is all too predictable.

Never mind doctors without borders; the next stop is doctors without qualifications.

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About the author
Dave Osler is a regular contributor. He is a British journalist and author, ex-punk and ex-Trot. Also at: Dave's Part
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Reader comments


I didn’t think it was possible to misinterpret a piece of work so fundamentally. Please also watch the video I have linked, as the workds from the mans mouth, rather than a completely incorrect interpretation of what is actually been said.

http://www.youtube.com/watch?v=-6t-R3pWrRw

A bad pop-up toaster can still kill you.

So I need a surgeon- what should I do?

Should I carefully research the available practitioners and make a selection based on their perceived ability, training, experience and the success rate of their work for the required procedure?

Or should I trust that anyone with a BMA rubber stamp can do the job?

Is my continuing good health my responsibility or that of the state?

Answers on a postcard……..

Spot-on, Dave.

5. the a&e charge nurse

Rule of thumb – “For commonly performed surgical procedures (including hip and knee replacement, ACL surgery, carpal tunnel surgery, and rotator cuff repair), find a surgeon who has been doing this procedure for at least 5 years, and is doing more than 30 each year. For less commonly performed procedures (including shoulder replacement, hip arthroscopy, meniscus transplant, and PCL reconstruction), find a surgeon who has regular experience with this surgery and has performed at least 30 procedures of that type”.
http://orthopedics.about.com/od/orthopedicsinformation/f/How-Many-Surgeries.htm

Additionally, There are more than 18,000 surgeons currently practicing in England – of which 5,600 are consultants, 9,200 trainees and 3,000 in specialist or non-training grades.
In Wales there are approximately 1,000 (330 consultants, 540 in training and 130 non-training).
There are 1.1 consultant surgeons per 10,000 head of population in the UK. This figure is not evenly spread across the surgical specialties and some specialties are currently short of their target workforce – for example, paediatric surgery, ENT and neurosurgery.
The average surgeon takes 11-12 years of further training after medical school to reach consultant level in his chosen specialty. A surgeon will typically be around 35 years old when they become a consultant. Gaining the practical craft skills needed means a close working relationship between trainees and consultants – there is currently an average 1:1 ratio of later stage surgical trainees to consultant.

On the other hand you could ask one of Milt’s disciples?

The flaw in Friedman’s ideas against licensing of certain professions is asymmetric information. A surgeon knows if he is a good surgeon or not. Their colleagues know if he is a good surgeon or not. The patient does not know and is unlikely to have sufficient expertise to find out if the surgeon is competent. Therefore, the patient is always at an information disadvantage, especially when they rely on surgeons in an emergency event. A body compromising people with the expertise licensing others is not the outrageous imposition that Friedman suggested. However, the closed shop whereby some professions restrict entry to boost wages is true. So, they are monopolists. Unfortunately they do not appear to be much good at screening out psychopaths.

Occupations with the highest rates of psychopathy:

1. CEO
2. Lawyer
3. Media (Television/Radio)
4. Salesperson
5. Surgeon
6. Journalist
7. Police officer
8. Clergy person
9. Chef
10. Civil servant
http://www.mediabistro.com/mediajobsdaily/tv-radio-jobs-are-among-top-10-to-most-likely-attract-psychopaths_b13338

6

Is there any reason or research for that matter, which shows that psychopaths should be precluded from any particular trade/profession?

Well seeing as the ultra free market loons are now openly saying that they might have to destroy democracy to fully implement their ideological, crazed bullshit , it is no surprise. These people are now the biggest threat to freedom and a decent living standard to the vast majority of the worlds population. Their policies only benefit a small elite who are getting richer, and more selfish by the day. They are far more of a threat to most people than any global terrorist organisation.

In fact I would call them the ultimate terrorists, and they are supported by most right wing govts around the world. Trouble is the basis of their beliefs is bullshit. There is no such thing as the free market. Never has been and never will be. Rigged market, yes, but not free market.

There are many separable reasons for concerns about the coalition government’s reforms of the NHS. For one, try this editorial in the British Medical Journal on 21 January 2011:

“What do you call a government that embarks on the biggest upheaval of the NHS in its 63 year history, at breakneck speed, while simultaneously trying to make unprecedented financial savings? The politically correct answer has got to be: mad. . . ”
http://www.bmj.com/content/342/bmj.d408.full

To my knowledge, there have been repeated attempts over the last 50 years to suggest to the public that the American healthcare market is the only feasible alternative to the NHS. It isn’t. Other west European countries have healthcare systems funded by various social insurance schemes. Independent surveys report that many of these systems gain greater expressions of patient satisfaction than does the NHS.

Try this report on the BBC website in January 2009:

“More than 3,000 hospital patients have died because of errors by NHS staff in England over the past year, figures show. Hospitals reported 3,645 deaths in 2007-8 from patient safety incidents, data from the Lib Dems showed.”

Well seeing as the ultra free market loons are now openly saying that they might have to destroy democracy to fully implement their ideological, crazed bullshit , it is no surprise.

What do you mean ‘now’? It’s always had a disgust for democracy because the people ‘will vote for what’s best for them and not the economy’, the whole point of monetarism and associated privatisation has been to take as much power and control from the voting public as possible.

“the whole point of monetarism and associated privatisation has been to take as much power and control from the voting public as possible.”

The Thatcher government formally abandoned monetarism – or the government’s Medium Term Financial Strategy – in the autumn of 1985, not least because MTFS was unable to keep the money supply within its own adopted targets. The IMF finally delivered an obituary on monetarism in general in 1996:

“…instability of monetary demand, especially in the context of supply shocks and declines in potential output growth, complicated the task of monetary authorities. As a result, during the 1980s most central banks – with some notable exceptions – either abandoned or downplayed the role of monetary targets”.
IMF World Economic Outlook, October 1996, p.106

Monetarist doctrines are neither essential for capitalism nor a crucial feature in Conservative ideology.

Many governments around the world have privatised state-owned industries as state ownership is not essential for the delivery of services. Where it is deemed necessary, governments can commission delivery of services through commercial contracts and natural monopolies can be regulated.

What happened with Credit Lyonnaise, the largest and state-owned bank in France isn’t much of an advertisement for state-owned banks – by the mid 1990s it had accumulated FFr 150 billion in loses, which French taxpeyers will have to pay for one way or another. OTOH the Heath government very sensibly nationalised Rolls Royce in 1971 to save the company from imminent collapse. The company was turned around and privatised in 1988.

We have been repeatedly fed a suggested idea that Milton Friedman represents the only or prevailing American notion among leading economists there of providing healthcare. That is not so. Try (Nobel laureate) Kenneth Arrow on: Uncertainty and the Welfare Economics of Medical Care (AER December 1963):
http://www.who.int/bulletin/volumes/82/2/PHCBP.pdf

In fact, America spends roughly as much as we do as a percentage of national GDP on the public provision of healthcare and about as much again on private provision. The total cost in terms of the percentage of GDP spent on healthcare is horrendous and higher as a percentage of national GDP than in any other affluent, industrialised country although average life expectancy at birth is marginally lower than in Britain.

Additional horrific aspects are that 40+ million Americans have no insurance cover for healthcare costs and unpaid medical bills in America are reportedly the largest single cause of personal bankruptcy.

Btw on retiring from Chicago University, Milton Friedman moved to take up residence in San Francisco, which is widely reputed to be the most radical, liberal city in America. A recent news item from there reported in the San Francisco Chronicle for 12 January:

“Transgender patients seeking medical care face discrimination even in liberal, cutting-edge San Francisco.

“But this being liberal, cutting-edge San Francisco, they also have a champion: Cecilia Chung, a transgender woman serving on the Health Commission.

“Appointed to the commission overseeing the Department of Public Health by Mayor Ed Lee in April, Chung made news by pushing the department to pay for gender reassignment surgeries for uninsured transgender patients – making San Francisco the first city in the country to do so.”

13. So Much for Subtlety

Naturally, it would be hyperbolic to maintain that the legislation is the full Friedmanite Monty. But it takes us more than half way there, and its impact on the standards of practitioners is all too predictable.

In other words you know this claim is bullshit but you’re going to make it anyway? No one is suggesting that totally unlicenced doctors operate on anyone in the United Kingdom. So the whole article is irrelevant. You may as well suggest that because Ed Miliband’s Father wanted to murder kulaks, Ed does as well. After all, it is the extreme fringe of the Leftist wing in Britain.

But Friedman’s work is nonetheless crucial to understand neoliberal thinking, largely because it provides the intellectual underpinnings for what Thatcherism, the Third Way and now the coalition have tried to do.

Sure – in the same way that Pol Pot’s thought is important to understanding the modern Labour Party.

That brings me to the present government’s decision to hand over the National Health Service to the private sector, which will effectively result in the transformation of hospitals into what Friedman called ‘department stores of health’, acting as intermediaries between patients and service providers.

Which is interesting but it has nothing whatsoever to do with Friedman’s ideas on closed cartels. No one is even coming close to suggesting anyone should be allowed to operate on other people.

Individual GPs and hospitals should be replaced by the medical equivalents of John Lewis and Selfridges, with consumers able to judge between them on the basis of reputation.

And why is that a bad thing? The NHS routinely covers up bad practice by doctors. The whole system is designed to protect administrators and doctors. Not provide good service. So outcomes are hidden. The NHS refuses to let us know which doctors are killing their patients. How can it be a bad thing to find out and tell patients?

That having surgery is an act in no way akin to purchasing a pop-up toaster is in no way considered an obstacle to such a vision.

In what way is it no way akin?

Never mind doctors without borders; the next stop is doctors without qualifications.

Except we have this already. The NHS serves the politically powerful. So we can get homeopathy on the NHS. Does it work? Of course not. But it has powerful friends and so people with no sane qualifications at all are allowed to treat people. Why is it better to let politicians decide what quacks can treat us than allowing us freedom to choose ourselves?

14. So Much for Subtlety

5. the a&e charge nurse

find a surgeon who has regular experience with this surgery and has performed at least 30 procedures of that type”.

Interesting. It is well known that teams that start doing heart transplants take a few years to get into their stride. Meaning anywhere from the first couple to the first dozen will die. Do they tell anyone? No. Do they have any particular restrictions on doctors starting in this field – do they have to go to a hospital that does them and get training? No. After all, the NHS is run for the doctors and admins. Not patients. So if a doctor wants to branch out, he can and if he kills his first dozen patients, well, tough. Heart transplants are high profile. The same is likely to be true for other types of operation as well. It just doesn’t get reported much.

The average surgeon takes 11-12 years of further training after medical school to reach consultant level in his chosen specialty.

Doctors are selected because they are good at passing exams. What is the link between being a good doctor and being good at passing exams? None that I know. They can go on to become a specialist if they are smart and they impress other doctors. What is the link between being a good golf player and being suitable for a specialty? None I know of. All this does is serve as a filter to keep the *social* status of doctors high – they want the children of the upper middle class. It works nicely, but that doesn’t mean it is optimal.

6. Richard W

The flaw in Friedman’s ideas against licensing of certain professions is asymmetric information. A surgeon knows if he is a good surgeon or not. Their colleagues know if he is a good surgeon or not. The patient does not know and is unlikely to have sufficient expertise to find out if the surgeon is competent.

Unlike under the NHS where patients are given full and complete disclosure about their doctors, right? Oh wait. Any government system becomes captured by the people it is designed to regulate. The NHS is designed to deny patients this information. They refuse to even collect it and they certainly won’t release it if they do. So it wasn’t the NHS that caught Shipman. It was the local funeral home.

It is absurd to point to the vastly worse problem of asymetric information under the NHS as a solution to this problem.

A body compromising people with the expertise licensing others is not the outrageous imposition that Friedman suggested. However, the closed shop whereby some professions restrict entry to boost wages is true. So, they are monopolists.

So we all see the problem.

Unfortunately they do not appear to be much good at screening out psychopaths.

You have seen the problem but you do not understand it. Why should they screen out psychopaths? Psychopaths kill patients and why should they care about that? It is precisely this sort of oligarchy which does not care about the impact on patients. From any cause. Which is why they did nothing to stop Shipman.

Mind you, it probably helps for doctors to be psychopaths and one of the purposes of medical training is to deaden doctors’ moral feelings so they will be more psychopathic. That is why young doctors have to work for 72 hours straight – so they won’t care any more.

9. Bob B

There are many separable reasons for concerns about the coalition government’s reforms of the NHS. For one, try this editorial in the British Medical Journal on 21 January 2011:

Sure. The House Journal of Left Wing doctors objects to the interruption of their gravy train and the threat they may have to actually work for a living. Film at 11.

Other west European countries have healthcare systems funded by various social insurance schemes. Independent surveys report that many of these systems gain greater expressions of patient satisfaction than does the NHS.

But this government is not trying to adopt the American model. They are trying to adopt the French model. By all means, Bob, let’s copy the French. Their system is vastly better.

13
‘No one is suggesting that totally unlicenced doctors operate on anyone in the United Kingdom’

Whether it’s suggested or not it won’t happen, what will happen, however, is the masses will be forced to pay towards training doctors and other medical staff, will be forced to pay national insurance, whether or not they want to participate in the system, and be cajoled into participating in public health progammes such as vaccination. No change really except that more private capital will gain access to this ready made pool of profits which consists of monies from the poorest tax-payers.

@8

“Well seeing as the ultra free market loons are now openly saying that they might have to destroy democracy to fully implement their ideological, crazed bullshit , it is no surprise. These people are now the biggest threat to freedom and a decent living standard to the vast majority of the worlds population. Their policies only benefit a small elite who are getting richer, and more selfish by the day. They are far more of a threat to most people than any global terrorist organisation”.

And yet these people will lie and tell us how they “love freedom” and are “democrats”.

Pinochet, that supporter of Friedman’s free market economic theories, had no time for democracy. Freedom was something that only his supporters could afford, the rest were crushed under his iron heel. The freedom that groups like The Freedom Association and others talk about is the freedom to make even more money at the expense of others. They were quite happy to support apartheid in South Africa too. They favour complete deregulation because they know it would favour them. [Warning! The next sentence contains sarcasm] In fact, they’d probably abolish driving licenses if they could get away with it.

Friedman’s PhD thesis was about the AMA. The American doctors that is. And his uni refused to publish it for some years because it was so explosive.

And the AMA is indeed worse than the UK doctors thingie (err, BMC?). For example, the AMA has, over the decades, deliberately lobbied, successfully, for restrictions on the number of trainee doctors. Places at medical schools. In order to limit supply and thus push up prices.

The AMA has indeed been acting as that monopolist that Friedman says they are.

TW: “For example, the AMA has, over the decades, deliberately lobbied, successfully, for restrictions on the number of trainee doctors. Places at medical schools. In order to limit supply and thus push up prices.”

Good point. And successive governments in Britain have gone along with limiting the output of medical schools here through government control over finance for higher education.

That is one reason why it has been necessary to import so many foreign-trained physicians to work in the NHS. Another outcome was that that France has getting on for twice as many physicians per head of population as we have, according to OECD figures. Frank Dobson, Blair’s first health minister, can take credit for recognising this problem and seeking to increase the output of graduates from the medical schools in Britain.

Adam Smith had it correctly:

“People of the same trade seldom meet together, even for merriment and diversion, but the conversation ends in a conspiracy against the public, or in some contrivance to raise prices. It is impossible indeed to prevent such meetings, by any law which either could be executed, or would be consistent with liberty and justice. But though the law cannot hinder people of the same trade from sometimes assembling together, it ought to do nothing to facilitate such assemblies, much less to render them necessary.”

Source: Adam Smith: The Wealth of Nations; (1776), Book 1, Chapter 10, Part 2] or p.111 in this link:
http://www2.hn.psu.edu/faculty/jmanis/adam-smith/Wealth-Nations.pdf

For info, try this illuminating report from the General Medical Council:

The state of medical education and practice in the UK 2011 – This is our first report on the state of medical education and practice.
http://www.gmc-uk.org/State_of_medicine_Final_web.pdf_44213427.pdf

20. Derek Hattons Tailor

The only bit of Friedman I can remember is
“The business of business is business”
Which I always saw as primarily an anti-statist, rather then an aggressively pro market statement. He was saying government and business do fundamentally different things, for fundamentally different reasons. They are not interchangeable and comparisons between them are meaningless. Business should pay tax but that ends their “social” responsibility. They should not therefore have ethical/green/social policies, as their wider responsibilities are met by paying tax to government, who use it to maintain the economic and social environment which they (business) need to operate profitably. Anything more (e.g power companies collecting wind farm subsidies) is an abuse of shareholders wealth.
In essence the private sector should stay out of delivering public services and vice versa. It is going wrong because businesses are not paying tax, and idiots like Blair thought that the private and public sector were, or should be, the same, and started “reforming” one to be more like the other. Result was public sector efficiency, as measured in the private sector, plummeted and the market is saying “we can do that better”. Even post 2008 a surprising number of intelligent people appear to believe them.

It is a sobering reflection on the realities of public sector enterprise to recognise that the transformation of China’s economy to achieve the astonishing growth rate in recent years is due to Deng Xiaoping’s liberalisation measures, starting in the late 1970s, not to Mao’s Great Leap Forward or the following Cultural Revolution.

As Deng had put it: It doesn’t matter whether a cat is white or black, so long as it catches the mice. What motivated Deng’s insight was the conspicuous difference in commercial attainment in China compared with the entrepreurial flair of overseas Chinese in Hong Kong, Singapore and Taiwan.

Britain’s pioneering industrial revolution, starting in the late 18th century, wasn’t due to state direction or planning. The prevailing ideology of Pitt’s government at the time was: laissez-faire, even though Parliament soon began to recognise that regulation by legislation was necessary to prevent unacceptable exploitation of women and children in mines and factories as the result of unfettered market competition. Starting in 1802, Parliament passed a long succession of factory acts:
http://en.wikipedia.org/wiki/Factory_Acts

The productive debate is about what laws and regulations are needed to enable capitalist market economies to function competitively but within accepted social norms.

22. So Much for Subtlety

15. steveb

No change really except that more private capital will gain access to this ready made pool of profits which consists of monies from the poorest tax-payers.

Well of course tax revenues overwhelmingly come from the richest 10% of the British population, but otherwise I am in general agreement. I just don’t see this as a bad thing. We, the general public, don’t care if the doctor is working for the state or not. We care that we get the best possible health care system for the least cost. And very little else. So if the private sector can do better – and face it, who couldn’t? – bring it on.

16. buddyhell

And yet these people will lie and tell us how they “love freedom” and are “democrats”.

The fact you agree with Sally tells us all we need to know.

Pinochet, that supporter of Friedman’s free market economic theories, had no time for democracy.

There is actually very little evidence on Pinochet’s views on democracy. What he did in a crisis when democracy broke down and the Parliament called on him to intervene is not evidence. But if you have some I would be interested to hear what he had to say.

They were quite happy to support apartheid in South Africa too.

Why not? Better than the alternative. As with Chile, as bad as both regimes were, given the alternative was some form of Stalinism, both countries were better off with the systems they had.

In fact, they’d probably abolish driving licenses if they could get away with it.

Why on Earth should we have driving licences? They are simply a make-work programme for bureaucrats. There is no justification for them at all. As long as someone can get insurance for any damage that they might do, why not let them drive?

17. Tim Worstall

And the AMA is indeed worse than the UK doctors thingie (err, BMC?). For example, the AMA has, over the decades, deliberately lobbied, successfully, for restrictions on the number of trainee doctors. Places at medical schools. In order to limit supply and thus push up prices.

The BMA also limits the number of doctors. After all, it is not hard. We have a government monopoly on training. They are consulted. And if the government does what it wants anyway, they control access because doctors have to train in hospitals so the BMA can just refuse to train them.

23. CaptainCrash

14. So Much for Subtlety

[i]Interesting. It is well known that teams that start doing heart transplants take a few years to get into their stride. Meaning anywhere from the first couple to the first dozen will die.[/i]

No. For the first few years as a surgeon, they operate with a consultant gradually taking over parts of the operation until they can do it themselves unsupervised. Surgical trainess aren’t left gung-ho to operate.

[i]Doctors are selected because they are good at passing exams. [/i]

That is but one metric that doctors are selected. You see AAAA A level students rejected all the time, because there are many other parameters that students are selected on e.g. thinking under pressure, experience, organisation, communication skills etc. And for what it’s worth, passing exams is a reasonable (even if not the only) sign of intellectual ability – something that’s quite desirable attribute in a doctor.

“Pinochet, that supporter of Friedman’s free market economic theories, had no time for democracy.”

Very likely Pinochet supporters also believed 2+2=4 but I’m not sure what that proves or that we should reject that proposition just because Pinochet supporters believe that it is correct.

As is fairly widely known, Friedman expressed explicit admiration for the free market system of capitalism prevailing in Hong Kong:
http://www.youtube.com/watch?v=xqh0zXSd4vc

Despite Friedman’s endorsement, I don’t read condemnations of Hong Kong, its market system or its people. Why is that? What are we to make of Friedman moving to San Francisco after he retired from Chicago University? Does that mean San Francisco, widely reputed to be the most radical, liberal city in America, is a “bad” place, best avoided?

Btw according to a recent report in the news:

The unemployment rate in San Francisco and on the Peninsula declined by 1.1 percent from December 2011 to December 2012.

According to California’s Employment Development Department, the local “metropolitan division” of San Francisco-San Mateo-Redwood City (to use its unwieldy demographic moniker) fell to 6.2 percent in December.
That’s down from 6.4 percent in November and down from 7.3 percent in December 2011.

California’s unemployment rate was 9.7 percent in December, while the U.S. average was about 7.6 percent.
Source: San Francisco Business Times 18 January 2013

25. So Much for Subtlety

23. CaptainCrash

No. For the first few years as a surgeon, they operate with a consultant gradually taking over parts of the operation until they can do it themselves unsupervised. Surgical trainess aren’t left gung-ho to operate.

Sure. But no one said they were. But if a real surgeon wanted to start doing heart transplants, what paperwork is involved? In the old days, they just did it. There was no system where they would have to go to another hospital and become trainees again. That is why I said “teams”.

That is but one metric that doctors are selected. You see AAAA A level students rejected all the time, because there are many other parameters that students are selected on e.g. thinking under pressure, experience, organisation, communication skills etc.

That is to say, what Daddy did.

And for what it’s worth, passing exams is a reasonable (even if not the only) sign of intellectual ability – something that’s quite desirable attribute in a doctor.

It is not obvious to me that it is desirable in either a doctor or a surgeon. Most jobs are probably better off with smarter people than dumber people, but what it is about giving Grandmothers flu shots that needs three A levels? In fact most of what GPs do could be done by a nurse with some experience. And often is. What surgeons do relies on dexterity and manual skills. That has nothing to do with anything you listed.

It is like the Air Force. We know what makes a good pilot. No Air Force selects for that. Rather they have felt the snobbery of the Army and Navy deeply and so use exam success as a way of raising the social tone of the Air Force. They want Upper Middle Class lads and they get them. Whether or not they are the best fighter pilots. So too with doctors.

What are we to make of Friedman moving to San Francisco after he retired from Chicago University?

You ask this question a lot, why not answer it yourself for a change, because clearly no one else finds it relevant.

22

If the private sector can do better, yes bring it on, but let the whole process remain in the private sector.
Let’s face it, in the main the US did operate a freeish market, so poor people were not forced into contributing and the rest can choose a private insurance scheme, no doubt some charities could take over in the poorest areas. Friedman had a point, let the state do what the state does best and leave the rest to business.

28. the a&e charge nurse

[25] perhaps there are 2 parts to this.
[1] the selection process.
[2] whether or not to deregulate clinical activity.

Both are interesting but the million dollar question is what is the main driver behind them – the needs of the patient, or the needs of somebody who stands to gain financially?

Apparently the profiteers regard x1 GP per county as good enough for out of hours services.
http://www.thisiscornwall.co.uk/doctor-covering-Cornwall-night-shift/story-17014827-detail/story.html

Cylux: “You ask this question a lot, why not answer it yourself for a change, because clearly no one else finds it relevant.”

I take it that Friedman took up residence in San Francisco on his retirement from Chicago University because he had a new job at the Hoover Institute at Stanford University in Palo Alto and because he regarded SF as a congenial place to live, which is a bit peculiar given the indisputable liberal credentials of SF and the persistent endeavours of the city council there to tighten gun control ordinances.

That seems to me a far more telling criticism of Friedman than repeated mentions of the “Chicago Boys”, who advised on the reform of the Chilean economy at the invitation of the Pinochet government. There is no doubt that the Chilean economy is performing a great deal better now as a result than the economy was performing under President Allende’s socialist administration in the early 1970s. If anything, that is something of an advertisement for the Chicago Boys. After all, the Pinochet government could have chosen advice teams from, say, the “salt water” economists at MIT, Harvard or UC Berkeley, instead of the “fresh water” economists at Chicago.

There are sensible criticisms to make about Friedman’s POV and silly ones. Sadly, the latter are made more often. There’s no doubt that PRC China’s economy has become a lot more like the Hong Kong economy since the early 1980s than HK’s economy has become like China’s economy, which Hu Jintao, China’s last president, described as “socialism with Chinese characteristics”.

I certainly don’t go along with Friedman’s expressed preference for unlicensed medics – the prevailing information asymmetries between patients and physicians make a rational unfettered market impossible. And I don’t go along with his sweeping condemnation of the Federal Drug Administration: I try to make a habit of checking FDA warnings on any new drug that I’m prescribed.

There are important lessons to be learned from Hong Kong. There used to be a flatted factory standing near Kai Tak airpost where small businesses could rent the equivalent of a room or two – the factory has long since been demolished, the airport moved and the site redeveloped. There are long-standing arguments between Chicago-minded economists and much of the rest of the profession over the extent of government intervention required to deal with polluting externalities – try Coase on: The Problem of Social Cost, available online in PDF format, for the Chicago position.

What experience with Kai Tak showed was that the regular minimalist practice of licensing or taxing polluting activities was impractical but not for any reason that could comfort Chicago school economists.

The trouble with the flatted factory development is that tenants tended to pour all sorts of waste chemicals down the drains. Disposed of separately in limited quantities, the waste chemicals might do little harm but their mixing in the sewers could have potentially devastating consequences. Extensive, detailed intervention is needed to prevent such adverse consequences but that wasn’t noticed by Friedman in his unstinting praise of Hong Kong’s free market capitalism.

Nor did Friedman mention that the freehold of land in KH is held in public ownership to prevent over-development or premature development of land where there is already an exceptionally high density of population per hectare by global standards.

Omissions such as those are serious gliches for Friedman to be taken as anything more than a polemicist.

Try this op-ed on: Lunch with the FT: Milton Friedman on 28 June 2003:

“The use of quantity of money as a target has not been a success,” concedes the grand old man of conservative economics. “I’m not sure I would as of today push it as hard as I once did.” Granted, this is hardly a conversion of Damascene significance. But, heck, it’s a start. It also shows that, at the age of 91, Friedman still has his critical faculties intact. The man once described as “the most consequential public intellectual of the post-war era” is still engaged – and engaging. . .”
http://www.freerepublic.com/focus/f-news/937366/posts

Please tell me who brought in ‘nurse practitioners’ and not properly qualified failed surgeons from Europe into our ‘independent treatement centres’ under the myth of telling patients they were being treated ‘privately’, but in reality to massage figures (waiting lists and the numbers of operations pre-bought by healthcare trusts)?

At least under the extreme free market that no-one has argued for (but you have argued against, i.e. a strawman), the patient has the choice of a conventionally or otherwise qualified practitioner.

Of course, if your local butcher wanted to try his hand at surgery, he may be limited by the fact no hospital would take him, nor would he be insured to practice out of his shop.

I also see the standard left wing myth that private companies paid for through tax represent a free market.

They don’t, they represent neo-socialism, the dangerous union of big business and government, where profits are ‘privatised’ and losses socialised all at our expense.

These in reality are government subsidised companies that are given monopolies.

A free market would allow people, OF THEIR OWN ACCORD, to spend THEIR OWN MONEY. Therefore companies that did well would do so because they were good and vice versa.

33. the a&e charge nurse

[31] ‘Please tell me who brought in ‘nurse practitioners’ – we have to go back a bit – Loretta Ford has been described as the co-founder of the movement which emerged in the US 50 years ago – the NHS introduced them at the back end of the 80′s.
http://www.cnn.co.uk/2011/09/30/health/living-well/loretta-ford-nurse-practitioner/index.html

With regard to ISTCs a recent report in 2011 ‘comparing Independent Sector Treatment Centres and NHS providers’ (Clinical Effectiveness Unit The Royal College of Surgeons of England) found – “Patients treated by ISTCs had a case-mix profile that made them likely to have better outcomes than those treated by NHS providers. The results of the Audit show a number of differences in post-operative outcomes in favour of ISTCs. However, most differences are small and their clinical relevance is uncertain, especially when compared with the impact ISTCs could have on the provision of elective services. Limitations in the case-mix adjustment model – due to differences in the preoperative patient characteristics that could not be adjusted for – may account for part of the differences that were found”.

As everybody knows real choice in a health market is cash dependent, or put another way choice is limited unless you have sufficient economic muscle – it was not for nothing that one of the founding principles of the NHS was treatment based on clinical need, irrespective of ability to pay.

In the news today:

Hospital pays £1,800 a day for a nurse in NHS staff crisis – NHS hospitals are hiring agency nurses at rates of up £1,800 a day in a bid to plug dangerous staff shortages, an investigation has found.
http://www.telegraph.co.uk/health/healthnews/9813361/Hospital-pays-1800-a-day-for-a-nurse-in-NHS-staff-crisis.html


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