Yes, second opinions are good, this is professional oversight, an insurance company actuary cannot do this. And few would be interested in funding a doubling of the diagnostic workload, under any purchasing model.

Where is the incentive for insurance companies to get the best treatment for their money? There is none - their incentive is to prefer the cheapest treatments and encourage the corresponding diagnoses. Ditto health boards.

The problem here is information. One prerequisite of a market is that the customer knows what they are buying. But for a diagnosis, the product is the same as the information about the product. The only competent buyer is one capable of making the diagnosis themselves.

Historically professional oversight has also been a joke. It is getting better, perhaps not fast enough.

The solution will have to find the right information as well as the right incentives, and the question elected health boards or social insurance is far too simplistic to get heated about.

As Bishop Hill says, Shipman was “insulated from…” and so was the cardiac firm at the JR in Oxford and look at their record. Yet the protectionism inherent in the system made them pretty well unimpeachable until it was too late for too many people.

It is the “vague impressions” as you put it that would drive such a market. Those “vague impressions” would make sufficient number of people (or even their insurance companies) seek second opinions, that clinicians that made regular mistakes by others’ professional second opinions would be spotted sooner.

It seems to me that elected local health boards have the *potential* to entrench that culture of “vague impressions” and inexpert opinions, whereas it is arguably possible that competing insurance companies wanting to ensure they get the best treatment for their money, with their actuaries studying clinicians’ records to determine whether or not they should get accreditation in one of the hospitals they use would do better in determining whether an objectively good job was being done.

Of course I could look for a diagnostician with a good reputation, but a reputation will be based on other patients’ vague impressions and guesswork. Harold Shipman probably had a good reputation before he was found out.

There is an information problem here, that is a barrier to competition. And I would rather get my diagnosis from someone who is insulated from the commercial consequences of his or her judgement.