Liberty Alone

Shocking news from Ross Anderson here:

auditors called 45 GP surgeries asking for personal information about 51 patients. In only one case were they asked to verify their identity

He also recounts that in 1996 whilst advising the BMA 30 false-pretext phone calls were detected within one week at one health authority. Reporting this to the Department of Health resulted in them being told not to work with the health authority anymore.

This is going to cost lives soon. It already is indirectly.

Of course, what do you expect from a state run service?

My wife’s Uncle has just undergone major surgery to remove a cancer from his face. Being in the US and being lucky enough to have health insurance despite being unemployed he is having excellent treatment and care.
The first estimate he got was of a 36 hour operation, but given the choice in health care afforded to him he could get various other estimates and someone else estimated a 12 hour operation. Still a long time, but considerably safer for an elderly man and probably less worry for his family.

I am left wondering what would have happened under the NHS. My guess is that the operation may not have even been possible, it is close to the cutting edge, if it was then he’d have had no option to switch surgeons like that as far as I know.

There are certainly cases in the NHS, although usually in less serious cases, where treatments are not available due to a decision by NICE that the improvement in quality of life of the patient is less that the expense – that is inhumane, but a necessary constraint of the central planning of the NHS. I fail to see how local control will improve matters much either.

What I want to see from a health care system is that everyone can get this level of care if they need it, and that everyone can decide how to spend the limited resources available for health care for themselves.
I want to do away with the necessity of NICE and quality of life assessments. Only the individual can do that so the individual needs the power to make those choices.

The NHS fails at this. The US system also fails. Both have systematic failures (as the opponents of universal health care in the US will tell you, they advocate reform of the US system too).
Thankfully there are many other systems out there in use, and even more possible systems. We need to move towards a fairer and freer system. A more liberal system.

Contrary to what many people might think, I’m not going to advocate a complete laissez-faire system here, actually I’m not going to advocate any system. What I want to do is look at what is wanted from intervention in health care by liberals, hopefully to serve as a starting point for looking at what a liberal health policy might look like.

If I were to suggest a laissez-faire system, I think the liberal objection would be that some people would be unable to afford health care at all (the socialist would argue about profit and how the state could run things better, the authoritarian or Tory radical would say that some people would spend their money on other things, neither of which are objections from a liberal viewpoint).

Given the liberal world view – that monopoly is bad and markets should be used where possible and that state intervention should be minimal and as a last resort, along with the freedom of the individual to pursue their own aims as they wish without interference (excepting where it comes into conflict to other’s equal rights) and the desire to ensure that everyone is given the opportunities to pursue those aims – there is one clear aim of liberal intervention in health care – to ensure the poor can access it (or economic and personal freedom plus social justice)

Once the poor can access health care, and the same health care market as others, the aims of liberal intervention will have succeeded, and intervention should not proceed any further – the final aim would actually be to eliminate any need for intervention, if nobody is too poor to access the health care market then what need is there for intervention?

This means that liberals should be supporting raising the poor into the market which they otherwise would have been absent from, a policy of raising opportunity for the disadvantaged whilst keeping the benefits of freedom for everyone – something which I think exemplifies the broader liberal approach.

How a liberal system might work is another matter, but this should provide the basis for developing models for health care intervention.

In this post Jock got me thinking. The key lines are these:

the welfare state as conceived by these reformers was a necessary but essentially temporary measure only needed in an economic system that favoured the land-owner, capitalist and banker.

I think that this should be the aim of all welfare, we should be aiming for a situation where nobody needs it due to lack of income.

Take a health service, surely the most liberal system would be a laissez-faire free market one in which everyone can participate. That is nobody is denied health care due to no fault of their own, but with no need for government intervention to ensure that. Whilst that clearly is a long way off at the moment, we should be aiming towards it., something the NHS does not do.

The excellent Marginal Revolution highlights this report in the New York Times.

Essentially Johnson & Johnson have declared that they will sell their cancer drug Velcade to the NHS on the basis that if there is not a reduction in tumor size after a trial period they will refund the cost.
Velcade doesn’t come cheap, it can cost $48,000 (~£24,000) a patient, but obviously Johnson & Johnson think it will work for many people and want to encourage its use.

Whether this will encourage the byzantine bureaucracy of the NHS and NICE to use a drug which could save many lives or not is another matter. Given the cost they may be afraid it will work. Such is the cost for our wonderful NHS though.

In my previous post, I called the NHS illiberal. This has received at least one criticism so I thought I’d explain.

Firstly, I’m not calling the concept of seeking to ensure every person in the country has access to health care illiberal. There are very good arguments for why this is liberal, and I tend to agree with them. What I am calling illiberal is the means we use to attempt to ensure this.

Unfortunately, there is a tendancy in this country to believe the propaganda which has been fed to us over the years about the NHS, that it is the envy of the world, that it is a marvelous system and there could be no better.
Frankly, that is utter rubbish. What we have is a system which is creaking at the seams, which cannot provide the coverage it claims to for everyone and which the rest of the world look at as an example of how not to do things.
This tendancy to idealise the NHS means that any attack on it is an attack on any system of universal health care. This is not the case. True, some in the liberal tradition do reject the idea of universal health care, they make good arguments, but I don’t believe their arguments are conclusive.

So, why is the NHS illiberal?
Firstly, it is state owned. As a rule of thumb, there is a liberal justification for national ownership of natural monopolies, but health care is not even close to a natural monopoly. To have a state owned health service flies in the face of liberal tradition and thought about restricting state power, of dispersal of power. Instead, the NHS is a socialist construct, constructed using the myth of state control being effective.

The NHS is centrally managed, a fact which makes it even more illiberal. It cannot respond to local circumstance. The national pay structure treats all nurses as the same, all areas of the country as the same, it distorts the labour market and makes it more difficult to work in more expensive parts of the country. Liberals try not to distort the labour market, they know that such acts are dangerous and distort market signals. The last Liberal government knew this when confronted with massive unemployment they sought solutions which would enable the market to operate more effectively rather than distort it.

If you wish to talk about equality, not of outcome but of the liberal concept of opportunity, the NHS fails on that front. It prevents any opportunity for choice in treatments or care for the vast majority of the population.
The monopoly the NHS has on care prevents some from getting the treatment they need. If you are mentally ill and violent towards staff, rather than getting care you are liable to be banned from getting care. The decrease in the number of hospitals makes it more difficult to get alternative care if you’re not satisfied with the care you’re getting.

Targets are a nonsense, and whilst not a central part in the construction of the NHS, they are part of today’s system. They are a symptom of the central control by politicians. Nobody can know the circumstance of every patient, nobody can hope to manage the NHS to provide the best possible care for all. Liberalism explains why.

The NHS is fundamentally an illiberal system. At its heart, the failures of the NHS are due to illiberal nature. A liberal government would seek to correct this. There are various possible systems, none without problems, but most more liberal. We need serious debate about them in the Liberal Democrats. It is possible to ensure health cover for all with a far far more liberal system and that should be our aim.

A thought just occurred to me – an aim for liberals should be for every person to be able to live independently of the state, without state handouts, without state subsidy of health care or education. How can you be free if you depend on the state for your income, health or education?

Rather than aiming for a welfare state, we should aim to have no need for one. Rather than supporting the NHS we should be aiming for a situation where everyone can afford personal private health insurance. Rather than supporting the status quo in education we should be aiming for a system of private education which everyone can afford.

Such aims are far away, but there are some steps which can easily be made – reduce taxation, especially on the poor, giving them more disposable income.
Education could easily be moved in the right direction by switching to a full voucher system with the opportunity for individual state sector schools to go private or independent of their LEA.
Benefits should be simplified, reduced to a few, based on income for the most part.
Health is far more difficult to transition and indeed to find a solution which will ween people off the state whilst not leaving people stranded (although the NHS is not universal anyway). First step would be to dismantle the behemoth and pass power to the local areas and to have local funding.

Along with these we of course need a healthy competitive economy so naturally free trade and lower regulation are required.

Whether its totally achievable to have everyone living independently of the state is debatable (some argue that mutual societies and charities would allow this – perhaps they would, perhaps they wouldn’t) but I certainly think that a large majority of people could live without state subsidy and almost everyone today could live with a lower level of subsidy.

Just some thoughts, but I stand by the idea that to be free we should be as independent of the state as possible, and that’s a lot more independent than we are today (I’m sure holes can be picked in my other ideas though ;) )