Which health care system is the best?

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At first blush you might think this is an easy question to answer: which is the best health care system? The American? Our own dearly beloved NHS? The French, Swedish, German, Canadian systems?

Then the real problem kicks in: best according to what criteria? Do we want a system which provides startlingly good care, like the US one, but patchily? One like ours that is a bureaucratic monstrosity but provides not all that terribly bad care to all? Do we go further with equality like the Canadians and near ban anyone at all from getting more than the government is willing to provide? Do we get the counties to run it, like the Swedes and the Danes?

We might even go further: part of the huge cost of the American system is that for those insured they've squeezed almost all of the waiting out of the system. The Rational Planner might not think that this cost is worth it but the Americans themselves seem very attatched to that part of their system. Is not having to wait a sufficiently desirable part of a health care system that huge amounts should be spent upon achieving that goal?

Your guess is as good as mine quite frankly: the criteria by which you judge these systems will depend upon your extant prejudices, little else.

But how are those international comparisons of health systems done then? What criteria do they use? The WHO for example, telling us that France is top, the UK 18 and the US 37? Glenn Whitman has done the work here. Only 37.5% of the index comes from actually measuring health care itself. The rest is one or another measure of how that care is distributed (ie, equally or unequally) and how it is financed.

When 62.5% of the weighting is given to the things we know that the US system is specifically bad at it's a surprise to see it quite as high as 37 th actually. The level of treatment must be pretty good to get it that high.

But much more than that, when 62.5% of the weightings are given to the things that the NHS is supposed to be good at, was specifically designed to offer: financial fairness and equal care for all and still it only comes 18th? Well, it must actually be pretty bad at providing the actual health care, the health level and responsiveness, mustn't it?

This might be a clue as to why no one has ever bothered to copy the British health care system for all we've been told for decades that it is the wonder of the world.

The NHS is not free

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 After Daniel Hannan appeared on American TV criticising the NHS, Twitter has been flooded by the #welovethenhs campaign. Looking at the tweets coming in, there’s a striking number saying this sort of thing:

NHS = free treatment when you need it. What's not to like?

I love NHS emergency care and my ongoing completely free treatment

I've had all my dental treatments and optician vouchers on the nhs - without the nhs I'd be at least £1000 poorer

Now, of course these people know that the NHS is paid for by taxation, so it’s strange that they give it such credit for being ‘free’. Then again, with NI contributions, stealth taxes, PAYE and government borrowing, it’s all too easy for us to forget how much we actually pay.

The next government (in the spirit of Cameroonian transparency) should send each household a yearly receipt. The average household’s would have looked like this last year:

Your Income: £30,390
Direct Taxes: £7,396
Indirect Taxes: £4,904
Borrowed On Your Behalf: £1,320
Your Total Bill: £13,620 (45% of your earnings, £6.97 for each hour you worked)

 Services You Paid For:

• Health £2,317
• Pensions £2,285
• Welfare £2,130
• Education £1,740
• Defence £895
• Protection £743
• Debt Interest £689
• Government Costs £564
• Transport £493
• Other Spending £1,767

Telling each citizen how much of their money is taken and for what purpose would stimulate democratic debate over the level and direction of public spending. When holding a receipt in their hand, people might tweet a different tune.

NB. Click for sources on taxation and expenditure.

Mark Thornton in 2006

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Yet another Austrian school economist explaining (approx. 39 mins) the housing bubble (this time mostly to kids) well prior to the credit crunch. Following this talk, the kids in the audience would have had a better grasp of US monetary policy than the Fed.

It is no time for Westminster to be squeamish over spending cuts

Dr Madsen Pirie writes on the subject of spending cuts and their link to our future prosperity.

The C-word is out in the open. The Prime Minister previously insisted the debate was between indiscriminate and savage Tory cuts, versus Labour’s investment in public services. The Prime Minister uses the term “investment” as we might talk about “investing” in a Mars Bar, which most people would call spending. Now Lord Mandelson has described Labour policy not as big spending, but as wise spending, to be contrasted with Tory “savage cuts”.

The Government is trying to pitch the debate as one between cuddly and sensible economies from Labour, versus Tories “salivating about wielding the axe”. The debate has changed, however, in that the public now expects cuts and even supports them. Moreover, they trust the Tories to better implement them.

They are correct. Several studies have identified savings to be made without cutting essential services. The James report identified £35bn, the Taxpayers’ Alliance and Institute of Directors report pointed to £50bn, and the European Central Bank has said that Britain could save £96bn if its public services could operate with the efficiency achieved in the US, Australia and Japan – and without reducing actual services.

The notion that the public services were simply under-resourced has been tested to destruction by Gordon Brown. The torrent of public money poured their way has not brought commensurate improvements. What it has done is to leave Britain poorly placed (not “best placed”) to deal with the global financial crisis, and with an overhang of debt that will stifle future development and growth.

National Debt is over £800bn and heading for £1tn, and far more than that if the cost of baling out the banks is factored in. A Britain saddled with the costs of paying the interest on that, never mind repaying the debt itself, would see its business and industry intolerably burdened, with its ability to generate the jobs and wealth of the future severely handicapped. It is like a ball and chain tied to the economy.

That debt burden can be diminished in two ways. One is to let the economy grow by tax incentives and deregulation. The other is to cut public spending. The first targets must be waste, profligacy and inefficiency. But after that we must ask which services currently provided by government could be better done outside it, and which should not be done at all.

The enemy of our future prosperity is not the savagery of any spending cuts, but the hesitancy of those not prepared to do what is necessary. It is no time to be squeamish.

Published on Telegraph.co.uk here.

So that 35 hour week means the French work less does it?

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There is, sadly, a terrible misconception about the world of work. This misconception leads to, as ignorance of the basics so often does, really rather bad policies being enacted. The misconception is that the only form of work we do is outside the home, the labour that we perform in offices and factories for cash and lucre under the lash of The Man.

This of course is not true, we all also work in the home, unpaid. There's always the washing, the cleaning and cooking, the maintenance, the clearing of gutters and painting and so on. Some people enjoy these things, true, but then some also enjoy their paid work as well, and they are both work. Possibly the best description of what is work and what is not is the one used in time use surveys: work is whatever you could pay somone else to do for you*. You cannot pay someone else to sleep for you but you can to make your bed: you cannot pay someone else to eat for you but you can to cook, cannot to wash on your behalf but can for someone to wash you.

So in these time use surveys there are three basic classes of time: personal services, work (both inside and outside the home) and leisure. Those who have more leisure are those who are spending less hours in work, assuming that that personal part remains reasonably constant, as it does.

So what are the numbers for leisure in a country which deliberately restricts the paid for working week? Surely they have more than those who do not, no? Well, actually, no, France has an average of 4.28 hours of leisure a day for each adult while the UK has 5.08. The Americans, who everybody knows keep their noses to the grindstone, have 5.18.

The reason would seem to be that if people are denied the opportunity to work the paid hours they desire (possibly to then buy in parts of that unpaid household labour) then they will try to make up that desired income by unpaid household work. But the world of paid work, with its specialisation, leads to work being done more efficiently. Thus it is necessary to work longer hours inefficiently in order to reach the same desired outcome in material (ie, not just cash but goods and services) income. It is more efficient in the use of labour for the butcher to make the sausages in his factory than for every housewife to do so inexpertly at home, after all.

All of which leads me to a tentative and counter-intuitive conclusion. The laws which deliberately restrict the length of the working week actually increase the amount of hours of work done by those subject to them.

*This definition does cause problems when considering sex for you can most certainly pay someone to have sex with your spouse if you should so desire: fortunately in this civilised era the amount of time spent in a week actually having sex is too small for this to cause problems with the figures.

NHS: No Health Statism

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No system is perfect. But the furthest you can get from perfection is a government controlled monopoly, such as education or healthcare. So it's no wonder to find the people who are culpable for what passes for healthcare provision defending it to the hilt, as if it was flawless, and claiming that those who criticize it are, "un-patriotic". (To see an un-patriotic Dan Hannan truthfully answer questions on the NHS, click here).

A healthcare system where users don't have to wait, drugs aren't rationed, care is not substandard and you're not more likely to leave with disease rather than a cure is all people request. What we get is the opposite: and to deny that fact (as Cameron et al. have) is to deny us a proper discussion about how our system needs overhauling. The remote political class are trampling over our desire to discuss the problems we face on a daily basis, a fact made even more galling because undoubtedly the majority of them will hold private health insurance.

Having experienced health care on both sides of the Atlantic, and paid for both (please understand that the NHS isn't free!), the NHS is second in a two horse race. That is not to deny the fact that there is a minority within the NHS who do provide excellent health care. But these people are few and far between, and very difficult to find! Politicians live in a land of ignorant bliss, where unprincipled sound bites dispatch them into a fantasyland detached from the pain that we as a whole suffer on daily basis at the hands of the NHS. We need a system that is driven by people and not politicians and their meaningless targets. To get to that stage though we must first hold a debate.

Not ideal

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 Do not consider Collectivists as "sincere but deluded idealists". The proposal to enslave some men for the sake of others is not an ideal; brutality is not "idealistic," no matter what its purpose. Do not ever say that the desire to "do good" by force is a good motive. Neither power-lust nor stupidity are good motives.

Ayn Rand

The truth hurts

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It is about time politicians and the public wake up out of their coma. Dan Hannan tells some home truths about the NHS and suddenly politicians across the country are required to swear allegiance to that great behemoth.

The NHS has always caused much controversy. Clearly all sides of the debate are guilty of taking individual cases and extrapolating general truths from them, yet the reality is that in both theory and practice the NHS is an awful system for providing healthcare.

Let us not forget that because we have the NHS:

- it is only the very wealthy who get a truly world-class healthcare as it is only they who can afford to pay twice.

- politicians are interferes in the way we choose to live ours lives – and increasingly so.

- healthcare is rationed – and increasingly so.

- public money is wasted on ineffective pseudo-medicine.

- 250,000 people are still waiting more than 18 weeks for treatment.

Of course, the US healthcare system also needs reform, but instead of looking across the Atlantic, Obama could learn a thing or two from the Cato Institute. And as a matter fact, so could most of our politicians.

Reform certainly, but cuts will still be necesssary

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In that speech to Demos on Tuesday, George Osborne told us that “we face a choice between progressive reform with the Conservatives and front line cuts under Labour." This is how the Tory leadership wants to fight the battle over public services, and this message will be at the heart of their election campaign.

It’s true that reform of the public services is desperately needed: as Osborne pointed out, the United Kingdom currently ranks 76th out of 134 countries in terms of public service efficiency. And it’s true that the Conservatives have some genuinely radical and exciting policies to improve the situation.

But, as Daniel Finkelstein explained in The Times last month, the full rewards of public service reform may not be felt for years, or even decades. The fiscal crisis will not wait: government borrowing is set to total £700bn over the next five years, and there is a real risk of the UK’s credit rating being downgraded. An incoming Conservative government will have no option but to cut spending sharply and severely.

Even when the potential efficiency increases are realised, they will not balance the budget. The Conservatives’ most radical proposals are limited to education, which makes up less than 6% of central government spending. Even substantial improvements in the delivery of bigger budgets like welfare and health would not be enough. There will have to be a reduction in service provision as well.

The Tories are right to be finding ways that public services can “do more and cost less". And if the voter buys it, the message of salvation without sacrifice may be a winner at the election. But in reality cuts will have to come, and frontline services will have to be reduced. As a nation we must face up to fact that every penny spent by the government is a penny that must be found from taxation. We must ask ourselves what level of public provision we want, and where our priorities lie. We cannot pretend that efficiency reforms are the whole answer; we must make the case for a smaller state.

Unions out of control

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After over a week of striking on the National Express East Anglia (NXEA) rail line, we seem to be in worse situation than before. During last weeks strikes, only 100 out of the scheduled 1,800 trains ran, causing huge amounts of travel chaos and wasting many worker hours, as tens of thousands of commuters were late for work. All too often commuters are attacked from both sides, by the government and the unions, when it comes to rail travel.

The RMT’s Bob Crow has blamed National Express for the problems:

This strike has been caused by greedy National Express bosses who have soaked up £2.5bn in taxpayer subsidies in the past 10 years and who have milked every penny out of this franchise while offering their staff peanuts this year,

The average salary for a train driver in the UK is £35,000 – not quite ‘peanuts’ as Bob Crow would like us to think. This is reminiscent of Alan Duncan being ‘forced to live on rations’. However much the unions are given, they always seem to want more without any consideration for the impact for the disruption. With so many in the private sector having faced wage cuts and redundancy in the past year, it is madness for the unions to be demanding wage increases for shorter working weeks.

Currently, disproportional levels of union control in the labour market are artificially forcing prices up for consumers who have no other options but to pay. At the same time, top-down inefficient government intervention is burdening the taxpayer at incredulous rates.It is time for the public, politicians and the private sector to make it clear that enough is enough.