Adam Smith Institute

Yes, I know, you'll have seen it too:

People in medieval times were healthier than modern Britons because they did not suffer from cholesterol related diseases, it has been claimed.

While those living in the Roman and Tudor periods faced hazards such as the "pox and plague", it seems that their daily diet lacked foods which could lead to heart disease.

The research also claimed that daily exercise has decreased by at least an average of 96 per cent since Roman and medieval times from eight hours a day to less than 20 minutes due to increasingly sedentary lives.

Or perhaps they were all being worked to death? 

Research by Lloyds pharmacy, the chemist chain, found that the daily diet consumed by Britons in the Roman period of fruit, fish, whole grains, vegetables and olive oil washed down with red wine amounted to approximately 120g of fat, 80g of protein and 600g of carbohydrates.

That is indeed a healthy (and often scrumptious) diet but the most important point is this:

Dr Henderson said: "The Roman diet was healthy provided you were wealthy enough to afford..."

The European Commission has delayed making a controversial announcement which could see the state health plans of one Member State paying the costs of patients who opt to be treated in another EU country.

The idea of the plan was that British patients, say, could travel to Spain or Hungary for their treatment, as many do - with Britain's National Health Service picking up the tab. Part of the argument for this is that some countries have more efficient healthcare sectors, with shorter waiting times, for example, and EU citizens should be able to benefit from the competition between them. Following the case of Yvonne Watts, who had a hip operation in France and sent the bill to the NHS, Britain's High Court ruled that the NHS should pay for treatment abroad if patients otherwise had to wait too long. Quite right, I would say.

Already UK doctors are whingeing because they know that lots more people would indeed go abroad for treatment if the NHS was forced to pay for it, rather than put up with the sink service they get in the UK. The British Medical Association's Dr Vivienne Nathansan said that if people started travelling for operations there might 'not be enough need' for that treatment in the UK, which could lead to closures. Yes, well that's competition for you, Vivienne.

Meanwhile Nigel Edwards of the NHS Confederation complained that the EU plan was a stalking horse to create a 'free market' in European Healthcare. Oh, if only it were. We're talking about harmonizing state health plans here. If the EU actually created the conditions for a proper, open market in healthcare - one that wasn't dominated by doctors and politicians - I think we'd all be a lot fitter.

According to a front-page story in yesterday's Sunday Times, "A woman will be denied free National Health Service treatment for breast cancer if she seeks to improve her chances by paying privately for an additional drug."

Preventing patients from topping up their NHS care privately is standard practice in the UK, and in accordance with Department of Health guidance. The Department seems to think that you have to be either a private patient or an NHS patient, and that any mixing is unacceptable: "Co-payments would risk creating a two-tier health service and be in direct contravention with the principles and values of the NHS."

I find it sickening that the government persists in putting their Soviet-era ideology ahead of the health of patients (which is surely the ultimate principle and value of the national health service). Rather than challenging the wholly artificial and enormously damaging public/private divide in health services, they would rather we simply received a lower quality of care. Their position is immoral and impractical.

It is also incoherent. People can already pay for private rooms in NHS hospitals, and for other non-clinical benefits. If it's ok to pay extra for your own television set, why on earth should you not be allowed to pay extra for a better drug?

Most importantly, their position may be illegal. I was recently at a luncheon addressed by one of the UK's leading medical lawyers. His position was as follows: the NHS Act entitles you to receive care that you reasonably require. You can only be refused that care if there is some legitimate reason to do so. Limited resources is such a legitimate reason. But if you are willing to pay for an additional treatment yourself, resources are not an issue and no legitimate reason to deny the reasonably required treatment exists. Thus you should be free to top-up your NHS care with privately purchased treatment, without being forced to foot the bill for the NHS services as well.

Immoral, impractical, incoherent and possibly illegal. This is just the kind of thing we've come to expect from government.

The two leading democratic presidential candidates, Hilary Clinton and Barack Obama, have begun a war sure to last through the primary season and into the nominations. While fighting over policy and personality, many attacks concentrate on their respective plans for universal healthcare. Clinton criticizes Obama, claiming that his plan will fail to cover everyone in the nation. Obama argues in return that her plan will also leave some out. The New York Times thinks neither of the plans goes far enough, approvingly citing an economist who thinks people should be fined for not having insurance.

These policies, and the fights and commentaries that stem from them, indicate an unfortunate trend in politics – a faith in the abilities of the government and the idea that programmes like universal care will mean more freedom, not less. Many falsely view government provisions as a release from economic hardship, rather than an intrusion into individual choice. Obama should be defending his plan because it allows people to opt out, not in spite of it.

The Democrats are fighting over the wrong issue, and pandering to the belief that the success of a government programme rests on the number of people forced to abide. One would think that the voters of a party meant to be the champion of individuality should be wary of any policy which forces all citizens into anything, and candidates from a true party of freedom would argue over the openness offered by their programmes, not the coercion.

As in the last campaign for a Clinton presidency, which Hillary nearly derailed with ill-advised health reform proposals, she has once again missed the point in her insults on private medicine.

On the campaign trail in New Hampshire she accused the US health insurance industry of spending $50 billion to avoid paying claims of their clients. But she has got the numbers wrong. Currently private health insurers are paying claims worth about $600 billion a year and spending $30 billion to adjudicate those claims, actually only denying claims worth $3 billion – not $50 billion. The cost of scrutinizing claims represents good value for money, because it keeps the premiums at bay by rejecting fraudulent and frivolous claims.

However, the ideological thrust of Clintons argument is targeting at gradual replacement of private with public insurance – in other words to expand Medicare for all Americans, with alleged administrative cost of only 3-6 percent. Her followers claim falsely that the administrative costs of private insurance (11-14 percent of premiums) alone would be enough to fund coverage for all presently uninsured Americans.

Fortunately, a meticulous actuary enquiry by the Manhattan Institute has recently dismantled this myth. Administrative costs for public insurance such as Medicare do not reflect the hidden cost of tax collection and other government functions for the administration. Under the "lowest plausible assumption about the excess burden engendered by the federal tax system" the total Medicare administrative costs would account to a minimum of 24-25 percent of all outlays. However:

A more realistic assumption raises the true cost of delivering Medicare benefits to about 52 percent of Medicare outlays, or about four to five times the net cost of private health.

According to Saturday's Times, the government's new 'five-year plan' for the future of NHS cancer services (due to be released today) admits for the first time that the UK has poor survival rates compared with Western Europe, the US and Canada. Long waiting lists for radiotherapy and chemotherapy, as well as rationing which means too few sessions of treatment are given, are at the heart of the problem.

Money isn't the issue here. Since 2000 the government has tripled spending on cancer, and the UK no longer lags behind Europe or North America on this front. The problem is structural. As Karol Sikova, the former head of the cancer programme at the World Health Organisation, told The Times, most of the extra money lavished on the health service has gone towards the salaries of people who don’t work with patients:

We have funded mangers to deal with targets while in France, Germany and Italy that bureaucracy just does not exist.

The government's addiction to targets is understandable, and, I think, based in a genuine desire to improve customer service. In the absence of competition and market forces to drive up standards, targets and regulation are the obvious option. Trouble is, they just don't work and have significant unintended consequences.

The only way to really improve the National Health Service (assuming its continued existence) is to create the freest and most extensive internal market possible. That probably means breaking the NHS up into smaller, more localized commissioning units which would fund patients (at a set treatment price) to go to the doctor or hospital of their choice (whether state or private), as well as the introduction of a capped co-payments scheme for treatment (like those that exist elsewhere in Europe).

Sadly, the government is not still not prepared to think that radically.

There seems to be at the moment fad for prefixing the word libertarian with a politically descriptive term and proclaiming that the latter justifies the first somehow and that they are mutually beneficial.

A recent example I came across was "On Being a Green Libertarian" in the latest copy of The Individual, a publication by the Society for Individual Freedom. The author of the article argues that his green beliefs can in fact be joined with libertarian ideology, creating an effective process for environmental protection. He correctly identifies the key tenets of libertarianism, as well as the irrational behaviour of most of the environmental movement in their clamouring for more legislation to enforce their arguments. But fails to expand on how the two ideologies can be married together successfully.

Most libertarians would suggest pricing, property rights and the common law as the answer. For example, if someone suffers from the ill effects of pollution then they can seek compensation through the courts. The person who pollutes will then be forced to price that compensation into their product before selling it on the open market. The negative environmental externalities would be internalized in the price, and people would then be free to buy their electricity (for instance) as they saw fit.  People would base their spending decisions on their own personally ranked concerns,  be they environmental, price or otherwise. The cost of developing nuclear power stations, tidal barrages etc would all be laid out in the prices offered to consumers, leaving them free – but not coercing them – to allow their beliefs to come into play. But power generators would indeed be reacting to the greatest demand, and how best to turn a profit – the free market at work.

In an ideal world it would be up to the 'greens' to argue, with well founded ideas, the best way forward and not seek to impose their ideology upon others through purely legislative means. They would change people's views so that they would then demand greener products from greener manufacturers.

Let the people decide how green they wish to be. They'll be libertarians...but with a hint of green.

There is a new survey out there from the always-interesting National Center for Policy Analysis It covers the rapidly growing global market for medical tourism. We have already blogged about it here . But it is now becoming clearer what lies behind the success of the global high performance hospitals.

The market leader is Bumrungrad International Hospital in Bangkok, which served a stunning 1.2 million customers from 190 countries last year. It is American-managed and creates returns of 20-25 percent each year. Many other hospitals are managed, owned or affiliated with prestigious American hospitals:

• Cleveland Clinic in Ohio has satellites in Vienna, Canada and Abu Dhabi.
• The Indian hospital chain Wockhardt is linked to Harvard Medical School.
• Johns Hopkins has an affiliate in Panama and in Singapore.
• Dallas International Hospital operates hospitals in Mexico.

All these hospitals are escaping micromanagement by third parties – or otherwise highly regulated markets – at home. And that's how they achieve such competitive pricing. It is not simply a question of lower wages for doctors and lower overheads for hospitals. It is the absence of third party bureaucracies (which do so much to drive healthcare inflation) which allows these hospitals to provide such high-quality, low-cost services.

These hospitals are free-market laboratories serving cash-paying patients. That gives them the edge of performing at the frontier of medical and managerial innovation. Bill Gates just purchased the supreme management software, Global Care Solutions, from Bumrungrad hospital in order to market it worldwide. We should expect more innovation being created overseas and then re-imported to strangulated hospitals in the US and Europe.

There may well come a time in the future when parents who choose to have children become stigmatised. Imagine the scene at an "Islington" dinner party some years from now when someone around the table mentions that their partner is pregnant. Cutlery is dropped onto plates heaving under the weight of the locally grown organic vegetables and the person is admonished for being "selfish beyond comprehension". How dare they not think of the global impact of that child. Some though are already thinking along these lines and are sterilising themselves against the possibility of lumping the world with what could be a climate tipping pile of carbon emissions, otherwise known as a child.

The right over one's womb is of course beyond question, and I do not, in any way, suggest that it should be taken from them. It is the fact that the rest of the rational population will ultimately need protecting against possible demands for legislation to be passed. We are probably not far from a world where we have to undertake "carbon awareness training" if we wish to reproduce and how to offset the carbon of the child we bring into the world. Currently many of us would laugh at such a suggestion, but I suspect if you raised that idea in environmentalist circles they would all think it brilliant and seek to implement it.

Caring for the planet through this course of action (self-sterlisation) raises a valid question though: How to reduce the carbon footprint further so as to alleviate the level of one's guilt to zero? There is a course of action that I could suggest that these people take, but I don’t think they’d like the consequences.

A rational approach to the hardcore heroin addicts is proving somewhat successful. A pilot scheme that has been running for the past two years has seen drug use and drug related crime fall among those undergoing treatment. The treatment involves two thirds of patients taking methadone (half orally, half injecting) and the remaining third injecting diamorphine (pure heroin) all under the watchful gaze of nurses, doctors and counsellors. This amassed support has helped many users back to a more stable life and a way of coping with their addiction.

This clinical version of supplying legalized heroin has cut the amount of crime normally associated with addicts. As Professor John Strang, of the National Addiction Centre, pointed out, about 40 percent of users had "quit their involvement with the street scene completely. Of those who have continued, which obviously is a disappointment, it goes down from every day to about four days per month.” Whilst it hasn’t totally cut crime, it has reduced it significantly and this is just as important for both users and society in general. This isn’t a cheap process; the treatment costs around £9,000 to £15,000 per patient but this is more than borne out by the reduced costs in policing and prosecuting their crimes.

The government has taken a very practical approach to the problem and has seen that 'legalizing' drugs can be done in a safe way and has many benefits, not just to the user but to society. Perhaps they could extend this to other drugs and remove them from the streets so as to be in direct competition with the current sellers. In future the government could pay for the treatment of those that become heavily addicted, or indeed suffer a bad reaction to the drug of their choice, through taxing the sale of drugs. Not only would drug legalization reduce crime overall but it would also mean that a large swathe of our society need never be in contact with the criminal element. 

The Daily Telegraph has reported a story about a Welsh couple prevented from moving to New Zealand because each was considered vastly overweight and therefore a likely strain on health services. Mr Trezise had secured a highly skilled job for Telecom, but had to go on a crash diet in order to enter the country. His wife, unable to lose the extra pounds, has still not joined him.

Now, arguments have arisen that this is discrimination and stigmatization, but aren't these the kind of problems a nation faces when the government decides to provide health care? Private health companies won’t allow you to buy a policy with a serious pre-existing health problem, and when services like health become nationalized it makes sense that unhealthy people would then be banned from the nation providing the service.

Once the government becomes the health insurer, translating health policy into immigration policy isn’t that drastic of a step, neither is drinking policy or smoking policy – both of which we've seen in the UK. Once the government gains one power, it can expand its purview into all manner of life activities, all justified under keeping you healthy and safe. Start to scale back those powers (less socialized healthcare, for example) and the state has fewer justifications for control. Funny how that works.

People working in the healthcare industry are beginning to understand that customer convenience, the top concern in other industries, should have its place in healthcare too. The reason for this is often overlooked. It’s driven by demographics. With ever-growing workforce participation in developed countries, time is becoming more precious – and so looking after your health is squeezed among other chores. That’s the principal reason why waiting lists for medical treatments are a medieval plague and absolutely counterproductive.

This is where Convenience Medicine kicks in. It’s also the story behind Wal-Mart's recent heavy engagement in healthcare. The world champion of retailers has prodded others to offer most common drugs so cheap that even the Medicare Pharmaceutical Benefit Scheme – introduced at huge cost by George W. Bush – is already looking rather obsolete. But it’s not only cheap drugs. Convenience care also offers a different approach to patients. Surveys show an extremely high rate of patient satisfaction with convenient care clinics.

Convenience care clinics provide reliable, immediate, low-cost healthcare to the general public, many of whom do not have access to traditional healthcare. With over 500 active clinics in the United States (projected to grow to 700 by the end of 2007), these clinics complement traditional medical services providers.

With the healthcare industry employing the biggest workforce in many countries and eating up increasingly vast chunks of government budgets, it is unsurprising that market forces are finally getting loose. It always struck me as hypocritical that those who insisted that healthcare was "morally different" were often the same people who shrugged off the industry's deplorable record of customer relations.