A fascinating question about womens' health care

Nadia Sawalha has revealed that vaginal birth under the NHS has left her mildly incontinent. In The Guardian we are told that this doesn't happen in France. Women who have given birth in the traditional manner are, there, given a course of physiotherapy including the use of Kegel weights and electrical stimulation of the pelvic floor.

This sounds to us like a very useful thing for a health care system to be doing and the question becomes, well, why do they and why do we not

Of course, while the embarrassment or comic potential of this kind of procedure is high, there is a serious point to make. Although electrical stimulation can be prescribed on the NHS, referrals to special “continence centres” aren’t routine. And an estimated 50% of women don’t seek treatment in the first place. But with the necessary, fairly small equipment, this treatment could even be offered – as it is in France – by local professionals rather than at specialist centres.

So, why in the UK are we encouraged by adverts to accept incontinence pads as inevitable when in France doctors routinely prescribe this treatment (as well as physio for the abdomen)? And since when did incontinence get euphemised with the term “sensitive bladder”?

Whether the problem is our inability to talk about it, or simply that the treatment isn’t commonly offered, it’s hard to say. But, if I, as a serial birther, can now leap on the trampoline with glee – surely British women, too, should be offered the chance to swap a few hours of embarrassment for a lifetime of dry knickers?

We would insist that the answer is in the structure of those health care systems. The NHS is, as we all know, a monolithic abhorrence planned along almost Stalinist lines. The treatments on offer are those the bureaucracy thinks should be on offer, in the volume and at the time and place deemed suitable by the bureaucracy.

The financing of the French system is mildly different but it does devolve to government guaranteeing treatment for all. But that guarantee covers myriad suppliers. That is, they have a multiple provider of health care environment. There are for profit suppliers, charitable, government owned, self-employed and just about every other possible and potential form of economic arrangement. All of whom compete for those government guaranteed and insurance company funds as the individual patient picks among suppliers.

That is, they have a market in the provision of health care even if there's a substantial state element in the financing of it. And as happens in markets, however financed, suppliers end up supplying what it is that consumers think best increases consumer utility.

Such as, for example, improving pelvic musculature among post-partum women.

Why do British women not get this routine in other places addition to their health care? Because the NHS. Why do French women get what improves their lives so much? Because not-NHS.

Markets deliver what consumers want as consumers exercise their choices. Monolithic bureaucracies, not offering choices of supplier, do not offer what consumers want. Which is why we want to have, with significant involvement of government in financing and even regulating health care, markets in the provision of health care.

That mothers should be able to partake of carefree leaps upon a trampoline may not be a convincing argument but a lifetime of dry knickers for all mothers seems like a reasonable enough goal. We do already spend 10% of everything on health care and it only needs a tweak to how we organise that spending to reach the goal.

A doctor’s mandate

Following today’s High Court judgment, it’s an easy commonplace that the Brexit project has been thrown into disarray. Better to take a clinical look at its effect upon the heart of May’s claim upon authority: the timing of an orderly process. Our unelected Premier has to control the pace of events, lest the ups and downs of Brexit negotiation spill over into delays by investors and recruiters or into acute market volatility. Given enough time, one or the other is bound to threaten the real economy and undermine her command. 

We gather that the Supreme Court is to pronounce definitively in mid-January. Notwithstanding the apparent clarity of the lower court judgement, this gives time for the Attorney General to come up with arguments for a reversal. The Court may even welcome them as excuses to avoid the disrepute of frustrating the popular will. 

If not, the parliamentary manoeuvre of an affirmative resolution (a simple yes-no vote - sounds familiar?) may cow such inclinations in the Commons. Save for one or two Remain zealots, the current mood on the Tory benches would be to support such a resolution. And with seventy percent of sitting Labour MPs coming from constituencies voting Leave, Corbyn is most likely to avoid embarrassing them by whipping abstention, failing which a free vote. Such manoeuvres may even dish the Lords for the time being, but make no mistake: they will not scruple from kicking over the traces once they see the Great Repeal Bill. 

In addition, some lawyers are saying that such a vote might also be open to court challenge, and that only a conventional bill with full scope for amendments in both Houses satisfies today’s ruling. If this is right, May’s momentum is definitively challenged by an adverse ruling on appeal. The government’s resort can only be faster enabling legislation. The conventional device, a guillotine motion, risks upsetting the Commons and in any event has restricted purchase upon the Lords. In such circumstances, May will have all the excuse she needs for a snap election. It is hard to see how she would fail to increase her majority, campaigning on the platform of a doctor’s mandate to implement the referendum in an orderly fashion without giving the game away to the other side. 

Given the incidence of the holidays, the earliest date for an election would be mid-February. May also needs a good reason to call it. Paradoxically, a disobliging ruling in mid-January, however unwelcome, would be just the ticket. 

It's possible that some people aren't quite getting the point of this vaping thing

A little discovery from detailed research in foreign. Some governments might not be quite getting the point or purpose of this whole vaping thing. We have discovered in Portugal that vaping, as opposed to smoking, is very much a minority pursuit. So much so that it is actually rather difficult to find the equipment, accoutrements and supplies.

We think we might have a clue as to the reasoning too. The Portuguese government has decided that the nicotine contained within vaping supplies should be paying tax just as the nicotine within cigarettes does. Got to keep that all important government revenue flowing in after all. This means that when purchasing vaping juice one picks a flavour, as in other places. But that flavour, that juice, contains no nicotine. Not quite the point.

The nicotine is then added from tax paid containers of the stuff to the desired strength. The imposition of the tax then makes the completed juice some 5 times more expensive than it is in one other continental country of our experience.

This might just be a clue as to why vaping incidence is so low in Portugal.

If you view vaping as just another example of Big Tobacco oppressing the masses then of course this makes sense. If however you think of it as a substitute, one with near (comparatively at least) no health implications then it may well not be all that sensible.

We would tend to the not sensible end of that spectrum of possible descriptions.

 

A quickie divorce, step three: the financial settlement

We now reach the final element in a quickie divorce: the financial settlement.

A one-off payment, probably in the single billions, will be necessary to cover items such as the UK’s share of EU pension and other future obligations, balanced by its share of buildings and other tangible assets.

Any periodical payment would be to cater for specific programmes that the UK found valuable, such as the Erasmus scheme of student exchanges. This might be a periodic payment in the hundreds of millions.

Some people suggest that the UK might be bulldozed into periodical payments for passporting financial services. City sources claim that as much as 20% of tax receipts from the City (£13.3bn) might be at risk from the loss of passporting or other disruptions. But sums like these are hard to credit, for at least half a dozen reasons:

* International banks do pay around 20% of total taxes sourced from the City, but only a fraction of their activities benefit from passporting into Europe. Passporting is intended to protect consumers, whereas City institutions largely deal with each other or leading commercial or industrial corporations.

* Also, international banks are but one of the City’s activities: others include the UK-based banks providing consumer, industrial and mortgage lending; as well as non-banking activities, including asset managers, currency dealers, hedge funds, life and general insurance and private equity; together with professional services including actuaries, fintech, law and risk-management. Almost none of this is vulnerable to the loss of passporting.

* If, moreover, the international banks concerned are European, they benefit from passporting into the UK, reversing the balance of arguments on the topic.

* Most UK collective investment vehicles operate via the Channel Islands, Dublin or Luxembourg, rather than using their passport from London. This tells us that a low-tax regime means more to them than any gains from passporting. Once again, this opens the way for the UK to revisit its tax regime to make the balance more attractive.

* Since passports were introduced, the growth of UK financial exports to the EU has barely improved. Meanwhile, UK financial exporters sell without passports to their two largest markets, Switzerland and the US.

* Finally, City institutions will adjust. They will find new sources of revenues, to serve as the wherewithal for future tax receipts under whatever regime then applies.

No one knows what the right figure for the sums at risk might be, but no reasonable estimate of them amounts to a good reason to pay into Brussels.

Try a thought experiment: imagine what the EU would charge the UK for full participation in the pertinent aspects of EU decision-making on financial services (one of the main concerns of City Remain voters). To make such participation worthwhile, it would have to include a UK veto on regulations affecting the City, with dispute resolution under the binding arbitration described above. Plainly, this is a pipe dream, which only reminds us of the limits to what a financial settlement can achieve.

-o-

The thrust of these three blogs has been that it is unrealistic to expect too much from prolonged (let alone detailed) negotiations. The EU-Canada trade deal debacle tells us that Brussels will find it close to impossible to develop a position which satisfies all its members. Its negotiators will be discouraged from offering any kind of flexibility to the UK, for fear that concessions are demanded elsewhere. Most of all, the EU has so much else on its plate that it would be delighted to do without the distraction of Article 50 negotiations carrying on till the second quarter of 2019.

The UK has no reason to make things unnecessarily tough for our neighbours. A quickie divorce eases the position for them and cultivates desirable conditions for us: reducing uncertainty at home and overseas, making the best of the EU’s own market and accelerating new departures in international trade.

Surprise! Someone does something entirely sensible and logical

This is not, as we continually mourn, something usual in our body politic. So, when it happens let us celebrate it:

Drug addicts are set to get heroin on the NHS, in Britain's first 'shooting gallery'.

For the first time the health service will prescribe pharmaceutical-grade heroin for free and provide a place to take it.

Plans were approved yesterday for the facility in Glasgow city centre, raising fear more will follow across the country.

Already, there have been three trials in London, Darlington and Brighton, providing free heroin, although this will be the first state-sanctioned injecting facility.

Fear that more will follow? Why not one in every town? For it is not the getting high which is the problem. It is the disease that comes from dirty injection methods, the deaths from impure or over strength injections, the theft and crime to pay for it all, which are the problems. 

Way back when the NHS used to provide free drugs to addicts. Then they stopped and addiction soared as dealing was the way to make the margin to be able to consume.

We're pragmatists around here as well as moralists. We insist that it is morally right that consenting adults get to ingest whatever they wish. But even aside from that the damage of drugs comes from their illegality. Prescription grade heroin might make you feel like doing not very much (although Shipman murdered hundreds while supposedly so incapacitated) but other than that there's no problem to it, not even to the health of the taker.

Lucy Dawe, from charity Cannabis Skunk Sense, said: 'This is tantamount to drug dealing by the state. I can't see it's going to reduce the number of addicts, it just gives them somewhere to go.'

Yes Lucy, you're right, it is only drug dealing by the state, it is only giving people somewhere to go to gain clean gear and accurate doses.

That's why it's such a damn good idea.
 

A quickie divorce, step two: trade in goods

In the last blog I argued that HMG first needs to flush out the attitude of the EU before committing time and political capital to negotiations. I suggested the EU’s sponsorship of the UK’s independent representation at the TiSA talks in Geneva as a touchstone of the EU’s intentions. If negotiations do take place, the UK’s position on services should be the status quo ante, governed by binding arbitration, failing which reciprocity.

I now turn to trade in goods, where a zero-tariff regime makes increasing sense. It has never been easy to get other countries to reciprocate a zero-tariff policy. But as events are turning out, zero tariffs are emerging as the most elegant solution all round. They should be combined with an invitation to the EU to reciprocate, addressing the concerns of integrated supply chains and manufacturing exporters in general. If this invitation drives a wedge between Brussels and its constituent exporting nations, that will work to the UK’s advantage.

Zero tariffs reduce costs for manufacturers and consumers. Politically, they also:

relieve both sides of the unrealistic burden of line-item negotiations;

take the high ground in the international community; and

show support for (eg) financial services or car manufacturers, who would probably lobby the EU to reciprocate.

Should the EU decline to reciprocate, a zero-tariff regime represents its own fall-back position. International manufacturers in the UK will be able to source from anywhere in the world, free of duties. They will then have to balance the undoubted gravity effects of the proximate European market with the UK’s other attractions, including any newly emerging relief in the tax regime.

Critics of this policy may fairly point out that it has only been taken up by the two city-state entrepôts of Hong Kong and Singapore, suggesting that it has little application to major economies. But this conclusion does not follow. The overall level of EU tariffs is 5.3%, some 180 basis points above world levels of 3.5%. Both are well below any reasonable test of materiality. It is also not at all clear which UK sectors need the protection of tariffs.

We sometimes hear that a zero-tariff regime would deprive the UK of bargaining cards in free trade negotiations. The facts are against this. Singapore has a network of free trade agreements (encompassing almost twice the GDP of those achieved by the EU), including agreements with the ASEAN group, EFTA, China, India, Japan, Korea and the US. Hong Kong has free trade agreements with ASEAN, China and EFTA.

We are also told that zero tariffs would deprive the UK of penalties for dumping. This is hard to understand as nothing in such a regime would cause the UK to relinquish its rights in such matters.

In the final blog, we will turn to the financial settlement.

 

Who cares about pandas when we can have dinosaurs?

There are many things to be wary of in the modern world. Terrorism, Jeremy Corbyn, spiders. But as of recently, people have forgotten their phobias to make way for the signaling of a brand new fear. That of mass extinction. Facebook walls across the world have been plastered with tear jerking videos of cute Pandas and cuddly Chimpanzees, accompanied by captions heralding the mass exodus soon to come if humans don’t stop their destructive ways. This is all in the wake of a report released by the WWF which brazenly proclaimed that “The world is on track to lose two-thirds of wild animals by 2020”.

What is to be done to save our fellow residents of planet earth? Should we stop intensive farming, stop logging, return to the caves from whence we came and pick up the wooden cudgels and bronze tools that we abandoned long ago?

Of course not. The answer to such an issue is perhaps not obvious. We should carry on as before. Developing, trading and innovating. Because there has never been a better time to be alive on planet earth. Free markets and competition have enabled innovation that not only makes the 21st century a great time to be a human, but also to be an animal.

When the German Chemist Fritz Haber produced ammonia (fertilizer) from hydrogen and atmospheric Nitrogen, like many great innovators, he benefitted man and beast alike. This, combined with genetically modified high yield crops and sophisticated irrigation systems, has meant that less land was needed for farming, leading to less destruction of animal habitats.

When societies become developed, they not only stop having so many resource hungry children, but they begin caring about the preservation of animal species as well, and so make a concerted effort to help. And as study after study has shown, there is an extremely strong link between the economic freedom and development of a country. Further, 20th century inventions and innovations like synthetic leather and fur help all. When societies build houses from bricks instead of forests, they are doing not only man a service, but animals also. Progress for mankind is often progress for wildlife. The Dodo would never have died out had it existed today.

But don’t take my word for it. The President of the Adam Smith Institute Madsen Pirie has said in his paper “Britain and the World in 2050” that by 2050 there will be lab grown meats and new, more nutritious vegetables. Perhaps more dottily, he predicted the ability of humans to be able to resurrect extinct species, including the dinosaurs. And let’s be honest with one another, who cares about the Panda when we can have dinosaurs? Given his persistently impeccable track record in predicting the future, this is certainly not a prophecy to be scoffed at.

The problem with the prediction of the WWF is that in forecasting the loss of two thirds of wild animals, it assumes that human development will stay stagnant between now and 2020. But History tells otherwise. With free markets and free people to trade and make progress, animals and humans alike can thrive in a more advanced world.

Obituary for Tony Hollick: a very British libertarian activist

It is with sadness that I report the death of the British libertarian thinker and enthusiast Anthony Hugh Hollick who died on Friday 29th October 2016. Aged 74, he had been born on 30 July 1942 in the London district of Paddington. Raised for a time in south London, he went on to win a scholarship to the prestigious public school Dulwich College and from there went on to study at Geelong Grammar School in Australia.

Always an autodidact he was in essence self-educated and never attended university. Over the years he worked with a range of libertarian organisations including the National Association from Freedom (The Freedom Association), the Laissez-Faire Bookshop and the Freedom Organisation for the Right to Enjoy Smoking Tobacco (FOREST).

One of four brothers, Tony never married. Curious, engaging, yet at times irascible, he not only immersed himself in the world of ideas but he also found endless fascination with the human capacity to combine progress and dignity with all manner of idiocies and diversions.

Brilliant with children and fiercely loyal to his friends, he not only kept in touch with his beloved nephews but was also good at inspiring in the young generally. Always respectful of children as young adults he combined intellectual rigour and compassion with wit and humour. Particularly close friends such Chris, Gerald, Kira and Gerald Hartup Junior will miss him hugely.

While he had long-lived in the Bristol area, he was always good at nourishing friendships irrespective of distance and time. Besides his legendary love of philosophy, his ‘special party trick’ for the young was his knack to ‘take his teeth out’.

Throughout his life, Tony’s enthusiasms and passions remained many and varied. His interests ranged from re-cycling decommissioned US submarines and the future of the United Nations, to powered roller skates and a market for replica guns!

Always a fan of the Adam Smith Institute he once stood up at an early ASI meeting to proclaim:

“Some people spend their lives in this world with all of its imperfections and follies. Some contemplate and imagine and more perfect future world. Uniquely, the Adam Smith Institute builds the rainbow bridge that can lift us up from all that this world is, to all that it might become”.

Always an ideas person, he leaves behind him his next of kin Petrina, his special friends Robin and Carol, and many others who will miss him. Tony Hollick, RIP.

Pity the Minister didn't recognise this when he was in office

For the rest of us are well aware of this already:

The British arts establishment is suffering from relentlessly left-wing “groupthink”, the former Culture Minister has said, as he argues it should stop simply begging for more public money and start pursuing more radical ideas.

It has always rather amused us that the inhabitants of this world are so relentlessly left wing. They're in possibly the most viciously capitalist business in the world. Produce some cod nonsense that makes a profit and you'll be very well paid to continue to do so. Produce great art that loses money and you'll be back in Rep before the awards season comes around. 

There is, after all, no other business where a beautiful young woman won't be given a job because she's now 28 or so. But when casting romantic leads isn't that rather the complaint we do get? What other line of business has a right to refuse us beta males a piece of the action? 

No, don't worry, we're not saying they should have to change. Rather, that this clash of the general view of those in the business and the actual practices of the business is amusing. As with the fact that it's even more of a tournament than investment banking. The very few who prosper gain plutocratic fortunes, the majority who try earn less than minimum wage.

Really, nothing so viciously capitalist as the arts. This though is entirely true:

He argued it was now essential for the arts lobby to challenge the overriding view that “all must stay the same”, and stop insisting that no library or museum should ever be shut down no matter how poor or under-used its service.

The unthinking left is now the most conservative grouping in modern society. Conservatism being, as we know, standing athwart the path of history and shouting "Stop!" Which really is the default position of that unthinking left these days. No changes must be made to a 70 year old management system in the NHS, no library must close despite e-books and the internet, we should have more jobs bashing bits of tin rather than realise that's all done by machine these days.

Nowt so conservative as that British left.

A quickie divorce, step one: trade in services

At 1.00am on the morning of Friday 21 October, Theresa May took the five minutes allotted to her at the end of dinner at the Brussels summit to point out that the UK remains in the EU until the Article 50 notice runs out. She had previously expressed her wish that the UK should continue as a good friend and responsible partner to our continental neighbours. This piece sets out how the PM may indeed act as the good friend to the EU she wishes to be, by saving the EU from prolonged Brexit negotiations so that it is free to address its many other problems.

This is best accomplished with the measures on which I touched recently in “A summary departure”. Despite the inelegance of the phrase “quickie divorce”, it is a good catch-all for policies to minimise uncertainty, respond to volatility in financial markets and cut the risk of deferred recruitment or investment by industry. It achieves these aims by providing an early and definitive framework for commerce, finance and industry; and paving the way for prompt discussions with other trading partners.

In services, the timetable of international negotiations presents the UK with an immediate opportunity to gauge the EU’s intentions. The Trade in Services Agreement (TiSA), is currently being negotiated in Geneva between 23 members of the World Trade Organisation, accounting for seventy percent of world trade in services. As a precondition for any negotiations with the EU, the UK should give it thirty days to sponsor the UK’s independent status at these talks.

This matters to the UK but should be no loss to other Member States. The EU’s response to this request will serve as a touchstone of its inclination to act positively. If not, the UK should walk away at the end of the notice period, invoking powers taken under the Great Repeal Act in order to exercise its rights under the Vienna Convention on Treaties and abandon Article 50 talks for lack of a serious intent to engage by the other side.

If the EU responds positively, the UK should then pursue the difficult course towards free trade in services.

Barriers to trade in the field are regulatory. The EU’s approach has been “harmonisation”, universally seen as heavy-handed, indeed one of the most unpopular aspects of its acquis. Even so, it has yielded some fruit in transport and financial services.

Otherwise, many European services remain shielded from international competition, in particular those provided directly by governments or otherwise heavily regulated. These include broadcasting, education, energy, environmental, healthcare, postal and transportation services.

By contrast, the UK has led the way in deregulating (among others) energy, environmental, postal and rail services. This has opened them up to continental entrants without similar opportunities for UK firms across the Channel.

Whatever the bluster, the EU is unlikely to be militant about financial services after Brexit. They would fear the possibility of the UK taking tit for tat action against Continental financial firms operating in the UK – or at least revisiting the unreciprocated access to UK markets enjoyed by Dutch, French and German transport, energy and local services providers.

Our negotiators should make clear their alternative to the adjudicatory role of the ECJ on trade disputes. This solution caters for domestic sentiment, conforms to best practice and creates no new bureaucracy. It would be binding arbitration in London under the laws of England, universally seen as the gold standard for resolving international disputes.

As this offer is silent on freedom of movement, it is likely to be seen as the “cherry-picking” against which so many EU voices have been raised. The UK will need to take pains to ensure that its fall-back position, reciprocity, is fully understood by the EU member-states and commercial organisations most likely to be affected.

In addition, the UK will be in a position to exercise untrammelled sovereignty to lift tax burdens, as briefly addressed in the following blogs.

In the following blogs we turn to trade in goods and the financial settlement.