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Samizdata, derived from Samizdat /n. - a system of clandestine publication of banned literature in the USSR [Russ.,= self-publishing house]
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Samizdata quote of the day “Excuse me. Would you like to defend the NHS?”
“No. I’d like to abolish it.”
(Incomprehension)
And
People in this country have no conception of how good they have it. Except with respect to healthcare, when they have no conception as to how bad they have it.
(Both these quotations supplied by the same anonymous donor.)
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Who Are We? The Samizdata people are a bunch of sinister and heavily armed globalist illuminati who seek to infect the entire world with the values of personal liberty and several property. Amongst our many crimes is a sense of humour and the intermittent use of British spelling.
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A key part of the problem is that this belief is pandered to, even by ostensibly ‘right wing’ politicians.
Worth repeating.
What many, particularly Americans fail to understand is that in the modern UK, it is the NHS which has become the state religion rather than Anglicanism and to speak against the NHS is to be guilty of the worst sort of Apostasy.
To be caught buggering Flossie the Sheep would lead to less ostracism than being seen as a critic of the “beloved” NHS.
Having lived outside the UK for many years, including several in the US and the Far East, I can attest that the NHS is expensive, well meaning, overmanned, overmanaged, patronising and shambolic.
I am far more impressed with the mostly-private Swiss and even (god forbid) public/private French healthcare systems than I am with the NHS.
The advantage of saying “Scrap it” is that it does at least have the value of making people think “What would we do instead?”, which is a much more sensible and interesting question.
The answer to the first question is another question “What do you mean by the ‘NHS'”?
Is it the principle of healthcare free at point of use, with near-universal access, underwritten by the state?
Or an (even more) unsustainable nationalised 1940s-throwback monolith from the age when the state really did own almost anything that moved, or planned to until the 1951 General Election put paid to all that? A model so good that no civilised nation still uses it (though plenty of uncivilised nations’ citizens still use ours)? A system which makes you better despite not because of the tenets of this national religion.
P.S. The original question must be hypothetical, as most who would ask it would refer to it strictly as ‘Our NHS’ (pbui).
My council has recently introduced a £40 annual fee for emptying the green garden waste bin, a service for which the charge was previously included in the council tax.
People are very annoyed. Petitions have been started, protests made.
They forget that the green bin service was only introduced in 2007 and that before then we all had to dispose of our own grass cuttings and fallen leaves by putting them on a compost heap in the corner of the garden or by taking them to a council waste depot in a car.
Once people have been offered a service for ‘free’ they resent any new scheme which involves payments.
Did their Council Tax go down by £40? If not they had every right to be aggrieved, or am I missing something?
“People in this country have no conception of how good they have it. Except with respect to healthcare, when they have no conception as to how bad they have it.”
So, so true.
“To be caught buggering Flossie the Sheep would lead to less ostracism than being seen as a critic of the “beloved” NHS.”
“Our NHS”, you mean. God, I hate that. It’s not ours; it’s theirs. Always was.
“I can attest that the NHS is expensive, well meaning, overmanned, overmanaged, patronising and shambolic.”
I could tell you that without anything to compare it with. The trouble with it isn’t that it’s some kind of third-world hellhole that people are terrified of (although it’s bloody close). If that were the case, something might be done. The trouble is that it’s barely adequate. It just about works, more or less, in a ramshackle, string-and-spit kind of a way. It scrapes by (on £130,000,000,000 a year). And that’s simply not good enough for one of the world’s most prosperous countries. It’s certainly nothing to be proud of.
I had an operation recently, and I’m cured. I can’t complain about that. In the strictest sense, The System did its job. But almost everything else about the experience, from waiting ten weeks (which wasn’t a ten-week wait, because that would be illegal; no, they gave me a “consultation” after the first six weeks which made it okay), to the patronizing letter telling me to turn up at 7.30am sharp or face the consequences then making me sit in a waiting room for six hours, to failing to send a copy of my discharge letter to my GP, to the near-impossibility of making an appointment with said GP (I haven’t seen her in over two years), to the mix-up in my post-operation prescription, has been absolutely bloody useless.
But hey… it’s “free”. I should be grateful, right?
Well according to the OECD, that “Free” (at the point of use, which is the key term) cost $3,286 per capita and since not all of the per capita pay taxes, it actually costs those that DO PAY a lot more still, so more like $5,000 per year.
I could buy a pretty decent health insurance policy for the money that is spunked away on our beloved NHS.
OECD – Health spending – Total / Public / Private, US dollars/capita, 2015
If you make people aware of just how much money they are paying in tax to support the “free” NHS they you will quickly get it abolished in its current form.
I did some rough numbers a few years ago and a case could be made that at least 20% of UK income tax is used to fund the NHS. Given its percentage of general taxation revenue. Now if you split out that amount and put the number (the NHS cost) in everyones payslip as a seperate tax they would soon get the picture. The way you would do it politically is to split the cost of the NHS into a separate tax and give everyone an opportunity of paying an extra “solidarity” tax of a few extra percent that would go directly to NHS funding.
I can guarantee you that very few, maybe 5% max, of UK tax-payers are willing to pay extra tax just to fund the NHS in its current form. When the average tax payer sees just how much money they pay every month for such a terrible heath care system just watch the sacred cows being slaughtered.
Disclaimer. I am writing this with a hand which has a NHS finger. it was chopped off in an accident when I was a small kid and they sewed it back on. I have direct family experience with the health systems of five countries, ranging from the UK through France to the US. For the UK the French system is probably the best alternative but once you realize the US system is very very different and act according to work the system it is the best in the world.
The US system has its own problems, all involving government interference destroying the market price discovery system so every single nightmare story I’ve seen in the US system over the years involved money. Which can be fixed. And was. Whereas as in the non-US healthcare systems every single nightmare story I’ve seen over the years has resulting in people dying. Which cannot be fixed.
Just on my way back to the US to get medical treatment for the side effects of another childhood accident. I have a choice of being treated by several European medical systems, including the NHS, but based on many decades of personal experience I’m going to use the best one. The US healthcare system.
I get a little lesson about the service that we get from the NHS whenever I take my cat to the vet. When I ring for an appointment the phone is answered straight away and I don’t spend any time on hold. I can get an appointment the same day and when I turn up with said cat, the consultation takes place at the time that they said it would. I have to pay for the treatment and then claim the money back from my pet insurance. I can’t help thinking that my cat has better healthcare than I do.
One more thing. If someone needs really expensive cancer drugs that are not available on the NHS, they are not allowed to pay for the drugs and have the remainder of their treatment on the NHS, it has to be all or nothing. Who came up with that rule and why?
People like getting healthcare. Illness and injury scare them in a primordial way. When they recover, they are very aware of how much worse things could have been, and they have a natural, primeval tendency to “Thank God”. Since they don’t believe in God any more, they thank the NHS instead.
Mostly, people have no conception that what they should be thanking is modern medicine, and the NHS is merely one means of delivering it to them. If they did, they could consider critically whether it is the best way, but they don’t.
Which is probably the strongest argument for abolishing the NHS that I’ve ever heard.
I would hazard a guess that this rule was drawn up by some government appointed bureaucrat. Sure, the rationale would have had some medical shroud drawn over it like “Any treatment regime can only be dealt with by a single medical team”, but since most doctors of any standing also operate in private medical practice, it’s just a shallow lie to keep the competition in line.
No, it’s more nakedly to prevent people “imposing additional costs on the NHS” by living longer than NHS treatment would have allowed.
In a bunch of severe cancer situations, for example, a few doses of a very expensive drug you can’t get on the NHS will buy you several years of extra life. During that time, you’ll still need regularly-expensive treatment. The NHS believes it is unfair to expend those resources on you, since by rights you should be dead by now.
It is probably prudent to start a discussion of this with somebody needing to be convinced by
“I believe that everybody should have access to healthcare, but the NHS is a really bad way of achieving this…”
Avoid mentioning the US or the developed Asian countries, and mention cuddly social democratic places like Switzerland, Netherlands and Switzerland.
Memorising 5-10 facts will probably be sufficient. Given that the NHS is a religion most people don’t bother to learn facts in order to defend it.
Probably much easier to convince somebody of the need to reform our healthcare system than to have the global warming debate, which is even more, much more, similar to a religion. It is also much harder to win this argument since as a last resort they can always say “well, you appear well read but you aren’t a scientist so why would I believe you”.
One more thing. If someone needs really expensive cancer drugs that are not available on the NHS, they are not allowed to pay for the drugs and have the remainder of their treatment on the NHS, it has to be all or nothing. Who came up with that rule and why?
To be fair most I know who push this line argue that ensuring rich people get the same healthcare as poor people makes them more invested in maintaining public healthcare (and its funding).
Comparing Switzerland, where I lived for a year, with the UK gives a great argument against the government having anything whatever to do with running healthcare, whatever one’s views on mandating it.
Switzerland mandates that all must buy health insurance, imposed a tax on that to cover no-money situations, and lets the market run the whole thing: insurance, hospitals, sanatoria – and AFAIK training and certification, but I could be wrong about that and/or they could inspect.
The government also does something else very important: it is vigorous in preventing the entry of foreigners who look like they have the remotest chance of becoming a cost to the country, and specifically not letting them make the tax on insurance grow large. There are some 7000 communes in Switzerland (which has over 5 million citizens and another 2 million residents, and it is not made easy for the latter to become the former). Each commune knows that it personally – not some general Swiss-wide fund – is on the hook for any health treatment a non-citizen gets but cannot pay for. The mayor of my commune was eager to meet me early on in my stay to see evidence I had arranged to pay any health bills.
The standard of care in Switzerland was noticeably superior.
Indeed. In her literature prior to the recent General Election, my sitting MP (Jenny Chapman) referred to the (alleged) threat to the A & E service at “our” local hospital, declaring, with no apparent awareness of the irony, that it had been in existence for eighty years, and that the Government intended to steal it from us. It was built in the early thirties, funded by public subscription, and was, of course, stolen from us in 1948, since when it has, as Sam Duncan pointed out, been “theirs”.
I forget the source – possibly “The Welfare State We’re In” – but I believe that, in the first decade and a half of its existence, the NHS built not a single hospital, but closed and merged several.
It is just possible the Charlie Gard situation will make some people more aware of whose NHS it actually is. The story broke today that the lawyer appointed (by the state, not by Charlie’s parents) to represent Charlie in the court proceedings – i.e. to act for Charlie and against the NHS who wish to terminate him – is the head of ‘Compassion in Dying’ (formerly ‘The Voluntary Euthanasia Society’), a euthanasia advocacy group. Apparently, Charlie’s parents have only just discovered this – although it seems they have wondered for some time why this state-appointed lawyer, not them and a lawyer they chose, is representing Charlie in these court proceedings.
Funny how that happens when you take steps to prevent freeloaders.
Not just the NHS. Here in the USA we decry governmental bureaucracy, while ignoring the elephant in the room that is the massive private sector bureaucracy of so-called health insurance (pre-paid medical might be a better term).
The costs of that bureaucracy are huge. An MRI here costs $3000 to $5000, at an in-network hospital. Or, I can drive 50 miles to an imaging center that doesn’t accept insurance and pay $500. They’ll give me a receipt and I can pursue our insurers for whatever I am owed.
Our GP charges $150 for an office visit. I asked him how much he could charge and still make the same profit, if he didn’t have to defray the costs of dealing with insurers. He replied “$65”.
At the risk of sounding Menckian, it is obvious that diverting the vast majority of healthcare spending into unproductive paper shuffling is A Bad Thing.
I have long argued that health insurance for humans, modeled on current pet insurance schemes, would be vastly more efficient. Consider my “pre-paid medical” remark: A typical plan for a cat does not cover things that you know are going to happen – such as vaccinations, or things that are elective* – such as spaying/neutering.
In other words, it is actually insurance, hedging against the unforeseen rather than pre-paying (at a premium) for things that you expect to happen. In a world where all health insurance worked like that, you could expect the cost of healthcare to plummet.
* For some value of the elector 😉
This may be true except for the ‘rich’ people, which should be ‘not poor’, or possibly ‘neither poor nor stupid’, as even many poorly paid persons would afford some basic insurance for healthcare emergencies. As we know really it is a special penalty tax (i.e. 100% VAT, assuming the private healthcare costs the same as the public sector version does) on those with the gall not to employ the public sector.
The Charlie Gard situation has got nothing to do with the nationalisation of health care and has everything to do with a far more sinister nationalisation – of children; embodied by the exceedingly sinister CAFCASS. The question, in this case, is not about who treats him or why, but who decides whether he should be treated.
This is naturally and traditionally the parents’ duty. And right. I am enough of a Tory to accept that very occasionally if parental decisions are manifestly and seriously against the child’s interests, then the court may have to step in and overrule them. But this CAFCASS thing takes it a whole leap further. Into outer darkness. The parents don’t even get to appoint the lawyer to represent the child’s interests in court. Instead it’s taken out of their hands and put into the hands of a quango. This would be intolerable even if there was a wholly private healthcare system. The battle that is being lost now is not the battle for privately managed health care. It’s the battle for privately managed children.
Contrary to what is often claimed, most people rarely demand new services or benefits from the government – but once such things are granted (normally by elite intellectuals pushing for them) such “free” services or benefits are almost impossible to take away. The people grow used to free services and benefits very quickly.
Witness Obamacare in the United States – such things as “no extra payment for preexisting conditions” (i.e. allowing people to buy insurance AFTER they are ill or injured, at the same price they could have bought it before they became ill or injured) obviously will not work – it is impossible for an insurance company to operate like that, it would need endless bailouts from the Federal Government. And why should the Federal Government endlessly bailout insurance companies? So the next stop will be government healthcare – like the NHS n Britain or the VA (Veterans Administration) in the United States.
Solution? As far as I know there is no solution.
Bankruptcy, economic and social (cultural), would seem to be inevitable.
Remember the left controls memory – at least the memory of most people. Most people sincerely believe that if you could not afford to pay for healthcare before the creation of the NHS – you died.
If you control most sources of information (schools, universities, television….) then within a generation or two, you control memory.
The most sinister aspect of the NHS is the secrecy, my GP never even bothers to tell me the result of blood tests. Apparently they are for her eyes only.
Orwell wasn’t kidding when he wrote:
It was as well understood then as it is practiced today.
Just to put these figures in context:
As a single white male over 50, the best quote I received last year for a basic Obamacare insurance policy with what was essentially a $6500 deductible was $1100.00 per month.
$13,200.00 per year. Add in the deductible which I must meet before enjoying any coverage, and you get to $19,700.00 before seeing any coverage.
I’m a relatively healthy guy – I last saw an actual doc about four years ago, and the time before that was probably eight years ago – so this isn’t some high-risk, preexisting-issue policy. It’s just a standard one.
So the $5000 per year above doesn’t sound so bad.
Until you actually need it, when you either have to wait 10-weeks to see someone who will start diagnosing what is wrong with you or they flat out say, sorry we can’t treat that on the NHS.
At which point paying $5,000 annually for nothing reverts to seeming somewhat expensive.
If we paid $5,000 annually and got the good and timely healthcare that we’ve already paid for I might take your point, but we don’t.
As others have said, the reason healthcare is so expensive in the US is largely not to do with the actual cost of delivery, but all of the non-optional regulatory bullshit that has to be packaged with it. Some of this comes from the state, but a lot of it comes from insurance, legal, compliance and other forms of rent seeking.
Often people defend the NHS by pointing out that any person could be financially ruined by contracting some kind of long term illness that is very expensive to treat. The point that I made earlier about the total professionalism that I experience when using the services of a vet is that, if they don’t do a good job then another vet will get my money. I often wondered if some kind of system like an insurance excess could work. You pay for small and relatively cheap things and have the less affordable stuff covered. That way minor healthcare providers could compete for your business and would be likely to provide a good service.
Can’t disagree with that. In all my life, I’ve never had to wait longer than 24 hours to see a non-emergency doc, emergency care has always been within an hour or two, and in the cases where I’m sent on to a specialist, it’s always been within three days. I’ve always been treated well and competently, and politely. And each doc has one assistant and a couple of admins generating paper.
I now deal outside of the insurance system for health care. There are offices with posted prices for non-insurance cases which give us the discounted insurance price. Still great service, cash on delivery, decent prices, and we’re all happier. I just hope they re-allow catastrophic coverage policies again. Obamacare made a mess of that, but with its “preexisting conditions” idiocy, I can just buy a policy after I know I’m sick.
(It’s like waiting for a house fire to buy fire insurance. They have to sell it to me, at the pre-fire price, and then cover the fire. Insane.)
As long as those offices also take insurance, though, you’re still paying more than you should, because a portion of the “discounted insurance price” goes to defraying the insurance related overhead.
The only places that you can pay a true(ish) market price are establishments that eschew insurance all together.
Indeed. Insurance that is actually, well, insurance.
bobby b, where are you getting such service? “There are offices with posted prices for non-insurance cases which give us the discounted insurance price.” Not where I live. Here, if you don’t have insurance they charge hugely inflated prices over the (negotiated) insurance company price. And there’s no competition: we have basically a duopoly, although as a practical matter the larger health-care “system” has about 80% of the market so it’s closer to an outright monopoly.
In the US, before all this current craziness unfolded, you could choose your premiums and deductibles in accordance with the kind of coverage you wanted. So if you wanted to pay for routine simple stuff out of pocket, you chose a higher deductible with lower premiums – and vice versa.
The minute the government steps in and provides a subsidy prices go up. Even if there are deductibles there is such a thing as an ‘income effect’; people are richer so they spend more.
If you combine the effect Paul Marks mentioned, that people get used to benefits super quickly (did you know that when the poll tax was introduced the poor were given additional benefits to pay it. The idiots gave the benefit out a few months before the tax was introduced, so people got used to the benefit and rioted when the poll tax came in – sorry this is probably not familiar to US readers), with the dysfunctional US system of government that is designed for gridlock, then changes becomes impossible. I’ve often thought that giving the President a ‘retrospective veto’ on all laws (except of course the constitution) would be an excellent idea.
Here, you have to wait well over six months to see certain specialists. Yes, we have two GPs who don’t do the insurance thing. One charges $250/mo retainer for people over some age, which includes me. He promises prompt service. I think there is no further charge, don’t swear to it. My Medicare Supplemental (which used to be major medical) = $ 236/mo + Medicare Part D (which I now have to have unless I can pry Ms. Gates away from Bill) is $ 22.+/mo. = $258!
But this guy points out you need Medicare anyway, to cover whatever he can’t fix himself. Oh good.
I forget what the deal is with the other guy. And you still need Medicare.
“The standard of care in Switzerland was noticeably superior.”
Unfortunately.
bobby b, July 17, 2017 at 3:14 pm, a point to note is that the NHS – well, the UK government/legislature, actually – acts to chec ambulance chasers and related effects in regard to the NHS. One of my relatives is an obs&gyn specialist. In the US, her legal insurance premiums would be huge! In the UK, they are much less. This is one undoubted effect of government-run healthcare – the state has a powerful incentive to legislate to limit how much they can be sued for, and whether they can be sued.
There is a downside, however. IIRC, thousands had to die in the NHS from ‘superbugs’ in the early 2000s before doctors’ demands for deep-clean to avert superbugs were finally heard by administrators and funded. Private hospitals knew that one such death would be widely reported with a “greedy commercial hospital saved on cleaning, killed patient” angle, followed by lawsuits, so their administrators heard what their doctors were saying much earlier. I have this from my NHS relations.
One of the great advantages of bureaucracy is that a private company would try and limit exposure to medical failures because of bad PR, but the government just throws bureaucracy at the problem, because they make the rules so fuck you.
This is fine if you are a taxpayer or an administrator, but as a victim of NHS malpractice or maladministration, not so much.
Even so the ‘could have been prevented’ death toll of the NHS is horrendous (and underreported), but even so the medical compensation bill still reaches £1 billion a year, even with the bureaucratic shenanigans.
PeterT is correct; subsidies always result in price increases; it’s basic microeconomics. That’s why college tuition in the US has increased far beyond what inflation rates and other exogenous factors would justify: it’s directly attributable to the increased availability of student loans, subsidies, scholarships and grants. Of course, since almost everybody is abysmally ignorant of basic economics no one seems to understand this, least of all the politicians screaming for more generous student aid.
Niall raises an interesting point, one which I had not considered: the benefits of sovereign immunity. If the healthcare system is owned by the government, the costs of malpractice insurance and damage awards should decrease dramatically (as long as the government takes a hard-line approach to such claims and refuses to permit most lawsuits). This should help drive down the cost of healthcare appreciably, even with the dead-weight cost of health insurance administration factored in.
Where I live, the dominant (and massive) healthcare “system” (which owns hospitals, numerous other medical facilities, urgent-care clinics, most physicians’ practices, etc.) has, through a legal sleight-of-hand, converted itself from a public nonprofit (with a Board of Trustees appointed by political leaders) into a private nonprofit which is completely controlled by the insiders, who now appoint their own Board. They offer facile (although thoroughly bogus) arguments for why this is in the best interest of the public, and few people seem to care, although it is being challenged in court. However, by the time that suit works its way through the legal process (with judges dragging their feet every step of the way) I fear the reorganization will be irreversible even though illegal. (That’s clearly what the system’s executives want.) But I’m going to suggest to my local legislators that the state “nationalize” (or whatever the word is for the state-level analog to that process) the entire system and take direct ownership of it. My rationale will be the immense cost savings which will result from invoking sovereign immunity (as well as the rather substantial profits [despite being nominally a “nonprofit”] redounding to a state which is chronically short of cash). And since the system doesn’t “belong” to anybody the state wouldn’t have to pay a dollar to take ownership of it. Win-win! It’s the perfect antidote to the venal administrators who now run the place, and who engineered the restructuring solely to line their own pockets. I love it! Of course, the downside is that the system will then be government-owned, but from my perspective I can’t see any difference.
But you can just as easily have legislated immunity, such as we have in our Workers Compensation system (which works quite well.)
In exchange for a fairly low cap on payouts and benefits, (meaning, a completely disabled worker will get a basic income for his working years, medical treatment for his injuries forever, and maybe a few hundred thousand dollars compensation), workers who are injured don’t have to prove that anyone was negligent or at fault – the fact of the injury at work grants the entitlement to benefits.
Businesses still guard against injury, because allowing a worker to be injured can wreak havoc with Workers Compensation rates going forward, enough to shut down a company if they’ve been reckless.
The lottery aspects of civil litigation for injury disappears – injured workers don’t get immensely rich from “their case”, but no one loses everything through courtroom vagaries. Business doesn’t always face the company-killer lawsuit for injuries. Lawyers’ fees are capped quite low, so there’s none of the 1/3-fee drag on the financials. It’s one of our better systems.
True, bobby b, but workers compensation programs require the payment of premiums by the companies covered, and also requires a fairly elaborate administrative process to run it. Sovereign immunity does neither, so is substantially less expensive. In my state, our Tort Claims Act permits recoveries against the state, but it puts caps on damage awards and prohibits punitive and exemplary damages and pre-judgment interest. It also has a fairly short statute of limitations. Yes, you could do all that for other (private) companies by statute, but politically it’s much more feasible (less objectionable) for the government to apply only to claims against itself.