Some rather weak responses to the TPA report on NHS performance

Cross-posted from the TaxPayers' Alliance blog

Here at the TaxPayers' Alliance we're used to rather unconvincing government responses to our reports. Tessa Jowell produced the memorably meaningless argument that it "is a mistake to view 2012 as a cost, rather than an investment" - as if investments don't have costs. The DFID managed to completely contradict their own press release in a response to our study on hate education in the Palestinian Territories.

Today we've had some equally lackluster responses to our study Wasting Lives: A statistical analysis of NHS performance in European context since 1981.

The King's Fund, quoted in the Guardian, were good enough to acknowledge that our basic methodological approach is valid. Unfortunately, they then tried to diminish the conclusions of our study by placing them in a completely inappropriate context.

Even if the statistic that total mortality is between 750,000 and 1,000,000 is accurate that isn't the correct number to compare with our estimate of 17,000 deaths from poor NHS performance. Most deaths occur either from a condition, or at an age, that they should not be considered amenable to healthcare and therefore have a limited part to play in any discussion of the ability of the NHS to save lives.

The proper comparison is with total amenable mortality and that comparison is contained in our study. As the Times noted "mortality from [amenable] conditions is 26.9 per cent higher in the UK than the average in the four European countries, and 48.6 per cent higher than in France, the best-performing country." This is a very significant difference. We only cited the number of lives lost more prominently as we didn't want the human tragedy to be lost in a fog of more esoteric statistics.

If the King's Fund don't think that 17,000 deaths is a high number then why do we concern ourselves with deaths on the road or deaths related to alcohol? Neither are nearly as lethal as poor NHS performance.

Health Minister Ben Bradshaw responds for the Government with a quote in the Guardian. First, he said that the gap between EU peers and the UK has been narrowing. That was clearly acknowledged in our study. However, it has been narrowing at pretty much exactly the same slow pace since 1981 despite a huge cash injection since 1999. There are probably several trends underlying that pattern, technological change that erodes established advantages is probably particularly important. There is a lot of analysis of the trend in our report but, suffice it to say, Bradshaw has to explain how exactly his government has spent so much more, £34 billion, and got exactly the same results.

He follows that with a meaningless ad hominem. Hopefully Guardian readers will be open minded enough to know that calling someone "rightwing" is a poor substitute for being able to point out how they are wrong.

Finally he accuses us of admitting that our figures are "more than three years out of date". We did no such thing. The data used in our report is the very latest available mortality data. It describes deaths in 2004 for the simple reason that mortality statistics for more recent years just don't exist yet. 2004 isn't that long ago and is five years after the cash injection whose effects we wanted to study. Almost all statistical analyses have to look a certain distance into the past thanks to the time taken, by the relevant organisations, to produce the statistics that they analyse. If Ben Bradshaw isn't willing to accept any study that does so you have to wonder how he understands health policy at all.

A new TaxPayers' Alliance report - Wasting Lives: A statistical analysis of NHS performance in European context since 1981

A report I have written, Wasting Lives: A statistical analysis of NHS performance in European context since 1981, examining NHS performance and putting it in context with an examination of trends in Europe was released today. It has done rather well in the media and will hopefully provide a new clarity to the healthcare debate - illustrating both the huge stakes and the failure of recent strategy.

The empirical method used, mortality amenable to healthcare, was obviously inspired by Nolte & McKee's 2003 study of amenable mortality, which was cited in the Better Government position paper (PDF). However, the analysis was inspired by this graph, and others like it, from the Department of Health (PDF):



Look at the pattern for England compared to the EU-15. Premature mortality from circulatory diseases is definitely falling - and converging on the EU-15 average. But its been falling pretty steadily since the eighties. If you look at that graph its very hard to spot what has happened to massive additional spending since 1999.


Replacing this graph of one condition with no filtering for conditions amenable to healthcare with the aggregate mortality amenable to healthcare numbers in our study was an enormous empirical task. It required exporting the numbers for a given gender, in a given country, in a given year from the raw World Health Organisation database to a spreadsheet. That spreadsheet filtered for conditions amenable to healthcare and then turned those numbers into an age-standardised rate. This had to be done for each gender, each year and each country. It was a big process but it gave us an aggregate measure of healthcare progress in Britain and the European countries studied.

We could then look and find out two things. First, we could get an estimate of the human cost each year of the poor performance of the NHS. These are mortality rates and it is easy to lose sight of the fact that they represent a staggering number of lives lost. Innumerable tragedies, a significant number of which, over 17,000 by our estimate, could have been avoided if we matched the performance of European healthcare systems.

Second, we can see whether massive increases in funding post-1999 have had been effective. It appears they haven't. There is no discernable effect of the additional funding in the mortality numbers. If we want to get the kind of performance in healthcare that people in Europe expect and receive we need to learn lessons from how they organise healthcare: we need to decentralise, encourage competition and end political management.

Barry Sheerman's ironic accusations

Epolitix.com (via ConservativeHome) reports Barry Sheerman accusing David Cameron of turning the Commons into a brawling house:

"In an ePolitix.com podcast, the chairman of the education select committee said: "Can I just say, there was appalling behaviour by the leader of the Opposition today.

"He has been around in Parliament long enough to understand the rules of Parliament.

"He used the word 'you' shouting across the despatch box six times. He wasn't reprimanded by the Speaker, which I think was unfortunate.

"If someone is going to turn this place into a sort of brawling house, I am going to do anything I can as a senior member of Parliament to stop him."

Asked whether he would be seeking action on Cameron's interventions, Sheerman said: "He's got the behaviour of a hooligan in the chamber.

"As someone who wanted to get away from 'Punch and Judy', he is dragging the House of Commons down into a pit that I don't want to see it in."

What's brilliantly ironic is that this is the same Barry Sheerman who got in a drunken fight with Bob Marshall-Andrews, from the Times:

"Barry Sheerman, the senior Labour MP and chairman of the Commons Education Committee, happened upon the scene and attacked Mr Marshall-Andrews for talking to his “friends” in the Tory party. Mr Marshall-Andrews shouted back at him and suggested that Mr Sheerman might have taken drink.

At that point Jim Dowd, the pugnacious Labour MP for Lewisham West, arrived to begin haranguing Mr Marshall-Andrews, who insulted him and again implied that he was the worse for wear. It was too much for Mr Dowd, who grabbed his foe by the lapels and began pushing him across the lobby, finally pinning him against a wall.

Fortunately, the Labour whips’ office is in the opposite corner of the lobby and they were quickly alerted. Tom Watson, the genial and rotund junior whip, raced to the fracas and pulled Mr Dowd away from his adversary.

Other whips — known as the Westminster “thought police” — appeared swiftly to surround the combatants and defuse the situation,fearful that the real police might have to be called in. Mr Dowd retired from the area and Mr Marshall- Andrews went back to his Conservative “friends”.

Later, with tongue slightly in cheek, Mr Mitchell described it as an “unprovoked and unpleasant attack on a distinguished senior parliamentarian. It was mercifully defused with speed and efficiency by the government whips."

What a hooligan!

The DFID respond to the TPA study on Hate Education

Yesterday we released a report on how British taxpayers' money supports hate education in the Palestinian territories. The response from the Government is a little confused.

As I wrote on the TPA blog:

"Today our study on Hate Education in the Palestinian territories was reported in the Express. The report included a response from the Department for International Development:

"A spokesman for the Department for International Development said: “We don’t fund the Palestinian Authority directly and therefore don’t fund textbooks."

How strange, on the 11th of July last year they put out a press release titled:

"UK leads the way in resuming direct aid for Palestinian Authority"

The release continued:

"The UK has underlined its support for the Palestinian Authority with a contribution of £3 million to allow it to begin paying off its private sector debts, Douglas Alexander, Secretary of State for International Development, announced today.

A month after Hamas’ takeover of Gaza and the establishment of a new Government by President Mahmoud Abbas, today’s announcement makes the UK one of the first countries to resume direct financial assistance to the Palestinian Authority." [emphasis added]

Beyond that, the problem isn't just direct contributions, as the Express notes: "the TaxPayers’ Alliance said that, by funding worthwhile activities, Britain was freeing up funds which could be spent in more sinister areas."

Our report raises serious issues about how the UK contributes to the long-term prospects for an end to the Israel-Palestine conflict. It makes positive recommendations, modelled on longstanding practice in Northern Ireland, for how our aid money can encourage an end to radicalisation and hate education. The DFID should look at those recommendations instead of issuing nonsensical rebuttals."

"I have to believe that when my eyes are closed, the world's still there."

There are some massive and flawed assumptions underlying Justin McKeating's angry post about those opposing opt-out organ donation. This section is a prime example:

"‘It strikes at our relationship with the state,’ they say. Well get this: You can’t have a relationship with the state when you’re dead. You can’t assert ownership over your own corpse. Why? Because. You. Are. Dead. What other freedoms would you like to exercise after you’ve shuffled off? I take it you’ll be putting your favourite songs on your iPod to take with you as well? It’ll be as much use to you as your liver."

You clearly can and do have a relationship with the state when you are dead. It doesn't take very long to think of some examples:

1. There is both a criminal penalty (I assume) and a massive social sanction to necrophilia.
2. People frequently refight criminal trials after the person convicted has died in order to establish their innocence.
3. A will has legal force.
4. Even under Brown's proposed reforms we will legally respect explicit opt-outs.

We clearly believe that people are entitled to maintain some kind of dignity after they have gone. This requires that we respect their wishes. Assuming that they would be okay with us removing their organs, rather than leaving them be if we don't know, is a fairly major change in how the state treats the dead. If you assume some kind of continuity between a dead person's identity and a live person's - which you should if you support the use of wills - then it most certainly does strike at our relationship with the state.

Balancing the dignity of the dead against the interests of the living is the philosophical question at the heart of any reasoned consideration of this problem. Plenty of people get very angry at the idea that their autonomy over the final fate of their bodies is being limited. Justin's rant isn't going to win them over. It isn't designed to. Those who die for lack of organs are never really used as anything but a rhetorical stick with which to beat assorted enemies.

Such a debate would look at alternatives like reforming how the health services treats grieving families. The Department of Health reckon they could increase organ donations by 50 per cent by better managing that process. That isn't enough but throw in some inventive new ways to get people to consent before death and I think you'd be fine. Beyond that, there's always commoditisation. Wat Tyler has more on the various alternatives to Brown's initiative.

I find the idea of an opt-out system for organ donation alarming for the same reason I found the idea - floated a while ago - that the HMRC should be able to take money straight out of our bank accounts alarming. It will mean that when inevitable screw-ups take place it will be far more likely that someone will wind up having their organs removed against their wishes. Bureaucratic procedure tends to err on the side of the default position; it seems almost certain that scandals thanks to overlooked opt-outs would become commonplace very quickly.

I don't actually feel outraged myself - I'm blessed with a rather moderate temperament - but I absolutely understand those who just feel very affronted at the idea anyone would presume consent to take their organs. As Justin says, even many of those who will quite happily take a donor card are angry at the presumption. Just the way plenty of people will give to charity but wouldn't like to find the RNLI lifting their wallet. Our bodies are our own, even after our death our wishes over how our corpses should be disposed of are quite rightly respected, and having them stolen grates even if it is for a good cause.

Canadian Heroics

This is the opening statement of Ezra Levant - brought up before the Albertan Human Rights Commission thought police - defending his decision, and freedom, to republish the Danish Cartoons. A real hero for our time.



There are more excellent videos on his website, from the actual interrogation, including his refusal to accept that his intentions should be a relevant matter, description of how these cases diminish journalistic expression and do more to contribute to racial animosity than the cartoons and finally how he refuses to answer to the state, rather than civil society, for his views.

You can donate, at his site, to support him in his struggle. A worthy cause.

Best of Blogpower 2007

There's an excellent set of self-nominated 'Best of 2007' blogs up at the Blogpower home. An excellent showcase of the variety the group has to offer. Go and take a look.

I nominated my post which set out, using some pretty simple statistics, why a clearly expensive survey by the British Council actually completely disproved the Tranzi line that we all need to think like 'global citizens' that they were trying to push.

The policy choices driving high oil and gas prices

Some excellent quotes highlighted by Tim Newman, from ExxonMobil President Rex Tillerson:

"High oil prices and perceptions of soaring industry profits have prompted many producing countries to give national oil companies more power to extract richer fiscal terms and greater control over resources, pushing out international players, Rex Tillerson, chief executive of US supermajor ExxonMobil, said.

Such policies will lead to tighter oil supplies as ExxonMobil and other majors stop deploying their technology, know-how and capital in some of those countries, he said.

“If there’s no room to share it then there is no role for us - it’s a simple as that,” he told business and political leaders at a meeting in Calgary, Reuters reported."

And:

"ExxonMobil boss Rex Tillerson, speaking in the wake of last week’s dire warnings from the International Energy Agency about unsustainable growth in energy use, sought to warn of the dangers of resource nationalism.

Talking about oil supply tightness, Tillerson told reporters during this week’s World Energy Congress in Rome that: “It’s not a resource problem. The world has plenty of oil.”

Instead, “it is an issue of whether or not the investment dollars, technology and the know-how to develop those resources in an efficient and reliable way…is going to be brought to bear on those resources”, he argued.

Tillerson talked about such nationalism as being counter-productive for the resource-rich countries where the people miss out on revenues and opportunities."

While Tillerson is talking about the really oil rich states very similar logic applies to the UK as well. Brown's response to rising oil prices was a big hike in taxation on North Sea oil. This will speed up the process of North Sea production winding down. This makes a small contribution to world supplies but makes our economy far more vulnerable to rising prices for oil and gas.

An unrelated, but fascinating, little fact in another post of Tim's:

"McDonalds is so highly thought of in Sakhalin that a few people we know there asked us to bring back a few McDonalds meals for them. At first I thought they were joking, but it turned out they genuinely wanted us to stick a load of McDonalds in the overhead locker for nine hours so they could reheat it and eat it on arrival. Madness."

Peter Hain and a house of cards

Should Peter Hain resign?

Well, it looks like he's broken the law. But, so did Wendy Alexander. If she didn't resign...

His failures can hardly be compared, in terms of the massive harm done, to the numerous failures at the Treasury. If Alistair Darling didn't resign...

There has to be a fear that if one of these people - or another Labour figure implicated in a new scandal - resigns the comparisons are going to become very uncomfortable. The house of cards will start to fall and the Government will be in an even deeper mess.

Tatchell vs. Nuclear Power

What Peter Tatchell has done in this article for Comment is Free is exploit Gordon Brown's turn of phrase. Of course, when Gordon Brown says "there is no alternative" to nuclear power that is just a lie. We could massacre nine out of every ten Britons, close off the country to immigration and our energy use would rapidly decline. We could give up on the whole idea of a modern economy and go live in the trees.


There are very few absolute, categorical musts in public policy. Although politicians and commentators prefer such statements - one example is the ludicrous and repeated statement that we just 'have' to recycle more - real life almost invariably requires balancing costs and benefits.


I'm pretty certain that what Brown really meant was that there is no alternative to nuclear power if you want to obtain serious cuts in carbon emissions without the economic costs being too high. This is a very plausible position and one that Tatchell's article does little to address. After all, it doesn't contain any numbers. None of his different measures comes with a price tag or a carbon emission saving attached.


The big difference between nuclear power and most renewable options is well summed up by this graph, via Wat Tyler:

That is why anyone serious about cutting carbon emissions - including, to his credit, the rather messianic originator of the Gaia theory James Lovelock - should think very seriously about nuclear power. It is, by a significant margin, the most economic low-carbon method for producing energy.

Nokia N95 8GB

Apologies for the lack of posts. Work has been pretty busy.

I've got a new phone. It's a Nokia N95 8GB. It's amazing.

The camera is 5MP which means huge amounts of detail and it focusses and shoots really quickly. It is good enough to handle just about any task that doesn't need an SLR.

I took this picture of Westminster Abbey while getting lunch:

The video camera's footage doesn't look like it was shot on a mobile phone. The frame rate is high (30 fps) and the detail is superb. The final footage looks like it comes from a reasonable dedicated digital camcorder.

It connects to the Internet both through its own 3G (or even 3.5G) connection and through a wireless network if there is one within range. I tried reading a few blogs and it is very usable thanks to a big, high-resolution screen.

With 8GB of memory you can store plenty of music and video. In fact, it comes preloaded with Spiderman 3. Having an entire movie on a phone is strange but could be pretty welcome on a long train journey. I think I'll fill it with South Park. It may also displace my iPod for the journey to work. The display quality is good enough to use its TV Out to watch a film or something you've recorded on the camcorder on a decent sized TV - which I did for a bit - and still have it look sharp.

It contains maps to, I think, the entire world - if not the entire world then most of the important bits - but also GPS. That allows you to give it two addresses and ask it to plot a route or one address and ask it to find you a way there. The very idea of sat nav in a phone seems insane. I tried it out and it followed me down Victoria Street pretty efficiently. It can also work out a route between my Hertfordshire and London homes with no trouble at all. I'll try more exotic journeys at some point.

It does have other features like the N-Gage gaming system but that doesn't particularly interest me. I haven't tried it out with e-mail yet but, to be honest, I'm not terribly interested in that either. I'm rarely away from my desk for too long at work so there isn't much need and it is nice to be disconnected sometimes. If you want to do a lot of e-mailing a Blackberry of some description is probably the best way forward.

The phone looks pretty good and the ability to slide the screen up and down to expose either the keypad or the media controls - and change the screen from portrait to landscape - is pretty cool. It's reasonably chunky though - you can't fit features like the ones on this phone in a RAZR.

The performance, which was apparently a problem on the earlier N95, is fine. The applications run pretty smoothly and you can flick around the various menus and applications reasonably freely without slowing it down.

A few days after getting it I'm still somewhat amazed at its features. When it effortlessly tapped into the TPA network; when it quickly found my position by satellite and when I saw the quality of the video it recorded I was stunned. Just a few short years ago carrying around five devices and a generator in a van couldn't get you these kinds of features at this kind of standard.

What a world.

Army advertising

Is accountancy fun? The Chairman of KPMG UK certainly makes it sound that way:

"I’ve been at KPMG for over 30 years and, broadly speaking, I’ve loved every, every minute of it. I think my experience, if I was to summarise it, is the sheer variety of experiences. I’ve had some wonderful clients, big clients, small clients, entrepreneurs, clients in trouble, clients doing extremely well. Every single size and shape, and in lots of different industries. I’ve had some wonderful people experiences. We’re a people organisation so there’s the sort of leadership and management challenges as you move up through the organisation, and I’ve had those challenges very early in my career and I’ve still got those challenges today."

On the other hand, this suggests it might be rather dull:



Neither account is exclusively accurate. It depends on who you are, the company or other organisation you join, when you join and innumerable other factors. You'll only really find out if it is for you after you've started - though you can get a pretty good idea before hand if you ask around. Is it some kind of unconscionable fraud that KPMG's chairman focusses on the positive? Of course not. It's staff advertising.

Yet, somehow when the Army - whose ability to recruit staff is a very public good - does the same, makes the positive case for a life in the Forces, the Joseph Rowntree Charitable Trust decides (PDF) that is a great injustice. As Lawrence James points out, there is no shortage of voices telling a young person that life in the army will have its hard side. Movies about the horrors of war and a strong folk memory of the trenches that they are likely to have had reinforced in school, for example. There is no reason the Army should be expected to forgo advertising and suffer resulting shortages of personnel.

Being in the Forces can do wonderful things for a person. Had my grandfather not joined the Army - as a boy soldier no less - he would have been far worse off. I would probably be worse off. He had few skills having finished a misspent education at just fourteen. He could still have reached a respectable position but would probably not have had the opportunity that allowed him to progress to become an officer. Also, he would have missed out on the intangible benefits of a career that inculcated discipline and would not have had a quality, specially provided, education for his children. Without all those things it is quite possible my family would not have done nearly as well for themselves as they all have. There is nothing wrong with joining the Army and its recruiters should not feel guilty for trying to recruit the soldiers that do such an important service for their country.

It is necessarily harder to leave the Army than it is to leave many other careers after a certain point but the process is not instantaneous and a term of a few years is not forever. Of course, there are particular dangers but everyone knows that.

Some people may find that they do not enjoy the Army life, just as some people may discover that they hate accountancy. This isn't due to misleading recruitment ads but the fact that it is impossible to know what being a part of the Army is really like before you start. No matter how balanced the advertising that will always be the case.

The conclusion to Lawrence James' article sums up the study well:

"The trust’s report is as predictable as it is misjudged. An understanding of the values of the military world are absent, just as we would expect from a Quaker institution. One might as well ask a vegan to review the charcuteries of Paris."

Wars aren't short

Great article by Max Boot for the Wall Street Journal. He makes the very simple point that short and sharp wars are not the historical norm. He then sets out one interesting example of a long conflict, that between England and Scotland. Shorter wars are a creation of particularly determined European nation states more than anything.

As he says, this does recast Israel-Palestine. There is a solid argument that Americans, with a history of short wars, assume it is overdue to end. The reality could be that, regardless of whether the Palestinians have a state, this conflict will rumble on for decades yet.

This can be added to the list of myths about war that the War Nerd set out years ago: that wars involve battles, that you win by killing the enemy, that hi-tech beats lo-tech, that insurgents will quit and that everyone really wants peace. All these are myths. Understanding that brings home the real strategic challenges of the coming century.

Back

Sorry for my absence since Thursday. I've been moving myself back into London and the Internet connection here has been broken.

Jeremy Leggett strikes again

Some people accuse the Guardian of being mindlessly opposed to marketing. Well, those people are proved wrong every time Jeremy Leggett is given, for free, space in the Guardian to sell his industry. Last time, he was drawing ludicrous analogies to Spitfires. This time, he's mounting an incoherent attack on the Government's nuclear plans. It isn't worth fisking most of his article as he isn't writing very well and gets lost in inane chatter about consultations. He takes what should have been the central argument in his article, the superiority of renewable power to nuclear, as a given and I can't imagine anyone who isn't a renewable energy executive being convinced.

The article is only worth noting for this, incredible, section - which is a masterpiece of the Comment is Free genre:

"In March the EU agreed a target of 20% renewables in the energy mix; 27 leaders signed up, Blair among them. The EC costed the switch to renewables at €24bn to €31bn a year, assuming an oil price of $48 a barrel. At $78 there would be no additional cost. Before the year was out, oil almost hit $100."

Does he realise what that is saying? Those are estimates of the subsidy that will be required to make renewable energy work. If we are above the oil price at which renewable energy has 'costs' (i.e. costs more than running on oil) then there shouldn't be any need for a subsidy at all.

Leggett clearly thinks the EC estimate is credible or he wouldn't be citing it. Fantastic! Let's scrap the various subsidies to renewable power and let those fine people in the renewable power industry outcompete expensive, peaked oil.

Gracchi responds on the NHS and lifestyle choice

Gracchi has some criticisms of my post on the NHS and lifestyle freedom. I don't think any of his criticisms stand up to scrutiny. I'll take the risk of pulling some sections of his post out for brevity's sake. I'm sure he'll correct me if I've taken anything out of context or missed important arguments.

"Those who support the NHS and support drug legalisation today often overlap. Whereas those who want to privatise the NHS and support drugs being illegal often overlap as well."

This is certainly true. A prime example, that I mentioned in my post, is the Liberal Democrat party that both aspires to be liberal, in the libertine sense, and also to support the NHS. People are quite able to hold positions that make their other positions untenable in practice. They'll be frustrated if they ever try to put their policy platform into effect over the medium term but that's not a concern for a Liberal Democrat. Equally, there are plenty of reasons other than lifestyle liberalism to support NHS reform - better results for example. Gracchi misses the point I was making: not that supporting the NHS makes any given thinker less liberal with respect to lifestyles but that the existence of the NHS makes it harder to sustain lifestyle liberalism in practical politics.

His explanation for illiberalism is the 'yuck' factor. This could be important at the margin but I don't think it can really be the driving factor behind bans. If it were why would there be a new crusade against the relatively attractive behaviour of middle class drinking?

People need to rationalise their beliefs and the 'yuck' factor therefore requires rational justification. I've seen, countless times, the cost to the NHS of a particular behaviour used as justification for a prohibition on that behaviour, a ban on advertising or a new tax. Even if some people are just disgusted by the obese and using the cost to the NHS to rationalise the ability to do so is still important. Rational debate is still relevant to politics even if it is, too often, bent out of shape.

"Matt misunderstands wilfully Mill's argument and consequently misinterprets the zone of Mill's freedom. Mill's concept of freedom is very tricky to understand- but if it were as Matt suggests inclusive of all actions that affected others in any way, the area of free rights would be tiny. Afterall all our actions in some ways effect others- even actions taken in complete privacy- a choice of job afterall effects others sometimes more than a choice of lifestyle does (even in a system with an NHS)."

This seems to be an argument that I should be wrong rather than an argument that I am wrong. Gracchi's criticism is the one that makes Mill's sphere rather weak in theory. However, the harm principle, as summed up by Mill himself, is pretty much exactly how I expressed it:

"The only part of the conduct of anyone, for which he is amenable to society, is that which concerns others. In the part which merely concerns himself, his independence is, of right, absolute. Over himself, over his own body and mind, the individual is sovereign."

It is highly imperfect. All of our decisions do affect others in some way. If I am unhealthy and die as a result then no matter the healthcare system others will be affected as they will feel bad, if only for a short while. However, that weakness has not prevented the harm principle becoming vital to effective liberalism. Non-financial externalities that affect friends, family and other close acquaintances tend to be socially internalised in a manner described by the Coase theorem. If I live in an unhealthy fashion and it risks my health those who care for me risk an emotional loss. However, their closeness to me allows them to influence my decisions. Whose mother doesn't check that they're eating well and hassle them if they're not? The more people care the more they will socially police behaviour.

These kinds of strategies allow for the harm principle to function despite its theoretical weaknesses. As a result, an approximated version of Mill's sphere, allowing choices that have societal effects smaller than a certain magnitude, is an important popular justification for liberalism. It is the best simple guide to what the liberal position is in the first place. It is what people mean when they say "it's none of your business".

The NHS makes people's decisions over diet, smoking and drink, and a massive host of other choices, the business of everyone other Briton. The fat man in Glasgow concerns me because I will contribute to paying if he becomes unwell but there are few practical ways for me to influence the health behaviours of him and millions of others socially and without enlisting the power of the state.

We might still allow people some unhealthy choices, taking a stressful job for example, but perhaps that is just the way the societal cost/benefit analysis plays out? We don't respect people's right to take a stressful job - it is just good for us if they do.

"Genes matter as much as environmental factors- would Matt accept a system in which companies were allowed access to our genetic code and set different premiums based on that for various people, sometimes prohibitive premiums."

People don't choose their genes. That means you can't incentivise people. It makes the public policy debate completely different to the one I was addressing. Being genetically predisposed to poor health is more analagous to having a pre-existing condition or being old than to eating an unhealthy diet or smoking. There is an interesting debate to be had over whether insurance companies should be allowed to take account of things like genetic predispositions but none of the logic in my original post pertains to that debate at all.

"What about such premiums actively discouraging people for example from performing various important jobs- take for example those who volunteer to be part of the royal lifeboat association (something that involves them in great risk for a real public good and for free)- that would incur them a higher premium is that fair- the same thing might be said about special constables."

These would not be among the unhealthy behaviours that you would want to allow providers of compulsory social health insurance to attach a price to - just as it isn't one of the activities that might, under Government proposals, get people denied NHS treatment. I don't think this flaw is critical even if you want to implement a system that allows insurers to present higher premiums for any reason at all but, for the purposes of the debate we're having right now, it just isn't relevant. There is no reason why the slope, allowing certain information about health behaviours to affect insurance premiums, should be so slippery that any case for greater flexibility is a case for allowing perfect information.

The NHS cannot properly incentivise healthy behaviours and creates a very real imperative and justification for lifestyle illiberalism. A reformed healthcare system need not create those pressures for a less liberal society. I hope this post has helped to flesh out why.

If you go down to the woods today...

Cry of existential affirmation to greet the New Year or bad movie in-joke? You decide...



Went on quite a fun little trip yesterday. First, Baconsthorpe Castle which was nice but a little too small and ruined to make a full day out. Then, on the way back, traipsing around Thetford Forest causing trouble.

The NHS and lifestyle choice

Threats to deny NHS care to those who don't maintain a healthy lifestyle are a paper tiger. We're not going to see smokers, the overweight and drunkards dying in the street with Gordon Brown standing over them wagging his finger and saying "look at the NHS Constitution". Even if the politicians were hard headed enough to do it, which they aren't, they'd struggle to bring the medical profession along with them.

The only thing that might actually happen is the denial of certain forms of treatment - particularly expensive treatments. Even that probably can't be institutionalised as their are too many borderline cases. Smoking aside, most lifestyles will contribute to health risks instead of obviously causing a condition and in uncertain cases it will be hard to deny treatment. Consider the pretty common case of a man who is somewhat overweight but not morbidly obese and also has a stressful job. We wouldn't want to punish someone for having a stressful job so it would be a moral nightmare to deny that man treatment. Cases like that will be very, very common.

That means decisions over whether to deny treatment will have to be, from the point of view of the public, highly arbitrary. The threat of denying NHS treatment is too idle, too vague and too uncertain to have much of an effect on incentives. It can't get around the problem that a taxpayer funded healthcare system makes each person's lifestyle choices a public good or bad.

Now, every healthcare system that pools risk faces this problem to a certain extent. If you have a compulsory social insurance model and mandate that all insurance policies are available to everyone (as the Dutch do, for example) so that no one is going to be left without treatment and the vulnerable (thanks to age or existing conditions) are looked after you might also wind up subsidising unhealthy lifestyles. However, there is a key difference.

When individuals, rather than taxpayers, are paying for their health insurance it should be possible to allow adjustments in their premiums for healthy behaviours. As Wat Tyler describes this is already happening in the private health insurance market. It doesn't face any of the problems that I've mentioned above and prevents unhealthy behaviours imposing a cost on the health conscious.

Sin taxes are a clumsy substitute that have to make do without price signals (the level of tax is arbitrary whereas the correct level for lifestyle compensation in an insurance fund can be discovered by a market process). They are an easy way to raise revenue rather than a serious attempt to internalise the externalities associated with poor health. They will always be inferior to a solution that stops unhealthy lifestyles being an externality.

Pooling the costs of bad health and turning lifestyle into a public good is a problem for the NHS that leaks into the rest of public policy, turning it in a distinctly illiberal direction. There are few individual choices that don't have some kind of impact on a person's health. Unhealthy behaviour is controlled in an ever more draconian manner through taxes, regulation and outright bans. The Millian sphere (the set of decisions that don't affect others and should be left to individuals) is always unstable but completely dissapears with socialised healthcare. Liberalism becomes almost entirely untenable.

One quick aside: If the Liberal Democrats were an intellectually serious bunch they'd take this issue very seriously. The contradiction between healthcare socialism and lifestyle liberalism is one more example of the kind of issue that makes an attempt to marry their attachment to Britain's socialist institutions with a notional commitment to 'liberalism' a complete farce.

Liberalism isn't just undermined by the real externalities to unhealthy behaviour, created by socialised healthcare, that I have discussed so far. It is also politically expedient to exagerrate the problems associated with unhealthy lifestyles. The NHS, as it is currently organised, just can't deliver the performance that people expect and that would warrant the huge amounts of taxpayers' money that politicians have spent. That is a political nightmare for any political party that can't countenance calling for serious reform. They can dilute perceived responsibility for that institutional failure by announcing measures relating to people's lifestyle.

That is how we should understand this new threat to deny care to people living unhealthy lifestyles. It isn't even a serious but vain attempt to address the problem that the NHS makes everyone's health a public good. Instead, it is another attempt to avoid criticism for the ongoing failure to deliver quality healthcare and value for money in the NHS.

Grizzly Man

I watched Grizzly Man last night. Gracchi's review of the film is superb and there's not a lot I'd like to add to it. He gets to the core of the film with admirable clarity and perceptiveness. There's little sense repeating him except to confirm that this film is well worth watching.

All I'd add is that I found the footage of Timothy Treadwell (the Grizzly Man of the title) with the foxes more distinctive than either Gracchi or Werner Herzog (the filmmaker) did. The bears did seem totally uncaring with their only real reactions to Treadwell a hostility if he got too close and, finally, killing him when they were hungry. By contrast, I do think there was a genuine reaction from the foxes. They are animals with a social instinct that, as we do with dogs, humans can, I guess, become a part of. At times he did seem to have formed a connection with them more genuine than the one with the bears that were more central for the film and Treadwell himself.

I would guess that the foxes weren't enough because the relationship was more genuine. As Gracchi says Treadwell wasn't after an authentic, reciprocal relationship but something unreal. He found love that could not be requited safer. While the relationship with the fox was not real in the sense that human relationships are I still get the sense he preferred the complete fantasy of his relationship with the bears.

The Closing of the American Mind

I've just finished reading Allan Bloom's The Closing of the American Mind - just twenty years after it was written. While its title and content is directed towards Americans Harry Mount is right to argue that the disease now afflicts us and all the Western nations.

Bloom's masterpiece is hard to precis. It begins discussing his students and how relativism has closed their minds; how a doctrine of 'openness' has perversely undermined serious dialogue between different opinions and cultures. It then goes on a tour of Western philosophical thought illustrating the struggles that brought us to where we are now. My understanding of his critique is that we have lapsed into nihilism without taking the condition seriously. We cannot take seriously old visions of the good life and have broken the processes and destroyed the environments in which new visions might flourish. He sees this as a broad problem for Western civilisation but sees the crucial centre of the problem in the decline of liberal education within the Universities.

This isn't a book to discuss in one post and I'm sure it will be brought up frequently on this blog in the coming months but what I thought I'd note right now is how it relates to Dalrymple. Theodore Dalrymple's social conservatism has been a frequent topic of mine over the last year and relates in a very interesting way to Bloom's work. Dalrymple discusses (most effectively in this essay - which I will keep linking to until I'm satisfied every one of this blog's readers has read it) how the relativism of the elite creates desperate social problems for the disadvantaged.

Dalrymple's work is excellent but if you only read Dalrymple and look at the problems of the poor it is as if you are studying an oceanic earthquake by measuring coastal waves and understanding the misery of those they make homeless. You need to understand the problem at its source. The source of the awful problems Dalrymple describes is in the elite and their intellectual decline. A philosophical decline in the West. Hopefully Bloom can provide a valuable first step in understanding that source of our problems.