Yes Polly

You\’re absolutely correct here:

Let\’s get one thing straight. The NHS does need constant reform – always has and always will. Megalomaniac politicians of all parties love mighty structural upheaval, but what works is detailed, expert and quite dull. Health economist Prof Alan Maynard, observer of many pointless upheavals, has made the case for evidence-driven medicine for decades. Money is saved and health improved by obliging all to follow best treatment guidelines. The Isle of White saved A&E admissions by sending nurses to teach asthmatics to use their inhalers correctly, so why not everywhere? Nurses can do 70% of what GPs can do, cheaper and, he says, often better because they do follow guidelines. And why have GPs just escaped scrutiny of their performance, by refusing to hand over their data? Prof Ara Darzi\’s research shows re-admissions after bowel cancer operations vary wildly: heart treatment was improved by eliminating the worst practice outliers. Nursing patients kindly sends approval rates soaring.

Forcing all the NHS to follow Nice guidelines doesn\’t need markets or politically inspired reorganisations. Money coupled with tough targets worked well for Labour, though it too squandered much on vainglorious \”new\” systems. Let\’s hope the Lords arrest the damage done by this one.

It really is all about how to get the system into that state where it is constantly striving to improve. How to get that detailed, expert and quite dull constant and consistent improvement in treatments as we gain new knowledge about what can be done and about how what we want to do can be done best.

We have essentially two systems which we can use to do this. We can have armies of bureaucrats with targets and clipboards insisting that everyone do it the way they think or have been told is best.

We can have autonomous organisations competing with others in a marketplace.

That\’s perhaps a rather stark and over-rigid description but it is the essential underlying truth. What is the best way of spreading best practice?

The 20th century ran this very experiment on a grand scale in a number of different places. East v. West Germany, the Soviet Union against the US, North v. South Korea. Very simple empirical observation would lead us to the conclusion that the market based approach wins in this competition.

We can even detail the mechanism by which this happens: resources are always constrained so what we need to look for is an increase in total factor productivity. Getting more from those resources that we have available to devote to a particular task.

It is said that the Soviet Union, in its entire existence, managed to not increase TFP by one single iota. All the growth they did have came from an increase in resource use. Whereas 80% of the growth in the \”western\” economies in the 20th century came from TFP improvements. Only 20% came from increased resource use. I could even point you to the Nobel Laureates who make this point.

It isn\’t actually necessary for us to peer any further into the black box. Commissars and tick boxes are outperformed by market mechanisms.

Therefore let us have market mechanisms in our health care system.


7 thoughts on “Yes Polly”

  1. If those nurses on the IoW had been following NICE guidelines they wouldn’t have gone out in to the community in the first place. Ditto surgeons trying different ways of operating on bowel cancer.

    Does Polly ever think things through before committing fingers to keyboard?

  2. Okay, here’s your fundamental problem; if you have market healthcare, you get all that nice competition, but some poor people are going to be untreated, and die, and things like that.

    But you can’t have a market without profits, so any kind of cod “market” in the NHS isn’t going to work.

    If you say the government will pay for everything but have it done by private sector companies, they turn into those ghastly things Americans call “government contractors” and a corporatist feeding frenzy of horrific proportions occurs.

    So, this is the serious question. You can have inefficient universal healthcare, or efficient healthcare and dead poor people. Which is it to be?

  3. Ian B

    “Okay, here’s your fundamental problem; if you have market healthcare, you get all that nice competition, but some poor people are going to be untreated, and die, and things like that.”

    So it is beyond the wit of statists to design a system with a safety-net? Have you ever looked at what happens in places such as…France?

  4. Singapore manages to have a health system with far higher TFP (About 3% GDP) and better outcomes than the NHS. Less coercion too, they use a combination of (mandatory) health saving accounts for non critical care and insurance only for serious conditions. This means that most healthcare is paid for directly by consumers, controlling costs and allowing service substitution.

  5. “You can have inefficient universal healthcare, or efficient healthcare and dead poor people.”

    Why wouldn’t inefficient universal healthcare kill people too, purely by it being inefficient? My father recently got given the wrong medicine by a pharmacist, and that was rather bad for his health – doctor’s orders were to take a dose twice a day, but the medicine he actually was taking was only meant to be taken once every 2 days. Of course it’s typically inefficient to reduce error rates to zero, but in an inefficient system these sorts of errors presumably occur more often.
    Plus of course, spending more money on healthcare because it was inefficient means spending less resources on something else, which also can have effects on mortality.

  6. Um, where exactly is the Isle of White? As someone born in Newport, Isle of Wight, I would like to know the location of this upstart territory.

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