The trouble with the NHS

Two years ago the American author David Goldhill caused quite a stir in the US media with his book 'Catastrophic Care'. At the time, Obamacare was being implemented yet Goldhill argued that the extension of coverage to millions of Americans was a sideshow. His critique of the health care system focused instead on the conundrum of rising costs at times of increasing competition (which should drive down costs).

To any observer from the UK, this may appear a worry too far. Since 1948, the UK operates a monopolistic tax funded health care system without insurance intermediaries. Competition is a dirty word here, with politicians of all colour consistently arguing that it's the strong monopolistic position of the NHS that allows it to negotiate low prices with all health economy providers (we will return to this point in a moment).

Yet, Goldhill also showed clearly that all modern health systems suffered the same ills. Profits in health care provision did not amount to anything resembling the mountains of gold presumed by defenders of socialist health care. In fact, 'all the profits of the famously greedy health insurance companies ... would pay for four days of health care for all Americans. Add in the profits of the ten biggest 'rapacious' drug companies: another thirteen days. Indeed, confiscating all the profits of all American companies, in every industry, would cover only seven months of our health care expenses.' (Goldhill, p.53)

In other words, profiteering in health care provision is a red herring when it comes to the magnitude of the cost explosion.

British and European health care systems don't fare much better. Whilst productivity is slowly rising in all UK industries, the NHS is notoriously the only industry where productivity has steadily been falling. The argument has always been that medical care is a labour intensive industry. But does that mean that it is an industry like no other, exempt from the conventional laws of efficiency?

Productivity down, costs up - and still no happy Unions - NHS unions in 2007

Health care appears to be the only part in society that we positively excuse when it operates at a loss to us as taxpayers. As technology has made things easier for everyone from the local plumber to the car mechanic, health care providers appear to be saying that the more technology they introduce, the more expensive things will become for us as consumers. In fact, we are so used to this argument that, reading this, you may not even have spotted the flawed logic in this sentence. It is only in health care that technology makes things MORE expensive, when, in all other contexts, the aim of introducing technology is the opposite: to make things cheaper by increasing productivity.

So, what's going wrong? What's at the heart of the cost explosion of the NHS? The first issue is that the NHS, as any modern health care in the Western world, deliberately severed the link between patient behaviour and costs. People are not rewarded if they visit their GP less. On the contrary, the more a patient turns up at the local GP practice, the more tests (most of them often useless or positively harmful, as Atul Gawande argued) and clinical interventions are showered on her or him. The system also rewards the absence of self-management of illnesses and almost expects a lack of responsibility for our own well being.

Yet, even more important, what was supposed to be a risk sharing model for acute care needs has become a model of comprehensive health care. Once, illness was narrowly defined as urgent medical attention in cases of life threatening diseases. The NHS was founded as a response to large scale epidemics such as TB. Fast forward to the 21st century and the NHS has become the nanny for all  discomforts in life, for free!

The original model of sharing risks at times of acute medical needs, many of those very expensive, has given way to a model of comprehensive care for everything from a brain tumors to blisters on the feet. The health care systems are thus not risk sharing mechanisms anymore, helping the poorest to spread the costs of acute care needs, but a dispensary of all round care for free.

The fact that we don't share risks anymore but appear happy to pay for everything for everybody has important consequences to health care costs. It distorts positive health orientated behaviour (hence the discussion about obesity and gastroband surgery on the NHS), but it also undermines the possibility of establishing truly risk spreading mechanisms that would help share the costs in adjacent fields such as social care. Social care insurance will remain unviable in the UK, as long as much of what goes for care needs is met by the NHS or local authorities (soon helping themselves to NHS budgets in devolved areas).

The advantages of having a strong negotiating position vis-a-vis pharmaceutical industries are puny in comparison to the costs of health care in a dis-incentivised context. Not least because allegedly lower prices of medicines are likely to be cancelled out by the expansive prescribing of low or non-effective pharmaceuticals. As long as we think we have a right to free all round care, we won't be restoring the link between what we do to keep ourselves healthy and what we spend on our health.

To name and shame?

For any liberal-minded citizen there is hardly anything more galling than the discrepancy between the way we first react to reports of injustice and our willingness to concede the possibility of redemption. Hearing about a callous murder, we think about the death sentence. Reading about a brutal rape, nothing less than capital punishment will do.

As the initial rage cools and emotional distance exerts its inevitability, we are often left with a sense of two irreconcilable reactions to the same deed, one that is animated by our immediate feelings and another one that speaks to our exercise of rationality. New forms of justice may just bridge this yawning gap.

In the US, some judges have for some time now imposed 'name and shame' sentences on criminals. Instead of incarceration, they require criminals to put up signs in their front garden, announcing publicly either the nature of their sentence or, alternatively, warning the public of the presumed nature of the person himself. The practice of naming and shaming has also won more supporters in the UK over the last couple of years and the media have (within the rules of the justice system) adopted similar tactics.

You are the executioner... enforcing sentences in Florida in 2013

The arguments against naming and shaming appear feeble. Why not do it if it prevents future crimes? The practice also appears to go hand in hand with a growing willingness to 'self-confess' and voluntary public exposure, exemplified by shows such as Jeremy Kyle and others.

Yet, I would argue that we should be careful about the effects of 'name and shame'. The first argument against it comes from our lack of knowledge about what motivates and regulates human behaviour. Naming and shaming may have a temporary deterrent effect but we do not know whether, in the long run, it may only lower the threshold of acceptability for everyone. People learn to live with all sorts of situations and adapt quickly. Our fabric of social norms may just be too flexible to make 'naming and shaming' an effective tool for crime prevention.

The other, more powerful, argument is more philosophical. It was made many years ago by Michael Pawlik (FAZ, 17.November 2004, p35). Pawlik argued that 'name and shame' would alter the role of the public in the justice system. Whilst court cases are open to public scrutiny, the role of the public in this context is not to pass judgement itself, but to validate the correctness of the judicial proceedings, a point to whose importance anybody living in a country without proper and independent judiciary can attest to. In effect, the gazing public in the court is scrutinising the procedure, not passing judgement itself. That is the fundamental meaning of court proceedings 'open to the public'.

The case is different for naming and shaming. It only works if the public adopts the role of judge and executioner at the same time, reinforcing public condemnation of the crime committed by marginalising the criminal within the public sphere. In this scenario, the public plays a different role. It undercuts the separation of powers that is ingrained in the justice system between judgement and executing the sentence.

Pawlik is sceptical about the ability of modern societies to resist naming and shaming. He points out that, in the long run, justice systems are likely to approximate prevalent sensibilities (or lack thereof) about what constitutes good and proper punishment. If he is right, we have one more reason to mistrust our initial feelings when we hear about abhorrent crimes. We may not be the best judges of either the deed or the most reliable enforcer of any future sentence.

On 'principled' politics

The political scientist Samuel Finer once noticed a simple truth about French political parties. Their names were inversely related to their actual position on the political spectrum. The 'Radical Party' was nothing like radical and the Socialist Party was anything but socialist.

I was reminded of this observation when listening to supporters of Jeremy Corbyn, the Jesus Christ superstar of the New Left in the UK. The tenor of their answer when asked why they support Corbyn is that he is a man of principles, standing up for what he believes in.

The implication is that the other candidates (and politicians in general) are not principled and that this makes for bad politics. I disagree. Politics is the art of the possible and good politicians are those that can jettison their principles at the right moment. So why are Corbyn's supporters so enamoured with 'principled politics'?

I believe there are two aspects of modern politics that have always been difficult to accept for the wider public. The first one is pluralism and diversity of opinions, the second is the notion of the public good as a result of bargaining or negotiation between collective interests.

The first aspect is underpinned by the popular belief that everybody must have the same views as me. Political psychologists call this confirmation bias and it manifests itself in the way we select which TV News we listen to just as much as who we choose as our friends. We prefer having our own opinions validated by others. And, saturated by views similar to our own, we start to believe that there are only people like us in the world. Dianne Abbott's support for Jeremy Corbyn is a good example. Only a few weeks ago she still believed that Corbyn could never win an election. Having attended (too many?) meetings of his supporters she is now adamant that he will sweep to victory in 2020.

Incidentally, the issue of a pluralist society containing a range of diverse views does not bother anybody of socialist conviction. Those on the extreme left have a simple retort to those disagreeing with them. Dissenters are simply mistaken and taken in by bourgeois propaganda, espousing a 'false consciousness'.

The second, more complex, issue is the fact that in a society with differing views and interests, any consensus about the public good is inevitably a result of negotiation and bargaining, with painful compromises for all sides. This is anathema for purists of the political process. They deplore principles being the bargaining tools in the political process. As uncomfortable as this may sound to any advocate of principled politics, this second aspect of modern politics flows naturally from the first, if you throw in the only principle that cannot be jettisoned in any modern society: the freedom to make up your own mind and to express it in public. This is why, to Corbyn's supporters, confirmation bias, plurality of opinions and negotiations are non-sensical. For them, freedom to think differently is just an awkward logical error on the way to a future where we naturally all think the same. So when Corbyn's supporters praise his principled stance, what they actually rail against is the freedom to have your own mind.

The dizzy heights of public ownership

In the winter of 2007, in a bout of hopeless nostalgia for socialist times I decided to spend my New Years Eve high up in the clouds above Berlin. Well, not that high, 290 metres to be exact, in the Television Tower of East Berlin.

By chance, I ended up sitting next to a former manager of the East German Socialist Planning Agency. The Agency was responsible to project the number of consumer goods needed, everything ranging from car tyres to toilet paper (there was only one kind, of the grey and rough variety). Planning periods ranged from 1 year (the short term plans) to five years. The projections would then be passed on to the Ministry of Economic Affairs which instructed East German factories to produce the relevant number of goods.

I remember distinctly that, despite this being almost 20 years after the collapse of socialism, my neighbour at the dining table was remarkably upbeat about the future prospects of socialist planning. The reason it had all failed the last time, he argued, was because they (at the Planning Agency) had not yet had computers with sufficient calculating capacity. This was likely to be different soon as computer capacity would become so large that you could plan the needs of millions of people at any point in time. At that moment, people would finally see the light and socialism would come back.

I was recently reminded of this slightly unhinged reminiscing with a former party comrade in Berlin's television tower when I heard Jeremy Corbyn suggest that most of the UK's problems would be solved once the railways, utilities and pretty much anything else would be taken into public ownership.

What really astounded me however was not that he advocated what had failed before. Rather, of all people, Corbyn did not seem to have read much Trostky. Having turned his back on Stalinism in Soviet Russia, Trostky produced a stinging critique of public ownership arguing, in essence, that where everybody owns everything, no one owns anything, leaving a small party political clique (or union nomenklatura) in charge.

Sometimes I wonder why socialists keep climbing the same dizzy heights of economic planning time and again. But then perhaps, the view from up high might be very comforting. Everything looks small from there, as if we can move things around according to the plans we have for them.

Labour's race for 2025 (sic)

The calculations of most political observers about Labour's electoral chances in 2020 focus on seats, Scottish Nationalists and political dynamics. Yet, there is also a broad consensus that, at the last election, the party had the wrong leader. Anybody who carefully listened to Diane Abbott on This Week any time before May 2015 knew it. Miliband was never going to be prime minister (Abbott always put it diplomatically: 'he might win'). The fact is that the gut feeling of moderate centrist floating voters (of which Abbott is none, yet I am indeed) is often right. Ed Miliband never looked like a prime minister in waiting and everybody knew it from the moment he looked flustered (and haplessly) around on stage as his victory was announced.

This 'gut feeling test' does not just work for the Labour Party. It goes for Conservative candidates as well. Michael Gove just won't be living in Number 10, no matter how radical he is in the various jobs he will hold in the next 5 years.

Much has to do with fluency of delivery in front of cameras and rhetorical discipline (both things easy to credit Gove with) but there is also stature and self-belief. Take all of these things together, and you have a credible prime minister in waiting.

This brings me to the four leadership contenders of the Labour Party who are currently slugging it out at hustings. Anybody of moderate central political views will see the same: four candidates with the calibre of leading the party in opposition but none to lead them to power in 2020.

First there is Liz Kendall, who still lacks the rhetorical fluency of Tony Blair and his polished media performances. Then there is Yvette Cooper who will probably make a suitably ruthless party leader (though with an unappealing hairstyle). Next there is Andy Burnham who would be clobbered with his dire role in the Staffordshire NHS scandal every time he would appear at the dispatch box (I also find his looks slightly creepy). And finally there is Jeremy Corbyn who probably would induce laughter on all benches if he ever makes it to the dispatch box at all (does he have a duffel coat for the celebrations at Cenotaph?).

The most interesting feature of this leadership campaign is who stayed away. Labour has credible candidates indeed, yet they have decided not to put themselves forward. There is of course Chuka Umunna who probably still needs some time to clean out some skeletons from his cupboards before he can safely stand. I would not be surprised if his girlfriend quietly fades from view over the next years.

And then there is Tristam Hunt, probably the strongest candidate for prime minister in waiting at some time in the future. He is also the most dangerous opponent for the Conservatives, given his background and already polished media performances. What he lacks (and that may have played an important role in his decision not to stand) is a top front bench job in a difficult portfolio like defence, health or foreign affairs.

There is of course no guarantee that either of them will ever have the chance to put their names forward after 2020. As George Osborne is doing a Merkel and moves the Conservatives to the centre, the Labour Party's reflex is to seek solace in the socialist nirvana of unmitigated nostalgia. But once the Coopers, Burnhams and Corbyns had their stab at failure, the Labour Party will be able to look for a credible candidate. At that time, people like Umunna and Hunt should be ready.

Summer games (not quite Olympic)

If anything, the recent spat in the Labour Party demonstrates once again its genuine altruism. As the great British public are getting ready to be bored by endless traffic jams and scorching summer heat on the beaches of Kent, the Labour Party provides us all with an entertaining spectacle worthy of Shakespeare. On one side, behold the modernisers, ready to pounce on anyone who dares to mention past ghosts still haunting the party (who are now jet-setting and sporting deep tans), on the other side, see the undead of the stalinist union sympathisers who smell a chance to hijack the party machinery for the ultimate battle to bring socialist nirvana to the (uninformed) masses. 

To any bystander however this spectacle resembles more shadow boxing than an actual debate about the future of the party. In the very centre of any party husting is the glaring black hole of ideas, right or left wing, or at least the stubborn unwillingness of either side to articulate any policies. That suits the incarnation of the stalinist undead from Islington who is trying to pass himself off as the older version of the Greek PM Tsipras, with some modest success. Corbyn, like any ideologue, revels in bland 'statements of principle' which offer instant appeal but have little to do with politics, the art of the compromise. 

The centre ground does not look much more attractive with a former PPS and Cambridge graduate trotting out the line that he is 'from Liverpool' which, he believes, gives him the 'common touch'. Then there is Yvette Cooper, who is mainly driven by an unfathomable ambition to be leader without ever quite revealing why she would want the top job. My best guess is that she does this as a kind of ego-trip to revenge the defeat of her husband. But that's only a hunch taken from the only comment of hers that made headlines so far, which was that she cried when Ed Balls lost his seat. Lucky those with supreme motives like her. 

And then there is Liz Kendall, which strikes everyone as a pale version of Tony Blair (pun very much intended). Her main characteristic appears to be that she lacks Blair's charisma and his way of connecting with people, or formulating any simple sentence that hits home, for that matter. Something she will undoubtedly learn in the next five years, even if not at the dispatch box opposite David Cameron. 

So, there we are, the sorry spectacle of the Labour Party selection process. I propose that we should talk about the really important things in life again. How about a national debate on whether we should put the clocks back for summer TWO hours instead of one? We always talk about this. Let's not be diverted by the small matter of the Labour Party making itself comfortable in eternal opposition. 

The phoenix of Marxist delusion

Growing up in East Germany sometimes felt like living in a fantasy world. It was not so much that East Germany was a land of plenty but rather that some people spoke a language that appeared to hover over reality without ever really touching it. In public, people seemed to engage in an elaborate linguistic game with strict yet inscrutable rules, juggling words without any meaning.

'Imperialist plots' were constantly afoot which were designed to prevent the 'vanguard of the working class' to march unhindered towards a 'glorious communist future'. Ultimately, however, resistance was futile since the Marxist logic of the march of history was undeniable.

In other words, some people appeared to live in a parallel reality. The question was whether they really believed the elaborate conceptual constructs they used in public speech. The end of communism answered that question, so I thought, and political and social affairs took on an air of pragmatic realism again. Or, as my grandmother put it: 'Looks like things will be normal again from now on.'

This normality of politics for long has informed the broader consensus in European politics. Cut through the ideological nonsense and find solutions to problems has been the motto of European politicians ever since they put their signatures under the Treaty of Rome.

The first extreme leftist Greek European government, in coalition with an extreme right wing party, (who says political extremes are polar opposites!) is a sign that this consensus is about to end. Listening to the Greek Prime Minister it reminds me of East Germany. It sometimes sounds as if he really believes the hollow phrases of neoliberal evil-doers and Greek comrades being humiliated by the international finance capital. Mixed into this melange of ideological clap-trap borrowed from the darkest Stalinist times is a good dose of eternal victimhood that traditionally curries favour with the Greek populace.

Seen as a clash between pragmatists and ideologues, the negotiations between the troika and Greece could only have one final destination: a confrontation between nationalist and ideologically charged rhetoric and shock and disbelief by European governments about the Greek Prime Minister for refusing to accept the basic framework of pragmatic European politics, resting on negotiations and compromise. Yet, we shouldn't be surprised. The attractions of living in a fantasy world have always be strong. And, you know, no one has yet conclusively proven that Marx was wrong.