Tuesday, 29 January 2013

The Great NHS Free-For-All

Today, an important but understandably touchy angle on the seemingly perpetual divide between the realists and the fantasists. Yesterday, the Labour MP, Dave Anderson had a letter published in the Torygraph bemoaning Nice - the National Institute for Health and Clinical Excellence. As you know, it is the job of this unfortunate set of souls to decide what we can afford to cure 'free'.

By this I mean they look at treatments and medicines, work out how much they cost and what benefit they deliver. They use necessary but harsh sounding units called "cost per quality-adjusted life year". They take all this into account and work out if the NHS should add this treatment to the sanctioned list that John Q Taxpayer can undergo or be prescribed free at the point of delivery.

It must be a desperately depressing job. When they rubber stamp something that helps people out, they are unthanked (naturally, one might think - it's their job). However in the absence of the smooth, they certainly get their 'fair' share of rough; when we do hear about them, it is not normally in a story showing them in the greatest light. You can probably recall at least half a dozen articles along the lines of 'Nice refuse to fund cancer drug condemning little girl to death' or other such monocular representations of the very complex situation.

Now the thrust of Anderson's letter was a criticism of the decision to place under Nice's remit the assessment of viability of "high-cost, low-volume drugs for very rare conditions." Sadly it appears he has previous experience with one such condition having lost two family members to myotonic dystrophy. However, in his concluding paragraph he exposed the ultimately flawed opinion which characterises his party.

He stated "people affected by rare diseases should not be faced with the uncertainty of knowing whether Nice would deny them treatment on the grounds of cost." Whilst I can empathise with someone who has experienced the terminal illness of a loved one, I cannot agree with this statement. We should strip out the "rare" part and analyse what he says - essentially "diseases should all be treated free of charge by the NHS regardless of cost".

This is one of the reasons why we have a cyclical political cycle. The Tories piss everyone off / stab their leader in the back / erupt into civil war and Labour get in. Labour then bankrupt the country because they subscribe to the economics school of Ocean Finance. Cue Tory return. Ad infinitum.

As I blogged about in part here, referencing this excellent comedy sketch (here), there is a finite amount of money to be apportioned to varying competing demands (and the same goes in all areas of Government, not just health). What Anderson is essentially saying is there should be no Nice. Drug companies should simply create procedures, treatments and drugs and the Government should pay whatever price those companies choose to charge, because everything should be free. Nothing's too good for our loved ones, surely? NHS means 'Free For All', right?

Anyone suggesting otherwise surely wants people to die? Painfully. What total Tory bastards.

Or of course, they know that there is only a certain amount of money and lots of ill people. So you have to take a utilitarian sort of view and try to do the most good and the least bad. Now those closest to illness are naturally biased. I would have been a terrible Chancellor or Health Secretary whilst my father was ill. I suppose I might have sold all the eye units, pawned off the heart disease research centres and put the maternity wards on eBay. I might have traded it all in for as much anti-cancer stuff as I could get my hands on. Luckily I wasn't in charge, so that didn't happen.

Like Dave Anderson's brother and sister, my father didn't make it. Unfortunately, that's life, and indeed death. It comes for us all, and there is likely not a family in the country who have not had somebody succumb to one illness or other. Many of them no doubt feel very strongly about funding for research into the disease or condition in question. But that's why we have Government to make impartial, unemotional decisions. MPs are part of that and should be able to speak as a representative of their constituency, not just of their family.

At the end of the day there isn't enough money (even if we had not been left in such a parlous state by the last Government) to treat everyone to the highest levels. Those lucky enough to afford private healthcare can mitigate this to some extent. Those lower down the economic scale cannot. So we have a system that tries to make sure the money goes as far as it can. Often this means refusing to fund medicine that would help some sick people quite a lot. It is not out of spite. It is because they have decided they can spend the same money elsewhere and make a few more people better.

It is very sad for the unfunded group, but we should not let Nice become a punching bag. Perhaps the equation they use could do with tweaking, perhaps it does not take all of the right things into account? But it has to be there in one form or other. It has to exist. It is as necessary as a medic on a battlefield deciding which soldier to treat - given the time he has and the equipment with him, where is his help best put to use? We should all feel sorry for the man left to bleed out as the medic moves to help the man lying next to him and then the next and the next, all in the time the medic would have taken to treat the first man and still perhaps not save him. We can make a song and a dance about it if we wish, but we should not question the medic's motives nor forget the greater good he did by not treating the first man.

This is Government; trying to do the most good for the most people but being realistic about the fact that we will never please everyone. Unfortunately, there are too many people commenting disingenuously about decisions on where we can afford to spend and where we cannot. We know there isn't enough money to go round. Yet we still hear bleating of evil cuts as if there was no need to budget.

This is the fallacy Labour would have us believe - that the cuts are for shits and giggles; some kind of old-Etonian 'screw the poor' party where all the spare money is spent on champagne and fox hunting or just burnt in great bonfires for fun. Because if they pretend the choice to fund a drug or not is not an economic one but a moral one and anyone who disagrees is just punishing the ill, they hope you'll forget the reason why so many of these decisions do actually have to be made from an economic point of view - because they screwed the economy of this country for likely decades to come.

We must feel great sadness for those who are struck down by illness and even more so for those whose treatment is not economically viable. It would be lovely for those falling ill to not have to worry about treatment costs, but to pretend their having to is the whim of a malicious, uncaring Government is poor form. They rightly do have to worry because there isn't enough to go around and objectively the money might be better put to use elsewhere. It is the fantasy of the centre and left, of Labour and Lib Dems, that all decisions should be made on principle and not economics. It is what got us into this mess in the first place. If they are let back in, they will cause chaos again in the economy - then the NHS really will be a free-for-all.

Saturday, 26 January 2013

Another Slice of the Golden Goose

This week David Cameron decided it was time to stand up to aggressive corporate tax avoiders to mixed reviews. Some companies complained of the added cost of being forced to publish their basic tax positions. This sounded a lot like saying "we'd rather you didn't know" since they already produce annual reports and statistics for various bodies, not least of all their shareholders. I can't imagine it would take an intern more than a day to look at the column in the excel spreadsheet that says "UK taxes paid", divide it by the column that says "UK profit" and multiply by 100. That would go some way to satisfying the desire to check tax is being returned in reasonable proportion to the country of the citizens who funded the profit.

Really the only people who are going to whine about this are indeed 'doing a Starbucks'. I don't think it's morally wrong - that's not important, and it's an opinion of which DC should have but didn't steer clear. As I've said before, a company owes it to its shareholders to maximise profits; this includes getting staff to work for as low a wage as they can reasonably offer, buying raw material cheap, selling product as high as they can and paying as little tax as they can whilst complying with their legal obligation to pay full tax in whichever jurisdiction their company structure allows.

Some people like to bang on about moral obligations - the 'fair share' tax lobby for instance. I, for one, think that's a load of old cock. Companies should behave in a moral way, but legally minimising one's tax bill (as anyone with a personal ISA or parents who pay into their children's ISA or child trust fund is) does not contravene moral behaviour. We're talking about not paying exploitatively low wages, not using child sweat shops, not trading in blood diamonds - that sort of stuff.

Trying to go the Clegg route of minimum effective rate of tax is not going to work. I think, for once, there is some merit in the idea, but actually far more applicable to personal not corporate tax. We can investigate that one another day. The main point though, is that this hasn't been thought through - like everything that leaves the Lib Dem leader's mouth. Putting aside the potential resulting disincentive for businesses to operate in a country that doesn't allow very effective (read: "aggressive" in today speak) tax avoidance, the law would be too complex and probably very easy to get around.

The far more obvious route to go is public pressure - look at Starbucks. If you make everyone show they're playing fair, consumers can talk with their wallets and not patronise those companies who they think take too much in profit from their country and return too little in tax. That's what DC is suggesting and makes sense - I just wouldn't have framed it in the somewhat anti-business rhetoric he did.

It is up to him and his Chancellor to set rates (and corporate tax rates are not the only relevant business tax - many others have been rising to offset the decrease in the headline corporation tax rate) that attract people to pay their tax bills in the UK. The key is being cheaper than the financial cost of setting up an avoidance system and the reputational cost of being exposed as an "aggressive tax-avoider".

But I've said most of that before. What I really wanted to talk about was how popular tax avoidance rhetoric is these days. So much so that Andy Burnham, the shadow health secretary has tried to jump on the band wagon with his new target. There is a group of people out there engaging in a disgusting tax avoidance scheme. They make Jimmy Carr look like Lord Sainsbury. Who are these people refusing to pay their fair share? Old people who refuse to get dementia.

Bastards. Old, fully-marbled bastards.

Let me explain, Manuel…

Labour have not learned that our money is not their money. Still. So they are trying to revive their "death tax" in response to the Coalition plans to introduce the social care cap (which looks like it may be the first actually well-thought out policy of this Parliament). Yup, beyond the already monstrous theft that is inheritance tax, Labour would like to take some more of your already taxed money to pay for the care of the elderly. Regardless of whether you ever need any yourself.


Having grasped the wrong end of the stick, Burnham thinks the extensive reviews into how to save those unfortunate enough to require care in their latter years from liquidating often their only asset which they have spent a lifetime paying for is actually an excuse to tax everyone some more. He and his moronic pals have thought this would be an excellent opportunity to make everyone pay an extra 10% of total estate on death to pay for someone else's care.

Now I have already written about the dubious script that everyone seems to accept unquestioningly that elderly care required for age-related illnesses (e.g. dementia) is somehow different from infant care required for age-related illnesses (e.g. premature babies and various infant conditions). Because it is apparently different, the latter is free at the point of delivery having been paid for by general taxation budgeted to the NHS. The former though is apparently something different - an optional extra like reverse parking sensors, built-in GPS or heated seats. Therefore it is something we all have to pay extra for if we require it.

Now you know I accept there is not enough money to pay for everything - it's why we don't have 10,000 uber-hospitals with 1:1 doctor:patient ratios and 15 minute waiting lists. I just think we don't present this one in the correct light - call it what it is. We have to charge people for elderly care because there's no money left. That's because we spent rather than saved whilst the sun was shining. We failed to recognise the burden of population growth. We sold all our gold at rock bottom. We raided our pensions. We sold all our Government assets to pretend we had annuitised income to spend on buying elections when really we were reducing our capital base and often then decimating our 'earnings' in a very short time renting back the assets. For 'we', I think you know what to replace in its stead…

Now Burnham and Labour think on top of all the taxes we pay through our lives, when we get to the end we should then pay another great whack to pay for extra care that should have already been covered by our taxes but instead was squandered by a Labour government who tripled NHS spending without improving anything because more money for granny's hip and little Timmy's asthma was a good news story. Apparently, having to pay the social care cap (or insurance premiums to cover it) is forcing people to pay a 'dementia tax'. Therefore those people who have the audacity, nay the temerity not to suffer in their old age are avoiding this tax. And that's not 'fair'. So let's tax them some more. It's always the answer.

Hopefully Labour will make this anti-tax avoidance message central to their election campaign. I think we'd all sleep a lot better in our beds at night knowing they will never get near Government with it.


Friday, 18 January 2013

The Great School Smokescreen

I've written a fair amount about universities, specifically about Government attempts over the last decade and a half to use them to embark upon various kinds of social engineering exercise. In case anyone is unsure (you can read more here), I don't think it is the responsibility of universities to ensure they take a cross-section of society. I think they should take the best students who will respond best to what they have to teach them. That won't always be those with the highest grades but the point is they are still adjudged 'the best' from whatever mix of attainment and potential the universities choose to use. The key is they aren't just filling quotas. What they certainly aren't responsible for is their schooling up until university.

Now I know what you're thinking … surely only a total moron would think that it should be up to universities to educate children at school? That would be the job of …  er … schools. Yes, schools. They seem ideal candidates for holding the responsibility for teaching children stuff up until university age. They seem to have the children for hours on end per day. They have books, teachers, desks and so forth. Almost ideally suited come to think of it. Well we've got one such moron, Vince's mate Professor Les Ebdon. I forget what the other side of the tawdry Coalition deal was that put the utterly daft Ebdon in charge of the worryingly 1942-esque Office for Fair Access. One hopes for many reasons that the Tories can stop the rot and win an outright majority in 2015. One of the most important is to be able to oust this interfering and utterly misguided man before he does lasting damage to our university system.

Now on the surface one might think that universities helping out preparing school students for the travails of university would be a good idea. But it isn't when it is dictated by political overlords hell bent on social engineering and who hold enormous financial power over said institutions; when part of their budgets is mandated to be used to encourage wider access. This is all just a very large smokescreen to hide the fact that a large proportion of the state system has failed. There are doubtless many state-educated students who do not gain places at university or at a good enough university because their school has not developed them to their full potential. There are also doubtless many students who would likely never be academically gifted enough to study at any university of repute regardless of the teaching standards at their schools.

The lefties, Les included, would rather we didn't discuss that. Nope, they would far rather point out that the only problem is all the evil, rich, elitist scum universities that only want to take thick rich kids, don't care about quality and instead of central heating just burn the poor. It is an incredibly dim view to take of the masters of our universities; quite a charge to lay at their door. But the press and the left lobby do it all day long. Clearly without an ounce of investigation. Go and find out how much universities spend trying to get children from unlikely areas apply. Find out how hard they scrutinise applications and try to discover the real value and the real potential behind the applications from across the spectrum of society. These are professional, caring academics, and they don't deserve the vitriol they are castigated with simply in the name of covering up someone else's failure.

So no, universities should not be targeting children from aged 7 to groom them for university. Schools should. We could call it education. The sooner we get off the case of universities and realise raising the quality of our schools across the board is far more important, the better.