Category Archives: Ideas: Bad

Why the proposed NHS Reinstatement Bill is a bad idea

Right now, there is the proposed NHS Reinstatement Bill, a lobby document which lays out a way to reverse many NHS reforms.

This lobby document, which is what is it, is familiar reading, and brings back various structures that in the past have failed. You can find information on it at this link.

What is interesting about this approach is the aura of respectability that it wraps itself in, by proposing the changes as a legislative draft, almost as though it were ready to go to committee.  This is, obviously, an influencing tactic designed to force debate onto the topics covered in the proposed bill, and disarm critics who don’t agree that the points in the lobby document are the right starting points. In that respect, the lobby document polarises positions, particularly against current policy direction.

The whole lobby document’s comments and notes identifies proposed changes to a variety of existing legilsation. What we don’t find, though is any evidence that the authors were in any way persuasive  or influential during public consultations at the time. We call that ‘sour grapes’.

Approaches such as this suffer from the following:

  1.  a belief that the fundamental values underpinning the health service can only be protected in a particular way and these are the ways things used to be.
  2. a belief that the changes that have been made have violated these values; moreover, that the solutions have made things ‘worse’ as they see it.
  3. selective use of academic research to support the positions that one wishes to avoid changing.

New PublicManagement as reform of government itself must sit uncomfortably with this regressive thinking.

For the authors, they would no doubt point to market failure logic to prove that the NHS should not be ‘marketised’ as they put it, forgetting that a greater fear is ‘government failure’, for which there is ample evidence, not just with the NHS but a whole host of other public initiatives and legislation that has wasted public money.

Healthcare systems are complex and by trying to overlay what they see as simple solutions to the problems they claim arise from the reform agenda of past years, they misrepresent what the actual problems are. As messy, or complex/wicked, challenges, the authors believe that by taking away that messiness, they’ll also take away the problems. But they know just as well as anyone, that their solutions will only create, perhaps even recreate, the very problems that led to reform in the first place, except now they will be today’s problems, not yesterday’s.

One might argue that the authors are committing a type 3 error, of unintentionally solving the wrong problem well, but that would assume that they have are not clear in their minds what they are proposing. Therefore, it appears they are do know better and are committing a type 4 error, of intentially solving the wrong problem well because that fits with their policy preferences, or prejudices.

That’s why this is a lobby document, designed to intensionally convince, (is mislead too strong?) others of their definition of what the NHS problem is.

Regardless, the lobby document and the authors are caught by a fundament policy trap: of solving the wrong problem.

Want to know more?

Government failure in the UK is examined in Anthony King and Ivor Crewe, The Blunders of Our Governments, 2013 (@Amazon) and in Richard Bacon and Christopher Hope, Conundrum: Why every government gets things wrong and what we can do about it, 2013. (@Amazon)

New Public Management was originally conceptualised by Christopher Hood, in 1991, A Public Management for All Seasons. Public Administration, 69 (Spring), 3-19. Some (Dunlevey et al) argue that New Public Management is dead and that governance in the digital era requires greater, not less, government. That may be the case for some, but if you actually look at the tools that are available to government in a digital world, you’d find that there is little reason for government to own or run very much. See Christopher Hood and Helen Margetts, The Tools of Government in the Digital Age, 2007. (@Amazon)

I have found Leslie David Simon’s book, (Woodrow Willson Centre, 2000) an early, and compelling way of laying out the digital agenda in a policy context really well. (@Amazon)

I would also recommend Vito Tanzi, Government versus Markets: the changing economic role of the state, 2011. (@Amazon)


Is health technology assessment morally defensible?

Capturing race

Is HTA like GO? (Photo credit: Wikipedia)

Increasingly widespread amongst the world’s healthcare systems is the assessment of medicines and devices using various types of cost-benefit or cost-utility analysis; this is called health technology assessment or HTA. HTA seeks to determine, using evidence of one sort or another, whether something is broadly speaking affordable, taking account of the cost of the medicine/device taken against the benefit to a particular constellation of diagnostic attributes in patients. This is usually quantified in a measure called a QALY: a quality-adjusted life year, which is a way to assess the value for money of a particular health technology. In short, it is a way of valuing lives.

HTA is a utilitarian approach to assessment. To some extent, this is not surprising as HTA is in the main a method developed by health economists, who, like economists in general, hypothesise that we make daily decisions based on the utilty of this or that, in terms of trade-offs (Pareto optimisation, for instance) and rational decision making (that people seek to maximise value, or utility in what they do). This approach is increasingly in dispute in light of the findings from neurosciences and behaviour economics: by posting that people do not always make decisions that are in their own best interests, a key assumption of traditional economics, that of the rational actor, always calculating trade-offs and maximising benefits, and so on, is questioned.

The problem with utilitarianism, though, is it doesn’t pay attention to the freedom of the individual; it positions the justification of its results on the net benefit to society, regardless of the impact on rights of individuals. Obviously, health economists don’t watch Star Trek or they would know that the needs of the one outweigh the needs of the many. But then, that, too, is a moral position.

Indeed, it is perhaps the sense that utilitarian conclusions don’t seem to correlate with many people’s moral sentiments that may explain why decisions of HTA agencies, for instance NICE in the UK (England) lead to moral outrage and a sense of, if not injustice, at least unfairness. While the results of an HTA process may lead to a quantitatively defensible conclusion, people sense that this conclusion is not morally defensible.

How are we to judge? Few would use utilitarian arguments in this way in other spheres: would we calculate who needs welfare in terms of the net benefit to society in terms of quality of life years, though perhaps we do allocate welfare on moral assumptions that some people deserve welfare while others don’t.

Do we allocate support to communities ravaged by floods based on their overall contribution, or utility, to society.  If you could donate £10 million to a university, would you pick Oxford University or Thames Valley University; which one is more worthy? But would you want to treat people this way?

HTA doesn’t even let us value lives in quite this way, since it neatly avoids deciding about the worth of any particular type of person, who just happens through misfortune to find themselves needing some medicine that fails the HTA tests. HTA keeps us from confronting the fact that HTA is a way of drawing a conclusion, without actually having to decide any allocations for any one person in particular. Bentham would approve.

There is, though, a technical problem with HTA and it has to do with whether at one level of assessment outcome, a utilitarian models can be used when the decision to be made does not have life threatening consequences for some people.

If the QALY threshold is, say £35,000, as it apparently is in the case of NICE, are the decisions below that threshold, which tend toward ‘yes’ or ‘approval’ morally different from decisions above that threshold?  I suggest that different moral criteria come into play above the threshold and this is where I think out moral outrage should be directed and where HTA fails.  Regretfully, HTA models see the results as broadly continuous, that is, decisions above and below this threshold are seen as essentially of the same type.  But I have argued elsewhere that above the threshold, HTA models fail but for reasons other their analytical soundness, because above this threshold, the conclusions may lead to a lessened quality of life, in other words, they actually crystallise the health outcome rather than avoid it.

Therefore, in valuing lives, those above the threshold experience greater injustice than those below; they are treated differently, unfairly, unjustly, perhaps less worthy, but certainly differently.  Indeed, above the threshold, we feel we are more in the realm of our moral sentiments about the value of human life, and less our moral sentiments about the allocation of scarce resources.

If this were not so, then we would be living in a society that believes that the determinant of all important moral and political decisions is affordability, and if that were so, they we could not even afford the costs of inefficiency brought on by democracy, the inconvenience of not being able to exploit people, the costs of equal rights.

Perhaps, though, on our financially contaminated world, all we can think about today is money and that is further contaminating our perception of what sort of society we are actually trying to foster.  Certainly, protests on Wall Street and elsewhere point to the view that there seems to be some unjust allocation of the benefits of government bail-outs that just doesn’t benefit those ‘at the bottom’.

John Rawls wrote that the we should distribute opportunity in a society in such a way as to ensure that the least well off benefit the most. In the context of HTA, medicines and technologies that benefit only a few, but at great cost, represent a cost worth having as the least well off, namely those who would need it most ( have the condition it treats, and in some societies can afford it least), would benefit, even if a little, as that is the price we pay for justice.

This, I suggest, is the root of our moral outrage at HTA, that is unjustly fails to serve those who need it most.

I am left with wondering about the underlying morality of HTA as a government scheme. Governments, as we know, are the last resort, when things are tough and one would hope, ensure that the least well-off in society are not penalised simply in virtue of being least well-off.  In healthcare, someone has to be the carer of last resort; using HTA as a way of avoiding this responsibility is not morally defensible.

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Where to be an entrepreneur in Europe? Not France!

dead duck

A French Entrepreneur (Photo credit: Dave Malkoff)

A paper by academics Nadine Levratto and Evelyne Serverin, “Become Independent! The Paradoxical Constraints of France’s Autoentrepreneur Regime” (available here) shows the failure of this programme to generate entrepreneurial behaviours.

What went wrong, and why should other member states not copy France?

Since January 2009, when the autoentrepreneur category of working was first introduced, over 550,000 people have registered. They system differs from the also complex Regime Reel in France by taxing autoentrepeneurs on gross turnover (up to the allowed ceiling of €32100, at the rate of between 12 and 21.3%) rather than on revenue (turnover less expenses). People in this category discharge all their taxes by paying this amount, but do not get to claim expenses and do not need to do VAT accounting. In France, the very high national debt is driving lawmakers toward a regime that is levying the regressive social charges on everything from the first euro (!); this is evidence more of desperation than leadership — that entrepreneurs have been captured by this is not surprising.

Almost 50% of autoentrepreneurs in France had an annual turnover of zero, while 15% had a turnover of less than €1000. Only 500 autoentrepreneurs exceeded the upper threshold.

This regime fails because it is not about being entrepreneurial, but about collecting tax and creating bureaucratic barriers to success: more specifically:

  • autoentreprenurs can’t hire anyone — the authors speak of them as ‘lonesome’, working out their entrepreneurial dream on their own, forbidden to collaborate with others, even hire an assistant
  • they can’t recycle capital to build the business as it taxed away at the turnover level as there is no recognition of the extraordinary expenses of business startups
  • because of the structure of business, they are a bad risk for banks to lend to
  • two autoentpreneurs can’t collaborate as tax authorities would view them as a company
  • there is an excessive concern for employment law and insufficient understanding that entrepreneurial behaviours are not about being secure, but about risk, and therefore has little to do with employment law itself.

There should be no surprise that the system failed and people outside France can say simply on this basis, and with some justification, that the French don’t have a word for ‘entrepreneur’ as clearly they don’t seem to understand what the word means. Indeed, the authors note that the programme has been such a dismal failure, that the French government is rebranding it as better for second incomes, than entrepreneurialism.

What we need is an analysis of these failing efforts at entrepreneurialism by member states, certainly as a warning to others, but more importantly to establish a general understanding of how entrepreneurialism should be treated within member states from the perspective of taxation and law.

If I were forum-shopping for a member state to pursue my entrepreneurial dreams, I would be looking for a country with light-touch taxation, and flexible employment rules.  Start-ups have real problems with cash flow and locking them into high social charges and rigid employment laws is counterproductive.

What is worrying is that other member states, according the authors, have copied this regime: Portugal (recibos verdes) and Poland (samozatrudnierie). Others may be thinking about it. We should all be very afraid of this.

If you are entrepreneurial or have experience in specific member states, please email or comment. Which do you think is the best country in Europe to start a business or be entrepreneurial?

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Digital Maginot Line

Cloche GFM (Ouvrage de l'Agaisen)

Fear, not protection. (Photo credit: Wikipedia)

As has been noted by other commentators, the French government has a problem with the internet, and endeavours to stave off its impact with ill-timed, and ill-thought out regulation. Of course, as a national government, they can try to build a digital Maginot line around France; they’re always doing that and as Santayana said, having failed to learn from history, they persist in repeating it.

One can only hope that such efforts will not be copied by other governments and certainly be given short shrift at the European level.

History shows that efforts to build up walls such as these are doomed to failure. Brute force, smarter opponents, and new technologies prevail in the end. France, regretfully, seems to prefer to hide behind its social-cultural rhethoric rather than deal with the opportunities that the internet offers, by fearing it more than understanding it.

The internet is not just a telecommunications novelty to send emails, view your vacation pictures, or keep in touch with friends. It is has become a digital glue that binds communities and nations together in a way that international treaties have failed. It could be seen as the ultimate success of the internationalisation of societies in a way that brings with it greater understanding and peace. Indeed, why do autocratic governments, usually just before they collapse, try to shut down the internet, for it, like the photocopier in what was the Soviet Union, represents all that they fear: openness, liberty.

Efforts to counter this new technological force of nature are at root authoritarian. They say the government in power knows better than individuals. Francis Bacon wrote in 1597, “knowledge is power” [Meditationes Sacrae], certainly not anticipating the internet, but deeply understanding that control of knowledge (or information as we think of things today) gave those who controlled it power. From this come cartels, censorship, autocratic governments, and authoritarian regulation from fearful democracies.

The former US Supreme Court justice, Louis Brandeis, is famous for saying that “sunlight is the best disinfectant”, and today the internet is the best disinfectant there is, for it is revealing where injustice lies, and uncovering official hypocracies. It is laying bare the landscape of opportunities for all, and not just a privileged few.

But some fear this for it also reveals where the internet challenges past comforts, vested interests, and the quiet whisper in the ear.

And so this digital maginot line that some countries are trying to build will fail, and fail for all the right reasons, as we don’t live in that kind of world anymore, and governments, both national and at the EU level need to grasp that as the internet changes everything, it also changes the very logic we use when we govern.

In a frictionless internet I can eliminate fr, .de, .uk, even .eu, with a mouse click, erase them from my universe more thoroughly than the thundering barbarian hoards.

Or I can make them the centre of my world.



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The destruction of meaning

“That” slide, which has now featured most recently in the NY Times, is a creature of a major consultancy firm. The slide obfuscates and confuses, and the Generals are right to wonder what it means.

Does the presentation of information such as this rest on critical thinking, with an evidence base; is it a conceptual model, without empirical importance; is it a sophisticated ‘guess’? In the end, it represents the thinking of a room full of people who designed this and thought it made sense.

The condensation of content onto the PowerPoint slide is bad enough. The mind-mapping software that they used to create this thing is also to be faulted, as such models lead to the suggestion of deep meaning; the authors have suitably coded the slide with colours, linking arrows, and a key explaining what the two little lines mean over an arrow — all this suggests meaning, but that meaning depends on how individuals make sense of it themselves; it does not emerge naturally from the slide itself.

I’ve loaded the whole image and you just need to click it to see all of it. Note the slide is from a working draft, v3, and calling it that is consultancy code so they can easily change it. That way they can avoid having to stand behind their conclusions. Note also it is page 22; I wonder what the preceding 21 pages looked like — maybe they were PowerPoint slides, too. What was the next slide? “…and in conclusion, General, this slide shows four bullet points summarising the key actions for the Afghan strategy…?”

The arrows bother me; there is some suggestion that they imply causality, a sort of ‘if/then’ for instance: IF ISR/Open Source Ops THEN Coalition Knowledge and Understanding of Social Structures.  Note too that the latter is also negatively affected by “Duration of Operation”.

This is the type of technocratic thinking McNamara’s ‘boys’ thought was helpful during the Vietnam war. To be fair, the situation is complex and dynamic, but we know that, and complex issues are often presented in this way.

What I want to know is this: if this is the answer, what was the question?

How to Muddy Water

Of Free-riders, and a shake-down

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Item in the new: “The manufacturer of a drug which could extend the lives of thousands of people suffering from a rare form of cancer has agreed to pay for further patient treatment as part of a cost-cutting scheme.”  This arises from a decision of the English agency NICE to recommend limited use of this medicine.

We have a situation where the pharma company is going to provide the medicine for free to a certain group of patients (the details aren’t important for this commentary) at a certain point in their treatment — in this case toward the end of that person’s life.

How are we to make sense of this?

Who benefits?: the patients get the medicine which they would otherwise not get it toward the end of their life; indeed, unless they were able to pay for it themselves, they would be deprived of the medicine. NHS gets a medicine, which it would otherwise not pay for, for free, for a group of patients, one might argue they were abandoning.

Who pays?: the pharma company absorbs the cost of doing this for one final application of the medicine if needed; the public sector does not pay anything.

When some derive benefit for free from the actions of others, we call the former free riders; that makes the NHS a free-rider. Indeed, one might view NICE and other HTA agencies as acting to achieve free-ridership for the public system, by rationing public funding according to the HTA assessments. The pharma companies, wanting their medicines to be used (they might actually also want them to be paid for), give them away for this group of patients for their own reasons.

This small group of patients would undoubtedly suffer, a price NICE deems worth the cost, and the NHS in this case, is willing to be bound by a decision which may actually increase suffering. The pharma company has come to the rescue of these few patients and is now doing what one would think the public system should do, alleviate suffering. Had the pharma company put profits before use (which they appear not to be doing otherwise they would have sought payment) no doubt they would have been criticised for their prices, which of course underpins NICE’s cost-benefit analysis in part.

Did NICE shake down the pharma company?

I have argued elsewhere, that public health systems must be the payer of last resort (the so-called Rule of Rescue), which should challenge NICE’s models that would increase suffering, as that cost is something no state should ignore. The unethical conduct of public bodies here is breathtaking.

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Canada’s dairy supply management system is a public health menace

Espace Opéra Milk
Hard to believe, but this is a symbol of politics in Canada: free-traders beware!

The supply management system inflates the cost of diary products to Canadian consumers. Canada also applies substantial duties on imported dairy products. Both of these practices are of dubious benefit to consumers, and cost them substantial sums of money each year. It also has public health consequences that have been ignored.

In other countries, and particularly within the European Union, prices for milk, cheese, probiotics, yoghurt, etc. are about 30-40% of Canadian prices. By comparison, in a typical Canadian grocery store, a litre of low fat milk ranges between C$2.14 and C$2.40, three times the price in Europe.

There is some evidence that high prices may discourage parents from buying milk for their children. This may correlate with family income relative to poverty thresholds. Research has quantified how children substitute sugary carbonated drinks for milk. Reduced dairy consumption may be contributing to rising obesity in children and perhaps rising incidence of Type II diabetes, something we thought only showed up much later in life.

Milk consumption is also lower for girls, which may predispose them to osteoporosis later in life. Recent Canadian research has shown that reduced milk consumption during pregnancy leads to low birth-weight babies. We are also seeing the return of rickets.

At present, the parties to the supply management system itself are the main sources of information for consumers on dairy products. This makes it virtually impossible for consumers to access independent information. This is a tight circle that may not be acting in the public interest when looked at in terms of implications to human health.

The logic of the dairy supply management system is weak when tested against public health outcomes.  It is time to abandon this policy, which favours the few, has public health consequences for the many, and adds costs to provincial healthcare systems already under significant stress.

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