Reviving GM foods

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A nice piece detailing the new GM foods which are being developed. The first generation of such crops concentrated either on increasing yields or on decreasing inputs, thus raising the profit margins of farmers and thus the quantities grown. All good news of course but not enough to sway the near hysterical opposition to the technology.

The new generation of such foods depends rather more on increasing the nutritional quality of the crop, rather than volume or the reduction of input costs. For example:

Cassava has been packed with new genes that help the plant accumulate extra iron and zinc from the soil, and synthesise vitamins E and A.

Cassava is the basic crop for hundreds of millions (some 800 million) around the world and its nutritional failings are responsible for  the damaging of many lives through under- and mal-nutrition. The addition of those nutrients will help to reduce such problems: that vitamin A will for example stop many cases of blindness.

Sadly, there are those who would oppose even this:

Claire Hope Cummings, a former lawyer with the US Department of Agriculture and author of Uncertain Peril: Genetic Engineering and the Future of Seeds, published in March, said: “People do not need miracle crops offering enhanced nutrients. What they need is a good varied diet. Who wants to eat a giant bowl of cassava or golden rice each day? These ideas are just a new way of marketing GM."

It's true that most people do not wish to eat a giant bowl of cassava or rice each day and yes, that they would prefer a varied diet. But that isn't something that's on offer just yet: we need to remind ourselves that life currently offers all too many people all too short a list of options, none of said options being all that enviable and some just plain awful. Like, perhaps, eating a giant bowl of cassava or rice each day or eating nothing each day and thus dying.

The GM cassava, like the golden rice which is also vitamin A enhanced, will allow hundreds of millions to continue living and reduce their risk of going blind while doing so (250,000 children currently blind as a result of vitamin A deficiency and a further hundred million at risk).

I realise that Ms. Cummings (and no doubt others) will disagree with me here but I take that to be 100,250,000 damn good reasons why we should get on with marketing GM.

From bad teeth to no teeth

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Back in the old days, dentists were paid a fee for each type of treatment they provided. After a contract change, dentists started receiving their income by doing a certain amount of work, known as “units of dental activity."

You can imagine the dentist: “I need to do 15 procedures to meet my weekly quota. I could fill all those cavities… but that takes a long time and requires numbing and filling materials. Or I could just pull the tooth out. It takes no time at all and requires no medicine or precious metals."

The NHS did not think about all this before implementing the new contract. But a damning new report from an influential MP’s committee shows how bad the situation is.

Dentists are extracting patients’ teeth rather than carrying out more complex repair work because NHS reforms have failed… The number of tooth extractions, many of them unnecessary, experts say, has risen since the new contract was introduced. At the same time, the volume of more complex work such as crowns, bridges and dentures has fallen by more than half.

The solution is not to reform the contract again, but to eliminate it altogether. We deserve health care that gets us the best treatment for our needs, but NHS contracts distort the incentive structure in such a way that dentistry works against patients. The NHS being inefficient, working against patients, and distorting the markets? Must be a slow news day if this is news.

Why legalisation works

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Or, perhaps, why criminalisation of certain behaviours doesn't. Leave aside which group of prodnoses it is in this case, and have a look at what the Wisdom of Whores blog has to say about prostitution in Cambodia. Put simply, in the face of the HIV epidemic rather than trying to stamp out prostitution the authorities decided to co-opt the infrastructure itself, to ensure that condoms were used at all times (erm, well, at all times of sexual congress, at least).

HIV infection rates came crashing down, halving in just 5 years. It is estimated that condom promotion had saved 970,000 Cambodians from HIV infection by 2007.

The pressure now though is to close down the sex industry altogether, something that no one has ever managed, thus disrupting the way in which that extant structure has been manipulated to reduce those HIV infection rates. Other than those who think that there's something inherently wrong about the commercialisation of sex, something that's in fact so wrong that it's better to try and fail to wipe it out rather than manage the effects, most people would think of this as rather counter-productive. That the sex workers themselves are demonstrating for the right to remain sex workers might also give some thought.

You don't have to fully sign up to the rather extreme version of liberalism that I do, that ingesting what you wish as you wish or offering your gonads for pay or for play, again, as you wish, is one of your natural human rights, to think that perhaps attempted abolition isn't quite the right way to go about things.

As with drugs and their decriminalisation and needle exchanges, perhaps red light areas, brothels and condoms, are better than 970,000 people being infected with an incurable disease that will kill them young.

From the purely utilitarian point of view, what's best? Reducing the ill effects of what people are going to do anyway or attempting and failing to stop them doing it and ending up with all of those ill effects?

Envy of the world?

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According to ICM polling for the BBC, 40 percent of Britons list the risk of potentially deadly infections such as MRSA and C–difficile as their main concern with the NHS. They are right to be worried:

• One in nine patients admitted to hospital contract an infection during their stay. MRSA accounts for 45 percent of hospital-acquired infections in the UK, compared with less than 5 percent in the Netherlands and 1 percent in Sweden and Iceland.
• Only half of inpatients surveyed by the Picker Institute regarded their ward as clean.
• The number of hospitals not complying with the Healthcare Commission's standards on infection control, decontamination and hygiene went up by 6.8 percent, 1.7 percent and 2.5 percent respectively in 2006/7. A third of hospitals failed to comply with at least one of these standards.
• The number of deaths caused by MRSA has risen by 39 percent since 2001/2.
• EU-wide figures on MRSA infections show that Britons are 45 times more likely to get MRSA than Swedes and Icelanders.
• Between 2004 and 2006 deaths caused by C-difficile increased by 69 percent. Only one in four hospitals has a C-difficile isolation ward, even though this is considered the best way to stop the spread of the infection.

The strange thing is that 81 percent of people surveyed also said they were fairly or very proud of the NHS. 51 percent believed the NHS was the envy of the world. One simple question – why?

Healthcare spending now consumes 9-10 percent of GDP every year, and yet the UK has one of the highest levels of avoidable mortality in Europe.  We spend more on cancer treatment than any other European nation, yet still have poor survival rates compared with Western Europe, the US and Canada. We're the only OECD country to show no improvement in stroke deaths since 2000. NHS patients wait much longer for treatment than their European neighbours, and are denied new medicines and treatments that are routine elsewhere.

The NHS is nothing to be proud of. The sooner people realize that, the better.

Conservative health policy

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A leader in The Independent this week made the following point:

It is widely agreed that an unprecedented injection of public funds into the NHS over the past eight years has failed to deliver the expected improvements. This is because the funds were not matched by wholesale reform of the system. Health-care workers were left to carry on delivering services in the same old way, rather than being forced to become more efficient and responsive to patients' needs...

Well, I couldn't agree more. Their leader was in response to the Conservatives' latest green paper, launched this week and entitled Delivering Some of the Best Health in Europe: Outcomes Not Targets. The gist of the paper was that central-government targets distort clinical priorities and prevent innovation, and should be scrapped.

That's certainly a welcome idea. Targets make healthcare providers accountable to Whitehall, when they should actually be accountable to patients. Targets also generate bureaucracy and encourage 'creative accounting' – effort and resources are expended on jumping though hoops, when it should be devoted to medical care.

Many welcomed the Tory proposals on this basis – but plenty of others moaned that they were not radical enough. I don't necessarily disagree, but the Conservatives' plans do in fact go much further than most people realize.

Essentially, what they want to do is give doctors and hospitals much greater independence, establish a comprehensive payment-by-results tariff, allowing unrestrained competition between the private sector and NHS trusts, and then allow patients to choose freely between providers. Patient choice would be underpinned by the publication of healthcare outcomes, so that competition would really be directed towards higher standards. All good stuff.

Regrettably (albeit understandably) the one area the Conservatives won't touch is healthcare funding. Services will continue to be free at the point of use, and financed out of general taxation. That's a shame. Supply-side reforms like the ones outlined above will undoubtedly drive up standards, but they can only go so far. And without funding reform, excessive political interference will continue to be a very dangerous temptation.

Helen Evans: the political class no longer believe in NHS

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The Institute of Economic Affairs has just launched a great new book by the Director of Nurses for Reform: ‘Sixty Years On: Who Cares for the NHS?’

Researched and written by senior nurse and health economist, Dr. Helen Evans, the study lays out the private opinions of the country’s top 100 health opinion formers. According to the author:

This groundbreaking new study shows that although politicians do not feel confident in proposing radical new models of healthcare, elite opinion in the media, in political circles, in academia and in policy think tanks has fallen out of love with the idea of a centrally planned health service providing and financed by government.

Indeed. The results this work presents show that the world has moved on in profound and important ways since the late 1940s. Crucially it shows that on the eve of its sixtieth anniversary, the NHS is no longer a much loved British institution. For the political class, as for the rest of us, it has become an embarrassment and a national disgrace.

What is there to think about?

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The government have announced a review of their policy of denying NHS services to patients who top up their care with private treatment. The rule has meant that cancer patients wishing to pay privately for a more effective drug not offered by the NHS have ended up having to foot the bill for all their treatment.

In the past, the Department of Health has maintained that, "Co-payments would risk creating a two-tier health service and be in direct contravention with the principles and values of the NHS." In other words, the health service's Soviet-era ideology was regarded as more important than the health of its patients.

Obviously, that this sickening policy is under review is welcome. But I really wonder what there is to think about. As I've said in a previous blog, the prohibition of co-payments is immoral, incoherent and quite possible illegal.

It's immoral because the government have no right to deny people services they have already paid for (through the tax system) just because they want to pay privately for some additional services that are too expensive to be offered on the NHS. Who is the Health Secretary to tell people they can't have a potentially life-saving drug even if they're prepared to pay for it themselves?

It's incoherent because people are already allowed to pay extra for private rooms, televisions and other non-clinical benefits in NHS hospitals. Why shouldn't they be allowed to pay extra for newer medicines?

As for illegal – well, the NHS has a legal duty to provide 'reasonably required' care unless there is some legitimate reason not to do so. Limited resources are a legitimate reason, but if you are prepared to pay the extra money yourself, then it's hard to see what acceptable grounds the NHS could have for refusing to allow the treatment.

It is high time the government moved beyond thinking that 'fairness' means preventing anyone from accessing better care. And they shouldn't need a lengthy review process to tell them that.

Polyclinics?

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A million people in the UK have petitioned Downing Street against polyclinics – the 'super-surgeries' that will absorb or replace many existing family doctor practices – the so-called general practitioners or GPs.That's almost as many who petitioned against road congestion charging. Given that they are both so unpopular, can we conclude that these ideas are both pretty daft?

Well, road charging is a sensible idea. It allows you to charge on the basis of use, and on the basis of the costs that road users cause to others when they all decide to come into town at the busiest times. People reject it because they know politicians too well: they fear it will be an extra charge, not one which replaces existing motoring taxes.

Polyclinics aren't a bad idea either. There's strong evidence that indiividual GP surgeries have poorer medical outcomes than group practices, where doctors can share administrative and nursing backup, can share patient loads, and can specialize to a certain extent. Making them even bigger, allowing diagnostics and even some surgical procedures to be done at the same site – saving patients from going back and forth to hospital – seems an obvious extension of this.

But now patients are saying they rather like their local GPs. They like to see the same doctor every time. They like the fact that their doctor is near to where they live. And NHS experts too worry that they are just going to duplicate what hospitals already do.

Again, it's the fact that the existing setup is state-run. That means there is no market information to tell the provider (the government) what people actually want. I suspect that in a market healthcare system, people would rather like small-scale medical services near where they live. Or maybe better, something near their work that was open on their way in and out, and at lunchtime. And probably they would like smaller (dare one say 'cottage') hospitals or clinics near where they live, in preference to the huge district hospitals that 1970s state giantism gave us. And they'd like more downline tests, consultations and monitoring, rather than having to turn up in person all the time.

But that's only a guess. Without the preference information that we get from having a market, we can't know. Which means that whatever the government does, it's bound to get wrong, and upset a lot of people in the process.

A distorted market

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Among the major perverse incentives that distort the US health care market are the tax breaks for immobile employers rather than mobile employees, and for non-profit hospitals instead of patients. Both tax subsidies are partly to blame for spiralling health care expenditures, making non-profit hospitals richer than their for-profit counterparts in the process.

The majority (60%) of the 3,400 US hospitals are not for profit. The 50 largest of them have increased their net income eight-fold between 2001 and 2006 to $4.27 billion, and the 25 richest earn more than $250 million per year. Originally set up to serve the poor, today poor or uninsured patients are billed the highest charges because they don’t benefit from discounts granted to privately insured and Medicaid or Medicare patients. One non-profit hospital group, Ascension Health, has piled up reserves of $7.4 billion, more than many large publicly traded companies. These tax breaks are ‘drawing fire’.

Nonprofits …are faring even better than their for-profit counterparts: 77 percent of the 2,033 US non-profit hospitals are in the black, while just 61 percent of for-profit hospitals are profitable, according to the American Hospital Directory data. The growing gap between many non-profit hospitals wealth and what they give back to their communities is raising questions about the billions of dollars in tax exemptions they receive.

The exact number for 2006 is estimated by the Congressional Budget Office $12.6 billion in tax exemptions plus subsidies from different government levels worth $35 billion for the whole hospital industry. These numbers show better than anything else what damage is caused when third parties instead of consumers run health care. It also shows a high degree of noble cause corruption: 'non-profits serving the poor'.

Privatizing the NHS?

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Yesterday Ben Bradshaw, the health minister, announced plans to allow the private sector to take over failing NHS hospitals. Gordon Brown backs the idea. On the one hand, this is a welcome development: the government is acknowledging that even in healthcare, private sector management can deliver better results at a lower cost. That realization bodes well for the public service reform agenda.

But the details of the plan are rather less appealing. The government will set a range of minimum standards that hospitals will have to meet. If they don't meet the standards, they will be given a deadline to turn things around. And then if they don't improve, management will be transferred to other NHS units or (potentially) to private companies operating under a franchise agreement (with lots more targets to meet).

Essentially then, this is about strengthening central control over the system. And, to adapt Reagan's line, central control is not the solution to the NHS' problems – it is the NHS' problem. Care is not focused around patients because management incentives all point in the opposite direction. Hospitals do not succeed by satisfying patients, but by meeting government targets. The targets are well intentioned, certainly, but they lead to bloated management, endless paperwork, creative accounting and distorted clinical priorities.

The NHS does need to be made more accountable – but to patients, not the government. Hospitals should be given their independence, and patients should be put in charge of their own care. That's the kind of 'privatization' I'd be in favour of.