Strokes and why the NHS isn't a good health care system

We’re told that the NHS doesn’t treat strokes well:

The procedure can reduce hospital stays by months. Some patients have been able to leave hospital the next day, instead of spending months in rehabilitation units.

Stroke specialists say a 24/7 service would save £73m a year due to the reduced costs of looking after people with stroke. But just 25% of thrombectomy centres operate as such, while 42% are only open from Monday to Friday during office hours, the report says, in part due to a lack of biplane suites, which contain specific radiology equipment.

Juliet Bouverie, the chief executive of the Stroke Association, said: “Thrombectomy is a miracle treatment that pulls patients back from near death and alleviates the worst effects of stroke.

The coverage rate is apparently some 0% in some areas outside London, up to 8% inside it.

It’s true that mechanical thrombectomy is a fairly new treatment, full trials showing effectiveness seem to have been completed in 2015 and 2018. But then this is exactly what ails the NHS - the length of time it takes new and better treatments to come into general use.

The American experience is of “The percent of patients with AIS receiving IAT increased from 1% in 2008 to 5.3% in 2018 (p>0.001).” They reached a much higher level ( yes, 5% of all is greater than the 0-8% range across Britain given that London isn’t by any means the majority of population) 5 years earlier than we did.

Which is exactly the NHS problem - productivity. Fortunately, we also know how to increase productivity. That comes from competition. No, it doesn’t have to be like the American health care system, it can still be tax paid, it’s that the organisations doing the actual work need to be competing to produce the finest results possible with the currently available technologies. That’s what does spark the adoption of the newly available and better - more productive - technologies over time. It’s also a self-sustaining process, it will apply to each and every new technology as one comes along.

That’s the argument for markets within the NHS. That they makes the system more productive, better, over time.

Or, even, markets in the NHS will stop some to many dying from mortality amenable to treatment, the one measure by which the NHS does appallingly in international comparisons.

Karl Popper, a philosopher of freedom

Exactly 120 years ago, on July 29th, 1902, one of the most remarkable and influential philosophers of the 20th Century, Karl Raimund Popper was born. As a teenager in Vienna, Popper was attracted by Marxism, and at one stage thought of himself as a Communist. What disillusioned him was the realization that none of the precepts of Marxism could be tested.

He formed the view that there was a difference between the ideas of Marx, Freud and Adler, and those of Einstein. Einstein’s theory of relativity could be tested by observation, and indeed was tested by Eddington’s experiments in 1919. By contrast, those of Marx, Freud and Adler could accommodate everything that happened; there was nothing that could happen in the observed world that could refute them.

This led Popper to the ideas he published in his 1934 “Logik der Forschung,” published in English in 1959 as “The Logic of Scientific Discovery.” Here Popper advanced his central notion of falsification. He said that although a theory could not be proved true, because an experiment might one day come along to refute it, it could be proved false if an experiment contradicted its predictions. Einstein’s theory could have been refuted, but wasn’t, whereas those of Marx, Freud and Adler could not be subjected to experiments that might refute them. They represented a determination to interpret the world in certain ways, rather than being capable of adding to our knowledge of it.

Popper solved Hume’s problem of induction. We expect the sun to rise each day because it has done so every day so far, although there are no causal links to explain why the past indicates the future, and why induction is valid. Popper replaced induction by conjecture and refutation. We form a theory that the sun will rise tomorrow, and test it each day. If one day it didn’t, then our conjecture would be refuted. Our scientific knowledge is thus not what we know to be true, but the collection of theories that we have been unable to refute. Theories that cannot be tested like this are not necessarily nonsense, but they are not scientific.

Popper’s other great influential work was his 1945 “The Open Society and its Enemies,” in which Vol 1 was “The Spell of Plato,” and Vol 2 was “Hegel and Marx.” Popper called it his “war book,” but it remains one of the most powerful demolitions of totalitarian ideology ever written. Far from being interested in “justice” and “virtue,” Plato was in fact justifying rule by the superior élite, and is profoundly anti-democratic and pro censorship and thought control. As Popper says, Plato’s idea of virtue is “the ruler rules, the worker works, and the slave slaves.” And Hegel and Marx enlist fanciful notions of where historical destiny is taking us to justify oppression and control. Popper opts instead for “piecemeal social engineering,” by which we gradually improve our circumstances by building on what has worked and making it better by removing some of its shortcomings. Democracy is not about choosing those best fitted to rule; it is about removing those who are bad or incompetent.

I was never happy with Popper’s idea that things could be “proved” false, thinking it subject to the same flaws as “proving” them to be true. We can decide to discard theories that are less good than their rivals at enabling us to predict what we shall observe, but that is a conventional decision to reject them, not a “proof” that they are at odds with some objective reality. My 1978 “Trial & Error and the Idea of Progress” was about that.

I knew Popper, and once spent a pleasant day and a half pacing the streets and the beach at St Andrews in his company. He was, I think, the most intelligent person I have met, in a linear, logical, Newtonian way. Hayek was perhaps wiser, bringing a greater breadth of knowledge to his more considered answers. But the two were friends and saw eye to eye on almost everything.

Paying for the choo choos

A fairly emphatic statement in The Guardian:

The best railway in Europe is publicly owned, in Switzerland.

This all being part of a proof that public ownership is best. The thing is it’s possible to mumble something or other about the definition of “best”. For example, a quick look at the finances of SBB shows that 40 to 45% of the gross revenue of the system is taxpayer support. This is not a function of covid lockdowns, this is a permanent feature. CHF 4 billion to CHF 4.4 billion on CHF 9 billion and change turnover. Which is quite a lot of money from everyone flowing to those who buy train tickets.

By contrast (without the influence of covid) 99% of the operating costs of the British rail system are paid from ticket revenue.

Which leads to a fairly basic question. Who should be paying for the train system? Our insistence is that those who get to ride on the choo choos should pay for there being choo choos to ride upon. For that just seems eminently fair to us. Everyone using an alternative form of transport has to pay their own way, whether that be shoe leather, bicycle tyres or petrol for the car (and yes, to head that one off at the pass, fuel duty is vastly larger than the road building programme*).

Something like that Swiss level of subsidy would cost every man, woman and child in the UK around £150 a year. No, people can pay for their own transport, can’t they? After all, it is them getting transported….

*This is still true considering externalities of fossil fuel use. The IMF calculations are here. Chart on page 18.

Not that we're gold bugs and yet.....

There are those who insist that money, currency, should be based upon gold. That this then restricts money supply to the productivity of mining is taken to be a benefit. We disagree. Well, mostly we disagree:

A gold coin stamped with an image of Victoria Falls has been introduced by Zimbabwe in its latest eye-catching attempt to tame galloping inflation and prevent another collapse in Africa’s worst-performing currency.

The government hopes to curb the hoarding of US dollars and tangible assets such as house bricks by tempting investors with 22-carat, individually numbered coins which are being minted from locally mined ore.

This is, we think, the third time Zimbabwe has faced hyperinflation and the destruction of the currency in recent decades. The authorities seem incapable of restraining themselves from overproducing any monies that they have the ability to produce.

That is, when considering what money should be linked to - gold, a basket of commodities, something purely fiat, whatever - that question of Thomas Sowell’s is always important, “Compared to what?”

It is actually possible for this modern monetary theory idea - government should just print whatever money it needs then spend it - to reach the stage that tying the money supply to the productivity of the mining industry is a good idea. Or, perhaps, it is possible for governments to be so incompetent that it becomes that good idea.

Which brings to mind a slightly different quote when considering how money should be managed and by whom. “You’ve got to ask yourself, do I feel lucky? Well, do ya punk?” The truth being that electoral choices do not always turn out lucky….

Henry Ford and the $5 a day wages

Chris Snowdon tells us all in The Times of how Henry Ford really didn’t raise wages so that the workers could afford the cars they made:

The left-wing equivalent of the self-financing tax cut is the self-financing spending splurge. The idea is that if you pay teachers more, they will spend more and pay more tax. As proof of concept, it is sometimes claimed that Henry Ford gave his workers a pay rise in 1914 so they could afford to buy his cars.

Ford actually gave them a pay rise to deter them from leaving the company. Even if all his workers bought a Model-T, the cost of the higher wages would have exceeded the extra revenue, and most of them would have struggled to afford one anyway.

This is indeed true, as one of us pointed out in detail for those who would like to check the numbers:

We can go further too. As we've seen the rise in the daily wage was from $2.25 to $5 (including the bonuses etc). Say 240 working days in the year and 14,000 workers and we get a rise in the pay bill of $9 1/4 million over the year. A Model T cost between $550 and $450 (depends on which year we're talking about). 14,000 cars sold at that price gives us $7 3/4 million to $6 1/4 million in income to the company.

It should be obvious that paying the workforce an extra $9 million so that they can then buy $7 million's worth of company production just isn't a way to increase your profits. It's a great way to increase your losses though.

The reason for the pay rise was not as some of our contemporaries seem to think it was. It was nothing at all to do with creating a workforce that could afford to buy the products. It was to cut the turnover and training time of the labour force: for, yes, in certain circumstances, raising wages can reduce total labour costs.

The story that Henry Ford raised wages to sell cars to his own workforce not only isn’t true it’s innumerate. So perhaps folk would like to stop parading their ignorance by repeating it?

A quite possibly interesting question

One to which we don’t know the answer:

Britain's biggest banks are demanding that Facebook, Google and telecom giants pay hundreds of millions of pounds to help reimburse victims taken in by scammers on social media. Barclays, TSB, Lloyds and Santander have warned that technology companies are not shouldering their share of the burden from the wave of online fraud gripping Britain.

They are backing a so-called "polluter pays" principle in which tech companies would be required to contribute to a compensation war chest for victims.

If a scam takes place through the Royal Mail does the Royal Mail contribute to the compensation? Or BT over telephones?

If a scam propagates through advertisements in the newspaper - this certainly has happened, whether it does now is another matter - then does the newspaper which carried the ad contribute to the compensation?

We rather assume that a newspaper doesn’t, we also rather assume that if such liability were being talked about then newspapers would be less likely to report approvingly on the idea.

We are, of course, aware that such scams do happen. One of us advised against one of them a decade back, before it had even launched. Then some years later gave evidence in a number of trials which jailed those who had run the scam. Financial, fiscal and investment scams abound.

We’d not, even, be averse to the idea that those who aid in propagating such a scam be liable for the compensation. However, that rule of law thing - any such system must be all who aid in propagating, not just one particular technological form of it. Nor, as we suspect is the case here, just those with deep pockets.

Which leads to that interesting question. Do other propagators face such costs, if not, will this new idea impose them upon all or just the disfavored few?

Australian restaurants teach us how to deal with climate change

Assume that all we’re told about climate change is true. No, go on, assume. The question then is, well, what to do about it? The secret of that is illustrated in this little tale from The Guardian:

Restaurants and cafes are constantly adapting their menus to try to mitigate the rising cost of produce and cutting staff hours, as inflation hits profit margins in the hospitality sector.

Jackie Middleton, who co-owns Earl Canteen, a small sandwich chain in Melbourne, and Dame, a high-end cafe on Collins Street, says not a single day goes by when she doesn’t get an email saying the price of a product has increased.

To handle it they are adapting their menus, substituting expensive vegetables with cheaper ones and finding inventive ways to use seasonal produce.

As the insistence is, in the face of climate change everything must change. So, how do we change everything?

As we can see here from Oz, a change in relative prices means that every supplier - and on the demand side, every consumer - is thinking about how to deal with that change in relative prices. How much lettuce is on a plate, which type of lettuce, the presence of lettuce at all. Change prices and the entire society, at the most microscopic level, includes those costs and benefits in each and every decision.

At a level which not even the most demented and powerful planner could ever reach of course.

So, if we wish to embed climate change into each and every decision in the society, at the most microscopic level, then we’ve got to change prices. If everything must change then we want the consideration of change to be within the decision making incentives of everyone, on every decision.

This means that the solution to climate change is the carbon tax - which embeds those costs and benefits in every decision made by everyone at the most microscopic level. That this also frees us from the power of planners, including the demented ones, is in itself a benefit, but even without that the point still stands.

If you’re in favour of doing something about climate change but not in favour of the carbon tax then you’re simply not being serious. Or, obviously, are a demented planner.

There is no good argument for subsidising Tata at Port Talbot

The begging bowls are out again:

Indian conglomerate Tata Group has threatened to shut Port Talbot steel works unless it is given a £1.5bn government lifeline to help reduce carbon emissions.

No, and no again, and Hell No.

This is not just because of our well known hatred of looting the populace by picking losers. There’s a technical point here which makes the very idea ludicrous.

Steel making is considered one of the hardest industries to decarbonise and the plant requires huge investment in order to switch to either electricity or hydrogen to make the metal, using green power. As it stands, Port Talbot uses natural gas and coal to smelt steel which is used in the UK’s car making industry and construction, among other industries. Losing the plant would threaten the viability of those businesses.

The plant makes virgin, or primary, steel - ore to metal. This is important.

Under decarbonisation plants, Port Talbot's two blast furnaces would be closed and replaced with electric arc furnaces which use recycled steel, reported the FT. This would end so-called primary steel capability at the plant where steel is made from iron. It added that Tata is seeking half the £3bn costs of converting the mill from the government.

Thre are certain steels you might not want to make from scrap in an electric arc furnace. Or even some that you cannot.

So, we’ve that technical reason that we want the blast furnaces to continue so that the car steel (say) continues to be made locally. That’s the argument in favour of the subsidy.

But when they get the subsidy they’re going to use it to close the blast furnaces and install electric arc (the hydrogen part is to do to direct reduction of iron ore pellet which, well, maybe but that’s unlikely) instead. Which is the very technology which can’t make those steels which can only be made from virgin metal.

That is, the subsidy wipes out the very technology and reason for the subsidy. We gotta have virgin steel so give us £1.5 billion to not make virgin steel? Couldn’t they manage something at least a tad more convincing than that?

To repeat. The argument in favour of the subsidy is that there are certain steels which cannot be made from electric arc furnaces. The subsidy is to install electric arc furnaces, which cannot make the steels which are the justification for the subsidy.

Tosh.

That even before we get to the fact that the UK has plenty of electric arc furnace capacity, they don’t cost £3 billion either. The subsidy wouldn’t even provide something we’ve not already got.

We know we really shouldn’t say such things these days but if we were in charge the next time these characters came around begging we’d be found discussing whether 3 or 4 seconds constitutes a sporting head start while polishing our shotguns. Come along gentlemen, at least make your justification for other peoples’ money believable. We’re not even in the steel business and we can see through this.

Goodbye, ASI!

I didn't quite know what to expect as I walked through the office doors for the first time not as an attendee of an event, but as someone now expected to work for and contribute to the esteemed Adam Smith Institute. For several years previous I had heard talks given and read papers written by those employed there, but I had not imagined that I would one day, albeit all too temporarily, have my own desk there.

The phrase ‘thrown in at the deep end’ does not really make sense at the ASI, because that is the only end there is. I was immediately set to work helping research upcoming papers, trusted to review, copy-edit and help write others, and most dauntingly, research and write my own. I was thrilled to have the opportunity to be supported in putting to paper ideas about which I feel very strongly. 

These included an article on proposed smoking legislation, attacking the fundamentally wrong core ideas behind government paternalism; and a briefing document to inform MPs about the consequences of agricultural subsidies and the opportunities available to us through their removal. 

No two days were the same; my time included being invited to a day of talks given at a prominent sixth form, meetings with other think tanks, and even a literal front row seat to witness Liz Truss announce her leadership campaign.

I was able to constantly learn by word and by example from the kind and talented staff who warmly welcomed and expertly guided me. The ASI has proven that an amusing work environment and a serious influence are by no means mutually exclusive. In all, I am firmly of the opinion that my time here has had a marked influence on my abilities, my outlook and my desire to continue with what the ASI stands for: sound people and sound ideas.

Contra Khan and the myth of the rational smoker

Sources this week revealed that the Government’s upcoming white paper on health disparities (likely based heavily on the recently published Khan review) has been delayed until the new Conservative Party leader is chosen. 

Amid leadership debates and desires for a revitalised direction for the country, we have been presented with the perfect opportunity to put a stop to what has been a defining feature of the past decade in politics: a doggedly persistent walk down the road to paternalism. One of the most indicative features of this marked shift is the now infamous Khan review. While the review contains some positive suggestions and highlights the troubling lack of awareness of smoking alternatives, the rest is replete with poorly substantiated research leading to condescending recommendations.

The review acknowledges declining smoking rates which are currently on track to hit 6.3% by 2030, just 1.3 percentage points higher than the government's Smokefree goal. Yet it fails to discuss whether its interventions are really necessary to encourage such marginal shifts in behaviour. The recommended measures might appear more reasonable if smoking rates had remained unperturbed by the rise of safer alternatives and changes in attitudes, but this is not the case. 

The review also relies on the argument of protecting the public purse; that eradicating smoking will free hospital beds, reduce waiting times and save billions. In fact, in the absence of smoking, the public purse would be hit with an annual bill of almost £20 billion from increased spending on pensions, healthcare, other benefits and foregone tobacco duty. There would be savings of course, but at roughly £5 billion, a rather sizable deficit would remain.

The essential question ignored by this report is whether or not we think adults are capable of deciding to smoke, irrelevant of whether it is harmful. John Stuart Mill eloquently explained that "If a person possesses any tolerable amount of common sense and experience, his own mode of laying out his existence is the best, not because it is the best in itself, but because it is his own mode."

As a society we have agreed that we should allow the practice of some activities which we deem unethical, dangerous or otherwise negative. Few people think open water swimming, adultery or drinking should be illegal. Evidently, personal danger, immorality or the existence of negative externalities are not sufficient criteria for outright prohibition. This therefore begs the question: are there any criteria besides public opinion and political expediency? As John Humphreys observed, those in authority can simply take the helm and bravely "ban things and treat us as children who are not sufficiently mature to assess risk for ourselves".

We do not want, nor should we want to live in a risk-free society, unencumbered by temptations and decisions. Perhaps so long as adults are informed and derive some form of enjoyment from smoking, the optimal number of smokers is not zero. And they are indeed informed. For decades surveys have found that practically everyone knows that smoking is harmful, and that we even overestimate certain risks, such as that of lung cancer. 

But surely addiction precludes rational participation in dangerous activities? Perhaps at some level. But when only 40% of smokers actually plan on quitting in the next year, and 10% in the next three months, the objection is somewhat tenuous. There may well be some degree of addiction where being so addicted removes one's ability to rationally make decisions, but it seems extraordinary to suggest this level is reached while the majority of smokers are happy to continue smoking for at least the foreseeable future. What Dr Khan may think of as the myth of the rational smoker, may not be such a myth at all.

The fundamental flaws in government paternalism aside, here are the headline sections from the report:

Stopping the start

Most recommendations in this section involve making it impossible, inconvenient or expensive to legally buy tobacco. The most extreme suggests raising the age of sale of tobacco by one year, every year. Given that most smokers started before the age of 18, it is clear that in this case as with many historical prohibitions, illegality is not a sufficient criterion for cessation. The age of 18 is also an extremely important one; it is the age at which we can buy alcohol, vote, and get married or join the army without our parents’ permission. To raise the age of smoking would be to assert that adults who are capable of making these other incredibly important decisions are not intellectually capable of deciding to smoke. 

Given that illicit cigarettes are cheap and easily accessible, Dr Khan’s call to significantly increase tobacco duty would only exacerbate the illegal cigarette trade, as demonstrated by a study (which included the UK) that found that a €1 increase in tax per pack increases illicit market share by between 5 and 12%.  

The review’s praise of mandated packaging and advertising bans are unsurprising but disappointing, given the breadth of research showing that plain packaging has no effect on actual usage. In most cases, advertising affects brand preference rather than uptake of new activities. Despite Khan’s expressed concern for underage smokers, the argument for allowing Stop Smoking Services to provide them with vapes to aid them in quitting smoking is not mentioned in the report, while mandating an on-screen warning while tobacco products are visible in films is.

He also recommends banning companies from giving out vapes for free, yet provides evidence that "free vapes significantly increased demand for stop smoking services, particularly in the most deprived quintiles”. This insistence on government-run programmes and unwillingness to allow the private sector to contribute is baffling.

The report also comments that snus is far less harmful than smoked tobacco, and mentions Norway, where it has all but replaced tobacco smoking in young adults. Surprisingly (or perhaps unsurprisingly) Dr Khan comes to the conclusion that he has not been persuaded that it adds additional value, and should not be a priority for the government's legislative time.

Quit for good

Happily the report then takes an optimistic turn, and highlights the safer alternatives to cigarettes. Dr Khan discusses public misinformation about vaping and lack of awareness of other nascent alternatives such as nicotine pouches. Whilst he suggests a mass media campaign to correct these issues, simply replacing the current health warnings and images on cigarettes with ones concerned with alternatives would be a far more cost effective and targeted way of disseminating this information.

System change

The review continues with suggestions of how the NHS needs to do better at helping those who want to quit do so, especially in the area of mothers who smoke, given the alarming statistic that one third of teenage mothers smoke during pregnancy. The financial incentive schemes mentioned in the report deliver good value outcomes in reductions in antenatal and postnatal complications. Disappointingly, they are rarely used.

Dr Khan does however continue to assume that all smokers wish to quit, and advocates implementing targets which, as demonstrated by this review, are likely to lead to ill-advised and unnecessarily restrictive policies. 

While the review suggests organisational improvements that should certainly be adopted in order to help those wanting to quit, and rightly highlights the issue of misinformation concerning smoking alternatives, many recommendations either ignore the case for individual responsibility or ignore research on the impacts of his suggested policies. Right now we have been given the opportunity to show the new Conservative leader that conservative values cannot be squared with this neo-puritanism; that they must lead the slow climb back up the slippery slope; that something must change.