Monthly Archives: February 2011

The railways – a classic public service

Railways cannot be simply a private enterprise with no concern but profit.  They are a necessity to maintain general economic activity. Take away the railways and a substantial part of those employed in London could not continue to work there because the roads will not take the extra traffic. The same applies, to a lesser degree, to other large cities and towns.  The railways also fulfill  important social functions in providing transport to those without cars, by reducing car use generally and moving much heavy goods traffic from the roads. Finally, railways have a strategic value in times of war or blockade.

The simple truth is that without massive public subsidy the railways could not be maintained. No national railway system in the First World operates without taxpayers’ subsidy. Parts of systems may be profitable but not the entire system. It is not that our railways would simply shrink if left entirely to private enterprise, most of the system would not run at all. Commuter traffic is running at near capacity in the South East of England and fares are already so high generally that the massive price hike needed to meet the full cost of rail travel would result in a vicious circle of decreased traffic and decreased revenue. 

The cost of maintaining Britain’s railways is simply beyond the private sector. Profit can be made on some intercity routes but that is about it. Even with the massive subsidies given to private companies since privatisation – ironically substantially larger than the pre-privatisation subsidies in real terms – private companies have signally failed to invest adequately. Indeed, the companies have radically reduced staffing levels – which may well have contributed to some crashes – and have constantly failed to meet their timetables.

The farce of the company with responsibility for railway maintenance immediately after privatisation in Britain, Railtrack, is a cautionary tale in itself. It created a completely different culture from that under the nationalised railways. Instead of employing most of the labour directly, they engaged subcontractors

to do most of the work. The army of skilled workers built up by the original private companies and inherited by the nationalized British Rail was dispersed in reckless fashion and, inevitably, control over standards of maintenance became much diluted as it always does with subcontracting.

To put the cherry on the Railtrack story, the financial resources of the company, even with public subsidies, proved hopelessly inadequate. In 2002 the plug was pulled and it went into administration to eventually re-emerge restructured as a not-for-profit company Network Rail. But before the administration was done and dusted, the  taxpayer had to cough up a great deal of money to compensate shareholders because the government was faced with legal action by the shareholders alleging maladministration, an action which looked as though it might not only succeed but in the process wash some very dirty government linen in public over exactly why and how Railtrack went into  administration.

The taking back into public ownership has also extended to the rail operators franchises. In 2006  a major franchise holder, GNER relinquished the east coast London- Edinburgh franchise in 2006 “after admitting that its promise to pay the Department for Transport (DfT) £1.3bn over 10 years was too much.” http://www.guardian.co.uk/business/2009/jul/01/national-express-london-to-edinburgh  . National Express took the franchise over in 2007 with a  bid £1.4bn for a seven-and-a-half year contract”. They gave noticce of relinquishing the franchise in 2009 also on the grouinds that it could not be made to pay.

In 1993, the Conservative MP Robert Adley aptly described the the privatisation as “a poll tax on wheels”.  It has brought nothing but increased costs and confusion to passengers who are now faced with a bewildering array of fares and companies instead of the sanity of a single nationalised railway where the only difference in tickets was between on peak and off peak, first or second class and you could go on any train  within those very broad constraints.

The welfare state is a good deal

The essentials of life are food, water, clothing, shelter, healthcare and a livable income in times when a person cannot work through want of a job, disability, illness or old age. Most people most of the time can afford to pay for shelter, food, water, heating and clothing from their private resources.  Most could not afford the rest of the essentials  and very few indeed could survive long term unemployment without state aid.

It is important to realise what small incomes the majority of Britons have. Take these figures from the Government’s Regional Household Income Comparison 2004:

“Inner London had the highest disposable household income (after tax) per head of population (£16,500) in 2004. The area continued the trend of previous years and in 2004 was 29 per cent above the UK average of

£12,800. This was lower than in earlier years. In 2000 it was 36 per cent higher than the UK average. Tees Valley and Durham in the North East had the lowest household income per head at £10,800. This was 16 per cent below the UK average in 2004.” (http://www.statistics.gov.uk).

The uncomfortable truth is that even the average disposable  British household income is insufficient to comfortably bring up a couple of children,  pay an average mortgage and make  substantial pension contributions.  Worse, much of the population has less than average household incomes, many very substantially less. But even those with household incomes substantially above the average – many of whom support the idea of private provision for those “who can afford it” – would find themselves deeply embarrassed if they did have to meet the cost of everything they now receive from the state.

To take a concrete example, that of a middle class husband and wife with two children with a net annual household income of £40,000. At present they can, if they choose, educate their children free at state schools.  The entire family can be treated under the NHS. Until they are sixteen, the children will not even pay prescription charges. If their children go to university, as they probably will being middle class, much of the cost of the education will still be met out of taxes (tuition fees even at their new levels do not come near to meeting the full cost of a university education). If either parent falls ill or is injured, the taxpayer will provide basic support.  The same applies in the case of unemployment. If  any member of the family isunfortunate enough to be the subject of a criminal assault, the Criminal Injuries Board will compensate them. The family will receive child benefit which is not a means tested benefit.

Just imagine what it would cost to either provide such services by buying them directly or through insurance if one could find an insurer willing to issue cover.  A decent private day school education would be at least £12,000 for two children and could well be a good deal more.  A university education would cost tens of thousands of pounds.

Private health insurance for a family to cover everything covered by the NHS cannot be obtained, but even the best that could be purchased – and it will provide a much inferior cover to that of the NHS – would cost several thousand pounds a year and will not cover existing conditions either at all or for several years – those who doubt this should check out the BUPA website and see what even their most expensive plan does not cover (you will get a very nasty shock). Drugs, including prescription drugs, will have to be purchased at their full cost.  If the family has a member with a chronic condition requiring regular  treatment  or a condition requiring  expensive  one-off treatment, they will soon find their private insurance will not cover the treatment  or will do so for only a restricted period.  Mental health problems and long term nursing care are rarely if ever adequately covered by private insurance.  Where private insurance will not pay,  the family will be left with bills which  at best will severely constrain their lives and at worst bankrupt them. (The most common cause of personal bankruptcy in the United States is medical bills.)

Private insurance for sick pay and unemployment pay is both very expensive and strictly limited in the time it is paid – a year is normally  the longest period covered. The same applies to  mortgage insurance cover. There would be no child benefit or criminal injuries compensation available without public provision.

If the cost of providing for the family is restricted to just  the items discussed above the family would be hamstrung by the bills even if no major disaster such as a serious operation hit them. A mortgage to purchase even a modest house in most areas would be out of the question. University education would become a very big gamble for the children.  If a major disaster did hit the family, they would not be able to cope for an extended period because any private insurance they could  purchase would soon run out.

The family I have described is by normal standards comfortably off. It might be able to struggle along provided it did not hit a catastrophe which robbed the household of its breadwinner(s) or an emergency such as a serious medical condition which swallowed up vast amounts of money, but it would not be a materially comfortable or psychologically secure family.  Most families (and individuals) have considerably less income than this fictional family and a substantial minority live on an income well below the average, while half the British adult population have no meaningful savings or occupational pensions. The large majority of the population would be utterly unable to provide for themselves in times of hardship such as sickness, old age and enforced unemployment.

Those who claim that all the poor in Britain are only relatively poor should reflect on this stark statistic: the latest Inland Revenue figures for marketable wealth distribution ( 2002) show the top 1 per cent own 23% of national wealth and the bottom fifty per cent of the population have a staggeringly small 6% (Office of  National Statistics (ONS) website – published 2004).

In short, the majority of the British population live as they have always lived:  from one pay packet to the next.  They do not have the resources to withstand the withdrawal of state provision and are very vulnerable to  the competition of immigrants and offshoring,  which either destroy their employment or reduce their pay.

What applies to what might be termed social provision applies to all other public charges – such as defence, policing and  the justice system. Most individuals do not have to bear the full cost of these because they pay far less tax, direct and indirect,  than is needed to finance a per capita share of total public expenditure.  A quick calculation will demonstrate this. The projected public expenditure for 2006/7 is £488 billion.  There are approximately 45 million adults in Britain. £488 billion divided equally between them runs out at nearly £11,000 per adult head.

The future is even bleaker because of the absurd cost of housing, the rising cost of a university education and the likely high cost of energy and water supplies. There are even suggestions in current price movements that cheap food may be a thing of the past and the price  of manufactured goods from China and its Asian cohorts is also showing signs of inflation as their populations’ wages and living standards rise and they consume more of what they make.

The effect of everyone “paying their way” just for things such as education and healthcare would have a severely depressive effect on already dangerously low Western breeding rates as people had fewer children because of the increased costs falling on the individual.

The moral value of general provision

If public provision is necessary should it be available to all? Why should it not be granted only to those who through a means test show that they cannot support themselves from their own resources?  The answer is threefold: personal dignity, practicality and the engendering of social cohesion.

Anyone who has had the misfortune to claim means tested benefits  or who has assisted someone to claim will know what a frustrating  and degrading experience it can be.  The rules relating to claiming are Byzantine  in their complexity and a simple error on a form (which can run to 20 pages or more) can result in benefit being withheld or delayed.  But even when the forms are correctly completed and the criteria  for the benefit are met,  the delivery of the benefit is frequently  seriously delayed because the  volume of claims  and their  complexity simply overwhelms the administrative capacity of the public servants dealing with them.

If all public provision was means-tested, including NHS treatment and education,  the administrative cost would be massive and  the efficiency of the delivery of the provision  greatly reduced.  The additional administrative costs would have to be set against any saving gained by denying provision to people.

General provision also underpins social provision. Where all  are eligible, all feel that they have a stake in the Welfare State. That improves social cohesion.  Exclude the better off and the odds are that eventually  political circumstances will arise which allow those with the power to reduce or even destroy utterly public provision.  At best, if social provision is seen as only for the poor, it will gain a stigma  and the quality of the provision will be of little or no account to those who do not benefit from it.

The provision of public services gives everyone rich or poor  the assurance that if the worst comes to the worst they will not be utterly without the means to live.  That is the bottom line of having the privilege of being a British citizen.

Apart from simply making life more pleasant and secure, a socially cohesive society  has considerable cost benefits, because it will experience  less anti-social behaviour. That translates into fewer police, fewer trials, fewer people in prison and, indeed,  fewer laws to moderate social behaviour to administer – regrettably many laws are passed in response to moral panics.

Why should the haves pay for the have-nots?

The most obvious reason for not allowing anyone to opt-out from that part of taxation which is devoted to public provision is that no one can be absolutely certain that they will not meet some calamity in the future which will leave them unable to pay. The experience of medical care in the USA shows how easy it is even for the rich to find their wealth shrinking to a point where they cannot get all the treatment they need – the Superman actor, Christopher Reeve, one of the highest paid Hollywood actors,  found his resources exhausted within a few years of suffering the injury which paralysed him.

But there is a more subtle reason. The wealthier members of society should  always remember that they owe their privileged position to  the restraint of the have-nots and the power structures  of society which are overwhelmingly weighted in favour of the haves. Individual  effort and talent do of course play a significant role

in  the lives of everyone,  but it is also true that most people’s lives are to a large degree determined by the circumstances of their birth. If you are born into a wealthy family, the odds are you will live  the life of the wealthy throughout your life. A person born into poverty will probably remain at the bottom end of the social spectrum.  The same applies in varying degrees to those born between the top and bottom of the social pile.

No one needs academic studies to prove the truth  and potency  of inherited advantage. All people require is the evidence of their own experience. Let any man examine the lives of all those he knows  and he will find that most will occupy a similar social position to their parents.

A simple  way of understanding how much inherited social position determines lives is to consider crime. Proportionately,  the working-class  commit crime much more often than the middle classes (and even within the working class the frequency of offending rises with the degree of poverty).  That cannot be because the working class  are innately less able, intelligent or self-controlled, because we know that many of the middle class are also dim, incompetent and socially inept, yet they rarely end up with a criminal record.

The only plausible explanation for the greater criminality of the working  class can  be  their different  material  and  social circumstances. These  are much more precarious than those of the better  off.  They lack money and the social network which eases access to better jobs, while the opportunities to intellectually develop that are commonly open to the middle class are denied them. Give every person the means to live a middle class life and crime would drop  dramatically  simply because the press of  material necessity would not be there and because the alienation of the poor through being poor would have been removed.

The better-off also need to admit to themselves that there is no moral basis for inherited wealth. The person who inherits  money and possessions has by definition done nothing to earn it. The person who earned the wealth,  if it has been gained through moral means – and often wealth, particularly great wealth,  has not been so gained -has a moral right to it, but no one else.  The same applies to non-material advantages such as social connections.

There are, of course, those who attempt to treat inherited wealth as a moral matter. They claim that a person has the right through the consequence of ownership to pass on what he or she has  to whoever they choose. That, of course, begs the question of how the wealth was obtained. But let us assume it was achieved entirely morally and by the direct efforts of the person – the best possible case for the supporters of inherited wealth.  Even in that instance the effect of the transfer of wealth to others is to  create a situation which is manifestly unfair, namely, the establishment of privilege for someone who has done nothing to earn it. Taken at the level of a society, that rapidly results in a permanent class privilege for the haves and their descendants.  The fact that the development of hierarchies is  an inevitable consequence of human society is neither here nor there when considering whether the consequences of a hierarchy is moral. Clearly  the deliberate disadvantaging of some to the advantage of others is  not a moral act, any more than enslaving a man is (the group now living who have by far the greatest moral claim to reparations are not the descendants of slaves but the descendants of the poor).

The American philosopher John Rawls in his book A theory of justice resurrected the idea of the social contract which was much in favour in the 17th and 18th centuries.  He posed, in so many words, the question “Suppose a group of people were to form a society from scratch, what society would they favour if each person knew nothing about the other people and had no idea where they personally would fit, socially  and economically, into the society?”  He concluded that the only rational choice would be one in which people had equality because no rational man would chose an inferior position for himself  and no agreement would ever be reached  which created an unequal society, whether in terms of social status, rights and duties or material circumstances. Note that Rawls did not rule out a man or woman choosing an unequal state –  some might do so thinking it would be worth the gamble to have a chance of gaining one of the favoured positions in an unequal society – he merely thought that it would not be a rational or normal decision.

Although Rawls’  hypothetical state (“The Original Position”) was not realistic, his thought experiment does demonstrate that what we have now as a result of the organic development of society is not what many, if any, would risk for themselves if they had the choice Rawls’ offered them.

Why not take away all inherited wealth? All of historical experience shows that such a cure is worse than the disease. Where the state controls (at least in theory) the totality of people’s lives, such as in the Soviet Union, the consequence is privilege and abuse not by the possession of money but by the wielding of state power.  There is also something peculiarly degrading about the idea that everything a person does is to be ordered and permitted by the state.  A degree of private wealth is a bulwark against state power. The trick is to ensure that wealth does not become too concentrated in the hands of the few, producing an uncaring and oppressive plutocracy.

As for the wealth which individuals create for themselves,  to tax to produce material equality would plausibly have a deleterious  effect on society generally. If a person is not to benefit from their own legitimate enterprise, why should they bother to make any extra effort or take risks? The obvious answer is they have no incentive to do so. However, that is to take to nakedly a material view of humanity. Even in circumstances where what someone did had no effect on their income, people would vary considerably in their willingness to work regardlessof the material outcome because personalities differ and there are rewards other than material ones such as the approval of others and celebrity.  Nonetheless,  it is reasonable to assume  from  the experience of communist societies that the overall effect would be to substantially reduce the individual will to work and take risk.

Of course, absolute material equality is improbable in any society, but the disincentive effect applies incrementally as the personal tax burden grows.  Once tax reaches a certain level people either work less or become dishonest and evade the tax. That applies not only to the obvious case of the entrepreneur but  to jobs generally, for people will be generally disinclined to take the more demading jobs if  the material rewards they offer are not significantly better than those for unskilled and easy employment.

It is also true that Man being a social animal will always form hierarchies because social animals necessarily organise themselves in that way (if they did not, sociality would never arise because the members of a species would be in constant antagonism to one another and could never reach the point of sociality).  Even if all material advantage was removed there would still be  the advantages and disadvantages of genetic inheritance, the differing qualities of  individual parents and pure accidental circumstances, such as the work available at a particular time and place, to create a socially layered society with patterns of dominance and dependence.

But  that does not mean that societies should simply be allowed to develop  without any state intervention to ameliorate  socially determined disadvantage.  Without social provision  of necessities the poor are left to live hopeless  lives which  struggle from day-to-day,  while untaxed or very lightly taxed wealth of the most successful results in a plutocracy within a few generations.

Plutocracy at best produces wider private charity – which is always inadequate –  and at worst an uncaring attitude towards the masses which sees nothing wrong in allowing them to starve if that  is a consequence of the economic circumstances of the society and times or even simply God’s will.  Plutocracy is in fact one of the most oppressive forms of society and one of the most difficult to end because it cunningly  presents itself as being the society  of individual opportunity (“the Ritz is open to all”) and is not nakedly oppressive in the same way that, say, Nazi Germany or Stalin’s  Russia was oppressive.  Consequently, there is no obvious focus for  discontent, no single hate figure and it has a much greater enduring power than an overt dictatorship.

What a society can safely do to narrow the  differences in life chances  at  birth is to act to ensure that all have access to education, healthcare and the means to live in a decent manner. That is the minimum.  A society can go further with the greatest public resources being directed at those in the poorest circumstances, for example, more money for schools in “sink” areas.  It would even be possible to devise a scheme for those who inherit little or  nothing by way of money or possessions to receive a payment from the state to remove to a degree the disadvantage of inheriting nothing.

What should be provided indirectly by the state?

Just because something is a necessity does not mean that the state must or should provide it directly. In fact, the less direct provision the better, because in a free society government should only touch that which it needs to touch. For example, whereas there are not many possible suppliers of air traffic control systems or railways, there are many possible suppliers of food. Government may safely leave food distribution to the private supplier and provide assistance where it is needed through payments to those in need. It should be noted that it is not the market or private enterprise which provides the general provision in cases such as food but the giving of taxpayers’ money to those who need it which provides the general provision.

Service is really the crucial criterion. Governments should become directly involved in industrial work very rarely – the exceptions are defence suppliers, utilities such as water, gas and electricity because of their status as natural monopolies and their immense importance. No nationalised industry making or extracting anything has ever been an economic success. Governments running manufacturers, farming or the extractive industries such as coal mining are neither necessary nor desirable, because private enterprise will always do the job adequately and more efficiently provided the economic circumstances are right, that is, vital industries are protected through tariffs, quotas or subsidies to the extent necessary to make them profitable.

But such vital industries are the Government’s business because they have both a strategic and a social and economic value. Consequently, governments do have is a responsibility to ensure that they are maintained.

Any country which cannot feed itself, produce all essential manufactured products and services, is not self-sufficient in energy and does not have substantial reserves of essential raw products such as iron ore, is constrained in what it may do both nationally and internationally and the greater the reliance of imports, the greater the constraint. Of course any advanced industrial state will not be completely self-sufficient, but it is possible for a country to have a large degree of self-sufficiency in the essentials especially food. With modern crop yields and modern animal husbandry, Britain could feed itself at a pinch if her market for food was protected to allow reasonable profits to be made by farmers using not merely the best or most convenient land, but the more marginal land as well.

Where a country is severely dependent on imports, as is the case with Britain, they are utterly at the mercy of international blackmail and events. Even the most powerful state in the world, the USA, is much restricted because of its reliance on imported oil. Such constraints have the most serious of consequences. Would George Bush have invaded Iraq if the USA was not reliant on Middle East oil? I doubt it.

The free trade dream of buying where a product can be produced cheapest is based on the absurd premise that never again will international circumstances arise which will place any country at risk of war or blockade. There is also the question of what happens when raw materials run short and the scarce materials either remain in the countries of origin or go to the richest and most powerful countries with the rest left to go hang. Free trade is not merely a fantasy but a dangerous one in the long term.

There is also the economic and social case for protection. Cheap imports from countries which have labour costs many times below those of the mature industrial states, goods made cheap by state subsidies and plain old-fashioned “dumping” means that no company in the West is able to compete with the imports. The effect of allowing such imports is twofold: either the workers in the importing countries must take lower wages or, more probably, watch the obliteration of the domestic industry.

The same thing happens where mass immigration is permitted. If the immigration did not occur the wages for the type of jobs which immigrants take would be higher. That in turn would lessen or end the shortages of native workers willing to do them. For most jobs all that is needed to solve a shortage of labour is a wage sufficiently competitive with other employments to attract enough applicants. A good example in Britain are nurses: a shortage of native applicants a few years ago has been turned into a surplus now by a substantially increase in their pay.

The loss of jobs and suppression of wages through cheap imports, outsourcing, or large scale immigration has considerable social and economic effects. Those who lose their jobs either remain unemployed or take jobs which pay much less, are less secure and have lesser benefits. Those who remain in their jobs but whose pay is suppressed suffer similar difficulties. Both groups find their spending power is reduced. They pay less tax. If they are unemployed the Treasury is a net loser. New immigrants compete for scarce public goods such as free healthcare, education and social housing. Most particularly they compete most directly with the poorer native members of society who have most need of such social supports. Poor pay, insecurity, unemployment and competition from mass immigration all place a severe strain on the social cohesion of a country.

Neither the Left or Right need recoil in horror at the idea of a judicious protectionism and a strong immigration policy. The Labour Party has been strongly protectionist throughout most of its history. The Tory Party was protectionist before therepeal of the Corn Laws in 1846 and protectionist again between 1931 and the advent of Margaret Thatcher. For most of their history both parties have been in practice opposed to mass immigration.

What should be provided directly by the state?

 Certain things should be reserved to the state as a matter of absolute principle. They are defence, foreign policy, policing, justice, the implementation of judicial sentences and decisions and the administration of welfare. They should be reserved absolutely because either they involve the use of force or the threat of force, punishment or the distribution of taxpayers’ money in areas such as unemployment benefit.

For reasons which I shall shortly examine, the state should also directly control any essential service which is a natural monopoly. What counts as a natural monopoly? Railways and utilities such as water and energy are examples They are natural monopolies because it is simply not practical to have competing lines running to the same destinations or competing utility pipes and cables supplying the same area.

It is possible, as has happened in some of the British privatisations, to allow different companies to compete to supply services such as trains, energy and water, but that is at best an insufficient or incomplete competition and at worst a wholly bogus one because the actual lines of supply – the railway track and the pipes or cables – still have to be maintained and owned by some organisation, private or public. That means the infrastructure has to be either owned publicly or, if owned by a private company, the company must be rigorously controlled by the state, as is the case with the British telephone landline infrastructure which is owned by the privatised erstwhile nationalised company British Telecom.

British government interference with natural monopolies since privatisation has gone far beyond controlling the infrastructure. In the case of the railways, a considerable public subsidy has been paid and continues to be paid to the private operators. In every monopoly industry a regulator has been appointed to control both prices and, in theory at least, to force companies to do things such as provide a certain level of investment in new equipment and to be conscientious when it comes to maintenance and operation of the infrastructure. To pretend that these monopoly industries are private companies working in a free market is patently absurd. They are effectively public services contracted out to private contractors.

A few services only work as monopolies, the classic example being the universal letter post, that is, letters delivered to any part of a territory for the same price. This only works if it is a monopoly because if there is competition from private companies or municipal postal services they will take sufficient of the profitable trade in the towns and cities to make it impossible for the universal supplier, in this country the Royal Mail, to subsidise the loss making deliveries to parts of the country outside the main urban centres. No private company would ever provide universal coverage unless they had a monopoly.

Why should the state directly control essential monopolies? Firstly, because there is no opportunity for meaningful competition and consequently the state must step in to prevent abuse of the monopoly position. To do that, as we have seen, it has to interfere very strongly with the running of the monopolies. In practice, it can only efficiently do this if it directly controls the monopoly.

If the state subcontracts an essential monopoly to private business or allows private business to buy a monopoly two general problems arise. The first difficulty is that a private business may at any point fail as a business or simply refuse to continue with a contract if it is not making money for the business. If that happens the state is over a barrel because it does not have the resources to immediately take over the enterprise, nor is it probable that another private company would be able or willing to step in at a moment’s notice – the worst outcome would be the cessation of a vital industry. Nor, if a company failed, is it obvious how a Government would prevent its assets being sold by a liquidator. In principle when Railtrack failed – the company which after privatisation had the responsibility for maintaining the infrastructure of the British rail network – the shareholders owned the assets (the railway infrastructure including much highly profitable land) and the creditors had a legitimate charge on them.

Clearly no government could allow the railway or vital industries such as water, gas and electricity simply to go under, either at the national or regional level. Hence, any government will, when shove comes to push, have to pay through the nose (your taxpaying nose in fact) to maintain the threatened industry, whether that be through enhancing a contract to make it more profitable, granting more profitable contracts to a new private contractor or through the payment of outright subsidies. A government is in a similar bind if a company is doing a bad job: they cannot simply sack them because who is to take their place?

Natural monopolies also raise other problems if they are in private hands. There is insufficient public control over areas such as maintenance and strategic planning. Good British examples can be found in the privatised water and energy industries. In the case of water the privatised companies have failed to invest adequately to stop the considerable loss of water from cracked pipes. Nor has a single reservoir been built in England since privatisation. These investment failures have occurred despite the water companies consistently making healthy profits. The Water Regulator huffs and puffs but achieves little because the water companies know he can do little. Indeed, he has to date not even fully used the powers he has despite issuing many warnings to the water companies. And the Government? Well, they could pass a new law giving them direct powers over the water industry but what then? If a water company simply refuses to do what is needed where does the Government go? Nowhere fast is the answer.

With energy it is the strategic planning which is emasculated. Successive British governments have allowed Britain to sleepwalk into a position where the country went rapidly from being self-sufficient in energy to becoming a net importer. This was entirely predictable as it was known long before it happened that North Sea oil and gas was going to decline substantially from the beginning of the century. Despite this no meaningful strategic planning has taken place since privatisation with governments until very recently childishly claiming that it was not for them to interfere in the actual provision of energy now the industry is privately owned (the Blair Government has just woken up to the strategic danger of being dependent on foreign supplies but even now -2006 – no definite decision has been made on future British energy policy). The upshot of this lack of planning has been rapidly rising energy prices since 2005.

If water and the energy utilities had remained in public ownership, the fact that politicians had ultimate responsibility for them would have ensured that maintenance and strategic planning was not neglected because no politician or government could afford to be blamed for a water crisis or soaring power prices. Government could also subsidise prices, something it cannot do now even if it chose to because of EU competition rules. The same principle applies to most of the privatised industries – take away the political responsibility and the profit motive rules.

Certain things are simply too important to be left to private efforts. Natural monopolies such as the railways, water and gas are literally essential to the survival of an advanced state such as Britain. Because of that stark fact alone they need to be treated as something much more than a commodity which can be simply left to the market. They should to be seen for what they are, strategic assets, and placed firmly under national control.

There is a further general reason why essential monopolies should be in public hands – the need for general provision. Left to private enterprise, even with an unfettered monopoly only the profitable parts of an industry would be supplied. Roads and railways would only be maintained if the traffic warranted it. Gas, electricity, water and telecommunications would only be supplied where sufficient profit could be made. The problem is we do not want roads and railways only over profitable routes, or the utilities such as gas and water supplied only to urban areas. We want them over the entire country. Only public provision can truly satisfy that need. Of course, private companies can have a duty to provide a general provision placed on the them but what if none is willing to take it or they take on the responsibility but then fail to meet it? The government then has to decide to either subsidise the company directly or to loosen the contract conditions to which the company has agreed.

 The final type of enterprise which the state should always take in hand are those which experience tells us are beyond the resources of private business. Private enterprise can never be trusted to handle really massive projects. A classic example of this is the Channel Tunnel. Margaret Thatcher insisted that no British public money would be involved and that private enterprise would bear the entire cost. It soon became clear that this was a nonsense. The Tunnel itself was completed but the companies which built it were not so much bankrupt as on another planet called Debt. And this was despite the very serious amounts of money pumped into the enterprise by the French Government, both directly and indirectly. The situation was rescued, if one can dignify what happened with the word, by the banks and other creditors rescheduling debts so far into the future that they all but vanished and the French Government surreptitiously pushing in more money via the French banks. To this day, the Channel Tunnel is the whitest of white private enterprise elephants, with the latest ” debt restructuring” always just around the corner.

Direct provision also has a further benefit. While assets are publicly owned and employees directly paid by the state, it is politically much more difficult to reduce or abolish that part of public provision. If the provision is supplied by a private company their contract can simply not be renewed or cancelled. If the provision is directly supplied, the government has the ticklish problem of having to take responsibility for the redundancies, something which greatly raises the profile of the removal of the provision.

The best example of the dangers of losing direct provision is the gradual privatisation by stealth of the NHS. To suddenly privatise the entire NHS would be impossible, but salami slice it over ten or fifteen years by continually increasing the private sector involvement and the position is completely different. Then the politician can use excuses such as “So much of it is in private hands now that the rest might as well be,” “We can’t have such a comprehensive service because private companies can’t provide it” and “Costs have risen so much that we have to cut this or that”. The whole system will be such a confused mess of public and private that the public will not know what to think. Also, the privatisation by stealth may have surreptitiously changed the way the public view the NHS so they see it no longer as a national institution but merely as a provider of medical care through disparate means. That in itself would reduce the moral outrage needed for any successful public protest.

How do we decide what should be provided by the state?

 It is easy in principle to decide whether something should be left to private enterprise  or public service. Simply ask five questions:

 (1) Is the service or product generally considered to be a necessity?

 (2) Will profit compromise safety?

 (3) Is the service obviously inappropriate to be left in private hands, for example policing or defence?

 (4) Can the service be provided by private enterprise without subsidy?

 (5) Can free enterprise be reasonably expected to deliver the necessity universally?

 If the answer to any of (1)(2)(3) is YES or the answer to either (4) or (5) NO, then it should in principle be provided either directly or indirectly by the state.

Be anti-social; live to a ripe old age

An unpleasant mentality is  distorting the notion that the NHS is a national health service. Increasingly, politicians, the media and medics are taking the line that treatment can be legitimately withheld from people wicked enough to disobey the official disapproval of smoking, drinking, getting fat and so forth. For example, Norfolk Primary Care Trust has decided that confirmed smokers are to be taken off waiting lists for “all non-urgent operations such as hip replacements ….[because] Smokers have three times the complications as non-smokers”. (Metro 23 10 2006) I think anyone needing a hip replacement would dispute the operation’s definition as non-urgent. It is worth adding that the story mentions the Trust is “£50 million in the red” and an unkind soul might conclude that the withdrawal of treatment to smokers is connected to the debt. Nonetheless, the fact that smokers have been targeted speaks volumes for the ideologically driven mentality within the present day NHS. It is only activities which come within the ambit of official disapproval and moralising that are the subject of such withdrawal of treatment – it is noticeable that no politician or health trust has suggested that treatment for AIDs or HIV should be withheld because it is in most instances the consequence of the individual’s behaviour.

The moralising which bolsters the supposed clinical case for withdrawing treatment from certain groups runs along the lines that people are being selfish and irresponsible by smoking, drinking, getting fat etc. Wild claims are made for deaths supposedly due to such behaviour – any smoker who dies at a ripe old age is as likely as not to be classified as dying from a smoking related disease. All this supposedly self-inflicted illness is portrayed as being a massive burden on society and especially on the NHS.

Most absurdly and dishonestly, smokers are claimed to be a drain on the taxpayer despite the fact that tobacco taxes (excise duty and VAT) greatly exceed any additional costs smokers might place on the NHS. Ditto with alcohol and alcohol related illness.

But do smokers, drinkers and the fat, who on average die younger than those who do not display such traits, actually impose extra costs on the taxpayer? Writing in the Sunday Telegraph (22 1 2006) the historian Niall Ferguson baldly and erroneously claimed those who smoked, drank and got fat are being antisocial because they “tend to expire slowly and expensively”. Most do not and whatever cost to the taxpayer arises from such people it pales into insignificance compared with those who live to a ripe old age. Not only do the latter draw pensions and benefits for far longer than the shorter lived smokers, drinkers and the fat, but the most costly of NHS patients are those who live to extreme old age for they frequently end up in hospitals or nursing homes for months and years. The most antisocial thing a person can do from the taxpayers’ point of view is live to an extreme old age.

Politically incorrect film reviews – Machete

Director: Ethan Maniquis, Robert Rodriguez  104mins  Released 2010

Starring: Danny Trejo, Robert De Niro, Jessica Alba, Steven Seagal, Don Johnson, Lindsay Lohan , Michelle Rodriguez,

This is a shameful film for any American actor to have agree to appear in.  Reviewers have generally given it a panning simply on the grounds of its general cinematic  incompetence, with a few of the  more “sophisticated” hacks  speaking knowingly about  it being a spoof on B movies  which builds upon the Grindhouse double bill  (Planet Terror and Death Proof ) Rodrigues made with Quentin Tarantino a few years ago. The reality is that it is simply an artistic  mess .  But none of this is the reason why it is shameful.  That distinction rests on the fact that the film is an unabashed propaganda vehicle for mass Mexican immigration into the USA which rams home in an excruciating  gross fashion  the message white unhyphenated  Americans BAD, Latino immigrants GOOD.  I would like to say Goebbels would have been proud of it,  but sadly I cannot because he would never have made anything so bluntly crass in its message.

The plot is liberal agitprop at its most over-excitable. Robert De Niro is  Texas  Senator John McLaughlin who is campaigning against illegal Mexican immigration and for the construction of a  barrier across the USA to prevent easy  illegal immigration.  He likes nothing better than to spend time riding out with a group of border-enforcing vigilantes  led by Don Johnson as Von Jackson. Early in the film  McLaughlin shoots dead  a female “wetback” with relish and just to make sure the message of his unequivocal  evil strikes home,  the woman is pregnant.

On the other side of the immigration argument is a one-time Mexican government agent (Danny Trejo as Machete Cortez) has his wife  and daughter  murdered by a drug baron (Steven Seagal  as Rogelio Torrez) whilst on duty.  This sends  him on the run and we next  meet him living in Texas illegally whilst  trying to eke a living as a day-labourer. 

 Machete is approached by  a man who unbeknown to him is the Senator’s spin doctor (Jeff Fahey as Michael Booth) as well as being a corrupt businessman. Booth offers  Machete $150,000 dollars to shoot McClaughlin,  saying he wanted him dead because McClaughlin  is all for sending illegal Mexican immigrants back home  and that would ruin the economy of Texas which it is claimed is dependent on illegal Mexican labour.   Machete is dubious but reluctantly agrees after Booth threatens to set US immigration on him.

 But it is a set-up. Just as Machete is preparing to shoot the Senator  a shot rings out and  Mclaughlin collapses  with a leg wound.  The non-fatal shooting has been arranged by Booth to gain the Senator support  by portraying a Mexican immigrant (Machete) as the would-be assassin.   However, Machete evades capture and  then goes on the run committing ever greater mayhem as he goes, stopping only to donate  his $150,000 to  the leader of  Mexican group devoted to smuggling Mexican immigrants into the USA (played by Michelle Rodriguez ) who variously goes by the names  Luz or Shé and runs her operation from a fast food van.(I am not making this up, honest!)

As Machete  weaves his shambolically violent way  through the film his  brother, a catholic priest played by  Cheech Marin, is killed by Booth  by crucifying him to the cross in his church. This  prompts  Machete to kidnap Booth’s wife and daughter April  (played by Lindsay Lohan in the least demanding “starring” role ever)  and Luz shoots dead  Booth as he attempts to find them.  The final stages of the action if it can be so dignified has Machete, Luz  and co engaging in a fight with the border vigilantes and (natch) routing them. In an heroically laboured piece of dramatic irony ,  Senator McLaughlin escapes, but is shot dead  the remains of the  vigilante group  who mistake him for a Mexican.

A US immigration officer Sartana Rivera (Jessica Alba )  of Mexican origins pops up throughout the action  and moves during the course of the film from being accused of being a  renegade helping the gringos who is  hunting Machete  to a supporter of Luz’s organisation who gives  Machete illegally obtained papers legalising his position in the USA.

That all sounds pretty silly doesn’t it? I dare say if Rodrigues was  challenged over the one-eyed portrayal of illegal immigration as  good and resistance to it as evil  he would try to shrug off it off by saying he was being ironic or merely spoofing B movies.  But that will not wash. There is the clearest of political messages being sent .   That message was immigrants have the right to come to the USA regardless of what Americans think. Indeed, it goes further than that: it says to stop them coming is criminal and only the vicious racist would dream of doing so. To reinforce this point ceaselessly,  every anti-immigrant character from McLaughlin to the humblest vigilante is portrayed  as  either having no redeeming feature or ,as is the case with Sartana Rivera, as someone seeing the light and switching their allegiance to the immigrants’  cause. Those who are pro-immigrant  throughout are presented as being without moral blemish.

The depiction  of Americans taking the immigrants’ side is a prime propaganda theme throughout. Not only does Sartana betray her duty as a US immigration officer, but doctors and nurses at a hospital are shown to be part of Luz’s group,  and one of the security men at Michael  Booth’s house suddenly gets the urge to say about illegal Mexicans that  “We let them into our homes, we entrust our children to them but we say they shouldn’t be here. It’s crazy”.   His fellow security men agree. Well, of course, the “we” here is not the “we” referred to by the security man.  He means the entire population,   but the “we” who make the decisions are the haves not the have-nots.   The latter are in reality fiercely opposed to such immigration and are the ones who have to bear the consequences of the immigration through competition for jobs and houses, higher taxes for welfare and the general misery of either having to live in the invaded areas or move out.

But to tar anti-immigration proponents with the racism brush is not enough for Rodrigues.  Michael Booth is presented as the immoral face of business. He supports  the idea of the anti-immigrant barrier not because he is against immigration but because such a barrier would allow the flow of  illegal immigrants to continue by making it possible for the likes of him to control  by controlling the entry points.   There would still be illegals but they would have to pay more to get into the USA.

The saddest thing about the film is Robert De Niro.  He has for all too long  been turning up in films  primarily to collect his pay packet. Here there is no primarily about it.  In easily the worst performance of his career, the awfulness of his acting is only mitigated by being placed against the  backdrop of a cast producing even more embarrassing fare.

What would have been an interesting film  on the subject of mass Mexican  immigration into the US?  How about one which showed it for what it is, an insidious form of conquest, with those resisting it being seen as patriots defending their territory , the immigrants as invaders and those Americans who supported and facilitated the immigration as traitors?  Somehow I doubt whether that film will get made any time soon.

The road to NHS privatisation

The good news  first.  The NHS was founded in 1948 on the principle that all treatment should be free at the point of use regardless of income. 63 years after its foundation the principle is largely intact. We have prescription charges and fees  for dentistry and the work of opticians, although  even these charges for the poor, old age pensioners and children are either considerably mitigated or waived completely. For the vast majority of illnesses and injuries NHS treatment is available and no one who is entitled to it need fear that they will be bankrupted by the cost of the treatment and care, and for the vast majority of ailments  it is unlikely that  the NHS will say no to treatment because it is too expensive. There are increasing disputes over the funding of expensive treatment, especially cancer drugs, but these affect only a tiny  minority of patients and often a refusal to fund treatment stems from doubts over a drug’s efficacy rather than its cost. The sole major NHS blot is dentistry where it is difficult to find dentists to take NHS patients in many parts of the country.

Now for the bad news:  the  NHS  ethos is under severe attack, not by piecemeal reform but frontal assault.  The Coalition Government proposes to put 80% of the NHS budget into the hands of GPs and allow private health companies, many of them foreign,  to enter the NHS market by bidding for contracts to run groups of GPs.  They also intend to increase  the outsourcing of non-GP NHS work to private companies.  The clear intention is to destroy the NHS as we know it by making it predominantly a profit- driven service rather than one propelled by patient need.  It is the penultimate  act of a drama which has been playing out for 20 years.  If these changes are pushed through the final act is likely to be  outright  privatisation.  

The drama began in 1990 when the introduction of the “internal market”  through the  NHS and Community Care Act  was the first major thrust at the unified integrity of the NHS with health authorities (HAs) given their own budgets to buy care for local populations hospitals and GP fundholders to obtain faster hospital treatment for their patients than non-fundholders .  This not only caused a large increase in NHS administrators, but also  struck at the universality of the NHS by allowing HAs to make different judgements about treatments and patients to be at the mercy of whether or not their GP was a fundholder or not.  

Labour supposedly scrapped the internal market when it came to power in 1997, but this was more PR than reality because foundation trusts were established which led to  hospitals once again competing for business.  Blair also  left in place the purchaser-provider split between primary care organisations and hospitals by scrapping GP Fundholding but replacing it with Primary Care Trusts (PCTs) through which 80% of NHS funding is now channelled.   (think of PCTs as local area health managers funding GPs, dentists etc.)

The next breach in the integrity of the NHS was devolution (1999) which allowed Scotland, Wales and (eventually) Northern Ireland to manage their own health budgets.  This   caused substantial differences in funding between the four Home Countries, for example, prescription charges have been abolished in  Wales and Northern Ireland  but not in England and  Scotland, and  the  variations in treatment, especially in the provision of expensive drugs, which were already in evidence before devolution were magnified.  

 The creation of The National Institute for Health and Clinical Excellence (NICE)  in 1999 also  complicated the issue  of drug treatments after devolution. Amongst other duties,  NICE  investigates the efficacy of drugs and makes recommendations which NHS health providers do not have to abide by,  but which are generally followed.  After devolution Scotland had a separate version of NICE , which often makes different judgements about drugs from  the original NICE,   a body which covers only England and Wales.  All this fragmentation of the NHS  has resulted in some treatments being offered in Scotland and Wales but not in England, for example drugs such as Aricept, Reminyl and Exelon which are used to treat Alzheimer’s are being denied to early stage Alzheimer’s sufferers while it is available to such people in Scotland and Wales (Daily Telegraph 18 10 2006).

NHS  change under the Blair Government was  “continuous revolution” lines.  In 2002  Strategic Health Authorities (SHAs) – which complicated the administration even more –  were introduced followed by  in  2006 by Patient Choice, which allowed patients a choice of several hospitals if they needed to go into hospital. This meant more administrative work,  increased the competition between hospitals for patients  and,  because it was introduced only in England,  a further diminution  of  the universality of the service.

To these strikes against the public service ethos of the NHS can be added the creeping privatisation of the NHS which ranges from the logistical and administrative to the medical. Hospitals have and are being built under PFI and their maintenance placed in private hands. Hospital meals and cleaning  are provided by private contractors. (I was in a large London hospital in 2009 and it was chaos. There was a PFI contract for meals, a PFI contract for ward cleaning, a PFI contract for the multi-media installations (TV, internet etc). It was chaos because the ward sister had no authority over any of the contractors.)  Medical supplies to hospitals are distributed by the German firm DHL. Most disturbingly, private medical firms, often American,have been  granted massive contracts to take patients away from the NHS, a policy made all the more dangerous for the long-term security of the NHS because the treatments the private firms undertake are the simpler ones. The NHS are left with a reduced patient base for the simpler operations, which can result in the closure of NHS departments or even hospitals, and leaves the NHS with the more difficult and expensive cases to treat.

The present Coalition proposals are  to abolish the PCTs and transfer the 80% of the NHS budget they administer to GPs.  Apart from the question of practicality – doctors are trained to be doctors not businessmen and accountants  – this will open the opportunity  for private companies (especially American healthcare  ones) who are profit-driven  to take control of large sections of  primary care provision.  Even where that does not happen, GPs will be forced to work to a budget which means they will have to start  routinely thinking not of the clinical needs of patients but the cost of treatment. Not only that, but patients will know that it is the GP saying yes or no to treatment not some anonymous person at a local area health office as is currently the case.   This  will utterly alter the relationship  between patients and doctor.

What do we need to do to save the NHS? Apart from making private medicine pay its way, the NHS ideally needs to (1) not only stop further privatisation but to take back into its direct control that which has already been lost; (2) ensure that enough medical staff of all sorts are trained in this country and NHS posts reserved for them; (3) end the practice of money following patients; (4) fund NHS healthcare on the basis of an area’s population and demographic distribution; (5) retain and where necessary build new local hospitals; (6) restrict treatment to the hospital within a health authority area; (7) lay down a national schedule of treatments which must be offered throughout the NHS and (8) restrict NHS treatment other than emergency treatment to British citizens.

No 8 is necessary because a great part of the problem for the NHS in areas such as London is that it is being overwhelmed by the large number of foreigners who one way or the other either have a right to NHS treatment or who obtain it because NHS staff are unwilling to check whether someone is entitled to NHS treatment. Of course, there are supposedly reciprocal arrangements for Britons to obtain health treatment abroad but the balance of advantage is all against Britain because the range and quality of provision in many of the countries which provide supposedly reciprocal treatment is inferior to that of the NHS. There are also potentially vastly more foreigners eligible for NHS treatment than Britons eligible for treatment abroad, for example, 400 million non-British EU state citizens.

The NHS consultants would doubtless froth and whine about reduced private work opportunities and it might be necessary to give their NHS pay a very large boost. But there are not that many of them and the cost would not be vast in the context of total NHS spending.

That is the ideal. How much of it could be achieved as things stand is debatable because our EU membership and other treaties severely restrict control over both our borders and what any British government may do. For example, while we remain in the EU we cannot stop any person legally  resident in the EU from coming here (apart from special cases of crime or terrorism) and either working for the NHS or claiming NHS treatment. PFI contracts also presents a severe obstacle because of the cost of buying up the PFI contracts, many of which extend to 30 years or more. Nonetheless it can be done, viz:.

“The NHS body was due to pay £2m a year for the next two decades to the private firm that built West Park Hospital in Darlington, County Durham. But after reviewing the costs, Tees, Esk and Wear Valleys Mental Health Foundation Trust decided to take advantage of a break clause in the deal. It paid £18m upfront to get out of the PFI contract 23 years early, but it now owns the hospital outright and expects to save £14m over the course of the deal once maintenance and inflation is taken into account.”  http://www.telegraph.co.uk/health/healthnews/8296685/Hospital-saves-14m-by-getting-out-of-PFI-deal.html

Let the NHS become anything other than what it is, a national health service free at the point of use and you will never get it back. It was created in the extraordinary circumstances of the immediate post-war national solidarity when both the electors and the politicians were determined that Lloyd George’s boast of creating “A land fit for heroes” should not be mocked twice.

The NHS goes to the heart of what should be public and what should be private. The prime distinction is between service and profit. Public provision is the provision of necessary services to everyone, which private provision never has nor can supply: private provision is simply the provision of services to those who can pay. This has  been lost sight of by governments over the past 20 years.

So you think private healthcare would beat the NHS…

Anyone who has ever had private medical insurance will know how incomplete the cover is. Common exemption clauses are a two year waiting period for existing complaints to be covered, a complete exclusion of psychiatric treatment and severe restrictions on aftercare, which is frequently excluded when active medical treatment ends.

Those who have had chronic and serious illness soon discover that the amount of private active treatment and aftercare they can obtain is considerably less than they imagined. Many enter  courses of treatment which end before the utility of a treatment is exhausted. They then transfer to NHS care. Frequently operations are funded by their insurance but not the subsequent nursing which is undertaken by the NHS.

Those in Britain who laud the idea of private insurance as a substitute for taxpayer funded health service should examine the effects of such a system in the richest country in the world, the USA. Around 40% of the population have no health insurance. Even those with insurance find themselves left high and dry more often than not. Here are the words of a British journalist and novelist living in New York, Zoe Heller, from the Daily Telegraph London 6/5/2000:

One of my best friends was short of cash one month and let her insurance lapse. That same month, she was diagnosed with breast cancer. Seven years later, she is still paying off the credit card debts. Another uninsured friend was rushed to hospital for emergency intestinal surgery. She will be paying her bill on an instalment plan. She counts herself lucky that the hospital has a relatively liberal policy about treating uninsured patients…

A recent study established that one in four of every American declaring bankruptcy in 1999 cited illness or injury as the main reason for his financial problems and that of that group, roughly half were insured. In other words, paying extortionate sums to the insurance companies doesn’t protect you from financial ruin if you happen to fall ill with something serious and expensive enough.

Even the rich in the US find healthcare beyond their means if the treatment is long and serious. The Superman actor, Christopher Reeve, one of the highest paid Hollywood actors, had exhausted his savings within two years of the terrible injury which left him paralysed. Private medicine will guarantee virtually any treatment – if you can afford to pay for it. That is the long and short of it. The NHS provides a remarkably wide range of healthcare free at the point of use. It mitigates strongly against “unfairness”.

As far as private medicine in Britain is concerned,  it currently enjoys a great deal of unacknowledged  public subsidy. Private medicine in Britain is notoriously prone to pushing any bungled private treatments back on the NHS without compensation. It also makes little investment in private sector facilities because it can rent NHS facilities for more complicated treatments, facilities which are purchased at well below any realistic cost. Private medicine also makes no contribution towards the cost of training medical staff. In short, private medicine in the UK lives off the back of the NHS and the taxpayer.

The media which is only too willing to feed the public with NHS “horror stories”. A good example is one from the Sunday Telegraph. On 27 August 2006 their front page ran ‘Blunders by NHS kill thousands of patients a year”. Does anyone seriously imagine that any healthcare system in the advanced world does not suffer such casualties or that private medicine is generally more efficient or safer? Of course the NHS makes many mistakes and these add up to a sizeable bald global figure but when you are catering for a population of 60 million that is scarcely surprising.  As a public body the NHS also records its mistakes so that its overall perfomance can be measured. That does not happen with the private sector.   A public audit of the safety and efficiency of private medicine  would make interesting reading.  I would be willing to bet that it would show two things:  (1)  that clinical outcomes for similar treatment in the NHS and private medicine are poor l more often in private medicine than the NHS and  (2) that the range of treatment offered by private medicine would be both much narrower and less demanding than that undertaken by the NHS. It would also be interesting to know how many patients had to be treated by the NHS after private medicine had bodged treatments, procedures  or aftercare, the ailments  of the patients whose treatments had failed and the cost to the NHS of picking up the pieces.

The harmful effects of private medicine on the NHS go beyond inadequate payyment for NHS facilities, medical training, the rectification of bodged treatments and the cherry-picking of treatments and patients.  Even  if private medicine  paid for NHS resources in full, it does not follow that would be a good thing for the NHS because the money received might  not adequately compensate for the loss of the NHS facility during the time it is in private use. This is particularly the case where complex treatments, especially surgery, are concerned because the number of NHS facilities able to offer the treatment will be very limited. It is worth mentioning that a sizeable proportion of private medical treatments in the UK, especially the more demanding cases such as those of serious heart disease, involve the treatment of foreigners. It is morally indefensible to allow NHS resources to be hired to be used on a foreigner rather than used to treat a British citizen on the NHS. Where there is genuine spare capacity in the NHS, private medical providers should be charged a realistic price for it. In cases where private medical treatment goes wrong, the private medical provider should pay for the remedial NHS treatment.

It is vital that the NHS survives because even with present life expectancies, there are going to be an awful lot of people who will need intensive medical support in their extreme old age. The cost of that will almost certainly exhaust the resources of even those who have made seemingly substantial private provision for their old age.

The NHS has many faults, but for most of the population, it is a better and more complete supplier of medicine than private medicine will ever be or could be.

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