Thoughts on healthcare
By D. J. Webb
I am sorry to have disappointed Dr Gabb by not posting for some time. Here is my explanation and some thoughts.
I went to the Ukraine in early December to stay for three months with a friend in a city called Dnepropretrovsk (renamed Dnepr). Apart from the weather, it was a very pleasant holiday. I particularly enjoyed learning how to make the dish, compulsory for New Year’s Eve, herring “under a fur coat” (herring under layers of potato, egg, carrots, beetroot, all mixed up with mayonnaise). It sounds terrible, but is very delicious. And I got to practise my Russian. I’m not impressed that a first-class degree in Russian, such as I was awarded by Leeds University in 1995, is given in this country to people with far from fluent Russian. Parliament ought to look into it. But my Russian is better than ever before.
But there were some unpleasant things. The number of burglaries in my building over 3 months was amazing. Getting into the lift and seeing signs of a struggle — blood and possessions strewn on the floor — and knowing someone was robbed there is quite disturbing. I got in the lift once with two people I didn’t recognise, and they wanted to know what floor I wanted, which was an alarm bell. I told them the 16th, although I lived on the 15th, and they didn’t get out at any floor: did they in fact live in the building? I got out at the 16th floor and quickly disappeared down the stairs and got home safely one floor down. The next day, my Ukrainian friend was held up in the lift and told I would be harmed, as they knew I was a foreigner, unless we gave money. They had knives and he gave them £30 and they stayed away for the rest of my trip. The police later said these people are believed to be desperate people who came over from Donetsk where the war is going on. Another surprising thing was the frequent power cuts. We frequently got home to find the lift not working, and there was only one option: to climb 15 flights of stairs to get into a flat with no Internet or lights working.
However, I took all these things in my stride. I went to the gym there (about £10 a month). We went to a karaoke bar once a week, where I enjoyed smoking Arabian-style waterpipes (hookah pipes). But my happy trip came to an end on February 5th when I fell on the ice near the building. The ice gets more slippery after a few days of milder weather and a subsequent refreezing of the ice. No paths ever had any salt applied. It was very slippery everywhere, but I coped for many weeks until I fell, and broke my arm. I couldn’t get up off the floor, and lay there for some minutes until an old man helped me up.
I went to a nearby shop where I knew they were friends with my Ukrainian friend and he came out straight away and took me to hospital by taxi. The state hospitals are not free, but the price for being bandaged up in a splint was around £20, including bribes that had to be given to get the X-rays immediately without waiting for 24 hours. The next day, we went to a better hospital, and they told me I definitely needed an operation, and the price would be at least £1,000.
Dima decided to take me to Kiev, as I was 500 km from the capital and relatively remote if I had to go home. I had a very painful overnight train trip lying down for 8 hours until we got to Kiev, while Dima struggled with all our suitcases. We went to a well-regarded hospital there where the doctors were friends of Dima’s friends, to see if they would operate. But my insurance company (I paid £31 insurance to cover me for three months abroad; quite cheap really) refused to allow me to have an operation in Kiev. In the hospital in Kiev, the local doctors, being friends of Dima’s and not seeking to rip me off, told me I would be far better off going home to England. The insurance company gave me two seats (to accommodate my arm) on the plane and a taxi home from Gatwick. I came home on February 8th, having planned to stay until February 23rd.
I went the same day to Lincoln hospital. They laughed at the dressings the Ukrainians put on me — they “mummified me” — but refused to operate, telling me a mid-shaft humerus fracture can heal on its own. After several visits to hospital, I’m not in a fracture brace, and 6 weeks after my accident, there is only minor sign of bone callus forming, and I’m looking forward to many more weeks of this.
My Ukrainian friends are convinced the NHS is trying to save money by refusing me an operation. Had my arm being pinned on day one, I could have moved the arm straightaway and begun physio. This “natural” way of healing is slower, and carries the risk of allowing the elbow and shoulder to become so stiff over such a long time without moving them that I may not get full range of motion back. In the Ukraine they believe it’s better to take the risk of disturbing nerves and operate without delay in order not to allow the joints to seize up. I’m wondering if the doctors — all the doctors in Lincoln hospital are from India — even really give a damn about an Englishman with a broken arm. But I have no choice other than to try it their way.
I can type, but more slowly, without moving my elbow, by positioning a USB keyboard appropriately. I have also had to do a large volume of work, as this is a busy month for me, and as a self-employed person I can’t take the risk clients will find others to work for them, with me gravitating towards the jobseeker’s allowance. So my life has been difficult. I can’t wash up, or have a bath, and find it difficult to cook. But hopefully before another six weeks has past I’ll be out of a sling. I didn’t previously know a broken arm took months not weeks to heal.
At this point, it might be appropriate to think of libertarian approaches to healthcare funding. People live in fear of illness in the Ukraine, as the doctors all want bribes, and will send you for test after test after test to make the maximum amount of money from you. At least in the UK, we have a healthcare system that is supposedly designed to give people the healthcare they need, not to simply extract money from them. But you are then left in the position, not of a customer, but of a recipient of government services. The doctors — actually, the state — will decide what you need, and you have no say in the decision. A big sign in Lincoln hospital announces “we do not offer second opinions”: the doctors’ decisions are final.
But I note that Dr Gabb has previously stated the view the cause of liberty needs to have a support base to advance it, and policies to simply delete free healthcare would harm the interests of less well-heeled people who might oppose political correctness and immigration. There are too many “cloud cuckoo land” libertarians who seek merely to destroy the livelihoods of the working class. Donald Trump is walking into the trap of seeking to implement policies that will raise the cost of healthcare, directly attacking his own base, and the only base of liberty in America, working-class Americans.
I would also regard abolition of the NHS with undisguised alarm. Libertarians need to be a little cleverer than to simply advance the economic interests of the already well-heeled, who are people who have overseen a huge reduction in the cultural space afforded to free speech and free association. Personally, I think market signals can play a role in GP surgeries: a fee to visit the doctor could cut down on visits from people who could just go to Boots for their cold medicines. We have free visits to the doctor, but not free prescriptions (or not for me, anyway). It would be much better for visits to the doctor to be charged for (by everyone), but drugs given free to those who need them; drugs that are the same as over-the-counter medicine should not be prescribed. People should simply be told to go and buy what they need from the chemist’s. Those who need non-OTC medicine should get it for free. This would be better as a large proportion of people do get their prescriptions for free anyway, and it would be better to shift the subsidy away from free consultations with the doctor to free prescriptions, so that everyone could easily book a consultation with their GPs on time.
I also do not see that A&E departments should check on immigration status. As a decent society, A&E treatment should be free for all in the country. We shouldn’t bring in (anyone) from the developing world in my view, and so we wouldn’t turn A&E departments into an international health service. And in all cases, operations, in-patient treatment, as opposed to emergency treatment, should only be made available for free to British citizens. The cost of healthcare should be constrained by “tort reform”. In almost no cases should a failed operation lead to monetary compensation.
Think about it. If your baby dies in hospital, you’re set up for life. You’ve won the lottery. You can pay your mortgage off. The fraudsters who seek these payments claim “it’s not the money, but the principle, that counts”, but if offered a small sum, they then cry, “are you saying my baby’s cadaver is worth only that?” Cadaver trading, which is what it is, should be outlawed. Someone dying in hospital– this is fully within the normal range of outcomes expected from hospital treatment. Real negligence should lead to manslaughter charges against the doctors. Without genuine negligence, a failed operation is just one of those things in life, without a lottery win attached. This way, the NHS would not have to insure itself against claims. The claims management industry would be thrown on the dole. And healthcare spending would be focused on real healthcare and not legal claims.
I would like to focus state spending on healthcare and pensions and delete over time the whole of the rest of the welfare state. I oppose public-sector occupational pensions. I would cancel the unfunded portions straightaway, including the unfunded portions of ones currently being paid out, for lack of interest in meeting this long-term pension burden. Look at it like this; if you work self-employed in the gig economy, you will get the state retirement pension, currently a maximum of £6,200 a year. And you will pay tax to finance NHS pensions, which are not fully covered by contributions those workers make. The online NHS pension calculator shows that someone who earns £30,000 a year and who has worked for 30 years for the NHS and plans to retire at 60 can expect a lump sum of £33,750 and an annual pension of £11,250, in addition to the £6,200 state retirement pension.
In my view it would be better to stop all net funding of public-sector pensions other than what is strictly financed by contributions made by those workers themselves, and pool the money saved to give everyone a better state retirement pension. The state should not maintain two separate lists of people — those to whom it has committed to pay £6,200 a year in their golden years and those to whom it has committed to pay £18,000 a year plus a large lump sum. The only pensions paid by the state should be the state retirement pensions. In 2015/16 £89.4bn was spent on the state retirement pension. In 2016/17 public-sector pension payments will be £40.1bn, but £28.7bn of contributions will be received, leaving a net £11.5bn cost to the Treasury that can be better deployed as a 13% increase in the state retirement pension for everyone. NHS workers would still receive their occupational pensions, but only that proportion of them that they have contributed to themselves.
I’m therefore not arguing the state should spend nothing. And libertarians who argue that are simply anti-working class and seek to attack those who culturally would support a rollback of political correctness. However, I do support eliminating personal taxation (income tax, national insurance, council tax, the TV licence, inheritance tax, capital gains tax, tax on share dividends, stamp duty). This is because ordinary people who are not companies should not have to disclose their earnings to the state. All state money should be garnered from a land value tax (which would not require income disclosure), taxes on business and import taxes. The approach I have outlined could see the state rolled back by around half to less than 20% of GDP in a Hong Kong-style small state.
Those who wish the state to raise no revenue ignore the socially created nature of windfall gains on property. Those who have privatised a socially created gain then pretend that the working class are the main beneficiaries of the current economy. I recognise that some gains are not privately created, and land and resources in particular belong to society as a whole and produce a revenue that should be used for public ends. This is also the stance that John Stuart Mill took on the land question. Libertarianism should not be a race to the bottom in a skewed economy where “free marketers” support a further skewing of it. A state that spent 20% of GDP, mainly on healthcare and pensions, and did not trawl through its citizens’ incomes would be much freer than England today — and a proposition that working class people could accept. As a libertarian, therefore, I declare that I deserve my free healthcare, and will continue trying to gain access to it. I would encourage Donald Trump not to listen to the “freedom caucus” that want to delete a requirement that insurance companies insure everyone regardless of pre-existing health conditions. What should those who have ill health do? Just keel over in the streets in the name of liberty? We need a libertarianism that can harness working class support, instead of endless think-tankery.