The New Economics Foundation challenges one of the most fundamental tenets of conventional economics today — that the price of something can be equated to its worth. It does so by l;lloking at the worth of various jobs, and compares that worth with what people are paid to do these jobs. As it says:
Pay matters.
How much you earn can determine your lifestyle, where you can afford to live, and your aspirations and status. But to what extent does what we get paid confer ‘worth’? Beyond a narrow notion of productivity, what impact does our work have on the rest of society, and do the financial rewards we receive correspond to this? Do those that get more contribute more to society?
Our report tells the story of six different jobs. We have chosen jobs from across the private and public sectors and deliberately chosen ones that illustrate the problem. Three are low paid — a hospital cleaner, a recycling plant worker and a childcare worker. The others are highly paid — a City banker, an advertising executive and a tax accountant. We examined the contributions they make to society, and found that, in this case, it was the lower paid jobs which involved more valuable work.
The report goes on to challenge ten of the most enduring myths surrounding pay and work. People who earn more don't necessarily work harder than those who earn less. The private sector is not necessarily more efficient than the public sector. And high salaries don't necessarily reflect talent.
The report offers a series of policy recommendations that would reduce the inequality between different incomes and reconnect salaries with the value of work.
And for the record:
Determining the right amount of tax payable is a specialist skill and often requires professional support. However, some highly paid tax accountants’ sole purpose is to help rich individuals and companies to pay less tax. We found that the positive benefits to society of these activities are negligible. However, every pound that is ‘avoided’ in tax is a pound that would otherwise have gone to HM Revenue. In our model we looked at how this lost revenue could have been better spent. For a salary of between £75,000 and £200,000 tax accountants destroy £47 of value for every pound in value they generate.
I think that sums things up rather well. Now how do we price that abuse out of the market?
Disclosure: I work with NEF but had no involvement in this project
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Hi Richard, so what was your profession for most of your adult life?
Tax accountant?
Senior partner of a firm of accountants that practiced tax compliance
Tax compliance is seeking to pay the right amount of tax (but no more) in the right place at the right time where right means that the economic substance of the transactions undertaken coincides with the place and form in which they are reported for taxation purposes.
I need not hang my head in shame
A couple of questions:
First, when they say ‘destroyed £47 of value’, how did they measure ‘value’? I assume they are assuming that the £1 saved in tax was put to less productive uses that it would have been if the tax were paid. How did they measure it?
Second, when they say that the hospital cleaner etc were involved in ‘more valuable work’, from whose perspective was this judged? I would assume not from the perspective of the respective employers whose actions (ie paying bankers more than cleaners) manifestly demonstrate otherwise. Is it from the perspective of a third party who employs neither? If so, I think I would regard the actions of those with skin in the game (ie the employers paying the bills) of being more sincere than those of outsiders who aren’t putting their own money on the line.
If the authors of the report think the cleaners are underpaid for the value of what they do, there is no law against those authors sending them a cheque in the mail!
@Juliet
What a profoundly nasty person you must be
Richard,
Any chance you’ll answer Juliet’s questions instead of responding with abuse?
Archie
I admit I thought I’d provided objective comment
Juliet could answer her first question herself by reading the linked report. I do not need to do that for her
Second she showed contempt based solely on pay
I think that wholly justified my comment
Richard
I wondered if someone would comment on the point that the valuation of people’s work might be dependent on your point of view. If you are yourself a wealthy city banker, your judgement might be, shall we say, rather specific to yourself. Most people would probably find that more value was contributed to their lives by the person who cleaned up around their hospital bed and who took care of their kids when they were at work.
However “most people” don’t have the large wads to throw at bankers, tax accountants and advertisers.
Salaries are in many cases determined not so much by value of work as by the pocket depth of those doing the paying.
Juliet perhaps needs to get out more into society. She might find that other people put more than cash on the line in their dealings with others.
Anyone who actually believes a tax accountant is adding more value that a childcare worker has really lost the plot.
I might also add that the authors of the report have been a bit canny. amongst the high paid they might have picked some really important people where it might be quite easy to say that they really were worth their salt. In fact, they have picked some right parasites, whom only a lunatic would get up and defend, Juliet!
@James from Durham
I always remember the birth of my first son. It was not an easy process: we got through 60 hours of labour and nine midwives before he eventually made it – entirely safely.
At 3am on the day he eventually arrived the only place my wife could be comfortable was on all fours, on the floor. There was some concern about my son’s heart beat. A midwife (I always recall her name was Sarah) who was covering for a colleague on a meal break did, without question lie on the floor with her holding a trace to her stomach to monitor that heart beat.
I was staggered. She endured real physical discomfort in the middle of the night for people she’s never met before and probably would never meet again for not a lot of pay and did not complain. Nothing was too much trouble.
By Juleit’s measure her effort was of little value
It shows how wrong Juliet is: her value was enormous
More than many a banker could probably manage in a lifetime
I feel quite sorry for those who can’t see that
Their world view is so distorted you have to wonder what humanity is left
Richard
But if a cleaner was paid the same as an accountant, then no one would bother getting an education. After all why bother paying money and spending years of your life training for less reward than sweeping the floor.
The first job I ever did was cleaning
By the time I was eighteen I was contracting others to work for me cleaning church halls
It was crap, smelly, hard and utterly monotonous work
It was all the incentive I needed to do something more interesting
Maybe you really do only work for cash Creg
Maybe you think education is purely vocational
Thankfully there are a great many a lot more enlightened than you in the world
And before you call be an inherently nasty person, I have been a street sweeper, and refuse collected and work nights in a laundry company to pay my way through university.
Richard, I asked some genuine questions – your abuse is offensive.
“It shows how wrong Juliet is: her value was enormous”
So how much did you tip her? My sister is a midwife in Australia and she gets lots of gifts from satisfied patients, whether in emergency or routine situations, sometimes monetary, sometimes a gift. In earlier stages of her nursing career she looked after elderly patients and on occasions would be often remembered (in one case very generously) in their wills.
Can you disclose how much you tipped her? I assume it is not against the law for you to have provided her with a financial reward to reflect this value (which I agree, is enormous). If it is more value than a banker achieved in a lifetime, I trust that as a man of principle you remunerated her generously within your means.
Please disclose, otherwise your example is meaningless.
Juliet, Richard does not have to answer re tipping. If you had any conception of this sort of thing you would know that a midwife or any other member of the caring professions, would consider it almost an insult to receive monetary reward in the way you suggest. I can remember when my husband was dying and I wanted to give something to the wonderful Macmillan nurses who cared for him – it was quite clear to me what I had to do.
@Juliet
Juliet
I think your comment is so, so sad
Yes my wife and I did offer our thanks
But to assume that the only way to show thanks, the only way to reward and the only way to establish value is in cash is, quite candidly, so perverted I cannot fathom your logic
I hope she and her eight colleagues appreciated what we did. I never expected them to say so: they didn’t.
One thing I do is to argue that they deserve good pay, proper resources, a god infrastructure to work in, right training,a good pension – all paid for by tax. I suspect that is the best thing I could possibly do for her and her colleagues. Gifts from grateful parents will never keep her in work: a well funded NHS will
So one thing I do is promote tax compliance
Do you?
If not, why not? Don’t you value what she does?
Richard
Its a strange report, which I suppose might engender strange comments.
Price is not worth – its simply a reflection of something’s relative scarcity and the demand for it. So the whole basis of this report is flawed. Not surprising, since it starts from the deranged socialist premise that we live in a homogenous world where everyone is equal. You only have to wander down the road to the corner shop to see what nonsense that is.
Put it another way. Cleaners in a hospital may well save lives – their work might be more valuable, or perhaps as valuable, as the surgeon. But on the other hand, there are a lot less people with the skills to be a surgeon than there are people with the skills to be a cleaner – scarcity of resource you see!
Richard
The report you mention recommends that the prices of goods and services should reflect the real costs and benefits of production and that consumption taxes are one way to achieve that.
I’d be interested in your view on how much VAT would have to increase on imported consumer goods manufactured in geographically distant and low wage economies. An example might be a TV costing £600 at Currys.
Philip
Richard,
“But to assume that the only way to show thanks, the only way to reward and the only way to establish value is in cash is, quite candidly, so perverted I cannot fathom your logic.”
Agreed! Pay isn’t everything, which might be a better title to the heading of the NEF extract above.
I have no problem with distinguishing between monetary and non-monetary value. And I am sure there was infinite non-monetary value in saving your son and the value it brought you, your family and (I suppose) the midwife too, who presumably derived satisfaction from her heroic actions. My sister beams for days when she does anything heroic.
Two things are clear from your actions with the midwife (and I assume from your response you didn’t tip her):
• The value you ascribed to her service was 100% non-monetary, and 0% monetary.
• The market failure (such as it is — I take your word for it) in giving monetary value to her service (and pay matters as the NEF extract suggests — the midwife has bills to pay) didn’t bug you enough to do anything about it when there was no obvious barrier to you doing so (i.e I assume it is not against the law, and I assume you can’t plead poverty on the issue – but I accept I don’t know how long ago this was etc). It cannot really have been that big an outrage to you at the time.
I have no problem so far with these choices. It’s your money, you can give it to the midwife, you can spend it on yourself, you can give away. Whatever. It’s yours!
And whether the midwife would or would not accept a tip is irrelevant — it is the actions of the payer that is one side of the coin that determines how much this midwife gets paid. How much she is willing to accept is the other side of that coin.
The reason I used my sister as an example was to show there are other people (including rich ones!) who are motivated to correct this market failure (for whatever reason). Sincerely and with no compulsion. Maybe that’s just an Australian thing — who knows.
But here is the problem I would like you to kindly explain.
Why should taxpayers (whether a millionaire banker or a bus driver on £12k) correct this market failure when you (as the child’s own father and with no obvious excuses not to do so) soberly and willingly refused to do so himself where it really counts — out of his own pocket.
Richard I certainly do work for money as my child and his mother cannot eat my job satisfaction.
May be later on in life when things are more comfortable I will be able to afford to take a job where job satisfaction is more important. Until then I have a family to feed and clothe.
Also you mention the non-monetry value some feel from their jobs, I suppose bankers are paid extra for not getting this warm comfy feeling of saving someone elses life. Unfortunatelthe can only get the monetary reward for their jobs
By the time I was eighteen I was contracting others to work for me cleaning church halls
It was crap, smelly, hard and utterly monotonous work
It was all the incentive I needed to do something more interesting
so you were an exploitative capitalist @ 18!
when did you see the light – after you sold your tax compliance / accountancy firm ?
@eugene
Eugene
I have employed hundreds, maybe thousands of people in my career
I make no apology for it
I hope I have paid generously
I hope I have provided the best work I could
I saw the light after the age of 18 I admit (I believed the crap economics I was taught then)
Awareness arrive at about 19
Richard
@Creg
Rubbish
Most of the world feed their children on vastly less than you make
You have made a choice
Don’t pretend otherwise
This is self delusional nonsense
Richard
@Juliet
I did not say the market necessarily got her pay wrong
I did not say she was necessarily demanding more pay
I am saying it’s the banker got the wrong pay
I am saying the midwife wanted the right environment in which to work
I am saying the banker seeks to deny her that
I am saying the midwife seeks more from her work from pay
I am saying she appreciates thanks in a number of ways
I am saying she may appreciate life in its wholeness
I am saying you do not seem to to do so
I am saying there is no market for a midwife – when there was many, many children died
I am saying that the value of a midwife is priceless
I am saying that market failure must be corrected by a tax paid for service
I am saying those who deny this undermine the value of life itself
I am suggesting that may be you
I am hoping you might appreciate how wrong you are in believing the market can provide
When I know that most of what is valuable is quite incapable of being priced by a market mechanism
And is therefore undermined and destroyed by those who do not appreciate that fact
Richard
Richard,
How much do you think a midwife should get paid?
@Peter
You entirely miss the point
I think midwives should be well paid as well qualified, risk taking professionals working anti-social hours doing a job of considerable value to society
But I think their whole service should be well funded
And I do not think the market will ever do that, as Juliet seems to be suggesting. So what if I can pay more? Does that mean my child is worth moe than the child of a person who cannot pay?
Clearly not
Does it mean fees should be means tested at point of supply? No
What it does mean that progressive taxation needs to secure the benefit of this service – well funded, in sage environments, with sufficient people, when needed, for all
The salary has to be commensurate with risk and experience and comparable qualification
But the total package of health care in which midwives work also matters
And there is no viable market solution for that in the UK or elsewhere (the States is a disaster)
And that is the point: the market is not able to value these contributions
Richard
Richard
I am confused by your reply.
You suggest there is a link between bankers and resources available to the midwife (whether to pay her or to give her the right environment).
I assume the logic of your assertion is that because they avoid tax (and/or help others do so — an activity of a small minority of bankers), such resources cease to be available to the midwife.
I assume the next step of your logic must be (if I understand your argument correctly), that if bankers stopped said activities (and more tax revenue were raised), that extra revenue would somehow find itself in the direction of midwives.
How so?
I argue the following:
• If resources available to midwives (whether for pay or working environment) were that important to our masters (politicians and bureaucrats), they could and would be made available out of existing revenues. The budget of the NHS is huge — lack of money is not the issue. The issue is that our masters have better things (in their eyes) to spend our tax money on. Midwives just aren’t the priority.
• Even if bankers stopped their tax avoiding activities, and tax revenues went up, I can’t see how that would affect the priorities of our masters. What will change? That, Richard, is the case you need to make. It isn’t an obvious one to me.
Juliet
Sorry – that is just crass
If you worked in the NHS you’d know there are not unlimited budgets
There are constraints everywhere
Of course it is not as efficient as anyone would like – most of that being because of the imposition of a market model where there is no market – but the reality is absolute shortage of resources
So yes, higher taxes would benefit the NHS
And midwives
Only the wilfully blind cannot see that
Richard
Richard,
Are you familiar with the former Dept of Health Commercial Directorate? Money thrown against the wall. 30 year old accountants with limited experience paid £700 a day for months and years on end (and armies of them) as independent contractors. External advisor fees that would blow your mind.
Remember the failed ISTC programme? Do you know about the IT project?
I was at a meeting recently where the local PCT was represented. Their role at the meeting did not require legal representation but they still brought one – a partner from a major law regional firm (£350 an hour??) who travelled half a day from her office some distance away for what was a very simple meeting. I don’t think that lawyer said anything at the meeting – a complete waste!
Spangly new premises just about anywhere you look.
Huge sums down the drain.
Go and ask your GP what they think of the PCT’s efficiency. I know a lot of doctors and I have never met one who spoke well of their PCT in terms of efficiency or usefulness. They have a spectrum of political opinions but not one has ever blamed market mechanisms as you do. They blame empire building managers who are constantly looking for ways to interfere and boss around.
I don’t work in the NHS but work closely with it (in local government procurement where we interact with local PCTs etc regularly) but the waste is just legendary. The examples I give above are typical, not isolated.
To suggest they underpay their frontline staff due to lack of resources is just not true. They don’t pay them more because they choose not to. They just plain and simple aren’t interested. It isn’t on the radar screen. And I can’t see how or why increasing the budgets through increased tax revenue will change it.
@Juliet
Juliet
You make a point I have made often: this is the result of imposing a so called market solution on a structure for which it is wholly unsuited
Get rid of that farce and we would all be better off
We have a point of agreement
Richard
I’ve only ever worked in the private sector. Don’t kid yourself that this type of excess and waste are confined to the public sector.
Richard, you didn’t read what I wrote.
Those in the know (doctors and other health professionals I know) never blame the market solution. Never heard one say it, ever. Regardless of their politics.
The NHS is rubbish at procurement (the running joke amongst the public sector) and even worse at contract management (they get very junior, inexperienced staff to do it). And the organisational structure they have built is just so expensive and complex to run even before a single patient has been seen.
The complete mess up with the junior doctors when there weren’t enough jobs for them (was it last year?) was just a testament to the difficulties of centralised planning.
Blame fairly mediocre management and a desire to plan every last detail but don’t blame the market.
Not that I could do any better. The point is: no single human being (or committee of even 100 of them – assuming they are very clever and well meaning) has enough information or the right incentives to micromanage these things to the level of detail that they seek. If there are such people alive today with such abilities, they don’t work in the NHS, that is for sure.
The point is: health care services just plain and simple don’t lend themselves to micromanagement by planners from afar. These services need to be nearby, local and (in order not to be excessively constrained by the planners) to some degree independent and accountable for their own actions. And we (the patients) don’t want the complacencies that go with any monopoly.
Juliet
Frankly this is naive
You can’t say “The NHS is rubbish at procurement …. And the organisational structure they have built is just so expensive and complex to run even before a single patient has been seen.”
and then say
“Those in the know (doctors and other health professionals I know) never blame the market solution. Never heard one say it, ever. Regardless of their politics.”
without the clear implication being that the problem is that those in the know are not asking the right question – which is why the NHS is so bad at non medical issues
The glaringly obvious answer is people are working in the wrong structure
That structure is the market model
To argue that duplication of that market model would make things better is ludicrous: it would simply mean more people pen pushing and as in the USA 25% having no access to reasonable health care
But that’s a price you market enthusiasts think worth paying for the right to cream more off the state, don’t you? You have no idea how to make money so you prefer doing it off tax payers instead
And those losers at the bottom – hey they’re losers, aren’t they? So what do they matter/
Have I got you right?
When you say ‘market model’ and ‘the wrong structure’ what do you mean?
To me, ‘market’ is just the description of the meeting of a willing customer and a willing seller. It can be a physical place or an abstract concept.
Within the NHS there always must be some element of ‘willing buyer’ and ‘willing seller’ and therefore some kind of market.
For example, patients (as customers) aren’t forced to use it (many willingly go private). And workers (i.e. suppliers of labour) aren’t compelled to supply to it. That seems to me to be a market structure which is unavoidable in a society where we don’t like to compel people to buy or sell (at least I don’t).
How exactly do you propose getting rid of the ‘market model’ from the provision of health?
The point I was making is that the market model is fine if you know how to use it properly. If you procure and contract manage properly, it works. If you do so badly it doesn’t work. But don’t blame the market, blame the competence.
@Juliet
Is this comment naive or disingenuous?
Patients are not customers of the NHS: they do not pay directly
Few willingly go privately
And if you’re a GP in the Uk find another buyer for your labour….
This is no normal market and rightly so – we do not have the excess capacity to waste to create choice in this arena
And yet the PCT / Trust structure creates an ‘internal market’ which requires the waste of excess capacity and inter-organisation trading to be recorded to create and illusion of a market where there should be none
This is dysfunctional: liaison across those competing organisations – where competition is for management and not consumer benefit – is ludicrous
This is the market model to which I refer that must be eliminated
And as for your comment that competence is not available – how would a market model improve it when it is that model that has created the problem?
Richard
@Richard Murphy
you might not like it, but patients are very definitely customers of the NHS. One of the main problems the NHS has is that it does not recognise this. One of the other problems is that because of its relative size it is a monopoly supplier.
So we are back onto the old chestnut that if we privatise the NHS, things will suddenly be better. Most people do not have the financial capability to pay for private healthcare. Anyone with a pre existing problem won’t be accepted by an insurer.
Hey, we may be able to find people really good at procurement, but only at a price, money which will then be diverted from the provision of healthcare.
Have you noticed that the US model, which is privatised and market-driven, is vastly less efficient than the UK model with its faults (which I acknowledge). The costs are higher, the coverage is substantially less than universal and the outcome for society as a whole is not much better.
“Customers” can buy private healthcare. They find, though, as my parents did, that when the problem is sufficiently serious it’s straight in to the NHS hospital.
I am really not interested in hearing more free-market fundamentalism applied to the NHS. This conversation has been repeated more times than I can recall. A mixed economy of free markets and state provison in vital areas. Now let’s move on.
Patients are customers of the NHS in the sense that
• They seek the medical care willingly. It isn’t forced upon them.
• They (and not the payer of the service) consume or enjoy the benefit of the service.
The point is that their role in the transaction is voluntary, not coerced.
You say few willingly go privately. BUPA and their mates are big businesses so there must be a few who sign up for it. Whether they do so willingly or not, well that is an empirical question. Do you know anybody who is coerced? I don’t.
“And if you’re a GP in the Uk find another buyer for your labour….”
There are lots of choices for GPs. Admittedly not as many as for accountants. They can move to another country (loads do). They can get private employment (admittedly small in the scheme of things in the UK) or work within the public sector but outside public medicine (e.g. military, universities, civil service, prisons). Or they can leave the profession – the pharma sector is full of ex-doctors. Or they can retire early (big issue right now as the baby boomers hit that age, and feel they can’t be bothered anymore, arguably earlier than previous generations) or just cut down the hours.
The point is, these people do have choices. If the NHS wants the services of these people to provide medical services to the general public within the clinics, surgeries and hospitals of this country, they must persuade them to provide them willingly. They can’t coerce them.
In any case, I am puzzled that on one hand you complain of the market structure in health, but then argue my point by suggesting the NHS is a monopsonist (which suggests that it is really a command economy) insofar as the employment of doctors is concerned. OK, I agree, they are a near-enough monpsonist, but surely that is not evidence of too little market, not too much market.
On this I agree with you: the illusion of the internal market hasn’t helped and has added a lot of non-jobs. But it isn’t a real market in any sense that I recognise — it is fake. For example, a PCT can’t choose to exit the market like a participant in a real market is free to do. Nor is it free to adjust prices and service offerings like a participant in a genuine market. It is a market in the same way World Wrestling Federation is a sport. Fake.
But you still haven’t addressed my ultimate question: why do you think a command structure works any better, given its litany of failures that I quoted to you earlier, and which are not atypical?
Also, can you please explain your comment ‘we do not have the excess capacity to waste to create choice in this arena’. Not sure I understand your point, but assume you are saying by having choice, each participant needs to create duplication by having its own HR function, its own IT, its own tea room etc, when it would all be just more efficient if there was only one.
Couldn’t you make the same argument about everything else — accountancy, cat food, airlines. Let’s have one provider and cut the waste and duplication of multiple overhead. Sounds good in theory, but it has been tried (e.g. Soviet Union where there was only one supplier of everything, planned from the centre). Not sure it did much to drive up living standards.
“And as for your comment that competence is not available – how would a market model improve it when it is that model that has created the problem?”
I don’t know. Why does the NHS attract such numpties? I am not trying to be funny, but I work with a lot of public sector organsations, mostly local government but also police, fire, home office, development agencies, universities, education, MOD etc. And NHS are outstandingly the worst. And it is a running joke. I am talking about management, not health professionals. Bottom of the pile. I was on a big project there in 2006 and I was just appalled at the calibre. Kids fresh out of college who can barely write properly let alone think — and well paid.
All I can say is that a market model would help by letting an organisation that recruits so poorly go to the wall. Close it down and start again. A non-market model as you suggest just keeps it alive.
“Patients seek medical care willingly. It isn’t forced upon them”.
THE most ludicrous statement I’ve ever read on this blog.
So if I have a heart attack I’ve got a choice about whether to get treated or not, have I? In that I could die instead, I suppose? By that logic, all taxation is voluntary – as I could always decide not to pay and go to prison instead.
Richard – given the new comments policy I’m very impressed by your generosity in letting stuff like this on the blog. But then it is the silly season I suppose… it’s certainly making me laugh 😛
Why, when the topic of healthcare comes up, are we always presented with this false dichotomy of the flawed US/UK models, as if a country can only have one or the other.
The reality is, and everybody knows this really, that there are far more efficient healthcare systems than either the US or the UK. E.g. much of Europe, Aus, NZ etc. If I were starting from scratch, I’d avoid both models like the plague. I certainly don’t won’t to get ill in either.
After a comment like “patients seek medical care willingly”, it really doesn’t matter what you say, the audience has left the building….
@Juliet
Juliet
Others have already pointed out how absurd your comments are
When a person is very ill they cannot make choices: they need service
But let’s ignore that issue. Let’s look at what you assume:
a) The NHS is a command structure. What do you think all private enterprises are? They make Stalin look like a pussy cat. Private enterprise is the last home of the dictator with the 5 year plan. The NHS is better than that
b) Health organisations should be allowed to fail. Who picks up the cost I ask? The health care need will not go away. The risk of moral hazard is enormous
c) Have you noticed how bad the private sector is at running things like railways? Some things are hard. Pretending they are part of a market model when they’re not makes it harder, but does not create success. and people pay for railways! There are customers
d) The argument about excess capacity is that if failure is to be allowed in health we must have resources available at all times to still meet demand – which means most of the time we’d be paying for them to go to waste
Your arguments make no sense and you clearly have no understanding of the issues involved from a social dimension
Please don’t bother tp post again – I gave you a chance and you’ve wasted time with dogma
I suggest that if you are advising the organisations you suggest you are the reason for failure is easy to identify – it is people like you! Your inability to understand the issue you are addressing is the cause of the waste
Richard
Richard
Please at least give me the chance to explain my comment which has been misinterpreted (perhaps my fault).
When I say they attend willingly, I am not saying they are willing to be sick. What I am saying is they can’t be coerced by the state or any particular doctor to be treated. Dr Smith can’t force himself on a patient who wants to be treated by Dr Jones. There has to be some degree of consent by the patient (or his parents) for the treatment, operation, therapy etc to take place. Of course, the patient will be suffering under the duress of his illness to seek medical care, but not the duress of the state or any particular doctor (state or private).
Sorry if I caused confusion, but I wasn’t attempting to say anything controversial.
Of course, there are execptions (eg children where the local authority has ‘parental responsibility’, where there are disputes involving right to die etc, children of Jehovahs Witnesses regarding blood transfusions etc).
Agreed, there choices are less in an emergency, but a lot of illness is not an emergency, and many patients do want a choice depending on the circumstance. Sometimes they want (need?) a specialist for a difficult operation, often coming with a personal recommendation. Sometimes they want the continuity of care from someone they have known a long time. Sometimes they have a simple requirement, where opening hours, location or the availability of home visits are more important. All depends.
The point I was trying to make is there is already a degree of voluntariness within it that has features of a market. In any case, it was not the main point, so I will leave it.
The issue I have raised, Richard which I would like you to answer is this:
The NHS see fit to spend £700 a day on 30 year old accountants at the Commercial Directorate (no longer in operation). They spend millions on PFI schemes. Not the actions of an organisation that is strapped for cash. But they still choose not to pay midwives £700 a day – nothing near it. I suggest the reason is, the people doing the spending prefer big spangly projects – paying the midwife is low priority.
If you doubled the budget, I suggest they are likely to want to spend the money on more big spangly projects, management consultants (that’s what they like doing – why should they stop?). I doubt the midwife’s remuneration will move up in the list of priorities, and in fact, new things will push into the queue and she will fall even further behind in that queue of priorities.
I may be wrong – but the behaviours and priorities of the masters that decide these things would need to change. More dosh for the midwife, less on the PFI lawyers. But what will happen to cause that behaviour to change? Please, please explain how or why this will happen.
Please explain, don’t abuse.
Peter, I fully 100% agree with you regarding other models. I am Australian, and whilst the system isnt perfect there, it seems to work. I understand it is pretty similar to the French system which also seems to work.
Juliet
You don’t really explain at all
You do not address the issues I raise
You just persist with the idea of choice
This is a false mantra: it exists in GP services now to some degree
But with them habit is more likely than choice – you ignore the cost of change
And hospitals are largely dictated by locality – and that is entirely reasonable
So we have natural monopolies – and so state control is needed. Your examples are a tiny minority – they are what you want to see – and I dismiss them based on what I know
In that environment the last thing we need are quais markets in finance (PFI) and internally (PCTs, Trusts etc). So we agree on this
So why do you appear to be a consultant in this market?
And why aren’t you campaigning to have the market eliminated from the NHS and public service put at its core?
Then we’ll get change
Nothing you have said will bring it about
This is possible – it takes a government believes that the private sector gets it wrong most of the time (as it usually does – you may have noticed our current financial crisis) and that the state is perfectly capable of being competent – as it can be
That’s the prerequisite for change
If you don’t agree you’re wasting time
Richard
@Richard Murphy
Richard
Your style is a complete turn off for me. Goodbye.
Philip
I note you are in private equity
You’re not expected to like my style
Your ethos and mine are poles apart
I expect I threaten what you do
Why should I seek to please you?
See http://www.taxresearch.org.uk/Blog/2009/12/14/why-be-awkward/
Richard
Richard
“You don’t really explain at all”
No, I was asking you to explain. Can you do so, please?
Here is what I asked you to explain:
1. When it comes to allocating NHS resources, it is decided by bureaucrats and politicians. Not by you or me. My own experience is they like big spangly projects. PFIs, IT projects, ISTCs – the list goes on. Funding the salaries of midwives, nurses is way down the list. Pay the bare minimum they can get away with (market rate, if you prefer).
2. If we give them more money, unless something drastic happens (which I want you to explain please), they will just spend on more big spangly projects. The midwife or nurse won’t move an inch up the list of priorities and may even move down it (relative to other priorities).
3. This is why I think increasing taxes won’t make a difference as long as you have the people in charge as they are, or unless those people in charge change. What will happen to either remove those people (why will they leave, who will push them?) or to cause them to change? I have seen too many episodes of Yes Minister to believe Sir Humphrey has any intention of leaving or changing. And he ain’t reading this blog, or trembling in fear at the thoughts of Mr R Murphy!
If you really want a well funded NHS, your first step is to remove/change the decision makers and simplify the monstrously complex organisation that just devours resources in administering itself, before a patient is evn treated. You might find there are enough resources from this activity to improve/expand direct health services without raising a penny in tax.
If you keep the same people in post, and don’t fix the structure, then any tax increases will just find nice big black holes to disappear down. They will never run out of black holes!
I really hope you can answer in an air of civility, concentrating on the arguments, not about me, or what I do. Please don’t call me names. I have never done so to you.
For your information, I did work on a big health project a couple of years ago (not PFI but something similar), and was absolutely disgusted. Any suggestion that the health service is starved of funds just needs to see one of those projects in action to see this is not true (or at least, wasn’t then – 2007) – it is about priorities.
“You just persist with the idea of choice”
Yes. Whilst there may be natural monopolies for, say, hospitals in small towns (less so in major cities), there aren’t natural monopolies on doctors (other than in the remotest of places). They come in all shapes and sizes – academic, practical, pleasant, gruff, accessible, busy, dedicated, lazy. Much like any other profession really.
And if I faced a life saving operation that required a detailed and difficult skill where there was a 5% chance of dying under the knife (as my father in law did recently – travelled over 60 miles from his home for his operation by a doctor recommended by his daughter, a GP – and it was a great success), I would recognise that all doctors and not the same, and would try to get all the recommendations I could before I let a surgeon touch me. My sister in law (the GP) says her patients are doing this all the time so her father’s story is hardly unusual.
If that is persisting with the idea of choice, then I am guity as charged. But sorry, I think many if not most rational people would do what my father in law if they were in the same situation. And I bet you would too – even pay out of your own pocket if it meant saving your own life.
@Juliet
At the core of this there is just one really important comment from you. You say:
If you really want a well funded NHS, your first step is to remove/change the decision maker
But you also say
When it comes to allocating NHS resources, it is decided by bureaucrats and politicians.
So you are arguing against political control of the NHS
Sorry, I don’t buy that
This is just a subversive call fro privatisation
And despite your sister in law’s claim my wife’s experience as a GP is very different – patients do not choose and do not know how to
Maybe your sister in law works in leafy England
My wife works in an area of deprivation
But I am concerned that the latter get the best service before those who can buy out – who seem to be your concern
So yes I agree let’s radically simplify
But that means simpler, more direct, and more accountable political control
And that means the end of the quangos we have now
The end of self employed GPs
And the end of the internal market
Then we can create what is needed
Your dogma still gets in the way of that objective and nothing you say suggests you have any alternative to what I suggest
Richard
What I find astonishing is that this debate even exists.
Whenever I have travelled to France (or even Spain) and needed treatment, the facilities have been fantastic, uncrowded, doctors have been easy to see and test results have come back quicker than would have been possible in the UK. A simple example: my father in law has prostate cancer and is getting fantastic treatment at the Royal Marsden by world leaders in their fields. But before he got referred there (which took a couple of years) it took him 3 weeks to get the results of blood tests back that in France (where he lives for 6 months of the year) were turned around on site at the medical centre on the same day.
It might seem simplistic, but can we not just do whatever the French do? I know, France is going bankrupt…only, it never actually does go bankrupt and seems to do most things better than the UK.
@mad foetus
The standard false assumption that health care is about how well you do procedures
Health care is about how well you treat the old lady who is “off her legs”
Juliet needs to answer that question
And suggest a positive model for change
Because all we’ve had so far is whining