How to abolish the NHS

The National Health Service enjoys strong support among the public, making it almost impossible to introduce radical reforms, even if the performance of the NHS is relatively poor compared with systems in other developed countries. Over the last thirty years reform efforts have therefore focused on greater private sector involvement within the NHS system and the deployment of some internal market-style mechanisms in an attempt to improve efficiency. In a recent initiative, for example, a private company has been contracted to manage a ‘failing’ NHS hospital.

The problem with such ‘part-privatisations’ is that they typically involve complex contractual arrangements and the creation of numerous ‘interfaces’ between government bureaucrats and the private sector, which may result in increased transaction costs and a reduction in overall efficiency. At the same time, private firms working within the NHS framework remain constrained by a strict regulatory framework on top of rigid contractual commitments. There is therefore little scope for the entrepreneurial discovery and innovation that brings such enormous gains within genuinely free market arrangements.

Moreover, since politicians and officials retain control over funding, the system remains unresponsive to consumer preferences and subject to capture by special interests, particularly producer interests such as the medical and nursing professions and the pharmaceutical industry. Mixed public-private systems therefore risk introducing additional transaction costs while suffocating the potential gains from private sector entrepreneurship. If this results in disappointing outcomes, as is likely, the whole concept of privatisation may be brought into disrepute.

There is therefore a strong case for taking a different approach. Rather than focusing on the gradual introduction of  ‘market reforms’ and public-private partnerships within the NHS system, an alternative strategy would seek to bypass the NHS by liberating the private healthcare sector such that the NHS became less and less relevant as more and more people opted out of state provision to avoid long waiting lists and substandard care. This option has the potential to create a virtuous circle – by reducing burdens on the NHS, taxes could be cut, wealth created, and more people would be able to afford private healthcare, reducing the NHS burden still further and gradually undermining its political base.

But radical regulatory reform is necessary if a dynamic private health sector offering low-cost, high quality and innovative treatment is to emerge. A selection of regulatory changes is suggested below:

  • Perhaps most importantly, the compulsory licensing of medical professionals should be abolished. Anyone should be at liberty to practice as a doctor or nurse, with patients relying on brand names or competing voluntary associations to ensure quality. Ending current restrictive practices is essential to enable private firms to increase productivity in the sector.
  • Restrictions on the types of treatment available ‘over the counter’ should be lifted to enable patients to obtain medication without recourse to registered doctors and regulated pharmacies.
  • Burdensome drug licensing regulations should be rescinded. Instead, the testing of new drugs should be left to private firms and free markets. Reputable companies would have strong economic incentives to ensure the safety of their products, while there would also be far more freedom for experimentation and innovation by new market entrants, with huge potential benefits for patients.
  • Prohibited recreational drugs, such as cannabis and opiates, should be legalised to allow the sick to benefit from their numerous medical applications.
  • Some form of tax rebate could be introduced for patients choosing to opt out of NHS treatment (see, for example, this study from the Adam Smith Institute).
  • Private firms should be free to bring in low-cost medical professionals from abroad and at liberty to determine rates of pay and working conditions through private contract.
  • Legal reforms could enable patients to waive their right to clinical negligence claims.
  • Planning controls and building regulations should be liberalised to enable the rapid development of new private healthcare facilities.

Finally, it should be noted that internet technology has mitigated many of the information asymmetry problems that have previously been cited as a rationale for heavy state regulation of health. A combination of new technology and a dynamic, entrepreneurial private health sector could make the NHS increasingly irrelevant.

i have been reading the posts here, and find it incredible, i know our nhs has faults, but i would state clearly that relying on one OECD report to support the fact that you think the NHS should be privatised, liberalised or whatever term you want to use is a bit niaive. There are lies, damned lies and statistics, to use a famous quote. there is no real comparator internationally as all the systems are slightly different as are the demographics and spend per patient and patient outcome. so it really depends on what is being compared. This is a lady who has used both NHS and the american system have a read even our own government states " Following criticism of and controversy over such an attempt in 2000, the World Health Organization (WHO) has decided not to publish health system rankings, and is not anticipated to do so in the future. It has simply not proved possible to create a satisfactory way to compare entire complex healthcare systems. in its annual report and as for deregulating Doctors and nurses, there would be a lot more shipmans and allitts if this was allowed :( and at present it is a criminal offense to pretend to be a health care professional, so you are in fact encouraging people to break the law :( There are some professions where people are indeed able to practice without registration, but fortunately at present many of the health care professions people do need to have undergone recognised training before they can use their professional titles. I guess you are a person who would think that a health care assistant who has undertaken a level 2 NVQ knows as much as a Registered Nurse who has undertaken a 3 year course. i know who i would rather look after me when i was ill. Why should our health care be sold off, to private companies. WE know it didnt work before, people only need to look back to prior to 1946 to see how bad the health of the nation was, how did people manage to see Doctors, go to hospital for treatment, what was life expectancy then for the general population! enough said. if you want a private health care system, fine go live in USA or one of the other countries you have named, but let us keep our NHS, the scandanavian countries all have some form of community welfare, but i notice they are never used in these reports when we are being compared, its always USA and europe, we can learn a lot from Scandanavia interesting comments here, from people in different countries
A friend was in the US and said he saw a man lying on the floor outside a hospital with a bleeding leg and the ambulance men refused to move him becuase he did not have insurance and they had called for an ambulance for a hospital that would treat him without insurance but they would not pick him up and take him there. The man was lying on the pavement bleeding. My friend said in America healthcare is like in the third world. An American lady I met said that in the US, every time you visit your doctor, your insurance goes up, like when you call out the AA. So it is bad news if you have a long-term condition. No wonder faith healers do so well in the US. They can't afford anything else.
A friend was in the US and said he saw a man lying on the floor outside a hospital with a bleeding leg and the ambulance men refused to move him becuase he did not have insurance and they had called for an ambulance for a hospital that would treat him without insurance but they would not pick him up and take him there. The man was lying on the pavement bleeding. My friend said in America healthcare is like in the third world. An American lady I met said that in the US, every time you visit your doctor, your insurance goes up, like when you call out the AA. So it is bad news if you have a long-term condition. No wonder faith healers do so well in the US. They can't afford anything else.
Four points worth making here: 1. The hospital would have been acting illegally in the US 2. None of the bullet points Richard proposes are features of the US system 3. Though it is true that care provision in some parts of the US system is poor, in other parts it is way ahead of the UK (though that is not the point) 4. 50% of healthcare in the US is financed (and much of it provided) by the state and most of the rest is so state controlled that the cost is shocking - including the subsidy for employer-funded plans, which causes no end of problems. Why do people bring up the US in these contexts, rather than, say, Holland or Switzerland?
Philip: My understanding of Richard's points above is that what he would like to see in the UK is a completely deregulated medical industry, to take the place of the citizen-funded and government-provided health service we currently enjoy. The US free-for-all, even while subject to regulation, is probably the closest approximation to that in the Western world. There is no universal access, and cover depends on the type of service you are eligible for (e.g., Medicare, Veteran's Administration, employer insurance, or individual insurance). By contrast, In Holland and Switzerland, health insurance may be privately provided, but cover and access are tightly regulated. It is for this reason comparisons are made to the US "system" rather than to the systems in Holland or Switzerland. On your other points: Yes, the hospital was most likely acting illegally in refusing emergency care before asking for payment. However, this point is not one which supports complete deregulation; in fact it is an argument against it. In a completely deregulated environment a hospital would have no duty or incentive to treat patients who cannot pay. Yes, the cost of providing health care in the US is shocking. However, this is due to a variety of things, including the fact that 30% of the entire health care bill is spent on administrative costs which have nothing to do with providing actual care. Much of this is due to the plethora of different plans with different eligibility requirements, differing cover, and differing payment obligations. None of this would disappear with deregulation as the different insurance companies and health care providers would compete to keep costs down, and patients with expensive illnesses away.
But so much care in the US is financed and provided by the state (much more than in Switzerland, I believe, though I must admit I have not checked figures). And the sector is incredibly heavily regulated. One of the first Friedman papers I read as an undergraduate was on how the US medical professions combined restrictive entry with price discrimination not to serve the poor but to raise costs and rents to the professions. The problem is that the US model is a bit like PFI - just as likely to exhibit the worst features of both state and private systems as the best. I am afraid that, if you think that people do not get left untreated in the NHS, you will get a shock at some stage. But, you are correct, Richard's point was about complete de-regulation, so cherry-picking the best of the EU systems is probably not appropriate either. I think that the argument probably needs to be conducted from first principles.
I have never read such uneducated drivel in my entire life. Richard Wellings clearly has very little understanding of the health care and would do better to keep his naive/ignorant thoughts to himself. Sadly this country is run by a lot of corrupt charlatans who will happily use this kind of drivel to back up their reckless privatisation of the NHS.

@Anonymous - It would be helpful if you provided some concrete arguments to back up your criticisms...

Richard - He/she doesn't have any concrete arguments, hence the personal abuse.
This is Taliban economics...fundamentalist beliefs of zealots whose religion worships only one god, The Market. No amount of rational argument will deter these fundamentalist economists from their misguided beliefs. As the Taliban in Afghanistan were prepared to destroy priceless ancient buddhas in the name of their religion, so these fundamentalist economists are prepared to destroy the very society that has nurtured and educated them. They should be ignored and consigned to the scrapheap of history, along with the rest of the Chicago school of economics and the followers of Milton Friedman. The arrogance of the declarations underlying the IEA's 'radical regulatory reform' is breathtaking. To claim that abolishing compulsory licensing of medical professionals is the key to enabling the private healthcare market to increase productivity is the height of stupidity and naivete. There was a time when there was an unregulated healthcare market of the type that is being advocated by the IEA, it was called the Middle Ages, when life expectancy was 35 years and when 2/3 of children died before they were 4 years old. The Medical Act of 1858 established for the first time a statutory body to regulate medical education and medical qualifications, and established the medical register which continues to this day. Previously anyone could call themselves a physician; and quacks and charlatans were able to operate with impunity. And this is what the IEA is seriously suggesting in the 21st century...turning back the clock 150 years to when ordinary people were at the mercy of unscrupulous individuals? "Patients relying on brand names and voluntary associations to ensure quality" - the person who wrote this does not understand medicine, history, or people. How can an 80 year of woman who has fallen and fractured her hip choose a 'brand name' doctor? How is she to tell who is a charlatan and who is a genuine surgeon? Why should she have to when she is in pain and distress? How does a mother in the middle of the night know that the 'low-cost medical professional' from abroad is competent enough to cure her child and not to kill her child? The study of economics should be accompanied by the compulsory study of ethics, social science, human behaviour and history. The production of economists with these irrational and unevidenced beliefs coming out of our universities is an enormous concern, for they are advocating the breakdown of social structures that have been negotiated over many years for the benefit of us all. Sadly there will always be politicians who take these fundamentalist economists seriously, and this can have profound and lasting effects on society, such as in Chile and Argentina who still bear the scars of the 1970's. I challenge the IEA to do some real analysis on their regulatory proposals. Do an impact assessment, and Instead of only looking at all the wonderful private healthcare beds that will open, all the profits going private companies and dividends to shareholders... look at the cost in human many people will be damaged, killed and maimed by unleashing unregulated 'doctors and nurses' on the public? How many people would scarred by botched cosmetic surgery, how many more PIP breast implants scandals would result from an unregulated supplier markets, how many children and mothers will die in childbirth as incompetent midwives and charlatans botch deliveries? How many patients will die at home from being overmedicated by incompetent 'low cost medics' from abroad? How many cheap dud antibiotics from the third world could be let loose on an unknowing public in an epidemic causing unnecessary deaths? How many people could one incompetent surgeon kill as there would be no regulatory body to check him and no register from which he can be excluded? And he would have no concerns about being sued as his patients will have 'opted out' of their right to clinical negligence claims. What would be the true cost of rolling back all the progress of the last 150 years just so that the Market can be freed up from all regulation? I challenge the IEA to take a real hard look at what it is proposing....or is human suffering something it is prepared to cause in order to achieve its aims, and so has negligible costs attached? 'People are expendable in an unregulated market' - is that the mantra fundamentalist economists whisper to each other? If the IEA believes that increasing human suffering is a price worth paying for unleashing the market, then say so instead of hiding behind a pseudo- academic facade which masks these beliefs.
This is a spoof, right?
Anonymous - I had also rather suspected that you previous post was a spoof. Every day you rely on safety-critical goods and services that are provided by unlicensed individuals. This does not mean that they are unqualified or incompetent or that they or their employers do not have to meet legal standards and do not have to take out insurance (and how expensive would their liability insurance be if insurers though that they were dodgy?). Licensure does not ensure quality - far from it, as Dame Janet Smith pointed out very clearly in her enquiry - in fact it gives a false sense of security. What's more, in markets individuals matter. It is in socialist systems that individuals are expendable as part of the master plan. You only need to look at North Staffs and Basingstoke to know that - the problems were widely known locally - yet people had no choice under socialised monopoly provision.
HJ - you are being entiirely disingenuous. Dame Janet Smith may have pointed out that licensure does not ensure quality, but her recommendation was not to dispense with regulation, but to strengthen the fitness for practice process to protect patients from dysfunctional and underperforming doctors. She welcomed the changes in the NHS to improve the quality of health care and facilitate the detection of aberrant practice, she did not say do away with it all and let the hidden hand of the market protect the public. I have no doubt she would abhor the misuse of her name to support your incoherent proposals. Medicine was a collegial self regulated model until the 1990's when the regulations were reformed in response to a number of scandals. "the collegial model adopted by the profession left it fatally vulnerable to the problem of "bad apples": those unwilling, incapable or indifferent to delivering on their professional commitments and who betrayed the trust of both patients and peers. Weak administrative systems in the NHS failed to compensate for the defects of the collegium in controlling these individuals...Though its vulnerability to bad apples had been present since the founding of the 19th century profession, it was the convergence of social and political conditions at a particular historical moment that transformed the scandals into an unstoppable imperative for reform. Huge public anger, the voice permitted to a coalition of critics, shifts in social attitudes, the opportunity presented for imposing standards for accountability, and the increasing ascendancy of pro-interventionist managerialist and political agendas from the early 1990s onwards were all implicated in the response made to scandals and the shape the reforms took." (Dixon-Woods Social and Science Medicine 73 2011) Note "huge public anger". How much anger do you think the public would express if all regulation of doctors were to be scrapped? Do you think the public would understand that preventing harm to patients can be dispensed with in order for the market to be unleashed based on no evidence of benefit at all, other than to make the 1% even richer? It is an utter disgrace to selectively cherry pick evidence and twist it to support malevolent proposals that will harm a trusting public. Are you so naive not to understand that the purpose of licensing of doctors is to PREVENT harm to patients...what is the point of relying on the honesty of law abiding suppliers when we know there will always be people who do not care about the harm they cause to people and put greed above all else? Do you think an unregulated market wll prevent harm from happening? Taking out insurance against bad things happening will not prevent people being killed, it will only partially compensate the grieving relatives or damaged individuals, this I would suggest is entirely unacceptable and seems to me the kind of callous attitude displayed by Stalin, Pol Pot and Mau Tse Tung. "In markets individuals matter, in social systems individuals are expendable"- what utter nonsense. In markets the only individuals that matter are the ones who are rich enough and powerful enough to look after themselves. Markets care nothing for the vulnerable, the elderly, children and the poor. Markets are about the survival of the fittest, the weakest are left to fend for themselves. Socialist systems are about fairness, and market zealots cannot bear the thought of fairness and equity for all. You spend all your time thinking up ways of destroying society and making it as unequal as possible so that the 1% can live the high life at the expense of the rest.
given the suggestion that national socialist Argentina was somehow a free market paradise, I am not sure whether to take anonymous' comments seriously. But, there is a serious argument to be had about an issue that is a matter of life and death and that we should take it seriously. On the one hand there are the problems that you point out (if one distills the serious points from the meaningless rhetoric). On the other hand, we must bear in mind that lack of experimentation in health care can easily kill people or make their lives a misery because new treatments are not discovered or tried out on people who may be content with the risks. Also, we have the problem - discussed by Friedman in an important paper - of licensing involving reducing the amount of health care that the poor can afford (whether tax financed or otherwise) and increasing rents to groups of very well off people. Do you remember the prices of specs before liberalisation? It is not just that licensing prevents people from using less-well-qualified people, the ability to licence reduces the number of qualified people.
@ anonymous: "Markets care nothing for the vulnerable, the elderly, children and the poor. Markets are about the survival of the fittest, the weakest are left to fend for themselves. Socialist systems are about fairness, and market zealots cannot bear the thought of fairness and equity for all. You spend all your time thinking up ways of destroying society and making it as unequal as possible so that the 1% can live the high life at the expense of the rest." Actually, we don't and you will struggle with this debate until you appreciate the perspective of those who disagree with you. I am an actuary. We do not deal with life and death issues like doctors do, but the issues of information asymmetries and so on are the same. As a profession, until 1981 we were entirely unregulated and had no reserved (licensed) roles. Yet, we were all over the life insurance industry - huge demand for our services. The life insurance industry was hardly regulated from 1870 to 1970 yet in 100 years there were hardly any insolvencies (two to be precise) and none that affected policyholders. Serious problems did not arise until the Equitable when statutory duties for actuaries had been around for nearly 30 years - in fact the problems arose quite soon after actuaries were given statutory dutie and the industry became heavily regulated though this may be a coincidence. You describe, of course, problems (pre-1990) in a monopoly profession which would have no incentive to keep itself clean. It controlled entry and had no competition. The opposite was true in the actuarial profession and reasonably clean and professional it was (such professions hardly devloped in countries where the industry was more heavily regulated). This does not prove the point that HJ and RW are trying to make, but can you not see that they might have a point; that the scorn you heap upon their characters because they happen to hold different opinions from you might be unreasonable? I have to say that, if this is how you conduct debate, the socialist society you desire will not be very social.
I can't help being amused by the fact that 'anonymous' accuses free market advocates as having attitudes akin to those of Stalin, Mao and Pol Pot and then goes on to claim that socialist systems are about "fairness". Talk about being self-contradictory!
Licensing prevents the use of 'less- well qualified people' in medicine for very good reason - to prevent medical disasters that kill people. 'Spectacles before liberalisation' is a pathetically simplistic example to use, medicine is far more complicated that selling cheap pairs of specs.... a dodgy pair of specs is hardly going to kill you. Having your child operated on by a dodgy surgeon or anaesthetised by an unqualified anaesthetist is quite another thing. If economists are to be taken seriously, then they need to at least try to understand the complexities of medicine and the harm that will be done by udeegulating the health market. This IEA article has done nothing other than to expose it as a bunch of radical economist extremists who haven't a clue about the intended and unintended consequences of their incoherent and childish proposals, and don't care. It reads like something an uninformed adolescent with no knowledge of the world would come up with in a school debate. You should hand your heads in shame. And I suggest that you are somewhat misguided about your knowledge of Argentina - the 2001 uprising was a revolt against deregulated capitalism. Argentina, during the 1990s, was the most extreme experiment in neoliberal transformation in the world at the time. They had the most radical program of reforms a la Friedman, which ended up in massive unemployment, impoverishment of more than half of the population, and in 2001, the collapse of the whole economic system. Do you not read modern history? You should. Those who do not read and understand history are doomed to repeat it (Harry Truman). ps Harry Truman was a US president.
'Anonymous' is very fond of being abusive to wards people who disagree with him or her. Of course, they must be childish if they disagree. Who is suggesting that anyone uses an unqualified anaesthetist or an unqualified surgeon? The issue is about licensure, not about qualifications or competence. There is no evidence that licensure improves standards or patient safety. Once licensed as a medic in this country, you are legally allowed to carry out all sorts of procedures for which you are probably not competent (cosmetic plastic surgery, for example) - licensure creates a false sense of security, not a guarantee of safety and quality.
@anonymous. I suppose if you are not interested in addressing the issues, there is not much point debating so i shall leave it after this one. The potential calamity of the outcome is not the key issue but whether certification rather than licensing will give rise to better outcomes. Better specs, safer surgery, safer insurance companies? Will a removal of monopolies lead to more doctors and better professional discipline or not? These are not issues that can be resolved by saying that people who disagree with you know nothing about medicine and are childish and because medicine is very dangerous it cannot lead to better outcomes as with specs (did you oppose the abolition of the specs monopoly by the way in 1981 - or thereabouts?). You said Argentina in the 1970s and not the 1990s - perhaps you should type more carefully. Yes, I do read history. Friedman was ambivalent about the currency board, would strongly have opposed a situation where EXTERNAL (never mind internal) government debt was built up to such an extent that interest payments alone were 85% of all export earnings and where trade was so heavily regulated. I am just astonished that you think that Argentina was the most radical neo-liberal transformation at that time. Or perhaps it was another typo and you meant the 1890s or something.
'once licensed as a medic in this country you are legally allowed to carry out all sorts of procedures for which you are probably not competent.." You clearly know nothing about licensing a medic. Licensing confirms your competency after a rigorous test of revalidation every 5 years. If you carried out procedures for which you are 'probably not competent 'you would be struck off the medical register for negligence or for practising medicine beyond your capabilities. If we are to have a sensible debate, then slandering the medical profession is not very helpful. Medics are continually appraised, peer reviewed, subject to clinical governance procedures, and have to submit evidence that they keep up to date with current practice, the sytem is designed to pick up anyone practising beyond his capabilities as soon as possible before he/she does harm. The issue IS about licensure... how can you ensure that professions who are performing invasive procedures on people are qualified and competent if you don't have a licensing procedure? Who is going to assess if they are qualified and competent if you don't have a body like the General Medical Council doing it? I have already shown that history has demonstrated that self regulation did not work, and if self regulation did not work, then no regulation would be even worse. If you perceive these criticisms of your ideas as 'abuse', you would not last one day in the medical world...we are trained to critically evaluate each others work constantly, this is one of the mechanisms to ensure good practice, and we are trained to base our expert opinions on robust evidence. The ideological reforms that you propose have no basis in unbiased generalisable research, and are thus, worthless.
Anonymous - I am afraid that it is you who knows nothing about licensure. There has been no revalidation procedure in the UK and one is only just being introduced. Most countries have no such system. This means that there is no evidence that it works. Here is what Niall Dickson, Chief Exec of the GMC wrote only last week: "Most patients think that there is a system in place already for checking that doctors are competent and up to date. They believe that, as in most jobs, and certainly those where there is a safety critical component; doctors are appraised and given feedback on their professional performance. In fact there is no universal system of that kind and only when revalidation becomes a reality will every doctor with a licence to practise become part of such a scheme. What is more, revalidation and the systems which underpin it should mean that doctors have access to the support they need to maintain and improve their practice. Over time we believe revalidation will identify problems in some doctors' practice earlier, and more widely that it will encourage self-reflection. That must be good for both patients and doctors because it will help to improve the care patients receive. Revalidation is not a panacea and we are not claiming it will produce instant results but it will be the first nationwide system of its kind anywhere in the world. Nor should we understate the scale of what is involved. This UK programme will cover 230,000 licensed doctors and hundreds of organisations. It is therefore hardly surprising that it has taken time to refine and test the plans. The immediate upside of revalidation, even before it starts, is that employers have been busy strengthening their appraisal schemes and improving the vital systems they run which govern their clinical processes. Both are key to safe care." So before you castigate others for their ignorance and their supposed naivety, I suggest that you look in the mirror.
Philip, you are the one not interested in addressing these issues, I am ready to debate with facts, not fantasies. I suggest you read Professor Ezequiel Adamovsky, an Argentine historian and professor at the University of Buenos Aires, instead of scoffing at imaginary 'typos'. The military dictatorship in Argentina after 1976 implemented a neoliberal programme, and the consequence was a drastic reduction of the industrial sector. In Professor Adamovsky's opinion (not mine) during the 1990's, Argentian was the most extreme experiment in neoliberal transformation, enacted against a background of systematic violence and murder of the opposition - trade-unionists, college students, protestors, and human rights activists. A similar cycle of violence, murder and repression in Chile in the 1970s accompanied the neoliberal deregulation of the market. Amartya Sen describes this experience a failure of Friedman-style economic liberalism, the economic reforms having been drafted by Chilean economists trained at the University of Chicago under Milton Friedman. Not much of a legacy for Friedman I would say, but no doubt, you and your colleagues would not agree.
there is nothing liberal about shooting people, but you don't seem to understand liberalism very well. I am surprised you cite Prof. Adamovsky as an impartial source, but it is now clear from where you are coming. In fact, as far as economic reforms alone were concerned, Chile was pretty successful - certainly compared with any other comparable country. But, to the liberal, of course, the ends never justify the means. Argentina is a different case, a different case entirely. And this really is my last contribution to this string.
HJ, that has got to be the most arrogant response so far, a non medic telling a medic about revalidation. Copying and pasting information from the GMC website does you no credit. Revalidation has been discussed and planned over the last 10 years and is currently being piloted among groups of doctors before being rolled out to the rest. Revalidation aside, medics are continually appraised, peer reviewed, subject to clinical governance procedures, and have to submit evidence that they keep up to date with current practice (CPD). The sytem is designed (even without revalidation) to pick up anyone practising beyond his/her capabilities as soon as possible before he/she does harm. Medics also have to participate in CPD (continuing professional development) in order to remain in good standing with our professional colleges and we have to submit a CPD return annually with a record of all educational activities over the previous year in order "to maintain and improve standards of medical practice through the development of knowledge, skills, attitudes and behaviour". Perhaps you could enlighten us as to how economists keep up to date and on top of their game? What system is in place to make sure that they are not a danger to the public? Doubtless it is an equally rigorous procedure. You have demolished your own arguments anyway, and set out all the reasons why licensing is the key to safe medical care. And if there is no evidence that revalidation 'works' as you say, then equally you have no evidence that having no system of licensing works either, and as your proposal carries the greater risks to the public, which do you think they would prefer? But I doubt if anyone would object to conducting a controlled trial, with an 'unlicensed group' in which all the IEA and their families sought their medical treatment from unlicensed and 'not so well qualified' doctors for the next 5 years, versus a control group of economists seeking normal medical care from NHS doctors. Then lets count the economic, health and social costs of the two groups after 5 years. The 'unlicensed' group would not be able to sue any unlicensed doctors for negligence, but on the plus side, they would have free access to cannabis and opiates, and also be able to have any drug from the pharmacy without prescription? Sounds fair and reasonable? I rest my case.
As Philip has bowed out of this discussion, to conclude for those of you following the string,...Chile was successful in the end, but not because of neoliberal policies. Milton Friedman (who was an economic adviser to the military dictator General Pinochet) liked to think of it as 'the miracle of Chile'. In fact, the truth was very different. After the coup which brought him to power in 1973, Pinochet brought in a programme of deregulation and privatisation - state controlled pensions, industries and banks. Real economic output declined by 20% and unemployment went up by 20%. 45% of Chiles population fell below the poverty line. It was only after Pinochet left office, when a programme of 'growth with equity' was started that poverty was reduced. Amartya Sen, Nobel prize winner for economics, believed that this improvement was not because of "free-market" policies but because of active public and state intervention. And that is my final word on the subject.
Philip and HJ: I think you must acknowledge that "the market" is inherently amoral. People or companies sell goods or services in order to make money. The driving motive is profit. Now profit is not inherently evil, however there are some who are willing to do evil in order to make their profit. (One example of this in the US is a health insurance company's willingness to rescind policies on fairly flimsy pretexts when an insured develops an expensive illness, sometimes in the middle of treatment). Richard's assumption in this article is that a completely unregulated market would operate to keep this at bay. There really is no evidence to support this assumption. The purpose of government is to serve its citizens. It does this by (among other things) putting a brake on the worst excesses of the market. One such function and potential brake is the assessment and certification of medical personnel who perform complex and risky procedures. This is not to say that the state always gets things right - far from it. However, regulation of the market to protect the consumer, in this discussion the patient, is a legitimate function, and is what I expect of my government.
Anonymous - The fact is that I was correct about revalidation, and you were wrong. It is only just being introduced (and the head of the GMC should know). And as you readily admit, other procedures were in place anyway to pick up anyone who might do harm. So why is licence revalidation needed then? As Philip has pointed out, we are not arguing against certification, CPD, etc. (many other professions have such things) just against licensure which, as Friedman pointed out is a statutory measure used to protect a profession. You have defeated your own argument.
@anonymous2 - I would put it slightly differently. A market reflects the moral choices made by those who participate in it - but so does government. A market has the restraint imposed of freedom of contract (you cannot force somebody to transact) and a government of a five-yearly election. In a rich and diverse free economy there will be institutions that distinguish themselves by their probity (the London Stock Exchange after 1801 is an example - people tried to get it abolished by Act of Parliament on competition and restraint of trade grounds because it excluded people who did not pay their accounts, but it thrived as a private institution because both investors and companies benefited from the reputation for probity). I am not against professions that certify (or even professions with a Royal Charter for that matter) and their reputation for probity (if upheld) is precisely what would make their members attractive. The question of whether this institutional diversity and potential for competition on the one hand or regulation by a government (made up of imperfect people who can be captured by the profession) on the other hand is more robust is the question we should be debating. A free economy - however rich with institutions - will not produce a perfect outcome; but neither will a government bureaucracy. I am afraid that I have to correct what is said about Friedman above - and it should probably be removed by the editor, though he is dead and cannot be libelled. Friedman was not an advisor to Pinochet. He met him once for less than an hour and wrote him one letter at Pinochet's request. Friedman had few stronger beliefs than a belief in floating exchange rates and one of Chile's worst economic disasters came from - yes - fixing the exchange rate. Friedman said: “I have nothing good to say about the political regime that Pinochet imposed”.
anonymous2 - I have no particular objections to a state-regulated profession as long as it allows competition (then people who feel safer with it, like you, can always choose that), though it may not be stable (in the sense that it would be difficult to prevent the state from favouring its own regulated option)
You are a lunatic Mr Wellings!
HJ you really should stop digging yourself further into a are making the IES a laughing stock in the medical community trying to defend these irresponsible suggestions that would cause high rates of mortality and morbidity among the population. You are on a hiding to nothing. Why the big deal about revalidation if you claim it hasn't happened yet? If it hasn't happened, then why is Richard Wellings proposing a change in the status quo? Licensing is a just a small part of a system that 'restricts' practice to those qualified and competetent. Richard Wellings is suggesting that "anyone should be at liberty to practice as a doctor or nurse, with patients relying on brand names or competing voluntary associations to ensure quality. Ending current restrictive practices is essential to enable private firms to increase productivity in the sector" he says. This could only be brought about by repealing the Medical Act 1983 (as amended by the Professional Performance Act 1995, the European Primary Medical Qualifications Regulations 1996, the NHS (Primary Care) Act 1997, the Medical Act (Amendment) Order 2000, the Medical Act 1983 (Provisional Registration) Regulations 2000, the Medical Act 1983 (Amendment) Order 2002, and the National Health Service Reform and Health Care Professionals Act 2002, The European Qualifications (Health Care professions) Regulations 2003, the European Qualifications (Health & Social Care Professions and Accession of new Member States) Regulations 2004, the Medical Act 1983 (Amendment) and Miscellaneous Amendments Order 2006, and The European Qualifications (Health and Social Care Professions Regulations 2007). The first medical act, was the Medical Act of 1858 which was passed in order to regulate doctors in the UK and because "it is expedient that Persons requiring Medical Aid should be enable to distinguish from unqualified practitioners". So if you and your colleagues are seriously suggesting 'ending current restrictive practices' of the medical profession, then the Medical Act would have to be repealed, and it would no longer be a criminal offence, as it is now, for an unqualified person to practice medicine. Thus opening the way for any tom, dick and harry to be let loose on an unsuspecting public. Is this what you are seriously advocating? Or perhaps you just wish to abolish medical education altogther...I mean after all, why would anyone want to go through 6 years studying medicine as an undergraduate, 5 years to train as a specialist, pay enormous amounts of money every year for medical indemnity insurance, membership fees of the General Medical Council and the Royal College, as well as spend hours and hours reading medical journals and attending clinical meetings, writing papers and being peer reviewed......why do all this when I could simply just set myself up as an unqualified, or 'less well qualified', medical practitioner with no governing body to quality assure my work or take me to task if I maim or kill patients. Why would I bother? You get my point? Licensing is a mere drop in the ocean, Competing voluntary associations to assure quality?. Oh yes brilliant idea, of course there would be no conflict of interest there would there? No perverse incentives for a 'voluntary organisation' to ensure that their 'doctors' were passed as 'quality assured'? Apart from the fact that the whole system of clinical governance and quality assuring doctors costs the state, and the doctors, a small fortune, how are voluntary organisations going to afford to do it? Who is going to quality assure them? The whole idea is laughable, I can't believe I am spending so much time explaining all this to you. Debating with the ignorant takes up so much more time that debating with people who actually have a smidgeon of knowledge of what they are talking about.
anonymous2 - well at least you got Philip to admit that a 2 tier system would be necessary. He says he doesn't mind having a "state-regulated profession as long as it allows competition (then people who feel safer with it, like you, can always choose that) " But for 'people who feel safer" you can insert "people who can afford it" or "people who can tell the difference between a quack and a doctor", This would exclude the poor, the learning disabled, the vulnerable elderly, children etc.etc, all the people that it is the responsiblity of government to protect. So here we have it, the proposal to abolish compulsory licensing of the medical profession is not so insane as it appears at first. The agenda is unmasked. They know perfectly well that those people intelligent and rich enough would never choose a 2nd class medical service, so there has to be one for the rich and one for the poor. They really can't bear the equality of the NHS, the fact that everyone is treated the same no matter how much they do or do not contribute. I hope they never have a car accident, and have to rely on our world class emergency services to send in their medics by helipcopter to treat them at the roadside, perform emergency surgery on the tarmac, chest drain, CVP, IV fluids. fly them back to an NHS hospital with one of our superb ICUs, where they are treated by top rate neurosurgeons and or cardiothoracic surgeons, all without being asked for a penny. Because if they did find themselves in that position, they will be in an awful bind, having to rethink why they have been seriously advocating the destruction of the NHS....all in order for someone somewhere to have the choice of buying a cheap pair of specs on the internet....nothing like throwing the baby out with the bathwater. And as for Milton Friedman and Chile. Philip is being rather economical with the truth. Friedman wrote to Pinochet, that is true, but in the letter he completely ignored Pinochet's human rights violations and instead denounced the trends towards socialism which 'reached their logical and terrible climax in the Allende regime'. He praised Pinochet for reversing this trend. In 1982, in a Newsweek article, Friedman described Chile under the dictatorship as an 'economic miracle' despite the dramatic rise in poverty and unemployment. He praised the dictatorship who had sharply reduced the role of the state. He visited Chile in 1975 and gave a series of lectures on free market economics, meeting with Pinochet and then later writing the letter described above. He may have been a proponent of individual liberty, but Chile was a blind spot for him, but then he would say that wouldn't he? The Chicago School had trained the economists who advised Pinochet, so to admit the failure of free market economics in Chile, would have been an admission of failure of his lifes work. Sadly, disciples of Friedman still have the same blind spot when it comes to acknowledging the devastating effects its policies have on 99% of the population.
Anonymous - yes dealing with the ignorant certainly does take time and, as a result I have no more time for you. You do not want to learn or debate, you just want to abuse anyone who has the temerity to think for themselves rather than conforming to your self-important view of the world. There is a huge body of research about the downsides of medical licensure and you would be hard put to find an independent voice who has looked into the issue in any detail who is in favour of it. I don't care what the 'medical community' think - as we have seen recently over the issue of pensions, self-interest is their over-riding priority. Incidentally, why is it necessary to spend 6 years as an undergraduate studying general medicine if you go on to be (for example) a joint replacement surgeon? Do we make all engineers do a general engineering degree first in order to, for example, specialise as an electronics engineer? Perhaps this is why cataract operations on the NHS are carried out by consultants at a cost of between £800 and £1600 (and there is a waiting list) when Sightsavers International do it using specialist technicians (still highly trained) to the same standard (and yes, it is the same standard - I have been involved in this charity for many years) at an average cost of just £17.
Anonymous - "They really can't bear the equality of the NHS, the fact that everyone is treated the same no matter how much they do or do not contribute." Try telling that to the victims of Staffs Hospital. Or to the 46% of diabetes patients recently revealed not be receiving proper checks. Or to older patients that the NHS has discriminated against. Insurance-based systems allow users to choose the care they want and providers must provide it - or they don't get paid. The NHS let's the providers do the choosing.
I think the editor should stop this comment thread as it is wasting everybody's time. Anonymous can distort the truth about many things that are simply too complex to continue debating on this blog. He can use other fora to just decry people with whom he disagrees as laughable, ignorant etc, but I do not see the sense in continuinig to use this forum to do so. Just one example of how he/she distorts things in order to try to win an argument (with no obvious interest in the truth): I said: "I have no particular objections to a state-regulated profession as long as it allows competition". He/she said: "anonymous2 - well at least you got Philip to admit that a 2 tier system would be necessary". I neither said that it would be necessary nor desirable, simply that I have no particular objections to it. People can follow the thread this far if they wish and draw their own conclusions.

@Anonymous - I'm afraid I can't see the relevance of your discussion about Chile to the debate on freeing up the healthcare sector. Moreover, references to Friedman's brief interaction with Pinochet are often used to smear an economist who did a great deal to advance liberty, including campaigning against the draft. Friedman's trivial personal association with Chile may be contrasted with the disgusting behaviour of leading socialist intellectuals who for decades excused the crimes of the Soviet Union and deliberately covered up or played down the famine in the Ukraine and other Stalinist atrocities.

@Richard - the reason that 'Anonymous' is attacking Friedman (as opposed to his arguments) is that Friedman famously destroyed the case for medical licensure. As 'Anonymous' cannot counter Friedman's argument he is resorting to the well-know 'ad hominem' attack tactic.
We have now decided to end the comments thread for the reasons discussed above. Thank you for all your contributions.