Dr Robert Lefever MA MB BChir ARCM
Personal Perspectives, No. 22
ISSN 0267 7156 ISBN 1 85637 767 9
An occasional publication of the Libertarian Alliance,
Suite 35, 2 Lansdowne Row, Mayfair, London W1J 6HL.
© 2004: Libertarian Alliance; Dr Robert Lefever.
Dr Robert Lefever runs the PROMIS unit of primary care at 2a Pelham Street, London, SW7 3HU, 020 7584 6511. He also runs the PROMIS Recovery Centre (www.promis.co.uk) in Nonington, Kent. This essay first appeared in its present form in the July 2004 issue of The Individual, the journal of the Society for Individual Freedom (www.individualist.org.uk).
The views expressed in this publication are those of its author, and
not necessarily those of the Libertarian Alliance, its Committee,
Advisory Council or subscribers.
FOR LIFE, LIBERTY AND PROPERTY
In 1970 I created the first NHS group practice in the South Kensington area. I believed in the NHS. I was a politically active member of the Labour Party. I was on the Inner London Local Medical Committee of the British Medical Association. I was the education secretary of the South London faculty of the Royal College of General Practitioners.
Within ten years, after a total of sixteen years working for the NHS, I was back in single-handed practice, exclusively in private practice and a member of nothing other than the Libertarian Alliance, a forum of like-minded individualists. I had tried the State system of healthcare, giving it all my energy and commitment, and I found that, for all its seemingly wonderful ideals, it did not work in practice. This is what I wrote at that time:
The Philosophy of the National Health Service is Wrong
The philosophical ideas upon which the National Health Service is based are wrong. It is not lack of finance that has destroyed the NHS as an instrument of health care. Nor is it faulty organisational structure. Nor is it over-administration. It is the ideas that are wrong. Over a generation we have seen the provision of health care in the United Kingdom degenerate into a free and comprehensive rotten shambles.
Any system of health care—or any enterprise whatsoever—is only as good as the ideas upon which it is based. However much one tinkers with the organisation and however much money one spends, the end result of any venture will be disastrous if the original ideas were unsound. After a generation it is surely due time to sit back from the day-to-day hustle and bustle of the NHS, leave the bickering and bantering and make a fundamental re-assessment of our ideas.
Could it be that the basic concept that the State can be compassionate is so utterly wrong as to be laughable? If it is wrong then it would certainly take only one generation to change a sincere profession into a money-grabbing rabble.
The ideas upon which the NHS is based are:
The State should take over ultimate health care responsibility from the individual.
Resources should be distributed according to need.
Services should be free at the time of need.
It is these high-sounding ideas that have brought the practice of medicine to its disgraceful state today. Is it disgraceful? Yes, of course it is, considering what it costs. Every year the NHS costs progressively more for every man, woman and child in the population. The service they get is not worth the money. I do not need to document the condition of our hospital buildings, the pitiful lack of general availability of specialist equipment, the painful and dangerous years on waiting lists for hospital admissions, nor the sad state of general practice in cities, where most of the population live. All this has been documented by others and the current evidence and future prospects are gloomy.
When we look at special fields, such as the care of the elderly, the picture is frankly horrific, even when we know that the problems of care for the elderly will present our greatest challenge in the future. And yet this is the NHS that costs thousands of millions of pounds every year, which is still held by some to be the envy of the world and whose basic philosophical principles are still thought to be right even by the many millions of people who know in their minds, if not in their hearts, that the NHS has failed in practice.
The philosophical inertia in any society is considerable. It is part of the strength of a society that ideas bind it together. It is a tragedy, however, when a religious fervour of biased opinion infects science. The fundamental idea of any scientific discipline should be that one’s concepts must be malleable according to observations. If we see that something does not happen in the way that we thought it should, then we have to change our ideas. Religious belief is by its very nature the opposite concept to scientific discipline. A religion does not assess evidence, nor does it actively and enthusiastically search to disprove its most cherished tenets. But science does—and must, or else it dies.
It is this quasi-religious fervour that is destroying the scientific basis of the NHS. No scientific idea can afford to be inviolate. We must re-examine even our most basic ideas or perish.
I say again: it is the ideas of the NHS that are wrong. Ultimately even the central philosophical concept of altruism is wrong. We are not our brothers’ keepers and we must not be—we diminish them if we try. Moreover, any State system that tries to enforce compassion becomes in time veritable hell on earth. As Ayn Rand says: “The difference between a Welfare State and a Totalitarian State is merely a matter of time.”
True compassion can only be individual. If I choose to help you then that is my affair. If I leave you to rot that is also my affair—but I shall pay the consequences of that. If I want a compassionate society then I have to earn it through my actions for others. By contrast, the State can never be compassionate: it takes from those who resent giving and gives to those who come to believe that they have a right to the product of the lives of others. Moreover, when A gives the life of B for the benefit of C, but A expects the credit for himself or herself, this is the essential prerequisite for totalitarianism and this is precisely why Ayn Rand is right.
Who says that I cannot reduce human life to algebra? Indeed I can and shall. To judge from limited personal observation but also from the medical and national press, the NHS is an increasing shambles, our doctors are becoming increasingly bitter, and the population is increasingly conned into thinking that in general it demands too much. I say the opposite—it demands too little! It is the Capitalist in me who demands and expects to give value for money. It is the scientist in me who demands that I challenge the ideas and in turn throw my own ideas open to challenge. In the process I may need to use a mathematical model as an example—but I vow never to close my mind to the extent of merely reiterating politico-religious beliefs.
So now let us re-examine the ideas upon which the NHS is based, let us list the inevitable consequences of these ideas and let us look around us to see if this theoretical model of the NHS, and its end result, are valid in practice. If it is a true representation then we simply must throw out the ideas before further damage is done.
1) If the State takes over ultimate health care responsibility from the individual then:
a) Individuals come to think that they have rights, and hence can demand a service without at the same time having to recognise that the service is inevitably the product of the life and work and integrity of someone else.
b) Any thinker who allows himself to be the property of someone else ceases to think. A doctor who allows himself to become merely a unit in the State provision of health care, rather than someone responsible for his own philosophical and mental integrity, is not worth asking the time of day let alone his opinion on a clinical or personal problem.
c) People assume that the State will care for the less fortunate. When presented with evidence that it does not do so, they complain that it should—but do not feel obliged to take any positive helpful action themselves. Thus the State is the cause of the Inverse Care Law, whereby those most in need of help are least likely to get it. The State creates a cruel, arid, uncaring society that smothers individual compassion and human charity. The State cannot be relied upon to produce responsible clinical care at the time that it is needed. A true sense of commitment can only be the product of an individual mind and personal philosophy. It can never be instilled by rules, regulations and committees, nor even by Royal Commissions.
2) If resources are distributed according to need then:
a) People compete to establish their need rather than their capacity to do well on their own account. The individual demands his so-called “rights” without any thought that it is at another’s expense. The corporate body, answerable for its expenditure of public funds, spends its budget up to the hilt—or even over-spends regardless of the needs of others—so that it can demand the same again or more the following year.
b) Little attention is paid to the capacity of the recipient to benefit from the resource. An absolute need may be totally unchanged even after all the resource has been devoured. Meanwhile, someone else with a lesser objective need is left with no possibility of the benefit that could have been his or hers because the resource has in effect been squandered.
c) Scientific assessment of benefit takes second place to the repetitive, mindless, arrogant hollerings of political pressure groups.
3) If services are free at the time of need:
a) Perceived needs become relative rather than absolute. Meeting a need does not satisfy: it merely shifts attention to another need.
b) Instead of the individual patient not being able to afford treatment, the State runs out of money so that either the individual cannot get treatment at all or, alternatively, the treatment that he or she can get is not worth having.
c) The proponents of the system point to a few people who have been dramatically helped “at no cost” and:
i) Play on the fear or pity of their listeners—and in doing so make them into supplicant pap.
ii) Disregard what is happening in general rather than in particular.
d) The State comes in time to be thought to be indispensable and with that goes every last individual freedom.
It is my own view that this theoretical model of the NHS is true in practice. There is no point in spending more time and money on it. As with any failing enterprise, more expenditure of time and money simply causes it to fail even more dramatically. If the ideas and principles are wrong, the practice will inevitably fail. We should scrap the entire National Health Service before it causes even more suffering than it has already. In its place we should have nothing whatever other than private practice and private charity and the principles of competition and paying for quality.
I have seen no reason to modify these ideas since then. Far from it. In recent years the NHS has had billions of pounds “invested in it” (taken from taxpayers) and its staff have increased in numbers (clinicians more than administrators) yet it still doesn’t work—for the very reasons that I spelt out in 1980. Correspondingly, I have seen no reason from practical experience to modify the views that I put forward in another article that I wrote at that time:
Paying For Quality
The Inverse Care Law states that “The availability of good medical care tends to vary inversely with the need for it in the population served.” Those most in need of care are least likely to get it.
The corollary is the Direct Care Law, which would be that those who are least in need of care tend to get it at the expense of those who need it most.
It is only when put alongside its corollary that the Inverse Care Law is seen to be little more than a political Trojan Horse: the method by which principles of genuine concern and compassion for those most in need are subverted to the political ambitions of those who wish to have control over all. Those who invoke the Inverse Care Law would not be satisfied merely by action against the Direct Care Law. It would not satisfy them if care, specifically that provided free by the State, was restricted to those who need it most. Their intention is that there shall be no alternative to State care for anybody at any time. For them, the actual level of quality of care given to an individual is not as important in principle as that no other individual shall receive better, particularly not if it is paid for at the time of need. They know very well, however, that the only way to achieve equality of outcome is to damage the more talented, hinder the more industrious, and to make providers feel guilty rather than proud of their skill and hence develop a sense of corporate obligation rather than individual self-esteem. Statism is not an outward looking philosophy that seeks improvement at each and every opportunity, but a bitter creed that seeks to reduce all to the lowest common denominator.
Those who consider that I overstate my case may care to reflect upon the closing sentence of the original description of the Inverse Care Law by Dr Julian Tudor Hart (Lancet, 27 February 1971). “The more health services are removed from the force of the market, the more successful we can be in redistributing care away from its ‘natural’ distribution in a market economy; but this will be a redistribution, an intervention to correct a fault natural to our form of society, and therefore incompletely successful and politically unstable, in the absence of more fundamental social change.”
The Law of Infinite Resources would state that money comes from the money tree. It is upon this Law that the Inverse Care Law depends for its material and non-ideological foundation. But, of course, the Law of Infinite Resources is not true. Money has to be created: it represents units of work. Even natural resources have to be harnessed by skill and effort; they do not become a resource in the absence of the application of the mind of man. Inherited or other fortuitous wealth is soon lost by those who do not respect what it has taken to earn it. Financial resources, particularly those confiscated in the form of taxes by Governments, should be respected. State money should be spent wisely and carefully in acknowledgement that the State has no resources of its own other than those produced by the labour of its subjects. State money carelessly or casually thrown around shows a disrespect for the life and labour of the men and women who created it. Money is a philosophical indicator: the attitude of any man or woman towards money and what it represents will indicate his or her attitude towards the value of his or her own life and the value of the lives of other people.
The provision of health care should be a business, much like any other. The successful businessman takes care of his staff, he pays them well and he appreciates them for the work that they do. He takes care of his customers, knowing that his future livelihood, and the continued employment of those who depend upon the business that he created, all depend upon the satisfaction of his customers. If he fails to look after his staff and his customers, or if he fails to react to changes in the needs of his customers, then he will go bankrupt and lose his business and deserve to do so. He goes bankrupt unless, of course, he has friends in Government who agree with him that his business is an essential business and that his unprofitable enterprise should be subsidised at the expense of others, thus, in turn, making it more difficult for those other businesses to survive. The market-place may be cruel but it is infinitely more so when Government intervenes.
So it is with health care. It should be run as a business, selling a commodity. Each and every provider should be in direct competition with others. They should know, as any businessman knows, that if their prices rise above, or their standards fall below, those of their competitors then they will have to face the economic consequence.
Again, the intervention of Government, however well intentioned, is catastrophic. Despite falling clinical standards, the security of income and employment for doctors and staff tends to be given a higher priority by their various Trade Unions than is given to maintaining and improving the quality of care to patients. State Health Services become little more than an employment agency. The providers of medical services should not be immune from the pressures and risks of any market-place. Providers of inefficient, careless, expensive or impersonal services deserve to be put out of business by competitors.
Thus, paying for quality has the corollary that we should not pay for poor quality. Doctors, nurses, technicians, social workers, porters, cleaners and all staff associated with health care should have minimal security of tenure in their employment. The nature of their work is too important for manifest incompetence to be tolerated. Peoples’ lives are at risk. Doctors and all health care professionals will inevitably make mistakes but we should no more tolerate an inadequate health care professional than we should tolerate a manifestly inadequate airline pilot. If, by its very nature, the State is incapable of being subjected to the forces of the open market, then the very least that the taxpayer and the patient deserve is that all employees of the State should be subjected to audit by peer review.
We hear daily that State Health Services are under-financed. This is not true. It could not be true. The aims of the State health and welfare services are not defined and never have been defined. Therefore, the resources allocated can neither be too small nor too large. The medical and allied professions have singularly failed in their responsibility to collect and publish data on the incidence of clinical and social conditions, the currently available methods by which these various problems may hopefully be alleviated, and the costs of doing so. If this were to be done it could then be a matter for public debate, and ultimately of Government decision, on which problems should be dealt with by the State within any particular predetermined budget and which problems should be excluded. To make no exclusions, to refuse to draw any line, is simply unreal and requires the invocation of the Law of Infinite Resources.
Do those who clamour that our State Health Services are under-financed really care for those most in need? If so, let them define the needy, define the need and define the resources that can be shown specifically to alleviate each need. If they are not prepared to make those definitions then we can reasonably assume that their true interest is not in helping those most in need, but rather in keeping them needy as a focus of shame and discontent. They seek to undermine the self-confidence of our country and undermine the proportion of our national budget that we spend on defence of our traditional family values of self-reliance. In particular, they may seek to undermine the budget that we spend on national military defence against enemies who do not share our traditional family values.
The political platitude, “Resources should be distributed according to need”, fails to define need and fails to determine the capacity of the recipient to benefit from expenditure of the resource. The person who determines need should be the person who possesses the resource, be it talent, material goods or the skill to manage and distribute services. Need should not be determined by the recipients, nor by their political henchmen: the beggars and grabbers who make the most noise are neither the best people to be aware of the needs of others nor are they likely to obtain the best results from the producers upon whom they depend. The necessary control upon the activity of producers is that they should be fully vulnerable to competitive forces and not protected with special privileges by Government, nor protected by special powers of corporate blackmail through the strength of their professional organisations or Trade Unions.
It is more practical, and less dreamily idealistic, to believe that talent and human compassion can both thrive when exposed to market forces than to believe that either could ever survive the lifeless uniformity of State control. It is also more probable that in human nature people will be prepared to care for others as well as for themselves, rather than instead of themselves. Our only defence against the historical inevitability of the future gulag is to be proud of ourselves as individuals and proud of the money that we earn through honest endeavour. We should reject all concepts of a something-for-nothing society. We should pay for quality and expect to get it. We should charge for quality and know that we must give it. We should acknowledge that private health and private education are the first rather than the last things that should be paid for by each individual and family.
Although children and the elderly are the largest users of our State Health and Welfare Services there is no reason to think that State facilities cannot be replaced by private. The State does not do all that it would like us to think it does. For example, the vast majority of elderly people live at home and either look after themselves or are cared for by their own families. We should do everything we can to encourage individuals and families to be self-supporting. If we need more Laws from Parliament, and I am generally in favour of less, then let there be a Family Protection Law to ensure that a man’s earnings are paid direct to his family. It seems strange to me that the Law at present is more interested in what happens at death or divorce rather than in life.
But what of those who cannot afford to pay? Cannot afford to pay for what? For food? For clothing? For shelter? Sure, there are some who will never have the capacity to pay for any of these things and I would be only one among millions who would be more than happy to pay a proportion of my income (preferably to a privately run charity rather than to the State) to help these people not only to survive but to live in dignity.
But I am not inclined to fight a revolution on behalf of free cough syrups and minor tranquillisers for all. The unthinking universality of provision in our State Health and Welfare Systems does not concentrate on helping those most in need. I do not believe, for example, that my own family should be covered by State benefits of any kind, including mortgage and pension premium relief. We are more than capable of providing for ourselves and of insuring against future mishap or disaster, as, I suspect, will be the vast majority of people reading my words. We do not need State help: we should forgo it for the benefit of those who do.
Health Care is not a universal birthright. We should have a two-tier system in health care, the same as in everything else: one tier for those who can afford it and one for those who genuinely cannot. We already have means tests in our system of Inland Revenue taxation. The idea of extending the taxation system into negative taxation in order to distribute the financial benefit fairly is not a novel idea and it might possibly work satisfactorily as a replacement for our current taxation and welfare benefit systems. Giving money, rather than theoretical access to goods or services, has been shown to be a better method of achieving equal opportunity and outcome.
Thus, the definition of those who genuinely could not afford private health care, private education, and private housing (in addition to private food, private clothing and private entertainment, if we are to be allowed to have any of these things privately) can readily be determined from their positive or negative taxation status. The poverty trap, like the taxation trap at the other end of the economic spectrum, is avoided through sliding scales of the positive and negative taxation system.
It should be remembered that the vast majority of tax revenue is raised from the most numerous Social Classes, II, III and IV (corporate taxation is, of course, handed on to the individual consumer in the form of higher prices) and these same social classes in return receive the vast majority of all State benefits. The Black Report on Inequalities in Health, perhaps the most politically scurrilous health document since the war, should have all its histograms re-drawn to take account of the size of each social class group. If this were to be done it could readily be seen that transferring wealth or other resources from social Class I to Class V may satisfy narrow political demands but it would achieve little else. Further, if the effect of the social class differences in cigarette smoking is also subtracted from the histograms of The Black Report then many inequalities in health might well disappear altogether. At best The Black Report is amateur: its quality is not worth paying for.
Then what is the point of the State taxation and welfare systems that do not rob Peter to pay Paul, which might almost in some circumstances be commendable, but rob Peter, muck about at great expense, and then give Peter back less than he could have bought for himself in the first place? The point, of course, is political. Both Peter and Paul are kept in the dark on the true costs of alternatives to State provision. They have to be made to believe that without State help they and their families would be diseased and destitute and would almost certainly die, lonely and uncared for. It is fraudulent to suggest that only with State resources which, even if not infinite, at least are taken from richer people than they, can Peter and Paul possibly survive. This whole charade simply is not true. It cannot be true. The State does not make money or any other resource: it spends it. With whatever level of resource the State begins, there must be less after the State has processed it.
With the exception of the sanitary Public Health Services (which remain the Cinderella of Health and Welfare Services, despite the historical perspective that over-all improvement in the health of the nation is more likely to come in the future, as in the past, from this discipline rather than any other), the only possible theoretical justification for State Health and Welfare Services is the redistribution of resources so that those most in need of help and most capable of benefiting from that resource should be those who receive it. This the State singularly fails to do. Even The Black Report admits that.
The solution should not be more State intervention but less. Peter and Paul should be left to look after themselves. The arrogance of those who assume that either Peter or Paul is a complete duffer, and would not know how to look after himself, is quite astounding. They are similarly arrogant in their assumption that nobody would look after those who have no capacity to look after themselves. The evidence is to the contrary: even with all our State provision today it is the Salvation Army and other private charities that truly help those most in need and whom the State pitifully neglects.
We should not forget that private charity built and ran many of our great hospitals and medical institutions before the State moved in. There is no shortage of private concern and compassion in our society today. The non-political aspects of the Inverse Care Law itself give evidence of individual concern for the socially and financially disadvantaged members of our society. There is no reason to believe that this concern is rare in our Society and certainly no reason to believe that it must be channelled through the State. The indignity of being given State hand-outs, that have been unwillingly prised away from others in the form of taxation, is far more degrading than receiving willing gifts from private charities. More importantly, private charity gives credit rather than criticism to the giver or producer, upon whom all future economic production and welfare depends.
Nor should we forget the magnificent contribution to clinical medicine and to research made by the privately owned multi-national pharmaceutical companies. To give just two examples, the advent of anaesthetics and antibiotics has totally transformed medical practice and hence the quality and expectation of life. If there is thoughtless over-prescription of many drugs, this can only be the fault of the doctors who write the prescriptions, not the fault of the companies who make and market them.
We should look now to the USA, to the experience of individual free enterprise and also, as an example of alternative ideas to those at NHS, to the experience of new corporate ventures such as the with-profit Health Maintenance Organisations. An excellent description of these organisations and of the implementation of many other ideas in the delivery of health care throughout the world is given in the book The Public/Private Mix for Health, (edited by Gordon McLachlan and Alan Maynard, and published by the Nuffield Provincial Hospitals Trust, 1983.) In Health Maintenance Organisations, general practice and hospitals work closely together and the clinical and financial interests of insurer, doctor and patient move in the same direction towards early and accurate diagnosis and treatment.
Many of these organisations extend their insurance cover to include dependants, be they old or infirm, chronically sick or disabled, schizophrenic, alcoholic, unemployed or whatever: the State is not indispensable—there are alternatives.
I suggest that we should re-examine the ideas of our State Health and Welfare Systems—and incidentally, also our existing private medical system which is largely parasitic upon the State system—and start again with clear ideas of what we are trying to achieve and of how it can be done. We should begin by adopting the prime principle of Capitalism: paying for quality.
I left the Libertarian Alliance1 when I came to recognise that some personal behaviours in some people are not free choices but are compulsions or addictions. I believe that the individual afflicted with these (probably genetically inherited) conditions are totally responsible for their behaviour in so far as it affects other people but they are not responsible for being depressed or being addicts as such.
This was also the basis of a further break between me and the State. In the NHS these patients tend to be looked after very badly. They tend to be drugged out of their minds with pharmaceutical substances, patronised or even punished with cognitive behavioural therapy or analytical psychotherapy (often in its abbreviated form of cognitive analytical therapy) and generally neglected and even despised. Yet this population has a fearful risk of suicide and of developing cancer (though nicotine addiction), heart attacks and strokes (through alcoholism, nicotine addiction and eating disorders), accidents and serious infections and overdoses (through alcoholism and drug addiction) and other desperate diseases affecting every body system and having widespread effects in social, educational, financial, marital and professional life. But still the NHS, even to this day, focuses on treating the end results rather than trying to accept and redirect the underlying genetic influence.
Experience as a Private-Sector Doctor
In 1986 my wife Meg and I re-mortgaged our home and our medical practice properties and built The PROMIS Recovery Centre, near Canterbury in Kent (www.promis.co.uk). Our son Robin now runs it alongside us. Our fundamental belief is that people with depressive illness and addictive disease (the two are synonymous, reflecting the clinical state before and after attempts at self-induced therapy) can be helped through the day-to-day behavioural changes of the Twelve Step programme first formulated by Alcoholics Anonymous. Our patients are able to fulfil their own individual potential, realise their dreams and avoid the medical and other consequences that might otherwise befall them.
In our experience of treating over 3,500 inpatients over the last 18 years, and a steadily increasing number of outpatients and juveniles in our new facilities in Kendrick Mews in South Kensington, we have observed that social and environmental changes are insufficient in helping depressed people to come out of their gloom or addicts to change their behaviour. Similarly, love, education or punishment (all appropriate at times in their own way) do not provide sufficient long-term prevention of progressive emotional decline or promotion of constructive and happy lives. Only continuing commitment to working the Twelve Step programme day-by-day provides their combined preventive and therapeutic effect. Furthermore, the Anonymous Fellowships, such as Alcoholics Anonymous, Narcotics Anonymous, Overeaters Anonymous, Gamblers Anonymous and Helpers Anonymous (for people with a progressive and destructive need to be needed), are generally widespread in their availability and are totally free and therefore no burden to the State or anyone else.
The purpose of the PROMIS Recovery Centre and our other facilities is to enable, through our educational and therapeutic programmes, a larger number of people to get better with the support of the Anonymous Fellowships that would otherwise do so. We endeavour to set an example to the State system of healthcare and welfare that these clinical conditions can be treated effectively and with respect for the dignity, safety and self-enhancing capacity of the patients and their families.
In all the PROMIS facilities we are independent of the State. We are independent of large corporations. We are independent of the private medical insurance companies. We depend upon nobody but ourselves, the personal supportive goodwill of our friends and the clinical satisfaction of our patients leading them to recommend other patients to us.
(1) But remained on very good terms. In November 2003 Dr Lefever was awarded the Libertarian Alliance’s Liberty in Action award which is “granted in recognition to an individual whose actions have contributed to the struggle for freedom and individual rights.” [Editor’s note.]
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