A crass attempt at transparency

Targets and indicators are essential if we're looking at improving well-being in our large, complex societies. Currently, though, our targets are chosen unsystematically and incoherently. So we see results like this:

One in three heart surgeons refuse difficult operations to avoid poor mortality ratings, survey shows.... [S]urgeons would look at a patient and think, 'I know what’s best for you’, it’s this operation. Now a surgeon looks at a patient and says, ‘I know what’s best for you but is this going to be good for my figures?' ...Since 2014 the [UK's national Health Service] has published the individual mortality rates for consultant surgeons on the publicly available website ‘MyNHS’, which was supposed to represent a milestone in transparency. 'Daily Telegraph', accessed 22 April

It's pitiful. A national health service will always need numerical indicators, but we should be making sure that achieving them is inextricably linked to improvements in people's health and well-being. Mickey Mouse micro-targets, like an heart surgeons' 'success' rates are, as we see, worse than useless. They are as crassly thought out as certain other targets, such as:

A notorious example was that some hospitals kept patients waiting in ambulances outside the hospital until the hospital could be confident that the patient could be seen in its accident and emergency department within the 4-hour target. Source

I suggest that instead of these idiotic micro-targets or idiotic attempts at 'transparency', we look at we target measures that are important to ordinary people: the users of health care services. My suggestion is that we issue Health Bonds, which would explicitly and impartially target improvements in longevity, Quality Adjusted Life Years, infant mortality rates and other general population health indicators. Resources are always going to be limited but decisions our healthcare goals and - and the basis on which they are made - should be made clear to ordinary people, so that we can participate, if we want, in their formulation.

The EU: punishing the poor

I set out my main reason for voting for the UK to leave the European Union here. It is not simply that the EU has corrupt, stupid, wasteful policies - most countries have those. It's that the EU has no mechanism by which these policies can be terminated. The EU's Common Agricultural Policy has done much to destroy Europe's environment, raise food prices for all Europeans while transferring taxpayer funds to Europe's wealthiest people and agribusinesses ('One in five [of the CAP's] biggest recipients are billionaires and millionaires'), and it has been doing all this for more than forty years. It swallows up 40 percent of the EU's budget and imposes further costs on ordinary consumers by putting up tariff barriers.

High import tariffs (estimated at 18–28%) have the effect of keeping prices high by restricting competition by non-EU producers. It is estimated that public support for farmers in OECD countries costs a family of four on average nearly 1,000 USD per year in higher prices and taxes. Source

These barriers have helped impoverish Africans by limiting their exports to Europe, and now, equally tragically, the EU is subsidising milk, which gets exported to Africa, and helps destroy the livelihoods of African dairy farmers.

European milk is pouring into Africa, with disastrous effects for local herders and farmers. ...Multibillion-euro dairy multinationals are exploiting rock-bottom European milk prices to expand aggressively into West Africa. Over five years, they have nearly tripled their exports to the region, shipping milk powder produced by heavily subsidized European farmers to be transformed into liquid milk for the region’s booming middle class. This milk rush is ratcheting up long-standing accusations that poor countries pay the price for EU farm policies crafted in Brussels. How EU milk is sinking Africa’s farmers, Louis Nelson, Politico, 8 April

The consequences can be seen in the Mediterranean: desperate Africans sacrificing their life-savings and often their lives, in an attempt to get to Europe.

How do our politicians get away with it? One answer is that nobody, except those with vested interests or their paid agents, can understand the Common Agricultural Policy or, indeed, any other policy throughout the protracted, arcane, corrupt and legalistic processes that lead to their enactment or modification. It's a good bet that if ordinary citizens knew that the CAP means they pay more for their food so as to enrich millionaires, devastate the environment and destroy the livelihoods of millions of Africans, then we'd vote against anyone advocating it. But policymaking is so obscure - deliberately so, perhaps - that apathy rules.

Social Policy Bonds could be the answer: under a bond regime, we'd target explicit goals that are meaningful to ordinary people. There would be many ramifications of such an approach; one happy one would be that corrupt and insane policies, such as the EU's Common Agricultural Policy, would fall at that first hurdle.

Killing for profit

Dr Jason Fung concludes his concise post about the corruption of Evidence Based Medicine thus:

So here’s a damning list of all the problems of EBM

1. Selective Publication
2. Rigged outcomes
3. Advertorials
4. Reprint Revenues
5. Bribery of Journal Editors
6. Publication Bias
7. Financial Conflicts of Interests

Killing for profit, Jason Fung, 12 April

My comment, after thanking Dr Fung for his post, was short: I think we need to re-orientate the incentives away from activities, publications, and other surrogate indicators, and focus entirely on outcomes that are meaningful to ordinary people: longevity, infant mortality, Disability Adjusted Life Years etc. In the abstract, this sounds difficult, but my suggestion of a new financial instrument could help.

Goals for health

Peter Jacobsen writes to the New Scientist:

One factor may be missed when comparing war severity between 1823 and 2003 using fatalities.... Recent wars have had fewer fatalities, but perhaps not because they were less severe. Weapons are increasingly potent but trauma care has improved a lot, and hence the lethality of war has decreased over time. A similar bias can be seen with the murder rate. Medical care means more survive modern war, Peter Jacobsen, 'New Scientist', 27 March

This points to the importance of choosing our social and environmental goals carefully. They need to be goals that are, or are inextricably linked to, what we actually want to achieve. Do we want to aim to reduce (for instance) deaths by violence, regardless of how much funding is to be spent on trauma care? Or would any additional funding be better spent on general health care with, perhaps, more lives saved per dollar spent? These questions need to be addressed for the operation of a Social Policy Bond regime, and they are not simple. But it's crucial to remember that they need to be asked too in our current policy regimes. They rarely are. Instead funding for healthcare is typically decided by people with little incentive or capacity to maximise improvements in health per dollar spent. Funding is often a function of history, or the charisma of medical specialists, or how newsworthy is a particular health problem. (See for instance this report from Australia: Men die earlier but women's health gets four times more funding.)

My suggestion is that we issue Health Bonds, which would explicitly and impartially target improvements in longevity, Quality Adjusted Life Years, infant mortality rates and other general population health indicators. Resources are always going to be limited but decisions our healthcare goals and - and the basis on which they are made - should be made clear to ordinary people, so that we can participate, if we want, in their formulation.