Health seems to have become the theme of the day in the Lib Dem leadership debate, at least amongst bloggers (John Dixon's "A Radical Writes" here, and Tristan's "Liberty Alone" here as examples). The two candidates themselves have both now produced manifestos of sorts with Chris Huhne (page 9) promoting "the principle of universal access on the basis of need" and Nick Clegg earlier (despite John Dixon's interpretation otherwise) setting down the principle that "our universal public services must be free to use and accessible to all".

Both have admirable reasons for wanting to retain this universality and free access; that if we choose any other paradigm the poorest will miss out by not being able to afford to pay in a non-free system. But, as I've said about education, and more recently touched on in my piece about protectionism last week to me this seems, if you pardon the terrible health-related analogy, merely a sticking plaster. The ideal revolutionary liberal position surely would be to ensure that everyone had the financial wherewithal to participate properly in a market system and then to trust them to make their own choices.

On the day that the Marmot report into diet and cancer appeared, and whilst acknowledging that he said that his commission was still to deal with policy recommendations, one can be fairly certain that they are not going to recommend that the government, local or national, takes control of what dietary choices people are allowed to make. And yet our knowledge increases all the time that such choices are likely at least as important to our health outcomes as the treatment we may receive once we are ill. So why do we not do the same for illness care when all the evidence suggests that despite £110bn a year public expenditure, we are still the "sick man of Europe"?

Surgeons operating
Originally uploaded by el Reino

The NHS was, I believe, a fantastic idea at the time, in the context of the war on the five wants. In a near bankrupt nation post-war it was also clearly in the national interest to try to use economies of scale and national bargaining to ensure that you could provide a basic level of universal service to all. But let's face it, right now it is a gigantic protection racket, the mother of them all if you ask me. We also heard today that the average GP salary is now at £110,000 - a ten per cent rise in the second year of their new contracts - and yet the Department of Health today has said that 1200 British medical graduates are unlikely to get training places in the UK this year. So there's almost certainly an economic rent arising from the triple protectionism of the NHS, the GMC and the BMA.

Hopefully at least this and the national bargaining for other staff would end with localization so that those parts of the country where it is difficult (read near impossible) to live on a Grade D nurse's salary can offer decent packages, but I haven't even touched on the protectionism of NICE, NHS drugs contracts, the drugs patenting system as a whole and the stifling bureaucracy surrounding anything innovative by way of ways of treating and so on.

None of this is to say that the "private sector" is necessarily the best solution in all areas. I'm against monopoly and public protectionism, not public service per se - after all the nature of the hippocratic oath is dedication to a public service. And the worst of all worlds could be one in which there's a certain amount of public funding up for grabs by private operators who have no incentive to innovate and be really efficient - that's simply transferring the protectionism to shareholders.

No, the problem is really one of how to ensure that everyone would have the ability to pay for their choice of provider. And I return to the Citizen's Income and the systemic economic imbalances that concentrate unearned wealth, or more correctly the wealth created by the community as a whole rather than by an individual's or firm's own innovation, investment and labour. I'm not a good one to talk on health issues - the last psychiatrist I saw reckoned my attitude to my developing diabetes was one of the "slow suicide". But I'll bet if I was faced with a bigger insurance premium or buying more fruit and veg instead of eating crap, I'd probably plump for the healthier lifestyle to minimize my insurance. Redistribute the common wealth properly to everyone as is our birthright and we have these choices.

Just look at Nuffield Hospitals Group right now - it's buying up private gym firms like Cannons (effectively turning private companies into social enterprises of course). Why would it be doing that? Because BUPA really wants its members to live healthily, not to call on them when they're in a preventable medical condition. I'm also sure that insurance firms are likely to be better, with safeguards against abuse, at sifting out bad clinicians; it's in their interests to do so. Their actuaries will be poring over doctors' success and failure rates to ensure they're not granting accreditation to people whose patients inexplicably drop like flies, or who routinely over-diagnose or over-prescribe. Nor would they be likely to allow their members to spend a single night in a hospital where they're more likely to come out with a worse illness with attendant higher costs, if they come out at all.

One model I've looked at, for example, would see a GP as a "personal health adviser" who advises their clients through the maze of choosing lifestyles, treatments, clinicians and therapies that will be efficient and varied. I'd like to see surgical firms organized more like barristers' chambers with large national firms specializing in different clinical areas ready to hot-foot it to a treatment centre several hours away at the drop of a hat to do an op in their specialism rather than a patient wait on a list for the local, perhaps only semi-specialist to have a free spot in a tight general surgery list. You could have a choice of a large general hospital sized treatment centre thirty miles away in the local city, or a ten bed rural town cottage hospital with one theatre with the same surgeon prepared to visit either for the right fee but with different approaches to aftercare based on different needs of patients and families.

Sure, there's still a role for some kind of local democratic input - most especially in procuring facilities and staff for emergency medicine, but even their funding options could be varied - with some able to provide that by engaging local charitable resources, others perhaps by raising a local tax of some kind, perhaps even through planning obligations, who knows. But one thing is certain: these options and innovations are unlikely to appear when the system is riddled with protectionism and political game-play.