What is it with bloggers today.
The DK is ranting on again about getting doctors to shut the fuck up and get on with patching people up. All because doctors want anti-binge drinking policies brought in.
Stop being such a tosser, DK.
Much as I agree that the BMA should spend more time getting the basics right (such as MMC, NPfIT and so on) and stop fiddling while Rome burns, public health is the most important area of medical intervention.
Why should we keep pulling people half-dead out of the water, when we could save far more lives by putting a stop to the fucker who is pushing them in up river?
Have you heard of the Broad Steet pump?
Binge drinking is causing enormous problems and is fueled by a profit-hungry drinks and entertainment industry who show as much interest in public health as the tobacco industry did. Or do you think that attempts to combat the marketing power of the tobacco lobby are also an example of "when will these fuckers stop trying to involve themselves in things that they don't understand and just concentrate on the pill-rolling".
Exactly what are your qualifications to give an opinion on health policy, DK? How about you shut the fuck up about things about which you are, frankly, ignorant, and stick to euro-bashing.
There's a good Devil.
(I should point out that I agree with much - but by no means all - of DK's critique of much of what is wrong with the suggestions, such as prohibition not working, but am pissed off at the suggestion that we have no right to get involved in the debate).
Saturday, June 23, 2007
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Dr Rant
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56 comments:
I'll cross post the comment I made at Devil's Kitchen:
It is a bad enough that the quacks managed to get their little guild recognised by the state, thereby artificially restricting the supply of medical care (causing untold pain and misery) and artificially increasing the size of thier pay packets. But to have these pompous bone technicians lecture us about how we may or may not "go to hell in our own way" is intolerable.
Solution:
1. End the last major closed shop in Britain (besides the legal racket) by abolishing the GMC and repealing all legislation regulating medicine.
2. Split up the NHS and hand it over to local private mutual friendly societies with membership and voting rights to all citizens in that area.
3. End all state funding of healthcare and medical training.
When the medical closed shop is ended, leading to a blossoming in the supply and diversity of medical care available; when quacks are effectively scutinised and their services purchased at consortium prices by large friendly societies; and when doctors have to pay for their own training our of their own pockets -- thenthey will be too busy competing with each other for work, like the rest of us have to, to have time to lecture us on how we live our lives.
You want to improve health in this country Dr Rant? Campaign against your own self interest for the end of your own closed shop.
As someone on another blog said "get your own house in order and leave us alone".
"by ... repealing all legislation regulating medicine"
Don't be so fucking stupid.
Even if you've not read George Bernard Shaw's The Doctor's Dilemma, only a village idiot would think that anarchy in medicine is anything other than a barking suggestion.
I know, why don't you entertain us with some predictions of how things would improve.....
Sure professions are a consipiracy against the laity. But would you rather have someone who has conspired how to do medicine well for many years treat you? Or some person who's got it off google and is now expert on all things?
Medicine and Law are high order intellectually snobbish professions. We have our worth and our pride. Sometimes we can be arrogant.
But even the most pure market orientated economists are unlikely to suggest reducing the standards of law and medicine. This is one case where a slightly distorted market is a useful means towards a greater good- namely reasonably safe medicine and law by experienced and skillful experts.
Thin Red Adair, "If you think professionals are expensive see how much an amateur costs you"
I totally agree with Dr. Blue. Fascinating article.
Dr Rant:
Ha ha, yeah because the GMC has a great track record of keeping perverts, psychos and incompetents of the register doesn't it? Paging Doctor Shipman!
The state makes a rotten regulator and always has, but the worst of all worlds is when the state mandates a profession to regulate itself.
And if you're going to use an argument from authority, best not choose a man who thought Stalin was a top chap. Weakens your point somewhat.
blue:
Who mentioned a conspiracy? You're in one of the few remaining guilds. Well done, wish we could all escape economic reality like that.
You shouldn't all feel threatened by what I say. The services of competent physicians will be in high demand in any economic environment. Your pronouncements on what should and should not be legal? Hmm, maybe not so much.
charles,
I accept what you say about GMC and medical/professional regulation not being perfect. State regulation even less so. Unfortunately the courts are not proactive in stopping murderers robbers and fraudsters, and GMC can only prosecute those who have broken the rules.
The "Conspiracy against the laity" quote is from George Bernard Shaw's preface to "The Doctor's Dilemma" He also accused the profession of having "an ignoble character" His dad was a physician, and the characters in Doctor's Dilemma are well observed and still very recognisable.
Whilst you can make a case for opening up medical provision if you overproduce/underpay doctors the reward/effort ratio will tip students away from doing medicine. MTAS may have achieved this effect. It's already driven many young doctors to point of considering suicide.
I know we are in a semi-protected/scarcity guild, but I think doctors need this if you want good doctors to continue.
If you'll accept anyone treating anything then good luck to you, but I'll be away to private practice, and charging a decent fee. The inequality that would lead to poor patients getting poorer care would not be pretty. The NHS currently limits medical private enterprise, and maybe that's a good thing.
Charles
The US, as a bastion of competition, has medical care twice the price of ours - and still has a shorter average life expectancy (by five years) and 25% higher infant mortality rate (so of any five American babies that die in the first year of life, one would have survived had it had the good fortune to be British)
So, there is good evidence that socialised medicine works. Indeed, healthcare is one of the few things in Cuba that works well (they also live longer than Americans)
I enjoy the priviledge of being able to try to offer patients the care they need despite the NHS, without needing to pander unduly to the worried well at the expense of those unwell enough to stop work.
Whether we should be making nanny-state pronouncements on public health is an entirely separate argument - and one of the two reasons we are not all BMA members (the other being its recent collusion with the government in the MMC/MTAS debacle.). I, personally, think you should have the right to smoke drink take drugs skydive and sleep around - as long as you are aware of the risks you choose to accept, and don't harm others in the process.
Somewhere in the archive is a post pointing out that annual vet insurance for a hamster is about three times the cost of UK GP care.
There is little doubt the government wants us to 'do a dentist' and so see most people pay for their own primary care - leaving it providing a poor quality 'rump' service for the poor.
Think about your dental costs, and then reflect that the mouth is only a very small part of the human body.
As a rough rule, despite its failings the medical profession is the only profession I don't have utter contempt for. For example, I do trust my GP, and also trust any specialist she tells me to trust by sending me to consult him/her (personally I prefer hers, because I tend to see men as ... can't find the right word ... rivals, or potential enemies, and so am wary and reluctant to give anything away.
But I've got to agree with the attitude that we should be able to find our own way to hell. Some people drink themselves to death, some people hang themselves or slit their wrists. All that is fine by me. I personally have smoked myself to death - first time I saw my current GP I told her that all I really expected of her was that she manage my decline so I don't suffer too much. Also told her that when I get to the point where I can no longer look after myself, or can no longer wipe my own arse, then it'll be time to go. A big shot of barbies and a bottle of good brandy if I can get the barbie prescription; other means if I can't. If I do have one seriously big whinge about the profession it's that you don't let people make their own judgement on when they've had enough. Do you think you know better? It seems to me that the desire to be done with it all is taken by you to be evidence of mental illness? Why?
There's a 15 yr old boy lives near me who slashes his arms; last week I asked him if he wanted to borrow my cutthroat razor (yes, I actually do shave with one of those - also makes a handy weapon in extremis if the jihadis ever find me :)) so he could make a better job of it. As I expected, he didn't take me up on the offer and hasn't spoken to me since. Suits me. If someone says he/she wants to kill themselves, my attitude is yes sir - can I help you with some barbies, a rope, the stairs to the roof?
You shouldn't impose your values.
No, I have no plans to die in the immediate future but when I me and nobody else decides it's time to go, I'm going. A doctor or pharmacist can make it easier for me, or they can impose their own values on me and make it harder for me. But I'll be going just the same.
I have a rather large tattoo on my chest that says "Never Resuscitate". What do you think the hardest part of dying is? Being doctors I imagine - though I don't KNOW - that you think it's the physical effects. If you do, you're wrong - it's the psychological processes. Once you've lost consciousness you've gone through all those psychological processes, the terror, the anguish; the worst is over. Then some fucker comes along and resuscitates you ... and you're going to have to go through all that again. Believe me, I know.
I appreciate the generality of the value doctors put on life, but please, don't think that the value you place on it is the only valid value available.
Of course, that bastardly bastard of a legal profession has a lot to do with the lengths doctors will go to keep someone alive long past the time they should have stepped off. If I had the power to do so, I'd deal with that profession by ... no, I'd better not say that: too many lawyers about.
If people want to binge-drink themselves to death, let them (personally I don't drink - or use any other drugs other than what's prescribed (used to, but don't now) ... apart from tobacco.
I know it's bad for you, but if you gave up smoking, and drinking, and other drugs, and shagging, and fighting - would you really live longer or would it only feel like it?
And try to get this into your heads as a profession. Millions of us don't have your lifestyle. Millions of us lead a shite life - and when you're living a shite life more life just means more shite, and everyone reaches the point where they've had enough shite. They drink, for example, to get absolutely shitfaced so they can forget the shite for a while. You'd take that away from them?
Apologies for the rant. Once I get going I could give the corporal a lesson or two.
And as for that bitch Warnock ... nah Sir h, leave it alone.
blue:
If you'll accept anyone treating anything then good luck to you, but I'll be away to private practice, and charging a decent fee. The inequality that would lead to poor patients getting poorer care would not be pretty. The NHS currently limits medical private enterprise, and maybe that's a good thing.
Welfare state myths. The poor get shit health care in this country with the NHS and the middle classes know how to game the system. Same with education. Look into your history. The trade unions and friendly societies (mutual societies of working people) were starting to get the doctors on the run, pooling their purchasing power as a consortium to get reasonable prices, before the state stuck its beak in disrupting the evolution of civil society as usual. But then, that's the story of the 20th century in general.
anonymous:
The US has nothing approaching a free market in medicine. It has its own equivilent of the medical closed shop, who to make matters worse are in active colusion with the cartelized insurance business.
As for Cuba, it is a vile dictatorship, so I couldn't give a shit if doles out the odd operation to its slave population.
I thought bloggers thought outside the boundaries of lazy mainstream myths?
pooter: So, when on holiday miles away from home you accidentally catch sight of a Guardian and suffer a massive heart attack, how are you going to evaluate which of the local unregulated healthcare suppliers should treat you?
You'll notice that all the countries that rely on insurance based healthcare have the highest costs for the least amount of treatment.
Sir HM -
Good on ya Sir. Your wish to not be resus'd is my command. Speaking as someone who has to do it to people. Resus I mean. Trust me when I say that your chances of making it through a resus are less than 1 percent in hospital. This figure is based in the audit I did at a DGH somewhere south of the Watford Gap. I was actively discouraged from publishing by my boss's boss. "It would cast the trust in a bad light." I would much rather not waste my time putting you through one of the most medically traumatic process there is. If you are gone or going I would love nothing more than to make you comfortable. In the UK the docs get to make that decision. Over here, in Oz, if your family want you brought back and we don't know about it we have to try and get you back. If at 50 (a random figure here) you come in with pneumonia and you suddenly stop breathing - you get resus. It could be 80. Unfortunately, TV makes it look like we can get you back. In hospital you have less than 1% chance. If you are brought into hospital in an arrest post trauma your chances are virtually non existent. But we still have to try. Both salutations are different but the outcome is much the same. Society as a whole demands equality. You cannot deny one person resus and offer it to another. It is there for all. You as the patient have to opt out. Your family often make bad decisions based on grief for you.
Currently every patient I look after (unless it is completely outlandish) gets a talk about resus or their relatives do. It takes me a minimum of an hour per patient. Because every patient has relatives and they always want to talk about it. Of course my decision about whether or not you should be resus'd is based on my experiences doing it to people. I am only one of the team that does it - but mainly I lead the process. I agree that my decision may not be your decision. I will try very hard to give the patient a clear knowledge base on which to make their decision. I am not allowed to be paternalistic. If you decide to be resus’d inappropriately I will follow your wishes. You are going to die with broken ribs and a tube in your throat. I will not belabour you with that fact. If I do I could bully you into a decision you do not agree with. After all if I am talking to you about it you are un a vulnerable position.
I applaud you Sir HM. Few deal with their mortality. Then again you are predicting your death based on your ?probable COPD. The previously well 80 year olds that I look after have often not even talked about resus with their wives or husbands. Let alone their sons/daughters who have not seen them for months at a time. Those children sometimes have guilt issues and make decisions based on that. Before you say that not all children are like that - I know. Some are though.
Can I advise that you talk about death and your wishes with your families? If you do not know about resus ask a doc. ER/House/Casualty/Scrubs etc are not reality. What they show you is not what happens.
Just a small point also - your docs and nurses are human. We really don't like inflicting torture on people. Resus is pretty bloody awful on the patient. It can be bloody awful for the resus team too. We are not sociopaths.
Shipman was one person. How many mathematicians or binmen are serial killers? I could have said merchant bankers or solicitors - the choice of job is incidental. Do not tar us with the same brush.
Dr Sniper
Anonymous:
Hmm, so instead of answering my points you ask what I'll do when I'm abroad and guess my newspaper-reading habit? As it happens, I find The Grauniad the least offensive of the UK papers (though obviously, Toynbee's economic illiteracy gets me hot under the collar, as it does all right thinking people).
Why do you assume that someone who thinks the NHS is non-optimum wants a US-style cartelized insurance-based model of healthcare? I've already explained that a better economic model for healthcare would be one of mutual societies of working people purchasing medical care from Doctors (or groups of Doctors) within an unregulated free market. This was the situation that was starting to develop in this country before the state stuck its beak in.
To answer you facile question: in the system I describe, my mutual society or trade union would have agreed limited reciprocal heathcare arrangements with trustworthy providers in other countries, in the same way the government does now. That wasn't difficult was it?
Why not try to develop beyond a two-dimensional, sixth-former, left/right, Cuba/USA view of politics and economics? Oh yeah, I know, because it is easier to just snigger about Daily Mail readers.
One thing the free marketeer's never address is the anti-democratic nature of the unregulated free market, a slight problem to say the least.
Obviously the corruption of democracy is a problem, however if state regulation is done away with completely then the consequences would be dire in the long term.
At least a state own monopoly is democratically accountable, a privately owned unregulated monopoly is an utter nightmare.
It's amusing that there are still some utter idiots who refuse to learn lessons from history that repeat themselves over and over and over again.
The extreme solutions of BOTH kinds do not work.
Ps
Charles Pooter- are you aware that junior doctors do pay for a large amount of their training already?
the diversity you talk of will mean people with less rigorous training operating on and treating patients, a very scary prospect
the market wouldn't lead to an improved service as if by magic, have you not noticed how the unregulated market can lead to the cut of service quality in order to maximise short term economic gains?
Charles
Apologies - one of the snags of being 'anonymous' is that other people post under your name.
What I want, is the best return on the healthcare pound (or dollar, if you prefer.
Cuba, and the NHS of yore, used to deliver this by being very very cheap - with pared down administration, clinicians paid less than cleaners 9and cleaners not paid well), and a innate resistance to new and expensive technology.
Fee for service healthcare is patchy, neglects the greatest need, and employs lots of layers of admin. i am glad we agree the US is a poor model to follow.
What could be better?
Multiple providers as you suggest? - possibly, but I suspect the admin costs outweigh the benefits (certainly the view of the French and German governments)
Competition within the NHS? - ie multiple independent regions - so no duplication of services, but comparative competitive data - why is your service not doing this when theirs is?
Financial incentives for staff? Almost certainly. Why not have a 5-10% bonus if targets met - as in much of the real world. As a simple example - GPs are paid a flat fee for providing 45 hours of availability Monday - Friday - and prohibited from charging a premium for a better service. Remove that bar, and evening and weekend clinics would emerge in urban areas - just as you can get dental care at the weekend if willing to pay.
Competition over time? Perhaps the franchise model, like the railways would work - a management team bids for the contract to manage a service for X years. With some creative thinking, ensuring that profit was aligned with improvements (or savaged if services got worse) we could actually have competition to run the system, without the waste of effort and duplication that a competitive market in healthcare creates.
(to take a simple economic model - if you have two ice cream vans on a beach, where do they park? Answer - next to each other in the middle. True competition would do the same to hospitals, which is stupid.
Just to elaborate on junior doctors paying for their training:
I have a study leave budget of £730/year. It's been reduced and will be again.
I have done 3 post graduate examinations directly needed to progress as a medic: the MRCP part 1, the MRCP part 2 written, and PACES. I was lucky enough to pass these first time round (many don't).
In addition I am expected to attend courses regularly for both general medicine and my speeciality (gastroenterology). I am expected to attend conferences. I want to do these things however...
I estimate that with textbooks, courses to prepare for the exams, travel to and from, not to mention the exams themselves (not cheap - ta to the colleges for that one) the exams alone cost me in the ballpark of £7000. I received £1200 back from my study leave budget - I did two of the exams in one calendar year and the budget does not take this into account.
Each conference costs on average £700 - more for some. I am expected to attend at least one/year.
Each course costs on average £600. I am expected to go to 2/year.
They're in the process of launching another exam I'll have to take in a few years time. £800 plus textbooks, courses, travel, blah blah blah.
And did I mention my pay will go down repeatedly as the BMA have been unable to pay protect us?
I hear about the lives of trainee solicitors and other professional juniors. Yes their hours suck. But they are very well looked after.
Replicating the franchise system of the railways for health is a truly awful idea. It just hasn't worked. At all. Quality of service is still crap and the prices have gone up, up, up, and away.
"Why should we keep pulling people half-dead out of the water, when we could save far more lives by putting a stop to the fucker who is pushing them in up river?"
Because you're paid to out of my taxes. Of course, I'd welcome a world of 100% privatised medicine in which case you would be free to decided your own policy and I wouldn't be robbed blind to keep you in a job.
"Exactly what are your qualifications to give an opinion on health policy, DK? How about you shut the fuck up about things about which you are, frankly, ignorant, and stick to euro-bashing."
Steady on their comrade, since when did you know whats better for DK than DK?
"Because you're paid to out of my taxes. "
Blimey, what a fucking moron. I mean, how can someone be so stupid? We're talking Ignorant Olympian here, the stupidest of the stupedest of the stupid. Ubermoron. Ultrathicko. Intergallactic, supernova, aneuronic, spaktard of the century. You can't buy that kind of stupid.
(1) The BMA are not paid for out of any taxes - doctors fund the BMA.
(2) Preventative medicine as a goal is a bad thing!?
(New Liberty? What's that, some kind of half-baked right wing white supremacy organisation?)
(New Liberty? What's that, some kind of half-baked right wing white supremacy organisation?)
I have no brief for this commentator, but shouting "racist", especially when there has been not the slightest evidence of such, is the modern equivalent of shouting "witch". Yawn, how pathetic.
P.S. "New Liberty" is probably a reference to this: http://www.mises.org/rothbard/newliberty.asp
The Austrian economists have a lot of interesting things to say. I think they have some blind spots, but certainly worth reading.
anonymous (Castro-worshipping one):
You haven't listened to a word I've said. My critique of medical provision is far deeper than a simplistic critique of the NHS. Indeed it is true that to "privatise" the NHS, whilst an artifical restriction on the supply of medical expertise is still in place, would lead to worse care rather than better. The NHS acts as a balwark against the Doctors' guild (which is why they were against its creation in the first place). It is a pretty crappy negotiator as the recent pay rises testify, but it is better than many consumers competing against each other for limited supply.
My solution to this is to end the artifical restriction on supply by removing state-enforcement of the Doctors' closed-shop.
So who controls quality of service?
At the risk of reapeating myself (I seem to be doing that a lot in this debate), I think that, in a free market, heathcare would be an ideal sector for mutual societies to act as consortium purchasers for their members. These mutual societies would also have the time, power and money to act as regulators and quality controllers, in a way that individuals do not.
This is not to say that people wouldn't also be free to go the crystal purveyors and snake-oil salesmen, but then they can now. Ultimately you can't protect people from themselves, but what I'm sure is possible is giving people the choice to pool their resources to get decent healthcare at a reasonable cost to themselves and their fellows.
Probably to the relief of all concerned, I've run out of things to say on this topic, so if anyone else wants to argue against the American healthcare system or other irrelevant ideas I haven't put forward, you can do so safe in the knowledge I won't be replying.
"I have no brief for this commentator, but shouting "racist", especially when there has been not the slightest evidence of such, is the modern equivalent of shouting "witch". Yawn, how pathetic."
I am suitably chastised. Apologies.
I still think he's an idiot, though.
"(1) The BMA are not paid for out of any taxes - doctors fund the BMA."
The non-tax funded BMA keeps "pulling people half-dead out of the water"?
I think it's pretty clear I was actually referring to the public sector tax-funded doctors whom the BMA claim to represent.
"(2) Preventative medicine as a goal is a bad thing!?"
No, it's probably a good thing, which is why I'd rather the government stay the hell away from it and everything else. It's not so much of a good thing that it should be forced down peoples thoats by the ivory tower brigade who, it appears, you are at pains to defend.
"My solution to this is to end the artifical restriction on supply by removing state-enforcement of the Doctors' closed-shop."
Amen.
"I think it's pretty clear I was actually referring to the public sector tax-funded doctors whom the BMA claim to represent."
No, I still don't have a clue what you are talking about.
I think you mean you think it is a waste of tax payers money to attempt prevention.
I also think you're a moron, but I'm open to suggestions on both counts.
(Oh, and Dr Rant is no supporter of the BMA, but given a choice between gin-swilling pompous asses and a bunch of people who think an unregulated market is a good thing for people's health, we have to come down on the side of the slightly-less cretinous group......)
slightly-less cretinous group
You sir, are a dick. Good day to you.
*sigh*
"I think you mean you think it is a waste of tax payers money to attempt prevention."
It may or may not be a waste, I dont care. I dont agree with funding preventative medicine, or anything else for that matter, through the use of unjust violence.
If you do then thats great, but then you'd be a hypocrit for trying to give us a moral lecture on the consequences of binge drinking.
"It may or may not be a waste, I dont care. I dont agree with funding preventative medicine, or anything else for that matter, through the use of unjust violence."
I think it's time for your medication. Unjust violence in what sense? The violence done to the cells of the liver by alcohol producers pressing their dangerous wares on vulnerable teenagers?
"If you do then thats great, but then you'd be a hypocrit for trying to give us a moral lecture on the consequences of binge drinking. "
How would I be a hipocrit? How is this a 'moral lecture'?
charles
(if you bother to return)
I have read your posts. The world contains a number of medical models.
Ineffective healthcare (most of it)
Cheap socialist medicine (Cuba)
Expensive privatish medicine (USA)
State monolith (NHS)
Competing but compulsory insurance
You favour the last model - but it has a number of flaws, and makes European health care more expensive - other countries are moving to a GP gatekeeper model because
if they don't compete, it changes nothing
if they do compete, then inevitably one selects its patients better (avoiding the ill), the other then makes a big loss, and is bailed out by the state (as too big to fail)
There are bits of the NHS that work well (general practice and true emergency care, paediatrics), bits that work less well, and bits that are awful.
Personally, I would
1. have a local NHS tax (as we do for fire/police) so that we stop the nonsense of stopping elective work for 3 months to balance the books, and to give patients a greater incentive to economise
2. reform prescription charges
Group A =free = live preserving
eg insulin, thyroid drug, asthma preventers
Group B = subsidised
eg most short courses of medicines, most cheap generics
Group C = full cost
if you want the branded/latest version, pay for it
3. Separate the NHS from immediate government control - you cannot run a service on a 4 year political cycle
4. Allow premium payments for enhanced services
eg 9.30 - 3pm free appointments
(60% of new docs female)
with a small premium for 5pm, bigger for 7pm - but with patients free to pay and docs free to charge
5. Competition
I would ask for competitive tenders to run a service for say 10 years - but set the terms so that service provision and development is rewarded, not just thrift.
If you have competing insurers all receiving the same state fee, you lose more in transition than you gain in competition.
If you have different levels of service for different levels of insurance, you are introducing Rationing and ending the current all services for all needs fantasy
To the anonymous who claimed that the free market is 'anti-democratic'.
What utter nonsense. The free market is the ultimate democratic system, it enables individuals to choose what is best value to them. It enables the most popular to be the most available, but if an alternative is more valuable you can still get it.
True, it prevents members of a self-selecting class who happen to have been elected by a tiny minority of people's votes deciding people's lives for them, but it increases democracy in terms of individuals actually getting to influence the world around them and make decisions.
As for health care - privatise the NHS, allow competition, let people decide to get insurance, or a health savings account or just go it alone (or join a mutual or whatever).
Break up the GMC. Certifications will arise and will be like brands - bad doctors will negatively affect the brand of the certificating authority meaning less custom for doctors certified with them.
Again with medicine. Remove all certification. Let people take risks if they like. It will mean cheaper healthcare and higher availability of more treatments.
As for travelling abroad - I buy insurance to cover me. My insurer will be able to supply the name of a suitable doctor or certification authority. Or my friendly society will.
There's no need for monopoly or state intervention, except to increase the power of the state.
The idea of mutualisation, though good in principle, will fail in practice in just the way insurance does. What happens when a family wants to join your scheme but they have four children, three of whom have cystic fibrosis? The accountant looks at the size of the group, shakes his head and mutters that it's all going to go tits-up unless you either recruit 200 more members, or increase your premiums by 30%.
In practice what will happen is the family will be told that the group is 'closed' (and they can take their genetic misfits elsewhere)
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