The following piece of mine appears in The Spectator's supplement, 'Blair: A Modern Tragedy':

New Labour had its limits, even in 1997. Those limits were made flesh by the appointment of Frank Dobson as Tony Blair’s first Health Secretary. For all the changes which the NHS has seen since then, there has been an underlying Old Labour consistency to Labour’s approach to the NHS over the past decade: spend as much money as possible, fiddle with the management structures, and all will be well with the wonderful NHS.

But if that was the answer, then one has to wonder what on earth was the question. Tony Blair’s legacy, after a decade in charge of the NHS, is a false dawn on reform and waste on an unprecedented scale.

Much attention has focused recently on the chaotic £12 billion NHS IT project (projected by the Public Accounts Committee to end up costing £20 billion). But that is a pinprick compared with the overall sums thrown at the NHS’s fiscal black hole. By the end of this financial year, NHS spending will be £92 billion - a rise of over £50 billion a year since 1999. But to what end? Even the King’s Fund, one of the NHS’ stalwart defenders, has conceded that three-quarters of the increased spending disappears each year in costs rather than “activity” (the jargon for treating people).

One unglamorous branch of the NHS’s activity is typical of the failure to solve the fundamental problems. The latest survey into waiting times for hearing aids found that the average wait in England for someone needing their first had risen for the third year in a row, to between 45 and 48 weeks. There are wide variations across the country; patients in the South East wait between 73 and 74 weeks.

So much for more money being the answer.

When Labour took office, its belief in the NHS as the only moral method of healthcare delivery was exemplified by one of Mr Dobson’s first acts – ordering local health authorities not to talk to the independent sector, let alone deal with it, unless in the most dire of emergencies. His instruction was based on nothing other than a visceral loathing of the idea of non-state involvement in healthcare.

Mr Dobson’s successor, Alan Milburn, had a more grown up approach and by October 2000 had signed the ‘Concordat’, which contracted NHS work out to the independent sector. This was by far the most significant development of Mr Blair’s period in office. Even Baroness Thatcher had run scared of such an idea, fearing it would confirm fears that she wanted to privatise the NHS. But the plain fact was that the NHS’ capacity could not meet the demands of patients; why on earth would the NHS (ital)not(ital) want to utlilise the independent sector’s spare capacity?

There was, of course, more to it than that. At the launch of Labour’s 2001 manifesto, Tony Blair spoke of there being “no ideological bar” to expansion of the role of independent provision in the NHS. What this should have meant was that the NHS would become simply a purchaser of services - the logical extension of the Tories’ original purchaser-provider split, but with real, open competition for the provision of services, rather than the pretend competition between different branches of the public sector.

But it was the familiar New Labour story – much promise, little reality. Take foundation hospitals. In theory a fine idea with the power to transform the NHS, foundation hospitals would have been tax funded but free-standing, independent hospitals competing with traditional NHS hospitals on the only worthwhile basis: quality and price. After a mauling from the Treasury, they were then subjected to an even more mortal foe – Labour backbenchers wedded to the existing NHS dogma. When the first foundation hospitals arrived in April 2004, they were barely worth bothering with.

Eventually, both Mr Blair and Mr Milburn came to realise that competition was key. Last year, all patients were promised a choice for elective treatment between four providers, one of which had to be independent. The aim was that by 2008 patients should have an entirely free choice between any NHS, charitable or independent provider that met the required standard at a national tariff price. The 2008 target will certainly be missed, and there is no confidence among reformers that 2009 will be any better.

But even this mess comes only after a catastrophic error. The notion has somehow taken hold that a radical Tony Blair was, as in education and welfare, stifled by his Chancellor from making the necessary bold reforms to healthcare provision. But it was not Gordon Brown who, in January 2001, sat on Sir David Frost’s BBC1 sofa and announced that NHS spending would rise to the EU average. It was Mr Blair. In reality, the Prime Minister was the prime mover behind the idea that money was the real problem and bounced a horrified Chancellor into a spending commitment for which the word profligate does not even come close.

Between 1999/2000 and 2007/08, spending on the NHS will have almost doubled in real terms. In 1999/2000 spending was £40.2billion; in 2007/8 it will be £92.6 billion. But the result, far from curing the NHS’s ills, has been paltry. So where did the money go? In its 2005 review of the UK, the OECD found that although the NHS budget increased by half between 1999 and 2004, the number of doctors increased by only a quarter. And Department of Health statistics show that although there has been an increase in the number of operations, it is much slower than the increase in the number of doctors or spending. Productivity, in other words, has fallen. So it should come as no surprise to discover that 56 per cent of the £5.5 billion extra spending that went into the NHS in 2005 last year went on pay.

The think tank Reform has led the way in unearthing statistics which put the past ten years’ performance in perspective. As its latest survey puts it: “The current behaviour pattern of the NHS now resembles that of the British economy in the era of stagflation. An inflationary increase in costs and rise in money expenditure – go - leads to a drastic stop which threatens investment and innovation for several years. The sheer size of the increase – a three fold increase in cash funding and a twofold increase in real terms – has made it impossible to use the funding effectively and swamped the management capacity of a system which had become adapted to working on much smaller increments.”

Labour’s 1997 campaign song, Things Can Only Get Better, has an especially hollow ring with regard to the NHS. After years of madcap spending increases, the brakes will soon be applied. Having squandered the money and done little to reform the fundamentals, the next few years promise a return to the same ferocious headlines of waiting lists and rationing on which Labour capitalised so effectively in 1997. The biter, bit.

My friend and colleague Helen Evans, a former senior nurse, has started a new campaigning organisation, Nurses for Reform. Healthcare reform debates tend to centre on doctors and policy wonks, but the poor bloody infantry rarely get a look in. And when they do, via the dreadful Royal College of Nursing, it's to resist reform and entrech the worst aspects of statism. The RCN is a 21st centrury equivalent of the NUM.

So three cheers for an organisation which is run by and designed for nurses, and which exists, as the site puts it:

[T]o campaign for more consumer-oriented and sustainable healthcare systems in Britain and Europe.

Even better, NFR has started a blog which you can read here. This is from the first entry, which is spot on:

NFR believes it is no longer acceptable for nurses to sign up to careers in public sector healthcare only to find they are unable to access the resources and autonomy they need to do their work. NFR rejects bland egalitarianism in favour of contestability. Above all else we believe that greater partnership with the private sector is to be actively welcomed and that this sector’s contributions are good news for patients and healthcare professionals alike.

Today, too many nursing trade unions and representative bodies fail nurses because they invariably stick to old and out dated agendas. Instead of championing substantive reform - and in doing so, championing the rights of consumers - they default to short term platitudes such as demanding more tax payers’ money or new forms of legislative favour. Such an approach is not only disasterous for nurses but it is catastrophic for patients.

NFR believes in fundamental change. It believes that only by putting patients and consumers interests first will healthcare improve. It is only when healthcare is opened up to real consumers and trusted brands that nurses will find themselves working in a sustainable environment and with the incentives, resources and encouragement to deliver a responsive, popular and truly high quality service.

The following piece of mine appears in today's Times:

In Saturday's Times Lord Harries of Pentregarth gave an interview in which, as interim chairman of the Human Fertilisation and Embryology Authority, he argued that women in their fifties and sixties should not be banned from having IVF because of their age.

Lord Harries was addressing the ethics of IVF treatment and the notion of age and sex discrimination. It is wrong, he said, that the over-50s are denied a procedure available to younger women. After all, “men can conceive at a vast age”.

The former Bishop of Oxford might have thought he was dealing with the issue of IVF. In reality he was delivering a rapier thrust against the NHS itself.

According to its “core principles”: “The NHS will provide a universal service for all based on clinical need, not ability to pay; the NHS will provide a comprehensive range of services.” In other words: you will be able to get everything you need on the NHS.

And yet. The NHS does not even implement the guidelines on IVF by the National Institute for Health and Clinical Excellence (NICE), which say that three cycles of treatment should be available, but only to women under 40. In 2004 the Health Secretary, John Reid, said that only one cycle would be paid for.

Lord Harries believes that it should be left to doctors to decide who should and should not have IVF treatment, with no upper age limit: “I don’t think it should be mandatory, I don’t think it should be legal. I think it should be a clinical judgment.” That is a perfectly reasonable position. But it cuts to the heart of the problem of NICE, of tax funding of healthcare, and of the NHS itself. Because doctors don’t decide. Gordon Brown has decided who should have IVF treatment, just as he has decided who should get Alzheimers drugs.

Not because he isn’t spending enough of our money on health. As every passing day shows, he is spending unimaginably huge sums on the NHS. No; it’s because he is spending our money on a tax-funded system with the State, through NICE, deciding who gets what. It shouldn’t be called NICE, but NASTY: Not Available, So Treat Yourself.

Lord Harries’s remarks point to the fallacy of the NHS as a supposedly full healthcare provider. IVF is like any other treatment: not available to everyone who needs it, let alone who wants it.

...and if Tuesday's CSpan broadcast isn't enough for you millions of healthcare policy wonk groupies, a webcast of my Heritage/Galen/IPI Capitol Hill briefing will be available here on Wednesday at 3pm London time.

UPDATE: It's here. My bit starts at 44'34''.

If anyone's interested in such things, I'll be wearing my wonk hat and taking part in a seminar on Tuesday at the AEI:

The Business of Health: How Does the U.S. Health-Care System Compare to Systems in Other Countries?

I gather that it is being shown on CSpan (although don't take that as gospel).

Daniel Finkelstein makes the critical point about Gordon Brown's silly NHS plan:

The NHS is not like the Bank of England. The Bank is setting the price of money. The NHS has an output not far off that of Portugal. It handles something like 10 per cent of our national income. It employs thousands and thousands of people. It is a very different animal.

There are two ways of holding such a body to account. The first is through voice — the right to protest to a political representative who depends on your vote. The alternative is exit — the right to take your custom elsewhere, with the seller dependent on your patronage in order to thrive.

Mr Brown plans to remove both these forms of accountability. When he describes the new board as independent, you just have to ask: independent of what, exactly? And the answer, it turns out, is independent of you and me.

As I point out on my CNE Health blog, none of Labour's reforms amount to anything beyond making the best of a fundamentally flawed model.

We have tried 'voice', and it doesn't work. In fact it has made things worse, with the government responding to voters' concerns by spending billions of pounds more as a supposed cure for the NHS' ills.

The government thinks it has introduced 'exit', by planning for a measure of choice amongst the providers of a service. This has an upside and a downside. The downside is that it is not real exit or real choice, since the choice to be made available is a limited one at the discretion of the authorities.

The upside, however, is that once patients start excercising choice of any sort, even on this limited scale, the genie will be out of the bottle and the issue of a wider, more genuine choice will arise. Patients will demand not just the limited choice they are to be given but the ability to decide for themselves where and by whom they will be treated. And that means not just within a tax funded NHS brand, but from any willing provider they wish. And once that happens, why would they want to carry on handing over taxes for the government to allocate on their behalf?

The NHS may not be dead yet, but it's only a matter of time.

It ain't my fault, guv...

Evolution and the environment, not just gluttony, has led to a global obesity pandemic, with an estimated 1.5 billion people overweight -- more than the number of undernourished people.

Here we go again.

I've just seen this excellent article by Melanie McDonagh in the Sunday Times, which is spot on:

...I do know the cause of obesity: we’re eating too much and exercising too little. Especially in Britain, which is, apparently, the fattest nation in Europe.

So far so straightforward. But the moment you suggest that fat individuals bring their fatness upon themselves you enter the minefield that is obesity politics, which has a language all of its own.

The World Health Organisation calls obesity a “rising epidemic”, which is fine if you think of the term simply as meaning a common condition. But the word is normally used about disease. And fatness is quite unlike most diseases in that it doesn’t fall impartially on the just and unjust alike.

There are any number of diseases occasioned by fatness, but the condition itself is brought about by your own actions. Or inaction. It’s not a contagion like measles. You don’t catch it like the plague. It’s even unlike those diseases that you do bring on yourself by bad behaviour— syphilis, say — in that it’s not transmitted by bacteria. To talk about an epidemic of obesity is like talking about a plague of inactivity or a contagion of overeating.

Which brings me to Anne Diamond, the formerly skinny television presenter who has shared her weight troubles with interested television audiences for about a decade. Now, by dint of weight-loss surgery, she is down to a respectable size 14. Her essay this week in Hello! magazine about the way society stigmatises fat people is a model of the sloppy thinking that characterises much of what passes for debate on the subject.

“We [viz fat people] are normally considered to be lazy, slobbish and lacking in moral fibre,” she declares. “Yet nothing could be further from the truth . . . it can happen to anyone . . . We’ve somehow been caught up in an epidemic.”

Don’t you love that word “somehow”, which suggests that there could be some mystery about cause and effect? Normal people attribute extra fat to the fact that they’ve eaten their body weight in Mars bars or never go out on two feet when they can use four wheels instead. Celebrity obesity victims take a different view. “Fat isn’t a sin,” says Diamond. “and it doesn’t demand punishment.” Well, no, fat isn’t a sin, but gluttony and sloth are. As St Thomas Aquinas, no lightweight himself, put it, “gluttony denotes inordinate concupiscence in eating”.

So Diamond has set up a website called Fat Happens! to enable overweight people who want to become slimmer to share views and find supportive friends. The aims are admirable and the means exemplary; it’s the underlying premise I take issue with. Fat doesn’t “happen”; you bring it on yourself.

I used to be fat. Genuinely obese. A porker. Now I am merely overweight. The reason: nothing to do with genes, with circumstance, or with any external factors. It's because I changed how I behaved.

The change came when I was, wearing my think tank hat, writing a pamphlet about adult onset diabetes in the US. As I was researching it, the penny dropped: I was a classic case. I was fat, I had a sedentary lifestyle and I had a family history of diabetes. If I didn't change, I was a slam dunk to become diabetic.

Now that's what I call motivation. So I did what anyone with half a brain would do: I changed. I went on a diet and lost weight, and I started excercising again. Why had I been fat before? Because I ate too much, and of the wrong foods. Whose fault was that? Society's? My friends's? My genes's? Uncle Tom Cobbley's? Nope. My own. No one else bore the slightest responsibility. Not advertisers. Not restaurants. No one.

I was approaching 17 stone when I started to be sensible (I can barely write that without going red with shame, since I'm hardly a strapping 6 footer on whom it might have been ok). Within eighteen months I was down to under 13 stone. And that's where I hover now (and have done for the past 3 years). It's more than it should be - my ideal weight, I am told by the experts, is about a stone less. But that is partly compensated for by the fact that I run three times a week (if I'm being wholly honest sometimes it's only twice) for up to an hour each time. And I box for half an hour once a week.

I write all that only to show that if I - Mr Couch Potato - can do it, anyone can. And if you don't, and you're overweight, there's only one person to blame. And you'll find him (or her) when you look in the mirror.

Wearing my policy wonk hat, my latest paper - Cholesterol:The Public Policy Implications of Not Doing Enough - is published tomorrow and launched at a seminar in Brussels.

To quote the abstract:

The purpose of this paper is to consider the implications for public policy within Europe of a continued lack of attention to the impact of high and rising levels of cholesterol between now and 2020.

Rather than dealing with the purely medical impact, it will concentrate on an area of public policy of universal concern, namely, the impact on Europe’s welfare systems and the knock-on effect on national budgets and economic growth.

After examining the likely state of play in future years, it will show how cholesterol levels will make the situation far worse and threaten to undermine proposed policy solutions. Finally, it offers non-medical policy solutions which might be adopted as a means of averting such problems.

Told you it was an insomnia cure.

As I say, it's launched tomorrow in Brussels. But you can download it here, today. Wow. Never say this site doesn't offer stunning opportunities to readers. I doubt the server will be able to cope with the rush.

One doesn't often learn much about political strategy and health care reform from a horse. But if David Cameron does not know the story of Norton’s Coin, he may find it useful.

The horse, trained by an obscure Welsh hill farmer, was entered for the blue riband of horse racing, the Cheltenham Gold Cup, in 1990. Up against the best steeplechasers in the country, not least the odds-on “people’s favourite”, Desert Orchid, Norton’s Coin was “more a candidate for last than first”, as the race card put it on the day. Norton’s Coin’s odds were 100-1. No serious observer expected him even to be placed.

You know what I am about to write: Norton’s Coin won. The received wisdom was wrong.

The received political wisdom is that the Conservative Party’s supposed hostility to the NHS is its Achilles’ heel and the sooner it is neutralised as an issue by Mr Cameron, the better. Thus his speech yesterday, in which he expanded on his weekend advertisement, which stated that: “We believe in the principles and values of our NHS.”

Until yesterday, the Conservative leader had not put a foot wrong. His broad strategy of moving the party — and, crucially, its appearance — to the centre is the only sensible option. Whatever one thinks of Tony Blair, his strategic genius is indisputable. Labour has won three elections in a row because Mr Blair has taken hold of the centre and pushed the Conservatives away from it. It is easy to sneer at the involvement of Bob Geldof and Zak Goldsmith but no party has ever won in Britain without being seen as centrist. Until Conservatives no longer seem in the eyes of the chattering classes like emissaries from Planet Zarg, the party will forever be doomed.

But that raises a fundamental question: where does the centre lie? The centre ground in the 1950s — Butskellism — was very different from the centre in the 1980s, defined by Thatcherism. It moves as circumstances and voters’ views move.

Clearly, from the 1950s, when a cross-party acceptance of the NHS emerged, the NHS was bang in the middle of the political centre. Even the Conservatives’ attempts at limited reforms in the late 1980s and 1990s — the internal market — were regarded by many otherwise sensible people as a form of ideological extremism. So it is understandable why the otherwise sensible Mr Cameron is keen to establish that the NHS is, as Margaret Thatcher felt the need to put it, “safe in our hands”.

But the centre is moving. Attitudes are changing. For decades, the alibi for the NHS’s failings was its supposed underfunding. Now spending is greater even than the sums demanded by those who argued that underfunding was to blame.

The result? The Office for National Statistics found in 2004 that productivity had fallen by about 1 per cent per year since 1997. And both the Prime Minister’s Strategy Unit and the Organisation for Economic Co-operation and Development went further, measuring falling productivity of up to 20 per cent since 1997.

David Cameron’s response to the disappearance of billions of pounds into the NHS black hole is to argue for improved management and more fiddling with structures, but to run a mile from questioning the system itself. The Conservative solution is: we’d do it better than they would.

But he is walking away from real reform at the moment when its need is at last becoming understood by voters. In a poll for the think tank Reform in February 2004, 69 per cent agreed that: “The NHS was the right idea when it was introduced in the 1940s, but Britain has changed and we need a different healthcare system now.” Only 40 per cent agreed that: “The Government is right to rule out alternatives to the taxpayer-funded NHS.”

In nailing his colours so firmly to an exclusively tax-funded NHS mast, Mr Cameron is making a huge mistake, both politically and for the good of the country. Labour’s policy of spending as much money as possible and fiddling with the system is a form of controlled experiment to discover if that is indeed all that is needed. The answer is now becoming clear: it isn’t.

For years, those of us who have argued that it is the very notion of an entirely tax-funded system that is the real problem were dismissed as ideologues and lunatics. Now, with the evidence showing that the NHS cannot deliver even with massive funding, real reform has at last entered the realms of acceptable debate.

That is a huge transformation in the political landscape. Yet just at this moment, Mr Cameron has chosen to cut off all such talk, neutering his attacks on Labour with his “me too” policy, and destroying any prospect of the reforms that might actually give us a system to deliver the best healthcare.

His speech included a litany of what the NHS does not provide. Indeed. But where does he think the money is coming from to pay for the extras? Even Gordon Brown’s massive cash injection — which is anyway about to come to an end — isn’t enough to cope with today’s demands and, as Mr Cameron rightly pointed out, they will be even greater in the future. How much more than Labour is he proposing to tax us to pay for it all?

We have to move to a mixed economy of healthcare funding. On the one hand Mr Cameron complains that we are so far behind the continent and, on the other, he explicitly rules out — indeed, condemns as unBritish — those very mechanisms that have made their resources possible.

Instead of betting the Conservative Party’s political fortunes on Desert Orchid — the NHS — he should notice the widely dismissed 100-1 outsider accelerating up on the rails.

Samizdata flags up a typically stupid piece by John Sutherland in the Guardian.

I've really come to loathe John Sutherland, who appears from his columns suffused with anti-Americanism and a clearly ill-merited sense of intellectual superiority. Take his piece today:

But the runaway success of Natural Cures also bears witness to genuinely troubling aspects of the American healthcare system. It has been estimated that some 50 million citizens have no health insurance. For these desperate people, who fall sick like everybody else, "natural cures" are all they can afford. "Socialised medicine", as the Clintons learned the hardway, has no place in America. Capitalistic medicine does. What John le Carré calls "Big Pharma" has made America the most drugged nation in history.

As the Samizdata post points out:

Which "explanation", unfortunately fails to account for some important facts: (1) the purportedly natural non-cures offered by quacks are not generally cheaper than the products of Big Pharma, even at US prices; (2) the most drugged nation in history, is on average (i.e., including all those without health insurance) rather healthier than Britain if you look at survival/recovery patterns for pretty much any disease; (3) The European quack industry is also fabulously successful, and expensive, despite the subsidised competition from socialised medicine.

There's a further point, which is my bete-noire. Sutherland writes:

It has been estimated that some 50 million citizens have no health insurance.

Er, no. It hasn't. Not accurately, anyway. The figure is around 44 million (which itself is hotly disputed for being way too high). Let's ignore his casual inflation from 44 million to 50 million. This is my real bug bear: to cite that figure as evdidence that even 44 million are "desperate people, who fall sick like everybody else" and that "natural cures are all they can afford" is utter rubbish.

That figure is a snapshot of the uninsured at any one time, which includes all sorts of people, from those between jobs, those who are unemployed and those who do not want insurance. The people who have a problem are the chronically uninsured - those who can't get insurance. And although the number of chronically uninsured is way too high, and needs to be dealt with, it is around the 8 million mark.

So Sutherland is wrong by around 42 million. Quite an achievement.

Three cheers for Patricia Hewitt, the Health Secretary. In a revolutionary break with the past, she has made clear that she wants to launch a “national debate” on the importance of introducing charges into the health service.

It is important, she says, that something is done before the entire system collapses under the weight of patient demand. She points out that it is only because GP visits are free at the point of use that so many frivolous visits are made.

She sees her job as to start “building a political consensus”, while winning the acceptance of 28 million patients on the merits of charging. “We need to decide in the course of this Parliament whether this is going to be feasible.”

Although there are some minor examples of charges, such as for dentistry and ophthalmic treatment, Ms Hewitt points out that: “Nothing on this scale has ever been attempted.” But the ever-greater demands placed on the NHS mean that “going on as we are is not going to work. Too often in the past, governments have concentrated on fixing the problems of the past 20 years. We must concentrate on dealing with the problems of the next 20 years” — a clear reference to the demographic changes that will make the existing method of NHS funding unsustainable.

Oh, hang on a minute. I have got my wires crossed. The Health Secretary said nothing of the sort. The quotes above are not from Ms Hewitt but Alistair Darling, the Transport Secretary. It is not Ms Hewitt who wants to launch a national debate about charges, but Mr Darling. And it is not NHS charges to which he is referring but road pricing.

How silly of me. It is the Transport Secretary who believes that the solution to too many car journeys is to put a price on them (typically, his idea of a market price is one set by Whitehall). As for the existing charges, he means the congestion charge, not NHS dentistry.

When Mr Darling came out with this yesterday, the thought crossed my mind that such an approach might be considered by other ministers responsible for public services that are funded by the taxpayer but free at point of use.

As if! How absurd of me to think that joined-up government might mean something.

There's a compelling piece in today's Guardian about an all too illustrative example of the state of today's NHS.

As the (German) victim puts it:

"I can't understand at all why people tolerate a health system like this one, but go demonstrating in front of Westminster because of foxhunting. There's violence over foxhunting, but there are no riots because of the NHS. I don't understand that and I don't find it funny. In Germany, there's always this view that the English are so eccentric, they're cute in a way. But I don't find that cute or funny."

Indeed.

But things are on the move. The NHS is bust, and neither this government nor any other can fix it. The more of our money the government throws into the black hole of a broken health system, the sooner the public will start to protest.

And then we will start moving towards a health system which is not a moral outrage.

Very funny piece by Roy Hattersley. Do read to the end. The pay-off is terrific.

Very funny line in a typically excellent column by Alice Miles, on her positive experience this week with her daughter in the NHS:

Our exclusive experience with the NHS is available to Michael Howard for use at Prime Minister’s Questions next week if he gives me a ring. Equally, if Labour would like to put us on an advert under the heading “forward not back”, it would particularly suit my daughter who can, in fact, only walk forward and not back.

Sky's headline today:

MRSA bug at lowest level since records began.

Sounds great. And it's true.

Just one thing: records began in 2001, and these are the 2004 figures. Lowest level for all of three years, in other words. Not that impressive when you realise that the MRSA problem took off long before records were kept.

And even in the past three years, today's figures hardly merit popping the champagne. The first set of figures, from April to September 2001, recorded 3,598 NHS patients infected with MRSA. The 2004 figures (also April- September) found 3,519.

Hardly a triumph. More like a disaster, albeit marginally less of one than in 2001.

Should you be so minded, you can read my written testimony to the Senate here

And you can see pictures of the hearing here!

I must apologise for the sporadic postings over the past few days. I've been swamped with work. I am about to testify before the US Senate Committee on Health, Education, Labour and Pensions (the hearing is on Thursday 17th February: Drug Importation: Would the Price Be Right?; I gather it will be live on CSpan) and so have been preparing myself.

(Wearing my non-blogging, non-journalistic think tank hat, I specialise in health policy, in particular in the very issue which is now raging in US politics over the re-importation of pharmaceuticals from Canada.)

I'll try to post this coming week, but don't be surprised if there's nothing up until after the hearing.

In the wake of Chris Smith's recent announcement that he has been HIV positive for the past 17 years, there's an excellent post on CNE Health, the site I edit, on how the private sector and the profit motive is critical to the advances in treatment. As a colleaague of mine always says, the only innovation made by the Soviet Union was weaponising anthrax.

Each of the EU’s health systems is in varying degrees of crisis. There is nothing new about that. It is the nature of the beast that there can be no such thing as a fully-functioning, economically- efficient, technologically- advanced mechanism which fulfils patient expectations, meets medical demands, and is fully affordable by all. Whatever the system and however much is spent on it, at least one of those functions will not, at any given moment, be met. Dealing with health policy is like pushing sand uphill: you might well get most of what you want, but you will never get everything.

To put it another way: there is no such thing as a perfect healthcare system. At the very least, member states have their own cultures and their own traditions, and what is acceptable in one may be viewed as a political or medical disaster in another.

But some are much more perfect than others – while others are more imperfect. So what matters is the balance that is struck and the immediacy and potency of the crisis.

Take the French system. It has immense strengths: patients can choose their physician and consult specialists as they wish; they can see their contributions on their payslips; and there is some co-payment. But this comes at a cost: it is now in financial crisis. The deficit of the compulsory health insurance fund is increasing by €21,000 a minute and now stands at a total of €11.9 billion. The Health Minister, Philippe Douste-Blazy, rightly said last year that “health insurance is bankrupt”.

The German system is also in the midst of a crisis and the UK system is soaking up vast amounts of tax revenue to little noticeable effect.

Although the symptoms may vary, the disease which is crippling healthcare systems stems from the same root across almost the entire EU and can be summed up in two words: state control.

We know from all the evidence that, as people become wealthier, they choose to spend an increasing proportion of their money on healthcare, whether indirectly through gym memberships and such like or directly through cosmetic surgery and procedures which are not vital but which can improve the quality of their life. When people spend their own money, that is not a problem. Far from it; it is all part of economic growth.

The problem arises when health spending is directed through the state, or is funded by taxation. Take pharmaceutical spending. Almost all the ‘reforms’ being adopted and considered across the EU have the same thing in common: cost containment.

Leave aside the economic stupidity of failing to consider the global savings to health budgets of reduced hospital stays which many new drugs can bring about.

Think instead of why increased spending on heath care is seen as a problem in the first place. It is because, funded out of taxation, budgets have to be capped lest tax rates shoot up to cope with the spending.

Yet the evidence shows that, when left to decide for themselves how they wish to spend their own money, patients choose their health.

So why is there a funding crisis in the first place? Because funding is directed through the state, rather than left to patients themselves.

Healthcare is not in crisis. The crisis lies in the means by which it is funded.

Moving 15% of procedures to private sector will wreck NHS

And the problem is?

Here's a first: the Guardian has a superb piece - nuanced and thought-through - on vivisection and pharmaceutical research.

I don't fit easily into the animal rights lobby's stereotype of a sadistic pro-vivisectionist: I don't eat meat, and when I was studying for a molecular biology degree I opted out of animal experiments knowing my future career would not be spent in medical research so I couldn't justify my participation. And as someone who cares about animal welfare, I am horrified by the way in which violent animal rights protesters are dominating the vivisection debate. If experiments are banned out of the UK, as they hope, it would not only hinder the development of new and effective treatment for human disease, but animal welfare will also suffer.

...The Home Office guidelines on how to keep laboratory animals are detailed to the point of pedantry on the temperature, the amount of animal/human contact, the provision of swings for primates, and so on. In my experience, albeit limited, animals in labs are happy to see humans and show no fear.

In the UK, scientists have to justify doing an experiment that causes suffering, and the numbers approved are small. Just over 2% of animal experiments are classified as causing death or severe pain; just over half are classed as "moderate", where pain would be mediated by anaesthetic; and 39% are classed as mild.

Undercover footage at Huntingdon Life Sciences found abuse by staff and illegal practices, prompting a sustained campaign of violence against the company. Such cruelty to animals is indefensible, but we should keep it in perspective: a proportion of pets also suffer abuse, but the average household isn't subject to the spot-checks or undercover investigations that animal research labs are.

Pharmaceuticals companies are profit-driven; they don't like wasting money. Keeping animals and doing the experiments are expensive, so they would only use them when there is a clear objective - either finding new drugs, or when they are required by law. The animal rights lobby argues that new drugs usually just mimic existing ones; there is some truth in this, but it is nonsense to imply that all new drugs on the market are similar to existing ones.

Ask the rheumatoid arthritis patients on Remicade, who have been released from a life of pain, or the cancer patients who took Glivec, literally life-saving for those with a certain type of leukemia. One "scientific" animal rights activist told me that Glivec was developed without the use of animals, and showed that vivisection is unnecessary. This betrayed a total lack of understanding of how the drug was developed. First, scientists had to understand the disease, and animal experiments were vital in this process. The choice is clear: no dead mice and no Glivec; no dead mice in the UK, but more animal suffering overseas and Glivec; or well-regulated vivisection in British labs and Glivec. You decide.

There are two words that, when taken in tandem, are almost guaranteed to induce narcolepsy. Those words are "parallel trade."

They may seem dull, but they go to the heart of how the EU single market operates and what it is supposed to achieve. And a new report (of which I am a co-author) calculates that parallel trade in one sector, pharmaceuticals, puts over 42 EU citizens per hour at risk of death.

Step back for a moment. The financing arrangements for health care across the EU may differ but all face funding problems. To deal with those problems, some member states impose price controls on the pharmaceuticals sold within their boundaries. Because health care is dealt with at member state level, those controls -- and thus the prices charged -- vary. A drug that is available in one country for £2 a pill might be available in another for £1 a pill.

The single market ensures that that whatever may be freely bought in one member state must be allowed into any other. Hence an opportunity for the easy money of parallel trading. Buy that drug for £1, take it across the border to the country where it costs £2 a pill, sell it for £1.50 and make an instant 50% gross profit. By the end of 2001, the parallel trade in pharmaceutical products had reached $3.3 billion in Europe and is calculated to reach $7.4 billion by 2006.

None of this is the result of costs being driven down by competition. Lower prices in the exporting countries simply reflect greater regulatory leverage. Prices are lower in countries like Spain than in Britain simply because the Spanish government has decreed that they be lower. And because the rules of the single market as applied by the European Commission do not allow companies to protect themselves by restricting supply to those member states with the most severe price controls, we are now entering a world in which whatever country has the most restrictive price-control scheme will become the largest exporter of pharmaceutical products through parallel trade.

There is some hope of sanity. In January 2004, the European Court of Justice annulled a fine levied against Bayer by the commission. Bayer had been found guilty of preventing parallel imports of the heart drug Adalat into Britain from France and Spain. Between 1989 and 1993, Adalat was sold in France and Spain at prices 40% below the price in Britain. French and Spanish wholesalers simply ordered extra supplies from Bayer and resold the surplus stock to British buyers.

Bayer was unhappy at the wholesalers' assault on its British margins, denying the German company 230 million marks in U.K. sales. Because Bayer could not ask its wholesalers not to sell in Britain, it restricted supplies of Adalat, ensuring that continental wholesalers had no surplus to export. The wholesalers complained. The commission fined Bayer but the ECJ disagreed. It could find no evidence of an agreement to restrict competition. Bayer may have restricted competition, but it had acted unilaterally.

The commission, however, is determined not to allow any limits on parallel trade. It issued a statement saying after the ECJ ruling saying that it would "continue to monitor carefully the behavior of the industry, which is of unparalleled importance to consumers/patients, for government finances and for completion of a European single market." The consequence is obvious, and is already happening. Some drugs are simply not being made available in the EU market.

Now for the added twist. More than 140 million medicines move around the EU every year. Invariably, they need to be opened, the blisters removed and the patient information leaflet exchanged. As such, it is not surprising that the unintended consequences of these arrangements are that product expiry dates are often wrong or missing. Batch numbers on the box often fail to match those on the blisters. And patient-information leaflets are go astray, are out of date, or are simply wrong.

Products marketed by the manufacturers can be tracked through the entire chain from factory to patient by means of elaborate computer systems. Defective products can be identified and recalled with very little difficulty. This is not the case with parallel imports.

Then there is the problem of counterfeiting. The World Health Organisation estimates that at least 7% of pharmaceuticals sold world-wide are counterfeit.

In 1990, it was estimated that an average of 20% of the population of a developed country are on some form of prescribed medication and that half of this figure covers medication that is required for the continuation of life or to avoid a catastrophic decline in quality of life. This being so, we can calculate that 37 million people (in the 15 member states before the May accession) are in more or less desperate need of their medication. The number of people known to have died or been seriously inconvenienced by incorrectly labeled or counterfeit pharmaceutical products in Europe is not significant. However, the numbers of people alarmed by media reports of these problems into suspending use of their medication are very significant.

Assuming, conservatively, that at any particular moment, 1% of patients heavily dependent on their medication are worried into not taking their medication as recommended by their doctors, one arrives at a figure of 370,000 people throughout the EU at any particular moment at risk of death or serious decline in their quality of life. That works out at over 42 people per hour who are at risk because of some of the problems raised by attempts to reduce the price of pharmaceutical products within the EU.

These are conservative assumptions. But even making them more conservative still and confining the populations at risk to the main destinations of the parallel imports -- Britain and Germany -- is worrying. Their population is around 140 million. Further reducing the figure of those not taking their medication as prescribed from 1% to 0.1% still gives us a figure of 14,000 per year -- or a potential death rate of 1.6 per hour.

Maybe these figures are too conservative. Maybe they are too high. Whatever the true figure, the facts cannot be denied. For the commission to defend parallel trade is not merely economically bizarre; it is life threatening.

If you're so minded, you can read a new paper I've co-written (The Human Cost of Pharmaceutical Price Controls in Europe: A Case for Reform), here.

The paper argues, in brief, that on the conservative assumption that one per cent of patients heavily dependent on their medication are worried by well-founded reports of counterfeiting into not taking their medication as recommended by their doctors, 370,000 people throughout the European Union are at any particular moment at risk of death or serious decline in their quality of life.

Taking this figure and averaging it throughout the year, over 42 people
per hour can be seen to be at risk of death because of some of the problems raised by attempts to reduce the price of pharmaceutical products within the European Union.

Confining this to the populations most at risk as the main destinations
of parallel imports – Britain and Germany (140 million) – and further reducing the figure of those not taking their medication from one per cent to 0.1 per cent, the figure is 14,000 per year – or a potential death rate of 1.6 per hour.

Go cure your insomnia...

Mike McLoughlin has an interesting take on obesity:

The best way to address the current obesity crisis - in men at least - is to publicise one of its most unpleasant side effects: excess fat in men converts testosterone into oestrogen which is a female sex hormone, thus reducing the size of the penis. Those comforting themselves by thinking it "appeared" smaller as it was getting lost in the folds of flab will have to think again.

I can't say I've noticed it working in reverse while I've been losing weight.

The coverage of the ‘obesity epidemic’, which has dominated the newspapers and radio this morning, misses the point completely. It’s not, as the coverage suggests, a problem for the NHS and government to deal with. It’s a problem which is caused by the NHS and government.

Yes, it’s right to be worried at yet another example of the ‘nanny state’: what possible business is it of government if I want to eat doughnuts for breakfast, lunch and dinner? If I eat stupid food and get fat, it’s not Krispy Kreme’s fault for making such heavenly doughnuts. It’s mine alone.

And that’s what I used to do, until I realised – I realised, not the government or the NHS – that I needed to lose weight or have a heart attack or diabetes. So I did and lost 4 stone. No one - other than the tiny number with a relevant medical condition - needs to be overweight. It is entirely a matter of personal choice. Rich or poor alike, we all have choices, and it is up to us how we excercise them. Eat too much and you'll end up a porker - and you alone are to be blame. Not McDonalds, not Mars, not Pizza Hut. You.

But the real issue is not the nanny state but the NHS. In a health system paid for by the government then, yes, it is the government’s business what I eat, since my obesity costs money.

The problem is that we have things the wrong way round, and that leads directly to the obesity epidemic. Although it is my responsibility what I eat (and as for the 3 year old girl who died of heart failure, whose fault is that but the parents?) the NHS system of taxpayer funding blunts the critical element of individual responsibility.

In a system where it wasn’t the state which funded healthcare but individuals, whether through insurance, medical savings accounts or another method (when people have, in other words, direct control of their health care funding) then people have an incentive to look after themselves.

That’s why obesity is so much less of a problem on the continent, where healthcare is insurance-based. (And as for the US, obesity is primarily a problem for the poor, and they are covered by the state funded Medicare, which has a similar impact on incentives as the NHS.)

So the solution is not to impose rules which deaden the role of individual responsibility even more by restricting our right to eat what we want, but to construct a health system where the incentives point to taking responsibility for our own health.

There’s a very important piece in today’s Telegraph by Roger Bate which shows how wrong-headed much of the WHO’s efforts are in tackling AIDS in Africa.

Here are the key points:

A recent article in The Lancet medical journal alleged that the World Health Organisation (WHO) and the Global Fund for Aids, Tuberculosis and Malaria are implicated in the wastage of taxpayers' funds intended for malaria treatment in Africa.

…The Lancet authors are angry that these two UN-affiliated agencies in 2003 approved and then funded applications from poor countries for two obsolete malaria medicines (chloroquine and SP) which, because of massive drug resistance in the deadly malaria parasite, fail to treat up to 80pc of patients who take them.

The WHO and Global Fund provided these obsolete medicines in stark violation of their own policy. Both say they give priority to a new sort of treatment, known as artemisinin combination therapy (ACT), but as the experts discovered, the agencies "routinely approve and finance inferior [medicines]" and violated their policy more often than not.

The obsolete medicines were supplied to countries where drug resistance is known to be rampant, and where child mortality of malaria is shown to be up to 1,100pc higher because of this. As a result, tens of thousands of children died of malaria - and continue to die - needlessly.

…These facts are hard to face for those who think the UN can do no wrong, but if their concern for patients in poor countries is genuine, the realities must not be ignored. About 7pc of the Global Fund's budget (over £65m) originates from the UK, and 60pc of its grants flow to Africa.

That means that, when the world's top experts condemn its decisions as medical malpractice, both British money and African lives are being wasted.
In 1998, the WHO launched a flagship campaign to "Roll Back Malaria". The goal they set was to halve the number of malaria deaths by 2010.

...So in 2004, at the halfway mark to halving malaria deaths, what has happened? Malaria has indeed "rolled back" with a vengeance. Rather than declining by 50pc as the UN promised, or even 5pc, malaria deaths have risen.

…All this leads to a fascinating question: if the WHO fumbled it so badly with Roll Back Malaria, which was their poster child campaign of 1998, why should they be trusted in the pole position of the latest global campaign, to treat three million Aids patients by 2005?

There is a direct link to the whole AIDS issue, and the grotesque attacks by anti-capitalist, anti-intellectual property, anti-pharmaceutical company activists whose campaigns are, in effect, campaigns to ensure that Africans die of AIDS. By pressing the WHO to endorse generic HIV drugs that are of lower quality and unproven safety and efficacy than the alternatives, or – even worse – the potentially harmful "Fixed Dose Combination" (FDC) 3 HIV drug, none of which have been approved under the necessarily rigorous standards applied by the US FDA, European or Japanese agencies and which would almost certainly not be approved for sale in Western markets, but which are somehow deemed good enough for Africans.

The hidden story here is that activists who proclaim their moral righteousness by appearing to champion HIV positive Africans are in fact foully cynical. Their real agenda is attacking capitalism; so consumed with hatred are they for the pharmaceutical companies, whose achievements stand as a glorious demonstration of what can be achieved, that they would rather Africans had sub-standard treatments than concede the need for the innovative and effective treatments which can only, and have only, come about through capitalism.

In many ways the WHO’s behaviour is worse. By issuing a disclaimer for the use of these drugs as coming under their "pre-qualification program”, they shunt responsibility for their quality, safety and efficacy to local drug regulatory authorities, which do not remotely possess the resources and capacity to do the necessary rigorous testing. As if Benin is really in a position to test these products according to proper international standards.

Feeling lonely? Call the NHS.

Anthony Browne has en excellent piece in The Times on how health care can be provided:

I was recently walking down a London street on a Sunday afternoon, when I decided to have a medical problem dealt with. I dropped into a medical centre I happened to be passing, which was open, and asked to see the specialist, who attended to me there and then with a smile. In a sparkling clean clinic packed out with a vast array of brand new medical equipment that seemed like something out of a science fiction film, dozens of tests were quickly done, which, as well as diagnosing my medical problem, checked out a range of other conditions from brain tumours to diabetes. The specialised medical apparatus that was prescribed for me was manufactured instantly.

I know you think that I am making this up, just teasing you, that it is too good to be true, but it is not. I promise you, within an hour of walking in without an appointment on a Sunday, I walked out of the optician with a pair of bespoke spectacles for my myopia and astigmatism, and a dream that one day all healthcare in Britain would be this way.

Of course, opponents of health service reform did not predict this when the General Ophthalmic Service was effectively privatised by Margaret Thatcher in 1989. They said it would ruin the service, when in fact it has turned it into by far the most successful sector of the medical service.

Health Secretary John Reid’s announcement today that ‘health tourists’ are to be charged in advance for treatment on the NHS has profound implications – and not just for the NHS.

As the NHS operates at the moment, anyone can turn up at a hospital and expect to be treated. That means that they do – and this includes some people from abroad who come here specifically to take advantage of a free NHS. Mr Reid calculates that this ‘health tourism’ costs the NHS £200 million a year, and his announcement today is designed to plug that leak.

But money is not the real issue. In terms of the NHS’ £68.7 billion budget, £200 million is, after all, chicken feed. And there is little evidence that ‘health tourism’ is any worse today than in previous years. What has changed is that, in the past, the idea of an NHS which was free – to everyone - was so widely shared that we put up with what we now think of as abuses, such as health tourism.

Indeed, the real waste is not these headline grabbing issues but more prosaic problems such as bed-blocking, when the elderly are forced to stay in hospital when they are medically fit to leave. Every day, more than 3,500 older people remain in hospital simply because no follow-up care is available outside. Around one-third of those are stuck in hospital for over a month. This bed blocking accounts for 1.7 million lost ‘bed days’ every year. Even with the reforms which the government has already introduced to deal with this, the Department of Health does not expect to be able to reduce the number of people delayed to less then 2,500 by the end of 2005.

So Mr Reid is looking to the US, where elderly patients of Kaiser Permanente, a not-for-profit health insurer in California, spend a third of the time in hospital that NHS patients spend for such problems as asthma, bronchitis and strokes, and yet achieve far better clinical results. That is also why he has decided to give foreign health care providers most of the £2 billion programme to build fast-track treatment centres to cut the NHS waiting list.

Times have changed since the days when no one really cared whom the NHS treated. The government is now ploughing so much money in - money which it has taken at our expense through tax increases - that the public is no longer prepared to put up with paying for the treatment of foreigners who come to the UK to mend their health on someone else’s money.  Mr Reid well knows that if he doesn’t demonstrate that he is alive to such concerns, he risks undermining Labour’s entire case for taxing and spending.

Once, however, we accept that health care should be made available not on the principle that everyone is always treated, but only to those who qualify for it then we transform the entire debate about the provision of health care. The Conservervatives brought this onto the agenda with their "Patient's Passport" proposals. Now New Labour is taking up the baton. And that means that although the sums involved in today’s announcement may not be that large, the implications are huge and their consequences range way beyond the NHS.

David Blunkett may have based his case on the introduction of ID cards on their use against criminals – and especially to deter terrorists – but Mr Reid has also become a strong supporter of the idea. If we had to carry ID cards then, of course, it would make it much easier to determine who should, and who shouldn’t, be billed for their treatment. It is one of the most controversial ideas dividing Cabinet: but Mr Reid's determination to act on it is a sign that it won't go away.

A lot of people got to feel good about themselves this week. World AIDS Day on Monday gave all sorts the opportunity to show just how much they care about the 42 million HIV positive men, women and children across the planet.

For most, that amounted to little more than wearing their red ribbon. For many of the most committed campaigners, however, it meant chanting a familiar refrain: the evil of the pharmaceutical industry. They charge so much for their drugs, so the story goes, that poor Africans don’t have a hope of treatment. And, to make matters worse, they refuse to allow generic (cheaper copied) versions of the drugs to be distributed. All they are interested in is making a profit over the bodies of the dying.

It’s a seductive argument. But it is dangerous nonsense. The real problem is not the pharmaceutical companies, without which none of the drugs would even exist, but the activists themselves, who are the ones really responsible for prolonging the misery of AIDS sufferers.

The only means by which AIDS will be cured is profit. Without profit, there will be no research, and without research there will be no drugs. It is that simple, and it is the activists who are campaigning, in effect, for an end to research.

The activists’ success has been entirely perverse. Today, around 30 per cent fewer companies are doing research into AIDS than were five years ago, and there is about a one third decline in the number of new products in the pipeline – and this in the context of a steady increase in overall research spending over the same period.

The money involved is mind blowing. In 2001 alone, the pharmaceutical industry spent $30.5 billion on research, and the average drug costs $802 million to research. But the consequence of the anti capitalist activism is that drugs companies now face an uncertain environment for their property rights and potential profit. Why, they ask, should they invest more resources, if the return is non-existent or marginal? And with every less dollar committed to research, the chances of a breakthrough diminish. That is the grotesque responsibility of many of the AIDS activists, who with their every campaign condemn more to die of AIDS.

But the real motivation of many of the activists is not helping AIDS victims, but destroying capitalism. Organisations such as the AIDS Coalition to Unleash Power (ACT UP), the Treatment Action Campaign (TAC) and the Consumer Project on Technology (CPTech) campaign on AIDS, but their agenda is much broader: they are classic anti-capitalist groupings. There are, of course, few more towering examples of capitalism’s success than the giant pharma companies. So the call comes out from the activists for their patented drugs to be released to generics manufacturers who will charge a fraction of the price.

Yet again, though, the consequences of this are dire. If the pharma companies cannot recoup their investment, they will not invest. The generic manufacturers are simply leaches – hugely profitable ones - on that investment. They fork out almost nothing in costs, and reap huge returns on someone else’s intellectual property. And have a guess from where many of the activists get their funding. Spot on: the generics manufacturers. It’s a fabulously poisonous cocktail of supposed angels who behave like devils.

Since 1998, the evil pharma companies – the ones who don’t care about Africa - have given the continent some $2 billion in products and cash. More, that is, than many African states’ entire health care budget (but a lot less than their arms budgets).

Work by Prof Amir Attaran of Harvard shows that most of this issue is a red herring, anyway. As he reports: “...essential medicines are rarely patented in developing countries”. 98.7% of the time, there are no patents on any of the World Health Organisation's list of 325 essential drugs. In other words, the fulminating over pharma companies’ patents concerns 1.3 per cent of the real issue.

That real issue is, as the Director-General of the WHO, Dr. Jong-Wook Lee, has said, when discussing the WHO's goal of providing antiretroviral drugs to three million HIV-positive people in developing countries by 2005, rather different:

“It is not just the issue of money, because clearly if all the money and all the drugs were available today, I doubt whether we could implement it right now because of the weak infrastructures, such as the shortage of nurses and doctors. It is more than just a funding issue”.

But you don’t get win emotional arguments for the anti-capitalist cause by talking about infrstatructure. You do it by blaming evil pharma companies. And prolonging the misery of AIDS sufferers in the process.

Some important truths in the fight against AIDS are spelt out by Roger Bate in today's WSJ:

Yes, to be sure, there is good news in the fact that the pharmaceutical industry has so far won approval for 80 drugs that fight HIV and the opportunistic infections that thrive alongside it. The latest figures from the U.S. industry group, PhRMA, showed another 83 drugs or vaccines in development. But AIDS drugs development is trending downward.

This is due to continuing attacks on drug patents and prices. This trend must be reversed if AIDS is to be conquered in the next 20 years, and that will only happen if AIDS research can pay for itself.

...The seemingly infinitely adaptable HIV side-steps therapy with appalling speed and every year new drugs must replace obsolete ones just to maintain a steady state.

A successful AIDS drug costs hundreds of millions to bring to market. The chances of a company recouping that kind of money are further reduced by factors other than resistance; notably, companies can no longer rely on full patent protection. Many governments around the world claim the right to override U.S.-style licensing laws, which allow the inventor a period of marketing exclusivity. And even the staunchly pro-property-rights Bush administration is likely to buy generic versions of patented HIV drugs from Canada, India or elsewhere.

AIDS claims more victims every year. Sooner or later, says Mr. Eberstadt, it will take hold of China and India. Perhaps only then will corporations be able to make enough money from the disease by having enough moderately wealthy customers. For now the hundreds of millions some big pharma companies are spending on HIV vaccine and drug research every year is economically unjustifiable and probably not sustainable.

The anti-globalisation activists who protest against patents and such like are, in a very real sense, ensuring that AIDS remains such a scourge. As patents and and intellectual property are weakened, so is the incentive for pharmaceutical companies to pour in the billions of dollars which they spend on research. (The average new drug costs $802 million to bring to the market). And anyone who thinks that research can or will be done elsewhere is living in la-la land. There are only two options: pharma company research or nothing.

Instead of protesting against patents, as the likes of Jamie Love and his fellow wreckers do, they should, if they really cared about medical breakthroughs, be protesting against those countries which ignore IP and which thus contribute to the many further millions who will die of AIDS and other illnesses.

...to be had with this.

For anyone interested in healthcare, this conference in Stockholmat the end of next month should be fascinating. Hosted jointly by the Stockholm Network and Institute for Public Policy Research, it covers most of the critical issues.

If you fancy a day or two in Stockholm, you can also register at the site.

The weekend's reports that NICE - the National Institute for Clinical Excellence - is considering recommending that IVF treatment be made available throughout the NHS to all infertile women under 40 must seem the ultimate paradox.

NICE was set up with one of the most misleading launch promises in history: spreading excellence throughout the NHS, ending ?postcode prescribing? and ensuring that all patients received access to the ?best? treatments available.

In reality, NICE was set up by Frank Dobson in 1999 to provide an independent, expert justification for the rationing which has always been fundamental to the NHS? modus operandi. It was a thinly veiled attempt to provide medical cover for intensely political decisions. Not so much NICE as NASTY ? not available, so treat yourself.

If the NHS was what some would like it to be ? a monopoly healthcare provider ? then the case for including IVF would be much stronger. But it has never been a monopoly. The de facto arrangement since 1948 has been that non-essential procedures are available either spasmodically on the NHS, or privately. Whether or not IVF treatment should be made more widely available is not, as NICE would have it, a question of doing the maths. It is about two fundamental issues: what the NHS is for; and whether there is any ?right? to children, the absence of which is something which the state, through the NHS, has a duty to rectify.

Eighty per cent of the 27,000 current annual IVF attempts are done privately. That's because the existing consensus is that there is no such right, and thus no such NHS duty. Forcing health authorities to provide IVF treatment means, in effect, redefining the purpose of the NHS to include the provision of all treatments, rather than just those which are clinically necessary. The NHS website defines its aims as being ?to bring about the highest level of physical and mental health for all citizens, within the resources available, by: promoting health and preventing ill-health; diagnosing and treating injury and disease; caring for those with a long-term illness and disability, who require the services of the NHS.? That begs more questions than it even begins to answer: what is ?the highest level of physical and mental health for all citizens, within the resources available?; what are ?the resources available?; what if ?the resources available? are not enough; what is ?health?; what is ?disability?; what?(fill in your own question here ? the list is endless)?

It's certainly true that, as new medical technologies emerge, so too our definitions of healthcare change. Viagra is perhaps the most obvious example. Erectile dysfunction can, in some men, have debilitating consequences across many other aspects of their lives, and a ?cure? can certainly be a clinical need. For others, of course, it is merely about pleasure. Again, cosmetic surgery can often be frivolous ? excessively so, as in the recent reports of some women having their toes shortened to fit in to fashionable shoes. But it can also be one of the most wondrous and necessary of treatments.

IVF falls squarely within these ?what is health? and ?what is disability? questions. The draft guidance says that three attempts with fresh embryos, and three with frozen, offers the best chance of pregnancy. NICE also says ? this is the nub of it ? that treatment will be most effective and offer best value for money if limited to women under forty.

NICE, you see, employs a deeply flawed methodology known as ?economic analysis? in reaching its decisions. Economic analysis compares the costs and consequences of alternative treatments for any given condition, and is promoted as a rational, scientific means of allocating resources and containing costs. But in reality it is little more than a spurious justification for imposing value judgements which are hidden from view and thus discussion.

Indeed, the very purpose of basing rationing decisions on the outcomes of economic evaluation is to provide an apparently objective alibi behind which intensely difficult, and usually unpopular, political decisions ? what, and how, to ration ? can be hidden. Subjective choices about which treatments to deny, and to which groups of patients, are thus disguised as objective decision-making, and given entirely bogus credibility, when in reality they are no more objective than any other political decision.

The chances of successful conception over forty are indeed small, and the amounts of money which would need to be spent to make such attempts possible on the NHS may well be a ?waste? of scarce resources. But be clear what NICE's guidelines mean: an issue which is fundamental to the critical questions of what we expect from the NHS, and what we mean by health, is being tackled not as the result of a national debate, not as the consequence of individual medical consultations, and not as part of a wider discussion of what we expect from the NHS.

Instead it is being dealt with by sham concepts such as economic analysis, without any consideration of the broader context of how such new medical technologies shape our ever-changing understanding of healthcare and good health.

The IVF controversy is but one, albeit stark, example of how incremental reform of the NHS is bound to fail. Until we realise that no nationally determined, state funded, state implemented healthcare system can deal with such pressures, we will never cope.

Have you had your copy of the now infamous pirated Jamie Oliver cook book, ?The Naked Chef 2?? Recipes from ?Monkfish wrapped in banana leaves with ginger, cilantro, chilli and coconut milk? to ?Roasted sweet garlic and thyme risotto with toasted almonds and breadcrumbs?, all with a fetching picture of Jamie on the front.

It turns out that the whole thing is a hoax. There's no new book on its way, and it's merely a compilation of his already published recipes.

But fun as it might seem ? and who wouldn?t want a free recipe for 'summer fruit and prosecco jelly? ? the circulation of this apparently harmless prank is based on an idea which threatens to condemn millions more AIDS sufferers to death, and which undermines efforts to cure cancer.

The idea is that int