How to abolish the NHS

The National Health Service enjoys strong support among the public, making it almost impossible to introduce radical reforms, even if the performance of the NHS is relatively poor compared with systems in other developed countries.

Over the last thirty years reform efforts have therefore focused on greater private sector involvement within the NHS system and the deployment of some internal market-style mechanisms in an attempt to improve efficiency. In a recent initiative, for example, a private company has been contracted to manage a ‘failing’ NHS hospital.

The problem with such ‘part-privatisations’ is that they typically involve complex contractual arrangements and the creation of numerous ‘interfaces’ between government bureaucrats and the private sector, which may result in increased transaction costs and a reduction in overall efficiency. At the same time, private firms working within the NHS framework remain constrained by a strict regulatory framework on top of rigid contractual commitments. There is therefore little scope for the entrepreneurial discovery and innovation that brings such enormous gains within genuinely free market arrangements.

Moreover, since politicians and officials retain control over funding, the system remains unresponsive to consumer preferences and subject to capture by special interests, particularly producer interests such as the medical and nursing professions and the pharmaceutical industry. Mixed public-private systems therefore risk introducing additional transaction costs while suffocating the potential gains from private sector entrepreneurship. If this results in disappointing outcomes, as is likely, the whole concept of privatisation may be brought into disrepute.

There is therefore a strong case for taking a different approach. Rather than focusing on the gradual introduction of  ‘market reforms’ and public-private partnerships within the NHS system, an alternative strategy would seek to bypass the NHS by liberating the private healthcare sector such that the NHS became less and less relevant as more and more people opted out of state provision to avoid long waiting lists and substandard care. This option has the potential to create a virtuous circle – by reducing burdens on the NHS, taxes could be cut, wealth created, and more people would be able to afford private healthcare, reducing the NHS burden still further and gradually undermining its political base.
But radical regulatory reform is necessary if a dynamic private health sector offering low-cost, high quality and innovative treatment is to emerge. A selection of regulatory changes is suggested below:

– Perhaps most importantly, the compulsory licensing of medical professionals should be abolished. Anyone should be at liberty to practice as a doctor or nurse, with patients relying on brand names or competing voluntary associations to ensure quality. Ending current restrictive practices is essential to enable private firms to increase productivity in the sector.

– Restrictions on the types of treatment available ‘over the counter’ should be lifted to enable patients to obtain medication without recourse to registered doctors and regulated pharmacies.

– Burdensome drug licensing regulations should be rescinded. Instead, the testing of new drugs should be left to private firms and free markets. Reputable companies would have strong economic incentives to ensure the safety of their products, while there would also be far more freedom for experimentation and innovation by new market entrants, with huge potential benefits for patients.

– Prohibited recreational drugs, such as cannabis and opiates, should be legalised to allow the sick to benefit from their numerous medical applications.

– Private firms should be free to bring in low-cost medical professionals from abroad and at liberty to determine rates of pay and working conditions through private contract.

– Legal reforms could enable patients to waive their right to clinical negligence claims.

– Planning controls and building regulations should be liberalised to enable the rapid development of new private healthcare facilities.

Finally, it should be noted that internet technology has mitigated many of the information asymmetry problems that have previously been cited as a rationale for heavy state regulation of health. A combination of new technology and a dynamic, entrepreneurial private health sector could make the NHS increasingly irrelevant.

23 January 2012, IEA Blog

New plans by Grant Shapps are a recipe for increasing homelessness

Housing minister Grant Shapps recently announced plans to make the unauthorised subletting of social housing a criminal offence, with offenders facing up to two years in prison. The stated rationale is to free up dwellings for those on council waiting lists. But the policy fails to address the distorted economic incentives facing social tenants and in practice it is likely to exacerbate housing shortages while extending official intrusion into the private lives of tenants, lowering incentives for family formation and reducing labour mobility.

Criminal sanctions will raise the costs associated with unauthorised subletting, and this will tend to reduce the activity. However, such a reduction also means that those who previously rented such property from social housing tenants will be pushed into alternative accommodation, adding to housing waiting lists (either directly or indirectly through displacement in the private rented sector).

Moreover, it cannot be assumed that reducing subletting will free-up enough dwellings to compensate for this effect. Given long waiting lists in many areas – and much higher private sector rents – tenants will be reluctant to give up their social tenancies. With the option of subletting less attractive, more may choose to stay put rather than cohabiting or moving away to seek work. Some may live with partners most of the time while visiting their official residence periodically to maintain the tenancy. (By vacating the dwelling they would risk moving to the bottom of the waiting list should the relationship break down). Thus the likely effect of the crackdown on subletting is to increase the proportion of social properties that are empty or under-occupied. This in turn may increase the risk that the dwelling deteriorates (e.g. from damp) or is targeted by vandals or squatters – as the government’s own research on subletting recognises. 

Then there is the question of enforcement. There are practical difficulties in determining whether the correct people are occupying a dwelling, particularly if traditions of privacy are respected. There are grey areas such as friends and relatives coming to stay for a few weeks. The crackdown is therefore likely to involve further authoritarian intrusion into private lives. The economic costs involved in employing specialist inspection teams, instituting contested eviction procedures, prosecuting offenders and imprisoning them are also likely to be significant.

Rather than trying to cure the unintended consequences of state intervention with more intervention (the flawed approach of the government’s welfare reforms in general), Shapps should instead focus on removing the distortions responsible for the shortage of low-cost dwellings. Liberalising the planning system and rescinding burdensome building regulations would free the private sector to provide cheap housing as it did in the 19th century. Social housing, together with the £20 billion annual Housing Benefit bill, could then be phased out, with voluntary organisations catering for those with special needs.

11 January 2012, IEA Blog

Fairness in benefits could save billions

A single claimant of Jobseeker’s Allowance or Income Support aged 18-24 receives £51.85 a week. This goes up to £65.45 for those aged 25 and over.

Tax credit and child benefit payments for a first child are significantly higher at £75 per week, while subsequent children will earn claimant households an additional £58 per week.

It would seem to be unfair that child-related benefits are paid at a higher rate than those for young adults. In particular, young adults may have to spend around a third of their income on utility bills, whereas families will enjoy the economies of scale resulting from shared living space, meals and transport etc. Moreover, it is inconsistent that the benefits system recognises economies of scale within families (hence the first child premiums) but not in its treatment of families vis-a-vis single households.

A fairer system would standardise first child payments at the young adults’ rate of £51.85 per week, with lower payments for additional children. This could be achieved in practice by halving the child element of child tax credits. The measure would have the additional advantages of improving work incentives and cutting billions from the annual £24 billion tax credits bill.

26 July 2010, IEA Blog

Making the country work again

Even Margaret Thatcher didn’t manage to dismantle Britain’s disastrous welfare system. Judging by the policy plans of the Lib-Con coalition, there is little reason to be optimistic that today’s leaders will be any more successful.The timid proposals on welfare are little more than an expansion of existing failed programmes.

It is unsurprising that welfare reform has presented such a problem for successive governments. The six million working-age adults who now receive out-of-work benefits – plus millions more over 60s receiving generous pension credits – comprise a large voting bloc. Labour would have risked losing its core support had it attacked benefit dependency.

Within the new administration, the rebranded, centrist Conservative Party will be wary of implementing policies perceived (wrongly) as an attack on the poor, while any major changes could face strong opposition from the Liberal Democrats’ hard-socialist left.

Nevertheless, the dire state of the public finances means the new government will have little choice but to make substantial cuts in welfare expenditure. Benefit payments now account for almost one in three pounds the government spends. Balancing the budget will be next to impossible unless welfare plays a proportionate role in the programme of cuts. In reality, the new adminstration may be forced to implement radical reform.

This represents a huge opportunity – not just to save money, but also to address many of the social problems associated with welfare dependency. Life on benefits not only encourages crime and anti-social behaviour; a growing body of research suggests that long-term claimants are more likely to suffer from poor physical health, low self-confidence, anxiety and depression. Studies have also linked worklessness to lower life expectancy. While one should be cautious about such findings, a convincing case can certainly be made that the benefits of employment are not just financial.

The negative effects of welfare dependency are amplified by its concentration in certain areas and among particular groups. On many social housing estates the majority of residents are reliant on benefits. Any sense of shame for relying on handouts has long since disappeared, replaced by an aggressive sense of entitlement. Worse still, the behavioural norms needed to hold down a job – honesty, reliability, good manners and so on – have been undermined. This catastrophic decline in standards will take generations to reverse. Eliminating the poisonous impact of the benefits system is, however, a necessary first step.

The key to reducing welfare dependency is removing the ‘poverty trap’. The current system means that for many claimants it is simply not worth doing low-paid work – at least not in the ‘formal sector’. Once additional work-related costs such as clothing, train tickets or petrol are factored in, someone working full time on the minimum wage will typically be just a few pounds a week better off. Because benefits are withdrawn as income increases, the effective pay rate can be less than £1 an hour.

Working may also mean losing the other perks given to those on welfare, including priority access to low-rent social housing. As a result of massive government subsidies, social properties are generally of superior quality to privately rented homes. Indeed, a high proportion have recently been refurbished with new kitchens, bathrooms and heating under the multi-billion-pound ‘Decent Homes Initiative’. It is almost as if claimants are being rewarded for their dependence on the state.

This approach has to change. Benefits, tax credits and other subsidies have produced close to a communist distribution for families earning less than the median wage. Yet welfare dependency will only be reduced when there is a big gap in living standards between those who work and those who do not.

A series of specific policy measures would push the system in the right direction. Child tax credits, for example, should be paid at a much lower rate to workless households to better reflect the additional costs of working. More can also be done to reduce the income tax burden on low-paid employees – the new government’s plan to increase personal allowances is a good start, though it would be far more effective if it were funded by benefit cuts rather than higher taxes on investment.

The poverty trap is a particular problem for those stuck on incapacity benefits. The incentives to move on to them are too strong and there are powerful reasons for claimants to hang on to these entitlements. But incapacity is a privately insurable risk. The government should not provide special benefits for those no longer able to work as a result of chronic health problems.

Perhaps most importantly, the perverse incentives associated with housing policy must be addressed. Social housing should be very basic – a last resort for the genuinely homeless rather than an aspiration for people trying to get accommodation on the cheap. This means paring down the £7 billion-a-year public housing subsidies and also reforming the £20 billion-a-year Housing Benefit system.

The latter is absolutely essential if work incentives are to be increased. Withdrawn at 65p for every pound earned, Housing Benefit is often the major reason why it is not worth working. Part of the solution is to ensure that a significant proportion of rent is paid from basic benefits such as Jobseeker’s Allowance and Income Support. In this way, tenants are encouraged to find low-cost accommodation and the negative impact of the subsidies is reduced. Moreover, the barmy rules that allow claimants to live in expensive areas such as Kensington and Chelsea should be phased out.

Yet reforming the benefit system is only part of the equation. The next government must also tackle other barriers to work. Key steps include abolishing the minimum wage, reining back employment law, and making it easier for the unemployed to relocate by liberalising the planning system. Indeed, by lowering the cost of housing and basic goods, a programme of deregulation across the economy would enable benefit rates to be cut without increasing poverty, giving a further boost to work incentives.

A policy of radical reform will clearly face stiff opposition from entrenched interests, including the bureaucrats that depend on bloated budgets within government. Small, incremental measures risk being obstructed and diluted, and the political will to push them through could easily dissipate. A more effective approach may be to undertake a fundamental rethink of the scale and scope of the benefits system. Certainly, only major changes will achieve a big reduction in welfare dependency within one parliament. A degree of consensus may even be possible. Many from the left are now joining the right in openly acknowledging the harmful effects of state handouts on the prospects of the poor.

The long-term aim should be to make work much more rewarding than life on benefits so that only a relatively small number of people in genuine need require assistance. At this stage, responsibility for their support could be returned to families, charities and community groups. Britain’s counterproductive experiment in state welfare could finally be wound up.

19 May 2010, a different version of this article was published in the Daily Telegraph

How to cut Britain’s £20 billion Housing Benefit bill

The cost of Housing Benefit (HB) has exploded over the last five years, rising from £13.5 billion in 2004/05 to £20 billion in 2009/10. This is a cause for deep concern, not just because HB is a major burden on taxpayers, but also because it produces severe disincentives for workless people to enter employment.

The benefit is withdrawn at a rate of 65p for every pound earned above a certain amount. For many claimants it is the main reason that it is not worth starting low-paid work. This withdrawal of HB is normally in addition to the withdrawal of benefits and labour market taxes that have to be borne at the margin.

The Housing Benefit trap is particularly pernicious in high rent areas such as London. The capital receives 26% of HB payments although accounting for 12% of the UK’s population. This may partly explain why parts of London have some of the highest rates of worklessness in the country despite the wide range of employment opportunities.

From time to time the newspapers print a story that illustrates the problem. Last month the Evening Standard looked at the case of a mother of six receiving HB to rent a £2 million house in St John’s Wood, at a cost of £6,400 a month. Once other benefits such as Child Tax Credits and Income Support are factored in, as well as Income Tax and National Insurance, it’s clear she would have to earn in excess of £150,000 a year to be better off in work.

Such perverse incentives, as well as the clear injustice of such cases, provide strong arguments for reform of the system both to reduce public spending and address high levels of welfare dependency.

A simple first step would be to phase in a requirement for HB claimants to pay a proportion of their rent out of their basic benefits (such as Income Support). This would act as a deterrent to those exploiting the system to live in luxury homes in exclusive areas and would encourage tenants to seek out low-cost accommodation.

A second measure would be to reform the “local connection” criteria which in effect provide claimants with an entitlement to live in a particular area, no matter how expensive. Councils should be far freer to house homeless families in low-cost areas. At the very least, they could be housed in cheaper areas within a short commute of the borough in question (for example, Westminster Council could house people in Barking and Dagenham).

The long-term solution to the Housing Benefit problem lies, however, in the liberalisation of planning and building regulations that prevent the supply of ultra-low-cost accommodation. A liberal approach to land use could finally bring an end to this costly, complex and counterproductive system.

15 March 2010, IEA Blog

Darling must cut UK’s huge welfare bill

Alistair Darling is staring into the abyss. Unless he makes severe cuts to government spending there is a real risk he will plunge the UK into another economic crisis.

Without a credible commitment to bring public expenditure down to sustainable levels, the bond investors funding Britain’s near £200 billion annual borrowing may demand a risk premium in the form of higher interest rates. A big rise in rates would in turn increase the cost of the government’s debt repayments, threatening a debt spiral which could jeopardise economic recovery.

Growth is already threatened by the well-known crowding out effect of public borrowing, which diverts resources from the productive parts of the economy. This may mean official growth forecasts are too optimistic, making cuts in spending even more necessary.

In the context of these grim economic realities, Darling cannot make savings of sufficient scale without tackling the major areas of government spending – health, education and, most importantly, welfare. Including state pensions, welfare benefits cost about £170 billion per year, around one in four pounds the government spends. This emphasises the magnitude of the problem. Even a highly contentious 10% across-the-board cut would save just £17 billion – worthwhile, but a fraction of what is needed.

Yet many welfare benefits are more about favouring particular groups of voters than providing a safety net to cover basic needs. For example, a whole host of payments have been introduced that favour the over-60s, including pension credits, winter fuel payments and free travel. These special benefits add up to at least £12 billion per year and often go to relatively well off households. They also reduce incentives to work and save.

A combination of phasing out special payments for the over-60s and reducing benefit rates by a relatively small percentage across the board would help ensure welfare played a proportionate role in rescuing the public finances. A failure to address Britain’s huge welfare bill in today’s PBR will augur very badly for the country’s economic future.

9 December 2009, IEA Blog

Time preference, economic crisis and social decline

The last decade has been marked by a combination of low savings rates and high debt levels in both the USA and Britain. Indeed in 2005, the savings rate in the US reached zero, while 13 million adults in the UK – more than 1 in 4 – have no savings or investments.

The lack of savings, together with the readiness to take on debt, suggests that a high proportion of the population has a high time preference. In other words, the present is valued far more highly than the future.

Arguably the current financial crisis cannot be divorced from the short-term, “hand to mouth” culture that has come to dominate the USA and the UK. The widespread unwillingness to defer material gratification contributed to the debt bubble that precipitated the crash.

But the negative consequences do not end there. People with no savings are also more likely to have to rely on welfare-state safety nets when they lose their job or develop a health problem. They will also tend to be more reliant on state handouts in old age and may therefore vote for socialist political parties that promise to increase such benefits. There is also a strong association between high time preferences and criminality.

While it may be tempting to blame “cultural decline” for the phenomenon, the absence of saving in countries such as the UK may in reality be a rational response to artificial incentives created by government policy.

It is perhaps not that low saving causes welfare dependence but the prospect of welfare that causes low saving. Benefit claimants with more than £6,000 may face steep deductions in means-tested payments. If they have over £16,000 they may receive nothing. And when they reach old age, the availability of means-tested pension credits means low to middle income savers will be barely better off than their spendthrift contemporaries.

Another issue is long-term residential care for elderly. While savers will lose their assets, including their home, non-savers on state benefits will generally receive care free of charge – this is a tricky issue but, at the very least, those who do not save should not be able to expect a guarantee of the same standard of provision as those who pay for themselves.

All in all, the incentives for deferring gratification and saving are very weak. This problem should be addressed urgently through the reform of pensions and benefit systems in order to restore the social and economic benefits of a low time preference culture.

24 June 2009, IEA Blog