Thursday, August 31, 2006

Be careful what you wish for, Scotland

Boris Johnson writes a gloriously provocative piece in today’s Telegraph:

As anyone will know who has witnessed the death of a relative from multiple myeloma, it can be a grim way to go. Your very marrow is in revolt, as the cancer takes over the blood-making processes.

Since it could happen to any of us, I hope you will concentrate for a second on the case of a constituent of mine, a distinguished and charming author. When I last met him, he was running the second-hand book stall at the fête, and seemed very cheerful. I did not know it, but he was already well down the track that begins with radiography and then goes on to chemotherapy and stem-cell transplants, and then to courses of melphalan and steroids.

Now he has come to the last drug in humanity's current pharmacopoeia. It is called Velcade, and it is a good drug, fully licensed in this country. His doctors have told him that it would improve the quality of his life, and perhaps prolong it by two to five years.

It is available free in the healthcare systems of virtually every other European country; and yet he cannot get it in Oxfordshire. It is not available to him, or anyone else, on the Oxfordshire NHS.

He says, rather mildly, that he feels this is "unjust". I think that is an understatement. It happens that Oxfordshire is one of those counties particularly penalised by Labour, in that our per capita healthcare funding is only about 85 per cent of the national average. It is true — though obviously grossly unfair — that there are some primary care trusts (PCTs) in England that do feel rich enough to be able to afford Velcade, and today it is still being given to many multiple myeloma sufferers in other English counties.

And yet, in just a few days' time, the position is about to become worse. The injustice will shortly become an outrage. On September 6, the National Institute for Clinical Excellence (Nice) is expected finally to rule, or "advise", that Velcade should not be dispensed on the NHS, with chaotic consequences for those English PCTs that are still giving it out.

And why is it being stopped? Because each course of treatment costs between £16,000 and £17,000. We must accept, in this country, that there are some treatments the state just cannot afford, and Nice will shortly rule that Velcade is not cost-effective.

Did I say "this country"? Forgive me. There will certainly be one part of Britain, if not England, where the NHS will continue to distribute Velcade, free, to sufferers from multiple myeloma. The drug will be available in Scotland, as it has been for some time; and, much as I love the Scots, it makes my blood boil that they should be so preferred.

Do you remember that deathless moment when a heroic Labour backbencher ambushed Tony Blair at Prime Minister's Questions, and asked him to describe his core political beliefs? The PM went white, and stammered, and, after a hilarious hiatus, he gargled, "Errr … the NHS", and flopped back in his seat. And when Gordon Brown, his heir-presumptive, is struggling to sum up the "spirit of Britishness", the thing that really unites the country, he always goes for the "unique values of the NHS".

In a way, he is right. The NHS is an essential half of the symmetry of British politics. In property and economics, we may be more inegalitarian than some other European societies; but we compensate at the moments of birth, sickness and death with the total equality of the NHS ward.

So let me ask you this, Gordon: how can you call it a National Health Service? I mean, run that National bit past me again. Which nation are we talking about here? There are two nations, and England gets £1,085 per capita health spending and no Velcade, while Scotland gets £1,262 per capita and free Velcade for Scottish multiple myeloma sufferers, among many other benefits.

Gentlemen of England now abed, here is the position. The Scots have free nursing care for the elderly — subsidised, under the Barnett formula, by us, the English — while we cannot afford it in England. The Scots have the luxury of refusing to charge their students top-up fees — since they are subsidised by us, the English — while English students have to cough up. Now we learn that the Scots have free cancer drugs — subsidised by us, the English — while we in England are told they are not cost-effective.

And all this injustice is provoked by a fundamental constitutional imbalance. It was because of devolution that the Scottish equivalent of Nice was able to decide that it no longer needed to obey the rulings of this so-called "National" body. It is because of devolution that Scots are able to make their own health arrangements, in the comfortable knowledge that Whitehall will bung them an extra couple of hundred quid for every Scot.

It is because of devolution that the numerous Scottish MPs, with their small constituencies, are able to vote on questions that affect England, while English MPs have no corresponding say over healthcare in Scotland. [...]

Scottish devolution … has smashed its Mel Gibson broadsword through the NHS.

There's no more NHS. There's an EHS and an SHS. This is no longer some abstract constitutional issue. This is life and death. Unless Labour sorts it out, the shires of England will not be asking for devolution, but revolution, and they will be right.

(read the rest here)

Hey, but the Scots have their legitimate grievances too: after all, the BBC commentators are really biased towards the England football team!


Oroborous said...

I have no problem with rationed public healthcare, as long as the public system covers all basic needs, and private insurance is allowed.

In fact, it's my belief that public healthcare must be rationed, or it'll bankrupt the nation. That's certainly been the experience of both America and Canada.

As for Scottish independence, all I know of modern Scotland comes from the articles that I read over at BrosJudd. If those accurately depict Scotland's demographic situation, then Scottish patriots are insane. Within twenty years Scotland would have the living standards of present-day India.

martpol said...

Boris makes no mention of Wales - which presumably is part of England as far as he's concerned. If he looked across the Marches, he'd find plenty more to gripe about: prescription charges to be abolished by 2007 (and the Welsh will be able to get half-price prescriptions even if they need medicine in England!), reduced hospital waiting times, a 50% increase in spending on dentistry; and not a private finance scheme in sight!

Brit said...

Devolution for Scotland and Wales is like heroin: wonderful in the short-term but, ultimately, suicide.

Brit said...


all I know of modern Scotland comes from the articles that I read over at BrosJudd. If those accurately depict Scotland's demographic situation, then Scottish patriots are insane. Within twenty years Scotland would have the living standards of present-day India.

Orrin pops up on the BBC World Service's Book Club programme, and says to the author Ian Rankin something like: "From an American perspective Scotland looks like a country in a state of chronic moral and spiritual decline, with Rebus [his detective character] the last man standing against this."

Now this 'question' sounds almost sensible in the world of BrosJudd. The audience laughs as if it's a comedy question. Which it is, because it is so ridiculously over-the-top.

If your idea of Scotland or Britain comes only from crime novels or the movie Trainspotting or Dalyrymple articles on BrosJudd, of course you'll assume that the country is on the brink of lawlessness and collapse.

Just as a Briton's view of America will be skewed if all he sees of it is LA Confidential or Taxi Driver.

The Timezone-Bound One is fond of saying of Britons: "they are what they think we are". But in fact we are what you are - a complex, ever-shifting mixture of good and bad elements too big and varied to meaningfully encapsulate in one pithy sentence.

Which does leave me needing to clarify my suicide sentence above: governments, countries make mistakes, which if taken to their logical end could conceivably leave them looking like India. But do I think Scotland really will end up like hellbound in a handbasket? Not really, because ultimately they'll sort it out before they ever get into that kind of mess - the process is just painful at the margins.

Peter Burnet said...


What, you are put out because Jeremiah didn't do nuance?

However simplistic and tiresome single-minded zeal may become, its absence causes problems of its own. Your "it's all so complicated, all things are self-correcting, it was worse in the 14th century, I'm all right Jack" approach neglects to take account that nations and societies actually do rise and fall, and that economies and societies are guided by human choices. Thatcher and Reagan didn't reverse serious decline and widespread intellectual constipation through subtlety.

One reason I'm in this game is I spent most of the 80's and 90's as a vague "thinking" conservative all too willing to wank on about the dangers of American hegemony and evenhandedness in the Middle East. Despite all the leftist cant around me, I just assumed it sat on a base of majority common sense that would keep baseline values safe. Then Durban and 9/11 woke me up. The floundering around of public opinion was appalling and scary. Civilization is hard-won and easily lost, something that tends to be forgotten by many of those who think it is just there forever to be enjoyed.

I'm sure Scotland has lots of good things going for it. Well, no, I'm not sure because I never hear about them. Your press makes it sound like one gigantic low-income housing estate and writers like McEwan paint it as a gloomy mess of social and personal dysfunction at all levels, including the police. Even the people who seem to have it together or are succeeding are ultimately revealed as either hopelessly corrupt or dangerously repressed. The only cheery moment in any of the Rebus novels is when they all go out for some Asian food. (Compare with the Donna Leon novels, in which her chippy leftist themes of corruption on high are balanced by the beauty of Venice, food and Italian family life).

So, Brit, how about just one example of why things are looking up for Scotland? More adult education courses in Gaelic doesn't count.:-)

Anyway, it is true the world is a complex place and much of the enjoyment of life comes from savouring its subtlties and enigmas. But there is also much reason to give thanks for possessed recluses in rural New Hampshire thundering: Repent, O ye Scotland.

Brit said...

Terrifically well-said (although I must point out that the word 'wank' is much, much ruder in the UK than it apparently is in Canada).

What is good about Scotland? Well, a strong middle-class, the best arts festival in the world, a thriving tourist industry based around Edinburgh, the Highlands and the Lochs, some cracking scenery, Andy Murray...

But I think the point I'm trying to make is this: it is one thing to warn about wrong paths, to oppose mistakes and then to vote for the Thatchers and reform etc. That's a sensible approach, and if you use a little hell-in-a-handbasket rhetoric to get the point across, all well and good.

But the New Hampshire recluse is quite different. There's no affection or perspective or balance there. He 'sees' (and I use that word in the loosest possible sense for Timezone Man) spiritual and moral 'decline' in Scotland, and because he positively yearns for it to support his theories about secularism, he is unable to countenance either good things or hope. His hell in a handbasket is literal and not founded in reality, and thus is both hysterical and useless.

Peter Burnet said...

I do apologize. Too bad, it is such a lovely, handy word. I hope it didn't make you cringe as much as I did once while visiting a friend at Oxford when I heard a mixed-sex group of toffs talk about how they were all going out together that evening for a thrash.

Brit said...

Two (or three) nations separated by a common language, eh...

The worst one is 'wog', which is a deeply offensive racial slur in today's Britain, but the Americans think it's a quaint term equivalent to 'Johnny Foreigner'. I had a terrible time trying to explain to Lou Gots that the 'worthy oriental gentlemen' myth is irrelevant.

Oroborous said...

If your idea of Scotland or Britain comes only from [...] BrosJudd, of course you'll assume that the country is on the brink of lawlessness and collapse.

No, I take nothing that Orrin says about any culture to heart.

I don't really have any opinion about present-day Scottish culture, other than a vague notion that it's close enough to America's that I'd have only minor difficulties adjusting if I were to move there. And, along with about one in four Americans, I have Scottish ancestors, way up the family tree.

But my impression is also that Scotland's demographics skew heavily older, and that the youth of Scotland, what few there are, often leave for more opportunity elsewhere.

If that's true, and Scotland does decide to become independent again, how in the world are they going to support healthcare and old-age pensions for all, unless they work until they're 80 ?

By way of example, one of my brothers-in-law is Welsh, and for a few years after their marriage he and my sister lived in Wales, (which she enjoyed, but in a we're-having-an-adventure kind of way). He really wanted to stay in the land of his birth, but they now live in America.

There just wasn't any future for them in Wales, or at least, none at the level and of the kind that they wanted.

There are states in the United States that are like that; mostly in the upper Mid-west, the Dakotas, Nebraska, Montana, and the like. The young often leave after they're grown, and the small towns increasingly look like retirement centers.
The youth that stay are usually those that are content to be waitresses, mechanics, and nurse's aids. The salt of the Earth, one might say, but not the cream of the crop.

Those states have a decent future outlook because they're part of a bigger organization, one that is willing to mildly subsidize them.
Likewise, it seems clear that in the future the Scots will need the support of "Polish plumbers" and other immigrants to England, as the population of working-age Scots is contracting.

Is that not so ?

Brit said...

Well, possibly. We don't know yet, since the experiment has only just started.

Demographics are very hard to predict. Take the example of Eire, which has turned from exporter of potato-famers to importer of world talent.

Even post-devolution Scotland isn't an island existing in isolation. It has a lot going for it: extreme natural beauty, bracing weather (!) and, in Glasgow, the most successful example of urban regeneration Britain has contrived.

If they get the economics sorted out, the kids will stay. The purpose of predicting doom is to ensure it doesn't happen, not merely to assume it, no? What happened to your famous optimism?

Oroborous said...

What happened to your famous optimism?

I don't assume that they're doomed if they go it alone, merely that the most likely outcome of doing so would be a reduced standard of living and a whole bunch of problems that they don't have to bring upon themselves.

My optimism is mostly of the "muddle through, it'll all be OK in the end" variety, which I've applied to them. I don't think that India's current standard of living is horrible, so ending up there isn't analogous to Pol Pot coming to power in Cambodia, but it is a worse fate than could easily be, otherwise.

David said...

"Wog" just isn't an American word. We never use it and wouldn't know that it exists other than "Wogs begin in Calais", which obviously doesn't clue us in that it's use is obscene.

"Wank" or "wanker" exist as American words but are unusual and are not used in everyday conversation. Speaking personally, it has more of a sense of mental masterbation, or useless wheel spinning. For example, an attempt by a fan of a book or tv series to reconcile two seemingly contradictory bits of canon is called a "fan-wank."

martpol said...

On a tangential note, last night I was watching Hell's Kitchen USA - which, incidentally, is much more entertaining than its British counterpart - with the filthy-mouthed Gordon Ramsay.

I was most entertained by the incident when a very self-righteous guest confronted the chef to complain that his risotto contained no pumpkin, and Chef Ramsay (as he's called across the pond) suggested that he shove it in an interesting place.

But I wonder whether offensive levels of swearing are as entertaining to Americans as they are to many of us Brits? I exclude my mother from this, of course.

Also, it's only recently that every TV channel in Britain, rather than just Channel 4, has permitted unending streams of all expletives as long as they're broadcast after 9.00pm. The same in the States?

Oroborous said...

As David said, in America a "wanker" is mostly just someone who's wasting time, or a mild way to call someone a "loser".

I wonder whether offensive levels of swearing are as entertaining to Americans as they are to many of us Brits?

Difficult to say.

There certainly are those in America who find foul-mouthed people to be more entertaining than those who don't swear a blue streak, but it's a sub-culture, and tends to be the younger crowd. And Leftists (but I repeat myself).

If the average Briton finds swearing funny in-and-of-itself, then the answer to your question is "no".

The same in the States?

Yes, more mature language is permitted in the late evening, but rather few broadcast channels take advantage of the freedom. For business and cultural reasons, foul language is still mostly found on cable.

Brit said...

That cowboy show Deadwood, with Lovejoy in it, has phenomenal amounts of swearing.