I was on the World Service this week debating soda taxes with a bloke from the Center for Science in the Public Interest. My section starts at 8 minutes in if you'd care to listen here.
You might also be interested in the report published by France's Institut économique Molinari yesterday on the same subject (it's in English here).
Saturday, 4 October 2014
Friday, 3 October 2014
The drug for 'mild alcoholics' - possibly slightly better a placebo
I've been looking at the evidence for nalmefene, the drug that is to be given to 'mild alcoholics' under the name Selincro (see previous post). I'm surprised by how weak it is. The London New Drugs Group/London Medicines Evaluation Network Review looked at "three multi-country European phase 3 clinical trials". In each case, drinkers were split into two groups, one of which was given nalemfene, the other was given a placebo. Both groups were given counselling.
Here are the results...
In short, the drug was associated with a reduction in alcohol consumption of 61% while the placebo was associated with a reduction of 43%.
In this study, the drug was associated with a reduction in alcohol consumption of 68% while the placebo was associated with a reduction of 63%. The difference between the two outcomes is not statistically significant.
In this study, the drug was associated with a reduction in alcohol consumption of 79% while the placebo was associated with a reduction of 64%. Again, the difference between the two outcomes is not statistically significant.
Perhaps NICE thinks that something is better than nothing, but considering the cost of nalmefene (£3 per pill) and the apparent effectiveness of counselling, we shouldn't expect too much from a drug that made no statistically significant difference in two out of three studies and made only a fairly modest difference in the other.
In any case, the widely reported claim that nalmefene can "cut alcohol consumption by 61%" needs to be seen in the context of the placebo which "cut" alcohol consumption by 50%. And that's only if confine yourself to the more optimistic evidence.
Here are the results...
ESENSE 1 was a 6 month, randomised, double blind, placebo-controlled, parallel group study in 604 adults (placebo n=298, nalmefene n=306), mean age 51.6 years, (67% men). For the co-primary outcome, nalmefene was significantly superior to placebo in reducing the number of heavy drinking days (-2.3 days/month [95% CI: -3.8 to -0.8]; p=0.0021) and total alcohol consumption (-11.0 g/day [95% CI: -16.8 to -5.1]; p=0.0003) at month 6 when compared to placebo.
The mean number of heavy drinking days in the nalmefene group decreased from 19 to 8 days/month, and the mean total alcohol consumption decreased from 84g to 33g per day. In the placebo group, the mean number of heavy drinking days decreased from 20 to 11 days per month and the mean total alcohol consumption decreased from 85g to 45g per day at month 6.
In short, the drug was associated with a reduction in alcohol consumption of 61% while the placebo was associated with a reduction of 43%.
ESENSE 2 was identical in design to ESENSE 1, included 718 adults (placebo n=360, nalmefene n=358), mean age 44.8 years, (73% men). With regard to the two primary end points, at month 6, nalmefene was statistically superior to placebo in reducing heavy drinking days (group difference: -1.7 days/month [95% CI -3.1; -0.4]; p=0.012) but did not achieve a statistically significant reduction in total alcohol consumption (group difference: -5 days last month [95% CI -10.6; -0.7]; p=0.088).The mean number of heavy drinking days in the nalmefene group decreased from 20 to 7 days per month, and the mean total alcohol consumption decreased from 93g to 30g per day. In the placebo group, the mean number of heavy drinking days decreased from 18 to 8 days per month and the mean total alcohol consumption decreased from 89g to 33g per day at month. Adverse events were more common in the nalmefene group however; the incidence of adverse events leading to withdrawal was at the same level as placebo.
In this study, the drug was associated with a reduction in alcohol consumption of 68% while the placebo was associated with a reduction of 63%. The difference between the two outcomes is not statistically significant.
SENSE was a 12 month study in 675 adults (placebo n=166, nalmefene n=509), mean age 44.3 years, (77% men). 422 of 665 treated patients (63%) completed the study. The reasons for this high drop-out rate are not clear from the paper, which is not fully published. Nalmefene did reduce the number of heavy drinking days and the total alcohol consumption over the study period and at most time points this favoured nalmefene. However, it did not achieve a statistically significant effect when compared to placebo at the primary endpoint of reduction in heavy drinking days and total alcohol consumption at month 6.
At month 13 the mean number of heavy drinking days with nalmefene had decreased from 15 to 3 days per month (15 to 6 in the placebo group) and the mean total alcohol consumption from 75g to 16g per day (75g to 27g per day in the placebo group).
In this study, the drug was associated with a reduction in alcohol consumption of 79% while the placebo was associated with a reduction of 64%. Again, the difference between the two outcomes is not statistically significant.
Perhaps NICE thinks that something is better than nothing, but considering the cost of nalmefene (£3 per pill) and the apparent effectiveness of counselling, we shouldn't expect too much from a drug that made no statistically significant difference in two out of three studies and made only a fairly modest difference in the other.
In any case, the widely reported claim that nalmefene can "cut alcohol consumption by 61%" needs to be seen in the context of the placebo which "cut" alcohol consumption by 50%. And that's only if confine yourself to the more optimistic evidence.
It's not a conflict of interest when we do it
From the Telegraph...
Not all 'public health' groups are in favour of this mass medication, but Alcohol Concern have been widely quoted in support of it...
Nalmefene is commercially sold as Selincro by the pharmaceutical company Lundbeck. Readers with an excellent memory will remember Lundbeck being mentioned on this blog before. In May 2013, I wrote:
Lundbeck are indeed funding Alcohol Concern. They sponsored their annual conference last month and they have funded various research projects, including a report that called for alcohol treatment to be extended to a wider range of drinkers.
I, for one, am delighted that Alcohol Concern is finally receiving some private donations. Hopefully they will now wean themselves off taxpayers' money (although I won't hold my breath). There are, however, two points that need to be raised.
Firstly, whilst I have no particular beef with the pharmaceutical industry in general, they have been rightly criticised for relying on over-diagnosis and over-medication to flog more product. The invention of a new category of patients termed "mild alcoholics" who show "no overt symptoms" and yet need to be put on state-funded medication is straight out of this disreputable playbook.
Secondly, the temperance lobby—like the public health lobby in general—is absolutely obsessed with supposed conflicts of interest with industry. In the last year, the Institute of Economic Affairs and other think tanks have been the subject of a ridiculous ad hominem attack from a gutter journalist writing for the British Medical Journal which was based on assumed financial relationships that did not, in fact, exist. I have also had to personally contact the Lancet to have the false claim that I am an "alcohol industry consultant" removed from one of the Sheffield University minimum pricing 'studies' (see correction here).
Writing about the intellectual sewer of prohibitionism, I have come to expect ad hominem attacks as a first, and often only, response. I assume that Alcohol Concern think that Lundbeck's drug is a genuinely useful product and that the company can help them advance their mission. It would be nice if they assumed the same good faith of others but, again, I won't hold my breath.
Either way, it seems incongruous to rant and rave about the slightest perceived industry funding and then jump into bed with Big Pharma (perhaps this is just another example of how the temperance lobby is emulating the anti-smoking lobby). If people now choose to describe Alcohol Concern as a Big Pharma "stooge", "front group" or "shill", they will have only themselves to blame.
New drug for 'mild alcoholics' drinking two glasses of wine a night
Hundreds of thousands of people drinking half a bottle of wine a night are to be put on the first ever drug to help reduce alcohol consumption, under plans announced by the National Institute for Health and Care Excellence.
Men drinking three pints of beer and women drinking two large glasses of wine per night and who do not cut down within two weeks should be prescribed a new drug, Nice has said.
There are an estimated 750,000 people in the UK who would be eligible for nalmefene who show no overt symptoms associated with their drinking.
Not all 'public health' groups are in favour of this mass medication, but Alcohol Concern have been widely quoted in support of it...
Jackie Ballard, chief executive of Alcohol Concern, said: “It is important that there is a variety of treatments available to support people who want help with their alcohol dependency.
"The introduction of nalmefene will be a useful addition to the clinician’s toolbox, when used in conjunction with other treatment methods to tackle the harmful consequences of alcohol misuse.”
Nalmefene is commercially sold as Selincro by the pharmaceutical company Lundbeck. Readers with an excellent memory will remember Lundbeck being mentioned on this blog before. In May 2013, I wrote:
Maybe Alcohol Concern has found some non-state funding at last. As the press release notes, "Alcohol Concern partnered with pharmaceutical company Lundbeck Ltd to commission and communicate the findings of the survey." Lundbeck have just brought out a stop-drinking drug.
Lundbeck are indeed funding Alcohol Concern. They sponsored their annual conference last month and they have funded various research projects, including a report that called for alcohol treatment to be extended to a wider range of drinkers.
I, for one, am delighted that Alcohol Concern is finally receiving some private donations. Hopefully they will now wean themselves off taxpayers' money (although I won't hold my breath). There are, however, two points that need to be raised.
Firstly, whilst I have no particular beef with the pharmaceutical industry in general, they have been rightly criticised for relying on over-diagnosis and over-medication to flog more product. The invention of a new category of patients termed "mild alcoholics" who show "no overt symptoms" and yet need to be put on state-funded medication is straight out of this disreputable playbook.
Secondly, the temperance lobby—like the public health lobby in general—is absolutely obsessed with supposed conflicts of interest with industry. In the last year, the Institute of Economic Affairs and other think tanks have been the subject of a ridiculous ad hominem attack from a gutter journalist writing for the British Medical Journal which was based on assumed financial relationships that did not, in fact, exist. I have also had to personally contact the Lancet to have the false claim that I am an "alcohol industry consultant" removed from one of the Sheffield University minimum pricing 'studies' (see correction here).
Writing about the intellectual sewer of prohibitionism, I have come to expect ad hominem attacks as a first, and often only, response. I assume that Alcohol Concern think that Lundbeck's drug is a genuinely useful product and that the company can help them advance their mission. It would be nice if they assumed the same good faith of others but, again, I won't hold my breath.
Either way, it seems incongruous to rant and rave about the slightest perceived industry funding and then jump into bed with Big Pharma (perhaps this is just another example of how the temperance lobby is emulating the anti-smoking lobby). If people now choose to describe Alcohol Concern as a Big Pharma "stooge", "front group" or "shill", they will have only themselves to blame.
Simon Chapman: Not even wrong
The sight of a libertarian politician speaking out against Simon Chapman's prohibitionist cult was enough to inspire the Australian brain donor to attempt a response, which Dick Puddlecote and Redheadfullofsteam have already mentioned. Predictably, it is full of misplaced sarcasm and ad hominems, but he does attempt to make one substantive point that is so stupid that it needs to be added to his catalogue of idiocy (for just a few of the previous entries, see here, here and here).
In the video that I posted earlier in the week, Senator David Leyonhjelm made the simple and truthful observation that smokers pay much more in tax than they will ever get back in services. Not only do smokers subsidise nonsmokers to a significant degree, but the extra burden of taxation is disproportionately placed on the poor because the poor are much more likely to be smokers.
He said:
This is indisputable, so how does Chapman respond? I will quote his reply to this particular argument in full in case you think that I am picking selective quotes to make him look like a dunce. Each quote directly follows from the previous one.
Note the early appearance of a straw man. The argument for lower tobacco taxes is that these taxes far exceed the costs to the public purse of smoking (which they certainly do) and that they are regressive. Neither Leyonhjelm nor anyone else is suggesting that the government encourages more people to smoke. Chapman fails to address either of these issues in his post. Instead he goes off in a totally different direction, making a poor attempt to answer a question that has not been asked:
This has got nothing whatsoever to do with Leyonhjelm's argument. Leyonhjelm is not claiming that smokers put more "money into the economy" than nonsmokers. He is saying that a disproportionate amount of money is being sucked out of the pockets of smokers and put into the hands of grasping government officials. He makes it clear in the very first lines of his speech that he thinks it is wrong that smokers are forced to hand over so much cash to the "big spenders in this parliament". Granted, he couched this criticism with irony, but the irony was so crude that surely even Chapman realised that he doesn't think that big government spending is a benefit.
The only way in which Chapman's nonsense about squirreling money away in jam jars would be at all relevant would be if Leyonhjelm was arguing that (a) the government should encourage people to smoke, and (b) higher smoking rates are good for the economy. Obviously, he was doing neither.
Next, Chapman starts arguing with his own side...
Indeed. And a rate of 57-70 per cent is much more than the GST (sales tax) of 10 per cent that applies to other products. Hence, as Leyonhjelm argues, it is regressive, unfair and discriminatory.
No kidding. Taxation does not generate wealth. That is an argument for cutting taxes and leaving more money in people's pockets, is it not?
It is, to put it mildly, unclear what point the geriatric sociologist is trying to make here. It is true that taxation is only a transfer of income, but you would only mention that if you were arguing against someone who claimed that taxation is a good thing because it creates growth. Again, Leyonhjelm is not saying that.
At this point, Chapman is so far from discussing the issue at hand that he is not even wrong. He started by debunking the notion that smokers put more money into the economy than nonsmokers. He then debunked the notion that tobacco taxes create wealth. He now seems to be debunking the notion that tobacco sales are good for the domestic economy (to which his reply introduces a whole new layer of wrong by implying that overseas trade is a bad thing).
I hate to repeat myself but no fair-minded reader could infer that Leyonhjelm believes any of the things that Chapman is trying to debunk. On the contrary, it is quite clear that he doesn't believe them. It should be obvious to the laziest reader of Chapman's article that he has completely side-stepped all of Leyonhjelm's objections to punitively high tobacco duty.
But it is not over. Chapman has another straw man to assault...
You won't be surprised to hear that Leyonhjelm made no reference whatsoever to these savings. None. (You can read or watch the whole speech here.) On the contrary, he tacitly accepted the (incorrect) belief that smoking places a net burden on the public finances by saying "Last year, smokers imposed $318.4 million in net costs on Australia's healthcare system." He merely compared the government's official figure of $318.4 million to the $8,000 million taken in tobacco taxes.
It is, however, true that there are net savings from smoking-related diseases (and, indeed, many other diseases). This is not just "partly right", as Chapman puts it. It is an economic fact that has been proven in dozens of studies and is supported by logical deduction. Indeed, it was confirmed again a few weeks ago in a study in PLoS One which concluded:
So how does Chapman deal with this fact? By bringing on the Nazis, of course...
Wow. We really are in the realm of mental, below-the-line internet comments now, aren't we? I don't even know where to start with that, suffice it to say that a fact is not right or wrong depending on what policy implications the Nazis might or might not have derived from it.
I think the reductio ad absurdum line was crossed when you brought Auschwitz into it, Simon. And whose "reasoning" are you talking about exactly? David Leyonhjelm never mentioned the savings associated with smoking, let alone did he suggest that the elderly be culled and concentration camps be built. He was talking about the revenue from tobacco taxes exceeding the cost of the externalities associated with tobacco use. You are talking to voices in your head.
If I was capable of delivering a low blow, I'd say that Chapman knows all about being a "living sponger". And being a "public health tit" for that matter. Instead, I will leave him to spiral deeper into his madness and I trust that the reader noticed his total failure to address any of the substantive points raised in Leyonhjelm's speech.
In the video that I posted earlier in the week, Senator David Leyonhjelm made the simple and truthful observation that smokers pay much more in tax than they will ever get back in services. Not only do smokers subsidise nonsmokers to a significant degree, but the extra burden of taxation is disproportionately placed on the poor because the poor are much more likely to be smokers.
He said:
The government collects around 8 billion dollars in tobacco excise each year. That's a lot of cash. Last year, smokers imposed $318.4 million in net costs on Australia's healthcare system. Depending on rainfall, smokers also cost the taxpayer about $150 million a year in bushfire control.
If you do even basic arithmetic, these figures disclose that you wonderful, generous smokers pay 17 times as much as you cost.
... Here's a little basic maths: if you spend $5,000 a year on tobacco, it's a bigger proportion of your income if you earn $30,000 per annum than if you earn $100,000 per annum. In the trade, that's what's known as a 'regressive tax'.
This is indisputable, so how does Chapman respond? I will quote his reply to this particular argument in full in case you think that I am picking selective quotes to make him look like a dunce. Each quote directly follows from the previous one.
Leyonhjelm thanked smokers for making (albeit reduced) lifetime contributions to tax collections. So are the 87 per cent of us who don't smoke just scrooges who deserve exposure for our unpatriotic parsimony? Should the government make a massive U-turn and encourage more people to smoke?
Note the early appearance of a straw man. The argument for lower tobacco taxes is that these taxes far exceed the costs to the public purse of smoking (which they certainly do) and that they are regressive. Neither Leyonhjelm nor anyone else is suggesting that the government encourages more people to smoke. Chapman fails to address either of these issues in his post. Instead he goes off in a totally different direction, making a poor attempt to answer a question that has not been asked:
The reason why this is more than nonsense is that non-smokers don't go home each day and squirrel away in a jam jar under the bed what they would have otherwise spent on tobacco, had they been smokers, vowing to never let this money into the economy. Amazingly, we spend our money on other things, all of which - with the exception of fresh food - is GST taxed. This expenditure benefits all who are involved in the manufacture, provision and retailing of the goods and services we consume.
This has got nothing whatsoever to do with Leyonhjelm's argument. Leyonhjelm is not claiming that smokers put more "money into the economy" than nonsmokers. He is saying that a disproportionate amount of money is being sucked out of the pockets of smokers and put into the hands of grasping government officials. He makes it clear in the very first lines of his speech that he thinks it is wrong that smokers are forced to hand over so much cash to the "big spenders in this parliament". Granted, he couched this criticism with irony, but the irony was so crude that surely even Chapman realised that he doesn't think that big government spending is a benefit.
The only way in which Chapman's nonsense about squirreling money away in jam jars would be at all relevant would be if Leyonhjelm was arguing that (a) the government should encourage people to smoke, and (b) higher smoking rates are good for the economy. Obviously, he was doing neither.
Next, Chapman starts arguing with his own side...
Yes, there is the special tobacco tax which - depending on which brand you buy and from which shop you buy from - ranges between 57 and 70 per cent of retail price (the rest goes to the manufacturers and retailers).
Indeed. And a rate of 57-70 per cent is much more than the GST (sales tax) of 10 per cent that applies to other products. Hence, as Leyonhjelm argues, it is regressive, unfair and discriminatory.
But this is only a transfer payment to government within the economy, not wealth generation.
No kidding. Taxation does not generate wealth. That is an argument for cutting taxes and leaving more money in people's pockets, is it not?
It is, to put it mildly, unclear what point the geriatric sociologist is trying to make here. It is true that taxation is only a transfer of income, but you would only mention that if you were arguing against someone who claimed that taxation is a good thing because it creates growth. Again, Leyonhjelm is not saying that.
Nearly all of the tobacco sold in Australia is manufactured by three transnational tobacco companies, none of which are listed on the Australian stock exchange and only one of which still manufactures in Australia. Most profits are expatriated to international shareholders.
At this point, Chapman is so far from discussing the issue at hand that he is not even wrong. He started by debunking the notion that smokers put more money into the economy than nonsmokers. He then debunked the notion that tobacco taxes create wealth. He now seems to be debunking the notion that tobacco sales are good for the domestic economy (to which his reply introduces a whole new layer of wrong by implying that overseas trade is a bad thing).
I hate to repeat myself but no fair-minded reader could infer that Leyonhjelm believes any of the things that Chapman is trying to debunk. On the contrary, it is quite clear that he doesn't believe them. It should be obvious to the laziest reader of Chapman's article that he has completely side-stepped all of Leyonhjelm's objections to punitively high tobacco duty.
But it is not over. Chapman has another straw man to assault...
The fraternal twin of this narrative is a continuation of one exposed in 2001, when it was revealed that Philip Morris had been advising the Czech government that the tobacco control malarkey would cost them dearly. By having the decency to die early, smokers were doing us all a massive national service. They would unselfishly trim the old age pension list, and exempt themselves from perhaps 20 years of greedily storming the public health system with the fervour of a Boxing Day sales crowd. Philip Morris publicly apologised for what they had been whispering to the Czechs.
Actually, they were partly right. Every time a poor smoker dies before pensionable age, somewhere in the Treasury, a bean-counter moves a bead on the national abacus into "savings" territory.
You won't be surprised to hear that Leyonhjelm made no reference whatsoever to these savings. None. (You can read or watch the whole speech here.) On the contrary, he tacitly accepted the (incorrect) belief that smoking places a net burden on the public finances by saying "Last year, smokers imposed $318.4 million in net costs on Australia's healthcare system." He merely compared the government's official figure of $318.4 million to the $8,000 million taken in tobacco taxes.
It is, however, true that there are net savings from smoking-related diseases (and, indeed, many other diseases). This is not just "partly right", as Chapman puts it. It is an economic fact that has been proven in dozens of studies and is supported by logical deduction. Indeed, it was confirmed again a few weeks ago in a study in PLoS One which concluded:
Elimination of diseases that reduce life expectancy considerably increase lifetime health care costs... The stronger the negative impact of a disease on longevity, the higher health care costs would be after elimination.
So how does Chapman deal with this fact? By bringing on the Nazis, of course...
But this is right in exactly the same way that those in charge of Nazi "arbeit macht frei" work camps were correct that the sick and infirm were no longer needed because they could no longer contribute to the work schedule.
Wow. We really are in the realm of mental, below-the-line internet comments now, aren't we? I don't even know where to start with that, suffice it to say that a fact is not right or wrong depending on what policy implications the Nazis might or might not have derived from it.
In Big Tobacco's world, smokers who die early are not to be pitied or a reason to think about how to prevent this [sic].
The reductio ad absurdum of this reasoning is that all prevention that stops people living into old age should be scythed as unpatriotic.
I think the reductio ad absurdum line was crossed when you brought Auschwitz into it, Simon. And whose "reasoning" are you talking about exactly? David Leyonhjelm never mentioned the savings associated with smoking, let alone did he suggest that the elderly be culled and concentration camps be built. He was talking about the revenue from tobacco taxes exceeding the cost of the externalities associated with tobacco use. You are talking to voices in your head.
How long will it be before the NHMRC is lobbied to audit and then blackball all health and medical research which might keep this flood of longer living spongers from sucking on the government public heath and welfare tit?
If I was capable of delivering a low blow, I'd say that Chapman knows all about being a "living sponger". And being a "public health tit" for that matter. Instead, I will leave him to spiral deeper into his madness and I trust that the reader noticed his total failure to address any of the substantive points raised in Leyonhjelm's speech.
Thursday, 2 October 2014
Whining doctors
I tend to write about 'public health' quacks on this blog rather than proper medics, but every now and again something like this crops up...
Ageing GPs 'may force practices to close'
Hundreds of GP practices are at risk of closure because of the ageing workforce, doctors' leaders say.
An analysis by the Royal College of GPs has identified 543 GP practices out of the 8,000 in England it believes could be forced to shut in the next year.
They all have over 90% of their doctors aged over 60 - the average retirement age is 59.
Firstly, boo-hoo for the poor doctors who retire at the average age of 59 while the rest of us work to 65 or later to pay for them and their massive pensions.
Secondly, workers get old and can be replaced without their businesses having to close down. It may well be true, as the BBC article says, that one in sixteen GP practices are staffed by older workers, but that does not mean that they 'risk closure'. That would only happen if the UK could not import GPs from abroad or was not training GPs at home. But we import many doctors from abroad and—as Nick Triggle (for it is he) admits in the article's final sentence—the number of doctors being trained in the UK is rising:
But the Department of Health said it was investing in new GPs. It said the number of GP training places was rising. Last year there were just over 2,700, but by 2016 it will hit 3,250 a year.
So this is just the usual scaremongering lobbying from a particularly plump vested interest. And, as always, it is about money:
RCGP chair Dr Maureen Baker said extra investment was needed just to keep the system afloat - never mind expanding it.
She said the amount spent on GPs as a proportion of the NHS budget had been falling in recent years, and needed to increase from the current "historic low" of just over 8% to 11% by 2017.
The amount spent on GPs as a proportion of the NHS budget is a red herring. The NHS budget increased threefold in real terms under Labour and is still increasing, albeit at a much slower rate since the recession. GPs' salaries also went up dramatically under Labour. The fact that anyone in the NHS has the nerve to complain about a lack of money after this staggering spending splurge is appalling, let alone doctors who have had their mouths stuffed with gold from day one.
No one should care about whether the amount spent on GPs has risen in proportion to the incredible largesse that has been enjoyed by the rest of the NHS. The only relevant statistic is whether the number of GPs has fallen relative to the UK population—and it has not. It is true that Britain has fewer GPs per 1,000 people than many other rich countries, but this has always been the case under the NHS and if that were to change it would have happened when Gordon Brown was throwing almost unbelievable amounts of taxpayers' cash into this money pit.
As is customary with this sort of special pleading, there is the usual claim that services are on the brink of collapse:
Comparing general practice to the "walls of a dam" that prevents the rest of the NHS being flooded, Dr Baker said: "So far much of the damage to the dam wall has been hidden from the public - they see the flooding downstream in A&E departments and in hospital pressures - but they haven't been aware that GPs, nurses and practice teams have been absorbing that pressure by trying to do more and more with less and less.
"But if we let that situation continue we will see whole chunks of the dam fall apart when practices have to shut their doors."
Blah, blah and, furthermore, blah. I've been told that the NHS is on the brink of collapse my entire life. You only have to click on Google to see how often the NHS has supposedly been in this perilous situation. It's a bluff. It ain't gonna happen. It's a publicly funded state behemoth and cannot go bust. At worst, it will give some patients poor care and treatment, but it always has and it always will. Moreover, those patients who receive adequate care will continue to feel pathetically grateful for their 'free' healthcare that actually costs them over £2,000 a year.
Like all public services, the NHS should be on the brink of collapse. If it wasn't, it would be even less efficient than it is. But it will not, and cannot, actually collapse. It will continue to suck increasing amounts of money from taxpayers ad infinitum, much of which will continue to go to fat cat doctors, consultants, lobbyists, public health parasites and—above all—bureaucrats.
I don't know whether the current reforms of the NHS are a good or a bad thing, but I cannot remember a time when doctors' lobby groups weren't predicting the end of civilisation as we know it unless they were given more money. I would be less inclined to regard them as a reactionary, grasping, scaremongering special interest group if, at any point in living memory, they had ever seemed to be reasonably content to be engaged in well remunerated and secure employment (see also: teachers). The fact that large numbers of them also wish to restrict our freedom is incidental in this context, but it only adds to my conviction that they should shut up and get on with their job.
Wednesday, 1 October 2014
Winding up prohibitionists with the truth
Liberal Democrat Senator David Leyonhjelm has caused outrage in Australia by telling the truth about the economics of smoking. This is recommended viewing...
Here is some of what he said...
Here is some of what he said...
"Ladies and gentlemen, thank-you for smoking.
Australian smokers contribute significantly to the pile of money that – as I noted in this place recently – other people then spend.
As you well know there are many such big spenders in this parliament, as are many of the people who malign you.
They don't like your habit, but in my view they have an even filthier habit: spending your money – and other people's money – on things that are often even sillier than spending too much on cigarettes and booze.
Your generosity to the nation's treasury is truly staggering. The government collects around 8 billion dollars in tobacco excise each year. That's a lot of cash.
Last year, smokers imposed $318.4 million in net costs on Australia's healthcare system. Depending on rainfall, smokers also cost the taxpayer about $150 million a year in bushfire control.
If you do even basic arithmetic, these figures disclose that you wonderful, generous smokers pay 17 times as much as you cost.
... Because the revenues versus costs figure is so lopsided, those who would tell you how to live have tried to add 'social costs' to the healthcare costs I discussed earlier. 'Social costs' take in things like smokers' spending on tobacco, and the lost productivity represented by smokers' earlier mortality. These, allegedly, represent income foregone.
By that logic, deciding to work part time to increase your leisure time is a social cost, as is going on holiday.
Arguments like that suggest to me the anti-smoking lobby is running out of ideas.
But when powerful, well-funded lobby groups run out of ideas and arguments, unfortunately they don't fold up their lobbying tents and head home.
They keep lobbying, and we've now reached the point where, thanks to their efforts, the government is about to kill the goose that lays the golden egg, handing all the lovely tax money it extorts from you over to organised crime."
... Here's a little basic maths: if you spend $5,000 a year on tobacco, it's a bigger proportion of your income if you earn $30,000 per annum than if you earn $100,000 per annum.
In the trade, that's what's known as a 'regressive tax'. And if – along with South Park's Mr Mackey – we can agree that 'drugs are bad, mmmkay', it's probably also fair to say that 'regressive taxes are bad, mmmkay.'
Calling regressive taxes 'sin taxes' doesn't hide the scale of the problem. Smokers are typically poor, which makes this vast tax-take all the more perverse. It means, for example, that social planners who want to redistribute money from the rich to the poor need to increase both welfare payments and income tax rates to achieve their goals. When the 25 per cent excise increase was imposed, the Australian Customs and Border Protection Service noticed an increase in seizures of illicit tobacco.
In 2013, it rose to 183 tonnes, representing forgone customs duties of $150 million. Remember, that's the annual cost of putting out bushfires due to cigarettes.
And it's also entirely to be expected: tobacco can't even be commercially grown in Australia. Smokers of Australia, despite your generosity, I need to apologise on behalf of the short-sighted pickers of your pockets in this place.
Maybe they haven't studied any history, because if they did, they would learn that the regime controlling cigarettes is no longer one of 'legalise, regulate, and tax.' Instead, it now resembles two other regimes, regimes that were and are catastrophic failures. I'm thinking here of Prohibition and the War on Drugs."
Minimum pricing model wheeled out once more
The latest flurry of activity from Sheffield University's minimum pricing activists researchers appeared today. As ever, it made headline news at the BBC...
A minimum price is a floor price. If a BBC hack doesn't understand basic terminology, s/he is unlikely to be able to get to grips with a speculative and partisan estimate from a deeply flawed computer model.
The gist of the press release (there is also a study, but the study is more of an appendage to the press release than vice versa) is that the ban on alcohol being sold below cost price will have much less effect on alcohol consumption—and therefore, in the eyes of theactivists researchers, alcohol-related harm—than a minimum unit price of 45p.
A few things need to be said about this...
1. The study, which has been published by the British Meddling Journal, is just the umpteenth reworking of tired old guesstimates about the possible effect of a 45p minimum price. Aside from the fact that no one is campaigning for a 45p minimum price any more (it is now 50-60p), the Sheffield model is based on absurd assumptions, such as the belief that heavy drinkers are more price sensitive than light drinkers, and it uses price elasticities that are at odds with almost everything that has ever been written about the demand for alcoholic beverages in the economics literature.
2. The claim that minimum pricing would be '50 times more effective' (ie. would reduce consumption by 50 times more) is also not new. The Sheffieldactivists researchers announced this factoid last year - in one of its many press releases - when the government announced the ban. They said:
This factoid was eagerly taken up by their friends at the Institute of Alcohol Studies (formerly, and more appropriately, known as the UK Temperance Alliance), who issued their own release saying the same thing. Today's announcement is, therefore, a reworked version of a 16 month old, policy-driven press release that was based on a hastily cobbled-together figure.
3. The government only banned the sale of alcohol below cost price (actually below duty+VAT) because the 'public health' lobby spent years whipping up hysteria about supermarkets selling alcohol as a loss leader. Those of us who live in the real world knew that such a ban would have very little effect because we knew that hardly any alcohol is sold below cost price. It was a temperance lie from day one.
4. More recently—ie. since the government capitulated on below cost sales—the temperance lobby has turned its back on the loss-leader argument and has claimed instead that a ban "will have no effect at all on health". Claiming that minimum pricing will be fifty times more effective than something that will have "no effect at all" is the same as multiplying bugger all by fifty. The new(ish) Sheffield study actually reckons that a below-cost ban will save 14 lives a year, based on a reduction in per capita alcohol consumption of three units. This is because they make daft assumptions about per capita consumption and alcohol-related mortality having a direct, linear relationship. A more realistic estimate is that it will save about as many lives as a 45p minimum price, ie. none.
5. Since the Sheffieldactivists academics started modelling the impact of minimum pricing in 2008, per capita alcohol consumption has fallen much more sharply than they predicted would happen under their pet policy. They have yet to explain why all the glorious health outcomes that should have accompanied this decline have failed to reveal themselves.
6. The problem with minimum pricing is not that it will have more (or less) effect than a policy that no sane person thought would have any effect, but that it is deeply regressive, iniquitous and illegal. Resurrecting the corpse of the Sheffield computer model will not change that, nor will it alter the fact that the model itself is a waste of time, energy and taxpayers' money.
Minimum unit price '50 times more effective' than alcohol floor price
A minimum price is a floor price. If a BBC hack doesn't understand basic terminology, s/he is unlikely to be able to get to grips with a speculative and partisan estimate from a deeply flawed computer model.
The gist of the press release (there is also a study, but the study is more of an appendage to the press release than vice versa) is that the ban on alcohol being sold below cost price will have much less effect on alcohol consumption—and therefore, in the eyes of the
A few things need to be said about this...
1. The study, which has been published by the British Meddling Journal, is just the umpteenth reworking of tired old guesstimates about the possible effect of a 45p minimum price. Aside from the fact that no one is campaigning for a 45p minimum price any more (it is now 50-60p), the Sheffield model is based on absurd assumptions, such as the belief that heavy drinkers are more price sensitive than light drinkers, and it uses price elasticities that are at odds with almost everything that has ever been written about the demand for alcoholic beverages in the economics literature.
2. The claim that minimum pricing would be '50 times more effective' (ie. would reduce consumption by 50 times more) is also not new. The Sheffield
The Sheffield modelling estimates that the impact of a 45p minimum price would be around 40 to 50 times larger than that of banning below-cost selling.
This factoid was eagerly taken up by their friends at the Institute of Alcohol Studies (formerly, and more appropriately, known as the UK Temperance Alliance), who issued their own release saying the same thing. Today's announcement is, therefore, a reworked version of a 16 month old, policy-driven press release that was based on a hastily cobbled-together figure.
3. The government only banned the sale of alcohol below cost price (actually below duty+VAT) because the 'public health' lobby spent years whipping up hysteria about supermarkets selling alcohol as a loss leader. Those of us who live in the real world knew that such a ban would have very little effect because we knew that hardly any alcohol is sold below cost price. It was a temperance lie from day one.
4. More recently—ie. since the government capitulated on below cost sales—the temperance lobby has turned its back on the loss-leader argument and has claimed instead that a ban "will have no effect at all on health". Claiming that minimum pricing will be fifty times more effective than something that will have "no effect at all" is the same as multiplying bugger all by fifty. The new(ish) Sheffield study actually reckons that a below-cost ban will save 14 lives a year, based on a reduction in per capita alcohol consumption of three units. This is because they make daft assumptions about per capita consumption and alcohol-related mortality having a direct, linear relationship. A more realistic estimate is that it will save about as many lives as a 45p minimum price, ie. none.
5. Since the Sheffield
6. The problem with minimum pricing is not that it will have more (or less) effect than a policy that no sane person thought would have any effect, but that it is deeply regressive, iniquitous and illegal. Resurrecting the corpse of the Sheffield computer model will not change that, nor will it alter the fact that the model itself is a waste of time, energy and taxpayers' money.
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