Wednesday, 27 November 2013

The Heartless NHS

From the BBC

The NHS must stop turning a "blind eye" to smoking and ban it in all hospital grounds in England, according to new guidance.

The National Institute for Health and Care Excellence said it wanted to see smoking shelters scrapped so patients, visitors and staff could not light up. Staff should also stop helping patients out of their beds to go for a smoke.

And patients who smoke must be identified and offered help to quit, the guidance added. It said nurses, doctors and other staff could give brief advice and then refer smokers on to NHS stopping smoking services.

This is what I despise about the big state, and one of many reasons why I am utterly in favour of privatising the NHS.

When I have a problem with my car, my mechanic fixes it. It might also be that he advises me about things I could do to prolong the life of it, and I appreciate that advice. If my mechanic tried to stop me wearing through brakes, he'd soon find himself no longer my mechanic. It's none of his business.

The NHS is there to fix people's health. Part of its job is also to advise people on what's good for their health. When it steps into trying to stop people doing things, it's not doing its job.

Right now, it can do this, because hospitals have a monopoly. Some elderly guy who's had a hip operation whose one small pleasure in life is his roll-ups can be stopped by an uncaring bully. You're not going to get those people to quit anyway. Most people who quit do so at a younger age. Old people figure something's going to kill them soon anyway.

So, let's imagine a competitive model. The old NHS hospital tells an old man he can't smoke when having his hip done. So, he tells his mate about it. When his mate needs his hip done, he says "no, not going there, I'd like to be able to go out for a smoke". The private hospital that considers what the patient wants, rather that their own opinions get the job. And we put a bunch of fascists out of work, or force them to modify their behaviour.

If I had the spare time, I'd create a service where I drove up to the hospital grounds, drove people off them where they could have a smoke and drive them back on again, just to piss off these bastards.


Mark Wadsworth said...

Agreed, obviously, I'm just wary about the phrase "privatising the NHS".

Surely you mean "allowing patients to choose their own provider, with the NHS paying the bill up to £ however much it would have cost the NHS to do that operation"?

The Stigler said...


Yes. I'm not in favour of say, the US system, more like the various systems in Europe.

I never understand why people are so nervous of that change. The NHS already has 2 bits that work like that: spectacles and prescriptions. If you want specs for kids (kids get them for free), you take a prescription to Tesco, they order them and claim the money back. If you want fancy frames or reactolites, you pay the extra to Tesco. Works brilliantly.

Antisthenes said...

I for a number of years lived in France and used their healthcare system and found it to be excellent. It used the choice of providers system from nurses(yes nurses) and doctors through to hospitals and medical testing laboratories.

The human race has always had two types of people those who wish to control others and those who wish to be left alone and get on with their life as they see fit. Before the two were in balance and it more or less worked now the banstabators, righteous do gooders and control freaks are in the ascendancy which has come about because we have an entitlement and dependency society. To put it another way the vast majority have been seduced by socialism and have therefore handed their souls over to large authoritarian statehood. As we know socialism eventually collapses as it knows how to redistribute wealth but has never found a way to do it in a true democracy coupled with which it always ends up destroying the wealth creation that it needs to sustain it. So eventually the controllers will go with the ideology that sustains them and the rest of us will be free of their menace for a while although it will be in a more impoverished condition socially and economically.

The Thought Gang said...

The NHS is a religion. If you keep saying these things then you will be hunted down and burned as a heretic. The NHS PR machine (which all the big politicos pander too) is so powerful that the notion that we can all chip in to pay for healthcare without necessarily also owning and running the provision itself is alien to most people.

A friend of mine was having huge problems getting anyone in the NHS to give a crap about a problem he had. I suggested looking for a private doctor. Not only had the idea never occurred to him, he had no idea how to go about doing it, or what it would cost. Why is it that we all know what to do if our broadband service is shoddy.. but if the issue is with our healthcare provider we're entirely lost?

Graeme said...

I have to second the ideas here. I am prone to ear infections. 20 years ago I was here in the UK and went to my GP ....3 courses of anti-bios later, she referrred me to a specialist and the thing got cured. Meanwhile I spent 3 months hearing as if was at the bottom of a swimming pool.

3 years later, working in the Netherlands...another nasty ear infection...referred instantly to a specialist and it was sorted within 10 days.

Give me the good old NHS any day! They really know how to fuck you over.

Graeme said... cost me 50 euros...which I could reclaim from insurance.

the NHS series of treatments must have cost in excess of £100, of which I paid about 15 in prescription charges. The lack of competence was what astonished me.

Antisthenes said...

Graeme. I can tell you loads of horror stories about the NHS as told to me by expats whilst I was living in France and who had been properly diagnosed and cured by the French healthcare system after being failed by the NHS. My own is fairly typical. For 20 years I had a stomach problem and I had been to a variety of doctors, consultants and hospitals in the UK none ever diagnosed let alone cured it. The first French GP I saw did so within weeks of seeing him he sent me for a blood test from the result of which he put me on a course of tablets and the problem went away after 10 days. I met a young lady who had a tumour the size of an orange removed from her abdomen in France that the NHS had failed to detect. The NHS is not a sacred cow or functioning healthcare service it is totally dysfunctional.

Bayard said...

My faith in the NHS was destroyed when two separate doctors misdiagnosed a complaint I had, which as a result lasted for about a year. When I finally got to see someone who knew what they were talking about, it got cleared up in a week.

DBC Reed said...

Oh my gawd.This all so right wing.
Last year I was in hospital (one of the seven most dangerous in the country).Bloke on my ward was due to have his leg off from the effects of heavy smoking .Every so often you used to see him lumber out of bed and outside for a smoke ,not brazenly, but not surreptitiously either.The staff accepted it. About the only bit of genuine compassion I saw. ( I had no pain killers of any sort after an operation. The nurse who gave me Paracetemol out of pity was reprimanded.) It was a cross between How the Poor Die by George Orwell and a Victorian lunatic asylum. And I'm a socialist. Still nothing spending a decent amount of money on the NHS would n't cure.

paulc156 said...

Deary me. Sounds like the whole crew went to Mid Staffs. I have a son born with a cleft lip and palate. Was treated at Billericay [now Broomfield] burns/plastic surgery unit. From birth to about a year ago [he's now 25] when he was offered a further operation [he'd had three over the years]which he declined I don't believe that anyone anywhere in the world could have received better treatment.
My 81 year old mother just had a double hernia op on Tuesday and at the local NHS and she was well impressed with the treatment and time taken with her prior to the operation by the surgeon and two of his team. Staff on the ward have been first class. Not surprised since she's had a partial nephrectomy there 3 years back and last year had a colostomy reversal. Along with all the attendant diagnostics and check ups she has had 'near' perfect treatment over an extended period of time. ...meanwhile my pal is in the process of seeking financial redress from a private hospital/consultant who gave my friends daughter a colonoscopy and then a camera down the throat to investigate a stomach complaint without first carrying out blood and stool tests. The hospital have admitted this was incorrect procedure but the consultant is self employed and he claims he only did it because it was requested by the patient [who of course was desperate for cameras up both ends, not]. No it was apparently because he gets paid per procedure and endoscopy's are good money earners, blood and stool tests a bit pony. Frankly I know of several cases over the years at private hospitals that would make the above complaints sound rather tame.

Antisthenes said...

DBC. It was socialism that brought in the NHS and it will be socialism that will eventually destroy it. Money is certainly a problem plaguing the NHS but then it always will be healthcare is expensive and becomes more so as it is able to treat more and more illnesses. However the answer is not to throw more of other peoples money at the problem that solves nothing and only ends up lining the pockets of those who work in it. The answer is to introduce private sector efficiency which the NHS sadly lacks by introducing customer/patient choice and at the same time foster a culture of caring although competition will do that anyway. All you get with socialism is short term gain for long term loss. Free enterprise has many flaws but they come no where near those of large state central control and planning. The answer is to ditch socialism embrace free markets and work to make them work to everyone's advantage. They do this anyway but not at a uniform speed and some benefit more quickly than others. Make it more equal then fairness, equality and justice for all will be better attained than by working to the lowest common denominator which is how socialism works and which in the end benefits no one.

Bayard said...

P156, so the private sector gets it wrong too, so what? At least with the private sector you get the opportunity to go elsewhere, like I did with my dentist as soon as I realised he was crap. As to being paid per procedure, my teeth have all been drilled to bits by NHS dentists being paid per filling.

A, you are wasting your time with DBCR. The socialist ideal is to have everyone employed by the state. Anything that reduces the number of state employees will always be anathema to them.

DBC Reed said...

All the opinion polls show that people are sick of privatisations and have rumbled the old " private sector efficiency " number.
@Paul 156
I did say the hospital I ended up in was on the seven "most dangerous to patients" list (published after I got out).The Officer Class of consultants ,registrars and doctors was excellent but it grieves me to say that the other ranks nurses etc were a scandal,not carrying out written orders: case directions.After the row about no pain killers a doctor (Polish: a great help as she dealt with the Polish guy who was lying on the floor shouting with pain) intervened and found my drugs chart which they had simply not bothered to read.And that I should have been released a day ago: so I was off , leaving them serving breakfast to a nil- by-mouth patient.My advice don't go in at the weekend: they have loads of Agency Staff in who are left too much to their own devices.(The mass staff panic when a very ill patient next to me started to slip away, was moved to a side ward and they could n't find the resuscitation ("resussi" ) bag haunts me to this day. )
We should n't delude ourselves that everything's right with the NHS.But I would tend to the view that bringing in private sector efficiencies has already gone too far: private sector agency staff , ward cleaning and an obsession with squeezing the (staff) assets have caused the trouble.Spend more money and re-professionalise the service seems the obvious answer.

DBC Reed said...

And a hearty bollocks to you too.
"The socialist ideal is to have employed by the state"
I have elsewhere stood up for small shops (against their real enemies the supermarkets and online discounters on classically liberal lines.
Please draw my attention to the part in the Communist Manifesto where it says everybody should work for the state.Not that I would be bound by that being a post war mixed economy Labour voter who sees a place for private enterprise.A pity you lot can't see any part for public service (even Tories used to make exceptions for the natural monopolies ).

Bayard said...

"All the opinion polls show that people are sick of privatisations"

People are sick of privatisations because they have been done so badly. However it is hardly surprising that the same public servants who failed to run the industries properly when they were in public ownership should make a hash of selling them off as well. It is true that bad management is not confined to nationalised industries, but is endemic amongst all industry. The difference between badly run nationalised industries and badly run private industries is that the latter eventually go bust or are taken over but the latter continue on for ever requiring ever greater amounts of taxpayers' cash.
One of the biggest failures of privatisation has been the failure to deal with natural monopolies and cartels. I suppose it is an argument against privatisation that the current lot in power (by which I mean LibLabCon in their manifestation de cinq ans) are bound to cock it up, but that would be an argument against nationalisation too, should that ever come back on the agenda.

"But I would tend to the view that bringing in private sector efficiencies has already gone too far"

That's because they have only been applied to the workers and not the bureaucracy that "manages" them. I suppose it the old problem that to the man with a hammer, every problem looks like a nail, so to a bureaucrat, every problem can be solved by more bureaucracy. Having worked in the ultimate bureaucracy, the Civil Service, I can vouch for how seductive that idea is.

"The socialist ideal is to have employed by the state"

Well I'm glad that you don't support this idea, which admittedly I have got from dealing with other socialists than you.

"A pity you lot can't see any part for public service"

Public service is a great idea, but sadly true public servants are in very short supply. Since this nation had its attitudes adjusted by the war, the idea of public service and that of doing a good job for its own sake has largely been replaced with the attitudes "what's in it for me?" and "can I get away with it?" plus a growing sense of entitlement exemplified by the multi-millionaire ex-Hulture Secretary claiming 5p on expenses for a paperclip.

Mark Wadsworth said...

B, DBC, I've said this before and I'll say it again.

Many of the "privatisations" in the UK were disastrously handled, the govt just throws money and freebies at its mates and allows privatised rent collection (PFI, landing slots, Rover, Royal Mail etc).

That's no way to "privatise" things, from the top down. That's hardly ever for the benefit of consumers, and usually only for the benefit of the insiders.

You have to do it from the bottom up. With regards to NHS, we do not need to reinvent the wheel, we can just copy what the Europeans do.

It's still largely funded or subsidised by the taxpayer/compulsory insurance, but patients can choose where to go, and having lived in Germany, all I can say is that it works.

What the Tories would probably like to do is sell off hospitals at undervalue to their mates. This is crap, of course.

What they should do is allow independent bodies (be they private companies, partnerships of doctors or nurses, trade unions, the local council acting as corporation, charities, insurance companies, whatever) to rent part of the hospital space, or to work out what operation X Y or Z costs the NHS and then say that if an independent body is prepared to do this for that price or lower, then it can offer its services to patients, who get it paid for.

Kj said...

Whether you are for or against public provision of health services, it´s quite possible to have one without all the neo-prohibitionist authoritarianism. It will inevitably try to creep in, but I don´t think we´ll be rid of the frothing anti´s by privatisation either.

The Stigler said...


That's because they have only been applied to the workers and not the bureaucracy that "manages" them.

The organisation is run by clowns and most of the administration is overstaffed and lazy.

I had to go to a hospital about my eyes. I get a letter, telling me to go on Choose and Book and see my hospitals. So, I do, and there's the private hospital down the road. "I'd like to go there"
"sorry, they don't have an eye section"
"So, why did you tell me to go there then?"
"Well, that's just hospitals near you" I grumble a little, but then say "OK, so where can I get it done".
"Well, there's the hospital at Gloucester". The hospital at Gloucester wasn't on the Choose and Book list at all, so utter waste of time.
"OK, when can they see me". Date comes back, it's like 2 months away.
"Really, that's the earliest?"
"Let me check. Oh, How's Oxford for you?"
"Oxford's good. When can they see me?". It's a date in about 3 weeks.
"OK, put me down for that"
"Well, Oxford's not this region, so you'll have to call them".
"OK, I'll call them".
"Well, I have to unlock the appointment and transfer it to them and once transferred, you're then stuck in Oxford region"
"Errr..." (I'm about to ask why, then I remember this is the NHS)
"You could call them, check it's still free then call back and unlock it"
I'm now wondering why that's not a real-time lookup, but never mind...
So, I make the call, it's still free. I call back
"Yup, can you unlock it, and book it?"
"Well, I can unlock it, but then you need to call Oxford to book it"
I then call Oxford, they unlock and book.

Meanwhile, in the real world, I booked a hotel room in Hanoi in 5 minutes via the internet.

paulc156 said...

@B "so the private sector gets it wrong too, so what? At least with the private sector you get the opportunity to go elsewhere"

Frankly that's nonsense as far as most people are concerned, indeed almost everyone. Of course most people aren't pursuing kind of 'out there' political philosophies so they might adopt your view if you could get them in a locked room for a few days.
You see, people look at health provision in a somewhat different way to say sweeties or motor cars and whilst caveat emptor is fine with those things, where health is concerned people don't generally want to adopt the shopping centre approach to heart by-pass surgery or colorectomy procedures and the like. Maybe with more routine treatments that can be easily corrected it's not such a big deal.
Where my own lad was concerned he was under a surgeon who was so respected amongst staff, mainly because he did so little private work [despite demand] and so liked by patients relatives because of his kind nature and the fine results he achieved, yet he spent a fair bit of time correcting botch jobs done in the private sector. Wasn't obsessed with the money you see. Obviously not very rational.

If dentistry as we have it organised today is the standard you'd like to see health provision operate under then you might need to keep those folks in a locked room for a while longer than I already suggested.

Mark Wadsworth said...

PC, there is no point saying things like "Frankly that's nonsense as far as most people are concerned, indeed almost everyone" because

a) You have no evidence to back this up, or to show that people are really that stupid.

b) Anybody who has lived elsewhere in Europe (that's Anti, Graham and me) knows perfectly well that people are capable of deciding what is wrong with themselves and going to the appropriate doctor, hospital etc.

How dare you deride the French, German etc health systems as "A shopping centre approach", it is quite the opposite.

The amount of actual "shopping around" is quite minimal, but if a doctor or hospital fucks up, word soon gets round (doctors and people do talk to each other) and that keeps everybody on their toes.

DBC Reed said...

Administration tends to be overstaffed and lazy per se: especially in private sector competition. Two competing firms have their own back office staff: human resources; computer operations,marketing .There's a merger and they shed one firm's HR etc. completely, operating with half the previous admin staff. There would be no point in merger otherwise . So: competition supports wasteful parallel admin QED

Mark Wadsworth said...

DBC, yes, you have said that before and there is some truth in it.

There is however also the observation that the larger teh organisation, the more layers of bureacracy you have, so merging two smaller ones into a larger one increases the amount of paperwork etc.

So there is an optimum size.

But we are talking about our experiences as individual patients in the NHS compared with European countries, and theirs are objectively better, that's just a fact.

If we look at global outcomes, life expectancy, value for money etc, then the NHS doesn't do so bad, that's a separate topic.

DBC Reed said...

@MW Its not a separate topic: its the topic under discussion!
"Health outcome figures" (curing people?) show the NHS near the top of international comparisons and the same goes for value for money,(so that's all the private sector efficiency argument from the enemies of the mixed economy out of the window).
Neither is it any good saying privatisation would be alright if it was done properly.This is the same as the First World War chateau generals saying' The last push was a failure, lets have a longer artillery barrage to let everybody know we're coming and churn up the ground and be prepared to take double the casualties (not to us personally).'
We can be fairly sure that the next privatisation will be an unpopular mess like the previous ones.And increase admin/ bureaucracy: (the American system consumes itself with costs for billing etc and leaves people doing manual work with hernias).You will say We don't want the present system of privatisation but that it what you will get .
The solution given the full range of information: is more spending on the NHS.
( I know I have rehearsed King Gillette's argument that competition increases bureaucracy before and you have acknowledged the validity of some of it,but there are newer contributors on here who appear to be enemies of the Post War British state founded on a mixed economy so some continued resistance is in order.)

Mark Wadsworth said...

DBC, we are comparing the UK system with the European systems, not some abstract concepts.

As my post of yesterday evening shows, Germany employs twice as many people (per capita of population) as the NHS for more or less the same cost to the taxpayer. And it delivers far better outcomes and patients like it.

I take it you've never lived in a European country and been a patient there?

paulc156 said...

"PC, there is no point saying things like "Frankly that's nonsense as far as most people are concerned, indeed almost everyone" because

a) You have no evidence to back this up, or to show that people are really that stupid."

What, evidence that people aren't inclined to adopt a "so what" attitude if a health provider messes up because you can get alternative treatment elsewhere, after the event, in a shopping centre type health system? Oh well...

"Anybody who has lived elsewhere in Europe (that's Anti, Graham and me) knows perfectly well that people are capable of deciding what is wrong with themselves and going to the appropriate doctor, hospital etc."

They generally require medical advice to assist in their diagnosis so it's hardly the case that they can just decide. Nor do many people know the best course of action to take once initial diagnosis is complete and prefer the idea that a Doctor offers advice... which preferably he doesn't stand to benefit from. Prior to the recent health reforms, people still had unrivalled trust in their GP's because of this. Even many GP's opposed this aspect of the reforms for the same reason. They didn't want to prejudice that relationship with the patient.

"How dare you deride the French, German etc health systems as "A shopping centre approach", it is quite the opposite."

Straw man. Didn't deride anyone.However if any French or German readers inexplicably took offence at my non mention of anything or anyone German or French, I do offer a full and unreserved apology.

Mark Wadsworth said...

PC, you keep digging.

"Nor do many people know the best course of action to take once initial diagnosis is complete and prefer the idea that a Doctor offers advice..."

Before the event, of course a person does not know whether it's serious or the best course of treatment.

But if there's something wrong with your eye, for example, you go to the eye doctor. He then tells you not to worry, prescribes you some drops, sends you to the opticians or tells you that you need a cataract operation as appropriate.

The patient at this stage has to trust the doctor, of course.

The patient can however very easily judge with the benefit of hinsight whether the diagnosis was correct (for example, nothing to worry about, it will go away by itself or the eye drops cleared it up), whether the problem was solved, how quick, convenienent of comfortable the treatment was (if required) and whether the problem was fixed.

Go back and read Anti's and Graham's real life comments on their experiences, which I can back up (I was in hospital in Germany for three or four entirely unrelated matters and can only agree with them).

That is not a "shopping centre" approach and seems to me to be preferable to what the NHS offers.

paulc156 said...

Yes fine, I already said with some relatively trivial complaints all's well the ends well etc etc but people value the decision made by a doctor on clinical grounds which no matter how you spin it is not the case in a system where GP's have vested interests in sending you somewhere even though they have to inform you of such interests.

"That is not a "shopping centre" approach and seems to me to be preferable to what the NHS offers"

As for Germany's system, I've put that in some context on the later blog/NHS employment... needless to say, Germans [over a thousand of them] don't appear to share the sanguine view you express.

Mark Wadsworth said...

PC, "Yes fine, I already said with some relatively trivial complaints all's well the ends well"

Do you not realise that Germans have genuine, serious illnesses as well, and that these get cured? They're like old women, frankly, all they do is talk about their aches and pains and their last visit to the doctor and when their next operation is.

I ask again: have you ever lived in a European country and been to the doctors there, with a serious or non-serious condition?

If you cannot make the comparison, don't start hypothecating about the comparison. That's like a man who's never eaten venison saying that it tastes like cardboard*. maybe it does, maybe it doesn't, but if you've never eaten it, shut up.

* I've never eaten venison so I wouldn't comment one way or another.

DBC Reed said...

Not to bore you any more with My Operation: the initial diagnosis was done by a GP .He then provided me with the addresses of four local hospitals (three of them in different towns) and told me to get on with it. I had a private appointment at the local NHS hospital's private annex( I think I paid for it: I was somewhat out of it) and ended being treated in the NHS (not very well but not for the want of trying) Was this an example of patient choice ?If so it was useless.

Mark Wadsworth said...

DBC, for "patient choice" to work, there has to be a reasonable number of patients offered a choice and who do their homework and ask around about other people's experiences and avoid the "bad" hospitals.

Once doctors know that if their patient numbers drop by ten per cent, they go out of business, then they make damn' sure not to get a bad reputation and to keep the customers happy.

So it only takes one or two horror stories to sink the senior management of/investors in a German hospital, so the next layer gets promoted upwards, new investors come on board and they do their best not to make the same mistake again.

Meanwhile, the front line staff continue merrily in the same job at the same hospital "under new management", well aware that if they f- up they will get sacked as well.

That's how it works, it's not idle theory. I've seen it in real life.

Antisthenes said...

What we are basically debating here is choice. Whether it is best for patients to be able to choose who they may go to receive medical attention or that choice should be made for them by a central agency that is in some way an extension of the government. The left believe that it should be the latter as they see by doing that way everyone will be treated equally and the rest of us believe the former as they believe the latter compromises considerably on quality and with built in safeguards will not undermine equality. Socialism arose from an urgent need to make society more equal and fairer in which it has been largely successful but having achieved that with the added bonus of making everyone more aware of their social responsibilities it decided to change it's role from being a champion of the people to become the peoples oppressors. They have done this by making the majority of us dependent on the state by given us state run jobs and/or hand outs in the form of benefits and subsidies. So the greatest danger to socialism is choice so the left have a vested interest to restrict choice as much as possible. Choice is so harmful to socialism because it represents democracy within which socialism struggles to exist. This is because socialism can only work in an environment that is capable of redistributing large quantities of wealth and can only do it with the use of large authoritarian government. Socialism has no mechanism for creating wealth so has to take by force from those who have and so in a democracy may find that their methods eventually become sufficiently resented and they are thrown out of office.

paulc156 said...

@MW "I ask again: have you ever lived in a European country and been to the doctors there, with a serious or non-serious condition?

If you cannot make the comparison..."

You started out quite rational in yesterdays response but your response here is hapless [as is your last one on the later NHS thread]. Yesterday 'evidence' mattered, today the evidence is a bit awkward for you so personal experience [you got sick in Germany, more than once even!] outweighs major international health report by highly reputable organisation.

'Your story' and those of your pals [with a world view to plug] do not stand comparison to over a thousand Germans who know more about health provision in their home country and have had many times more experience of it than you, even if they are being miserable gits. [after all, doesn't this site pride itself on such attributes?]

It's far better to do such systematic studies than rely on 'man down the pub stuff' you see. Or else we'd all be making sweeping recommendations on the basis of flimsy tales.

DBC Reed said...

How was I to know what the other hospitals were like i) because I was ill and past caring and ii) three of them were in different towns (where I would not receive visits, my wife not driving). As the one I used was subsequently listed among the most dangerous in the country, this does not present a choice.A broad range of choice allows some really crap ones to stagger on messing up the unwary.
As with education ,which I know something about the solution is absolute Stalinist uniformity so wherever you end up you will get exactly the same treatment with the same procedures, drugs and staffing levels.You do not have a broad choice for services such as the fire brigade and the criminal and civil law .Why do you need them for health? No choice because everywhere's the same good standard.