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Does the proposed amending directive on providing medicines information to the general public (sometimes thought of as advertising) actually enhance patients’ rights? Will it lead to good regulation? The document in question can be found here.

I’ll grant that a lot of people have been involved in this, so there must be some consensus, but is the proposed directive strictly in the patient’s best interests and how are we to truly cost the benefits?

The document itself is cumbersome as if trying very hard to close off any possible loop-hole in case advertising disguised as information might slip into the hands of an unsuspecting patient. To do this, a variety of tests are proposed, a net through which information must pass, presumably though, not advertising, that might meet these tests:

• objective
• unbiased
• evidence based
• up to date
• reliable
• factually correct
• not misleading
• understandable
• meet patients’ needs and expectations

These tests are all good things, and I have no issue with them as such; certainly one would not wish to be in favour of subjectivity, bias, opinions full of errors and likely misleading, despite being incomprehensible — I suppose much like an insurance contract.

If I prioritise the last though, meeting patients’ needs and expectations, information would need to pass these tests for a reason other than internal scientific tests, namely, that it be useful. My fear is this process will produce information that may struggle meeting the test of being understandable. The reason for giving the information itself is to help the patient after all, so starting with their needs seems to me to the test against which I would assess everything else. Of course, little in this world passes these tests anyway, or if it does only for a very short space of time, and even then, facts can be in dispute and there are differences of opinion over how to interpret them. What we are left with in this proposal is a technocratic solution for what in the end is a human need for information.

What are policy makers afraid of in drafting this directive? What do they fear should patients have more information? And have they fully costed this approach?

It all seems to very old-fashioned and dated. Like trying to put the genie back in the bottle, I think this in time will prove to be the actions which caused more harm than good. Indeed, it may be that the benefits are less than the total system wide costs.

The question, then, to ponder further, is what decisions by patients are enabled through this directive, how does it specifically enhance the rights and needs of patients (keep in mind that most health systems neither respect nor completely understand what these mean). Certainly, taking a decision-based approach, perhaps a ‘decision architecture’ which determines what information in what form is needed to help patients make what sorts of choices, then we might know better what degree of ‘coercion’ is needed, if any — but can you give me an example where it is even ethical to withhold information from a patient?

Of course, such an approach would would be in conflict with this directive which builds on the view that only health professionals know best. Hardly a firm foundation for legislative reform of this magnitude. But we need to think of whole-system regulation and the distribution of costs and benefits on that basis, and not just the information issue itself.

I am not surprised that it has come to this, as there is a sort of ‘consensus’ amongst professional vested interests that an information and advertising free for all would lead to chaos, loss of control of drug budgets, and a flood of advertising on our televisions and newspapers about drugs influencing hapless patients and consumers (as though advertising to doctors didn’t achieve similar effects). But compared to the monastic model we have now, where patients know less about the drugs they take than the amount of fat in a kilo of ground meat, it would serve to open up to greater scrutiny industry claims and counterclaims. This lack of knowledge itself has a cost and serious consequences for the costs of healthcare systems.

Recently, the Economist has noted in an article on red tape in Washington how the various costs of regulation are identified, and how wider public benefits are calculated or missed. The US Congressional Budget Office has speculated that a moratorium on DTC would likely have perverse consequences and be unlikely to lower drug prices, and only shift advertising toward physicians. This of course challenges the narrower focus (not meant pejoratively) of the Directive which clearly fails to take account of wider regulatory costs, which are ignored as they fall outside EU competency. These regulatory costs include but are not limited to:

• the potential beneficial impact on treatment costs and compliance with medicines regimes arising from wider engagement of patients in their care
• the potential corresponding (and likely beneficial) challenges to the authority of health professionals (but ignoring that many countries are seeking to encourage patient selfcare which is designed to achieve just this result), who are influenced in other ways in their choice of medicines, with considerable evidence of irrational and inappropriate prescribing, despite efforts to counter this
• greater awareness by the public of national medicines policies which may actually encourage greater cost efficiencies, such as trade-offs between medicines and inpatient care, as well as greater public scrutiny of how new drugs gain market access (a process which the public has little knowledge of and which has perverse consequences in many cases for patient access to new medicines — something an informed patient may wish to have a view on)
• greater public awareness of the decisions of health technology assessment agencies, which may raise serious social and ethical issues
• the possibility that the costs of regulation and claimed benefits to the health system may lead to the loss of research productivity and innovation from a more open environment; indeed the losses here may swamp the regulatory benefits.

I think keeping patients in the dark, as some have written, leads to greater system costs, and perverse consequences and incentives, than full and open disclosure to the public of medicines information, and indeed, even advertising. In an open environment, claims are tested in the real world and can be taken into account in whole-system benefits realisation, not exactly something that is designed to create an additional layer of regulation. In the end, the patient is excluded from playing an informed role in their own healthcare.

Want to know more?

Keeping Patients in the Dark, by Cardy, Edwards and Gay, Civitas, 2000. (Amazon sells it)

Benefits and harms of direct to consumer advertising: a systematic review, Gilbody, Wilson, Watt, Qual Saf Health Care, 2005 Aug;14(4):246-50.

Direct to Consumer Advertising is legal in the US. This is some material from the FDA: Information for Consumers: http://www.fda.gov/Drugs/ResourcesForYou…

US Congressional Budget Office, Potential Effects of a Ban on Direct-to-Consumer Advertising of New Prescrption Drugs, May 2011, Economic and Budget Issue Brief.

Green is good = lower public debt

Vito Tanzi’s book on the modern state “Government versus Markets” is a mine of fresh perspectives. His subtle challenging of the ability of governments to intervene in market failure is thoughtful — when is market failure simply an excuse for hyperactive civil servants to do something, rather than clear evidence of a problem? And not to speak of motives as we are familiar with the ‘rent-seeking’ behaviour of public bodies/officials which can frustrate efforts to streamline and prioritise public services.

European governments are today the cause of considerable global anxiety with their bloated state bureaucracies, high levels of taxation and disincentivised, but pampered (subsidised) industries. It is instructive to reflect that a large component of state debt arises from their healthcare sectors; that much Greek debt lies in the capital funding of hospital construction, and that rising taxes in France are designed to protect social welfare and health benefits through the regressive social charges (contribution, in French).

Tanzi also challenges the scale of modern governments, as a percentage of the economy.  An article by Neil Reynolds, writing in Toronto’s Globe and Mail started the discussion. (lead article here) A subsequent article in The Globe and Mail listed the following countries as a short list of small state sector countries: (specific reference here):

Hong Kong: Population: 7.1 million. GDP: $302-billion (U.S.). Per-capita GDP: $42,748. Unemployment: 5.3 per cent. Inflation: 0.5 per cent. Five-year compound average growth rate: 3.1 per cent. Percentage of GDP spent by the state: 18.6 per cent.

Singapore: Population: 4.8 million. GDP: $240-billion. Per-capita GDP: $50,523. Unemployment: 3.0 per cent. Inflation: 0.2 per cent. Five-year compound annual growth rate: 4 per cent. Percentage of GDP spent by the state: 17.2 per cent. Singapore requires its citizens to buy their own health and employment insurance – a requirement that has produced an exceptionally high level of savings and one of the richest countries on Earth.

Chile: Population: 17 million. GDP: $243-billion. Per-capita GDP: $14,341. Unemployment: 10.8 per cent. Inflation: 1.7 per cent. Five-year compound annual growth rate: 2.8 per cent. Percentage of GDP spent by the state: 21.1 per cent.

Costa Rica: Population: 4.6 million. GDP: $35-billion. Per-capita GDP: $11,579 (the highest in the country’s Central American neighbourhood). Unemployment: 7.8 per cent. Inflation: 5.8 per cent. Five-year compound annual growth rate: 4.5 per cent. Percentage of GDP spent by the state: 20.9 per cent. (Costa Rica is running a deficit these days – keeping tax revenue as a percentage of GDP to 15 per cent.)

Taiwan: Population: 23.1 million. GDP: $736-billion. Per-capita GDP: $31,834. Unemployment: 5.9 per cent. Inflation: 0.9 per cent. Five-year compound annual growth rate: 2.5 per cent. Percentage of GDP spent by the state: 18.5 per cent.

Now, returning to healthcare, these countries also tend toward healthcare systems that are not social insurance or national taxation based, but are what some authors (see S-Y Lee and C-B Chun, The National Health Insurance system as one type of new typology: the case of South Korea and Taiwan. Health Policy  2008 Jan;85(1):105-13. Epub 2007 Aug 20. Abstract here) are called “national health insurance systems”, characterised by a large government interest through establishing rules and standards, but mainly private delivery, with high co-payments, consideration patient choice, and rising levels of investment. These emerging successful, small state sector economies may also be inventing an affordable and sustainable healthcare system, which could be explored in more detail in European countries as they grapple with public debt. The current financial crisis in Europe, entails the need for root and branch reform of the largest elements of public expenditure — health and social care, university funding, etc. — along with venting the gaseous expansion of the regulatory state.

It will be difficult for European-level policymakers to engage in sensible policies when key drivers of cost are driven at the member state level. An obvious example is Spain, where the debt resides at the regional level, but the policy tools for that debt are owned by the national government. To illustrate, Castille La-Mancha can’t pay the pharmacists for drugs, so pharmacists are asking patients to pay cash. (article here: scroll down to find the specific reference).

Having 19th century sized governments, does not entail having 19th century healthcare.

A French Entrepreneur?

A paper by academics Nadine Levratto and Evelyne Serverin, “Become Independent! The Paradoxical Constraints of France’s Autoentrepreneur Regime” (available here) shows the failure of this programme to generate entrepreneurial behaviours.

What went wrong, and why should other member states not copy France?

Since January 2009, when the autoentrepreneur category of working was first introduced, over 550,000 people have registered. They system differs from the also complex Regime Reel in France by taxing autoentrepeneurs on gross turnover (up to the allowed ceiling of €32100, at the rate of between 12 and 21.3%) rather than on revenue (turnover less expenses). People in this category discharge all their taxes by paying this amount, but do not get to claim expenses and do not need to do VAT accounting. In France, the very high national debt is driving lawmakers toward a regime that is levying the regressive social charges on everything from the first euro (!); this is evidence more of desperation than leadership — that entrepreneurs have been captured by this is not surprising.

Almost 50% of autoentrepreneurs in France had an annual turnover of zero, while 15% had a turnover of less than €1000. Only 500 autoentrepreneurs exceeded the upper threshold.

This regime fails because it is not about being entrepreneurial, but about collecting tax and creating bureaucratic barriers to success: more specifically:

• autoentreprenurs can’t hire anyone — the authors speak of them as ‘lonesome’, working out their entrepreneurial dream on their own, forbidden to collaborate with others, even hire an assistant
• they can’t recycle capital to build the business as it taxed away at the turnover level as there is no recognition of the extraordinary expenses of business startups
• because of the structure of business, they are a bad risk for banks to lend to
• two autoentpreneurs can’t collaborate as tax authorities would view them as a company
• there is an excessive concern for employment law and insufficient understanding that entrepreneurial behaviours are not about being secure, but about risk, and therefore has little to do with employment law itself.

There should be no surprise that the system failed and people outside France can say simply on this basis, and with some justification, that the French don’t have a word for ‘entrepreneur’ as clearly they don’t seem to understand what the word means. Indeed, the authors note that the programme has been such a dismal failure, that the French government is rebranding it as better for second incomes, than entrepreneurialism.

What we need is an analysis of these failing efforts at entrepreneurialism by member states, certainly as a warning to others, but more importantly to establish a general understanding of how entrepreneurialism should be treated within member states from the perspective of taxation and law.

If I were forum-shopping for a member state to pursue my entrepreneurial dreams, I would be looking for a country with light-touch taxation, and flexible employment rules.  Start-ups have real problems with cash flow and locking them into high social charges and rigid employment laws is counterproductive.

What is worrying is that other member states, according the authors, have copied this regime: Portugal (recibos verdes) and Poland (samozatrudnierie). Others may be thinking about it. We should all be very afraid of this.

If you are entrepreneurial or have experience in specific member states, please email or comment. Which do you think is the best country in Europe to start a business or be entrepreneurial?

Is this a sign on the European innovation road?

The World Economic Forum meeting in Vienna this week will be grappling with the challenging problem of European innovation. The evidence is suggesting that rather than leading the world, Europe is worryingly backsliding. Worse, of course, is the public rhetoric is not backed up by actual real-world action by governments, who persist in the old ways. This has produced the current complex mix of disincentives for risk-takers with governments fearful of the disruptive impact of innovation on European preferences (ranging from employment to lifestyle), coupled with frequently ineffective and unreformed public sector organisations. This has been admirably addressed, too, in the WEF report on the future of government.

Rather than FAST government (flatter, agile, streamlined, tech-enabled) as the WEF calls for, we find hierarchical and bureaucratic, slow and sluggish, complex and unreformed, tech-naive government — these are hardly attributes needed if the public sector is to play a role in public/private partnerships to drive forward innovation. Our innovation culture instead gets:

• social costs that burden small and medium businesses with a disproportionate share of social costs, which kill off risk takers because they can’t even afford the first day of business; this includes unreasonable start-up capital requirements (1€ should be enough), pointless company start up procedures, wrong-head bankruptcy laws, and inflexible employment laws;
• unreformed central governments, which absorb productive capacity , require very high levels of tax funding to support, and which generate administrative and regulatory red-tape to little end other than to control;
• public ownership of intellectual property as the default position for publicly funded research, coupled with the poor commercialisation record of state-owned research infrastructure, leading to hoarding of innovations within bureaucracies, and not accessible to risk-takers;
• weak academic performance amongst the universities, with little competitive forces within academe to encourage researchers to move outside the university to become entrepreneurs, or to work with investors to generate new ventures, as it frequently jeopardises public sector employment contracts as in many countries academics are civil servants (that is itself is undesirable) — there are very few world-class European universities, based on recent global rankings.

I have some experience here, and while governments value stability in their civil services, what they often get instead is classic ‘rent-seeking’ behaviour, whereby civil servants seek to monopolise whole areas of the economy, ranging from failing to control regulatory creep, to governments having all sorts of pre-emptions rights over private arrangements. This latter point is particularly concerning when it comes to pre-emption rights over intellectual property created with public funds — as the Commission has noted, Europe badly needs its equivalent of the US’s Bayh-Dole Act.

I put my money in a few areas, not just because I know a little about them, but because they have the benefit of driving wider benefits — they act like breeders for other innovations, as well as magnets for innovations developed in other areas:

• health technologies, including life sciences, devices, new materials, nano-tech, imaging, remote monitoring;
• information technologies, including the internet (many governments are fearful of the disruptive influence of the internet);
• new media as the convergence of technological delivery systems (potentially disruptive and problematic when the state is an owner of media).

There are no thousand kilo gorillas in Europe because Europe’s governments have become authoritarians that fear disruptive innovation that may challenge deeply held beliefs and challenge the European model. This is the type of pride that goes before a fall.  So, action is needed in at least four areas:

• liberating the investment climate to encourage a higher tolerance of risk and acceptance that higher risks should lead to higher rewards, which has implications for taxation, capital gains/losses and bankruptcy;
• liberating labour markets, to incentivise business to create experimental forms of employment, whereby firms in acknowledged startup situations can have greater flexibility retaining and rewarding staff without being confronted with first euro social costs and minimum wage regimes;
• understanding the tremendously heavy burden unreformed government and excessively zealous taxation has on entrepreneurs and the need to liberate the entrepreneurial system from official structures as much as possible; this also means that government needs to understand what it can and should do (and of course what it shouldn’t do);
• placing publicly funded intellectual property on the open market — I would suggest even creating an auction market for publicly funded IP.

The European Innovation Road is not a paved autobahn; it is full of holes, and in some places just goes over a cliff, but it has the potential to be a superhighway if we get the fundamentals right.

Uncertainty can never be removed from the innovation process. We shouldn’t act as though it can.

Want to know more?

Just searching on the internet will produce an avalanche of information. Regretfully, much academic research is still published in journals that are not open access which means accessing them requires either a subscription or the payment of a fee, despite the vast majority of this work having been publicly funded. These articles are not listed. However, authors of papers who would like to have their papers listed here, and provide a pdf for download are encouraged to provide a paper for listing here.

Also consider:

Martin Fransman, The New ICT Ecosystem: implications for Europe (Kokoro, 2007) presents a thoughful policy framework.

Anything by Annalee Saxenian, but her The New Argonauts: regional advantage in a global economy (Harvard 2006) is worth reading in the context of European regional development.

Josh Lerner, Boulevard of Broken Dreams: why public efforts to boost entrepreneurialism have venture capital have failed, and what to do about it (Princeton, 2009) offers a research-based critique of the role of government and why for every dollar/euro/pound government puts into commercialisation of research, the private sector takes one out.

The new report from NESTA, Atlantic Drift [here] is worth reading for its US/UK investment comparisons with important insights for other countries.  It is authored by Josh Lerner, Yannis Pierrakis, Liam Collins and Albert Bravo Biosca.

Lawton Burns, The Business of Healthcare Innovation (Cambridge, 2005), explains important innovation drivers in healthcare, which offers some thoughts on how Europe can succeed here, despite widespread government control of healthcare systems. It is worth noting that virtually all EU countries and their regions have prioritised biotechnology/healthcare/life sciences in at least their top 5 areas.

Outpost on the Digital Maginot Line: doomed to fail

As has been noted by other commentators, the French government has a problem with the internet, and endeavours to stave off its impact with ill-timed, and ill-thought out regulation. Of course, as a national government, they can try to build a digital Maginot line around France; they’re always doing that and as Santayana said, having failed to learn from history, they persist in repeating it.

One can only hope that such efforts will not be copied by other governments and certainly be given short shrift at the European level.

History shows that efforts to build up walls such as these are doomed to failure. Brute force, smarter opponents, and new technologies prevail in the end. France, regretfully, seems to prefer to hide behind its social-cultural rhethoric rather than deal with the opportunities that the internet offers, by fearing it more than understanding it.

The internet is not just a telecommunications novelty to send emails, view your vacation pictures, or keep in touch with friends. It is has become a digital glue that binds communities and nations together in a way that international treaties have failed. It could be seen as the ultimate success of the internationalisation of societies in a way that brings with it greater understanding and peace. Indeed, why do autocratic governments, usually just before they collapse, try to shut down the internet, for it, like the photocopier in what was the Soviet Union, represents all that they fear: openness, liberty.

Efforts to counter this new technological force of nature are at root authoritarian. They say the government in power knows better than individuals. Francis Bacon wrote in 1597, “knowledge is power” [Meditationes Sacrae], certainly not anticipating the internet, but deeply understanding that control of knowledge (or information as we think of things today) gave those who controlled it power. From this come cartels, censorship, autocratic governments, and authoritarian regulation from fearful democracies.

The former US Supreme Court justice, Louis Brandeis, is famous for saying that “sunlight is the best disinfectant”, and today the internet is the best disinfectant there is, for it is revealing where injustice lies, and uncovering official hypocracies. It is laying bare the landscape of opportunities for all, and not just a privileged few.

But some fear this for it also reveals where the internet challenges past comforts, vested interests, and the quiet whisper in the ear.

And so this digital maginot line that some countries are trying to build will fail, and fail for all the right reasons, as we don’t live in that kind of world anymore, and governments, both national and at the EU level need to grasp that as the internet changes everything, it also changes the very logic we use when we govern.

In a frictionless internet I can eliminate fr, .de, .uk, even .eu, with a mouse click, erase them from my universe more thoroughly than the thundering barbarian hoards.

Or I can make them the centre of my world.

If only the Grand Challenges were that simple!

The State of the Union message by President Obama focused around key challenges facing the United States to embrace the changing world. His list included:

• education
• innovation
• infrastructure
• government reform

This is not a bad list for starters. In my own work with clients, these are key recurring issues, which today take on new urgency, and are as relevant to the US as the EU and emerging countries. The one issue that does wake ministers of finance up in the middle of the night is the rising cost of healthcare, and that is its own challenge.

Let’s briefly reflect on each of these four, though, for now:

Education

A 10-year old girl in a public school will enter the world of higher education or employment in perhaps the year 2020: how is her experience of education preparing her for that world? Are her teachers the very best for developing her for the future, encouraging curiosity and helping her be adaptable and courageous? Is the higher education system ready for the challenges of the future? I somewhat despair about our universities, and do think they need to revisit their social mandate, as they are at present our key and only institutions for the inter-generational transmission of knowledge, yet academics seem pre-occupied with other matters (such as the length of the CV and research), while teaching seems to suffer. We need to re-energise the learning part of higher education, and not just through a technological fix of e-learning, but through the invention of new institutions of learning. Increasingly scarce public funding should not be wasted on unreformed higher education, but should reward innovative and potentially disruptive learning opportunities.

Innovation

Yes, more and better and faster. The historical forces that got us to the present have been silenced as we have become trapped in regulation and rules that discourage risk-taking, and reward the compliant at the expense of the disruptor. Companies and government, both, have trouble with trouble makers who don’t adopt the institutional rhetoric. Access to early-stage funding for innovations is weak and research suggests likely to be harder to get but governments may find themselves unable to provide all the necessary funding under current circumstances. Innovative ways to innovate and commercialise are necessary and which bridge the ‘valley of death’ with effective strategies that de-risk the innovation development process. Regretfully, to some extent, our universities frequently have a small view of their role here (technology transfer), but leaving this to others to take the risks is no longer an option. Entrepreneurialism is needed within the research communities, linked to real-world challenges (I am not ignoring the need for pure research to create new knowledge). And perhaps some better priority setting: while it may be nice to have the latest smartphone, we do need to solve the problem of malaria, unclean water, poor quality nutrition. These challenges do not go away just because we can text our friends more easily — yet within the smartphone technology may lie ways to solve these threats to humanity if we are creative enough to think those thoughts.

Infrastructure

This is the never-ending struggle for government and industry. Capital investments in public infrastructure offers opportunities for innovation to build faster, cheaper, better. Innovations in building technology can give us better roads, improved rail-links, better public housing. While we are focused on the digital technological infrastructure (of wireless and web), we cannot ignore the need to drive forward new infrastructure thinking around energy and transportation to name two big ones. Many (Western) governments may be trapped with legacy infrastructures, making it hard to leapfrog to new approaches. But perhaps we are at the point where we need to literally junk industrial-era infrastructure logic and make that leap of faith — in ourselves and our future. Timidity is no longer an option.

Government reform

“Smart government”. Is that an oxymoron? How has the digital revolution altered the size and structure of governments? Having looked at this issue, I find that governments are frequently wedded to ponderous and very hierarchical internal processes, characterised to a great extent by caution (legislate in haste, repent at leisure?).  We also find protective practices, which can make it hard to reform government working practices even when there is the will to act. Governments are expensive; indeed, governments are monopoly suppliers of government, and if they do their job badly, we all suffer. The next ‘bubble’ will likely be from the public sector, and in particular from central governments, where the need for reform is greatest. Open and transparent government has all of us as stakeholders and the more we take an interest as taxpayers in the functioning of government the greater the likelihood we will get the reforms for the government we need.

Charlie Chaplin from the film The Great Dictator

The health of nations and their peoples can be closely linked to the state of their leadership. David Owen, in his book “In Sickness and In Power” (review here), presents a variety of examples from recent history of leaders with illnesses and in what ways their illness affected their abilities as leaders.

One particularly important ‘illness’ he mentions is called hubris.  Hubris in leaders means they are unable to acknowledge defeat, read the handwriting on the wall, admit mistakes, and importantly, resign from office.

Some of our fellow travellers on planet Earth are inflicted with leaders subject to this illness, and who don’t know when to resign. The countries where this is apparent are many, not all are autocratic states, but it is in autocratic states that the power of the leaders can silence opposition and perpetuate their unhealthy tenure in office.

So here is some career guidance for autocrats:

1. Nothing is forever.  You won’t understand this. As a probable psychopath you’ll cling to power until your hands are chopped off. But more importantly, you don’t understand history. Every single autocratic regime in history has either collapsed from within or been overthrown from abroad. Your time is limited, and you may think you’re different, that you’ll create some time-defying legacy, but you’re wrong. The problem is knowing when forever ends, as you are like the boiled frog — the incremental slow building up of social, political, economic forces inside your little world are relentlessly cooking you and you are not noticing this. You’ll learn too late that it is too late.  Better to go at at the top of your game (that way you don’t have to spend the rest of your life hiding in some desert with your money frozen in a Swiss bank account). But you don’t understand this either, as the good times are rolling for you and you don’t think about the future as you live in the here and now. Tick tock.
2. Love your children. Your efforts to create a dynasty will only serve to delay the inevitable. If you are really concerned about your children, you will not want them to follow you. Succession within families, even monarchies, is a difficult process, and the accumulation of public dissent over the years and across generations means that you are often signing the death warrant for your children. As a caring father, (most autocrats are male; it has to do with testosterone), you should listen to your wife (assuming you’ve restrained yourself to one) who understands better than you that a dynastic approach will lead to the sudden termination of your children at the end of a rope or a bullet.  So better to decide that you are the first and last of your kind, and ensure your children get a good education and do not follow in your own footsteps.
3. Trust others. Of course, this is hard to do as you are unlikely to trust many people, but think you can at least trust your family. If the only people you can trust are in your family, be warned: families can become breeding grounds of real jealousy, particularly between siblings — that’s why you shouldn’t buy off your brother’s affections by making him head of the secret police.  This advice only applies if you display normal human emotion such as love; otherwise, you treat your family simply as pawns in your self-serving game.
4. Embrace dissent. Since you have probably run your country with an iron fist for sometime, people around you have become sycophants; better that than be put in one of your dirty jails. That means that you are not going to get good career advice from your advisors as they will be self-serving, too — you can probably still dish out the treats for those around you and there are always people who suck up to people like you (you like this, but fail to notice that it lacks sincerity). They will not tell you that you have passed your sell-by date. This means that you should be mindful of those who disagree with you, as they may be right. Exiling them only buys you time, as they have a tendency to show up a few years later to replace you.
5. You can’t be a benevolent autocrat. This is an oxymoron. People don’t love you, despite what you may think. What you see as benevolence is really just evidence that you don’t think your fellow citizens are smart enough to lead their own lives; you act as though you are the only one who knows what they need. But this is of course silly, despite the fact that you may hold court in some palace where the ‘ordinary citizen’ comes for guidance, even justice. Such a forum is simply medieval and perpetuates your belief in your own importance, but carries little by way of real substance.  Furthermore, the evidence that you aren’t loved is all around you if you took the time to look: you travel everywhere in armoured vehicles, surround yourself with a private army, sleep fitfully, perhaps suffer from constipation and that can make anyone bad tempered. You kid yourself into thinking that you are acting in everyone’s best interests, but if you’ve read the other 4 points, you know you are living in a gilded hell.

It is worth adding that this advice can apply to all of us, whether democratically elected politicians, appointed chief executives, very rich, parents or simply ourselves.

Debt Crisis: Waiting for healthcare

Along with austerity measures to bring debt-laden countries into improved financial health will come some actions with an impact on healthcare and the health of people.

Some examples have a specific impact and might include increasing the patient co-payment, introducing new co-payments, or  reducing public capital expenditure on healthcare infrastructure.

In other cases things are already happening: increasing premiums (Ireland), or increasing control of drug pricing (Spain).

Other actions will have a knock-on effect, such as increasing tuition fees which may impact student numbers and thus the supply of health professions (UK). Tighter access to debt will have some impact on new build in healthcare, as the ability of the state to finance new hospitals will be reduced along with willingness to fund the running costs (big hospitals cost hundreds of millions a year to run). Perhaps we may see some flight of research capacity as whole clinical research teams up-sticks and relocate to countries where investment in medical research is increasing (such as China and India).

And, as people find they are unable to afford to pay their health insurance, their costs are then picked up by the taxpayer. Countries with high rates of unemployment (many) will understand the carrying capacity needed to pay for the healthcare of the uninsured.

We know, broadly speaking, that people are happy with the quality of the healthcare that they receive.  The real issue is always about gaining access to that care. To date, most EU countries appear able to manage this (despite these costs contributing to their debt burden).

But for countries facing austerity measures, under what circumstances might reduced access to care begin to manifest itself. The issue then will be increased burden of ill-health, with all its consequences.

Will we not have converted a debt crisis into a health crisis?

This is a list of the top 25 from the top 100 innovation cities prepared by Innovation Cities, based a combination of factors which together suggest a measure of innovation. More information at: http://www.innovation-cities.com/innovation-cities-top-100-index-top-cities/

1. Boston
2. Paris
3. Amsterdam
4. Vienna
5. New York
6. Frankfurt
7. San Francisco
8. Copenhagen
9. Lyon
10. Hamburg
11. Berlin
12. Toronto
13. Stuttgart
14. London
15. Munich
16. Milan
17. Stockholm
18. Hong Kong
19. Melbourne
20. Tokyo
21. Rome
22. Kyoto
23. Washington DC
24. Shanghai
25. Dusseldorf

Silence, please, presentation in progress.

In these days when the use of taxpayers’ money to bail out failing economies, and politicians are grappling with rising public debt, it is always timely to reflect on how the Commission spends our money. Without obvious evidence that it understands the notion of ‘belt-tightening’, meetings where the minutes are taken and the hours are lost will continue to proliferate without some mechanism to constrain this upward spiral of expenditure. Can Council members constrain this growth with the funding of the European institutions, when they themselves are beneficiaries of the very same profligacy with taxpayers’ money in their own countries?

As health is my area of expertise, I am always interested in how the Commission determines its direction in the health space, how it uses the various agencies operating at the EU level to counterbalance the influence of the member states. And of course how criticism is absorbed or neutralised within this great steampunk machine.

I wondered about this when I was reading the latest (draft) minutes of the renewed (!) Health Policy Forum. I was struck by the possibility that this group is not designed to be a critical participant in the developing of ideas and therefore, I wondered what purpose it served.

There is a clue on the Forum website: “The Health Policy Forum brings together pan-European stakeholder organisations in the health sector at EU level to ensure that the EU’s health strategy is open, transparent and responds to public concerns.”

But the efforts at renewal were designed specifically, as far as I can see, to align this group with the Commission’s workplan and to ensure that it acts favourably toward Commission initiatives. We read (of the opening of the meeting): “In her introduction to the meeting Ms Testori Coggi presented herself and underlined the importance, role and mandate of the EU Health Policy forum. She stressed in particular the importance of activities in the field of disease prevention and health promotion including lifestyle related activities and health literacy.” In other words, this is what is important, regardless of whether you think otherwise.  I have no difficulty with these as general goals but they are largely opaque generic terms. The devil is always in the detail, and that is what we didn’t read about.

The meeting must have been most enjoyable, as it seemed to consist of a parade of presentations (no doubt more ‘death by powerpoint’) by people telling the Forum attendees what they were doing. Why bring your brain to a meeting like this?

I was also taken by this interesting line in the minutes: “Member organisations of the EUHPF are in particular invited to talk to their constituencies in the Member States in view to engage as well the national, regional and local level with the aims and objectives of the EU 2020 strategy in order to strengthen the health and social impact in the implementation of the strategy.” In other words, your job it to get the word out, not to engage with ‘us’ critically about what the strategy should be. Do your job, we bought you lunch.

The minutes indicate that questions were asked, such as CPME’s on e-health and cross-border healthcare, to which the presidency ‘agreed’, but whether anything will actually happen isn’t clear. The questions were absorbed into the rhetoric of the meeting, with soft noises of agreement and acknowledgement. But nothing really challenging was asked (assuming the minutes reflect the dynamism of the meeting) and, no doubt, no one was offended.

I wonder if those attending knew they were quiety being co-opted to act as agents of policy rather than engage in a meaningful policy-oriented discussion within a market-place of ideas.

I guess that’s what a Health Policy Forum is for.

Is there a directory of entities like these, do we know what are they for, do we know what they cost, and do we know if they make a difference?

Am I bad tempered about this? No. I want these processes to work, I just worry that in the rush to be accepted as a stakeholder, these groups may neglect their critical perspective. One must always be mindful of rent-seeking behaviour by the Commission, especially when it comes to forms of consultation.

NOTE: The forum lasted one day, involved 10 Commission employees, a secretariat of 4 people, 2 people from the Council (Belgium, Spain) and some 67 people from the ‘renewed’ stakeholder membership.