Showing posts with label ration. Show all posts
Showing posts with label ration. Show all posts
Wednesday 16 August 2023
Saturday 27 May 2023
Sunday 12 June 2022
Thursday 19 May 2022
Tuesday 14 December 2021
Sunday 12 April 2020
NHS ‘score’ tool to decide which patients receive critical care
Doctors will use three metrics: age, frailty and underlying conditions write Peter Foster, Bethan Staton and Naomi Rovnick in The FT
Doctors coping with the coming peak of the coronavirus outbreak will have to “score” thousands of patients to decide who is suitable for intensive care treatment using a Covid-19 decision tool developed by the National Health Service.
With about 5,000 coronavirus cases presenting every day and some intensive care wards already approaching capacity, doctors will score patients on three metrics — their age, frailty and underlying conditions — according to a chart circulated to clinicians.
Patients with a combined score of more than eight points across the three categories should probably not be admitted to intensive care, according to the Covid-19 Decision Support Tool, although clinical discretion could override that decision.
The UK is set to exceed 80,000 coronavirus cases on Sunday and 10,000 deaths in hospital with government models showing the peak of the outbreak is now expected to be reached over the next two weeks, leaving the healthcare system facing arguably its toughest challenge since its inception.
The scale of the pandemic and the speed at which Covid-19 can affect patients, has forced community care workers, GPs and palliative carers to accelerate difficult conversations about death and end-of-life planning among vulnerable groups.
The NHS scoring system reveals that any patient over 70 years old will be a borderline candidate for intensive care treatment, with a patient aged 71-75 automatically scoring four points for their age and a likely three on the “frailty index”, taking their total base score to seven points.
Any additional “comorbidity”, such as dementia, or recent heart or lung disease, or high blood pressure will add one or two points to the score, tipping them into the category suitable for “ward-based care”, rather than intensive care, and a trial of non-invasive ventilation.
Although doctors and care workers stress that no patient is simply a number, the chart nonetheless codifies the process for the life-and-death choices that thousands of NHS doctors will make in the coming weeks.
A frontline NHS consultant triaging Covid-19 patients said the “game-changer” for assessment of patients with coronavirus was that there is no available treatment, meaning doctors can only provide organ support and hope the patient recovers.
“If this was a bacterial pneumonia or a bad asthma attack, then that is treatable and you might send that older patient to intensive care,” the consultant said, adding that decisions on patients were “art not science” and there would be exceptions for patients who were fit enough.
“The scoring system is just a guide; we make the judgment taking into account a lot of information about the current ‘nick’ of the patient — oxygenation, kidney function, heart rate, blood pressure — which all adds into the decision making,” he said.
But it is not just hospital doctors who must make tough decisions. GPs, hospice workers and families with vulnerable members are also involved.
Last week NHS England wrote to all GPs asking them to contact vulnerable patients to ensure that care plans and prescriptions were in place for end of life decisions, leading to many difficult conversations. These have been made harder by the need to conduct them on the phone or via Skype to observe social distancing rules.
Ruthe Isden, head of health and care at Age UK, the charity, said the need for haste had unsettled many elderly patients, who have felt under pressure to sign “Do Not Resuscitate”, or DNR, forms.
"Clinicians are trying to do the right thing and these are very important conversations to have, but there’s no justification in doing them in a blanket way,” she said. “It is such a personal conversation and it’s being approached in a very impersonal way.”
The subject of DNR notices is particularly unsettling for individuals and families who want the best care for their loved ones, but often feel the choices have not been fully explained.
The data clearly show that resuscitation often does not work for elderly patients and can often cause more suffering — including broken ribs and brain damage — while extending life only by a matter of days.
Doctors coping with the coming peak of the coronavirus outbreak will have to “score” thousands of patients to decide who is suitable for intensive care treatment using a Covid-19 decision tool developed by the National Health Service.
With about 5,000 coronavirus cases presenting every day and some intensive care wards already approaching capacity, doctors will score patients on three metrics — their age, frailty and underlying conditions — according to a chart circulated to clinicians.
Patients with a combined score of more than eight points across the three categories should probably not be admitted to intensive care, according to the Covid-19 Decision Support Tool, although clinical discretion could override that decision.
The UK is set to exceed 80,000 coronavirus cases on Sunday and 10,000 deaths in hospital with government models showing the peak of the outbreak is now expected to be reached over the next two weeks, leaving the healthcare system facing arguably its toughest challenge since its inception.
The scale of the pandemic and the speed at which Covid-19 can affect patients, has forced community care workers, GPs and palliative carers to accelerate difficult conversations about death and end-of-life planning among vulnerable groups.
The NHS scoring system reveals that any patient over 70 years old will be a borderline candidate for intensive care treatment, with a patient aged 71-75 automatically scoring four points for their age and a likely three on the “frailty index”, taking their total base score to seven points.
Any additional “comorbidity”, such as dementia, or recent heart or lung disease, or high blood pressure will add one or two points to the score, tipping them into the category suitable for “ward-based care”, rather than intensive care, and a trial of non-invasive ventilation.
Although doctors and care workers stress that no patient is simply a number, the chart nonetheless codifies the process for the life-and-death choices that thousands of NHS doctors will make in the coming weeks.
A frontline NHS consultant triaging Covid-19 patients said the “game-changer” for assessment of patients with coronavirus was that there is no available treatment, meaning doctors can only provide organ support and hope the patient recovers.
“If this was a bacterial pneumonia or a bad asthma attack, then that is treatable and you might send that older patient to intensive care,” the consultant said, adding that decisions on patients were “art not science” and there would be exceptions for patients who were fit enough.
“The scoring system is just a guide; we make the judgment taking into account a lot of information about the current ‘nick’ of the patient — oxygenation, kidney function, heart rate, blood pressure — which all adds into the decision making,” he said.
But it is not just hospital doctors who must make tough decisions. GPs, hospice workers and families with vulnerable members are also involved.
Last week NHS England wrote to all GPs asking them to contact vulnerable patients to ensure that care plans and prescriptions were in place for end of life decisions, leading to many difficult conversations. These have been made harder by the need to conduct them on the phone or via Skype to observe social distancing rules.
Ruthe Isden, head of health and care at Age UK, the charity, said the need for haste had unsettled many elderly patients, who have felt under pressure to sign “Do Not Resuscitate”, or DNR, forms.
"Clinicians are trying to do the right thing and these are very important conversations to have, but there’s no justification in doing them in a blanket way,” she said. “It is such a personal conversation and it’s being approached in a very impersonal way.”
The subject of DNR notices is particularly unsettling for individuals and families who want the best care for their loved ones, but often feel the choices have not been fully explained.
The data clearly show that resuscitation often does not work for elderly patients and can often cause more suffering — including broken ribs and brain damage — while extending life only by a matter of days.
Thursday 9 April 2020
Who to let die and who to keep alive - On the Nice guidelines
The coronavirus pandemic response is normalising the notion that some lives are disposable writes Frances Ryan in The Guardian
‘In a health crisis, it is not only the virus that risks infecting society but our prejudices.’ Photograph: James Tye/University College London (UCL)/AFP via Getty Images
In a pandemic, triage starts long before some of us get sick. A new document issued by the British Medical Association (BMA) has set out guidance to ration treatment if the NHS becomes overwhelmed with coronavirus cases.
The BMA suggests that in cases where ventilators are scarce, those facing poor prognosis could have the life-saving equipment taken away from them – even if their condition is improving – with younger and healthier patients given priority instead.
We are already seeing this play out. Last week, one man tweeted that his brother, who lives in a care home with limited mobility and a cognitive disability, went to hospital with a chest infection but didn’t make “the pandemic-led prioritisation cut”. He died a week later.
Meanwhile, it has been reported that a GP practice in Wales issued “do not resuscitate” (DNR) forms to a small number of patients, ensuring that emergency services would not be called should they contract coronavirus and their symptoms worsen. One adult social care provider has said that three of their services have been contacted by GPs to say that they have deemed the people they support should all be DNR. One woman who has received the form so far is in her 20s.
These stories of disabled and older people being denied care have been emerging for weeks as the virus has struck hospitals around the world, but have generally failed to find attention outside the disability community until now.
The National Institute for Health and Care Excellence (Nice) was forced to make a U-turn last week on their advice for the NHS to deny disabled people treatment, but only after disability groups threatened legal action. Nice had told doctors they should assess patients with conditions such as learning disabilities and autism as scoring high for “frailty” - thereby meeting criteria to be refused treatment - based on the fact they need support with personal care in their day-to-day life.
In a health crisis, it is not only the virus that risks infecting society, but our prejudices. It’s a slippery slope of ethical compromises in a culture and medical system that already struggles to support people with disabilities. Research shows that an estimated 1,200 people with a learning disability die avoidably every year due to poor care, while the terms “learning disabilities” or “Down’s syndrome” have been given as the reason for “Do not resuscitate” orders.
In the coronavirus pandemic, doctors are having to make difficult clinical judgments: would a medical intervention help a patient or does their underlying health condition prevent them from benefiting? Is it better to facilitate a peaceful death rather than administer a futile and distressing treatment?
However, judgments based on the efficacy of treatment are not the same as judgments based on the quality of a disabled person’s life. That might be falsely equating support needs with “frailty”, or adopting a blanket policy that withdraws treatment from a whole group of people rather than basing decisions on each individual’s needs and choices. That isn’t healthcare, it’s discrimination.
These are complex issues and we are in deeply difficult times; medics are risking their own lives for the NHS and will face impossible choices as even oxygen and face pumps run low. But that should not mean abandoning debates around key decisions. Indeed, in an emergency it is more important than ever to question our attitudes and responses.
It is worth considering why the default position is to deny life-saving treatment to some disabled people rather than to ask why a wealthy nation that had months to prepare doesn’t have enough resources in the first place. It is worth considering whether talk of “limited resources” is excusing and normalising the long-held idea that disabled lives are disposable.
In recent days, I have seen disabled people take to social media to list their achievements, as if trying to make the case that they are worth saving. A disabled person who has their ventilator removed during this crisis may have gone on to cure cancer. But then, they may have just been loved. A mum with heart disease who always burns her daughter’s birthday cakes. An accountant born with muscular dystrophy who watches Dr Who every Sunday. Disabled people, like all minorities, are only fully human when we are permitted to be as wonderfully average as anyone else.
Utilitarian calculations over the value of certain people’s lives may appear pragmatic right now, but they cost us a part of ourselves. In the coming days, it is inevitable Britain will lose more lives. We need not lose our humanity too.
In a pandemic, triage starts long before some of us get sick. A new document issued by the British Medical Association (BMA) has set out guidance to ration treatment if the NHS becomes overwhelmed with coronavirus cases.
The BMA suggests that in cases where ventilators are scarce, those facing poor prognosis could have the life-saving equipment taken away from them – even if their condition is improving – with younger and healthier patients given priority instead.
We are already seeing this play out. Last week, one man tweeted that his brother, who lives in a care home with limited mobility and a cognitive disability, went to hospital with a chest infection but didn’t make “the pandemic-led prioritisation cut”. He died a week later.
Meanwhile, it has been reported that a GP practice in Wales issued “do not resuscitate” (DNR) forms to a small number of patients, ensuring that emergency services would not be called should they contract coronavirus and their symptoms worsen. One adult social care provider has said that three of their services have been contacted by GPs to say that they have deemed the people they support should all be DNR. One woman who has received the form so far is in her 20s.
These stories of disabled and older people being denied care have been emerging for weeks as the virus has struck hospitals around the world, but have generally failed to find attention outside the disability community until now.
The National Institute for Health and Care Excellence (Nice) was forced to make a U-turn last week on their advice for the NHS to deny disabled people treatment, but only after disability groups threatened legal action. Nice had told doctors they should assess patients with conditions such as learning disabilities and autism as scoring high for “frailty” - thereby meeting criteria to be refused treatment - based on the fact they need support with personal care in their day-to-day life.
In a health crisis, it is not only the virus that risks infecting society, but our prejudices. It’s a slippery slope of ethical compromises in a culture and medical system that already struggles to support people with disabilities. Research shows that an estimated 1,200 people with a learning disability die avoidably every year due to poor care, while the terms “learning disabilities” or “Down’s syndrome” have been given as the reason for “Do not resuscitate” orders.
In the coronavirus pandemic, doctors are having to make difficult clinical judgments: would a medical intervention help a patient or does their underlying health condition prevent them from benefiting? Is it better to facilitate a peaceful death rather than administer a futile and distressing treatment?
However, judgments based on the efficacy of treatment are not the same as judgments based on the quality of a disabled person’s life. That might be falsely equating support needs with “frailty”, or adopting a blanket policy that withdraws treatment from a whole group of people rather than basing decisions on each individual’s needs and choices. That isn’t healthcare, it’s discrimination.
These are complex issues and we are in deeply difficult times; medics are risking their own lives for the NHS and will face impossible choices as even oxygen and face pumps run low. But that should not mean abandoning debates around key decisions. Indeed, in an emergency it is more important than ever to question our attitudes and responses.
It is worth considering why the default position is to deny life-saving treatment to some disabled people rather than to ask why a wealthy nation that had months to prepare doesn’t have enough resources in the first place. It is worth considering whether talk of “limited resources” is excusing and normalising the long-held idea that disabled lives are disposable.
In recent days, I have seen disabled people take to social media to list their achievements, as if trying to make the case that they are worth saving. A disabled person who has their ventilator removed during this crisis may have gone on to cure cancer. But then, they may have just been loved. A mum with heart disease who always burns her daughter’s birthday cakes. An accountant born with muscular dystrophy who watches Dr Who every Sunday. Disabled people, like all minorities, are only fully human when we are permitted to be as wonderfully average as anyone else.
Utilitarian calculations over the value of certain people’s lives may appear pragmatic right now, but they cost us a part of ourselves. In the coming days, it is inevitable Britain will lose more lives. We need not lose our humanity too.
Monday 21 March 2016
Why are corrupt politicians popular in India
This is an excerpt from a speech by India’s Reserve Bank of India chairman Raghuram Rajan. The full text is available here.
Even as our democracy and our economy have become more vibrant, an important issue in the recent election was whether we had substituted the crony socialism of the past with crony capitalism, where the rich and the influential are alleged to have received land, natural resources and spectrum in return for payoffs to venal politicians.
By killing transparency and competition, crony capitalism is harmful to free enterprise, opportunity, and economic growth. And by substituting special interests for the public interest, it is harmful to democratic expression. If there is some truth to these perceptions of crony capitalism, a natural question is why people tolerate it. Why do they vote for the venal politician who perpetuates it?
A hypothesis on the persistence of crony capitalism
One widely held hypothesis is that our country suffers from want of a “few good men” in politics. This view is unfair to the many upstanding people in politics. But even assuming it is true, every so often we see the emergence of a group, usually upper middle class professionals, who want to clean up politics. But when these “good” people stand for election, they tend to lose their deposits. Does the electorate really not want squeaky clean government?
Apart from the conceit that high morals lie only with the upper middle class, the error in this hypothesis may be in believing that problems stem from individual ethics rather than the system we have. In a speech I made before the Bombay Chamber of Commerce in 2008, I argued that the tolerance for the venal politician is because he is the crutch that helps the poor and underprivileged navigate a system that gives them so little access. This may be why he survives.
Let me explain. Our provision of public goods is unfortunately biased against access by the poor. In a number of states, ration shops do not supply what is due, even if one has a ration card – and too many amongst the poor do not have a ration card or a BPL card; Teachers do not show up at schools to teach; The police do not register crimes, or encroachments, especially if committed by the rich and powerful; Public hospitals are not adequately staffed and ostensibly free medicines are not available at the dispensary; …I can go on, but you know the all-too-familiar picture.
This is where the crooked but savvy politician fits in. While the poor do not have the money to “purchase” public services that are their right, they have a vote that the politician wants. The politician does a little bit to make life a little more tolerable for his poor constituents – a government job here, an FIR registered there, a land right honoured somewhere else. For this, he gets the gratitude of his voters, and more important, their vote. Of course, there are many politicians who are honest and genuinely want to improve the lot of their voters. But perhaps the system tolerates corruption because the street smart politician is better at making the wheels of the bureaucracy creak, however slowly, in favour of his constituents. And such a system is self-sustaining. An idealist who is unwilling to “work” the system can promise to reform it, but the voters know there is little one person can do. Moreover, who will provide the patronage while the idealist is fighting the system? So why not stay with the fixer you know even if it means the reformist loses his deposit?
So the circle is complete. The poor and the under-privileged need the politician to help them get jobs and public services. The crooked politician needs the businessman to provide the funds that allow him to supply patronage to the poor and fight elections. The corrupt businessman needs the crooked politician to get public resources and contracts cheaply. And the politician needs the votes of the poor and the underprivileged. Every constituency is tied to the other in a cycle of dependence, which ensures that the status quo prevails. Well-meaning political leaders and governments have tried, and are trying, to break this vicious cycle. How do we get more politicians to move from “fixing” the system to reforming the system? The obvious answer is to either improve the quality of public services or reduce the public’s dependence on them. Both approaches are necessary. But then how does one improve the quality of public services? The typical answer has been to increase the resources devoted to the service, and to change how it is managed. A number of worthwhile efforts are underway to improve the quality of public education and healthcare. But if resources leak or public servants are not motivated, which is likely in the worst governed states, these interventions are not very effective.
Some have argued that making a public service a right can change delivery. It is hard to imagine that simply legislating rights and creating a public expectation of delivery will, in fact, ensure delivery. After all, is there not an expectation that a ration card holder will get decent grain from the fair price shop, yet all too frequently grain is not available or is of poor quality. Information decentralization can help. Knowing how many medicines the local public dispensary received, or how much money the local school is getting for mid-day meals, can help the public monitor delivery and alert higher-ups when the benefits are not delivered. But the public delivery system is usually most apathetic where the public is poorly educated, of low social status, and disorganized, so monitoring by the poor is also unlikely to be effective.
Some argue that this is why the middle class should enjoy public benefits along with the poor, so that the former can protest against poor delivery, which will ensure high quality for all. But making benefits universal is costly, and may still lead to indifferent delivery for the poor. The middle class may live in different areas from the poor. Indeed, even when located in the same area, the poor may not even patronize facilities frequented by the middle class because they feel out of place. And even when all patronize the same facility, providers may be able to discriminate between the voluble middle class and the uncomplaining poor. So if more resources or better management are inadequate answers, what might work?
The answer may partly lie in reducing the public’s dependence on government-provided jobs or public services. A good private sector job, for example, may give a household the money to get private healthcare, education, and supplies, and reduce their need for public services. Income could increase an individual’s status and increase the respect they are accorded by the teacher, the policeman or the bureaucrat. But how does a poor man get a good job if he has not benefited from good healthcare and education in the first place? In this modern world where good skills are critical to a good job, the unskilled have little recourse but to take a poorly-paying job or to look for the patronage that will get them a good job. So do we not arrive at a contradiction: the good delivery of public services is essential to escape the dependence on bad public services?
Money liberates and Empowers…
We need to go back to the drawing board. There is a way out of this contradiction, developing the idea that money liberates. Could we not give poor households cash instead of promising them public services? A poor household with cash can patronize whomsoever it wants, and not just the monopolistic government provider. Because the poor can pay for their medicines or their food, they will command respect from the private provider. Not only will a corrupt fair price shop owner not be able to divert the grain he gets since he has to sell at market price, but because he has to compete with the shop across the street, he cannot afford to be surly or lazy.
The government can add to the effects of empowering the poor by instilling a genuine cost to being uncompetitive – by shutting down parts of the public delivery systems that do not generate enough custom. Much of what we need to do is already possible. The government intends to announce a scheme for full financial inclusion on Independence Day. It includes identifying the poor, creating unique biometric identifiers for them, opening linked bank accounts, and making government transfers into those accounts. When fully rolled out, I believe it will give the poor the choice and respect as well as the services they had to beg for in the past. It can break a link between poor public service, patronage, and corruption that is growing more worrisome over time.
Even as our democracy and our economy have become more vibrant, an important issue in the recent election was whether we had substituted the crony socialism of the past with crony capitalism, where the rich and the influential are alleged to have received land, natural resources and spectrum in return for payoffs to venal politicians.
By killing transparency and competition, crony capitalism is harmful to free enterprise, opportunity, and economic growth. And by substituting special interests for the public interest, it is harmful to democratic expression. If there is some truth to these perceptions of crony capitalism, a natural question is why people tolerate it. Why do they vote for the venal politician who perpetuates it?
A hypothesis on the persistence of crony capitalism
One widely held hypothesis is that our country suffers from want of a “few good men” in politics. This view is unfair to the many upstanding people in politics. But even assuming it is true, every so often we see the emergence of a group, usually upper middle class professionals, who want to clean up politics. But when these “good” people stand for election, they tend to lose their deposits. Does the electorate really not want squeaky clean government?
Apart from the conceit that high morals lie only with the upper middle class, the error in this hypothesis may be in believing that problems stem from individual ethics rather than the system we have. In a speech I made before the Bombay Chamber of Commerce in 2008, I argued that the tolerance for the venal politician is because he is the crutch that helps the poor and underprivileged navigate a system that gives them so little access. This may be why he survives.
Let me explain. Our provision of public goods is unfortunately biased against access by the poor. In a number of states, ration shops do not supply what is due, even if one has a ration card – and too many amongst the poor do not have a ration card or a BPL card; Teachers do not show up at schools to teach; The police do not register crimes, or encroachments, especially if committed by the rich and powerful; Public hospitals are not adequately staffed and ostensibly free medicines are not available at the dispensary; …I can go on, but you know the all-too-familiar picture.
This is where the crooked but savvy politician fits in. While the poor do not have the money to “purchase” public services that are their right, they have a vote that the politician wants. The politician does a little bit to make life a little more tolerable for his poor constituents – a government job here, an FIR registered there, a land right honoured somewhere else. For this, he gets the gratitude of his voters, and more important, their vote. Of course, there are many politicians who are honest and genuinely want to improve the lot of their voters. But perhaps the system tolerates corruption because the street smart politician is better at making the wheels of the bureaucracy creak, however slowly, in favour of his constituents. And such a system is self-sustaining. An idealist who is unwilling to “work” the system can promise to reform it, but the voters know there is little one person can do. Moreover, who will provide the patronage while the idealist is fighting the system? So why not stay with the fixer you know even if it means the reformist loses his deposit?
So the circle is complete. The poor and the under-privileged need the politician to help them get jobs and public services. The crooked politician needs the businessman to provide the funds that allow him to supply patronage to the poor and fight elections. The corrupt businessman needs the crooked politician to get public resources and contracts cheaply. And the politician needs the votes of the poor and the underprivileged. Every constituency is tied to the other in a cycle of dependence, which ensures that the status quo prevails. Well-meaning political leaders and governments have tried, and are trying, to break this vicious cycle. How do we get more politicians to move from “fixing” the system to reforming the system? The obvious answer is to either improve the quality of public services or reduce the public’s dependence on them. Both approaches are necessary. But then how does one improve the quality of public services? The typical answer has been to increase the resources devoted to the service, and to change how it is managed. A number of worthwhile efforts are underway to improve the quality of public education and healthcare. But if resources leak or public servants are not motivated, which is likely in the worst governed states, these interventions are not very effective.
Some have argued that making a public service a right can change delivery. It is hard to imagine that simply legislating rights and creating a public expectation of delivery will, in fact, ensure delivery. After all, is there not an expectation that a ration card holder will get decent grain from the fair price shop, yet all too frequently grain is not available or is of poor quality. Information decentralization can help. Knowing how many medicines the local public dispensary received, or how much money the local school is getting for mid-day meals, can help the public monitor delivery and alert higher-ups when the benefits are not delivered. But the public delivery system is usually most apathetic where the public is poorly educated, of low social status, and disorganized, so monitoring by the poor is also unlikely to be effective.
Some argue that this is why the middle class should enjoy public benefits along with the poor, so that the former can protest against poor delivery, which will ensure high quality for all. But making benefits universal is costly, and may still lead to indifferent delivery for the poor. The middle class may live in different areas from the poor. Indeed, even when located in the same area, the poor may not even patronize facilities frequented by the middle class because they feel out of place. And even when all patronize the same facility, providers may be able to discriminate between the voluble middle class and the uncomplaining poor. So if more resources or better management are inadequate answers, what might work?
The answer may partly lie in reducing the public’s dependence on government-provided jobs or public services. A good private sector job, for example, may give a household the money to get private healthcare, education, and supplies, and reduce their need for public services. Income could increase an individual’s status and increase the respect they are accorded by the teacher, the policeman or the bureaucrat. But how does a poor man get a good job if he has not benefited from good healthcare and education in the first place? In this modern world where good skills are critical to a good job, the unskilled have little recourse but to take a poorly-paying job or to look for the patronage that will get them a good job. So do we not arrive at a contradiction: the good delivery of public services is essential to escape the dependence on bad public services?
Money liberates and Empowers…
We need to go back to the drawing board. There is a way out of this contradiction, developing the idea that money liberates. Could we not give poor households cash instead of promising them public services? A poor household with cash can patronize whomsoever it wants, and not just the monopolistic government provider. Because the poor can pay for their medicines or their food, they will command respect from the private provider. Not only will a corrupt fair price shop owner not be able to divert the grain he gets since he has to sell at market price, but because he has to compete with the shop across the street, he cannot afford to be surly or lazy.
The government can add to the effects of empowering the poor by instilling a genuine cost to being uncompetitive – by shutting down parts of the public delivery systems that do not generate enough custom. Much of what we need to do is already possible. The government intends to announce a scheme for full financial inclusion on Independence Day. It includes identifying the poor, creating unique biometric identifiers for them, opening linked bank accounts, and making government transfers into those accounts. When fully rolled out, I believe it will give the poor the choice and respect as well as the services they had to beg for in the past. It can break a link between poor public service, patronage, and corruption that is growing more worrisome over time.
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