Via Samizdata comes the story that researches have found that cannabis can be effective in treating Alzheimers. This follows other studies which have shown that cannabis can be used in the treatment of glaucoma and to relieve side effects from treatment of cancer and AIDS.

Despite the downgrading of cannabis from Class B to Class C, it remains a prohibited substance in Britain and, indeed, in much of the world. But this policy has done nothing to stop a thriving criminal trade in the drug, with both smuggling and home-grown production continuing to evade the law. More worryingly, this policy does little to ameliorate the harmful effects of over-use and abuse, as users are obliged to keep their use private and secret. Meanwhile, those who simply enjoy an occasional use of the drug are at risk of being criminalised despite doing no obvious harm to anyone, even themselves. Few would argue that occasional use of cannabis represents a threat to society or to the individuals in question.

Where some individuals may be susceptible to a bad reaction to the drug, they are extremely unlikely to receive any support or assistance. By putting cannabis sale into the hands of drug dealers, the law cannot place any requirement on them to consider the welfare of their customers; controlled sale by licensed outlets would, on the other hand, ensure that people are fully informed of any risks and side-effects, and given the best possible opportunity to receive help.

The view that something must change is growing. The absurdity of maintaining prohibition of cannabis whilst completely failing to enforce it cannot last, and if the best efforts of the last 30 years at enforcement have failed then they are not likely to succeed in the next 30 years. In fact, no greater blow could be dealt to crime than to remove the easy source of profit made by selling illegal drugs at inflated prices. Legalise it, and we might just have a chance at a more sensible approach.

Three blog posts have caught my attention today: this from Lib Dem Voice, this from Cicero and this from John Hemming MP. All are on the subject of the National Health Service.

First up, Grace Goodlad's post at LDV. She rightly attacks the government's PFI schemes - a wasteful, poorly designed approach to funding any project, let alone something as important as healthcare. But rather than identify mismanagement, lack of proper structures and lack of critical oversight as the cause of the problems in the NHS, she identifies choice as being to blame. This is, to my mind, most odd, especially as she correctly states that:

As good Liberals we should all be backing the concept of choice in public services – patients should be allowed to choose appropriate treatments that are accessible and convenient to them.

I think that's a rather minimal case for choice, but it makes sense and ticks all of the liberal boxes - freedom, diversity, empowerment. Freedom to be treated where you prefer, diversity of options to choose from, and empowerment for patients to demand better services. But she quickly amends this statement by saying:

Fine – I agree with all that, but what price choice?

This question goes to the very heart of not just the debate on health, but the debate on government in its entirety.

It's at this point that I must return to the earlier point - that Goodlad's case for choice is incomplete. It's not simply the case that choice makes people feel a little better about their circumstances; that by choosing where to be treated they might feel as though they're getting a bit more control over things. This is important, but it's the consequences of choice that really matter.

To explain the issue further, I turn to John Hemming's recent post. In it, he recounts the tale of an NHS doctor who, disillusioned with the management of the service, went public with his observations via a blog entitled 'Angry NHS Doctor'. Or rather, he did so until the management uncovered his identity and ordered him to stop posting or lose his job. Now, to be fair, it has to be said that most of what was posted was an angry, even offensive, rant. But it certainly throws a different light on the view that the NHS is having its 'best ever year'. The one interesting revelation was his casual assertion that NHS waiting list figures are, seemingly, routinely fiddled:

8 year old kid from school. Fell over grazed his knee. Played football for 30 mins after injury. School not happy to take responsibility to wash graze and give him a Paracetemol. Poor kid - waited 4 and 1/2 hours – (3 hours 59 mins Mrs. Hewitt - don’t worry we fiddled the figures so that we had a 100% target figures).

This is where choice matters. You, and I, and the Health Secretary cannot see what goes on in every hospital in the land at all times. It's especially bad for the Health Secretary, who is the first and only democratically-elected person in the NHS chain of command. Believing in central change management, the government has, for most of the last nine years, pursued a policy of central control, informed by statistics and reports emerging from the NHS bureaucracy below. This is often referred to as 'target culture'. If a hospital is failing, your best hope for that failure being addressed is to hope that a) that failure is recorded and b) that someone, somewhere on the NHS chain of command notices that failure and does something about it.

The problem, as should be apparent to anyone who has ever worked in an organisation which uses inspections, targets or statistics as its primary means of identifying success or failure, is that getting good figures has relatively little to do with treating patients well. Figures can be fiddled, statistics can be massaged and inspection reports can only show what the inspectors saw. No wonder Patricia Hewitt thought that the NHS was doing so well - it's probably exactly what she was told.

Choice does two things. Firstly, it short-cuts the process for individuals; if your present hospital is failing, you can go elsewhere. Secondly, it provides an alternative means of measuring hospital performance. 'Target culture' tries to gather information about the NHS through statistics which, supposedly, reflect some objective measure of performance. Leaving aside the question of their inaccuracy, it's not even clear that what one person regards as 'objective' criteria will be regarded as similarly objective by another. 'Choice culture', on the other hand, says that each individual's assessment of performance matters. Rather than using statistics and bureaucrats to measure performance, choice turns this power over to individuals who actually use the service - the only people with no incentive to lie about their opinions. Indeed, people who are using a hospital have every incentive to be critical about failings in that hospital - their life may depend on it.

If the hospital treating you has a problem with MRSA, would you be comforted by being told that, overall, the hospital has good statistics for the last five years? I doubt it. Would you turn a blind eye to dirty wards, long waiting times or overworked staff? No, you wouldn't. Choice gives people more than just a way of choosing about their own treatment; choice gives people a way of improving the system for everyone by voting with their feet and rejecting substandard service. To say that restricting choice might somehow solve these problems is an act of incredible faith in a bureaucratic system that has shown no signs of being capable of tackling them in the last ten years.

Furthermore, as liberals it is our first duty to be on the side of the people against overmighty institutions, be they governments or true corporate monopolies. The NHS is the largest employer in Britain, a tax-funded service with considerable resources at its disposal, representation at the highest levels of government and a vast bureaucratic machinery. It is also the beneficiary of considerable public goodwill - we want the NHS to succeed. But for precisely that reason, it needs to be exposed to greater choice, greater accountability and greater scrutiny. The centralised mess that is the Department of Health needs to give way to a decentralised system, more responsive to people's needs and delegating greater authority to people with real expertise - the doctors and nurses on the wards. We need to cut out the middleman and allow patients and doctors to engage more directly, instead of being shuffled around like pieces on a board to satisfy government PR criteria. In my opinion, these arguments are in favour of more choice, not less.

A short blog-post by Tom Hamilton on Assault in the NHS is heartily recommended. In it Tom criticises lazy journalists for not spotting what amounts a fairly pointless and probably counterproductive policy generated by the Goverment's obsession with new measures to tackle anti-social behaviour. Luckily for us Tom gives this measure a sound thumping - something that would cause a fine if you were on NHS property....

This got missed a few days ago, but it appears that the answer to the question is "the Lib Dems", at least according to ICM's poll for The Guardian:

And negative headlines about NHS deficits and job cuts have left Labour trailing the other parties on their traditional strength of health. Just 28% said Labour could be trusted to run the NHS, against 29% for the Tories and 30% for the Lib Dems.

What's remarkable about these numbers is that none of the parties emerge with an astoundingly high score. The Lib Dems are most trusted, but that still leaves a large number of people who don't think any party can run the NHS particularly well.

I think this cynicism reflects the mismanagement of the NHS by both the present and the previous government. Central government can't run the NHS well, and Labour's approach of trying to hire-and-fire local administrators on the basis of targets has been a failure. Whilst Blair promises perfection if he can just carry out one more reform, the public have become profoundly cynical about the whole matter.

Such centralised reforms are not the solution. It's wrong that if you have a problem with your local hospital, the first elected person who has any say in the matter is the Secretary of State for Health - responsible for the entire NHS (devolution provides Scotland and Wales with a slightly better ratio of people to power, but still not enough).

Looking back at the 2005 manifesto, I'm struck by how good some of the ideas sound. OK, "Lib Dem member likes Lib Dem policy" is hardly a story, but it's worth looking at some of these policy points:

• Scrap central government targets and the associated paperwork
• Abolish the quangos responsible for monitoring and inspection, merging their inspection role with existing social services inspectorates
• Move the healthcare commissioning role of Primary Care Trusts to local authorities
• Abolish Strategic Health Authorities, passing their commissioning role to local authorities or consortia of local authorities where necessary
• Plough the savings into frontline care

The movement of power away from the centre to local authorities is hugely important. Instead of a choice between "Labour spending and Tory cuts" as Blair and Brown would have it, there would be genuine local choice about how healthcare spending should be managed. Most importantly, local politicians live in the area, they have to use the local hospitals themselves and they are much easier to reach with criticism and feedback. The need for this becomes clear when you consider just how out of touch national ministers can become. Instead of an expensive and complex set of targets and quangos, voters would be able to express their view through the ballot box.

That such a bonfire of the bureaucrats would save considerable money - money that could ease or eliminate the deficits the current system has created - is a secondary benefit, but also a very important one. The fact that the NHS is sacking nurses because of deficits, whilst maintaining a vast bureaucracy, is a scandal. Moving the funds away from the needless target-setting and towards treatment-giving represents the best opportunity for the NHS to deliver better care.

Labour (broadly defined) has replied in two ways to Steve Webb's revelations that 24000 jobs are about to go in the Health Service.

Yellow Peril says it isn't true:

Lib Dem's have had a rocket aimed at them as a result of their desperate attempts to get scare stories about the NHS in the media.

Jackie Ashley in the Guardian has another point of view: the problems are there, but it was Milburn wot done it:

Milburn will be remembered for many years for his long stint at health, where rampant instability now threatens as his erratic market goes live. Payment by results is exposing old debts he ignored, inflated by his incompetent contract that gave GPs a £20,000 rise by mistake. He encouraged his successor, John Reid, to forget debt in a dash for pre-election NHS targets regardless of cost, with a reckless £20,000 pay rise to consultants.

Milburn is a man for the broad idea, not complexity. That inattention to detail may cause more hospital closures, more sackings of staff and local uproar than is politically sustainable, as the NHS is market-tested to political destruction despite the highest spending ever. It was Milburn who provoked the needless ideological row over foundation hospitals (remember them?) while fatally ignoring the less glamorous purchasing role of primary care trusts.

I love that "he encouraged his successor" - in the finest showtrial tradition.

The sad thing is though, that Ashley is robably half-right on this. Market mechanisms might work. Central direction might just work. But lazily-defined market mechanisms combined with central direction have little chance of working.