This paper examines various aspects of the value of and the access to CM from the perspective of the patient, the GP and the government regulators.It looks at a long catalogue of questions involving the efficacy of CM, the patientís choice, cost effectiveness, etc., including 'Does the practitioner have an incentive to give too much treatment when paid per session and too little when salaried, and is there potential for abuse?'Terms like agency problem, consumer choice, equity and externality, commonly used by economists, appear throughout.The paper concludes with the question 'Does the government have a right to save on expenditure, given the fact that the UK spends about half on health compared to countries like Germany?' and argues that an NHS which incorporates CM gives better value for money.
Our question is should the Government fund complementary medicine. By 'should' we mean does the public (as a whole) have better value for money when health care is funded by individuals paying for their own healthcare or when healthcare is funded by the Government via tax revenue' Such a question can be answered from many different perspectives, such as politics, or sociology. But here we are taking the perspective of economics.
The National Health Service (NHS) was created in 1948 because it was believed that a comprehensive health service should be provided and funded by the Government. At that time, healthcare consisted mainly of orthodox medicine. But today there is growing use of complementary medicine. So if there are social, political and economic grounds for the Government to fund orthodox medicine (OM), are these grounds also valid for complementary medicine (CM)
Now there is a clear need for a public warning. My arguments are phrased solely in terms of economics. The NHS was set up at the end of the war in response to social and political factors largely related to the war effort of those fighting, their families and civilians suffering from events such as the blitz. The economic aspects were considered in broad terms, but the specific arguments were not formulated until much later. Today the social and political backcloth is quite different, and despite our understanding of health economics suggesting that on the whole state provision is better value for money than private provision, the evolution of healthcare is going in the opposite direction. In other words, justification of the NHS on economics grounds is not sufficient when the social and political backcloth is of a different texture.
This paper begins by considering the general argument of when it is in society's interest for the Government to fund a commodity rather than individuals buying it directly with their own income. Four factors are then discussed related to the notion that the NHS, by incorporating CM, gives the consumer best value for money. Section 2 considers how healthcare is a need not a want - for both CM and OM. Section 3 looks at how CM widens consumer choice and its probable cost effectiveness could improve the value for money of the NHS. Section 4 considers the issues of income and forms of insurance and finally Section 5 looks at CM in terms of cost benefit and argues that the NHS best serves the economy when it incorporates those forms of treatment with the best cost benefit. Section 6 makes some concluding remarks.
1. Government Funding v Private Spending - The General Argument The argument that the Government should fund OM, and even CM, rests on the premise that the state can offer better value for money for certain goods and services than can the private sector. During the last 50 years there have been many changes regarding the extent to which government funds and/or provides certain services. Funding refers to a service being paid from government revenue - which ultimately comes from individual income via tax payments. Provision is when the public sector provides or produces the service. Not all services are both funded and provided by the public sector. The NHS is one case when this is so. Education and the armed forces are others. Some other services are funded and provided by a mix of the public and private sectors. Waste collection is funded by the public sector but provided by the private sector. Mail delivery and the London underground are provided by the public sector but funded privately. Both private and public services may receive government subsidies.
The peak of the government role in funding and providing services was in the 1970s. Since then there has been a steady shift of both funding and provision from the public sector to the private sector. This reflects a shift in perception that the market is more efficient in providing goods and services than the public sector. Is it valid to say that the market is the best way to run the economy and not the state' The simple answer is yes - providing certain conditions hold. And when they do consumers have the widest choice, and producers are more efficient while making their profit on entrepreneurial skill. Competition within the market maintains low prices, high quality and a wide choice, with workers and owners receiving a fair remuneration for their work.
These conditions for the market economy to operate properly have been well understood by economists for many decades. If they hold, the market is very efficient in providing goods and services. But in fact they rarely, if ever, hold completely. In some cases they hold more, and in others less. The less they hold, the more the market is inefficient - and a poorer deal the public get from the market. The costs of an inefficient market come from a number of sources. The market will be inefficient if there is a lack of competition, i.e. monopolies, if consumers do not know what they are buying, if they cannot plan their expenditures properly or if the price of a good does not reflect the full benefit attained from it. For example, consumers lose out when purchasing from monopolies, if left to market forces the price would be too high and the quality too low. The lack of competition can lead to prices being set too high. It can also lead to costs being too low. Large producers can underpay suppliers and workers. If some firms can charge prices which are too high, and pay costs and wages which are too low, then their profits are higher than they would be under competitive conditions - thus contributing to the income inequalities which we have seen throughout history.
The alternative is for government to mitigate against the worst effects of a market economy. These can take the form of regulations, such as a minimum wage, or food, health and safety regulations. Or when the potential inefficiencies are larger they can take the form of the funding and provision of goods and services. And because the conditions for the market to work hold more for some goods and services than others, so in some cases regulation is sufficient, while for others funding and provision is better. In this manner government can protect the consumer against high prices and low quality, and the workers from being paid too little. But regulation and government provision all carry costs. There are costs associated with setting up regulations and applying them in the form of bureaucratic processes, inspectors, and so forth. Government provision is accused of not being efficiently produced, and of not responding to changes in consumer demand. The concept of a mixed economy is an attempt to create a trade off or a balance between market forces and government control.
So where does healthcare fit in this picture' It so happens that, in the case of healthcare, the conditions for an efficient market hold less than for practically most other goods and services. Generally speaking, the market fails to operate efficiently in healthcare because it cannot adequately provide healthcare for the chronically sick, children, women (because they often do not work or are low paid) and other low paid workers. The NHS is founded on the basis of equity - of providing for a need not a want - concepts which the market economy cannot deal with - even when the market economy is operating efficiently. Nevertheless, the healthcare sector has changed during the last two decades reflecting the degree in perception to which the market is the best way to run the economy. Thus while many other parts of the public sector have been privatised, healthcare has been subject to 'an injection of market forces within'.
As such, there has been an increase in private sector provision with an increase in private hospitals such as those of BUPA. There is also an increase in private expenditure on health. Many more people now have some form of private health insurance, and there is a perception that people pay to see a consultant that did not exist prior to the 1970s. Some of the 'market forces' which have been introduced into the NHS are new forms of accountability, and different budget procedures. Contracting out is widespread - when a service is provided by a private firm and paid for with public funds. This has long since been the case regarding drug prescriptions. And since the 1980s many more services have been contracted out such as cleaning and meal services within the hospitals. Furthermore, many new NHS hospitals are built and managed by private firms and funded by the Government.
These changes represent a shift in perception regarding the extent to which the market is more efficient in providing healthcare than the public sector. It does not imply that the market is always more efficient - no one is suggesting that the NHS be scrapped or privatised. But the interpretation of how much healthcare should be funded and provided privately or by the public sector has changed dramatically. Yet if there are valid reasons to argue that the provision of healthcare should remain largely outside of the market system do these reasons also hold for complementary medicine' In other words, would the public have better value for money were complementary medicine to be incorporated into the public sector
2. Needs and Wants The arguments supporting orthodox healthcare in the public sector being better value for money centre around healthcare being a need not a want, the affordability of healthcare, the lack of consumer choice due to consumers being ignorant of their healthcare choices, and the relevance of the price of healthcare not reflecting the benefit to an individual consumer. In this and the following sections we shall take each of these in turn and consider them in the context of complementary medicine.
One critical reason why the market place fails to allocate healthcare is the difference between needs and wants. There are social, philosophical and other definitions. In terms of economics, the difference is whether a (smallish) change of income or price will affect expenditure. For most goods (you can think of chocolate if you like), if the income rises by a smallish amount, our expenditure will rise. If the price falls, our expenditure will rise. Not so healthcare. If we are ill, the price can rise, our income can rise or fall (by smallish amounts) and still our expenditure is the same. We do not want to spend money on healthcare. We do not if we are well even if prices fall and our income rises. But we must if we are ill even if prices rise and our income falls. This fact alone puts healthcare outside the normal demand and supply theory of economists.
When we have a want, like chocolate, we buy as much as the benefit (enjoyment) can be justified by the cost (given our income). We stop buying more when 'it is not worth it'. If there is a reasonable amount of competition, producers will produce 'enough' at a 'fair' price and consumers will buy 'enough' at a 'fair' price. Now enough and fair are bad enough concepts even in the face of reasonable competition. They get worse with poor competition (i.e. monopolies). But they make no sense in the case of healthcare. If we need treatment (and we have the income) we pay for it. What stops us getting treatment is not price, but enough income.
Now it is widely accepted by health economists that healthcare (referring to orthodox healthcare) is a need not a want. But orthodox medicine existed for many years as mainly a mono healthcare system, and even now largely dominates healthcare. So when you are ill, your need could only be met by a single system. Furthermore, your need was not met by 'healthcare' but by a specific form of healthcare. This means there are little or no substitutes for your treatment. So in a private system, if you need it, you pay for it or you do not, and you do if you have the income and if not you cannot. You need it when you are ill - not at a later date. Nor is there much scope buying part of it. Therefore there is little scope for competition. One consequence of this is a potential for abuse by private suppliers.
Now it is interesting to note that the demand for CM does change with income and price. But CM is an alternative to OM, or in economist language a substitute. It widens the possible ways to treat an illness. The need for treatment does not alter when there is a widening of the possibilities for treatment. But our willingness to try alternatives does. So while treatment is a need, are any or all of the alternatives a want' Does this make CM a need or a want' We first need to consider whether healthcare met by CM is for the same illnesses that are treated by orthodox medicine or not.
Illnesses treated by orthodox medicine are defined as needs. Hence it follows that when CM also treats these illnesses they are also treating these needs. But if CM also treats illnesses which are not treated by orthodox medicine, then we may need to examine carefully whether these are needs or wants. But I think it would be accepted that there are few illnesses treated by CM which are not also treated by OM. If this argument can be accepted at this level, without further ado, then the question is, if the NHS meets needs within orthodox medicine, why does it not meet the same needs with CM. This then raises the concept of cost effectiveness, or cost benefit.
At present, orthodox medicine treats those illnesses for which it has an effective treatment. Put simply, the medicine, at least, reduces the symptoms of the illness. When a second or additional treatment exists, orthodox medicine will use the one which is more cost effective. That is, if two treatments have the same level of effectiveness it will choose the cheaper. A certain amount of discussion will arise if the more expensive can be argued to be more effective - especially when they are produced by different pharmaceutical companies.
So one part of the query whether CM offers value for money, rests on whether it is cost effective. The fact that people pay for CM when they do not pay (directly) for healthcare on the NHS suggests that CM meets needs that OM cannot.
3. Consumer Choice - How Real is it? In the last section we argued that CM meets a need in the form of healthcare, just as orthodox medicine does, and on that basis that CM should be included in the NHS. However, best value also implies consumer choice, which we consider here, and having sufficient income, which we discuss in the next section.
I have already touched on the limited nature of consumer choice regarding healthcare in the last section. Healthcare does not meet our need. If I have a broken leg, I want the fracture treated, I do not want a treatment for a sore throat, even if it is cheaper and even if I do not have much money. We also saw in the last section that CM widens the option for consumer choice. Consumers now have the choice of being treated by CM or orthodox medicine. Even here the choice is limited. If I have a broken leg, I will go to the hospital and get it put into plaster. Now as a herbalist I will then take one of my decoctions to get well quickly - especially as I am self employed and want to get back to work quickly! If I have a sore throat, I have the option of going to the doctor or taking one of my decoctions. Both can treat the sore throat.
In this sense, CM widens the options. In economist language it increases the number of substitutes. And when this happens, there is more competition and consumers get better value for money. But on what basis does the consumer decide to go to the doctor or to the CM practitioner' From the economist's point of view they should go to the one who is more cost effective. To make this decision, they need to know the cost and the effectiveness of the treatment. But they cannot accurately know either.
In the case of orthodox medicine they know the cost of each prescription, and that they pay nothing to go to the doctor. If the condition is serious then they know they pay nothing to go to hospital. In the case of CM, they know each visit will cost a certain amount in consultation fees, and perhaps there will be a cost of herbs or other substance on top. In both cases, additionally they need to consider the cost of travel, and any other costs associated with being ill such as losing income from not working. But they do not know how many prescriptions they will need. Nor do they know how many visits to the CM practitioner they will need. And they certainly do not know which alternative treatment will be more effective. They neither know that x% of the population benefit more from one or the other treatment, nor do they know if they individually would benefit more from one or the other. It is very difficult to calculate the cost of a treatment. And much less can they calculate the effectiveness of treatment. Within OM, some doctors are better than others. Within CM, some therapies are more effective at treating certain illnesses than others, and within each therapy, some practitioners are better than others.
Would cost effective research help the issue' It might reduce the lack of information but it would not solve it. In OM, cost effective research looks at the effectiveness of a form of treatment, but not the diagnosis of the treatment. In Chinese medicine, the diagnosis and treatment are much more interrelated since they are individualised much more, and therefore it is much harder to estimate the effectiveness of a treatment abstracted from the diagnosis. The most important aspect of consumer choice is simply that the public wants their sore throat treated and go for the treatment of the sore throat. But a sore throat is a symptom. It is not a diagnosis in either OM or CM. Both OM and CM then interpret the symptoms to make a diagnosis and with this form a treatment plan.
The consumer relies on the OM or CM practitioner to make the correct diagnosis and devise the best treatment plan. Now the problem is clearer to explain in private healthcare. The person who determines how much the consumer needs to buy is the same person as the one who sells it. If I want new curtains, I decide that I want them and what I want. I may take advice from the shop, but I have adequate knowledge on the subject of curtains to make my own decision. Not so in healthcare. The consumer is in the hands of the one who sells the product. This is what economists call an agency problem - that there is an asymmetry of information between the consumer and provider. In other words, people know their symptoms but not the best treatment required. This is true of not only OM but the problem is less overt with OM due to the NHS. But the principle remains. Abuses can take place. The provider can offer the wrong treatment, too much treatment, or a treatment that is ineffective.
However, the provider has more incentive to do this when their income is on a per treatment basis, and an incentive to give too little treatment when paid a salary (or per patient registered as are GPs in the NHS). In other words, the way the NHS is set up, inherent abuses will be less with OM then CM which is private. It is a solid reason to incorporate CM into the NHS, but one I suspect the CM professional bodies will not use too often.
To reduce or control the agency problem in OM, codes of practice are established which oblige doctors to give advice which is divorced from self interest, that treatment must be objective and not based on financial considerations and overt competition between doctors is eliminated.1 Similar codes of practice are established with the professional bodies of CM practitioners.
This agency problem is of great concern in OM. But the rise in CM brings about some interesting points. The agency problem assumes that people are passive to the advice given by GPs. But the rise in CM is precisely because people do not feel that GPs always can give the best advice or treatment for a particular disease despite paying little or nothing for a NHS treatment. Now there is a new element of the agency problem - GPs are often not in a position to judge whether they or CM therapists can give the best treatment for a disease. GPs also complain that CM therapists are not in a position to refer a patient back to them (despite the fact that the case is more likely to be that patients turn to a CM therapist after or in addition to seeing a GP). It remains true to say that much of the motivation to see a CM therapist rests with the consumer since the convention is to see a GP first, and also because of the near zero cost of having treatment under the NHS and that patients pay from their pocket to see a CM therapist. In other words, now the consumer has to decide whether there is a benefit with low cost to see a GP or a benefit with higher cost to seeing a CM therapist.
4. Income and the Choice to Meet our Healthcare Needs We have so far seen that the very nature of healthcare places it into the category of a need rather than a want. This means we require the product irrespective of the cost and our income. We have also seen that consumers are largely dependent on an expert telling them how much healthcare they need in order to treat their illness. Thus there is little competition within healthcare, and there is a large potential for abuse. The NHS is an effective structure to meet these needs while minimising the abuses and as such it represents much better value for money than a private system. While CM widens the choice of treatment, it does not undermine any of these arguments - rather I believe they only serve to justify the incorporation of CM into the NHS.
There is one further justification for the NHS. The quantity of healthcare we purchase under any private system will be limited not by price, but by our illness and whether we have the income to pay for the treatment. There are serious issues of equity here as healthcare is most required by the chronically ill, children and women all of whom have the least opportunity to earn their own income and pay for their treatment. The NHS meets all these issues of equity. Furthermore, even for the relative healthy male worker, the private system has its drawbacks. Illness is often unpredictable and can incur very large financial payments. Take the case of a healthy male in his 30s, who may have a car accident, get ME or cancer. It is very difficult for the average person to plan for such contingencies.
The literature on healthcare recognises that the demand for healthcare is characterised by uncertainty, unpredictability and potential large payments.2 It is uncertain and unpredictable because we do not know how much illness we will face nor when it will be. The potential large payments relate to the cost of hospitatisation, the use of high tech diagnostic tools, certain types of medication and if the illness is chronic.
For any good where the demand is characterised by uncertainty, unpredictability and potential large payments, the market offers a solution in the form of insurance. Hence we insure our car, our house etc. The NHS is a national insurance system, paid not by premiums, but by tax payments. It is a separate issue whether most people are better served by private insurance or state insurance. However, you may find it interesting to note that while the UK spends 5-6% of its total income on healthcare, France, Germany and the US spend 11%.3 An interesting difference between the UK and these other countries is that the NHS is funded and mainly provided by the state, while in the others the state system is funded but mainly provided by the private system.
Uncertainty of demand and unpredictability is equally true for CM, but the CM market is largely paid out of the pocket, and thus outside the NHS and private insurance system. It treats mainly middle to high income earners, the chronically sick and women - the latter two being among the most disadvantaged in pay from the pocket system. Yet CM is growing precisely because it does not incur large payments. But CM is not meeting the needs of all the chronically ill or low income people who could otherwise benefit from it. Is insurance, public or private, a solution for them
Insurance covers the risk element, and spreads the cost of payment. The insurance company works on the principle that it can reasonably predict the annual cost of healthcare and thus calculate the average cost of healthcare per insured person.4 Some people claim more than they pay, and others less. This is the principle that we all accept when we buy insurance. However, the cost of insurance also includes an element to cover the cost of administration and profit. And we are prepared to pay this because our fear of needing to claim exceeds the probability of our needing to claim, this is our 'better just in case' scenarios. In other words, the insurance companies can only exist if we are prepared to pay more than the average cost of healthcare.
Furthermore, how much we need to pay over the average cost of healthcare and how much we actually do pay in part depends on the lack of competition in the system. In a perfectly competitive system, where there are many companies competing with each other, the amount we pay over the average cost of healthcare will just meet the administration costs plus some minimum profit element. In a system with little competition, the add on component will be greater. We get better value for money in a competitive system than a monopolistic one except when the monopoly is a state system and then there is no profit add on to consider. Critics claim that a monopoly state system is inherent in inefficiencies. So there are - just as there are in a monopoly private system as both systems have no competitor to stem their activities and both systems rely on 'regulators' to ensure the public have reasonable value for money.
It is an empirical question whether the state or private systems give better value for money, and a question which cannot be discussed in more detail here. Suffice to say that 'comprehensive' insurance systems are better than selective ones. The larger the pool of participants, the better for all - over their lifetime. The larger the pool, the more likely that the healthy are included and not just the unhealthy, and the young as well as the old. This keeps down the cost for all in the long term, as we cannot predict when we will be unhealthy even when young and less so when we are old. This is why even in the US most healthcare insurance schemes are employment schemes - to keep the pool as healthy as possible. Do not forget that the chronically unhealthy often do not work!! and the low paid do not participate in such schemes. Such persons depend on the State for healthcare. So the larger the insurance pool the better value for money for all participants. But the larger the pool, the more monopolistic the system. In a private system this means more potential for high cost and high profit and low value for money. In both systems there is room for inefficient administration.
State insurance schemes are also characterised by notions of equity, and thus benefit those on low income, the chronically sick and women. Devos (1991), Donaldson and Gerard (1993) argue that State insurance schemes are the most efficient form of finance (although Donaldson and Gerard doubt it is necessarily the most efficient form of provision). Critics, such as Culyer (1994), argue that State systems are prone to inefficiencies and are not cost effective. However, this argument seems at odds with the lower cost figures we cited earlier.
So why is so little CM covered under private insurance schemes both private and public' Is the cost of insurance, given the added on element for administration and profit just too high to justify the risk of being ill and the chance of 'potential large payments', or are these 'potential large payments' just not large at all in the case of CM. In other words, is the financial cost of CM so low that insurance is not worth it' Does this imply that those who can afford CM are quite happy to pay for it out of their pocket' That is, that the market for private insurance for CM is untenable' Or simply that the private insurance companies have not woken up to the fact that there is a market for it
And what about those who cannot afford CM' At the heart of the NHS is the element of equity that everyone should have equal access to adequate healthcare. If CM offers healthcare so adequate that people are prepared to pay for it even when the alternative under the NHS is free - surely there must be a case to include adequate CM under the NHS
5. Does the Price Reflect the Benefit? Finally, the last part of the argument that the public gets better value for money from a NHS, including one which incorporates CM, relates to the concept of externality. This means, does the person who pays for healthcare get the full value of it, or do other people benefit from my purchase without contributing to the payment' In the case of healthcare, the answer is definitely no, and one of the reasons for CM to grow is this, as I shall now explain.
When we are sick there is a cost to being sick. In a private system we would pay to get treatment because the cost of the treatment and the benefit we get from this is lower than the cost of being sick. In other words, we do not like being sick and we pay to get treatment. But if we have an infectious disease, we can infect other people, so all those who potentially are at risk from our illness, benefit from us getting treatment. But in a private medical system they do not pay. We pay, but they benefit from our being healthy. This is the concept of whether the person who pays gets the full benefit, or whether others also get it but do not pay. It is what economists call externality.
Likewise, if we are sick and our company pays our income, the company benefits from us getting the most effective form of treatment but does not pay the cost. If the state pays us when sick the state benefits from our effective treatment. Without going into more detail, society benefits from a healthy population. The NHS meets this scenario in the sense that society pays for healthcare treatment and benefits from effective treatment. This argument is in addition to the aspects of need, equity and the question of the most efficient form of insurance which we discussed above.
It thus follows that the NHS should include not only all the cost effective forms of treatment, but also the cost benefit forms - that is those that take into account these externalities. Thus we are arguing that a NHS which incorporates CM gives the best value for money. It even implies that society as a whole has best value when CM is in the NHS rather than it being in the private sector.
6. Conclusions We have argued in this paper that within the private market there are degrees of efficiency at providing wants, but it cannot adequately deal with needs. Nor can it deal adequately with the equity issues of healthcare especially in the case of the low paid, chronically ill and women. The NHS has dealt with these - plus the potential abuses of a consumer's lack of information regarding appropriate healthcare whereby the NHS is a highly cost effective and fair insurance system.
Despite CM also meeting healthcare needs, and treating many people who are women and/or chronically ill, CM has remained in the private system. We argued that society as a whole benefits with a NHS offering the most cost effective, or those with the best cost benefit. However, CM has remained outside. We argued that this was not advantageous to society.
While this paper has concentrated on economic issues, many of the issues here cannot be answered by economic analysis. Equity cannot. And nor can the question of how much need to provide - a thorny question within the health service.
At a time when successive governments have tried to stem expenditure on orthodox healthcare, they are none too keen to extend the range of services. The cuts on expenditure have been justified as reducing waste. But all too often it has been at the expense of provision. This begs the question of what is 'too much' when healthcare is a need and not a want. Economists have no answer to this simply because a want relates to income and price and a need only relates to the reason for the need. Nevertheless the consensus is that the cuts have done little to increase value for money in the NHS. Some critics claim that the Government is simply paying too little for healthcare. And certainly the UK does spend a lot less on healthcare than other countries.
The offshoot of these cuts is the rise of private insurance or the culture of the need to pay for healthcare and this may have some interesting outcomes. These are purely speculative, but I believe of some interest. When individuals have to pay for their own treatment - it is they and not the GP or CM therapist who will decide who can best treat their illness. The agency problem will become less important. Secondly, the consumer will have to decide the cost effectiveness of treatment from the GP or CM therapist. They will have to decide whether to pay for CM with insurance or from their own pocket.
Alternatively, if the insurance company gives them limits for spending, they will have to decide how to spend their insurance claim - on CM or OM. Or they will pay for insurance companies on the basis of the size of limits for OM or CM (as is already happening). Which ever of these happens, it still amounts to the same concept that the consumer is having a larger say in deciding which type of treatment is best for them and the GP or therapist is then only deciding how their treatment can best be given for the individual.
This scenario still omits that one factor - that the person has enough income to pay for the insurance or the CM from their own pocket. In the US - the country of large private health insurance only 40% of the population are covered by health insurance. Another 8% are rich enough to pay for healthcare from their own pocket. That leaves over 50% of the population with inadequate healthcare.
Is this what we want?
(The Bibliography and References for this article are printed in the hard copy of The European Journal of Oriental Medicine Vol. 3 No. 2; Millennium 2000.)
Dianne Stewart Dianne Stewart has been an acupuncturist and Chinese herbal practitioner for a number of years. She has a PhD in economics and is a former univeristy lecturer in economics. She now has a private practice in Canterbury in the UK.