[brightshiny]

I've worked in the NHS, for several different organisations at different levels of the hierarchy (PCTs, SHAs, CCGs etc), as a contractor, over several years.

I would privatise it tomorrow. The amount of waste in terms of time and money were eye-watering, every time. The amount of politicking was immense. A project that should take a few weeks could easily expand into a couple of years. I resigned from my last contract because it actually felt immoral to be taking a large amount of cash to either sit around twiddling my thumbs, fight with people, or do work at the slowest possible pace in the most ineffective way. I'd rather do something else. Basically, I've never worked for a private company that was anything like that, even the worst ones, and I find it hard to believe any private company would survive very long working that way.

I'll add, my Japanese girlfriend and her friends are utterly unimpressed with the level of service. As was my Spanish girlfriend, who also worked on a hospital's grounds as a medical researcher.

I'm not saying we should copy the Americans, no way, but the Japanese system is private, the German system is private, the Dutch and French systems are also private. Going private does not mean chucking the idea of universal healthcare on the fire, it means properly separating the regulator from the provider and removing the kind of conflict of interest that led to the cover up of high mortality rates, among other things. There is more than one way to skin a cat.

And no, I'm not a Tory. Try picking up a copy of Private Eye if you want to divest yourself of the notion that the NHS is a saintly institution. Or work there.

[majewsky]

> The amount of waste in terms of time and money were eye-watering, every time. The amount of politicking was immense.

Have you ever worked at a reasonably large private organization? It's exactly the same there. It's a complete fairy tale that large private organizations are somehow more efficient than large state-run ones.

[rdtsc]

Exactly. It is also interesting for as much as free market and competition is touted as the golden standard of organizing things, most large multinational companies are really run in hard line Communist style command economy: top down bureaucracy and planned allocation of resources.

[majewsky]

I wouldn't call it communist, it's more of a centralized dictatorship in practice [1]. Which is particularly interesting because of how it completely contradicts the general political mainstream that says that more democracy is always good.

[1] Although one that still, from time to time, listens to the people at the bottom who actually know their stuff.

[brightshiny]

Yes, I have, so no, it's not a complete fairytale. I was quite clear on my views.

[wildmusings]

The difference is that private organizations that don't perform eventually fail to turn a profit and go out of business.

[Osiris]

It's doesn't logically follow that every business that has internal inefficiencies will stop making a profit. They may make less profit than they could if they were more efficient. My father-in-law works for a very large corporation and he's always complaining about the wasted time to get simple tasks done, but they aren't going out of business any time soon.

Every company I've worked at with lots of red tape got there because they were actually trying to solve a problem due to the lack of "regulations" or rules.

[duncanawoods]

I think this is usually because their profit engine breaks rather than being overwhelmed by waste. All big orgs seem to have one part of the business printing money while the rest tries to burn it. So long long as the printer prints, the bonfires burn.

[wildmusings]

If your competitor can produce the same output with less waste, they can lower prices and take your customers.

This is especially true of health care where there's not much salient differentiation or other dynamics that would naturally produce monopolies.

[acdha]

That's a very simplistic view: it assumes that the product in question is an easily-compared commodity, the business has low barriers to entry, and that there aren't other factors (long-term contracts, regulatory requirements, natural monopolies, etc.) which would make switching hard.

In the case of healthcare, consider the cost of entering a competed space: nobody is better at everything so you won't have a clear advantage for many patients, the startup costs (time, money, permits, staff, etc.) are massive, people like to keep their existing doctor and won't change without cause, and the complexity of the problem defies simple solutions. You can't save on staff costs without losing in-demand professionals, things like billing are both intrinsically complex and disastrous if you get them wrong, and so are all of the safety and other regulatory compliance issues. You might be able to shave bits here and there but it'll take time, have indirect costs, and it's going to be a modest percentage over time.

[ZenoArrow]

Only if those competitors can arise. If the established players are all happy to keep their market share and increase profits by raising prices, you won't see the same race to the bottom.

Companies require capital to start. The level of capital to start a company differs depending on the industry. One of the main reasons you see far more startups in IT than in telecommunications (think Verizon, AT&T, etc...) is due to the difference in cost of entry into those markets.

[gerbilly]

>I would privatise it tomorrow.

I'm glad you aren't in charge then :-)

Sure there is going to be waste, but once you privatise, the 'waste' will continue in the form of profit taking by insurance companies and all the other private actors in the system.

I know it feels unfair that there is waste. But IMO profit in healthcare is another form of 'waste' anyway, one that is made worse by the fact that it distorts the incentives away from providing care.

[chimeracoder]

> Sure there is going to be waste, but once you privatise, the 'waste' will continue in the form of profit taking by insurance companies and all the other private actors in the system.

Profit-seeking isn't unique to private entities. State-run programs are still subject to the exact same economic forces; the difference is solely in how they're accounted for.

It's similar to the situation with state-run prisons: the profits are divvied up between the vendors who supply the prisons, the unions representing the correctional officers, and other entities who are required to make a prison actually operate. And even in state-run prisons, these entities have incentives to lobby for the expansion of the prison-industrial complex (which they do). Vendors, suppliers, and LEOs extract massive financial benefit off of the entire system, but because the program itself is state-run, we don't talk about that as 'profit'. Instead, we talk about that as the 'budget' (with a surplus/deficit).

But suppose we turned the state-run system overnight into a vertically integrated, private system, with all the roles served by the exact same people. That is, all the correctional officers are the same (making the same amount of money), all of the suppliers vendors are the same (but many are now owned by the private system). Suddenly, from a discursive (and accounting) perspective, we get 'profit'. The amount of money being traded hasn't changed. The steady-state flow of money hasn't even really changed[0]. The only thing that's changed is which entities we group together as units. But they all work symbiotically in the exact same way, no matter whether you view them as a single entity or a composite system.

As for the NHS - you absolutely bet that there is a profit motive amongst providers (and the agencies themselves). The language is different, and the way it gets assigned to the entities who comprise the system is different, but the fact that it's a state-run program doesn't mean that all that 'profit' magically goes back to the taxpayer.

[0] There would be an overnight, single-time transfer of cash due to the overnight privatization (same thing that happens anytime a company spins out a subsidiary into a separate private entity), but the ongoing cashflow would be the same.

[gerbilly]

>But they all work symbiotically in the exact same way, no matter whether you view them as a single entity or a composite system.

That sounds like a utopia. None have been seen in the wild. Factions can form inside vertically integrated systems as well.

I also never claimed that there can't be profit taking in the nationalized system.

I only said that if there's going to be waste, I'd rather have it come from a system that isn't structured to deny care, or to make it prohibitively expensive.

Nobody likes people who are cheap. Did you ever go to somebody's house for dinner where they measure out wine with a graduated cylinder, and put out tiny portions?[1]

How about people who a cheap with the necessities of care for their loved ones? I'd rather treat everyone at the hospital like royalty, and not be cheap.

We can afford it. Just cut back on true waste like astronomical defense budgets for starters.

[1] Excluding cases where the hosts are truly poor.

[zigzigzag]

The NHS is dripping with profit, everywhere.

The staff make profits. If they weren't making profits then someone would assess how much they needed to live and pay their bills and that'd be the amount they got paid. In practice they get paid, some of them like senior doctors get paid large sums of money that they can then spend as they see fit.

The unions make profits. They charge membership fees and then justify those fees by organising industrial actions in order to increase the profits of the staff.

The equipment manufacturers make profits. Often by charging wildly varying prices for the same goods to different hospitals.

The drug manufacturers make profits. They have to, otherwise they'd not be able to do the research they do. University research is really no substitute.

Without profit the NHS wouldn't exist anymore.

[gerbilly]

By profit I mean charging a patient for treatment.

Everyone should get paid of course, and even handsomely including doctors, but what I meant was that no private company should be able to bill a patient for treatment.

[zigzigzag]

You have a really weird set of arbitrary lines in the sand.

So it's totally OK for a single doctor to make huge profits off the NHS when they charge patients for treatment, but if those doctors form a company to share the load and amortise overheads, then suddenly it's a terrible evil that must be forbidden?

And don't get confused by simple word changes: when a doctor turns up at a hospital and does work in return for a large paycheque he is very much "charging a patient for treatment". The fact that the charges come in the form of taxes and take a long route to get to the patient's wallet doesn't alter the fact that the money comes out of the patient's pocket and ends up in the doctor's pocket!

[gerbilly]

>the money comes out of the patient's pocket and ends up in the doctor's pocket!

It comes out _partly_ from the patient's taxes, and the rest from everyone else's taxes.

The cost is spread. That makes a big difference.

[kalleboo]

As a European who lives in Japan now, the regulated-private system also has a lot of pitfalls. Costs are regulated, so hospitals will drag out procedures over more visits than are required to milk extra money out of the public insurance to game the system (they're professional enough not to avoid important stuff, but it's especially pronounced in stuff like dental care where stuff can wait). I still prefer it over the completely fucked-up US system, but it has both advantages and downsides compared to the European systems that deserve to be debated.

I wouldn't say any country has healthcare "solved", but I don't know how anyone can look at the US system and say that it's a good situation for a developed country.

[brightshiny]

Yes, healthcare is "as long as a piece of string" in so many ways that I don't think it's a solvable problem, but definitely could do with a better level of debate than the sacred cow of the NHS vs the straw man of the US system.

I'm possibly moving to Japan soon, so I guess I'll get a better comparison soon enough.

[lumberjack]

"so much waste" is always the excuse for privitisation of public corporations. I fail to see why it matters when after privitisation you get the added profit motive and costs go up.

The Dutch health care system is a prime example. After partial privisation costs went up.

[zigzigzag]

Because it's possible for the efficiencies gained to be larger than the profits. For that you normally need competition to keep profits in check. Governments are quite bad at 'designing' markets to have adequate levels of competition but it can happen.

Privatised telecoms markets are the canonical example of this. Not many would go back to the days of state-run telco monopolies.

[oliwarner]

You've worked as a private outsourcer. The problems you see, this politicking, waste, gerrymandering is all because of forcing everything out to tender. Or having PFI interests.

The NHS needs to work hard to in-house more stuff. There's fat to be cut, for sure, but it's the existing private elements where most of the real waste comes.

[oliwarner]

This pattern of waste echoes throughout British government, national and local, Thatcher onwards. That's when we stopped governments being able to do stuff.

Companies like Serco, G4S, ATOS and Capita have all supplanted "failing" public services by either promising to be cheaper or replacing another company that submitted a wildly inaccurate bid and themselves under-delivered.

I highlight "failing" there because many of these failures aren't organic; a government has broken them and then threw them under the bus.

After a few years of substandard services and a daily ragging in the Telegraph, the magical tenets of tender and PFI are just too tempting. We paint this picture of the lean bulging muscles of private industry, but it's the same problems with added layers of obscurity and greed.

Worse is the transition from cooked-in-house school/hospital meals to having them driven in from a factory 200 miles away is you replace so much infrastructure that there's simply no going back. You used to have a kitchen full of ovens and hobs and staff who knew how to operate them. Now you have a room full of freezers and microwaves and the cheapest possible immigrants interfacing between the two. To reverse that requires hiring and training and investment. Who's going to invest in that when they could just keep selling them [awful] ready-meals?

Or you sold your land to a PFI so they could give you a hospital. The catch? They get super high rents and "maintain it" at huge expense. After 20 years you've spent more than twice the amount it would have cost to build and maintain it yourself. It's loan-sharking.

The tragic thing here is that many public services are the ultimate embodiment of lean. They do so much with so little and are forced to be transparent. They are people so there's obviously some variance but we've spent so long villainising these organisations that we've forgotten how good some of them really were before it was too late.

This country needs to find a way to start fixing this.

If I were king for a day, I'd start with a new nationalised housebuilding scheme. That would raise revenue (means tested rents, fair price sales), create jobs, lower poverty and homelessness, create new markets for local services.

[Angostura]

How much of that inefficiency was caused by the part-privatisation? Much much paperwork is caused by the inefficient but politically-attractive internal market successive governments have tried to set up.

[brightshiny]

Approaching zero. It wasn't paperwork holding things back, but people who knew there was no problem with poor performance. The contractors knew it and would milk it as long as they could, and the permanent staff treat it like a sacred way of life. Trying to get them to work quicker through good practice was impossible.

Sorry, but that's the way it was.

[lumberjack]

I'd rather get health care from employees who are a bit too comfortable on the job that health care from management that treats me as a cost item of their profit making entity.

At least the lazy employees of the public health care system will not rush me out of hospital hours after a major surgical procedure as some other private health care systems do.

Now of course you might disagree but that's more of a matter of opinion than some objective fact.

[Osiris]

I currently have Kaiser insurance. As an HMO, they integrate a lot of services, which has really helped save a lot of time for us (like using email to talk to a doctor, who calls the specialist, then replies, without making a visit).

However... when we do go in for a visit, I get the distinct feeling that there is a lot of pressure to keep appointments within a specific time interval and basically get patients in and out as fast as possible.

Overall though, the integration of doctors, specialist, labs, and hospitals does create a smoother and less stressful experience.

[kincardine]

> The contractors knew it and would milk it as long as they could

That would be one of those inefficiencies introduced by part-privatization... So it's hard to believe it's approaching zero. Not to mention that you have no real basis for making that statement from personal experience alone...

[zigzigzag]

No it isn't. Contractors milking their customers isn't an inefficient introduced by privatisation: as brightshiny pointed out, the entirely state employed people were even worse.

Contractors milking their clients is something that competent buyers are supposed to prevent, but NHS procurement is a disaster-zone, as is commonly the case in the public sector. Just look up the different prices paid for basics like rubber gloves.

[kincardine]

Contractors milking their customers is an inefficiency introduced by privatization, because without privatization it doesn't happen... How state employees behave or the competency of the buyer is irrelevant.

Saying that the inefficiencies due to privatization are "approaching zero" is a bit disingenuous.

[zigzigzag]

Just replacing contractors with employees just means it's the employees milking the NHS instead, but now with the downside that they're unionised and hard to switch to an alternate provider.

[DonaldFisk]

Many of the problems are due to the internal market, with NHS staff encouraged to work in their own self-interest rather than in the interests of the patient, which in practice means they game the system. This, and the reasons behind it, are explained in a 3-part documentary called The Trap by Adam Curtis.

The NHS is good value for (taxpayers') money: it's about half the price of the American system for the same quality of care.

It's a fairly open secret that the Government is encouraging patient dissatisfaction and privatizing the NHS by stealth. It's only a matter of time before patients have to pay for treatment.

My experience of it as a patient is generally favourable. I usually get seen promptly, and it's free at the point of use. I've experienced the health services in two other countries (Hong Kong and Belgium).

[Certhas]

The German system is not really private in that sense though. What is covered by insurance and what isn't is proscribed by law, and how much a hospital/provider can charge for it is too. And whether you are allowed to treat under insurance is organized, too, limiting the number of doctors per location. It's also more expensive than the NHS.

In reality it is a different way to administer single payer health care that leaves the doctors and hospitals (and the patients) some more freedom, but at increased cost.

From a micro perspective large organisations are often dysfunctional. You need to look at the statistical measures to compare them against other systems. And the NHS manages to give universal coverage at half the cost of the US system.

[kincardine]

It's interesting that you note the amount of waste in terms of money that you experienced (which is extremely anecdotal, obviously) and yet the publicly run healthcare systems are often substantially cheaper than the private ones in terms of overall cost.

[keithpeter]

"I would privatise it tomorrow."

How?

I mean what model of commercialisation would you use? And how do you propose to convince the electorate that your model would be an improvement?

[rihegher]

French guy here, I wouldn't say the french system is private, It's a mix between public and private actors. If you want more detail wikipedia seems a good start:https://en.wikipedia.org/wiki/Health_care_in_France

By the way, I've been living in the UK and spain, the small experience I had with NHS was ok. But I managed to get confused with the system to the point I started crying in front of a medical secretary after spending a day trying to get an appointment with a doctor.

[raarts]

Dutch guy here. I wouldn't say the Dutch system is private either. It's a mix of private and public as well. Users of the system have a similar experience as described in the article. Also the Dutch system consistently ranks top of Europe [1]. When I moved to live in the US as an expat, my insurance company said they had to double my monthly payments because of the cost of health-care in the US. All other countries would be normally covered. My stomach medication and my daughter's birth control both cost us more than 10 times what we paid at home. (Anecdotal of course). My spotty experience with the health care is that the systems are of comparable quality. BTW France's system is also held in high regard here.

[1] https://en.m.wikipedia.org/wiki/Healthcare_in_the_Netherland...

[DanBC]

> I would privatise it tomorrow

There are plenty of examples in this thread of how good the emergency treatment is, and some bad examples of GP treatment.

In the UK your "NHS GP" is paid for by the NHS, but is employed by a private company.

The private bits of the NHS fucking suck.

[laurencerowe]

> The amount of waste in terms of time and money were eye-watering, every time.

While there is waste in any organization, overall the NHS is perhaps the most efficient healthcare system in the developed world. The US spends as much on public healthcare as the UK yet large numbers are left uninsured (while spending the same again on private healthcare.) [1]

> I'm not saying we should copy the Americans, no way, but the Japanese system is private, the German system is private, the Dutch and French systems are also private.

If we want Japanese/German/Dutch/French levels of service then we have to be willing pay what the Japanese/German/Dutch/French in their health service, around 11% of GDP instead of the UK's 9% of GDP.

Yet despite spending significantly less than Germany/Franch/Netherlands the UK mostly compares favourably on health outcomes. [2] [3] [4]

Should the UK spend more on healthcare? Probably some. But it may not be the best way to improve health outcomes. Infant mortality is higher in the UK than France or Germany (though not nearly as bad as the US.) Given infant mortality is highly correlated to inequality it may be more effective to spend more on redistribution than health care.

As populations age, and the need for healthcare increases commensurately amd efficiency becomes vital in healthcare provision. Insurance based system (as in France and Germany) cost more for equivalent outcomes.

[1] http://stats.oecd.org/index.aspx?DataSetCode=HEALTH_STAT

[2] http://www.commonwealthfund.org/publications/fund-reports/20... (full report http://www.commonwealthfund.org/~/media/files/publications/f...)

[3] http://ec.europa.eu/eurostat/statistics-explained/index.php/...

[4] http://ec.europa.eu/eurostat/statistics-explained/index.php/...