[rleigh]

> that's not what anyone wants

The NHS has been turned into what is effectively a state religion in some quarters. It's untouchable. It can't be criticised. It's immune to meaningful improvement and reform at this point. Yet everyone I know who works for the NHS has a litany of stories about the inefficiency and waste. And it consumes an increasing proportion of the GDP. Eventually, something will have to give.

Its been on an unsustainable path since its inception. It's always been in crisis and needed increasing amounts of cash. Cash that we taxpayers have no choice but to pay up. The NHS isn't optional, it's mandatory.

If we have the option to opt out of paying for the NHS and go private, many will do so. I already have to pay twice over. I pay privately through my employer's plan, and then again for the NHS. I suspect if there is the possibility of opting out and going entirely private, many would do so. At this point it's the only way to ever get a GP appointment for many of us.

The problem with the debate here is that it's always framed in terms of UK vs US funding models, both of which are horribly broken in different ways, and never looks at other European countries or other systems around the world, some of which have systems which work better and provide better health outcomes for less money. If we were to privatise it along French lines, for example, it might be a massive improvement all around. But that debate has never happened.

[neilwilson]

"I pay privately through my employer's plan, and then again for the NHS."

And yet it is the private system in the UK that is taking away scarce supply from the NHS making it more vulnerable.

There is a supply side limit on doctors and nurses, which means private healthcare works like the Fast Track queue at Alton Towers. All it does is allow people with money to jump the queue at the expense of everybody else.

And remember that since the inception of the NHS Primary Care, ie the GPs, have always been private businesses. Yet that is the bit that is completely on its knees at the moment.

This isn't a private vs public argument. It's far more fundamental than that. It how do we share out increasingly scarce resources in a country that is getting poorer.

[robertlagrant]

> And yet it is the private system in the UK that is taking away scarce supply from the NHS making it more vulnerable.

It's not a system doing it. Healthcare professionals are choosing to work for private companies instead of the NHS. If you would like to ban that, then say so, but don't pretend there's an amorphous system to blame.

[neilwilson]

There is an amorphous system to blame - too much demand and not enough supply.

Some of that demand has money, therefore the private system will take capacity away from the NHS to supply the money. Of course it will.

That is jumping the queue.

Therefore as a society we have to ask whether we want to uphold the NHS's founding aim: "Healthcare free at the point of delivery based upon need not ability to pay".

We can't fix the supply shortage by taxing the rich. But we can stop the queue jumping by constraining who private healthcare is permitted to treat and in what order.

For the record I don't like the Fast Track queues at Alton Towers either. That's not the British way. In Britain we stand in line - whether Lord or Leper.

[rleigh]

> how do we share out increasingly scarce resources

We make people pay for them. Like we do with every other resource on the planet.

Healthcare is something which should be accessible for all, and we can of course subsidise the less well off. But it still ultimately needs paying for.

[physicsguy]

The supply side limit is purely because the government chooses not to train sufficient staff. We have a government imposed cap to train 7500 doctors per year at University. Then when they finish, they do two years at FY1 and FY2 level, but there are not then sufficient places for all doctors to go onto a training programme. A friend of mine is applying for the January intake of anaesthetics this year for e.g. and there are something like 25 places in the entirety of the UK for that specialty. So people end up working as locums, working to fill gaps in rotas, which has a high hourly rate. Then, when they do finally manage to get a training place, they take a big pay cut and work more hours. That’s if we’re lucky - because plenty of them just go to Australia where the standard working week for a Dr is 40 hours, and many of them don’t bother coming back. But this is a problem created entirely by the government’s choices.

We also have a hugely archaic system in the Royal Colleges. In no other profession do we expect people to sit regularly very expensive professional exams, and expect the staff to fund them out of their own salary rather than them being funded by their employer. £600 a go is not unheard of.

[neilwilson]

"We have a government imposed cap to train 7500 doctors per year at University."

We do. And you know why. Because the NHS has no more capacity to train any more than that. In fact this last year it has struggled to do that because it was more interested in ensuring its staff had masks on properly than getting the job done. First year medical student placements in hospitals were the first to get the chop.

To train more people in any system, that system has to do less of what it is currently doing and more training. We can't afford that in the NHS, which is already struggling to meet demand.

Ultimately the problem is that we spent the seed cord in the 1990s, and we're struggling to replace it.

[aprdm]

Canada doesn’t allow for private practises and it’s in a bad place

[googlryas]

> It how do we share out increasingly scarce resources in a country that is getting poorer

In this instance, the resources are humans, and it seems you want to force humans to do something they don't want to do. If you want slave-doctors just say so. It worked for the Romans I guess.

[forgotusername6]

This is the argument I hate the most from Americans w.r.t. nationalised healthcare. It's unbelievable

[googlryas]

Except it isn't an argument against nationalised healthcare. The UK has nationalised health care and that is what OP is complaining about. I think it would be more an argument by OP against "nationalised healthcare with legal private healthcare".

The exact argument is "doctors/nurses are limited, and they aren't behaving how I think they should behave. Let's fix the system so they have no choice". I guess that isn't slavery, that is just funneling people into a single path which they clearly don't like, because they reject that path when they have literally more than one option open to them.

[andrewjl]

Who is doing the rejecting and regarding what path? What specific proposed fixes are you referring to?

[googlryas]

It seemed like OP was arguing that private medical practices, which are still allowed in England, should be banned because they're using up all the "resources" the NHS needs (doctors/nurses).

[_benedict]

You are not paying twice over. Your private insurance is dramatically cheaper than it would be if it covered everything covered by the NHS.

You do have overlapping cover, but the most expensive cover (GP, long term chronic conditions, emergency care) are provided by the NHS. It’s far from clear that you would pay less if you had to cover the whole through a private policy.

[matthewmacleod]

I find this is a common and totally unjustified take. The NHS is fairly frequently subject to alteration and reform in various ways, and there is no real truth to the “piles of bureaucracy and waste” stories - it remains broadly pretty efficient as a healthcare system when compared with other developed countries.

You’ve also misrepresented the nature of private healthcare in the UK - this is almost universally not a replacement for NHS services. It will offer you things like faster GP appointments, consultants, and routine operations. It will not replace many of the specialist or emergency services offered by the NHS, leaving you dependent on it anyway.

A bigger “problem with the debate” is that we so frequently find people like yourself who are insistent on having some kind of “debate” without really knowing about what, or why.

[gpderetta]

All employer provided healthcare setups I have encountered in the UK do not even offer a GP replacement service [1]. You still need to go to your NHS GP and get an open appointment and then the insurer will redirect you to an approved service (where you will indeed get a faster appointment). Also most insurers do not cover most chronic problems (you'll have to fallback to the NHS) and are really meant to cover just acute issues.

edit: and of course you'll rely on NHS for any emergency.

[1] at least not without paying out of pocket for the significantly more expensive premium coverage. Some now offer phone consultations but you still need to go to the GP for referrals and prescriptions.

[rleigh]

> You’ve also misrepresented the nature of private healthcare in the UK

I mentioned that we don't have the right to opt out of paying for the NHS. It's not possible go entirely private. If you could opt out, you could pay that money to a private provider instead and entirely forego the use of the NHS. That isn't an option today. But it should be.

[simonh]

I have private health care through my employer, I've only used it once but it was very handy. I don't agree with your take at all, there's no way a private health care outfit could efficiently provide an effective emergency service across the entire UK for all possible injuries and illnesses, completely replacing or duplicating the NHS. The USA has tried this and it's an incredibly expensive disaster.

Employed middle aged workers in the USA pay about the same as we do for the NHS to support Medicare, Medicaid and CHIP through taxes, and then have to pay about the same again to actually get health care for themselves. Plus the system that costs twice as much as ours per citizen still leaves tens of millions of Americans without health insurance. It's utterly godawful. Our current system where everyone supports the NHS, and if you want top up services you pay for it, ensures solid funding for everyone's health care. The fact that my private care actually subsidises the NHS by reducing demand on it is a feature, not a bug. There's also the fact that private health care increases overall investment in health care, so in emergencies the NHS can call on private medical facilities which otherwise wouldn't be available. I know there's a fairness argument, but in practical terms our system benefits everyone.

[koshergweilo]

Yup, as an American this is a pretty accurate assessment for the most part. It's also worth noting that several states actually have different systems to close the gap for people who don't fit into the medicare-medicaid-chips safety nets. In California we have medical, which adds an extra tax, but does help a lot of people who would be uninsured get health insurance. Different states will have massively different levels of care and expertise available.

For what it's worth if you have the money you can get some pretty world class care here. My dad had cancer and due to my mom's really good (publicly provided mind you, she worked for the school system) insurance got my dad great care and he's still out an about to this day

[tehbeard]

And when you have a heart attack in the street, who's responding?

In this scenario, why should an NHS ambulance pick you up when you don't contribute? Surely it should prioritize those on public healthcare? Some poor lad whose leg is broken from a fall?

[ricardobayes]

Your insurance would pick up the tab in this scenario.

[ljf]

The question wasn't about the cost, is was 'who is responding'.

[XorNot]

"opt out" is how conservative parties kill public healthcare systems.

Because the public healthcare system winds up subsidizing the private one: private insurers dump bad risks onto it when they get too expensive too insure, after years or collecting the payments that don't go to the public system.

It's the definition of privatizing profits and socializing risk.

You want to opt out? You get to opt all the way out. You don't get to come back, it's a one way street. Still keen?

[physicsguy]

I’m Germany, that’s the way it works, once you choose to go private you cannot opt back into the public system. People sometimes do it if they don’t plan to stay in Germany though, usually if they are immigrants.

[detaro]

Depends on the age. Above 55 it's indeed quite difficult, under that you can switch back if you fall back into the required status (i.e. take a job with a salary under the limit)

[simonswords82]

I think if you’re forced to go private due to long nhs wait times the money you have spent on paying for the nhs via your taxes should be refunded to cover private care cost

[Teever]

Why do you think this should be an option?

[rleigh]

Why should it be an option? Because we live in a free country, and should be free to spend our money as we see fit. Even if others don't agree with it. Why should we all be compelled by the force of law to divert a huge fraction of our income to an organisation which is so ineffective and inaccessible?

We are forced to spend a significant fraction of our salaries on the NHS whether or not we want to. If we feel that this is not good value for money, or of poor quality, we don't have any real option of choosing to pay an alternative provider. Like all nationalised industries, it's inefficiently run because top-down administration of huge organisations blunts initiative and freedom of action. It's run by Whitehall and politicians, with little input from those actually doing the real work. And the result is that it's in perpetual crisis, with COVID having pushed it right over the edge. Is it really fit for purpose? I don't personally think so, and haven't for many years.

Competition is good for many reasons. It improves the quality and value of goods and services. The NHS has no real competition. There's no direct cost of failure, no direct cost to poor purchasing decisions, no direct cost for poor quality of service, and no real driving reason for improvement in the quality and efficiency of its services. They get the money anyway.

Other healthcare systems in Europe have fully private provision--you have the choice of where to take your money, even if you paid into a public system. If a particular hospital or clinic is providing poor or expensive service, you can take your money elsewhere which is better quality and better value for money. That's a very real incentive to drive improvement and efficiency. That is not the case for the NHS system. There is no choice, and the incentives to improve are minimal.

If there is to ever be any improvement in the NHS, there needs to be competition. The NHS should be somewhere you choose to have treatment because it's the best option, not because it's the only option.

[ricardobayes]

Even though I agree with your comment, I don't know of any European countries where you could opt-out from paying social security. Even if some small eastern european country has this option, it is probably unsustainable for a larger country (or one with more healthcare spending).

[rleigh]

It could be done multiple ways. You could pay into a government insurance scheme or you could pay into a private one. The main point is that the payment of the insurance premiums is decoupled from the service provision. Right now the two are tightly-coupled and you can't realistically choose either of them. Look at the French model as an example.

On a small scale, there is some degree of separation. Sometimes the NHS pays for treatment in private facilities, and sometimes private insurance pays for treatment in NHS facilities.

[DanBC]

We've had privatisation experiments in English healthcare for years.

Dentistry is a fucking mess. Eye care is a fucking mess. Care and Nursing homes are a fucking mess. Large private provision of GP care? They can't do it and they hand the contracts back. Specialist commissioning in mental health? It's a fucking mess.

> It's run by Whitehall and politicians, with little input from those actually doing the real work.

If you say things like this it makes me think that you don't know that NHSEngland/Improvement is an arms-length-body, nor what that means in terms of command and control of the English NHS. It makes me think that you didn't know what CCGs were nor how they worked, and that you don't know what an ICS/ICB is nor how they work.

[DanBC]

We've had privatisation experiments in English healthcare for years.

Dentistry is a fucking mess. Eye care is a fucking mess. Care and Nursing homes are a fucking mess. Large private provision of GP care? They can't do it and they hand the contracts back. Specialist commissioning in mental health? It's a fucking mess.

> It's run by Whitehall and politicians, with little input from those actually doing the real work.

If you say things like this it makes me think that you don't know that NHSEngland/Improvement is an arms-length-body, nor what that means in terms of command and control of the English NHS. It makes me think that you didn't know what CCGs were nor how they worked, and that you don't know what an ICS/ICB is nor how they work.

> If there is to ever be any improvement in the NHS, there needs to be competition.

What is "choose and book"? We tried competition, and it dramatically increased costs without doing anything at all to improve care. We're now spending considerable amounts of money rolling back some of that law.

[missedthecue]

"Dentistry is a fucking mess. Eye care is a fucking mess. Care and Nursing homes are a fucking mess"

A mess in what way? Do you have to wait 2 years for a private dentistry appointment? Because that's the current wait time for an NHS psychiatrist.

[rleigh]

Dentistry is a mess because of the funding model. It doesn't pay to be an NHS dentist, so most practices ceased to take NHS patients. If they fixed the funding model, the problem would resolve itself. The problem here was entirely self-inflicted by the NHS in its fixed price lists, which weren't sufficient to run a viable business on. The very opposite of a proper free-market economy. Finding an NHS dentist in some areas is impossible, but finding a private dentist is not. I've used both, and both were absolutely fine. The private dentist was more expensive, but they were charging a reasonable amount to fully cover their salaries, facilities and consumables. As with everything, you get what you pay for.

Regarding competition, the NHS hasn't really tried competition seriously now, has it? Not really. Not actually doing a complete decoupling the insurance funding and the service provision. The "choose and book" isn't that, is it? It's a small attempt, which is better than nothing, but it's not really surprising that it didn't drive a huge amount of change, when it's not really going to have a big impact upon the bottom line.

[gautamcgoel]

Isn't your argument really an argument against paying taxes in general?

[rleigh]

It wasn't intended to be so, but overall I do think that taxes could be reduced significantly. I do think that taxes are used inefficiently and that individuals are better at making decisions in their own and local interests in place of poorly-accountable bureaucracies. But I certainly am not advocating for not paying taxes at all!

[ljf]

An average of £2,647 per person.

[ricardobayes]

I just don't know why that is, every piece of that puzzle I have met, was really efficient and generally doing a good job. Spain is now trying to fix this and pensions by doubling self-employed tax. UK should probably follow suit, UK self-employed tax is ridiculously low. 20% on profits until 50k pounds won't cover a functioning healthcare system (or pensions for that matter).

[yetanotherloser]

What on earth? UK selfemployment tax is far more aggressive than this and the tax authorities have been on an aggressive campaign against selfemployed people for many years, leading loads of people - including me - to give up selfemployment and end up paying LESS tax as a result.I miss selfemployment! but it doesn't bring enough benefits to justify being reamed AND demonised.

And fuck the NHS. Smash the shit out of it. We'll all die exactly the same number of times without it, but be healthier and happier on the way.

[Nextgrid]

I disagree with the threshold you mention. 50k£/year isn't exactly "rich", and even less so given the current conditions with regards to inflation, housing prices being through the roof, etc.

[nradov]

Governments shouldn't be providing anyone with pensions in the first place. Instead they should make defined contribution plans like IRA and 401(k) available to everyone.

[loriverkutya]

In the UK id you are self employed you still need to pay National Insurance which is as far as I know used for funding healthcare.

[yetanotherloser]

It's not reserved for anything and hasn't been for ages.

[nly]

Total tax on someone in the UK earning the median full-tike salary of ~£32K is actually only ~15%

[physicsguy]

… no it isn’t?

Someone with the default tax code would take home £ 25,539.52 which means they pay 20.2% in tax. It’s quite low by many countries standards but certainly not 15%.