[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.

[DanBC]

Your dentist example is a bit weird - you're comparing private provision with NHS provision, and that doesn't work. If you want a private dentist, or a private psychiatrist, you pay and get rapid access.

If you can't afford private treatment you go on the NHS. At the moment NHS dentistry is simply not available for very many people. Those people cannot get treatment at all. But for psychiatry, the vast majority of people who need a psychiatrist will get same day or next day access. This is one of the problems - that's a statutory function, they must provide it, and so community care has been cut in order to meet the statutory function.

> Because that's the current wait time for an NHS psychiatrist.

This is untrue in the way that you've presented it. I'm not able to find this statistic any where - what's your source for it please?

There are long waits for some community mental health services, but these are mostly caused by decades of underfunding of MH treatment. Also, your argument says that this problem would be fixed with competition. We've competition and right to choose for first episode of mental health care since 2014[1] and that competition has done nothing to improve things and in many situations has made things worse.

For Early Intervention in Psychosis services (these are services for people with their first episode of psychosis) the current numbers[2] are that 83% of people were seen within 2 weeks after referral.

The number of people in contact with specialist mental health services has increased[3] since 2019 from 1.3m to 1.6m people. This is combined with a decrease in bed numbers and a complex change from CCGs to ICSs. New referrals data is complicated (one person can have multiple new referrals; someone already in contact with services can have a new new referral) but the trend is increasing[3]. The number of young people accessing MH services has increased a lot over the past 12 months, from 575,000 in Mar 2021 to 690,000 in May 2022.

[1] https://www.england.nhs.uk/wp-content/uploads/2018/02/choice...

[2] https://www.england.nhs.uk/south/our-work/mental-health/earl...

[3] MHDS Mental Health Time Series data dashboard

[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.