[roryirvine]

The problem with changing the 'free at the point of use' principle is that under any likely replacement it would continue to be free for expectant mothers, children, the disabled, and the elderly - precisely the people who consume the largest proportion of healthcare resources.

And that means that introducing per-appointment charges would likely have only a very minor effect on reducing waste & improving availability. Healthy people of working age would see it as imposing extra charges for no tangible improvement.

Either that, or you'd need to be looking at introducing a two-tier NHS, which I don't think many people would be happy with - "it might work in Europe, but what if it ends up being more like America?" would be the worry.

I think your point about the importance of triage to being able to running "lean" is a better place to look for improvements. The Single Patient Record ought to make automated triage a lot more reliable, for instance. And taking a broader view of ongoing health & economic impacts would help with your ADHD/autism assessment use case, as well as similar issues affecting people of working age (maternity care, being another obvious example).

[ben_w]

> The problem with changing the 'free at the point of use' principle is that under any likely replacement it would continue to be free for expectant mothers, children, the disabled, and the elderly - precisely the people who consume the largest proportion of healthcare resources.

The disabled were scapegoated for much of my teens, I wouldn't be surprised if that continues; the elderly… I won't be surprised if someone realises an old person who needs treatment to live, doesn't get it, dies, isn't going to vote against the party responsible for that in the next election the way a pensioner whose income doesn't rise with the cost of living will be able to.

Mothers and children are still going to be important to look after. But with ever-decreasing fertility rates, I wonder if this has become much cheaper per capita already, and the "true" (steady-state) cost for this part of the NHS is therefore hidden, just as old-age care costs were hidden when the population pyramid was the old shape?

[mishellaneous]

i think instead of asking the best way of dividing the costs, we should ask why does it cost so much. we've managed to bring down immensely the cost of technology over the past decades everywhere else.

[ben_w]

Baumol effect is my best guess. Nursing tracks the cost of labour, the tech is (so far) making a small fraction of the worldload a lot more efficient, but the bulk of the workload is not (yet) amenable to automation.

That said, I do hear people sometimes complaining that the administrators were fired to save money, and this just put all that administrative burden onto the doctors and nurses who weren't trained in it and didn't go into medicine to perform; if that's true, tech may be able to assist with reducing that burden?

[roryirvine]

The doctors vs administrators argument swings back and forth every 15-20 years or so. More (and better) tech might change things a bit but, in truth, it's mostly just a slightly different form of the "more administration" side of the debate.

But, actually, some of the tech programmes from the past decade have been effective - NHS Digital & NHSX, the NHS Spine, the work that's led to the Single Patient Record. All much smaller, simpler, and more agile than the gigantic, nightmarish NPfIT money pit of the 2000s. The post-Covid reorg, putting everything under NHS England, inevitably killed some of the momentum but there was real value created and people are doing their best to learn from the experience.

As you say, labour is the real cost driver - but a lot of that labour ought to be done under the banner of Social Care rather than the NHS. Of course, fixing Social Care isn't exactly simple, and will become almost impossible should the nativist right succeed in slashing the supply of care workers.