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Russell Hamilton
Russell Hamilton
2 months ago

I would once have agreed with the author, but have become more aware that what people on ‘the left’ (like myself) expect is that we should all be living in the Garden of Eden. That the government should spend ever more on … just about everything.

I’m not sure what we should do about teenagers with ‘undetected’ autism – mass screening? The definitions of these conditions seem to be ever expanding. Australia has a 10-year-old disability insurance scheme which appears to be heading for bankruptcy due to autism alone.

People need to be more realistic about what is possible – we can’t consume the mountains of junk/snack food all around us, mostly sit all day, be increasingly alone, treated as a ‘human resource’ at work, and expect to be happy & healthy. Sometimes we have to cope with unpleasant symptoms or struggle with disability. Perhaps we need to prioritise care for the young and healthy, and let people who are dying, and wish to control their own death, do it. Utopia isn’t coming any time soon.

Last edited 2 months ago by Russell Hamilton
Walter Marvell
Walter Marvell
2 months ago

Remember the Left were proposing to make access to free healthcare a legal human right? The idea (and base lie) of NHS exceptionalism has been inculcated by decades of propaganda on the BBC via hosts of TV dramas and hero doc docs. Grubby cynical politicians of all parties including the Tories have genuflected to this creaking Fax using monolith. But then they locked us up and wrecked our economy to protect it – not us. ‘NHS First’. So people clapped and now are dying in droves to spare the blushes of a patently outmoded over bureaucratized institution. Name the idiot managers who got rid of hospital beds in the service of efficiency targets. We had near 300,000 in the late 80s. 144,000 a few years later. No more. Look to France and Germany and end this utter nightmare.

Tony Price
Tony Price
2 months ago
Reply to  Walter Marvell

I suspect that you haven’t read the article fully.

Dominic S
Dominic S
2 months ago
Reply to  Walter Marvell

As our population expands at an extraordinary rate, thanks to pretty much untrammeled immigration, the beds and service available from the NHS has withered to a poor and pathetic excuse for a health service.
No wonder that I heard a doctor say today that his primary health aim is to stay away from doctors.

Dominic A
Dominic A
2 months ago
Reply to  Dominic S

Maybe….and without high immigration the NHS would far deeper in the hole – almost 20% of their clinicians are immigrants, ditto care homes. Moreover, the average NHS spend on immigrants is lower than for Brit borns. Finally, the govt/NHS has not properly policed their service supply – a lot of people get treated no questions asked, no bills given.

Last edited 2 months ago by Dominic A
JJ Barnett
JJ Barnett
2 months ago
Reply to  Dominic A

“…without high immigration the NHS would far deeper in the hole – almost 20% of their clinicians are immigrants, ditto care homes.”

I think this might be faulty logic. You seem to be suggesting that high ongoing immigration is required, in order to obtain foreign staff to do those circa 20% of roles in the NHS and care sector.

But those two things are actually not linked, unless we want them to be. Most nations around the world decide who comes into their country, and offer visas and citizenship pathways to the types of immigrants they need/want, without accepting people by the million and hoping some are doctor’s who will apply to work in the NHS.

Australia needs engineers, so they offer visas to people with engineering skills, or coming to the country to study engineering (and afterwards work in this field). If you’re not an engineer, or on the list of professions they prioritise, you’re not eligible for those immigration pathways.

I think that is fair. It’s their country, they can choose who comes in. In fact, this was basically the default mode of thinking for all countries — only rather recently have we had major orgs and governments pushing open borders, and relentless high immigration without sorting.

We seem to be constantly boxed in by the notion that you either buy the whole bag of skittles, or you have none. That’s a false binary. If we know we need green and yellow skittles, why are we randomly buying whole bags full of skittles on the off chance they have green and yellow ones? — Would it not make more sense to sort for the green and yellow ones?

Dominic A
Dominic A
2 months ago
Reply to  Dominic S

Over the last 40 years the UK population has gone from from 56 to 67 million – an increase of 20% – Whilst Dept of Health and share spending has gone up 400% – in real terms, over the same period (Nuffield Trust).

Billy Bob
Billy Bob
2 months ago
Reply to  Walter Marvell

We can look to the Germans, if you wish to pay an extra 20% per capita for the health service, with the gap being as high as 33% a little over 5 years ago. Between 2015-2019 the Germans also spent over treble compared to the UK on hospital infrastructure to increase capacity. France I believe also costs more per capita but only covers 80% of the costs.
I’m not saying the NHS doesn’t have problems, but simply swapping to the continental model without the extra funding, increasing infrastructure or fixing social care so hospitals can actually discharge patients will fix nothing

Last edited 2 months ago by Billy Bob
Tony Taylor
Tony Taylor
2 months ago

I like the watertight way the Aussie NDIS classifies Autism:

“Level 1 – requires support. Level 2 – requires substantial support. Level 3 – requires very substantial support.”

Xaven Taner
Xaven Taner
2 months ago

I entirely agree. No health service, no matter how well run, can compensate for a chronically sick society.

Andrew Wise
Andrew Wise
2 months ago
Reply to  Xaven Taner

Yea.. let’s blame the customers. The NHS would indeed be wonderful without them.

Dominic S
Dominic S
2 months ago

Yup, its all our fault. Obviously.
Have you not thought for a moment about the way in which government after government has acted in ways which divide people, split them apart from one another, and encourage them to live independently? From the attacks on family through moral and tax methods, to the folly of thinking that everybody can have their own house, governments have divided, for their own ideological purposes. Lockdown was the final nail in that coffin. They’ve made people dependent on them and on the services paid for from taxes, and now you’re going to claim that those poor people are personally responsible for the situation?

Russell Hamilton
Russell Hamilton
2 months ago
Reply to  Dominic S

I’m not holding people totally personally responsible – things are more complex than that. But if people don’t feel a degree of responsibility then things won’t change much. We can’t demand that the government make everything that isn’t perfect, perfect.

Because we would like more police, and better schools, more public transport and a better equipped defence force, more support for the arts etc etc. We need to be realistic about what we can afford and what should be prioritised. And we need a view of life that can cope with unfulfilled wishes.

Dennis Taylor
Dennis Taylor
2 months ago

The author needs to be congradulated for and honest assesment of the British healthcare system,ours here in the US is not perfect but its a hell of a lot better than the Brits.

Kate Heusser
Kate Heusser
2 months ago
Reply to  Dennis Taylor

The US system is the bogeyman held up to frighten the UK population into further support for our creaking NHS. You’d have to provide a rabbit out of the hat to persuade us that the US system works better for the majority of America’s inhabitants than the NHS does for ordinary Brits.

Kate Heusser
Kate Heusser
2 months ago

The ‘Left’ seems to have decided that anyone over – what, 60/70/75 – should be exterminated with as little fuss as possible for the ‘benefit’ of those somehow more deserving younger people who have not yet begun to draw down on the services into which they have spent decades paying. The ‘Left’ should be careful what it wishes, because reforms take a while to gather momentum, and may well not come into full swing until they themselves are ready for ‘society’s’ knacker’s yard.
In the meantime, the Left should re-read Brave New World and re-watch Soylent Green.

Peter Appleby
Peter Appleby
2 months ago

Things will not improve until we transition from a disease management system to a proper heath care system where health promotion is prioritised over the most profitable downstream Pharma-promoted interventions and treatments. Pharma’s deliberate dumbing down of medicine in the 20th century has left us with a legacy of doctors who don’t seem to know, for example, how to treat viruses anymore.
As for autism, it barely existed when I was young (less than 1 in 10,000), but is now expected to reach 1 in 2 in males by 2032, at current rates of increase. Pharma would have us believe that’s been caused by better diagnosis, but if their diagnoses get any better, we’ll all have to admit we were born with undiagnosed autism. In fact, autism often arises in temporal proximity to injections, which shouldn’t be too much of a surprise considering the brain inflaming contents of many of them, and before Wakefield came along, Merck listed autism as a possible side effect of their MMR jab, and the Vaccine Injury Compensation Programme in the States had already paid out over 70 times for this very connection.
Imagine the costs of looking after a severely autistic person for life, or for treating any of the 1200 plus illnesses Pfizer listed as possible side effects of their hurried novel Covid Jab. So my prescription for saving the NHS is to ‘First Do No Harm’ and to better promote healthy lifestyles, but these obvious changes will inevitably be fiercely resisted because it will affect Pharma’s bottom line.

DenialARiverIn Islington
DenialARiverIn Islington
1 month ago

If people of “the Left” actually realise that the Garden of Eden doesn’t exist and is simply the product of a flawed view of the world; why do you remain a person of the left? Doesn’t make rational sense.

Stephen Walsh
Stephen Walsh
2 months ago

We don’t train enough doctors; haven’t for years. Doctors in their late 40s now started university in the early 1990s. Then, as now, there were too few medical training places, dictated by a government imposed quota system. This was partly to save money, as medical degrees are vastly more expensive to deliver than arts degrees, and partly to bolster the incomes and prestige of the medical profession. Many of the medical places which did exist were sold off to highly paying students from east and South Asia in particular; this suited the UK medical profession very well, as there would be less competition for them, and universities profited also. Since then, the population has increased and aged, the working hours directive kicked in, and an increasingly female medical profession was no longer willing to work the long hours which were historically the norm. So an inadequate number of doctors became utterly insufficient, leading to the shipping in of doctors trained in the developing world. No doubt the design of the NHS is sub-optimal. But any system will struggle if it doesn’t train and retain enough doctors of sufficient standard. Hence overwhelmed and increasingly inaccessible GP surgeries, hence over-reliance on prescribing antidepressants and other drugs, hence missed diagnoses, hence many medical decisions being made by non-doctors, frequently not very well paid and not very bright.

Last edited 2 months ago by Stephen Walshe
Peter Hall
Peter Hall
2 months ago
Reply to  Stephen Walsh

I believe that it costs £170,000 to train a doctor but that doctor will pay £1.5m in tax over his or her life. What a nice return on investment! As well as all the benefits to a healthy society.Why would you restrict university places unless it is to boost the earnings of doctors?

Last edited 2 months ago by Peter Hall
Milton Gibbon
Milton Gibbon
2 months ago
Reply to  Peter Hall

The only problem with this is that in the NHS 100% of a doctor’s wages come from the taxpayer.

Billy Bob
Billy Bob
2 months ago
Reply to  Milton Gibbon

In the German system 100% of doctors wages come from the taxpayer, they simply go through a third party first

Guy Pigache
Guy Pigache
1 month ago
Reply to  Milton Gibbon

Strictly speaking only private sector workers pay tax. Public sector workers’ tax payments to government are funded by the government. Might as well pay them net and not collect tax.

Hugh Bryant
Hugh Bryant
2 months ago
Reply to  Stephen Walsh

And yet there seems no shortage of university places and government subsidies for liberal arts courses with the word ‘studies’ in their name. And no shortage of highly paid nothing jobs in the bureaucracy for those who complete them.

Graeme Cant
Graeme Cant
2 months ago
Reply to  Stephen Walsh

Yes, money saving was an influence and the other factors you mention but you missed a major factor in the doctor shortage. I think you will find a piece of research from the 70s which showed that health care demand was directly related to the number of doctors has been extraordinarily influential among policy makers in the Anglo world.

I know it produced policies inAustralia which put severe restrictions on the number of medical school places for locals. I suspect it had its effect in the UK too.

James Surry
James Surry
2 months ago

Thanks Ian. I have worked across the NHS and Social Care, and I think this is the best analysis of the problems that I have seen written over the last few months.

Last edited 2 months ago by jaasharpe
John Howes
John Howes
2 months ago

I commenced nurse training in 1962. I retired after 49 years, a number of my colleagues encouraged me to hang on for the 50 which would have seemd meaningless to me. By that time I had held a number of management posts, worked as a Full time Union official for the Rcn and at one point during my membership I had served as a member of Council, (the governing body) during my 49 years I was involved with compromises, most of which resulted in control passing to Administrators, some talented, some charismatic, many having neither of these essentials of leadership. With the coming of Blair we gort Patricia Hewitt (formerly with Andersen consulting) then the merry dance began, we had ‘General Management’ with Roy Griffiths, under whose guidance patients became ‘customers’ who had little say in the health care purchased on their behalf.The health service became a serious of markets, buying and selling from each other. Spending on Management Consultants pre Hewitt was approximately £900 000 yearly, it then rocketed to almost a £million monthly. Care became the bottom line on a spreadsheet. In my own hospital, the CEO said I can get 3 HCA’s (Health Care Assistants) Band 2 for the price of 2 Band 5 Staff Nurses. This logic has continued since I retired 11 years back. The current crisis of not enough staff has been perpetuated by generations of ‘Nursing Leaders’ who have had more concern for their corporate lifestyle than the nurses they ‘lead’. The ONS has clearly recorded large sums of money going into the health service then piddled away on vanity projects, diversity and all the minutiae of an organistion that has not only abandoned any sense of purpose, and is now unfit for pupose.

Last edited 2 months ago by John Howes
Steve Murray
Steve Murray
2 months ago

I commented on a recent similar article that it’s only a Labour government that might have the political werewithal to instigate meaningful change to the NHS. The noises coming from Starmer suggests he recognises this.

Quite simply, history – and the British people – will not forgive him if he passes up the opportunity likely to be presented to him. No pressure there then; but at least a start must be made in the first year or so under his watch.

I’m not sure why the author thinks bringing GPs back into line by relieving them of Practice management roles so they can concentrate on seeing patients is a bad idea. He calls it “nationalisation” but it’s meant to be a National health service. Using loaded terms doesn’t help here. The article does, however, offer many thought-provoking insights, not least his exposure (which anyone with long experience of dealing with the system will recognise) of arrogance and medical egos getting in the way of optimal patient care. That was the most shocking thing i discovered when i started out in the NHS in 1981, and it still lies at the heart of most of the scandals we hear about today – and many that never see the light of day.

Last edited 2 months ago by Steve Murray
Rocky Martiano
Rocky Martiano
2 months ago
Reply to  Steve Murray

I have written to my (Tory) MP asking why we are hearing these noises about reform from Starmer and not from the current government, which should be making a start on reform now instead of waiting for the inevitable arrival of a Labour government, by which time the NHS may well have descended into total collapse. Not that I trust any politician to actually do what they say they will do once they are in office……but at least making the right noises is a promising start.

Martin Bollis
Martin Bollis
2 months ago

It is impossible to reform an organisation this big. There are too many vested interests, both internally and externally, too much inertia and too much money involved.

Both politically and practically governments should stop talking about reforming the health service and start talking about task force style solutions to specific issues.

Getting elderly bed blockers out of main stream hospitals would be an obvious good place to start and the care system is not a monolithic bureaucracy so can be more easily and quickly manipulated with the right financial and regulatory stimuli.

Properly targeted and funded interventions, on key sub problems, have much more chance of freeing up the core system than “root and branch reform.”

Alison Wren
Alison Wren
2 months ago
Reply to  Martin Bollis

Well if they hadn’t sacked well over 100,000 health care workers (mostly working class women on not much more than minimum wage) because they weren’t willing to be vaccinated ( I’d wager nearly all had naturally acquired immunity) maybe we would have fewer “bed-blockers”.

JJ Barnett
JJ Barnett
2 months ago
Reply to  Martin Bollis

You’re definitely right re the sheer size of this organisation making it nearly impossible to reform. It’s like the Titanic — we can see the iceberg, we just can’t turn the ship around fast enough to avoid hitting it.

What we can’t have is a situation where the existing system collapses, which it will of it’s own accord (it’s happening now, in semi-slow motion), and will also happen if the government decide to try a complete overhaul all at once.

I like your task forces idea. I was thinking maybe the smart policy would be to propose a completely new, more decentralised system, and set it up in parallel, node by node. Start in manageable sized regions, pulling them into the new framework first. Task forces could meanwhile address the key areas of stress & failure in the NHS, to get those functioning better until the larger regions can move into the new framework. They could specifically focus on this — not only addressing the issues, but resolving them in the direction of the new system, such that they help get the most critically important parts of the NHS ready for migration, so to speak.

I think the central feature of the new system has to be that it’s decentralised. Modernising the system is great, and should be done, but a core issue with the NHS is the centralisation of power, which has caused bureaucracy to overtake mission, and has brought it to a scale that is irreformable, as you note. Over time, that will happen again in a new system, unless it’s designed from the ground up to prohibit that.

Philip K
Philip K
1 month ago
Reply to  Martin Bollis

What we can do is develop a set of key objectives, with underlying assumptions which minimise change caused by lobby groups, that we aim to achieve over a number of years. One example would be technological change – minimising admin work for medical staff, and giving a clear view off patient data. Another could be expanding social care to alleviate bed blocking. The list can go on, but must be achievable. With a clear strategy, we have a better chance of success.

Last edited 1 month ago by Phil K
Jacqueline Walker
Jacqueline Walker
2 months ago

Excellent article with a thorough analysis and proposals for solutions should be required reading for the whole country.
Does anyone which to imitate the NHS?Sadly yes, Ireland is still aiming to launch their own version expanding the reach of the woeful HSE which is way worse than the NHS already.
I would be all for digital records if I as patient had control over them, literally as in I bring them with me and allow the doctor to see them. Here you have to FOI the HSE if you want your medical records.

Eamonn Toland
Eamonn Toland
2 months ago

Having been treated for a heart attack in Dublin four years ago, the HSE is nowhere near as woeful as people make out. A&E is a horrendous bottleneck (unless you utter the magic words “chest pain”) but once inside the system there is first-class medical care. For routine checkups GP appointments can be obtained fairly quickly (often same day or following day) albeit if you are better off you will pay €60 to see a doctor.
Nearly 40% of people in the Republic of Ireland already have free access to health care through medical cards, but the NHS free-at-the-point-of-use system for all is fetishized north and south of the border, despite the fact that life expectancy in southern Ireland is now two years longer than in Northern Ireland, where GP bottlenecks and surgery waiting lists are astronomical even by comparison to the English NHS. I have come around to the idea that modest co-payments are a good thing to reduce abuse of the NHS, which frankly has been two-tiered for decades.
The English NHS, specifically Ashford Hospital near Heathrow, saved my life twenty years ago, when I had my first pulmonary embolism after long-haul air travel. I was unlucky enough to collapse just before Christmas, when the hospital was overrun with perfectly healthy older people (due to “granny dumping”) who had to be accommodated by overwhelmed staff. I was put in a disused operating theatre with lonely, dying men. At one point they forgot to feed us for 16 hours, until my wife came in to see me. When I was well enough to be transferred into a private hospital near my home, I was given a private room with cable TV and a room service menu.
The NHS is clearly in need of reform, but people need to see that change is not a slippery slope to the US model, where people take out insurance that costs 10X more than the UK equivalent simply to avoid bankruptcy in the case of an emergency. An English friend of mine who lives in California was bitten by a venomous snake in a freak accident. He was charged $30,000 for two days in intensive care, and $270,000 for two vials of anti-venom – a UK-based company had exclusive rights to the life-saving medicine in the state, and charged accordingly. Without insurance he would have been ruined.

F K
F K
2 months ago

Well analysed and well said. Those of us who have had the misfortune to experience the less than positive side of healthcare understand exactly what the author has highlighted (and of course there are some fantastic people out there if one is lucky enough – care and compassion!). However, the worst of it is often ego, arrogance, train track thinking, lack of effective administration on all levels, even before getting to the often lack of genuine care on offer – not at all helped by the breakdown of family and community. The author’s message needs to get out there. We need ideas for this change to the health system and perhaps the author should get together with someone like Andy Street – ex John Lewis and now mayor of Birmingham – to help the Country come up with a blueprint to help push things along. Nothing is changing and we seem to be descending to a very bad placed indeed.

Peter Hall
Peter Hall
2 months ago

Two other important reforms that need to be implemented. 1. The Australian system of the equivalent of an NHS card that allows patients to choose who provides their healthcare with the government reimbursing the provider at a set rate per procedure. Power is transferred from the monolith to patients. 2. Means testing of access and the end of middle class welfare for many procedures.

Guy Pigache
Guy Pigache
1 month ago
Reply to  Peter Hall

I suspect many of the “middle class” would be prepared to pay more for state healthcare. But how many would believe that they were going to get something better for that extra outlay? We don’t have hypothecated taxation in the UK.

Jorge Espinha
Jorge Espinha
2 months ago

Dear Brits. The wall has fallen in 1989. Mr Attlee and Co. with the best possible intentions turned the UK into the United socialist kingdoms of Great Britain, they just didn’t come around and change the name (USKGB). If it wasn’t for Tatcher the country would have gone belly up in the 80s. In a way Margareth was a bit like Lenine, she instituted the NEP that saved the USKGB and your ever-growing commissariat. Even a basket case like my country, Portugal, allows for a mixed system, people that are employed by the state use it enthusiastically ( they have a separate system, called the ADSE that allows current state-employed and state pensioners to avoid the company of proles in the state-owned hospitals). Spain which is run by lunatic Socialists has one of the best private Health systems in the world and receives thousands of paying foreigners every year in a very lucrative business of health tourism. It’s unfortunate that your so-called Conservative party is just slightly less socialist than the Labour party, the only capitalist aspect of their policy is the way they sell passports to international criminals. Isn’t it about time to follow your eastern European comrades and break the shackles of socialism?

Doug Pingel
Doug Pingel
2 months ago

Thanks for telling it like it really is.

Diane Tasker
Diane Tasker
2 months ago

Being further down the path to ‘old age’ although physically and mentally as active as ever, the thought of being incapacitated in any way under the prevailing NHS care system has me contacting Solicitors for Ageing to make a Living Will and set aside funding for a trip to Switzerland should the Assisted Dying Bill not succeed. 50 years of working and paying contributions is unlikely (if the current trend of ‘care for the elderly’ continues its downward spiral) to see me depart pain free and in dignity.

D Glover
D Glover
2 months ago
Reply to  Diane Tasker

This author is opposed to voluntary euthanasia. He also writes approvingly of refusing all treatment beyond the age of 75. I’m not sure how pain free and dignified we’d be if we just let our last illness take its course untreated.
Time to debate voluntary euthanasia again? If it’s OK for people with the means to reach Switzerland, why is it not OK everywhere?

Diane Tasker
Diane Tasker
2 months ago
Reply to  D Glover

The Assisted Dying Bill is currently being debated in the House of Lords – few people in this country would let their dog die a lingering death in agony in the face of a veterinary diagnosis. I agree that it’s yet another – and infinitely more cruel – disadvantage for people without the ability to raise the capital.

j watson
j watson
2 months ago

Agree with quite a bit in this article and at least this Author gives some real policy suggestions. He does zero in on two themes impacting on all health systems – whether patients can flow out of secondary care efficiently because Social Care functions appropriately, and how we all recalibrate to an aging population – it’s not just the 80yrs+, it’s the fact that most 65yrs+ have two chronic conditions needing regular support and intervention. These dynamics mean we are in a different place to 15-20yrs ago.
We know there is a difference between how we individually pay for health services and how they are delivered. I doubt many think we should or could move away from ‘free at the point of delivery’. So that aspect of the NHS unlikely to change much. On delivery the theme of the last 30yrs is what is the role for plurality and competition between Providers? It’s had v mixed results with consistent attempts to increase competition. In part because fundamentally we don’t deploy much choice when an emergency, nor can every locality have plurality of Providers without some regualrly going bust. And allowing a healthcare organisation to go bust is not an easy thing for any politician to allow. (although choice of GP is there and capitation revenue does move with patient).
We have to recognise that we have dramatically slowed the rate of investment last 13 yrs and that has an impact on per capita doctors, nurses and care workers where we are now significantly behind countries we typically compare ourselves with. Doesn’t mean everything can be blamed on this but it’s material and to argue otherwise is not a serious comment.
Psychologically we don’t really want a ‘Health’ service do we? We want an ‘Illness’ service that ‘rescues’ us when we need it. I suspect a large proportion of UnHerd readers would not welcome more state intervention to push healthier lifestyles and will feel freedom of choice paramount. It may though therefore mean it is an Illness not a Health service we are favouring, so far as it relates to ourselves.

Last edited 2 months ago by j watson
Graeme Cant
Graeme Cant
2 months ago
Reply to  j watson

Unless you see ‘free at the point of delivery’ as the fundamental roadblock in the way of any effective reform, you are part of the problem.

No health – or illness – system can be provided with the capacity to satisfy every whim which is what ‘free at the point of delivery’ means. If no sorting takes place, the system’s finite capacity will be allocated by queueing and rationing.

Rachel Taylor
Rachel Taylor
2 months ago

With an organisation of this scale, it is not possible for anyone or any body to know the solution, because no-one can have the knowledge to correctly diagnose the problem, or the experience to identify a solution.
The approach taken has to be a meta-solution. What do you do if something is too big to grasp as a whole? You break the problem up into smaller chunks.
And funding is also not the linear matter it is usually supposed to be: too little, about right, too much. We don’t discuss the level of “funding” for holidays or cars or food, because the production and consumption are both part of the economy. What matters is whether the money is used productively, without excessive waste. As we know from long experience, that only happens with competition.
With any change, the obstacle is the vested interests. They act like a black hole, dragging all changes back towards the status quo.
So I think it is extremely unlikely that the system will allow any significant change, because the significant change would be to break the system up.

Mel Shaw
Mel Shaw
2 months ago
Reply to  Rachel Taylor

I have wrestled with the problem of how you would transition from the current NHS model to something closer to the social insurance model used in Europe. Unfortunately I can’t think of a way. Breaking the problem into smaller chunks might work, but all of the chunks would have to be coordinated to arrive at the same destination. As you say, there are too many vested interest to allow that to happen. My sad conclusion is that the NHS will need to get much nearer to total collapse before radical change will happen.

Hugh Bryant
Hugh Bryant
2 months ago

Systems people have known for decades that protocol driven networks are vastly more efficient and effective than command driven monoliths.

If we knew the best way to run a school or a hospital it would make sense to run them all in the same way. But we don’t. So it doesn’t.

Michael Furse
Michael Furse
2 months ago

There is a fundamental flaw in health provision as practiced in the UK. It doesn’t service health – it services sickness. Health education is seen in the main as the responsibility of educational providers, who in turn see it as a distraction from their core provision, though less of one than music, to their eternal shame.
Health education has a clear preventative effect and should be a core function of any centralised health service. There needs to be a philosophical revolution, without which no amount of tinkering will address the core issue of health consumers being in the main convinced of their rights with no concomitant responsibilities. And the medical profession, who have been fed on a diet of “the NHS is perfect if only others did things better” (more money, healthier patients, more nurses, more drugs) are as much to blame, though there are notable exceptions.
Like the UK teaching profession, the combination of poor quality leadership, excessive bureaucracy and extensive unionisation can result in very poor outcomes indeed, and like all bureaucracies, the incumbents close ranks when criticised. One might go so far as to say the bigger the bureaucracy, the tighter the ranks.

Rob Nock
Rob Nock
2 months ago

Interesting that nobody really comments on the inherent problems of a socialist healthcare system: nobody wants to pay yet everyone wants it well funded.

On top of that if the patient is not the customer then they will not be treated like a King.

In the UK nobody is the customer, we are all just inconveniences for the NHS. In the US the insurance companies are King. Neither system serves the real customer.

We need to replace the NHS with a system where the patient is in control and pays for their treatment, even if they claim it from the insurance company/state.

Michelle Johnston
Michelle Johnston
2 months ago

Anyone who has read my previous comments on the NHS will no I am delighted with someone who sees this as primarily though not exclusively a demand problem.
Social Care. Some argue as many as 2/3 rd of beds are taken up by those who should be in it. it is far too many.
Voluntary Poor Health 8% of the budget goes to type 2 diabetics.
End of Life. I am completely with Ezekiel Emmanuel on this. Look where this ‘no one must ever die’ got us with the outbreak of a new respiratory illness.
The lack of joined-up one-stop information retrieval is a joke. When my mother was alive A & E rang me to ask what medication she was on.

Ben P
Ben P
2 months ago

“Britain has clung for so long to this weird comfort blanket, the risible idea that the rest of the world was looking with longing at a health system that has been in crisis for much of its 75-year history.”
No they haven’t Ian. That is the propaganda we have been fed by the media for seventy years.
This country is governed by MEDIA OPINION not public opinion. You lot are the opinion formers, ramming garbage down our necks like LGBTQ+-$%£ while the rest of us try and get on with our lives and avoid being splattered with this filth.
If this country is on its backside (and it is), it’s because the media have driven us there because they’re in charge.

Alison Wren
Alison Wren
2 months ago
Reply to  Ben P

The eligibility for free healthcare needs to be restricted to real health needs, not the “need” of a mentally ill female patient to construction of a pretend male organ.(NHS to offer phalloplasties….) and other unnecessary procedures.

Janny Lee
Janny Lee
2 months ago
Reply to  Alison Wren

Quite right and a view in tune, I suspect, with the vast majority of the public. But what do we know?

Malcolm Knott
Malcolm Knott
2 months ago

My mother was refused financial help towards her care on the grounds that she was insufficiently frail i.e. did not tick enough boxes. She was dying and indeed died two days later.

John Riordan
John Riordan
2 months ago

What a brilliant essay. Well done the author.

Peter Lucey
Peter Lucey
2 months ago

Excellent piece. Ditto the BBC.

Allison Barrows
Allison Barrows
2 months ago

Without competition and accountability, what incentivizes any institution? Government-run entities can just shrug, say they need more money, pass the blame onto some nebulous bogeyman, and lumber on failing in their duty.

Jack Martin Leith
Jack Martin Leith
2 months ago

The NHS houses four internal consultancies (and there may be others I don’t know about) providing services in the areas of process improvement, service design, organisational change and leadership development. They are:
NHS Improvement
• Advancing Change Team
• Intensive Support Teams
NHS Transformation Unit
NHS Horizons
NHS Leadership Academy
I know from personal experience as an independent innovation and change consultant that there is significant overlap in services offered, and that there is some degree of competition for business.
Would it be beneficial to merge the four consultancies, eliminate duplication, eradicate competition, and create a world-class organisation that attracts the best talent and fosters genuine transformation, by which I mean change of form?

Last edited 2 months ago by Jack Martin Leith
Graeme Cant
Graeme Cant
2 months ago

“Innovation and change consultants “ are part of the problem, not the solution.

Janny Lee
Janny Lee
2 months ago

Ye Gods! Innovation and change consultants. Your entire comment depresses me beyond measure. Protect us from the army of highly paid, irrelevant and fundamentally useless ‘consultants.’ They are part of the problem and most certainly not the solution.

Lesley van Reenen
Lesley van Reenen
2 months ago

None of this will work without assisted dying – dying with dignity.

CHARLES STANHOPE
CHARLES STANHOPE
2 months ago

Our view of death is frankly mawkish due to the pernicious influence of “you know what”. The behaviour of the National Horror Show (NHS) only seems to exacerbate this.

The ‘Ancients’ were, as you might expect, far more robust over this matter. In fact the Romans regarded suicide as quite acceptable under certain circumstances, such as political failure or military defeat.

O that it were so today!

Dustin Needle
Dustin Needle
2 months ago

They’d have to cancel Davos due to absence of attendees.

Frank McCusker
Frank McCusker
2 months ago

The Romans lol. Death culture

CHARLES STANHOPE
CHARLES STANHOPE
2 months ago
Reply to  Frank McCusker

What about Bobby Sands and the others?

Rasmus Fogh
Rasmus Fogh
2 months ago

It would certainly relieve pressure on the health service if old and demanding patients could be convinced to die with dignity and stop consuming resources. Not sure I would like or trust such a system, though.

Russell Hamilton
Russell Hamilton
2 months ago
Reply to  Rasmus Fogh

We have voluntary assisted dying in Western Australia, but the health profession certainly can’t ‘convince’ anyone to take up the option. The Act says: “A health care worker who provides health services or professional care services to a person must not, in the course of providing the services to the person —
(a) initiate discussion with the person that is in substance
about voluntary assisted dying; or
(b) in substance, suggest voluntary assisted dying to the
person.

Doug Pingel
Doug Pingel
2 months ago

Interesting to compare that with the Canadian model where, I believe, Medicants of all shapes and sizes are encouraged to push it.

Diane Tasker
Diane Tasker
2 months ago
Reply to  Rasmus Fogh

That suggestion puts a different slant on the ‘cradle to grave’ promise on the founding of the NHS

Janny Lee
Janny Lee
2 months ago
Reply to  Rasmus Fogh

Nor me.

Ian Barton
Ian Barton
2 months ago

It can work without assisted dying, but I’m fully on your side here, as assisted dying should be a fundamental right (for those capable of competent decisions)

Billy Bob
Billy Bob
2 months ago
Reply to  Ian Barton

I’m not against assisted dying in theory, however I’d always be worried it would end up far too lax like the Canadian system

Susan Osterwoldt
Susan Osterwoldt
2 months ago
Reply to  Billy Bob

Yes, I was going to mention our experience in Canada, with MAID (medical assistance in dying). We seem to have a few over enthusiastic providers of death, as the definition of those who qualify has expanded to include those with mental health issues, those with “home insecurity”, etc.
On the bright side (dark humour alert!) …apparently the shortage of organs for transplant has been somewhat alleviated! Shades of China…

j watson
j watson
2 months ago
Reply to  Ian Barton

I agree with the ‘right’. The practice though is much more difficult. For example people drifting into dementia – at what point do they lose capacity to make the decision?
Therefore you need a massive cultural change in Living Wills made when we are younger. Even then though the specifics we give as guidance to others on our wishes is not straightforward and our views probably change over time too.
I suspect it will increase, but the desire to live is v strong and for those not in v acute pain the take up of ‘assisted dying’ will remain v limited and quite close to the natural end of life anyway. Thus the broader ‘economics’ largely unaffected.

Last edited 2 months ago by j watson
Hugh Bryant
Hugh Bryant
2 months ago

cf: Canada?

Andrew Dalton
Andrew Dalton
2 months ago

In principle I agree. However, I strongly suspect abuse of such regulation and at least a possibility that it would creep toward something that removes the agency of the patient.

Justin Clark
Justin Clark
2 months ago

Don’t know why the thumbs down on Lesley’s point. I want the option in place to go with dignity when it’s right – not to be kept going at all costs.

Dominic A
Dominic A
2 months ago

I like the Thai village answer – nightly opium for the elderly, who are still part of the village life, helping out when and where they can, and being fed and watered and cared for when they cannot.

David Whitaker
David Whitaker
2 months ago

I believe that the idea when the NHS was established was that there would be a “once-and-for-all” campaign of improving the health of the nation and that after that the effort required would be less. I suggest that there is a comparable big task to be done now, which is to improve the lifestyle of the nation: better diet, more exercise, reduce alcohol and drug consumption and so on. Once that objective has been achieved we may be able to manage with a more modestly resourced NHS.

Elaine Giedrys-Leeper
Elaine Giedrys-Leeper
2 months ago

Well this is refreshing ! an UnHerd contribitor who actually knows what they are talking about and with extensive personal experience (of good and bad patient / social care) and even some possible solutions !

I share other commentator’s concerns about the accuracy of Mr Birrell’s comments on funding. Some much more nuanced and useful comments on this morning’s “More or Less” on BBC Radio 4, from Ben Zaranko from the Institute for Fiscal Studies. Available here : https://www.bbc.co.uk/sounds/play/m001h3zf  from about 7min 25sec. The full report on which this interview is based is available here : https://ifs.org.uk/publications/nhs-funding-resources-and-treatment-volumes
The 3 comments Mr Zaranko made that really stuck with me were :
⦁   there is no universal objective definition of how much care is “enough” (access, quality, service)
⦁   2010 – 2019 the annual funding to the NHS did not allow it to even “stand still” in terms of service provision in the face of an increasingly ageing population and increasing demand.
⦁   countries that spend more on their health care per capita (Sweden, Germany, France, the Netherlands) are also wealthier than the UK and are therefore ready, willing and able to raise higher taxes to pay for this increased health spending per capita.

The other two great programmes recently with wide ranging analyses of the NHS and some solutions are from the Briefing Room again on BBC Radio 4 :
The staffing crisis in the NHS https://www.bbc.co.uk/sounds/play/m001bbxm a counterfactual to Mr Zaranko’s assessment of the staffing situation (it is way more complicated than just gross numbers and there is a long history of understaffing).Are there any quick fixes ? https://www.bbc.co.uk/sounds/play/m001gx1s the short answer being “No”.
I agree with Martin Bollis that building a new health delivery sytem from scratch with a completely different funding mechanism is unrealistic and eating this elephant one mouthful at a time is the only sensible route. Unfortunately I don’t see any politicain with the required size 32 gonads springing into the boxing ring to take this on – it will be a proper marathon extending I would guess over 15 – 20 years.
I forsee just more rearrangement of deckchairs on the Titanic.

Last edited 2 months ago by Elaine Giedrys-Leeper
Peter Stephenson
Peter Stephenson
2 months ago

Nice one Ian. But does anyone believe that rejigging the national milch cow will involve anyone but the backhanding, mutual backpatters who buzz in & out of the revolving doors of power, feathering their own nests while listening out for the next woke tune to dance to?

mike otter
mike otter
2 months ago

The worst side effects of NHS’ deification are that people who wipe bums, wash the sick & hand out pills think they are owed £50-60k+ pa, and those that shill for big pharma are worth 120-200k. The NHS managers are on big salaries or contract rates too compared to real world, and i don’t begrudge this as much as i do for the technician level – eg doctors, nurses et al. What is clearly wrong is the number of managers and layers. A Spain /Suisse/German model will come, but when and at what cost in health and £ terms?

Last edited 2 months ago by mike otter
Alan Thorpe
Alan Thorpe
2 months ago

Socialist systems cannot be reformed, only closed down.

Milton Gibbon
Milton Gibbon
2 months ago

Great article. More like this please Unherd (solutions not problems).
A few points for the author if he ever reads this far down the comments. First he says that we are tipping our money down a black hole but then at several points demands more spending pledges – especially in social care which he wants to see folded into NHS spending equalling, surprise, surprise, more NHS spending! Either wholesale reform (and subsequent cuts in budget) is the answer or everything is fiddling around the edges. If the paperless drive has taken a decade to deliver and it still isn’t finished then there is a good argument for letting it all collapse and building again from the ground up? Second, why was there no mention of the biggest proposed shake-up of social care in a generation with Theresa May’s disastrous pay-through-house-sales idea? It was so unpopular with the public but looking back it seems the most clear-eyed and fairest way of funding what seems (to a young person) to be ever expanding senior care sector. I am against euthanasia but could get on board with the Ezekiel Emanuel idea as long as the decision was made by someone under the age of retirement. I don’t think that the euthanasia nuts would get on board with this however – as in go there and no further. Lastly, why should care workers be paid more than a supermarket stacker? One is clearly a more productive member of society – feeding both the working age population and everyone else. This is capitalism at work. If people really cared about their old age care they would save up for it so that these people weren’t paid a pittance, but they don’t, they blow their pension pots on expensive holidays in their early retirement instead (with potentially 30 years of life left). Choices.

Sandy Henderson
Sandy Henderson
2 months ago

Deleted

Last edited 2 months ago by Sandy Henderson
Diane Tasker
Diane Tasker
2 months ago

BBC’s ‘More or Less’ 18 Jan on NHS – stats are shocking ….and inexplicable!

James Kirk
James Kirk
2 months ago

I’ve never seen what there is to be envious about other than in its original form when it was a safety net to catch the poor and the sickly. People did not live as long then and often died undiagnosed or without the means to treat them. Cosmetic surgery was in its infancy and heart surgery rarely survivable. Cancer was a death sentence.
Take a leaf out of veterinary care’s book. If you have the money, pay for it. Limit the private sector to how much they charge.

Steven Farrall
Steven Farrall
2 months ago

De-nationalise the Damn’ thing and issue everyone with ‘health vouchers’ and let us all sort out this mess.

Seth Edenbaum
Seth Edenbaum
2 months ago

First starve the NHS then say “Look it’s dying!” Brilliant.
“Take out Greater London—the prosperity of which depends to an uncomfortable degree on servicing oligarchs from the Middle East and the former Soviet Union—and the U.K. is one of the poorest countries in Western Europe.”
https://www.barrons.com/articles/italy-without-the-euro-would-not-be-argentina-or-turkeyit-would-be-the-u-k-1527078883

Billy Bob
Billy Bob
2 months ago

I would be interested to know where the author is getting his figures from. Every piece of info I can find on Google seems to suggest that the UK spends around 20% less per capita than France or Germany (who he compares it to) on its health system, and this was as high as 33% only 5 years ago. I’ve also had the pleasure of dealing with Hinchinbrooke, and after it’s experiment it was an absolute hellhole. They may have found millions in savings, but that seemed to have come from no longer actually treating the patients.
I am however pleased that he didn’t resort to the lazy reporting of it being too top heavy, as the foreign models spend more on admin but tend to be more efficient, maybe because it frees the doctors from tedious paperwork.
I think the NHS does well with the limited funding it has, however we expect much more from it than other countries do from theirs and on a much more limited budget. There’s no doubt reform is needed however

Stephen Walsh
Stephen Walsh
2 months ago
Reply to  Billy Bob

Comparisons of that nature are distorted by movements in exchange rates. Sterling weakened by up to 20% vs the Euro between 2016 and 2018. While health expenditure was rising in GBP terms it was falling in EUR terms and therefore looked to be falling relative to France and Germany. This was misleading. What matters is expenditure expressed in purchasing power parity. Now Sterling has recovered somewhat, but that doesn’t mean health expenditure is rising relative to Eurozone countries in any meaningful way. As I understand it, UK public health expenditure is comparable to its western European peers, but private expenditure is lower.

j watson
j watson
2 months ago
Reply to  Stephen Walsh

Yes that’s about correct on combined expenditure. but of course a percent or two against GDP has a massive multiplier effect over 10-12 years.
The data is v clear on us having less doctors, nurses and care workers per capita though. We are significantly lower than likes of France, Germany, Netherlands etc. Now that might be worsened by us not spending what money we have on the right things but even then you could sack every senior manager and not have enough to make up the difference.
In the Care sector though that argument won’t apply, it’s much more linear dynamic with how we fund social care. Fund less = Pay less = Provide less. And then if Social care malfunctions you generate a whole series of inefficiencies back up stream as hospitals and primary care have to compensate and compromise other activity as a result. Now if we could sort Social Care we might just find our NHS does much better on VFM too.

Martin Bollis
Martin Bollis
2 months ago
Reply to  Billy Bob

I thought this was an excellent article but that statement did stand out and made me slightly question the impartiality of the piece.

The actual words are:

“This pivotal report also found Britain spending almost the average on health for rich nations.”

“Undefined rich nations” and “average” are malleable terms in this context but didn’t damage, for me, the overall argument.

Billy Bob
Billy Bob
2 months ago
Reply to  Martin Bollis

I agree, the numerous problems with the NHS are well documented, the worst of which being a lack of social care to discharge patients to. This blocks beds, which in turn creates queues for ambulances as they are unable to offload those they pick up.
However I find comparisons to other nations healthcare systems are often blinded by ideology. Those on the left always compare it to the shambles in America which costs taxpayers a fortune and offers no cover, while those on the right compare it to the French or Germans yet fail to mention both spend around a fifth more per person on their systems (and the French only covers 80% of the costs I believe).

Julian Pellatt
Julian Pellatt
2 months ago
Reply to  Billy Bob

The Australian healthcare system seems to be very good overall. I have family and friends who live there and sing its praises. Ditto Canada.

Last edited 2 months ago by Julian Pellatt
Mike F
Mike F
2 months ago
Reply to  Billy Bob

I would imagine the author is referring to percentage of GDP spent on health care, by which measure we are pretty average. You can only spend what you have, and if we could improve productivity we’d be able to spend more per capita on health than we do now.

j watson
j watson
2 months ago
Reply to  Mike F

Sort Social care and NHS productivity automatically rises significantly.
What we’ve got is a public policy failure to address one system – Social care – rebounding on another, Health Care.
Try getting a patient who needs a 2-3 times a day package of care discharged so you can use the bed for a cancer op. You’ll wait weeks for the assessment and then provision of the care package because Social care capacity has been crippled. Hence a bed where you might have cycled 3-5 operations and related hospital stay through it has been blocked. Extrapolate that thousands of time every day across the country. Then after discharge the care package fails, person has a fall at home trying to wash themselves when the care worker doesn’t arrive and they get re-admitted to hospital with a fractured hip and subsequent infection. And repeat.

Billy Bob
Billy Bob
2 months ago
Reply to  Mike F

We are a whole percentage point behind the Germans though. If you look at it in terms of military there is less than a percentage point between the UKs and German armed forces, but in terms of equipment and ability they are poles apart.
An increase of 1% of GDP to the healthcare budget to bring it in line with the Germans would see spending on healthcare increase by around 20%

Last edited 2 months ago by Billy Bob
Anna Bramwell
Anna Bramwell
2 months ago
Reply to  Billy Bob

Could you tell me where the figures on admin come from? NHS digital has 48% nonmedical staff, while its figures for med8cal staff include paramedics and auxiliaries. Germany spends 10% on management, and has many times the number of nurses, doctors and beds, with a decentralised system. Private hospitals in the UK spend 10% on management, the rest on medical staff. Italy’s NHS costs way less than the NHS per capita. They use pharmacies a lot, particularly to make hospital appointments following a doctor’s prescription ( their computer systems cover all hospitals in in region). They also make small charges for hospital tests and outpatient treatments. . I can call my GP in Italy and get an appointment immediately. Beds available 8n the UK since 1984 have gone down to an amazing degree, mostly because of the closure of small hospitals and convalescent homes. It can be hard to compare health systems because structures vary, but my experience of four European systems has been very positive.

j watson
j watson
2 months ago
Reply to  Anna Bramwell

Think we’ve been over this one before. Two different data sets not measuring the same thing.
The NHS 48% includes all HCAs, catering, cleaning, portering, transport, receptioning, sterilisation units, basic HR & Finance, IT service desks, facilities management etc etc. Management is c4%, albeit always depends a bit on what one deems ‘management’.
As everyone will appreciate Germany doctors and nurses aren’t making the dinners, cleaning the floors etc etc. You get the point.
You are right though in a number of euro countries you could get a primary care consultation today without great difficulty. They have significantly more doctors per capita though and that makes a big difference. Yet we can still learn something for sure.

Frank McCusker
Frank McCusker
2 months ago

The private sector is not fit to run a public health service.
See my blog on why the private sector will make a b***s of the NHS:
https://ayenaw.com/2020/07/30/asset-stripping-the-nhs/

Dominic A
Dominic A
2 months ago
Reply to  Frank McCusker

Correct, but for the wrong reasons – the private sectors (management) that the NHS hires fail for two major reasons: they operate in a false market, where the usual market discipline and incentives do not apply; and because the client is incompetent – the fake private sector runs rings around NHS management.

Peter B
Peter B
2 months ago
Reply to  Frank McCusker

I’ve read your article now and the first 80% is pretty good. It reads well too. I think you rather ruin it by going into an unrelated and quite unecessary anti-Tory and anti-Brexit rant at the end – you claim and appear to be moderate and then spoil it with that. There is no great difference between what Blair’s Labour and the Tories have done on health (remember Labour were big on PFI and private equity involvement). You should also ask yourself if any sane investor would want to buy the NHS.
Apart from that, you don’t address the obvious point that a more mixed healthcare model seems to work in most of the rest of the developed world.