To think the time has come to abolish the NHS healthcare model

Australian here. So thankful for our healthcare model. Can get to a Dr generally either same day or next with either a face to face appointment or phone call -your choice. None of this wait all day for a phone call rubbish or sitting in a phone queue all morning to not get anywhere. No restrictions on where you go depending on where you live, it’s your choice to go to any Dr if they have availability which a lot do. We pay to see a Dr but it’s subsidised by the Government . Low income earners and Pensioners are generally free. We can attend a public hospital for emergencies for free (contribution to public health is via our taxes). You can also pay for private health if you wish to expedite non emergency hospital type surgery. I would be an anxious mess living in the UK not having reliable access to medical care.

up until recently your position has been that the delivery model is fine, but the NHS needs more funding and that’s what’s broken

Completely untrue, you’re confusing me with someone else. The delivery model has been broken for a very long time and it needs radical review and reform. Obviously that will need investment. The funding model is fine, everyone pays something now through taxation. Even those people below the income tax threshold pay tax in the form of VAT, fuel tax, etc. Reforming delivery is a gargantuan task by itself, we can’t afford the distraction of upending the funding model.

I think you need to decide whether you think the delivery or the funding model is broken…up until recently your position has been that the delivery model is fine, but the NHS needs more funding and that’s what’s broken. But based on what you have written in this post, you now think the delivery model is broken, and the funding model is fine (but presumably needs more funding).

I thought it was fairly obvious how the social insurance funding model used by European countries to deliver better outcomes for patients is the check. The state runs the social insurance, deducts money from tax payers and controls the funding. The social insurance scheme pays the providers. The healthcare providers are on the whole either not for profit or private businesses. They are successful by delivering quality healthcare. But they don’t have a blank check to charge whatever they like, because, there are many suppliers and the social insurance scheme has the buying power. In addition the framework of what services is provided / paid for / charged is overseen by an independent organisation.

The other advantage is that is does begin to decouple healthcare from politicians, who are woefully under equipped to have any say in it. One organisation (a little like NICE) sets out what the system needs to support. The social insurance scheme sets premiums / contributions on a whole country basis so everyone pays something, and the combined contributions create the social insurance fund. Meanwhile, delivery is provided by motivated individuals and organisations, who have a vested interest in providing good service, facilities and outcomes because they better they are the more patients they are likely to attract. The existing private health cover can exist alongside, though some may decide that they no longer need it.

I know that’s not how the NHS works…but it is how world class healthcare is delivered. Why are we not entitled to world class healthcare, just because ‘NHS’…?

£3billion spent on nhs dentistry - that’s not tiny!

It may not be tiny it’s still a budget “cut to the bone” which is why NHS dentists are as common as rocking horse shit.

www.bda.org/media-centre/nhs-dentistry-sees-biggest-fall-in-budget-in-decades/

Pharmacists are doing more and more, certainly not just handing out gp prescriptions. They’re doing more and more of issuing drugs etc themselves plus giving jabs etc.

£3billion spent on nhs dentistry - that’s not tiny!

GPs issuing prescriptions are mostly self employed, ieprivate, and some have their own pharmacies owned by the gp partners!

I have always believed that the nhs should not be left to the whims of politicians. It should be other/ out side of political control. Run by medical professionals who have to be clear and transparent in their actions. Funding should be set by act of parliament which cannot be altered other than increase (the only parliamentary input). Oversight would be via non political, non profit body.
The health of the nation is not the plaything of political parties or big business.

If you insist on NHS medics making the diagnosis before the private sector can deliver the care - you will hit the same bottlenecks. There are not enough of them.
Increasing the workforce will take time and funds.

Let's see what the Darzi review comes up with

How is the funding the check? It seems to me the insistence on changing the funding model is what’s ideologically driven. The delivery model is broken and now you seem intent on breaking the funding model too.

The services you mention involve very little NHS expenditure @taxguru. NHS dentists are like unicorns, opticians only provide NHS funded eye tests to a small part of the population and glasses to an even smaller one. Most elderly people buy their hearing tests and aids privately. Pharmacies fill prescriptions written by NHS doctors. None of that involves writing private providers a blank cheque.

But you’re not writing a blank cheque. That pure hyperbole. The check is the funding mechanism. It works perfectly well elsewhere in Europe and delivers better patient outcomes. To ignore that is to put ideology and politics ahead of public health and patients.

You are, either deliberately or though lack of understanding, conflating a pure private system like the US with a hybrid public funded / private and not for profit delivery model to try and support a position that isn’t really defensible, because it’s ideology driven.

NHS dentists have done it for decades. They decide the work needed and claim from the NHS. As do opticians for eye tests and nhs glasses. Ad do spec savers for hearing aids. Same with pharmacies. All mostly private firms claiming nhs funds. NHS do spit checks to check the claims are valid. Years ago I had to go to a different dental surgery where some kind of auditor checked my teeth to make sure my own dentist was doing the right course of treatment before it was authorised.

But why should they be employed by the NHS?

Because otherwise you’re allowing a private provider to write themselves a blank cheque for taxpayers’ money. It couldn’t be more open to abuse. It’s nothing to do with politicisation. Yes, there needs to be a review of delivery, it’s badly needed and that review has to include checks and balances on the finance otherwise it will go the same way as the utilities have. Look at the water companies.

But why should they be employed by the NHS? That means that heath care becomes more becomes more politicised.

If we look at successful healthcare services in Europe, the decision making clinicians are generally not employed by the state. But in almost allcases the funding, via various types of insurance/social fund provisions, is. History shows that our approach, whether we starve it of cash or throw cash at it always deliverers worse outcomes for patients than other European models.

There’s a particular British arrogance in assuming that our way is the best way - not just in the NHS , and a peculiar ‘little England’ approach to change. That’s to say, we don’t like to. There needs to be a root and branch review, and it needs to separate funding from delivery. And it needs the politics taking out and patient needs put first.

Let's be clear - clinicians and patients should decide about interventions - not 'the system'

Quite right. And those decision making clinicians should be employed by the NHS. No wonder it’s a bottomless pit. That’s bloody scandalous. Hopefully this model will be changed as part of the coming review because that’s a very obvious way of improving value for money.

I don't think- I know - because I work in the system. It is effectively a blank cheque, which is why there is data on how expensive it is to deliver NHS care this way. And also cherry-picking, because the private provider needs to be a able to turn a profit.

Your ICB may decide they need to provide hip replacements or cataract surgery to the people of Bromley for example. The local hospitals cannot deliver it due to lack of capacity. Joe Blogs and Co set up a company and kit out a building with consultation rooms and a theatre, and pay consultants to assess and operate. Patients from Bromley are referred by their GP and assessed by the consultant. Treatment offered is according to NICE guidance but that is it.

There isn't some alternative threshold beyond that and is dependent on the diagnosis of the clinician making the assessment.

NICE sets standards - not NHS. And many interventions are based on the patients symptoms - which is subjective. Let's be clear - clinicians and patients should decide about interventions - not 'the system' - so I absolutely agree with the way it is done. I just wanted to clarify that the decisions about who needs intervention is not top down - it is (as it should be) based on the clinicians assessment

•Why do you think the NHS determines the diagnosis?•

Because it sets the standard for the level of diagnosis it will pay for. Private providers don’t have the level of autonomy you appear to think they do. According to you they can write a blank cheque.

Of course not. The diagnosis is not authorised by the NHS. The private provider assesses the patient, determines the diagnosis and treats them. Why do you think the NHS determines the diagnosis?

There is a difference between private providers who are there to catch up on wait lists - so diagnosis already determined and they are essentially clearing a backlog of already diagnosed patients. Then there are private providers who are paid to deliver care. They can be commissioned to do so but anyone with inspected premises that meets safety standards is able to open a facility and bid to deliver 'NHS' services

Of course it isn’t privatisation. Those surgeries are paid for with taxpayers’ money via the NHS which is only authorised after an NHS diagnosis. Privatisation is the bulk of UK dentistry now where there’s no input from the NHS and no public money involved. It’s not the funding model that needs review, it’s the delivery model.

Precisely this.

Huge sums of money are going to private contractors, however they are taking the 'easy' cases

Many, complex cases get thrown back to GPs and NHS services who have less funding available due to the contracts

Waiting times for complex cases are increasing as a result

But if 60% of an NHS service (cataract surgery for instance) is performed by private providers - isn't that wholesale privatisation? And if we have more of that as is planned for orthopaedic surgery etc - isn't that wholesale privatisation?

I agree that most people do not care who is delivering the service as long as it is efficient, safe and high-quality. However, I am not convinced backdoor privatisation delivers cost-efficiency in the long run, which is why an open and transparent review of the funding model is required. To be clear - a review of the funding model is required because the current one does not work and is not the funding model being utilised in an exponentially growing proportion of the NHS.

The "plusher surroundings" is a red herring.

When my OH goes private for his MRI scans, he couldn't give a toss whether the waiting room chairs are softer or he gets offered a coffee (they aren't and he doesn't!). What he cares about is the ability to easily phone to make a convenient appointment. What he cares about is that it's the only way to get an "open" MRI scanner because he needs a full spinal scan every year which otherwise means over 45 minutes in the NHS tiny tube which he can't tolerate, even with sedation. The NHS can't offer an open MRI scanner, so he has to go private to get it!

But yes, more efficiency is definitely a price worth paying too. The sheer luxury of being able to phone up easily the person making appointments (no long waiting times, no having to leave messages on an answerphone never to be returned), no having to call between 10 and 12 on the week when there's a full moon (ok slight exaggeration, but that's how it feels sometimes). Just call the number, discuss what times/days are best for you, they make a few suggestions, you choose one, email/text ping immediately confirming, and you're all done in a couple of minutes!

I don’t know why. Nobody working for the NHS has ever treated me as if they’re doing me a favour. The difference between the NHS and private providers for me has been immediate treatment in rather plusher surroundings.

But why @BIossomtoes can an outsourced provider provide their services conveniently, on a timely basis and with courtesy whilst the NHS can't. In my opinion it's a cultural issue and the NHS repeatedly falls down on service standards because of the entrenched view that the staff are doing the public a favour.

People aren’t saying that private providers in any part of the NHS is bad. They’re saying wholesale privatisation is, two entirely different things. Provided the cost is the same or less and the standard of the service the same or better I have no issue with private providers. The real problem, as you identify, is the absence of expertise in the NHS in negotiating contracts.

I earn just above minimum wage and I have problem with the NHS being privatised. It’s needed and it doesn’t have to be the USA system. People say that to scare people. It needs to stop.