So the NHS has long gone

[DarkKarmaIlama]

At what point do we think the government will do something about the massive elephant in the room the NHS has fucked off out of the window and is never returning.

This healthcare no man’s land is quite frankly terrifying. What are your predictions on this? All I keep reading is “it will get worse”. Can it actually get any worse?

If they set up a paid service, desperate people would pay for a quick response in a really serious situation. Thus reducing the pressure on the free service. When my relative was lying on the floor with a broken hip I’d gladly have forked out a couple of thousand to get an ambulance immediately.

Not always in Scotland! Area dependent, might be better into the central belt but in Aberdeen, several GP surgeries have closed and they just can't get the GPs. My mother was given a follow up GP appointment for 4 weeks time after being discharged from hospital following a stroke and having concerns about her blood pressure. The GPs are impossible to get hold of and are presumably massively overworked.

We have not found the NHS in the Highlands to be very patchy indeed, negligent in several occasions. A family member would be alive still if they lived where we live in England. Another one wouldn’t have had a bodged operation in the wrong side of their heart. Yes, really.

Just to respond to the people who are saying we need to expand medical school places:
I'm a GP and also work as a senior clinical academic in a medical school, with responsibility for some of the clinical placements.
Medical school places have expanded massively in the past 20 years. Student numbers have increased on all existing courses and there have been several new medical schools. We still get a lot more high caliber applicants than we have places for.

The rate-limiting factor is clinical placements. Doctors need to be trained by doctors, and in the clinical environment, for a significant proportion of their degree. We are already replacing as much as we can with simulation, but we are struggling to place students in clinical areas with high workload pressure (which is most of the NHS these days, but particularly general practice, A&E, psychiatry and acute medicine, which are also the areas where we will need most of our new doctors to work) as the same doctors who are doing the heavy clinical workload are the ones who have to train the next generation.

The major issue is people leaving once they're trained. Some of this is junior doctors seeing that they can have better pay and quality of life in other countries/jobs and leaving, but most of it is experienced consultants and GPs either retiring early or reducing their clinical sessions per week due to the ridiculous situation with the NHS pension scheme, which essentially penalises senior doctors for working full/more than full time to the tune of a 4-5 figure tax bill each year.

Also lots of GPs in mid-career are choosing to reduce their sessions to make their workload manageable, as a normal 'full-time' workload (8 sessions clinical, 2 non-clinical) equates to about 90 hours a week. There is no other mechanism for limiting incoming workload in general practice. There is a lot of burnout and 'moral injury' in a system where doctors are increasingly unable to care for their patients in the way that they want to, and many feel their practice is unsafe.

would it be possible to second some of the pupils overseas for part of their clinical placements/medical training? Expensive but surely better than this? Costs covered by the government (given how much we spend on NHS, this would be drop in the ocean). Mainly to English speaking countries- Ireland, Australia, Canada, New Zealand, Singapore etc

@socialmedia23 other countries' health systems are surprisingly different in terms of clinical protocols, and have different burdens of disease. Most students do a medical elective abroad at some point in their course already, but it doesn't really train them to work in our system.
A far better solution would be to fix the NHS pension issues, so that our experienced clinicians could provide additional sessions for training students without risking a massive tax bill.

Which you'd think would be pretty easy - allow doctors to decide what percentage pension they save for - problem is unlike private companies who actually put the money into a scheme, the Gov only notionally puts money away - so allowing doctors to decide whether to take the cash rather than put it in their pension is going to cost more money for the Gov now. The other option is to allow doctors to opt out - many would be better off receiving no pension payments at all - are they allowed to opt out? Not that I'd expect the unions would be happy with this arrangement.

There's no link between paying NIC (which is a tax, not insurance) and healthcare. Only about 20% of NIC contributions go towards healthcare, most of the NIC contributions go towards state benefits inc the state pension.

Before IR35 was imposed on the NHS around 4/5 (?) years ago, doctors could do locum work etc via their own limited companies which was just simple pay, not contributing to their pension scheme, etc. A lot of retired GPs set up their own limited companies to continue doing occasional shifts in their old GP surgery to cover staff holidays/illnesses etc. Because of IR35 they can't do that anymore, so those older workers do longer do any work because the tax/nic/pensions implications far outweigh the benefits of working.

The IR35 issue has caused massive problems not just in the NHS - the only way we can hire a contractor now is via payroll on zero hour contracts - we are then subject to very complicated holiday arrangements, as a consequence of the Harper Trust versus Brazel ruling last summer...forget the tax benefits - that could be easily fixed to ensure contractors were paying the same tax as payroll, it's the contractual issues that are making things a very complicated nightmare. Efficiency in business is not a priority for this Gov - they were too busy looking the other way.

RE: NHS pension scheme
This is a defined benefit scheme with fixed contributions on all salary up to full time (not on additional sessions) - for senior docs this is 13.5%.

There is no 'pension pot' as contributions are used to pay for current pensions, however each member has a 'notional pot' which is 'increased in value' by CPI+3% each year in addition to contributions. The value of this notional pot bears no relation to the actual pension, which is based on final salary (pre 2010) or career averaged earnings.

The cap of £40,000 per year increase in value of pension (which was brought in to stop high earners putting loads of pre-tax income into pensions as a tax-avoidance measure) can be managed with defined-contribution or SIPP pensions by reducing contributions, but this isn't an option in the NHS pensions scheme as the government need that money to cover current pensions.

This means that a mid-career (mid-40's) or older consultant or GP can easily end up over the £40,000 limit per year (especially when inflation is high) and with a large tax bill for money that they can't take of the scheme and will never see the benefit of. There are three ways to deal with this:

1. Opt out of the NHS pension completely, but it's a good scheme so people don't want to do that.
2. Opt out for a few months every year, then opt back in. This is a big administrative faff and the pension scheme is difficult to deal with (Capita runs the service!).
3. Reduce clinical sessions, so that you pay contributions on a part-time salary. This doesn't actually reduce their income much, as if they can go over the £40,000 pension limit then the tax bill is often greater than the income they earn for the extra clinical work. For doctors who are in their 50's and have more-or-less paid off mortgages and grown-up kids, and who are tired from working in a broken system, this is the most appealing option. Once they have done it (and realised the benefits of a better work-life balance) they are unlikely to ever go back to full-time clinical work.

We all know that the NHS pension is a good scheme, but the vast majority of doctors already do considerable 'unpaid overtime' and no-one is willing to pay to work.

Agree 100%. The alleged tax benefits could have been VERY easily solved in other ways.

In fact, to a large extent, it was "solved" a few years ago by the extra tax imposed on dividends which makes the tax paid by the PSC director/shareholder very similar to the tax/NIC suffered by an employee on similar wage levels when you factor in "ALL" taxes such as corporation tax and income tax combined.

Diverse groups, including accountants, federation of small business, and other business associations, warned successive governments repeatedly about IR35 which is the wrong tool to deal with the problem, yet, from Brown onwards, Chancellors have ignored those who understand the reality at ground level, and persisted with something that would never work.

It's a common theme, isn't it, with politicians and senior civil servants (mandarins). They ignore the people at the sharp end who understand the problems and have the answers and they persist with making their own "answers" which inevitably don't work, cost a fortune and end up being scrapped. Latest example being "making tax digital" for the smallest of businesses which has, again, been "deferred" for another couple of years, which is the latest delay in a long succession. Just like IR35, accountants know it won't work, know it's not the answer to the problem, have offered alternative "solutions", yet the Treasury mandarins just carry on chanting "la la la" covering their ears, with their eyes on early retirement and their knighthoods!

With the increase in Corporation tax this year - I doubt there will be much difference at all in the tax paid by off-payroll and payrolled staff - but after the monumental screw-up by Liz Truss, no one is going to touch areas like this - it was the only good thing she did.

Yes
we're at the second generation of senior mgmt idiocy now

all those people wanging on with blue sky thinking twenty years ago...it has filtered down, I think, so we have two whole generations of workers with no interest in the practicalities.

According to that twat Daniel Finklestein in the Times today - things aren't that bad and we just need to be positive and optimistic - start with a smile. This is the problem - fucking optimism does not solve problems. Acknowledging they exist and doing something about it might sound dull and practical but that's what we've been missing.

Remember the fiasco for baggage when Heathrow Terminal 5 opened? Exactly the same thing - baggage handlers told seniors there was a problem and they were ignored.

Politicians and mandarins only listen to vested interests, i.e. the big firms mostly with products/services to sell. They don't listen to the mere mortals at the sharp end who actually know what the problems are and know the answers!

Take "making tax digital" for income tax. Accountants knew in 2015 when it was first announced that it wouldn't work and wouldn't answer the perceived problems it was aimed to solve. But instead of listening to grass roots accountants, they only listened to the big software firms. Now, it's years past it's original introduction date, and just been delayed yet again and now the smallest of businesses have been told it won't apply to them (finally, only 7 years after accountants asked for that!). How many millions/billions have been spunked by the Treasury and HMRC in developing policy and then developing computer systems that simply don't work, and almost certainly will be scrapped? Parallels with the "big" NHS database that cost millions/billions and ended up being scrapped?

Until they can do the simple stuff, they shouldn't be doing the big stuff! And that means that they need to start listening to people at the sharp end who are doing the work day in, day out! For the NHS that means properly listening to grass roots staff, not just doctors and nurses, but also the administrators, receptionists, etc who are the ones who see and have to deal with the day to day issues!

'Until they can do the simple stuff, they shouldn't be doing the big stuff! And that means that they need to start listening to people at the sharp end who are doing the work day in, day out! For the NHS that means properly listening to grass roots staff, not just doctors and nurses, but also the administrators, receptionists, etc who are the ones who see and have to deal with the day to day issues!'
Amen to that @Badbadbunny! Do you think it'll ever happen?

Sadly, no. For decades, politicians and mandarins have ignored "normal workers" and prefer to pay millions for consultants and other "experts" instead.

And we see the consequences in day to day life in almost all areas!

@Liebig , over in the Chat thread today, there's one running about waste, inefficiency, duplication and other routine moneypits within the NHS. It simply isn't true that all it needs is money.

You are right the current goverment would rather privatise the NHS. Problem is if they do then people who cannot efford health insurance what happens to them?

Was that rhetorical ?

Over in chat is a shorter thread full or people who would like to convince you that it dreadfully inefficient despite evidence to the contrary

That may well be true.. though i'm not sure all MN posters are truthful and don't make things up.

The NHS scores highly on efficiency in comparison with other healthcare systems so i'm not sure why there is all this "apparent" waste?

DD tells me of shocking over spend with the privatised elements esp on medical aids for living at home (for those able to claim)

This is an old survey 2018 but the efficiency stuff should still be relevant but what stands out is low numbers of med staff and equipment/scanners.

www.nuffieldtrust.org.uk/news-item/nhs-receives-mixed-scorecard-in-major-analysis-of-international-health-systems

@Alexandra2001the other thread wasn't talking about efficiency in medical procedures which I accept is good, but about stupid wastage across routine estate management like thermostat controls running so hot that windows had to be open in winter, door handles repeatedly falling off after incompetent maintenance and general procurement failures, especially over-paying for office supplies.