To wonder if perhaps the answer is just to stop paying?

[Resurgam2016]

Listening to the radio the other day and there was a South African lady who was having kidney dialysis in the UK because she couldn't afford it in her home country. Apparently in SA they don't fund this treatment for the over 65's. There just isn't the money. She was a medical tourist but that is another issue entirely.

So what if we contemplated something similar to help 'save' the NHS? No treatment for life limiting conditions over, say 70 years. No treatment for conditions that are not life saving (so fertility treatment or breast rebuilding for example). Making people (or their relatives) pay for all but the medical care they receive (so food etc.). It's a horrible thought but maybe the answer?

FYI I have a chronic illness so might well be 'caught' under these new rules. I'm just wondering if it is 'acceptable' in SA why we don't debate it here.

I do think there is a nettle to be grasped. Every cause is worthy, yet when something is free at the point of consumption - there will always be abuse.

I read that health tourism is worth a very small percentage, but that small percentage is still half a billion pounds.

I also think it is very easy to get entrenched ideas about funding as this is a political football and a stick to beat parties up with.

However - we talk about under funding but spending has gone up, but then so have calls on the funding. The NHS is the 5th largest employer in the world and the largest in europe by a country mile. In fact according to wikipedia between 2010 and 2015 it gained 300,000 employees. It now employs 1.7m people.

In order for the service to remain - there will have to be root and branch reform.

• no more prescriptions for OTC drugs
• crack down on health tourism and charges
• charge for all appointments at outpatients and allow a claim back if they attend.

-introduce a charge for GP visits

• sort out the overly integrated supply chain there are huge opportunities to sort this out and savings to be made
• sort out the HR issues - more people are off sick every day in the NHS than are in the RAF - there a huge loopholes that wouldnt be seen in any other organisation
• de-couple external suppliers from the concept of "privatisation".

Some of the changes will be political dynamite but people have to realise that as a massively vertically integrated supplier it will have huge inefficiencies. -Getting outside suppliers to provide things will inevitably save money but will not be popular.

In 05/06 the NHS budget was 75bn
in 16/17 it will have spent £120bn.

for reference the replacement for trident will cost 31bn or enough to run the NHS for 3 months.

What has changed?

PFI

The idea of Gordon to built spanking new hospitals effectively leasing them is costing a vast amount - but it kept the spending off the books so he was able to splurge money on lots of shiny stuff knowing the bill wouldnt fall due until after the election. And they were off the national debt - so magic money...

Now- like it or not - the country has to pay these bills for years and as a result the country spends vast amounts more than it takes in. This deficit is added to the national debt. This debt is £1.8 trillion pound and costs 43bn pounds in interest each year (which due to the costs for things like PFI) just get added to the debt. So either we keep running up the bill like an out of control quidco spender or we pay off debt, reduce the deficit and make the money go further.

In order for the NHS to survive some shibboleths need addressing.

I think this can be done without disadvantaging those who cannot truly pay, the needy and the disabled. In fact that should be our priority - but the chipping away from all sides means there will never be enough to go round.

I wouldnt want to be chancellor - for every department needing more money, there is a special interest group. They lobby loudly and effectively and have the media on speed dial. At the same time, people who pay a lot of tax (see the squeezed middle) say enough! we dont see the benefit - the lobby calls for just a penny on income tax and my [insert worthy cause here] will be ok. Unfortunately, they are all worthy, they all need more money and we cant keep printing it.

Ah - i dont have the answers - but alas it is so very far from simple.

[btw i got the data from the net via google - so E&O excepted]

I have always wondered why we don't do an NHS lottery. Yes it isn't coming frim taxes but what a worthwhile cause.

@SomethingBorrowed

Germany operates a compulsory insurance system. Everyone is covered. You have an insurance card and present this when you are treated. No card, no treatment - except for emergency treatment. Care is free at the point of delivery as it is in the UK.

The big difference is that you carry on paying - according to your means - post retirement. So rich retirees pay. Poor ones do not. Also those whose income derives from property and investments also pay - unlike in the UK where NI is only paid on earned income.

The system has its pros and cons and is I would argue less efficent than the UK. But your rarely have to wait to see a doctor and if you obviously have a knee or ear or gynae problem you can go straight to a doctor specialising in that area. So the patient experience is better.

No health tourists in Germany except those who pay.

Surely a lot of NHS waste is because they have contracts with very expensive providers of essential hospital equipment and don't get the best deals (due to cronyism and corruption) and for example, hiring agency nurses who probably cost the NHS a lot more than simply by paying a decent wage and cutting out high agency costs? I remember a nurse friend telling me that they earn so much more working through an agency.

There seems to be reams of unnecessary bureaucracy, unworkable computer systems ("computer says no") and nurses/doctors milling around because they have to wait for the necessary paperwork etc. Why not look at the German model for a well functioning health system.

and the point about alternatives - i think of the most advanced economies - only the US has the fully private system - dozens of countries have free healthcare but manage it very differently.

The biggest barrier to sorting it out is political will. And the fact it is a massive massive supertanker - and they take a while to change course.

as for the "i paid my stamp". NI has always gone into the general pot of taxation. I think it was Bevan who said the secret of the fund was that there was no fund.

The people who paid back then were paying the pensions being taken out them. The NI being paid today is paying their pensions.

There is no, and has never been a fund. Even the final salary schemes have no fund - again the come from the government current account. The transfer values are what they are "worth".

The only will in this country is the Tory will to privatise the NHS sadly

MN jealousy bingo again, with the person very early on the thread who wants those who have 'income from property and investments' to pay extra as they don't pay NI.

Sorry, sweetybumps, property and investment are paid for by WORK unless you inherit. And work means paying NI. So your actual target needs to be all those who inherit. I hope you will ensure your children (if any) get nothing from you by this principle.

might as well say 'stop bothering to treat premature babies or young kids' as they've never earned and so are worthless. Happy with that? I hope not!

the taxes need to go up for us all. The personal allowance threshold has risen but tax rates above that need to rise. We've got lots more people in the house and so the cost of living has rocketed.

Also higher taxes on new cars, electronics and all the other buy-to-chuck stuff to encourage reuse.

My Dh and I would pay extra for evening and weekend appts....
I would also expect to pay if I missed an appt (like I do at the dentists and hairdressers!)

And yes to NI increase!

Mothertrucker - I dont think so - the problem is when someone (say a civil servant doing purchasing) is spending someone elses money on something they wont get utility from - is value for money at the front of mind - or is it just "it will do"?

certainly when i deal with government - they are nowhere near as hard a bargain as commercial customers. But I wouldnt say they are corrupt - just a bit soft. Not saying they get over charged in any form as they can drive big discounts for volume

rookie GP appointments are free at the point of use in Germany yes, and I've always been offered one on the day if I want or at a time convenient to me if it's non urgent and I can wait a few days.

I really would like to understand the thread about "privatisation".

perhaps instead of shouting its all a tory plot - how about suggesting what could be done with the 120bn better? (up 45bn since 05/06) since employing 300,000 more staff and spending all that money hasnt improved things, in fact it would appear to have made things demonstrably worse. So clearly more money and more people are not the answer?

when something is free at the point of consumption, demand will always exceed supply. Do you manage demand or constantly increase supply until you reach an economic event horizon?

Our local rag carried a story a few weeks ago after an FOI request of the local hospital paying £98 per hour for agency nurses, and I have a doctor friend who does agency work and often earns £900 per day for weekends. Needs to stop - bleeding NHS dry.

@special subject

No jealousy on my part. I have rental and investment incomes of my own in UK and would be impacted by any change.

My point is that the NHS should be funded fairly. Those who can pay, should pay. Those who can't pay, should not need to do so. And there is no good reason for entire income streams to be exempt. Why should a worker on £16000 pa be expected to pay NI when someone with an income of £100,000+ derived from pensions and investments does not? Why should an employee with a £100,000 income pay NI when a wealthy person who is not employed is exempt? It makes no sense.

And much property IS inherited. Any many others - myself included - have made a lot of money through investing in property and sitting back and watching the value of that property ratchet up. That money was not earned. And it is a travesty to pretend it was. It was not the result of hard work. It was pure luck. It is the only wealth in the UK that is not taxed. And our children and grandchildren are paying for it in the form of massively increased housing costs.

Some may pay tax on property portfolios when they die. But the majority will use tax avoidance schemes to ensure the amounts are minimal. Just look at what the Grosvenor estates have paid in death duties.......

The answer would be to stop voting in a party that has deliberately underfunded the NHS for the last 7 years.

notanewuser is right.

One of the biggest drains on budgets is the need to fund PFI agreements, taken out during Labour's first term in order to fund new hospitals and still keep to their 1997 manifesto pledge to stick to Tory spending plans.

These deals are crippling the NHS: for example, a building that cost £70 million to build will cost £350 million over the entirety of the PFI deal. Then there are the necessary alterations that come under the deal, such as widening access doors, replacing light bulbs, repainting ... in some cases, hospitals have been charged £15,000 to widen a doorway by two inches and £60 to change a light bulb.

What really needs to happen is for government to renegotiate these deals, or for these deals to be paid off upfront without penalty by central government.

I do not like to be politically partisan, but it was criminal what Labour did between 1997 and 2001 with PFI deals within public service provision.

PFI was never meant for that kind of endeavour; it was designed for projects like the Dartford Tunnel and the Channel Tunnel where commercial income streams would fund the deal, rather than the payments coming from public expenditure.

There does come a point where people are being kept alive by pills and potions in their 90s, barely existing, miserable with no quality of life. My nan was one. When she eventually died it was a relief as she had been more or less a zombie for 5 years.

I do think she should've been allowed to fade sooner. Controversial maybe but it's how I see it.

Course you need a socialist government, and you buggers keep voting Tory

The last Labour government we had is the cause of most of the NHS problems now. If they didn't have the PFI debt that Brown saddled them with they would be ok. The debt interest they are paying is crippling.

Lohengrin makes a lot of sense

in some cases, hospitals have been charged £15,000 to widen a doorway by two inches and £60 to change a light bulb

You don't need PFIs for that kind of stupidity - local councils are just as capable of it, even when open tendering is (supposedly) in place. The point seems to be that, shorn of any accountability or real understanding of what's involved, those responsible indulge in financial incontinence knowing they'll probably never be challenged on it

Which is why I don't believe money is the whole answer ...

I suppose there is an argument (not a very good one) that profits from these PFI companies will form part of the investments which pay people's private pensions....

Thats the trouble. It's all so complex and interdependent.

I wonder if we need to tackle this from the bottom up. So a movement to encourage more supportive community action and behaviour. A change to the idea that we (and by this I mean men as well as women) are responsible for supporting and caring for those in our families who are dependent be they very young children or very elderly adults and that it is not all about the state.

I would say the NHS is there to provide medical care to all but not to replace community networks of care and support which could possibly prevent the hospital admission in the first place.

I also think there needs to be more discussion on what quality of life really means.

I realise I can think this all I want and bugger all will change.

Good luck getting men to take more of a caring role when there is rampant sexism from a young age implanting in kids' heads the firm belief that there are gender roles which society supports and encourages... Girls are now allowed to do boy things, but it's a lot harder for the boy who wants to play with dolls or the young man looking to work in childcare or nursing.

Happens in the private sector too, Puzzledandpissedoff, alas. Client capture by the outsourcing supplier is a really big issue in the IT industry and IIUC the construction industry.

It's a common game of chicken: "Just how much can we get out of the client before they're so pissed off they'd rather paralyse their build/business for the 6 months it'll take to unwind our contract and hand over to a new supplier."

TBH I don't understand why this "free at POC" means so much, as long as you get your money back shortly after...

Well what happens if you don't have the money rom pay upfront at the POC? Not everyone will have that money available so should they just suffer because they can't afford to wait x amount of time to get reimbursed?
The NHS needs to be better funded. I would happily pay a little extra in taxes if I could guarantee that the money would go directly to the NHS.
Closing tax loopholes could also make more money available which could be spent on the NHS.
Cutting non essential treatments - IVF and cosmetic (but not reconstructive) surgeries would also help but wouldn't be popular.
Stopping prescriptions for cheaply available over the counter medicines and gluten free foods would also help.
All small measures but combined it could make a significant difference.

What I see in the NHS:
Committed staff who often earn the lowest wages giving hands on patient care usually done with humanity and care (=coal face)

Middle management running around trying to balance the books, file pointless reports, often providing a bit of hands on in their own area...stressed/resigned/defeated (depends how long they've been at this job) but fire fighting describes it.

Upper management having many, many meetings with many, many highly paid executives to decide strategies (idealists) they decide to tighten things up and commission some publicly work for their staff to make them 'work harder' 'value patients' etc.

Meanwhile coal face staff who do value patients are still missing breaks and not giving as much time to patients as they like because they just don't have enough staff.

Fire fighting managers dealing with the complaints, recruitment and HR issues caused by stressed understaffed depts. Responsible for cascading idealists 'good ideas' either in colour posters, talks or post it notes on the PC

Outside monitoring agencies having many many meetings with many many expensive highly paid executives (often travelling somewhere to do so...at cost and wasting time) Outside monitors agree that they need more data to identify scale of the problem and they also set new targets and decide on punitive measures for failure. (Ivory tower dwellers)

(Coal face staff still providing healthcare with humanity but lack resources, beds and staff to offer great care or find time provide the newly demanded data.)

Idealists meet to decide what they can do about these failures at the coal face. Lots of meetings with highly paid idealists. They decide to cut services and brief fire fighters about their failings.

Ivory tower dwellers decide that they need a committee to look at the problem and draft a report...so they commission lots of highly paid people to travel to regular meetings (hospitality included because they've travelled...) Takes a year

Meanwhile coal face still seeing patients...

Ivory tower dwellers decide they need a 'body' to oversee the work of the coal face and idealists because they are failing. Body will be highly paid specialists and funded to travel, meet and review evidence. Evidence to be provided by the failing stressy idealists in the same time as existing role.

Idealists juggle covering up failures whilst exposing problems and whipping coal face staff a little bit

Coal face staff workforce reduced as several have said fuck it and left.

Ivory tower report that this staffing crisis will be resolved by developing the workforce so that an unqualified person can do the work of a highly qualified experienced person.

They commission a training provider to develop a training package. This is reviewed by many highly paid specialists at many many meetings (hospitality provided as they have all travelled)

Coal face staff would love someone else to provide coffee and biscuits in a nice hotel and chat for a bit but since they don't get breaks it would be pointless....

Training package eventually in place at great cost because setting up new Skills for health courses doesn't come cheap. They recruit highly paid specialists to fill the roles. They also recruit highly paid quality assurers to assure high quality training so that junior staff can safely fulfil the roles of the experienced highly qualified staff who said fuck it and walked... They design systems and processes to monitor the work of the junior staff.

They require the idealists to administer the QA processes. The idealists need the coal face workers to train the junior staff. No extra time is given. Newly recruited, under qualified staff in post do their best but they aren't experienced highly qualified staff so it isn't the same but if partly fills a gap.

Ivory tower people congratulate themselves and meet at a hotel with hospitality provided to do so and report back.

This is the failing I see. The complete refusal to recognise that money spent on staff who actually give face to face care to patients is cheaper than all the money wasted on strategies to manage the issues caused by not enough money spent on staff who actually are face to face with patients.

The money is targeted right at the top...not in the middle....way above ....at NHS England, Public Health England, DoH, Skills for Health and so on.