What are your thoughts on privatising the NHS? Good or bad?

[Supernova23]

I would also love some input from those who have lived in countries that have private healthcare systems. Is it better or worse in your country?

For context, I love the prinicple of the NHS. I’m an NHS nurse. I also like a massive chunk of NHS nurses and doctors, think of looking for a way out on a daily basis. The lure of going abroad tempts me daily.

But as we know, we live on a tiny over populated island. People are living longer and getting sicker. People also abuse the system on a daily basis. I’ve been kicked, hit, spat at, called every name under the sun. I’ve been threatened numerous times. Me and my colleagues have been threatened by a maniac with a machete.

We are haemorrhaging staff on a daily basis. People either leave or go off long term sick. I can’t blame them.

Patients are becoming more medically complex with multiple co morbidities. In the nicest possible way, advances in medicine has meant that people who would have kicked the bucket long ago, are now people kept alive due to modern medicine. People are also getting much, much larger; this makes them more complex to manage in every sense. Even with basic bog standard care. We frequently have patients so large it takes at least 4 people reposition them. You try finding 4 spare hands on the wards; it’s a nightmare.

In my hospital alone, every single ward has multiple complex long stay patients that have been on the wards for 6+ months. In some cases it’s a year or more. The cost of these stays often runs into the hundreds of thousands, perhaps even millions, and is obviously reducing the number of patients we can admit.

I could ramble on. The system has been at breaking point for years. Would privatising the NHS improve it? Or is that cloud cuckoo land?

@taxguru I hadn't thought about the vat. But it certainly makes sense for small businesses to stay under the Vat threshold.

I almost feel the whole of the taxation and benefits system the the UK is far to complicated and could do with simplification. Reducing the amount of admin costs from both the Governments side and the Individuals side.

It also means that my plumber won't take on an apprentice, so no young lad is going to learn on the job. Sole trader John, his real name, can't do more than one project without cutting his personal earnings by a third to pay the apprentice. So, no apprenticeship.

Work life balance is a different issue though; totally understandable and easier to achieve when you manage your own hours, or ask to go part-time.

I’m surprised at many people in higher paying jobs (a) able to choose to go part-time just like that, and (b) doing so deliberately to earn less money, especially as, by the time you get into higher paying positions you are generally not rigidly sticking to hours anyway. And cost of living.

I don’t get the bit about ‘losing’ VAT. If he were registered for VAT he’d have to start charging it (and would also be able to reclaim it on buying tools, equipment etc) but that would be on top of his current rates. I can understand staying below the VAT threshold to avoid admin, because it’s a right pain, but unless he thinks he won’t get business with VAT inclusive rates (unlikely) that seems to be a flawed decision.

It is work life balance AND tax motivated though. My work life balance wouldn’t be much different if I worked 10-20% more, but at a lower take home due to change in tax bracket for the incremental work it just isn’t worth it to me.

all of my female friend in high paying jobs went to 3-4 days a week when kids were young due to work life balance, and then realised what a minimal impact it had on take home pay once you factor in other benefits, so never went back to full time.

But you wouldn’t have a lower take home. Your mean hourly rate would be lower, and maybe that wouldn’t be worth it for you, which is fine. But it’s not as if you’d be losing money overall.

I’m going to stop after this one but this situation is just that the plumber’s business is not big enough to take on an apprentice. That’s all. And if he’s keeping it artificially low that’s on him (though if he’s doing it for income tax reasons he should remember that the apprentice’s wages and employment costs would be set against tax: he wouldn’t be paying him out of taxed earnings). You can’t blame the taxation system for this.

If you are no longer eligible for the 20% tax free childcare, you might actually be worse off if you are earning £102k than if you go down to £92k. FT nursery is £2k per month here.You’d be using fewer days so your overall bill would go down, you’d get the 20% off. You’d be paying about £15k per year not £24k. The net change in take home pay will be less than that (put it in a salary calculator).

It’s a specific set of circumstances, but people with children in nursery really are better off until their salary is substantially over £100k. It really is a cliff edge.

Yes, @NewFriendlyLadybird, up to a point. But the plumber can still only be in one place at a time, doing one job, and the apprentice will have to be present too. There's no shortage of work for plumbers; even the not very good ones are as busy as they want to be. The shift from sub-contractor, sole trader to small business is a big one, with a price in time and admin burden.

I know quite a few tradies, some now have substantial businesses with capacity for large projects, like new build estates. Most began to reach this point when they felt experienced enough to handle the planning, marketing, ledger and payroll, but lots just don't want to do so.

Don't you understand competition? Especially in the domestic market.

If there were two similar B&Bs, would you really go to the one charging £120 per night if next door were charging £100?

Or would you pay an electrician £1200 for some new sockets when another electrician quoted £1000?

Or buy a sandwich and drink from a cafe for £6 when another cafe nearby was charging £5 for the same?

If the non VAT registered business could up their prices by 20% and not lose customers, don't you think they'd have already done it??

You CAN blame the tax system for all the purely artificial cliff edges that are simply unnecessary and if removed or smoothed out would massively drive business and the economy to grow, take on more staff, encourage employees to work more hours (or at least not reduce their hours).

There are two many points in the tax/benefit system where you can be worse off by working more, or have high marginal tax rises/benefit losses of typically 70%/80% where you basically are very little better off by working more.

Of course I understand competition and know perfectly well that it’s not just about price.

I would take a tradesman’s being VAT registered as evidence that he had a lot of work and would therefore infer that his work was of high quality. Obviously I would also look at testimonials and ask around ( though I always ask for recommendations first as a matter of fact).

Competition on price alone just ends up as a race to the bottom.

@NewFriendlyLadybird i didn’t claim to be worse off financially by working more(though in some situations you might be), just that the tax cliff reduces my take home so substantially that I don’t feel like it is worthwhile to work. If I charge clients £100/hour and take home £75 as a general rule and have a nice life, I am not particularly motivated to take on a bunch of extra work where I only get £30/ hour or less depending on how it affects other benefit calculations.

most people are not trying to make as much money as possible after achieving a certain standard of living - if they were, there would be more people taking on 2nd and 3rd jobs because more work = more money. The larger point is that tax policy affects behaviours and can be a disincentive to work.

Not being VAT registered means the plumber will be able to charge less than companies who are VAT registered.

If he can get clients to buy materials they are paying VAT on them directly to the supplier but not paying VAT on his labour.

It's a business model that works for him. He might also be doing some slightly dodgy cash jobs that aren't mentioned in the books either.

I know Doctors, Lawyers, Accountants who all work part-time because working full-time and pay 40% tax and childcare just isn't worth the stress. Even once kids are bigger and beyond the childcare years it's there career has taken a hit, and their partner is often grades ahead of them so they stick with part-time.

It's been widely reported about hospital consultatants doing the same thing it's not worth them working 5 days a week.

People definitely make decisions based on taxation, and work life balance. There is definitely a point where having a few extra £££ in a month isn't worth it.

I have a friend who opted to change jobs dropping a grade and £10k, £4k was going straight to tax man, she reckoned £4k was going on travel cost, so £2k worse off less stress and 90mins a day less travel.

Absolutely this. We need a system based on how much you pay in and how much you look after yourself.

How many people do intense exercise 3 tunes minimum per week and eat 7 lots of fruit and veg per day?

How many are popping pills for Disbetes, blood pressure, heart conditions, cholesterol. How older people stop moving and become fragile. Young people puffing and panting down the street? That's why the NHS has a big problem.

"Having a lot of work" means nothing of the kind. Lots of businesses just engage random subcontractors when they have too much work, so no guarantee of quality at all.

Price competition is far more prevalent at lower end of the scale, i.e. small cafes, small guest houses, window cleaners, "one man" or mobile garage mechanics, sole trader plumbers, electricians, gardeners, etc. The kind of "business" who typically has lots of small customers, usually doing pretty small jobs/sales, and usually domestic customers.

It's a completely different market from the bigger firms doing bigger jobs.

Mrs Miggin's guest house in Morecambe isn't competing with the Holiday Inn or Crowne Plaza - it's competing with Mr Jones' guest house next door.

The type of electrical contractor who are typically doing commercial alarm fittings or rewiring a supermarket or hotel isn't competing against the one man band moving sockets or wiring in a new cooker!

@Needanewname42

He might also be doing some slightly dodgy cash jobs that aren't mentioned in the books either.

That's actually more likely for the VAT registered trader who'd be happy to accept "cash" for the customer to save the 20% and the trader to save more than 20% being the tax and NIC! Lots of VAT registered traders accept "cash for no VAT" which costs the country billions and it's getting more and more common and more traders are being more open about it.

The ones who aren't VAT registered don't save as much - they have nothing to offer the customer, so if they give a discount, it comes straight off profit, and they only save the tax/nic on the smaller amount.

"If we allow the NHS to fail, our economy will fail with it”

The Rational Policy-Maker’s Guide to the NHS presents evidence and analysis to demonstrate that:

1. The overall business model of the NHS is not only sound, it is the best healthcare model yet demonstrated in practice in an advanced economy;

1. The current serious underperformance of the NHS is the inevitable result of 13 years of underfunding – no healthcare system can withstand such levels of sustained underfunding;

1. If the NHS is allowed to fail, the economy will fail with it – the UK economy cannot afford not to fund the NHS properly.

The report was put together by a multi-disciplinary team of volunteers led by The 99% Organisation, and supported by Keep Our NHS Public, Every Doctor, the National Health Action Party and others. The authors have deep expertise in a range of relevant areas including NHS management, senior clinical roles, economics, and financial analysis.
The Rational Policy Maker’s Guide to the NHS includes results from a model which maps the inter-relationships between the health of the population and the health of the economy. It demonstrates how underfunding the NHS inevitably creates an increasingly sick population which in turn leads to lower productivity, and lower economic output. This results in less money being available for healthcare funding; and the downward cycle continues. A decade of this has been harmful; continuing with this policy would be a disaster.

The report further shows that the funding required to return the NHS to its pre-eminent position in relation to other leading healthcare systems need not involve punishing tax rises or risk inflation. After a short period of re-investment, ongoing levels of funding in the NHS will gradually return to 9% of GDP; in line with – or in fact below – most other advanced economies. The report also demonstrates that popular ‘fixes’ for the NHS, such as insurance-based funding or privatisation, are certain to fail to deliver what is needed – either for people or the UK economy. Using this analysis, the report gives policy makers clarity on how they can return the NHS to the position of best healthcare system in the world. And it shows that far from being an impossible task, it is in fact perfectly achievable.
https://99-percent.org/the-rational-policy-makers-guide-to-the-nhs/

Thanks for this, will have a read

Feel like so much of what gets claimed is just supposition and armchair theory that dovetails conveniently with whatever opinion / ideology was already held

You lost all credibility with that first point. If the NHS is the best healthcare model yet demonstrated, why has it never been adopted elsewhere?

my experience with it was shit before the tories came in - having lived globally for 20 years, my worst experience of a healthcare system was the nhs under Labour.

From the Telegraph, which remains a good news source even if you dispute it's political view, but which keeps its content behind a pay wall.

A comprehensive internal study of NHS efficiency published this week revealed that, despite an increase of £20 billion in funding and about 15 per cent more doctors and nurses, it is carrying out barely more routine treatments than before Covid. Productivity, admitted NHS finance director Julian Kelly, is actually “still lower than it was pre-pandemic”.
Consider that for a moment. Despite all the billions that have been poured in; everything we did during the pandemic to “save the NHS”; the recruitment of thousands more doctors and nurses – hospitals are 11 per cent less productive than they were before lockdown was imposed in March 2020. That’s a damning indictment of an organisation which received £182 billion of our hard-earned cash last year.

Well, I don’t think this report will be any different - just look at the list of organisations that contributed/ supported. Not exactly ideology free…

Where should we look to find ideology-free opinions? They don't exist. I believe this and you believe that. The truth is somewhere in between, probably,

I surmise that when it comes down to informed medical opinion, the answer will be that this and that both look promising. Translating that into routine practice that improves health at population level so people live longer in better health is actually far more difficult,

An extremely instructive article -a perfect example of why privatisation is a horror show, in terms of cost and accountability:

www.theguardian.com/commentisfree/article/2024/may/18/child-care-cost-year-wealth-funds-councils-britain-residential