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Comment by nickdothutton | Hacker News Reader

Unfortunately the NHS is [broken]— — — —[sub-optimal] (choose where on the spectrum you wish to stick your pin) “architecturally”. I dont mean technically, although yes there are problems there. I mean in the way the various parts of it are arranged as a whole and regionally. To fix this will require another major reform and since the UK has (foolishly IMO) collectively decided the NHS should be the national religion… nobody in power is going to reform it. It’s like the 3rd rail of British politics. Touch it and you die. A real shame.

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I will counter this with the following.

My mother turned 60 late January this year, she received a bowl cancer screening kit which she did and they recommend she come in for a colonoscopy, which identified she highly likely had bowl cancer. 3 Weeks later she received the results for a CT with contrast scan which found no evidence of cancer else where in her major organs and nodes. 3 Weeks later she is having surgery to remove the cancerous bowl.

All for free.

Tell me again why America has the highest rate of Stage 5 Cancers over 65.

Just because the NHS doesn’t fail in all scenarios, or even most scenarios, doesn’t mean it doesn’t have serious problems.

GP isn’t making any claims that the US system is better, they don’t even mention the US, they’re pointing out that the NHS has some pretty serious deep seated issues. Which quite frankly should be obvious to anyone who’s interacted with it.

Knee jerk responses like this are precisely why attempting to fix the NHS is political suicide. It impossible to even have a open discussion out the problems the NHS faces without people piling on to defend the NHS and drown out criticism.

Personally I worry about the future of the NHS. The inability to have an honest and open discussion about the future of the NHS means it’s just going to continue lumbering on until it collapses completely from extraordinary pressures it’s placed under.

> The inability to have an honest and open discussion about the future of the NHS means it’s just going to continue lumbering on until it collapses

Agreed. Unfortunately, it often seems that "honest and open discussion" rapidly segues into rancour. The NHS is a behemoth, and healthcare can be astonishingly complex.

The NHS was designed for different times and different needs. It's been hacked about and is struggling to hang together. It's a political football, and it's been under-funded for years, probably decades. Cash isn't the only way to fix things, but it's a big part.

To counter your counter and to refocus the point on the potential improvements for the NHS. I think the parent is correct with regard to the NHS there are a lot of issues with it. And with meaningful consequences for people's health and well-being, but having followed discussions about it there seems to be an overt focus on comparisons to America and American healthcare costs. The UK and by extension the discussions on issues with the NHS would be better served by comparing and looking at healthcare costs and outcomes of other neighbouring peer countries. Such as the Netherlands or France. Or even further afield in the likes of Singapore.

Note, I'm neither from the UK nor America, and looking in from the outside this aspect of the UK discussion comparing and contrasting with America seems to be the wrong idea.

The NHS has been unable to send an ambulance to me in two separate cases in which the operator confirmed I was high priority.

5 years apart. Once in York, once in Bedfordshire.

But it doesn’t matter —- it’s anecdata.

The NHS has a lot of data available. Some is public, some available only to those that have a commercial relationship with them.

There are areas in which the NHS is exceptional — generally those areas which require no personalisation of care and a mass-production style of work (e.g. cervical smear tests and their associated health outcomes) - and then there are the many areas in which it really is appalling.

Lionising the NHS doesn’t help it. Opening discussing its faults does.

Your mother was quite lucky, the NHS doesn’t do much prevention compared to other healthcare systems. Everything goes through GPs, that are the medicine homologues of a guy that works in IT and can set the background of his Drupal blog. GPs have budgets, are very vocal about it, and would rather run silly experiments for months than writing a referral (the latter impacting on their budget). My girlfriend’s GP wanted to change her birth control pill because it was too expensive, and he has a budget (it’s not a problem anymore, because thanks to Brexit that pill is no longer available in the UK). Children are not assigned to a paediatrician and women are not assigned to a gynaecologist. Women go through pregnancies without ever seeing a person with a degree in medicine, it’s all handled by midwives. If you want access to western medicine you either have an insurance or you’ll have to spend 200-300£ per visit. For some weird reason the NHS has you covered if you need a magician, such as an osteopath, or some magic homeopathic pills.

The NHS has seasons, for instance a few years ago it was chlamydia season and so I was forced to go through a chlamydia screening, but it proved impossible to get tested for any other STD. It is possible that your mother was saved by the colonoscopy season.

> Everything goes through GPs, that are the medicine homologues of a guy that works in IT and can set the background of his Drupal blog.

I don't follow you. GPs go through specialist training and assessment (general practice is, perhaps paradoxically, a specialism). The comparison you draw seems to be with someone who is unskilled. Can you explain? Perhaps I'm missing something.

While it seems true that GPs are the gate keepers for referral to secondary care, this is largely due to factors that are outside the control of GPs themselves.

I'm not sure I understand your complaint. Do you expect to have direct access to pediatricians and gynaecologists without referral? There simply are not enough of them for that. I'm curious; without being identified as someone who needs specialist care, why would you want access to someone like that? The -icians and -ologists within the NHS deal with specific situations. Perhaps you think you'd receive better care if you simply had direct access to secondary care. Fair enough.... so, that itch you get occasionally, or that nagging ache... are you going to visit the neurologist, or the rheumatologist, or the radiologist, or....?

> GPs have budgets, are very vocal about it

I've literally never heard a GP mention budgets to me as a patient. Or are you referring to GP representation in the media?

> would rather run silly experiments for months than writing a referral (the latter impacting on their budget).

You say that GPs will knowingly experiment on their patients to save money. Are you sure that's what's happening?

> My girlfriend’s GP wanted to change her birth control pill because it was too expensive

Is that actually the reason they gave? Or something you've inferred? Did they, perhaps, want to provide your girlfriend with the service she requested, using what they had at their disposal?

> I don't follow you. GPs go through specialist training and assessment (general practice is, perhaps paradoxically, a specialism).

You spend 20 years prescribing paracetamol and homeopathy to old ladies and you eventually stop being a real doctor, like somebody who takes a PhD in computer science and then spend 20 years replacing hard disks in a call center.

> I'm not sure I understand your complaint. Do you expect to have direct access to pediatricians and gynaecologists without referral?

Yes, in Italy that is the norm and it sounds silly that you think it’s a weird expectation. That’s probably one of the reasons why the British infant mortality rate is 50% higher than the Italian.

> Fair enough.... so, that itch you get occasionally, or that nagging ache... are you going to visit the neurologist, or the rheumatologist, or the radiologist, or....?

I’m not a hypochondriac, so I don’t go to random doctors on a weekly basis. But given the taxes I pay to fund it, I’m expecting a Western European healthcare system and not this thing that would be below par in a middle-income country.

> I've literally never heard a GP mention budgets to me as a patient. Or are you referring to GP representation in the media?

Sure, that’s what my GP said, she didn’t have a budget for that. I’ve left out the part where I said that it didn’t matter because I had a private insurance and the NHS wouldn’t have to pay for my treatment. At that point she totally lost it and started yelling that the Tories are privatising the NHS and insurance companies are their accomplices or some other crazy thing like that.

> You say that GPs will knowingly experiment on their patients to save money. Are you sure that's what's happening?

Rather than referring my partner to a gynaecologist, the GP kept making up pseudorandom diagnoses for roughly 3 month, until my girlfriend gave up on him and decided to go to a private doctor (it’s not the same person that hates private insurances and at the time I didn’t have an insurance). The private gynaecologist identified the issue in 20’ and prescribed a 3 day treatment that fixed the problem. 3 months of randomness vs 20’ of professionalism.

So, to answer your question, I was being sarcastic: the GP wasn’t experimenting, in the sense that he knew what he was doing, he was just making stuff up to not spend his budget on referrals.

> Is that actually the reason they gave? Or something you've inferred? Did they, perhaps, want to provide your girlfriend with the service she requested, using what they had at their disposal?

My girlfriend had been using a pill for years, after testing a few under the supervision of a gynaecologist (again, that’s the norm in Italy, GPs don’t come up with birth control pill suggestions). Then she moved to the UK and the British GP told her that she should change the pill, because it was too expensive. My girlfriend said she was fine paying for a more expensive pill (in Italy you have to pay for it). Then the doctor went on explaining that the NHS would have to pay for it and that she should use too much public money. I eventually had to intervene, because my partner’s assertiveness is below 0 and the doctor was putting her health at risk to save 5£ per month.

Your GP "yelled" at you and "made up" random diagnoses to save a few £ per month, deliberately putting your partner's health at risk?

Any GP doing what you say would lose their job and not be allowed to practice again.

My understanding is that you (and maybe your partner) had specific expectations about who you would see and what they would do for you. Your expectations were not met, and you've interpreted this very negatively through some basic misunderstandings of how the NHS works.

> My girlfriend said she was fine paying for a more expensive pill (in Italy you have to pay for it). Then the doctor went on explaining that the NHS would have to pay for it

Despite the fact that you clearly dislike this, it is indeed true. You can't ask an NHS GP to prescribe a specific medication and offer to pay for it yourself. The NHS buys meds and issues them through prescriptions. That's pretty much it.

Just to be clear: I fully accept that not all experiences with GPs are perfect (and neither are all experiences with consultants).

If you want to tell a doctor what you want and have them give it to you, stick to private care. Your opinion of NHS GPs is clearly very low, and unfortunately seems misinformed.

> but it proved impossible to get tested for any other STD.

You've asked for direct access to specialists, and in England you do have direct access to sexual health clinics where you don't need to be referred by GP, you don't even need to tell your GP, and where they'll test for just about everything.

Your mother was lucky. It would be interesting to see if this impacts the health seeking behaviour of individuals. It is practically outsourcing the healthcare to a third party agency that has the potential to slip up. In some cases, it does (as the OP). American cancer rates have different etiologies and is not apples to oranges comparison.

You say that, but the government is currently engaged in a new reform of the NHS. Having previously pushed decentralisation, competition and increased use and engagement with private providers (Health and Social Care Act 2012 [1]) they are now reversing their position and instead centralising control of everything, abandoning competition, disbanding many of the bodies they created and recreating old ones with new names [2]. This constant churn of politicians with new ideas about how to “fix” the NHS is a big part of why it’s broken.

You should also remember that the British public says they love the NHS but they don’t like paying for it. Current health care funding per capita is well behind other equivalently wealthy nations [3].

[1] https://en.wikipedia.org/wiki/Health_and_Social_Care_Act_201...

[2] https://www.kingsfund.org.uk/publications/health-and-care-ac...

[3] https://www.ons.gov.uk/peoplepopulationandcommunity/healthan...

Among the Europeans I know living in the UK, the NHS (the system - not the excellent staff) is a laughing stock. There is a better way, but I worry that the public of the UK are so militantly resistant to any change to the NHS’ structure that it’ll never be changed.

The UK spends far less per head on Health than other European countries. It is incredibly cost effective.

The first step would be spending as much as other countries do before judging if a different structure would be better.

I agree, it should be funded more, but I think there are definitely problems which are inherent to the NHS’ current structure. A lot of mismanagement, beyond the point where I can just blame it on underfunding.

No, the UK spend on the NHS slightly more than the EU14 average. The NHS is more expensive than the Italian and Spanish healthcare systems, while being significantly worse.

Among Italian expats we wonder how is it possible that a paracetamol dispenser with some ni-no-ni-no cars is so expensive.

Have you taken into account account for private expenditure? There are far more out of pocket expenses in Italy for patients than there are in the UK.

I completely agree. If you criticise the NHS on Reddit you're instantly branded as a Tory sympathiser who just wants to destroy it, even though it's pretty obvious that there are loads of things that need to be improved.

Appointment booking is probably the most obvious clusterfuck. I still can't book appointments with my GP online.

We got a referral to ENT for a child. They sent us a letter, telling us to call them. On the phone they said they have chosen an arbitrary appointment date for us and will send the details in another letter. When we get that letter, if the time isn't convenient then to call them back to rearrange it. Madness!

It is very very slowly improving, so I think eventually these sorts of brain dead issues will mostly go away. Hopefully while I'm still alive.

> I still can't book appointments with my GP online.

You can, you just have to decide which of the myriad fly-by-night apps you want to (give access to your data and) use.

Bafflingly insane IMO, the list of random scammy sounding private companies I was given a non-exhastive no-recommendation list of when signing up to a new GP. Why isn't it just one 'NHS GP' app?

I say this as a staunch Conservative. What are they possibly going to compete on?

> You can

I can't. As I understand it, it's organised separately by each surgery. So you might be able to but I can't. That also explains the use of sketchy apps!

> Why isn't it just one 'NHS GP' app?

Completely agree. They already have an app!

Who is They? GPs are typically small independent businesses contracted to the NHS, which is one of the reasons for the fragmentation.

The NHS of course. GPs already have to interface with other NHS systems.

The OP makes the point that there already is a primary key. It strikes me as the standard enterprise response to say, we can't fix your thing til we fix the whole thing, and fixing the whole thing will never happen.

My suspicion generally is that fixing small things at scale is more likely to lead to enterprise level results than trying to fix big things in a particular silo. But, it's just a feeling.

Refactoring, in other words.

I wonder if OP has spoken to NHS Digital.

I see they have.

OP, there's a trick to navigating bureaucracies, you just bounced off the armour.

You need an insider, someone you can have an off-the-record chat with.

Back in the 1950s when the NHS was created, it was doing a very different thing to what it's doing now. People are living longer, there's more treatment options for everything, there's new branches that never existed - all kinds of stuff. The NHS was never designed for the sheer scope and magnitude of what it's doing now, and it shows.

My better-half works in a hospital where the concrete roof is 20y past designed life and is now actively failing to the point of being supported by hundreds acrow props.

Tory government says it's still deciding if it'll be one of the arbitrary eight hospital projects they'll fund.

They made nursing a degree course, put tuition up to £9kpa, and removed both the nursing bursary and final-year medicine tuition grant... and wondered where all the new doctors and nurses went.

You're not right. It's not foolish to want to protect the NHS, it's foolish to trust a Conservative to fund it adequately. And yes, some of these problems were caused by poor policy of their Labour predecessors.

> nobody in power is going to reform it

This kind of thing is only ever said by people who've got no idea how the NS works.

Just today Javid announced his intention for a new, major, change to the way that primary care will work.

Except the NHS has went through multiple massive reforms. Like the Conservatives instituted one after they came to power in 2010 (after famously promising not to institute a massive top down reform pre-election they promptly went ahead an did probably the largest change since the formation of the NHS)

Sad, but true. NHS is the new religion of the U.K. Remember the mindless banging of pots and pans in the street for them? When quite a lot of the hospitals were empty? I can vouch for this because I worked in the biggest hospital in Brum.

Anyway, what am I saying, of course socialist works, were just not doing it right! All hail the NHS!

I found the "pots and pans" thing back in 2020 to be eery.

It was once said "Prussia was not a country with an army, but an army with a country"; the UK is not a country with a health service, but a health service with a country.

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