Hacker News Reader

Comment by vintagedave | Hacker News Reader

> All criticism is digs that are wrong.

Often, when people criticize the NHS they have an ulterior motive, like privatisation. Consider all the political difficulties the NHS has had in the past few years. As such, negative remarks can be read or misread as dogwhistles for other views, so they're something that have to be phrased carefully and within context.

I was unclear: did you publish a book, or did your sister?

In general, for something both as key and as endangered as the NHS is, criticism isn't always useful -- support is. Problems can be recognised and addressed through support.

View on HN

I did.

I'm not anti-NHS, I've no agenda to see it privatised, I just want it to be better. I tried many, many private routes first. I tried NHS England, NHS Digital, the Innovation Service, AHSNs (many sections having since been renamed/reorganised). About 20 different contact points over two or three years, most of which seemed inappropriate but I made sure if anyone told me it was someone else's responsibility I checked with them.

The problems had already been recognised through public inquiries and yet were still ongoing.

I even offered to build the software for free, which, hopefully, for an individual dealing with an organisation with a budget into the hundreds of billions, falls under supportive. But as far as I could see, offering support was getting me nowhere.

I just had people acknowledging the issue and then shrugging their shoulders, pointing fingers at everyone else. So I wrote a book on it, spoke about the issue publicly and within months it was decided to spend tens of millions on sorting it.

> I even offered to build the software for free, which, hopefully, for an individual dealing with an organisation with a budget into the hundreds of billions, falls under supportive.

I think it's wonderful that you offered to do that but it simply isn't realistic. Who is going to support this software in the long term? How are you handling privacy concerns? What guarantees can you offer about server security? Who is paying for and maintaining the servers in the long term? What happens (to be blunt) if you die the day after the software is delivered?

There's so, so much wrong with the way governments provision software projects from outside parties. But there is good reason to have contracts the length of the Bible. Picking up work from individuals on a whim is courting disaster.

I don't live in the UK, but the stories we hear about the NHS from people who lived and worked there are honestly shocking.

One guy had a brain infection and was told to wait four months for an appointment. Another went in for a root canal, left without a tooth, and fainted outside the clinic. Someone else was refused an X-ray after an accident.

Meanwhile, in my tiny country, we have a dual public-private health system, and the facilities, doctors, and dentists are top notch. It really makes you wonder what's gone wrong in the UK, considering how much taxes British people pay.

The UK pays less per capita towards the NHS than most similar-income countries do.

And, it's very much a "public-private" health system. E.g. all GP's and most dentists are private businesses, paid for by the NHS to varying degree, but also with many providing private services.

The NHS uses an extensive network of private providers, including (when sufficient funding is provided) to drive down waiting lists. I've personally had a procedure carried out at a private hospital at the NHS's expense.

The NHS has many problems, but at the root of a whole lot of them is that the NHS needs a funding increase of 20%-30% to get to similar levels of funding per capita as similarly wealthy countries.

The UK spends about as much per capita on the NHS, providing universal care, as the US does on just Medicare and Medicaid.

>at the root of a whole lot of them is that the NHS needs a funding increase of 20%-30% to get to similar levels of funding per capita as similarly wealthy countries

As a percentage of GDP, UK healthcare spending is well above the EU and OECD averages. We spend a greater share of our national income on healthcare than Belgium, the Netherlands, New Zealand, Australia, Denmark, Finland or Norway.

https://data.worldbank.org/indicator/SH.XPD.CHEX.GD.ZS?most_...

That's another way of saying the UK economy is relatively weak compared to some of the richest countries in the world.

Thanks for the info

It really makes you wonder what's gone wrong in the UK, considering how much taxes British people pay.

Unfortunately the main problem is chronic underinvestment by successive governments of all political inclinations. We tend not to fix our roof in the summer because we hope the other guys will be in government by winter when everyone inside is getting wet and they'll get blamed for the consequences of our decision. We've also made some poor choices historically around selling off national assets and questions of privatisation or public ownership.

This isn't unique to the NHS and ironically among the current Labour government the Health Secretary, Wes Streeting, is one of the few people suggesting significant changes that actually do make sense for the long term future of our country. Unfortunately a lot of them will probably require more than 5 years to implement and that puts the results over the horizon beyond the next general election. So the price for trying to "do the right thing" might be that he won't get re-elected to see it through. This enables the cycle of short-termism and lack of consistent investment to continue even though its horrible results are increasingly clear for all to see.

I see. A polarised two-party system makes long-term planning really hard, like in the US.

Ironically, that's not a problem in China, they have a one-party authoritarian state and can plan 10, 20 years ahead without worrying about elections or political instability.

China also has a healthcare system that has been far more private than public for the majority of the existence of the PRC, that is only in recent years getting close to providing universal coverage for basic service provisions....

I think a great many countries have problems with healthcare. I think if you went hunting for anecdotes of healthcare failures you'd be rich in examples in a lot of countries. That said, I think in the UK it's a result of inefficiency and chronic underfunding for, at this point, decades.

I've lived in both the UK and the US and there are issues with healthcare in both. Maybe the model your country uses could scale up to populations the size of the UK and the US, maybe it wouldn't. Difficult to know.

I agree. Every country has its own set of challenges, and in the end, it all comes down to personal experience.

TBF the government and its agencies - including the NHS - are doing themselves no favours with how they're managing IT at the moment.

There are persistent and valid claims that the NHS is inefficient in its use of technology. It wastes lots of money, wastes clinicians' time, and sometimes fails to get accurate information to the people who need it in time to be used.

But there is a best being the enemy of the good problem here. The amount of regulation involved in supplying any kind of tech product or IT service to these public sector organisations is becoming prohibitive. Parts of the industry that have been providing these products and services into the NHS are being crippled in productivity or even literally shutting down whole supply chains because it's too onerous to comply with all the red tape. It's not just individuals but the small businesses that employ or engage them and then the medium-sized business that use the small ones.

If you're working with big consultancies with their own legal and compliance teams then sure you can write hundreds of pages of contracts and require compliance with several external standards about managing personal data and IT security and whatever else. But that regulation flows downhill to the smaller suppliers who don't have resources already available to deal with those issues and at some point it becomes overwhelming and everyone has had enough and decides to become a gardener. Now your only options for supply are big consultancies engaging big suppliers who charge big prices and provide big company levels of service and responsiveness (in the most pejorative sense of these terms).

Surely this isn't the best strategy for a system that desperately needs to be more efficient and sometimes more innovative. There is a broad spectrum between "adopt a one-off product with no support from a single well-meaning individual" and "everything requires so much red tape that only the places charging those £x000-per-day consulting rates we're always mocking are actually allowed to provide it".

> I think it's wonderful that you offered to do that but it simply isn't realistic. Who is going to support this software in the long term? How are you handling privacy concerns? What guarantees can you offer about server security? Who is paying for and maintaining the servers in the long term? What happens (to be blunt) if you die the day after the software is delivered?

Good questions, but the quickest way I can answer them all is to say that my company had delivered software for national security purposes to central government departments. This really was nothing.

It certainly wasn't my preferred option. The offer was mostly a tool to ensure that cost of development could not be used as a reason to reject.

As someone who does software for NHS Scotland, I can easily believe the tale of multiple difference directorates/orgs believing it was someone else's remit as the NHS is a super complex organization of organizations. But in your case specifically data protection laws probably made it far worse and that's true of pretty much any tech you build/deploy in the NHS. There are strict information governance rules that have to be followed for any personal information, even just emails, which exist for very good reasons and aren't particularly onerous, but they are strict so in situation like your where it's not clear who would own/be responsible for what you were offering I can could see them getting in the way.

There are some rules that exist for very good reasons - and which have been widely undermined by front-line healthcare services though this does at least seem to be improving a bit over time.

There are also plenty of rules that exist for dogmatic reasons and impose absolute requirements that don't always make much sense in context instead of stating principles that should be appropriately applied.

I understand that those administering these rules don't want to leave loopholes where people or cost-conscious suppliers will cut corners for convenience and/or to save money. There is obviously a danger of that happening if you don't write everything down in black and white.

But you have to remember that the starting point here is receptionists at medical facilities asking people to email over sensitive health information or casually discuss it on the phone when they don't even know who they're talking to and what information is appropriate to share with them. Doctors are trying to read vital patient information from scrawled handwriting on actual paper in potentially time-sensitive life-and-death situations. Expensive scanning equipment in hospitals relies on software that runs on 20-year-old versions of Windows from a supplier that shut down long ago.

In this context you probably win a lot just by having clear policies and guidelines that really are short and simple enough for rank and file staff working in a wide variety of different jobs to understand. A reasonable set of basic technical measures would be far better than much of what is in widespread use today. Trying to make everything perfect so we have fully computerised health records and integrated diagnostic and treatment systems and everything is 100% secure and privacy-protected and supported is a laudable goal that would obviously be much better for patient outcomes and also for the daily lives of everyone working in healthcare. And in 50 or 100 years maybe we'll be able to do it. But not today and not tomorrow.

I've written software used across the NHS previously, and a lot for national security purposes since. It wasn't the only option on the table, just one that I was mainly using to ensure cost of development couldn't be used as a reason to reject and so that there was a strawman architecture on the table to help generate discussion.

It certainly wasn't even my preferred option, I'd have been much happier if they said they had a team that could run with it.

> Often, when people criticize the NHS they have an ulterior motive, like privatisation

This kind of political insecurity is toxic for rational conversation. Blindly rejecting the criticisms of our political opponents is just as naive as blindly accepting their criticisms. Either way we handover control of the conversation.

Rhetoric exists. Astroturfing exists. Wishful thinking and name-calling do not make them go away. You might not be interested in politics, but politics is interested in you.

Reply on news.ycombinator.com