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Comment by tonyedgecombe | Hacker News Reader

I generally agree with the article but there are a couple of issues.

>France has roughly the same population as the U.K., but almost 50 percent more homes.

France also has four times the land area compared to the UK.

>The Economist ties Britain’s energy scarcity to its overly rapid and haphazard push for decarbonization; having banned coal, and with natural gas now extremely expensive due to the Ukraine war, the UK has been forced to rely on hideously expensive offshore wind power.

The dash for gas came about well before decarbonisation was on the agenda. It was instituted by Thatcher after the coal miners strike and because we had an abundance of it in the North Sea.

https://en.wikipedia.org/wiki/Dash_for_Gas

The NHS is struggling because we have an unhealthy population. A lot of that can be put down to behaviours we have adopted from the US (poor diet, car centric lifestyles and lack of exercise).

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> The NHS is struggling because we have an unhealthy population

I think we should stop pretending the NHS doesn't have quality and availability issues, which are validly pointed out in the OP article. I was shocked to discover that the NHS is paying out £60bn in compensation: https://www.bmj.com/content/391/bmj.r2211

Some of that seems to be claims inflation, but it also has to indicate a very real problem. The NHS runs an extremely "lean" system where people are triaged and it errs on the side of under-treatment. That saves money on treatment, but has other costs that don't immediately appear.

There are whole areas which are systematically under-funded to the point of nonexistance. If you're going to try for an adult ADHD or autism assessment, you're going to wait a very long time.

I don't have any answers myself, but I do wonder if going for the sacred cow of "free at the point of use" might work. But NHS dentistry isn't free and still experiences massive funding problems.

The problem with changing the 'free at the point of use' principle is that under any likely replacement it would continue to be free for expectant mothers, children, the disabled, and the elderly - precisely the people who consume the largest proportion of healthcare resources.

And that means that introducing per-appointment charges would likely have only a very minor effect on reducing waste & improving availability. Healthy people of working age would see it as imposing extra charges for no tangible improvement.

Either that, or you'd need to be looking at introducing a two-tier NHS, which I don't think many people would be happy with - "it might work in Europe, but what if it ends up being more like America?" would be the worry.

I think your point about the importance of triage to being able to running "lean" is a better place to look for improvements. The Single Patient Record ought to make automated triage a lot more reliable, for instance. And taking a broader view of ongoing health & economic impacts would help with your ADHD/autism assessment use case, as well as similar issues affecting people of working age (maternity care, being another obvious example).

> The problem with changing the 'free at the point of use' principle is that under any likely replacement it would continue to be free for expectant mothers, children, the disabled, and the elderly - precisely the people who consume the largest proportion of healthcare resources.

The disabled were scapegoated for much of my teens, I wouldn't be surprised if that continues; the elderly… I won't be surprised if someone realises an old person who needs treatment to live, doesn't get it, dies, isn't going to vote against the party responsible for that in the next election the way a pensioner whose income doesn't rise with the cost of living will be able to.

Mothers and children are still going to be important to look after. But with ever-decreasing fertility rates, I wonder if this has become much cheaper per capita already, and the "true" (steady-state) cost for this part of the NHS is therefore hidden, just as old-age care costs were hidden when the population pyramid was the old shape?

i think instead of asking the best way of dividing the costs, we should ask why does it cost so much. we've managed to bring down immensely the cost of technology over the past decades everywhere else.

Baumol effect is my best guess. Nursing tracks the cost of labour, the tech is (so far) making a small fraction of the worldload a lot more efficient, but the bulk of the workload is not (yet) amenable to automation.

That said, I do hear people sometimes complaining that the administrators were fired to save money, and this just put all that administrative burden onto the doctors and nurses who weren't trained in it and didn't go into medicine to perform; if that's true, tech may be able to assist with reducing that burden?

The doctors vs administrators argument swings back and forth every 15-20 years or so. More (and better) tech might change things a bit but, in truth, it's mostly just a slightly different form of the "more administration" side of the debate.

But, actually, some of the tech programmes from the past decade have been effective - NHS Digital & NHSX, the NHS Spine, the work that's led to the Single Patient Record. All much smaller, simpler, and more agile than the gigantic, nightmarish NPfIT money pit of the 2000s. The post-Covid reorg, putting everything under NHS England, inevitably killed some of the momentum but there was real value created and people are doing their best to learn from the experience.

As you say, labour is the real cost driver - but a lot of that labour ought to be done under the banner of Social Care rather than the NHS. Of course, fixing Social Care isn't exactly simple, and will become almost impossible should the nativist right succeed in slashing the supply of care workers.

>I think we should stop pretending the NHS doesn't have quality and availability issues, which are validly pointed out in the OP article.

I don't think anybody is pretending it doesn't. We just need to ask why it has got so bad since Covid and why we seem to be struggling more than similar European countries.

> France also has four times the land area compared to the UK.

This is not by itself of great importance.

There's several different meanings of "built on", but even with the most expansive definition for this purpose, the UK could double how much is "built on" at a cost of around a tenth of what isn't: https://fullfact.org/economy/has-92-country-not-been-built/

There's other reasons to say "perhaps not a good idea" to a higher population (food security, energy security), but the land is there for more (or simply bigger) housing.

That land use has to compete with other uses such as agriculture, leisure and wildlife so the smaller available area is important if you want to make that sort of comparison.

Everything has to compete with everything, but:

(1) agriculture is both the biggest user and not done in a way that comes even close to maximising land efficiency; nor is there any reason it should, given there's not much pressure on agricultural land and the UK has easy access to cheap food imports.

(Even if there was pressure on farmland due to a loss of trade, it would be access to fertiliser that would cause more long-term issues than the land itself; phosphorus shortages would reduce carrying capacity in the range of 9-39 million depending who I ask).

(2) even with the UK's right to roam legislation, leisure use of most land is close to a rounding error. I mean, think about it for a moment: unless you live somewhere like Cambridge where the cows roam in the middle of the city, how often do you go to the middle of a cow pasture for a picnic? Ever tried taking a shortcut through a field of sunflowers (I did as a teenager, I don't recommend it)?

That said, on (2), UK land dedicated specifically to golf courses is close to (a little smaller than) UK land dedicated to housing: https://www.bbc.co.uk/news/uk-41901297

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