This isn't a collapse of emergency healthcare, it's a very predicted collapse of community social care: hospitals can't discharge if they need a care home place that doesn't exist.
Without inpatient bed availability, ERs and AMUs can't admit to specialties and everything gums up at the front door.
Let's be clear: we do need many more doctors and nurses, but the existing ones can't do their jobs because their wards have turned into medically-fit nursing homes. They spend half their days trying to send people (who don't have care requirements) home faster than they'd like.
Why? Because central government withdrew funding. Social care is now on the council to fund and many councils have squashed social care, along with libraries and early years provisions. The trap of outsourcing caught many councils out.
Turns out the whole endeavour was yet more myopic, Tory penny-pinching.
It is too bad that corrupt government officials keep systemically defunding Social Health programs with the objective of pushing private for-profit healthcare (which just doesn't make sense). Then they point to the deficient healthcare and blame the "socialized" aspect of it for the issues.
Here in Mexico we've seen it all play out: We had an amazing social healthcare system (in the form of the IMSS) in the 70s and 80s. But the corrupt government officials kept dismantling it and allowing corruption to run rampant within the system. All to get a piece of the private for-profit health system including Health Insurance.
Back in 2004 when I lived in the UK, the NHS was really good. And I remember hearing at that time that it was nothing compared to the NHS in the 80s and 90s. I seriously hope it doesn't have the same outcome as our system had in Mexico. For-profit health is inhumane.
>with the objective of pushing private for-profit healthcare (which just doesn't make sense)
Maybe it doesn't make sense for you, but it makes their buddies in the private sector a lot of money. And that's the game in capitalism, making a lot of money.
The government competing with affordable options for everyone against the private sector is "bad for business".
You're correct that the game is to make a lot of money but the key to making that work is ensuring transactions are beneficial to all parties.
It doesn't matter how you structure things you end up with some way to climb the hierarchy. The problem with pure communist systems is they try to prevent all hierarchies. Human nature attempts to circumvent this, the only way to do so is via corruption and political power. Corruption and political power exist in abundance in free markets as well, but there is another outlet for personal ambition. People can get rich. The hope is that you can build a system that incentivizes people to get rich by providing value for everyone. You can have private for-profit healthcare but you have to make sure that people get a good deal out of that. Normally we rely on competition to ensure customers always get a good deal. I don't think that works in this setting. Healthcare is tricky, I don't think we've found a good way to setup incentives for heath systems to have the best outcomes. We will need strong government regulation no matter what we do. Competition will not provide sufficiently good outcomes.
In the US you have great hospitals but at astronomical costs, the entire system is distorted by insurance companies and massive bureaucracies. Here in NZ the hospitals are terrible underfunded socialist messes. We can't hold on to staff because we don't pay enough. Emergency waits are hours. My friends wife just spent 3 days before getting emergency surgery to reattach nerves and tendons in her hand. She had to travel 3 hours to another city to get that care. The last two times I required emergency care the wait was over 8 hours. I can't pay for better service and there is no private emergency option.
If a hospital were worked owned and controlled, they’re not gonna bribe their Tory buddies to shutdown public medical services because most people aren’t that ridiculously selfish and no one individual gets wealthy. And if it’s a private hospital, the doctors and nurses will use profits to pay themselves well and cut down on costs, because again, they are face to face with people trying to pay foe their medical care.
> It doesn't matter how you structure things you end up with some way to climb the hierarchy. The problem with pure communist systems is they try to prevent all hierarchies.
That is a massive non-sequiter though, nobody is suggesting that factory workers rise up and sieze control of the hospitals. Or even that nurses do so. The proposals for healthcare usually involve the oligarchs being in control and the public enforcing standards. Which typically turns out to be unsustainable because the middle class is where the people who know how to run things come from and they just got cut out.
The problem here is excessive centralisation where if (more practically, when) the government becomes corrupt or makes a bad decision it becomes illegal to do something different to the regulatory standard.
Politics by people with communist leanings isn't helping the situation, but the fundamental issue here is people keep proposing 'solutions' that don't work and effectively block people from actually solving the problems. Eg, I bet someone with a good idea of how to organise an independent emergency healthcare service wouldn't be allowed to do it in England.
The only reason I mentioned a pure communist system is to compare it to a pure capitalist system. I then argued that neither will solve this problem.
I agree that centralization causes huge problems.
My main point was that I don't think we've found a good system for providing hospital care and whatever that solution is I don't think it lies at either extremes of the left - right political spectrum.
We need to change human genes. That's the best long term way out of this. Corruption is just gene trickery. "Best for me, not for thee". Unless "thee" is genetically related.
Unbelieavable wealth and seeking power is gene survival. More wealth more survival resources. More power more survival and reproductive resources.
Genes drive everything that is "wrong" with the way things are.
It definitely came across that way to me in your comment as well. You associated corruption with capitalism via "and that's the name of the game" as though the objective of capitalism is to destroy public institutions, when what's actually the case is that the objective of corrupt people is to destroy or co-opt public institutions for their own benefit. The economic system is largely immaterial in that effort. Actually, you could argue the opposite in that capitalism helps prop up public institutions versus other economic systems because there are minimum levels of regulation, rule of law, and security that are required for capitalistic economies (ranging from the US, to Sweden, to Singapore) to function and for capital owners to profit.
The Soviet Union accrued massive debt due to internal production inefficiencies caused by corruption and mismanagement. Russia has extraordinary natural resources, by all rights they should be one of the most wealthy countries on earth.
Notice how on that list none of South America countries appear after 1990s? Venezuela has been hostile to the US, yet they are still there. Brazil, Argentina, Chile, Ecuador, Peru, Bolivia have elected socialism-leaning governments multiple times during the last 30 years. Not to mention Nicaragua or Mexico, that are not considered South America. Colombia is the latest example. So they are poor because of US meddling, and not even a tiny part due to their policies? You have to try harder if you want to blame their issues on the US.
> Notice how on that list none of South America countries appear after 1990s?
This is regime change /that we know about/. Intelligence agencies haven't made a huge habit of discussing their covert successes.
> Venezuela has been hostile to the US, yet they are still there.
Yes, because the international response would be quite severe if the US decided to what - destroy Venezuela?
Foreign occupations and coups decimate countries who then have to deal with the effects for generations. The new regime is usually beholden to the powers that put it there (or the old one has to abide by the occupier's demands), permanently crippling the government or the economy or both. Many countries continue to suffer under the conditions created by their overthrowers, so maybe they share some blame but it's largely the longlasting effects of foreign incursions.
> You have to try harder if you want to blame their issues on the US.
It's really not that difficult to understand cause and effect here. If you destroy a country's economy, divide its people, cripple it's infrastructure, and install an authoritarian government, it's going to take a long time to recover.
Yes, the US had its hand in Argentina as well - they supported the violent military junta that saw Peron overthrown and leftist journalists and activists murdered by the thousands during the Dirty War. When I was studying there, the family I stayed with had relatives who had been abducted and "disappeared," which was such a widespread phenomenon under the right wing government that they have a name: "Los Desaparecidos". Here's a Wikipedia article about how the CIA contributed: https://en.wikipedia.org/wiki/Operation_Condor#Argentina
Also, your article is unfortunately paywalled, but an op-ed from someone at the WSJ isn't going to change my mind.
Exactly. They should know better and vote for governments that are aligned with the US government's interests, so they don't need to go through a CIA-sponsored coup.
Much of that poverty has its roots way back in the time of the Conquistadors and the generations of Spanish and Portuguese families that looted the riches of the Inca empire.
The descendants of those families still have huge wealth and influence in South America.
I really don't understand how people can simultaneously believe that governments are corrupt and the private sector would support the public's interests. Guess who is corrupting government: the private sector who only support their own interests.
I know this is difficult to understand how it works, but the beauty of the free market is everyone benefits while selfishly working for their own self-interest.
Socialism, however, requires altruistic behavior, and very few people are consistently altruistic and self-sacrificing for the common good.
> I know this is difficult to understand how it works
Are we going to pretend that free market capitalism and its magical benefits haven't been pounded into all of our heads from every angle from the moment we were being taught anything about how the world works? It's not difficult to understand, it's difficult to see in a world where companies commit crimes and collapse in mountains of debt, but no one goes to jail. Not a situation that Adam Smith would approve of.
The reason the benefits capitalism are spread out to any degree is because there are riots when they aren't, so you need to at least reward the people responsible for putting those riots down through violence, technology, and bureaucracy. Hence, the middle class.
> Socialism, however, requires altruistic behavior, and very few people are consistently altruistic and self-sacrificing for the common good.
"Socialism" requires cooperation, and people do it just fine. Even capitalists are socialist amongst themselves when it comes to keeping out competition.
Are you really going to pretend -- to this audience -- you haven't enjoyed the (yes) magical benefits of profit-seeking innovation?
Progressivism conquered America a century ago. Antitrust law. Central bank. Income tax. Universal suffrage. Old age pensions. Public education, research grants. National parks. Interstate highways. Welfare, public housing. Equal opportunity employment. Disaster relief. Socialized medicine for the poor and elderly. Workplace safety. Automobile safety and emissions standards. Space shuttle.
Recently, a flirtation with Universal Basic Income.
People are (hopefully) concerned with growing inequality, wealth centralising into small pockets of society, the lawlessness in which multinational corporate entities operate, the damage being caused to the environment by heavily promoted consumerism..
> Are we going to pretend that free market capitalism and its magical benefits haven't been pounded into all of our heads from every angle from the moment we were being taught anything about how the world works?
My dad was a professor of finance in a midwestern college. He'd have students coming up to him saying "I didn't know there even was a case for free markets!"
> "Socialism" requires cooperation, and people do it just fine.
Both socialism and free markets require cooperation. The difference is that socialism requires forcible cooperation, and in free markets the cooperation is voluntary.
The driving force between market capitalism isn't selfishness Walter. It's competition.
People innately like to compete and will do so over the dumbest things, like who can get the little puck in the net with sticks the most, or who can correctly guess the sum of a pair of dice.
Market capitalism coopts this most basic of human instincts,not greed, and selfish greed is actually the root of many failures of capitalism endeavors, and human endeavors in general.
Because a socialist system is ran by the public. It is beholden to the public as its shareholders. Mcdonalds needs to taste tasty, but only to get you hooked enough to choose mcdonalds over other foods. You think the shareholders would rather their customers actually eat healthy which means limiting consumption of Mcdonalds? No, they are practically in the business of selling cigarettes but in the form of fats and sugars. They want you addicted. The goal of the capitalist isn't to make their customer happy, its to extract as much of their available disposable income as possible.
Every country that tried having the government run food production produced starvation.
Those goalposts were just fine where they were, put them back and address the actual argument. Nobody was advocating for 'government run food production'.
Pleasing the customer is not always good for the customer. I'm sure nicotine addicts get a lot of pleasure from smoking a pack a day. In fact i think that is still Newport's slogan.
Plus your quip is a little bit dated honestly. The soviets had famines because they literally didn't support evolution for quite some time. They believed Lysenko and allowed him to execute his critics. Meanwhile today, look at China the past few decades when modern agricultural practices were finally well established around the world. Another 600 million people in 50 years. Huge population growth doesn't happen because of starvation.
> Pleasing the customer is not always good for the customer.
Ah, the arrogance of knowing what is best for others. (Of course, I know what's best for everyone else, too, but my arrogance stops at taking the next step of being entitled to force it on them.)
> The soviets
You can make excuses for the Soviets. But you gotta explain the starvation from every other communist country. The starvation in Jamestown when they tried communist agriculture. The starvation in the Pilgrims' first year when they tried communist food production. The failure of the Kibbutzen in Israel to feed themselves without government subsidy.
It goes on and on.
P.S. China stopped starving when the stopped collectivist agriculture.
Now for the flip side. Which was the first country to eliminate famine? The US, around 1800, with free market agriculture. Next, which free market agricultural system has suffered from a famine?
lol you misspelled "ran by corrupt authoritarian governments that don't give 2 shits about the public unless they can exploit them"
You can ding corporations... but the real world socialist examples are worse.
Corporations aren't perfect (and we don't live in pure capitalism anyways. Common sense controls exist for good reason). But they are better than socialist governments.
McDonalds is able to sell garbage food because most Americans are addicted to sugar. Your free-market evangelism is the economic equivalent of their junk food.
I enjoy a meal at McD's regularly. I just have a QP, I never buy shakes or soft drinks. The QP is healthy food.
Besides, the US under free market agriculture produced the tallest people in the world up until WW2. It's kinda hard to believe that Americans grew that tall from eating garbage.
Well, socialism isn't communism, and money still exists under socialism, so if the service center isn't doing their job, then, as you capitalists like to say, money talks.
Capitalism, like democracy, is the worst form of government, except for all the others. To believe that the US brand of capitalism can do no wrong is to be as deluded as the communists were. If the free market were perfectly efficient, there would be no such thing as conmen or MLM scams, and every consumer would be 100% informed and perfectly rational. That's ridiculous, so the government needs to step in at times, to promote a freer market than one without regulation.
Go eat at a restaurant in Times Square. They exist only because of their location, and the fact that tourists don't stay long. So their food is bad AND they don't need to try and harder because it doesn't hurt their business. They're a total ripoff and a tourist trap and that's with capitalism's vaunted free market backing the enterprise.
My family owns a bunch of McDonalds. Success is tied to location mostly. The product is pretty meh at best. The only products that have maintained quality are fries, coffee and coke. The rest are worse by any measure.
There’s a reason why Five Guys, etc are everywhere. People who want a good burger go there.
it works like this. In a free market, you dont have to buy my services, but you will if it is better for you on the whole than not. I may consider you cattle to be exploited for profit, but you probably wont just give me your money if i try to sell you my grass offcuttings for $10k. If i somehow come up with a way to produce a great lawnmower that costs me $1 to make, and I sell it to you for $100, you would perhaps think this is a great thing, while I make out like a troll. win/win. If I offer you a shitty lawnmower for $100k, you simply decline.
Socialism would absolutely not require selfless people-it would simple require that workers control and own the companies they work in, and the knowledge that fixing other people’s problems makes everyone’s life better. Less theft, violence, better mental health, no more mass shootings, no more homeless encampments.
Imagine if that co-worker that doesn’t contribute or might even drag the team down can just quit and play PS5. Glorious.
How do I know people don’t need coercion or even pay to produce great products? Open source software. Windows is capitalism and Linux is socialism. Which do you prefer?
The politicians you vote for can regulate those companies, that is how the system is intended to work. If those politicians takes bribes to not regulate those companies, then the problem is corrupt politicians taking bribes, you don't fix that by giving those politicians more power you fix it by voting them out and voting in politicians who does what you want.
> Guess who is corrupting government
How are they corrupting the government? Is the private sector deciding who gets power in the government somehow? Sounds like your democracy doesn't work then. Giving all the power to politicians when the democracy doesn't work just leads to the same scenario as in Soviet.
Bribing the government isn't "corrupting" them, a politician who accepts bribes or tit for tat deals is already corrupt.
How about we have a national vote on what phone you get? Which car you get? Whether carrots or tomatoes get produced? What movies get produced? What clothes are produced? Which diseases get funding? What apartment you get? How many ounces of meat you get per week? What music you get to listen to?
Corruption is a human ingrained need for trickery to gain advantage of potential gene competition. It is ubiquitous for humans and increases with perceived genetic difference, up to a maximum.
2004 was the peak of Blair-Brown Labour party investment.
They didn't get it all right. They used PFI and outsourcing to fudge the sums on major investments, and I dare say they didn't invest in mental and social health care in the amount required. But nobody ever has.
The job of fixing this is so expensive and requires so much political force. We're still worried French immigrants are going to eat our dingos, or something. I'm fairly certain now we're destined to limp into an American insurance model; eat the poor.
PFI was used because it was a way to get "free money" for the NHS by pushing the real costs into the future.
The core problem for the socialized model is that nobody can assemble a voter coalition that agrees to raise taxes. The poorer Labour voters say no, the rich should pay, or alternatively, the money already exists it's just the evil Tories refusing to fund the system. The more affluent conservative voters say no, because either, the NHS is wasting money and should fix that first e.g. the massive spend on diversity officers, or, the NHS is always overloaded due to uncontrolled immigration, so fix that first. The NHS doesn't have enough admin support as a result. Then the woke middle classes say no, reducing immigration is awful and we will fight it all the way and of course we won't pay higher taxes because if we allowed unlimited immigration the new taxes from all the highly skilled doctor/engineer immigrants would fix the problems.
In the UK there's also the issue that the social care workforce was one of the only professions forced to take vaccines. Lots quit and the rest learned that they have fewer human rights than other people. So having treated the social care workforce like shit, which was already overstretched, the system is now in total collapse for lack of workers.
State run systems always have problems like this. It's one size fits all, so the different groups with their different priorities can never agree and the result is deadlock and collapse. The people who run it are too far removed from the front line and the "too big to fail" problem rears its ugly head. The NHS could never survive as is, it's just a pity that it had to end like this.
> Back in 2004 when I lived in the UK, the NHS was really good. And I remember hearing at that time that it was nothing compared to the NHS in the 80s and 90s.
In a lot of respects, this isn't very accurate. It got pretty bad in the early '90s, anything that needed to go beyond the GP had really bad wait times, people stuck on trolleys in A&E, etc. By 2004 it was much better, so that anything which required a hospital visit would be dealt with much more quickly and effectively but the GPs were coming under more pressure from a growing and aging population so the first point of contact had a less personal touch.
I have to wonder how much of the current "crises" we are seeing right now are simply because of a massive aging population. Of course the medical system is going to have issues, no matter if it is public or private, if you suddenly increase the demand, as the older you get the more health care you need, while at the same time all your most capable and experienced doctors are retiring.
Another is housing, right now we have one generation coming up right as the most populous generation is towards the end of their life, resulting in an increased demand and price, in 20 years as more and more the later generations start passing on they'll be leaving behind houses and properties, it's not like those disappear when the people do.
I've noticed that the media seems very engaged in making everything the crises of the moment and the focus on looking at things over the course of years or decades is often ignored in favor of sensationalism.
An aging population is a significant factor, another one is the increasing range of treatments available today - and of course they combine because most medical expenditure happens during the last part of a person's life.
> Back in 2004 when I lived in the UK, the NHS was really good. And I remember hearing at that time that it was nothing compared to the NHS in the 80s and 90s.
That sounds like some seriously rose-tinted nostalgia to me. Yes, the NHS certainly has its problems. But within the past decade, my wife has been through several fairly major health issues, including cancer, and our overall experience of UK healthcare has been quite positive.
She is from the US (and had "good" insurance there), but feels that the UK system has served her far better than the American ever did.
When you put politicians in charge of healthcare they will play politics with it. Politicians playing politics doesn't make sense to you? Remember most don't really care that much about the healthcare itself, only how it can be used to further their agenda and be spun for their constituency. It's the tradeoff from private where the money rules.
In 2004 when I worked in NHS emergency care we had such a problem with no space in ED to unload ambulances that the ambulance service threatened to put a mass casualty tent in the hospital car park.
Seen exactly this in my local area. Libraries closing or cutting hours/resources. The number of children's centres (where you go for check-ups/weigh-ins of young kids, to get feeding advice, etc.) reduced by 80+% in some counties. It's dire.
you're misunderstanding the issue. NHS funding _always_ increases. Its not increased by enough and social care (a different budget) has been cut meaning that hospitals have to deal with patients that have nowhere to be discharged.
This is all due to 2008 can kicking. The needed to cut, didn't want to get blamed for cutting so just massively cut central funding for councils who were left to make the hard decisions. Year on year the cuts increased the drive for "efficiencies" grew. There is no slack left and nothing left to cut that isn't obvious.
I hope that someone learns that just because you've taken the cost of the balance sheet doesn't mean the problem it was solving goes away, it just ends up as an inefficiency somewhere else, in this case in the NHS where staff cannot discharge perfectly healthy patients.
Cash doesn't help bedflow if it's not going towards the places required for getting people out of hospital… which I've already said is now a local issue.
Job deterioration, Brexit and the pension cap have all lead to an increase in more expensive locum cover. Few people want to be locked into a job where you have a daily meeting to be shouted at by your site team for not discharging people who have nowhere to go.
Still not in line with what is required. An aging population which is also living longer couple with poor staff retention and management has left it in a much worse state that 12 years ago.
>Social care is now on the council to fund and many councils have squashed social care, along with libraries and early years provisions. The trap of outsourcing caught many councils out.
It could be phrased as - social care was a way to paper over cultural and societal cracks, by paying peanuts to people with limited job choices.
As in most things, our response to Covid has just exposed the endgame much quicker than expected.
People can’t be sent home because English people don’t give a shit about their family members. Brits think that the government should provide everything for them, even something simple as looking after an elderly person who is otherwise fine. What happened to family bonds and a bit of responsibility? Every winter around Christmas young family members (40-50 year olds) refuse to take their parents home because “they don’t want them at home over Christmas as it’s inconvenient for them” so they literally demand from the hospital staff to keep them in hospital for 1 or 2 weeks longer. Unfortunately the NHS is not allowed to dump these patients on the street. The problem is brazen entitlement. The NHS needs reform. Zero tolerance for those parasites, charge people for not showing up to appointments, charge people for simple medicines, charge people for choosing to be obese through an obesity tax.
> This isn't a collapse of emergency healthcare, it's a very predicted collapse of community social care: hospitals can't discharge if they need a care home place that doesn't exist. Without inpatient bed availability, ERs and AMUs can't admit to specialties and everything gums up at the front door.
How does that manifest as ambulance wait times? Do you think ambulance drivers are sitting around for an hour before responding to calls for help because... the hospital is full? That's like saying my train to the airport was late because the airport was full, it doesn't make much sense. How does one back up into the other?
If you come to our local DGH's A&E in an ambulance and you're not a trauma or cardiac or stroke, you face seven to twenty hour wait in the carpark.
You will see multiple paramedics as they change shifts in situ.
In fairness the ambulance service has scaled amazingly well given most of their staff are now pegged in hospital carparks, but yes, waiting times for critical calls are extended, people are dying because ambulances aren't available.
All because they can't hand over to A&E. Because A&E can't ingest patients. Because wards can't discharge. Because care homes don't exist.
It's that simple. If you doubled the number of community care placements, staff, etc, you'd buy the NHS another ten years.
On top of that, it's also now significantly harder to get a GP appointment vs 2-3 years ago so more people are ending up in A&E instead. My own GP surgery has gone from offering "turn up and wait for an appointment" at set times 4 days a week (and call to book a day ahead otherwise) to "you can't do anything without booking in the online system and then the GP will call you at a totally unpredictable time 3 days later when you're not available" because they think its "better" (which I suspect means because it has cut GP workload).
Yes, The ambulances are waiting outside the hospitals with the last patient so they can't go to get the next one. Source: Family members have recently waited some hours outside A&E in an ambulance.
This is hard to believe. Just wheel the patient through the front door and let the hospital do the babysitting. There is no sense in using an ambulance as a waiting room.
Babysitting? These are patients deemed medically unfit enough to bring in. Who's looking after them after they're turfed out the ambulance? Every bed in every bay in A&E is occupied, each with an allocated nursing provision.
Oh we just double the number of nurses? Yeah, but no. They don't grow on trees. The current ones don't stretch (we asked). You can't just absorb 20-40 patients into your acute departments without space and staff. The paramedics are acting as those staff, their ambulances the space. Yes it's far from optimal.
I don't really see how patients so severely ill that they need a bed in A&E with dedicated nursing provision could be discharged into community social care, though maybe I'm missing something...
About a third of beds are blocked at our local DGH by medically fit people who still require community care provision. These are people waiting to go home (or to a home) from an inpatient stay.
Until they go, A&E can't admit people through to the beds they're currently in.
Even if you lie to the population and claim you'll add 7000 beds this winter, those beds aren't staffed. We can't surge 5000 nurses and 2000 support staff out of nowhere. They're all busy.
I think perhaps their point is that, if some of the patients not discharged are consuming a nurse budget that isn’t required (because they are healthy and can be discharged), then this nurse budget could be redeployed to those waiting in admissions. Not sure how reasonable this is, I’m sure the hospitals will have thought of it themselves. But it does seem particularly silly to have the paramedics stuck in place and unable to serve anybody who may be even more critically ill.
The emergency department fills up because they can't find beds to admit people to. When the emergency department is full, there's nowhere for the ambulance patients to be put.
The patients are waiting in the ambulance because the waiting room is full, but I see your point. Why not just tip the patient onto the pavement outside the waiting room? I'm sure a full hospital with a full waiting room won't be to busy to sort that out.
> Why not just tip the patient onto the pavement outside the waiting room? I'm sure a full hospital with a full waiting room won't be to busy to sort that out.
Literally yes. Keeping them in an ambulance instead of the sidewalk won't get them into the ER any faster. And keeping the ambulance tied up at the hospital won't do any good for the next guy who has an emergency and is sitting on the sidewalk at the site of the accident either. At least if you move the injured people to the sidewalk at the hospital, the nurses can look outside and prioritize the worst. And the problem will be highly visible to the public, instead of papered over by using ambulances as waiting rooms.
What they're doing now is obviously prioritizing for appearances, not patient outcome.
Then you only rush to another patient who you can't treat either. Paramedics also need to hand off their treatment to hospital staff, if that doesn't happen then hospitals won't know what treatments were administered.
Using a parked ambulance as an ER room is gross mismanagement because the 'waiting room' for an ambulance 'ER room' is casualties spread across the entire city, such that the worst cannot be prioritized.
Even if the hospital's ER room has saturated capacity, moving all the casualties to the hospital waiting room as rapidly as possible still has utility because that allows the hospital to prioritize the worst, which they can't do if the worst is laying on the street a mile away with the ambulances all parked at the hospital.
I can promise you that the many smart people working in hospitals have considered this issue.
If someone is walking-wounded, they WILL be unloaded to sit and wait for 6 hours in a corridor.
The people who the ambulances are holding for long periods are those who are too sick to be left without attention. The paramedic staff continue to monitor them in order to escalate further if their condition deteriorates, and depending on the situation, medical staff from the hospital will be involved in this.
The ambulance staff obviously have a moral and legal duty of care, and can't just leave a seriously unwell patient on the floor outside the hospital entrance to get to the next call, which would likely be a patient no more ill than the one they just abandoned.
I’m happy that healthcare workers tend to be more empathic than what you are suggesting and will take care of patients end-to-end. You can’t load balance sick humans on the fly to achieve some optimal outcome.
> Do you think ambulance drivers are sitting around for an hour before responding to calls for help because... the hospital is full?
Yes, this happens - my grandfather attended with a head injury, and we were stuck in a side room with the ambulance crew (along with another patient and a second ambulance crew) waiting to do a handover.
>Areas with poor, old populations can never pay their way.
The root of the issue is that this area is now the country. Giving all old people the labor necessary to support them in old age was easier when the ratio of working people to non working people was much higher, in conjunction with old people not living as long.
Turn that population pyramid upside down due to drastically reduced birthrates and medical technology allowing people to live longer, and you get the current situation.
It's actually through the local governments, many of which are Labour yet have the same issue.
Root cause: the law says to raise local taxes beyond a certain amount councils must hold a referendum. They systematically refuse to do this because they know they will lose.
Voters by and large think local councils are wasteful and don't really need more money. There's also another issue: some local councils especially in the North have a history of deliberately cutting front line services whilst e.g. expanding the central bureaucracy, because they know they can blame the Tories for not giving them "enough" money and the voters will fall for it. The councils could raise taxes, or rebalance spending, but that wouldn't energize their base.
Well I suggest you visit Norfolk. Councils have sold off their long-held land to developers, dumped their investments to their mates, stripped down services and tendered the rest. Serco does everything.
Save the odd blip, Norfolk is as blue as it gets. Interestingly they also blame central government.
And local tax raising is pretty blunt. How much your house would have been worth in April 1991, if you're working. High-retirement or high-unemployment areas usually have lower rates, and much lower incomes, while needing more than rich areas.
Yes, I said "many of which are Labour yet have the same issue" i.e. it's an issue with local governments of all stripes. There's a culture of spending more than tax levels allow then expecting central government to make up the difference.
On your second part, this study also shows a significant 25y fall in the number of 85yo+ who are in homes. We aren't increasingly relying on the state.
Your statistics show an actual fall in the past 10 years. It's worse than that because the true picture needs to factor in local government spending now.
If we pretend there's been steady investment, and imagine stable demand, the same thing can cost more than it did before.
But irl, budgets have collapsed, demand is soaring and costs have already risen and are about to explode due to fuel-driven inflation.
So no, starved on three counts. The baseline cost is deviating from the investment. And yes, there are many, many elements to why.
>>Your statistics show an actual fall in the past 10 years.
From 22.79% of GDP in 2010, to 21.49% in 2016 (the last year provided). This is after an increase from 10.44% to 1964 to 22.79% in 2010. The big picture is a massive multi-generational increase in social welfare spending, interspersed with tiny downward fluctuations over a small proportion of the years covered.
>>It's worse than that because the true picture needs to factor in local government spending now.
This is aggregate public spending, so it should already be factoring in local government spending.
>>If we pretend there's been steady investment, and imagine stable demand, the same thing can cost more than it did before.
Per capita GDP has increased in inflation-adjusted terms, so when social welfare spending as a percentage of GDP increases, that means a real (inflation-adjusted) increase in per capita social welfare spending.
The only possible way this leads to less support for citizens in need is growing mismanagement of the funds by the social welfare programmes.
You asked how this amounted to Tory penny pinching in another stub but you're answering it. Since Tories came to power in 2010, a 1.3% fall in all social spending in an economy that has grown slower than inflation means an actual terms cut.
It's important to note that social welfare also covers housing, unemployment and other things not care in the same sense as being discussed. Housing costs have exploded in price so even more of that stagnant budget has been diverted away from care.
Once you allow for inflation, there is a growing underspend in care. A starvation. Yes, generations of growth, but not finding it appropriately now (and for a decade) means it's being starved.
I'm leaving it with the Health Foundation, there. I'd suggest you read that if you really want an appreciation of how budgets and inflation work together but if you just want to tell me "they have more money, so it's being wasted more" you don't understand how money works; I can't help you.
And if you're reading around, be wary of COVID era numbers as they include boosts for testing and extraordinary measures. Nothing that increases provisionable service.
If spending was the issue, the doubling of social welfare spending's share of GDP would have provided such a massive amount of resources to these programs that a 1.3 percent drop in relative spending wouldn't lead to the dire outcomes this article references.
And if you call the Tories reducing spending by 1.3 percent of GDP, what do you call a doubling of spending as a share of GDP? The Big Picture here is massive spending growth over the long run, that totally eclipses this minute drop.
>>Once you allow for inflation, there is a growing underspend in care
Wrong. The UK has seen significant per capita GDP growth, after accounting for inflation.
So rising social spending as a percentage of GDP means rapidly rising inflation-adjusted spending per capita.
Community care is far cheaper for society than having families take on extra dependants, especially at the most taxable end of their lives. Its interactions with the economy are very much like childcare.
But neither are happening. Old people are abandoned to healthcare providers. This, in turn impacts on the life expectancy of much younger people requiring emergency care who won't get it because the hospital and ambulances are full. It's not sustainable for patients or providers.
There are two ways out. Choose to do this properly, or choose a much uglier withdrawal of care for the old and infirm.
Before you choose, remember that these are people who worked for 45 years being told that their National Insurance payments were paying it forward for this kind of care. If you're going to change the rules —and especially if you're going to start incinerating grandmas when they get "too costly"— you have to expect the next generation probably isn't going to stick around. Many of that exodus will be doctors.
Seems to work better in this case, as essentially the only buyer of pharmaceuticals in the country the NHS are in a better position to negotiate deals in bulk than if hospitals had to negotiate individually. The UK has higher life expectancy than the USA for 2.5x less per capita healthcare spending.
I’ve heard a big part is all the doctors have been going on vacation all at once now that COVID is largely over, after not taking them for two years. They don’t have enough staff to cover even partial shortages.
That plus the elephant in the room of paying nurses/doctors more to keep them in Canada is always an issue.
There's a public sector salary cap in many parts of Canada, despite roaring inflation.
And a general vibe from the public and the government that generally despises public sector unions and would almost certainly backlash against nurses and teachers should they sensibly decide to go on strike.
For two years they busted their asses for the public in tough straits and now COVID numbers in the hospital system are still crazy but the public is pretending they aren't, and basically expecting the health care system to "deal with it."
A prov government here in Ontario that screwed the public health care system and nurses in particular all through the COVID crisis, and has every intent on doing more of that ... was just re-elected with a landslide majority.
If you put foxes in charge the hen house, it's not a surprise when the nurses^H^H^H^H^Hhens start to disappear.
It's the opposite of what you'd be doing if you wanted the system to function correctly... But what if you didn't? Because you wanted to replace it, but it was dangerous to say that out loud?
The Conservatives (and to some extent some Liberals as well) have been playing a long game -- since the 70s when it was introduced -- to get rid of medicare.
It's incredibly popular with Canadians as a whole, but if you take conservative leadership aside, get them drunk, and get them to speak honestly ... they want it gone. Or at the very least, severely curtailed and a private option introduced.
Klein tried to do it in Alberta in the 90s (bring in more extensive private services) and the feds (under Chretien) beat him back in the courts. But now they're getting quite open again about it in both Alberta and Ontario and pitching it as a solution to a crisis. A crisis they helped creat.
EDIT: again, I think the system needs reforming. But likely not the way they want it reformed.
I'm still an outsider (recent immigrant to Canada) but my impression of right vs left politicians here reminds me very much of Dems vs Reps in the US.
When the right obtains power, they incrementally and consistently put the pieces in place to ensure that the quality of gov-provided services decreases over time. Then when the left obtains power, they simply maintain status quo, never improving or fixing the problems created by the previous administration.
And of course, we have issues where practically no one shows up to vote and a widely-disliked premier gets a majority government, a premier who will continue to ensure the gov-funded options get worse.
> When the right obtains power, they incrementally and consistently put the pieces in place to ensure that the quality of gov-provided services decreases over time.
My favourite was when one promised 'fiscal restraint' and no deficits, so they sold off a 99y lease on a tolled highway to plug their deficit. They promised prices wouldn't go up more than 30% in 15 years, but they went up 200%.
While your point about aircraft landings is funny, I'm guessing general aviation in Canada is similar to that of the US. It's not really uncommon for planes to land on highways in the US. Even busy ones. It just isn't very interesting to be honest, so no one makes much point about it. I think the FAA publishes numbers on that sort of thing.
You're missing the point. The 40x series highways around Toronto are some of the most gridlocked transportation networks in North America. I believe often ranking worse than LA or Atlanta etc etc. The 401 is pretty much bumper to bumper every single day all day except maybe at like 3am.
The 407 toll route the author is describing takes basically the same route as the gridlocked 401. The toll on the highway is insanely high, probably 10 x higher than anything you'll see in the US on any of the EZpass etc type routes. If you were to take it end to end (100ish km or 60 miles, maybe a 45 minute or 1 hour drive tops) you'd probably be paying at least $60 CAD or so.
Because it's so high, it's essentially vacant large parts of the day.
Yes planes can land on highways and do so all the time. The point is that the only highway they could do that on in the GTA is the 407. Because it's priced so insanely high.
And that money is going straight into private sector bank accounts, not into public coffers.
I've been around Toronto and agree: the roads are mostly parking lots. I actually wonder if the low average speed reduces the cost of maintenance since the roadway should be less worn.
But aren't tolls meant to be set high enough to discourage their use? Otherwise the average travel time on them would be about the same as the untolled route.
The 407 could likely handle 3, 4 times the capacity it holds right now.
I don't know what the elasticity situation and supply/demand looks like for that highway. I can guarantee you that the owners do, and they've set it accordingly to accomplish their goals ($$). But not necessarily the goals the benefit the city.
For me it's the difference between being able to work at certain employers in the west end of the GTA vs not. The fee, paid daily, would be a big nope to me. And I'm upper middle class.
Ah alright, that makes discussion of this rather complicated. We don't really know what the road would have ever looked like when completed by the Canadian government.
In the U.S., it was the left that got rid of the civil service exam.
My guess is, rules that make life harder for teachers, such as ongoing education requirements, also tend to come from some wing of the Democratic Party.
I am just trying to give some examples and not make some grand claim; I think both sides do a lot to make governance ineffective when they don’t want that kind of governance, or are having a bout of manic stupidity.
I think you're giving a lot more benefit of the doubt to the Liberals (and US Democrats) than you should.
You're assuming they have wildly different aims. But I don't think history has borne that out. If you want to know why they're so tepid and inept in their opposition to the right and far right, it's because there's not enough of a substantial difference in fundamental direction and policy. (And liberals are on the whole conceptually unable to mobilize in a populist way because they distrust mass politics.)
Yes, on the cultural issues front there's substantial disagreement. Though less so in Canada where there's more of a socially liberal consensus.
But on the economic and political side of things, it's not clear to me that there's a strong ideological dividing line here.
Both are roughly in favour of the same neo-liberal economics. Private sector == good, low corporate taxes == good. Essentially supply side conformity.
But both are responsive to different bases.
The Liberals in Canada cannot move against social programs at this time, or cut social spending broadly -- but they absolutely have done so in the past. The Chretien Liberals enacted the most brutal austerity initiative in Canadian history, and in fact one of the most drastic in the entire G7.
At this point, the Liberals broadly support a kind of neo-Keynesian aggressive social spending. But I'd argue that this is not based on fundamental principles, but based on their need to acquire votes and to squeeze out the NDP. With inflation and various budget indicators being what they are, I am pretty sure the Liberals are prone to leaning back into an austerity direction ... if the NDP vote were to collapse completely, like it did in 1993 (down to 9 seats its worst performance ever), you can pretty much bet the LPC would be back to massive budget cuts. And I think Singh is taking the NDP in that direction, so.
I think you'll have a hard time seeing a strong economic policy differentiation between Harper's Conservatives and Trudeau's Liberals. (Or McGuinty/Wynne and Ford) Both responded with intensive social "stimulus" spending in economic crisis (2008 & 2020 respectively). Both used debt as a tool in a massive way. Neither side showed serious fiscal restraint. Both sides have kept a massively low corporate tax rate (one of the lowest in the western world and drastically lower than the "right wing" USA) Both favoured policies that pumped up the real estate market. Both had aggressive immigration and temporary foreign worker programs. etc etc.
... And both directed their spending at their respective voting bases in a way that verged on corruption (Harper threw money at Alberta in a huge way, Trudeau more in central Canada).
The basic fundamental difference between the two at this point boils down to which sector of Canadian capitalism they represent. The Conservatives are 100% aligned on the energy sector and its demands, and the ideological banners erected in its name in Alberta (along with all the climate change pseudo-denial/defeatism that goes with that). The Liberals represent different interests, some regional to QC, some of it sector-based (real estate & manufacturing). None of it altruistic, or principled, and none of it truly pan-Canadian.
Excellent summary. Might be worth noting that even if a party arose that wanted to make significant economic changes they'd be dealing with US and international finance interests that would make that very difficult, and we are probably stuck in the same political rut that US citizens find themselves: economic and material change is not really on the table for any party. You just get to pick your flavor of social stance and the general economic sector the little money that does come gets directed to (urban/real-estate or rural/oil). We're baked into the international religion of the holy free market, same as everyone else.
Hey, if you object to privatizing healthcare, why do you hate the free market? Don't you think that private healthcare and insurance companies should be able to skim billions of dollars off the top of all health-related spending? Are you some kind of commie?
In reality what we have in Canada is already like that to some extent. Doctor's clinics are private businesses. And they bill the government. Yes the terms of that are fixed (and continually under dispute.) But the profit taking and skimming absolutely happens. Just that, unlike the US, there's a single public payer of it.
It ain't socialism. Parts of it may look like it, but most parts do not (unless your definition of socialism is "guvernm'nt does stuff", which is silly).
It's also not working particularly well right now.
>Don't you think that private healthcare and insurance companies should be able to skim billions of dollars off the top of all health-related spending?
The drug companies and medical supply companies already do that whether or not healthcare is "private". We need a massive overhaul of the patent system if we ever want to bring down the cost of healthcare.
Same playbook in every Western country, with a long game from very deep pocket interests. Inevitable declining force barring a resurgence of power in democracy against capital - i.e. a change in our voting system, which will forever be locked to a 2/3 party system which is easily captured.
The business idea behind the salary cap is to make budgeting more predictable. If the budget is $X and you need a staff of Y, your salary cap of $X/Y makes it easier to manage... in theory.
In reality, if $X/Y is low, then you can't find anyone who will work at that rate and you either have to cut back services or outsource (which is often in a different budget - see traveling nurses).
It is the opposite of what should be done, but if you're trying to fit things into a fixed budget then it is what must be done. The way to fix it is to get the budget to expand up to what is needed to supply services. That is a difficult sell in the public sector.
At the same time there are plenty of medical specialists in the sunshine list making 400K+ CAD. Keeps me wondering why radiologists are paid that well, compared say with oncologists. Also do not forget 1) province caps on medial school admission and 2) administrative bloat. Nurses shortage is only one of the many issues with the healthcare in Canada.
However when I was taking a $300k+ CAD comp package at Google for a (relatively low ladder) SWE position, it was really hard for me to sympathize with people griping about anybody being overpaid in the public service.
Pricing irrationality is one of the usual critiques that libertarian types have against state-run anything. Thing is that the US health care market also exhibits similar distortions. I think it's a constant struggle.
I think the Canadian system (and probably UK NHS) is due for major reform. I just do not trust the people in power to make the right kind of reforms. Again, foxes and henhouses.
Only the small fraction of doctors that are government/hospital employees will show up on that list. The vast majority that are contractors or under non-governmental employee arrangements will not.
I think radiologists tend to be employees since they usually don't physically see most of their patients, but not sure.
And those showing up on that list as employees may still have other revenue from services they can bill for as contractors.
I'm happy for them that they made it to the point they can actually take time off. A big issue over here (NL) is that the doctors and nurses have fallen ill themselves, either from the 'rona or long covid, or from being overworked for so long. And because of the workload, a lot of people have quit as well.
There's somewhere from 1000-2000 health care workers that work in the Detroit area, but live on the Canadian side.
When the borders were sealed shut-ish, they were going back and forth regularly and not required to quarantine upon return at any point during COVID like most everyone else returning was.
Kinda defeated the purpose of trying to keep a virus out of Canada when you literally have Canadians caring for the most afflicted people regularly with relatively few restrictions upon return.
Certainly it does, but one can guarantee more than 30min wait time at some emergency rooms coming up as they are closing outright due to staffing issues.
https://bc.ctvnews.ca/8-more-overnight-closures-on-the-way-f...
It's a real problem, and not just in BC. Some have argued this is a politically manufactured issue to force more talk of private care ... regardless, people are suffering in the mean time.
Most larger places publish these numbers in real-time. But the info can be very limited. Some things can wait, other things can't, and they don't publish the bucketed numbers:
My 80 year old grandfather was due for a knee operation and it was delayed twice. On the day after the second time it was delayed, his knee collapsed and he smacked his head on the concrete floor. His speech was slurred, his vision was affected, and he was in extreme pain. Bearing in mind in his younger years he's had eyes slashed open and fingers cut off, so he has a high pain threshold.
The ambulance took six hours to arrive. If his brain was bleeding he would have died. When they arrived at the hospital they were waiting a further six hours to be seen.
The NHS is a tragedy and I almost wish they'd just hurry up and privatise it so I don't have to pay with it with my taxes anymore, which means the Tories achieved their goal.
If I didn't have private healthcare I'd have left the UK by now. I was born and raised here, so I think that says something.
Not that it helps, but this is happening in most Western countries.
In Canada, healthcare has similarly collapsed. Decades of mismanagement and absurd government policy finally broke the system during the COVID lockdowns and now the system is worst than many third world countries.
Like in your example, it will take hours to get ambulance and I don't mean in some rural town in Canada, I mean in downtown Toronto. Most people are just Ubering or getting driven to the hospital and camping out at the ER - and I do mean camping because it could easily be a day's wait for something fairly urgent. We've had plenty of people die in waiting rooms this year.
The worst part is there is no private system allowed here - in fact the provincial BC court recently ruled that private health clinics operating outside the public system are not allowed[1]. As a Canadian you no do not have a right to healthcare if that healthcare is private - your choice is die in the public system's waiting room or hopefully be rich enough to fly to the US for care.
> The worst part is there is no private system allowed here
This is not the worst part. The worst part is years of strategic systemic defunding and dismantling of the supports of the public system while spreading propaganda far and wide has led to a desperate public with Stockholm-syndrome wishing for private healthcare.
>The NHS is a tragedy and I almost wish they'd just hurry up and privatise it so I don't have to pay with it with my taxes anymore, which means the Tories achieved their goal.
I hear this bandied about a lot, but do you have any evidence to support this claim.
"In 2006/2007, 2.8% of NHS spending went to private providers, rising to 4.4% in New Labour’s last full year in government and 4.9% in the first year of the Coalition. About 7.6% of NHS revenue spending in 2015/16 went on purchasing care from private providers.12 In the three years from then to the Covid-19 pandemic, private spending flatlined, with the combined non-NHS spend of Commissioners and Trusts being under 8%.13 The Chief Executive of the NHS predicted in 2015 that the proportion of NHS work going to the private sector would be unlikely to increase beyond ‘the margins’.14 He has been proved right." https://journals.sagepub.com/doi/full/10.1177/01410768211049...
From what I've read Labour was also responsible for the privitisation of healthcare.
Not that I'm personally opposed to some privitisation in a sensible manner, but the privitisation debate just seems to be some form of political attack with little grounding in reality.
Why do you say that, do you have any evidence to back it up? Not saying the US healthcare system is anything to write home about, but it always seemed to me that as long as your pockets are deep enough you should be able to get healthcare when you need it in the US.
There are some private practices that will let you pay a premium for quick appointments, but if you need a hospital, you're probably going to experience some wait.
The US isnt listed on either of the Key Data graphs? Clicking read online, and browsing to section 2.2, it seems the US doesnt fare too well in figure 2.1 (The share of people who sometimes, rarely or never get an answer from their regular doctor’s office on the same day varies by more than two-fold across countries), but does much better in figure 2.2(The share of people waiting one month or more for a specialist appointment is two-times greater in some countries than in others). I dont see the US listed in any of the other figures?
The thread reminds me of the Guardian's podcast "Sewage Sleuths" which uncovered catastrophic sewage being dumped into England and Wales's rivers and streams. Very informative and enlightening how bad some government infrastructure can be (hint: in the podcast they also enlightened HOW the failure got bad).
It's worth clarifying that the issue with the government infrastructure is with the regulatory agencies, rather than the water infrastructure itself which is privatised.
It's a failure of privitisation 30 years in the making since water and waste management was privatised in 1989 here in the UK. Of course you can lay some blame at the door of the regulator but let's not forget the tens of billions that have been siphoned off to shareholders and fatcat CEOs, some of whom are arguably criminally negligent and should be put on trial for the catastrophes that have become apparent in recent years.
I really don't like this kind of knee-jerk "privatisation bad, fatcat CEOs bad" reaction sadly prevalent in the UK. Let's talk about the underlying argument, shall we?
Firstly, you're talking about a failure of a regulator to regulate an industry and prosecute alleged perpetrators, and the implied solution is to… nationalise the industry, somehow assuming the nationalised entity will be managed better by the very same regulator? I don't think it's a good argument really
Secondly, if we go even deeper, what pressures would such an entity have to provide good service and not be wasteful with their resources? Right now there's at least market pressure, the companies trying to outcompete their peers, cut costs, and ensure future profitability by investment. What pressures do you think exist for a nationalised entity that don't exist for a regulator?
Thirdly, do you actually have any evidence to prove that those companies are uniquely profitable? Because unless they are, it's only fair that people investing their own money into infrastructure (remember, that was one of the goals of privatisation, tapping private budgets in addition to tax money) get some return on it, otherwise they'd just invest it elsewhere, e.g. into Apple stock, which would benefit British people much less.
Privatisation per se is not the problem, political failures are.
How can you look at horrible evil companies literally destroying the environment around us just because it makes them more money and say there's no alternative??? If you need a regulator to make sure companies don't literally dump sewage all over the country then it's pretty clear that this is a failed system with bad incentives.
What pressures would a nationalized system have? How about the fact that normal people don't want to ruin the environment around them? You don't need additional pressure to make sure that doesn't happen. If you stop optimizing for short term money the problem goes away.
And I don't give a shit about private budgets. The government doesn't need that shit, it can create money as it needs to allocate resources. And if it needs to reduce money supply that's what taxation is for.
>What pressures would a nationalized system have? How about the fact that normal people don't want to ruin the environment around them? You don't need additional pressure to make sure that doesn't happen.
Elsewhere in this thread people are literally talking about nationalized healthcare systems where people are waiting hours for ambulances, or dying in hospital waiting rooms. I think the statement of "normal people don't want to ruin the environment around them" is applicable to the people working in those healthcare systems, yet it's still apparently happening.
Entirely different situations. One is happening by design, the other is happening due to external circumstances.
Private companies pollute because dealing with externalities costs money. It's not a problem they're trying to solve, it's a feature they implemented to increase margins.
The NHS doesn't have appropriate funding. If you increase funding you fix the problem. From what I've seen, the NHS used to be great until the 90s when the cuts began.
The NHS is collapsing due to politicised defunding. The NHS is a sacred cow in the UK so the right can't overtly criticise it, instead it's death by a thousand cuts (pun intended).
Remember Noam Chomsky's quote on this subject? "Privatisation technique: defund, make sure things don’t work, people get angry, you hand it over to private capital". The latter part is already happening.
Because I'm well aware of horrible evil governments doing exactly the same. Norilsk became what it is now under Soviets, which were not keen on private enterprises. Pollution is more or less orthogonal to the form of ownership.
No, the problem does not go away. You start optimising for short term political goals (see also: ongoing property debt crisis in China), and minimising short-term drama (see also: regulatory capture by unions). Sometimes you also start implementing insane projects just because your glorious leader decided to do them and cost/value is not an issue (see also: Chinese war on sparrows). Sometimes you just minimise the expense and make everyone disagreeing with you shut up, because they don't have a choice either way (see also: Chernobyl not having containment). You also get way less feedback, because you're spending someone else's money (i.e., taxpayers'). So no, "government consists of decent people and they won't optimise for the short term even though they are doing it now because there'll be no commercial company controlling it" is a very optimistic take at most and definitely not a realistic one.
Stop fighting with the man in your head and actually engage with the argument. Private for profit companies inherently optimize for profits. Dealing the pollution costs money, so they don't do it. This is by design. This is a bad system, and it will never work no matter how much duct tape you throw at it.
Neither government agencies or crown corps are perfect, but at least they're not inherently flawed either. Yes they're subject to different circumstances than market companies, but that can be dealt with. Capitalism's inherent drive to cut corners and destroy the environment can't.
Even if the water companies were state owned, dealing with the pollution would still cost money and there are a bazillion other demands on the state's finances which are more pressing than keeping rivers clean, such as providing healthcare. This isn't a hypothetical. Scotland has a state-owned water company, and it'd be impossible to write an article like this about theirs not because they're doing better - all indications seem to be that that they're not - but because it relies on information from monitoring equipment that just doesn't exist there. It was pretty recently added in England too, over the last few years, so it's clear that the Environment Agency does actually care about this... not that you'd even know that had happened from the UK news coverage, especially the Guardian's.
Other places in Europe seem to be even worse. For example, I've seen people from Ireland shocked that thsi would happen and preaching the benefits of their state-owned water and their fight against privatisation and water billing. There are places there which literally have no sewage treatment plants still. As in, their sewage goes straight from their houses into the rivers and the sea untreated, not because of a fault or undersized treatment plants or heavy rain ( all of which they have problems with too) but because the sewage system is literally designed to do that 24/7. The government was meant to have fixed this decades ago according to EU rules but has kept dragging its feet on building sewage plants. And they're probably not unique - they were literally the first country I checked, and the second, Spain, had the same issue as well.
No, the argument is that nationalisation/privatisation is irrelevant to the problem at hand. There is no causality, there are plenty of examples of well-regulated private companies and disastrous state-owned ones. There might be a correlation, but you didn't show any numbers to that effect.
"How can you look at horrible evil companies literally destroying the environment around us just because it makes them more money and say there's no alternative?"
I guess for me I just don't understand how nationalising a given company makes it stop emitting carbon.
There's no competition for water here. And even if there were, what are they competing on? They don't produce water, they don't manufacture anything, there's no innovation to be had. The water is the same whatever the case. There's no advantage to a market.
So how do you seek profit as a water company? You can't seek more customers, since that is constrained by population. All that's left is reducing overheads and increasing margins. By reducing quality of service. By not improving infrastructure, or letting it fall into disrepair. Or, as discussed here, dumping sewage and ignoring costly environmental responsibilities. A tragedy of the commons.
As for the regulator. They are duty bound to ensure water companies are making profits. The incentives are all wrong.
You are assuming they are competing. They are not, you get one choice for water company in the UK. Therefore, by your own argument, they have no incentive to provide a good service.
I mean, in theory there's the backstop of getting water delivered by truck and everyone having a septic tank. Service would have to be extremely bad for that to be the better option, though. Just like how trains compete with buses, cars and planes.
I work for a private energy company so you don't have to tell me it's complicated when it comes to the private vs public ownership debate. There is a complex spectrum between the extremes. There are very obviously the wrong incentives in the water setup and a failed market. Tbh, I'm open minded about nationalisation in some areas of some sectors with what I'm seeing right now. It's undeniable when you look at the history.
I hadn't (here in the USA) heard anything about "collapse of emergency healthcare in England" -- can anyone provide some links for some context? What is actually going on, and (to the extent people know/educated guess) why? Have wait times been gradually increasing, or has there been a sudden increase? ("collapse" sounds sudden?) Etc etc.
The Conservative Party have been in power for 12 years. When they gained power they pursued a policy of "austerity" to reduce the size of the govt and local govt, reduce the funding of nationally funded things, and to replace such govt owned things with "public private partnerships". This can be seen everywhere from social care (private care homes), schools (academy schools), transport (where area contracts are bid for by private companies), etc.
With health specifically the goal is to have more privately owned profit making companies in the NHS. The NHS as it is constructed doesn't allow for this. But for the Conservatives this opportunity for them and their backers. For the public, there is a national pride in the NHS.
So we entered the pandemic with an already under-funded and stretched health care system.
Much to the chagrin of those in charge though... this has not led to any calls for privatisation. Nor has it led to a boom in people taking out private health care cover.
It turns out that the British stiff upper lip response to something they're nationally proud of is that they'd rather die than embrace health privatisation. So we're in uncharted territory... the playbook that had allowed the privatisation of almost everything else isn't working now, it's just killing people.
> It turns out that the British stiff upper lip response to something they're nationally proud of is that they'd rather die than embrace health privatisation. So we're in uncharted territory... the playbook
Good for you guys.
Basic healthcare should be a public service to maximize most coverage at a reasonable quality level.
Not privatized to get the most money for the least amount of service, which is the practice of virtually every long-lived business.
>> The Conservative Party have been in power for 12 years. When they gained power they pursued a policy of "austerity" to reduce the size of the govt and local govt, reduce the funding of nationally funded things, and to replace such govt owned things with "public private partnerships".
Folk talking about austerity as a tory thing are going to be in for a monster shock if energy prices persist through the next elections, and when they realize the size of the Covid bill vs the GFC bill. It may very well be Labour sitting as the final nails are driven into the NHS, just by sheer luck of timing
The end of the NHS is unlikely to be caused by money or lack thereof, given the NHS was founded while the UK was still suffering the economic consequences of the pyrrhic victory of WW2 — food rationing was still a thing, and was only completely ended six years after the NHS was founded, just in time for the Suez crisis to bring it back for a few more months.
> the NHS as it is constructed doesn't allow for this.
This is simply untrue. (What is Livewell South West?) We've had private provision of NHS services for years and the Lansley reforms explicitly embed privatisation (state funded private provision) in the NHS. Commissioners are forbidden by the 2012 law from preferring NHS providers over NHS providers.
For years people have been raising the warning about the pressures on healthcare system, and for years the conservative party have asked the NHS to do more with less.
What does collapse look like?
Well, in the early days, it looks very gentle. The four hour wait for ED treatment goes up a bit. Healthcare people say "Look! This is concerning!" and politicians say "eh, it's just winter pressure, we know things are rough in winter."
Or you say "Look at the waiting list for community eating disorder treatment, this is concerning!" and politicians say "we're taking people out of mental health hospitals and giving them treatment in the community, so there's a transition period" (they cut beds for ed treatment, but didn't also fund community ed treatment, so wait lists have gone up a lot).
It's like Buckaroo or kerplunk or jenga. You can load the donkey, pull the straws, pull the blocks, and stuff still sort of works (less safe, less effective, more harmful) but then something happens and blam you've tipped over into catastrophe.
This is especially true in the UK, but I think the surprisingly under-appreciated, under-explored fact of western democracies for the past 50+ years is that ultimate power truly lies with the mainstream press and what they're willing to cover, and whose politics they're willing to tolerate.
There is no institution more powerful in shaping the minds of the public, and they do very frequently act as a monolith, especially in the UK.
> Almost 333,000 hours were lost by ambulance crews because of handover delays in the 12 months to July 2022 – 18 TIMES higher than the 17,600 hours lost during the same period in 2019 to 2020.
They subtract COVID deaths from excess deaths to get the baseline, forgetting that COVID deaths were counted somewhat liberally, and some percentage of non-COVID deaths were counted as COVID deaths if someone was infected close to their time of death. This can be seen in the following chart: https://ourworldindata.org/explorers/coronavirus-data-explor... (You need to change the "Metric" dropdown)
If you compare excess deaths in 2022 to COVID deaths in the same period: Peaks in COVID deaths don't produce peaks in excess deaths. So saying that excess deaths are higher now than they were in the past is likely due to the underestimation of con-COVID excess deaths during COVID, and not a real effect.
> They subtract COVID deaths from excess deaths to get the baseline, forgetting that COVID deaths were counted somewhat liberally, and some percentage of non-COVID deaths were counted as COVID deaths if someone was infected close to their time of death.
If COVID deaths were counted liberaly and even after subtracting those inflated numbers you still have excess deaths, then that only further underlines their point that these excess deaths are not COVID-related.
Just because you think the criteria for counting COVID deaths were wrong doesn't make every conclusion based on those numbers incorrect.
No, they say that current non-COVID excess deaths are higher than non-COVID excess deaths were during COVID. They underestimate non-COVID excess deaths during COVID because of the subtraction, which makes current excess deaths higher than average. In reality, they underestimated the average that they compare to. Hope it's clear now.
I see what you mean, yes it does make it difficult to prove a trend between periods with high rates of COVID infection and low rates of COVID infection.
But proving such a trend is problematic regardless of what the criteria for a COVID excess death is. Simply because during a period of high COVID infection a lot of people are dying from COVID before they have the chance to die from other causes.
However, Covid preys heavily on the already sick. We should see a *reduction* in deaths because Covid killed off a lot of people that didn't have a lot of time left. We don't even have an accurate baseline to compare to at this point.
I don't have time to go in depth on this but I'm a bit skeptical of the claims here
After adjusting for age, the english excess death rate is 5% above. It is the highest. But it also just came from being the lowest several months ago. How much natural variance is in this data. Is this moment noteworthy? Is it possible we're not seeing more people die sooner but rather a large chunk of people putting off death a few months all kicking the bucket now for some reason?
Twitter confuses me a bit but reading all the thread here seemed to hide some additional posts which were important. The rate of people going into the emergency room is normalish. The rate of people leaving it is slow but not clearly slower than normal. This does suggest the general problem is really that we don't know where to put all these incapable poor health old people.
But... If we assume that people are leaving the system at the same rate as before (afaict no data here), and that the health system had large inflows of patients from covid earlier, it seems likely that this is just the system slowly returning to equilibrium and dealing with that excess bulge of patients who entered and are hard to get rid of. The problem is probably not that patient outflows have gotten worse. It's just that there are more patients in there now because there were a lot more new patients shortly before now.
He's got one critical chart which shows that hospital occupancy % has been growing from 6% to 8% 2010-2020. It is now at 12%. But the data is missing for the pandemic period for some reason. So... that seems like an important bit. Is this problem correcting itself? Kind of depends on the rate of change we're seeing in this figure if the rest of the analysis is to be believed. But it's hidden and too short term to make a good forecast on just the recent months.
> This does suggest the general problem is really that we don't know where to put all these incapable poor health old people.
This has been the case for years: there are plenty of people who should not be discharged home to fend entirely on their own, but there's no social care in place to look after them, so they aren't discharged. This is also technically the responsibility of the local council rather than central government.
During the pandemic there was almost unlimited money available for Test and Trace, some for the entirely temporary "Nightingale" hospitals, .. and basically no effort to increase staffing levels or solve the social care issue.
>This has been the case for years: there are plenty of people who should not be discharged home to fend entirely on their own, but there's no social care in place to look after them, so they aren't discharged. This is also technically the responsibility of the local council rather than central government.
Not to mention that local government had has its funding cut to the bone (and beyond, in many cases) over the last 12 years of Conservative government.
But my point is that this seems to have been a gradually growing problem for some time, but the recent spike from covid is likely a temporary bump greatly exacerbating it. It'll drop down again. Then, gradually, climb back up to where it is now. If it reverts to the mean quickly, it still won't take that long to get to where it transiently is now based on a straight line trend so maybe it's just a point of pedantry.
tl;dr at a glance it looks like lingering effects of covid have pushed the english health care system into a state a single digit number of years ahead of schedule. It will likely wear off, but getting back on track isn't much of a relief.
That could be true of some queueing systems, but its certainly not true of all queuing systems. It is certainly not true of this system because you cannot stay in the queue forever. Over the long term this will converge on a steady state determined by rate of arrival and rate of departure, treated or otherwise, and nothing else.
Anecdotal, but I have twice in the last year heard from the same friend of 2 instances where the waiting time for an ambulance was around an hour.
The first was when he observed an accident where a car hit a guy on a scooter. The guy was hurt, but not in a life threatened manner.
The other was a guy in a bar who probably overdosed on something and his heart stopped. If someone hadn't been around who knew CPR, he would have been dead.
Even more worryingly is that London has some of the fastest response times in the country.
Last two times I had to call 999, for ambulance and police respectively, I was on hold for more than 5 minutes before even being connected to an operator. The overall ambulance target response time is 8 minutes.
NHS has been underfunded for years. These issues are, in a way, not new. But it just kept getting worse and worse, COVID added burnout and a huge backlog of treatments and missed diagnoses.
It probably doesn't help that a lot of the medical staff were from the EU and just before COVID were PTFO.
I'm still waiting for those hospitals to be built by all the money saved by Brexit.
How do you know the problem is in fact underfunding? The UK seems to spend as much on healthcare as many other first world countries, but with worse results.
Well, let me rephrase. NHS has for a long time been unable to spend money it considered necessary for a sufficient level of ongoing and preventative care.
At the tail end it certainly seems plausible, stories about lack of funds for hiring doctors, and visible queues at A&E have long been a staple of healthcare. What caused that tail-end lack of funds, I'm not sure.
Increase in demand - much of which is attributed (by the NHS itself) for people having poor life-styles (meaning tending to obesity [0] and not maintaining physical and mental fitness), and the tendency for people to be kept alive longer existing with chronic conditions that a few decades ago would have naturally expired (dead!).
There's been an endemic problem for the last 30+ years where-by a large proportion of the population has a sense of entitlement to NHS care without at the same time bearing responsibility to keep themselves reasonably fit and healthy.
@ [0]: "Nearly two-thirds of adults in England are overweight or obese. In 2016/17, 617,000 admissions to NHS hospitals recorded obesity as a primary or secondary diagnosis"
> Nearly two-thirds of adults in England are overweight or obese.
That means the issue is systemic and one needs to look at things outside of individual control. Yes, often systemic issue can be overcome by individuals - by the top quartile kind of individuals with more luck, better genes, better education (including what they picked up at home while growing up), more money, more suitable lives than the majority, or with outliers in levels of personal discipline. But systems should work for the people that actually live, if you need to blame two thirds of the population(!) it's most likely your system that is wrong.
Yes you can look at most of the individuals that are part of those two thirds and find what seems to be personal choices - but you miss the environment and the pressures from it that lead people into making those choices.
For example, that a lot fewer people know how to cook today than several decades ago (example link: https://www.bonappetit.com/entertaining-style/trends-news/ar...), do yo want to blame each individual? To me this very much looks like a bigger societal issue. It's not like people make such choices after careful consideration, it "just happens" and they "slip" into those behaviors without much deliberation, based on their living situations.
You can both blame people and society. Modern living makes it easy to be fat, but plenty of us don’t succumb to the temptation of easy meals and overeating.
I’m not sure how you’d even change modern life to get around this, save maybe for incredibly large sin taxes on everything from soda to every restaurant. I’m sure we’ll just end up with a pill sometime soon. Semaglutide comes close.
I wonder if metformin does the same thing, but the patent fell off too soon, so there just wasn't much marketing for its benefits to decision-makers.
metformin for 26 weeks lead to a net 6.6kg weight loss in non-diabetic obese patients (I would've preferred BMI reduction as the outcome measure, and a placebo-control arm, but can't have it all):
The UK has an ageing population. A higher percentage of older people and fewer younger people. Saying that those old people should have died earlier would be disgusting so I'm sure that's not what you meant.
So to be clear there's an increase in demand because British people are living longer. That's a good thing and should result in increased funding.
It's exactly what I mean. There is absolutely no value in hanging on to the last possible moment due to ever increasing levels of interventions.
Living longer is not "a good thing" if that life is costing (not just in financial terms) society and the country so much more and the person can not sustain an independent quality of life.
In 1946-47, when the NHS, National Insurance (state pensions), and related programmes were created the average survival after retirement (60 for women, 65 for men) was 10 years or so (average mortality was 75 for men and little later for women).
So pension funding only needed to last on average 10 years and there was no comprehensive costly life-sustaining interventions to keep people alive that would otherwise have popped their clogs.
Now the average age of mortality in men is 85 and 89 for women, and these are rising. And as these are averages there are a lot of people lasting a lot longer - many spend years sitting in a chair effectively waiting for Death to show up.
So now the same pension funding has to provide for 20 or more years AND there are many costly and life-sustaining health interventions and "social care" that add cost and load on a dwindling number of tax payers.
I'm a farm-boy born n bred, as is my father, who is now 86. He's been amazingly fit his entire life but the last two years he's going rapidly downhill due to onset of mild dementia, but also due to not accepting doctors advice on treatments and medicines (this he's been doing for 40 years!) and subsequently hitting crisis where there have to be expensive emergency interventions.
As far as I am concerned he is abusing the NHS - like those who are obese or mistreating themselves in other ways - and if it were up to me I'd refuse to treat his emergencies if he is not prepared to look after himself by simply taking medicines that would prevent the emergencies.
Personally, I'll kill myself when I can no longer be useful.
Humans need to learn from how the rest of the planet's breathing life-forms treat life... and death, and lose the sentimentality. The planet already has twice as many humans on it as it can naturally sustain.
Meanwhile in the US there’s been a push to limit the copays for insulin, pushing the cost of all of those almost entirely preventable type 2 diabetics on to everyone else.
Lack of qualified staff willing to work at the current pay rates. There are shortages in plenty of sectors at the moment so medical personnel who have had enough are leaving or retiring early and they can’t be replaced because pay rises are not keeping up with inflation. I’m going to look for my source just now but I read that there are 100,000 vacancies in the care professions currently. Postal workers, train drivers, bus drivers, dockers and barristers(!) are all planning to strike in the next month or two because of inflation effectively causing large pay cuts.
There's a big problem where social care got moved from the department of health to local government a few years ago.
Then, shortly after, the government cut local government funding massively. It used to be funded by a mix of local taxes and funding from central government that was about 50/50. This was part of a strategy to insulate richer areas from the impact of cuts, while poorer ones (which relied more on central funding) took the hit.
This means there's a huge problem with elderly patients who need to be discharged into social care not having the support they would need to go home or a spot in an old people's home to go into.
Which, combined with covid still being around and the fact that even before covid government obsession with efficiency meant that there were a relatively low number of beds which already had a high occupancy rate.
So there was no spare supply to begin with, increasing demand due to a growing and aging population and covid, and lots of people who are stuck in hospital because they need support to leave which doesn't exist.
Both. Demand has increased faster than expected because of covid, and supply has been hampered by covid, but even in the counterfactual world that has not faced this pandemic the UK has not funded enough nursing places to meet the previously forecast demand (the ageing population told us demand was going to go up, but the government cut funding in 2017 that reduced nursing degree applications in England and Wales by 23%), and Brexit reduced the number of nurse applications from the EU.
In England social care (care homes) are funded by local authorities, not the NHS, and are overwhelmingly provided by private providers. We've had decades of under-funding of local authorities, and the Conservative government has made it very difficult for LAs to raise funds via taxation.
So, during a time where we have an ageing population we do not have nearly enough beds for these people to be cared for.
When people go into hospital, either as a planned (elective) admission or as an emergency, and they get treatment, and they're ready to leave hospital they have to have somewhere to go to. Lots of people will go back to their own home, but some people will be unable to do this because it's not safe to do so. These people need a care or nursing home. Because there aren't any available beds, and because there aren't any available suitable home care packages, these people stay in hospital on the wards.
Those beds are now not available to be used.
So, now you have a problem of flow of patients through hospitals. You can't discharge patients from the ward, which means that ward can't now accept patients from elsewhere (surgery, ED) in the hospital. This means that elective care reduces, and emergency care slows down. People wait in Ed for very long times. And because ED is full people can't get in to ED, so ambos queue outside ED for hours. This means many ambos are queued outside ED waiting to transfer a patient, and not available to travel to people. So now people in life-threatening emergency or with severe injury are waiting far too long for an ambo.
Fixing care homes and nursing homes would do a lot to fix patient flow, but it's not going to happen because we have a government that hates the NHS and hates LAs and hates taxation.
On top of all of this we have an incoherent approach to staffing. The English NHS is full of staff who've come to England to work. We need these people - they improve the quality of care and they increase the amount of care we can deliver. We should be making it easier for people to come here, but we don't, we put up a load of weird bureaucratic blocks. (Because we have a government that hates immigration.)
We need to train very many more staff (there is something like 100,000 staff shortage, at least 10,000 doctors and 50,000 nurses) but we've made it more expensive to train to become a nurse, or a doctor; we've cut pay for all staff (for junior doctors to achieve pay restoration they'd need something like a 25%-30% pay increase).
We need to retain the staff we already have, but there are a range of things that make working for an English NHS trust pretty terrible. It's not just pay, but poor pay doesn't help. There's a weird thing around pensions that means many doctors can either retire early or face a massive increase in their taxes. Lots of staff have trouble getting paid on time when they start work at a new organisation. People have to pay for car parking, and they're fined if they overstay even if that overstay was caused by saving the life of a very ill patient. (These can be over-turned but why should it happen at all?). Rest areas are generally awful and expensive. Hot food is generally not available 24 hours a day. Rotas are chaotic. Doctors can apply for leave a year in advance and then have that denied with very short notice. Some NHS trusts have toxic work cultures and problems with racism, sexism, and bullying. And these are just the things I can remember, the real list is very much longer.
About demand: there has been an increase in demand for healthcare. GPs are seeing more people than they were before pandemic, but there's a perception that it's quite hard to see a GP. (I don't have much trouble, but I have cancer and my GP is pretty good, but I recognise other people have difficulty with weird access restrictions). This trickles through to ED - a few people turn up to ED needlessly. Before pandemic we had clear evidence that it wasn't really enough to make much difference to the overall ED demand. The picture is less clear during pandemic - certainly people going to GP not ED if they need GP is a good thing because they get better care, but it's hard to know if it's making the ED problem much worse.
Its always the same answer. People stuffing their faces with garbage food and chilling on the couch all day. Apparently there was an explosion of obesity in UK during covid. These people clog up all the available supply leaving very little for the rest. Its the same story everywhere. Ppl whine about funding, shortages ect but no one cares about if we can do something about the demand.
Govt pushed covid vaccine on young healthy people saying its good for the community if we all get it and its our duty to society. So why isn't getting off the couch and going for a walk considered duty to society.
lol. i don't see how this being marketed as duty to society like covid vaccine. No denunciation or shaming of voluntarily obese as a strain on society. No "COVID is a disease of unvaccinated" by the presidents.
90% of health care costs are attributable to chronic disease in usa per cdc. [1]
Americans with five or more chronic conditions
make up 12 percent of the population but
account for 41 percent of total health care
spending.
Hypertension, high cholesterol, diabetes are top chronic conditions. Course of treatment for all those is "lifestyle changes" ( along with meds for managment). [2]
Yes there are significant and multiple areas where private healthcare companies are being paid to 'provide' services to the NHS in a classic outsourcing process similar to what you would see in IT.
Private company charge a lot more, pay their staff a bit more to attract workers from the NHS, extend their contracts to provide more services where there are NHS staff shortages. Taxpayer money turns into company profits. I wouldn't object if it provided more efficient care but it doesn't seem to.
It's a bit complicated. Private providers can have different staff mixes, so you might have more healthcare assistants and fewer nurses. You might have more unregistered nurses and fewer registered nurses. You might find more staff are on zero-hour contracts, or things like "hotel services" (food, cleaning) are contracted out to companies that are low pay poor condition companies.
When are people going to realize that medical care is the cornerstone of advanced society. Increasing average lifespans raises the collective memetic IQ of the population, and lets us build more advanced things.
I don't think it is coincidental that there is also now a large push in England for State sanctioned suicide. Especially after reading how administrators in Canada are treating it.
Not sure what OP is referring to exactly either, but there has been a bit of talk about euthanasia in the press following the case of a man who killed his wife who was dying of cancer (and then attempted unsuccessfully to kill himself): https://www.theguardian.com/society/2022/jul/22/law-euthanas...
My impression is the attitude towards euthanasia is becoming more favourable. I wouldn't be surprised if it becomes an Labour election promise over the next decade (the Lib Dems already support it I believe).
Boris Johnson really historically screwed over his country. Even as bad as some of our leaders have been, it seems like Boris significant eclipses their incompetence.
Blogs don’t make sense for the most prolific creators. Here’s something I saw recently
> I gave up blogging after decades because the ROI simply wasn’t there any more. Why spend hours on a post that will get hundreds of views when a tweet composed in minutes gets tens of thousands to millions?
And it’s the same with Scott Hanselman, who’s quoted in that tweet. Hasn’t blogged since last year, stopped after 20 years. He’s big on YouTube and Tiktok now.
Scott Hanselman states he stopped because he was tired, not that he's switched mediums. The Tiktok / YT comment was a joke; he still does lots of media for his job though.
If you are serious about communicating then you MUST blog in addition to tweet. Twitter is for soundbites, not lengthy articles. You can't expect people to read tweet after tweet when they would rather read a long continuous article.
The dude probably has the software that breaks down lengthy articles and tweets them in reverse order but that shouldn't be abused.
And what happens when you fall foul of twitter's rules and get banned?
Not sure why you were downvoted, as those are valid points. Twitter is the best medium when it comes to talking about subjects in depth. It is good when it comes to making a quick hot take, but not in depth articles or explanations.
Unfortunately, a lot of people don't engage much in long form discussion as much as they would a tweet. Tweets are much easier to discover, find, and view compared to a blog post. It's much easier to click like on a tweet or retweet something, and bigger engagement numbers == better. So people instead will write out tweets instead of blog posts. I don't care for it much myself, but such is the modern internet I guess.
This twitter thread is excellent. Here are selected tweets to highlight the crisis from hospital and ambulance waiting times.
---
"England & Wales as the only part of Europe that has recorded sustained and rising excess mortality over the last few months with no obvious natural explanation."
"Patients who waited 8-12 hours had a 16% higher chance of dying in the subsequent 30 days than average."
"This was after adjusting for a huge range of possible confounders, i.e this was not due to those patients’ characteristics, conditions etc, but due to the length of the wait."
"You may have heard almost 30,000 people waited 12 hours in English A&Es in July, but that figure actually only refers to the wait after initial assessment"
"Thanks to @Rebeccasmt’s reporting, we know that if you include all time spent waiting, 100,000 people waited 12+ hours!!"
"Take ambulance delays, for example: for emergency situations including suspected strokes and heart attacks, the average wait for an ambulance to arrive on the scene is now one hour, and 40,000 people with these sorts of emergencies waited 2 hours last month."
"As before, the peaks in ambulance-related harms broadly coincide with peaks in England’s non-Covid excess mortality.
"It’s a grim picture, and an increasingly conclusive one."
could you link to that pointing out? which parts don't stack up? the 12+ hour wait times, the hospital occupancy, the discharge rate, the aging population and the slashed spending are all seem to be hard numbers (dare I say facts?) ... what doesn't add up?
the 12 hour wait is once the person enters the doors of the facility. In a hospital, if you walk into the ER, people are observing you closely and expediting people at immediate risk of death. A person who can sit in a chair for 12 hours waiting didn't have an emergency. Instead, they were using the ER for non-urgent care.
If the people triaged into 8-12 hour queues have a 16% higher chance of dying in the next month, that's a pretty obvious indication that many of them are, in fact, in critical condition.
I wouldn't trust a stat like that without digging into the underlying causation. The whole twitter presentation is a nice narrative but I see many places where it could just be outright wrong, or saying misleading things (I work in medical biology and have plenty of familiarity with how hospitals run their ERs).
Fortunately the previous tweet linked to the original source, a published study of 5 million ER visits which appears to have a full set of controls and specifically measures time to inpatient transfer in excess of 5 hours as a mortality risk factor
https://emj.bmj.com/content/emermed/39/3/168.full.pdf
A retrospective, observational (IE, after the fact data analysis from a population without controls) study found a risk factor (association). That's not enough to make any real conclusions as to whether this is causal.
It may not be conclusive on the subject of whether the 16% additional deaths were specifically influenced by the additional wait, but in light of that data point, you're going to need a whole lot more evidence to justify your original claim that the cohort that dies 16% more than the baseline population in the days that follow were, without exception, not in any urgent need of medical care...
All I said was: if you can wait 12 hours, it's not an emergency. The emergency room is for things where a person couldn't wait 1 hour without dying. People dying 30 days later: not an ER problem.
Nope, the emergency department of an NHS hospital is absolutely not reserved for things where people couldn't wait one hour without dying (or people who are in danger of death period).
And since we're talking specifically about the subset of NHS emergency department attendees who are more likely to be dead within 30 days if it takes longer than the NHS' target of four hours for them to receive an inpatient bed, I'm pretty unconvinced that the alternative route of booking a doctor's appointment in the next few days to see if he'll refer in a week or two is the more appropriate one...
I know NHS works differently from the US, but the health care providers in the US that are used by major corps (IE, benefits) all have urgent care lines. I've done this repeatedly (to avoid my wife going to the ER with a sick kid). Typically, while it takes a month to get a routine appointment, the kid's doctor always can see them the next day for something urgent.
If you think about it, this makes a lot of sense because ERs are tuned for low latency, low throughput, high cost for emergencies, and if lots of people who just need urgent care go, they make it hard for the emergencies to be seen with low latency.
A few years ago I had an infected gallbladder. It was enormously painful, and I went to ER. It might not have been potentially fatal (I'm honestly not sure if you can die from it), but I didn't know that. I just knew I was in a ridiculously amount of pain.
Anyway, so I went to the ER and to begin I did sit in a chair like you said, however I don't think anyone was keeping an eye on the patients, since by the time someone came to look at me, I had been writhing in pain on the floor for an hour or so, and it had taken another patient to call a nurse over.
All and all it took 4 hours before I got to see a doctor, but this was pre-pandemic.
Still, I think you're probably right and people do show up to A and E for non-urgent issues, however it's probably also tied to how difficult it is to see a GP these days.
Your last sentence is really my underlying point: people use the ER for non-urgent issues because it's available. Ideally, we'd have far more non-ER urgent care (which costs much less to staff and run than an ER) and that would be most people's place to go when their normal doctor couldn't see them.
For the gallbladder, if it's just an infection, not fatal. If it's a gallbladder attack, it can lead to rupture. Definitely needs emergency surgery.
What is the situation of urgent care establishments in the UK? Places you can go for non life threatening but life stopping events, like say a broken leg?
It all goes through A&E, which unfortunately is meant for both the life threatening situations and urgent but not leathal ones yet. You have to go in, register and sit and wait - if it is "just" a broken leg yes you might wait a few hours before being seen.
There's a trend in the US to have urgent care facilities. For example, in my system if I have a problem I call (24/7) and they route me either to urgent care or the ER.
During my visit to urgent care (so early in the days of COVID that there was sign saying only people who had just flew in from Wuhan could be tested), I was seen immediately, the doctor stopped while seeing me, said "the person in the next room is having a heart attack and I have to send him to the ER immediately- I'll be back".
> Instead, they were using the ER for non-urgent care.
FWIW, this isn't always a call that person makes - I've had multiple family members advised to attend by the non-emergency service (111) and ended up with a 6-8 hour wait.
You also can face lengthy waits for something that needs treatment soon but isn't immediately life-threatening (grandfather fell and hit his head on a table, requiring stitches - ~4 hour wait for a handover from the ambulance, another 2-3 before he received an MRI and stitches).
A few years back the doctor sent me over to the ER. Had I gone home instead there would have been zero (above background average) risk of dying in the next 12 hours. That doesn't say the doc was wrong in sending me there--I had a kidney stone, the risk was kidney damage and infection, not dropping dead.
I had a similar situation (sitting in the ER absolutely needing immediate surgery at risk of death), but after a bit I called my parents, who called the surgeon, who saw me immediately (outside the hospital) and then immediately scheduled me for surgery back at the same hospital, all before I would even have been seen at an ER.
As a UK tax payer, and as a UK tax payer that winces every time they see how much they lose to taxation in their P60 each year (six figures in tax), what are people's solutions to this?
It seems like the NHS budget keeps on going up and up and up [1], as does the number of doctors and nurses (while "managers" has either declined or stayed relatively static) [2]. So NHS is getting more funding, and there are more doctors and nurses. Yet there is still outcry about how we need MOAR MOAR MOAR!
We're spending ~10% of GDP on the NHS at the moment [3] - how much more do people want? 10% appears to be roughly comparable to other developed nations (except USA...) and the data says that nurses and doctors are increasing in numbers while "managers" are not, so the usual cries about the money being spent on "management consultants" appears to be ill-founded, as does the complaints that it is the Tory party reducing funding.
Throwing money at the problem appears not to be working because the budget keeps going up, the numbers of doctors and nurses keeps going up, yet people are still complaining about it being awful? What gives? What is the solution when just spending more money isn't working?
The best thing about NHS (from my perspective as a US person, although I lived in the UK for a while) is the use of QALYS to allocate budget, rather than spending huge sums on a small number of interventions at extreme cost and limited benefit. Has that focus shifted?
(My personal belief is there should be a level of universal medical care funded by some public entity, probably the nation state currently, but it should be capped at a relatively low level, probably closer to 1% of GDP and allocated on a QALYS and emergency or communicable biased, with private care in a relatively unregulated market outside of that. Probably would end up in the 5% range overall, but with universal access to basic and cost-optimized care and probably a wider variety of private, charity, experimental care.)
We should not spend excessively on medical care vs. other interventions -- it's absurd that in the US we can have homeless people on the street with extremely limited assistance on housing or lifestyle interventions, but as soon as they develop some medical condition, they get essentially unlimited much higher cost intervention to remediate those things, but still nothing to address the underlying cause. There are a bunch of cases where we could shift $1k out of medical spend for $10 in other spend and achieve a better outcome for the person and for broader society.)
We still use QALYS. The problem is you don’t get to choose how much a given level of health care costs, and I think 1% of GDP is woefully inadequate. You spend about 4% of GDP just on Medicare alone.
As a US tax payer you pay about as much for Medicare, Medicaid and CHIP as tax payers in most developed countries do on health care in total. But then to actually get health care yourself you have to pay about the same again fir private health insurance.
I get private health care here in the UK through my employer. I pay for the NHS through taxes, and that’s actually how I and my family get most of our health care in practice. The private cover is basically a top up. If I use it I can get treatment more quickly, but at no cost to the NHS.
I think this is the best of both worlds. As a nation we get health care comparable to the US at half the cost, it’s truly universal so millions of people don’t fall out of the system. So I fully support the NHS, as a beneficiary of private health care I still think I and my family have got excellent value for money from it throughout my life. Private health care expands health care capacity, and reduces demand in NHS services, so everyone benefits. It may not see, ideal, but in practice I think it works very well, and frankly it’s how well it works that actually matters.
Currently the NHS is in rough shape, but this is mostly down to the flat economy since the financial crisis and the pandemic. Spending levels at the peak of the boom in 2008 were unsustainable whoever was in power.
The problem is I don’t think it would. That logic just doesn’t scale. If one tenth of spending gave 90 of the benefit, then one hundredth of the spending should give you 90% of that, or about 80% of the benefit. That’s not how skilled labour intensive service costs work though. It’s probably more like one tenth of the spending would get you about 20% of the benefits. That’s certainly more efficient, but it’s just not going to be acceptable.
I think my example was extreme but is closer to the truth than yours. My realistic estimate would be perhaps 25% of the cost covers 90% of the benefit. Preventative medicine is cheap as is ending broken bones in children. What is really expensive is open heart surgery and three rounds of chemo for an elderly patient.
Cost x years of benefit really favors the easy interventions in the young.
Is there a list somewhere of the QALYs for every intervention?
It becomes enough of a hot potato to say "drug X works, but not enough so we're not paying for it" because it lets you complain that the drug companies are charging too much.
But when you say "surgery X works, or 1:1 therapy works, but not enough so we're not paying for it", criticism now comes from both sides: the workers doing their job and the public.
Agreed...the biggest failure of "Obamacare" was not separating out a basic level of care as a minimum that all citizens get and requiring those kinds of plans be made available in every state.
Where I live I can only buy plans that include things like Chiropractic and Acupuncture and all kinds of other non-basic or catastrophic services. If I want a low-cost basic care + emergencies plan, I'm SOL.
Funding may go up but demand increases more because UK population is old and overweight… and getting more so. This is the reality of an aging population plus socialised health care.
It's because they're acting as an emergency care home.
My local 450-bed DGH has over 150 medically fit patients waiting to be discharged into community care that isn't available.
And this happened secondary to central government funding being withdrawn from social care.
So hospitals like this one are actually running at 120% in summer. They do need "MOAR MOAR MOAR" but that more is a place to look after the patients that don't need to be in hospitals.
> Yet there is still outcry about how we need MOAR MOAR MOAR!
Was the budget increased enough in the first place to what the experts recommended? "I generously give my employees a raise every, single, year, of 0.5%, and yet all I hear is that they want MOAR MOAR MOAR"
Is it possible the NHS took on lots of 'bad deals' in the 2000's, and is now having to repay them? Things like a "Get this cheap building, but now you're locked into paying inflated rent and service charges on it every year for the next 50 years"
Oh yes. There's a comment elsewhere talking about how the Blair-Brown years had heavy NHS investment and how they used PFIs to fudge the numbers, and that's exactly how it worked - instead of paying the upfront cost of, say, a new hospital they got a private sector firm to build it and committed future governments to paying a bunch of expensive fees to that firm for decades. So they got lots of nice fancy NHS investments and improvements to point at whilst eating into the capacity of every future government to fund... well, everything really. It wasn't sustainable at all.
There are potential answers to your questions in other comments in this discussion that have been there for hours, it might be more useful to move understanding forward to address them rather than just opening a new thread as though they aren't there...
Other countries spend more (10 - 20 % more) and get better outcomes, so it seems like the solution is indeed to spend more. The fact that it has been climbing slowly and we haven't seen radical improvement doesn't contradict that. Sorry.
From your first source; The combination of a mismanaged economy plus an aging population has meant that the NHS spend is 50BN less than projected but is a now a larger share of GDP compared to other EU economies because the UK economy has performed so badly compared to the rest of the EU. Productivity has flatlined while people bought more and more expensive houses of each other on credit. My theory is that the conservatives have fucked the economy by being too tight fisted with public sector pay causing a drop in disposable income for about 1/4 of UK workers leading to lower spend in small businesses like pubs and hairdressers etc which has caused 10 years of general stagnation.
Note that your bma source contains a graph titled "Regular healthcare expenditure if it had kept pace with the historical average over the last decade"
I agree with you that we cannot persist with above-inflation spending increases. This is economic fact. Moreover, we're currently enjoying an artificially cheap healthcare system by underpaying nurses and doctors.
My partner and many friends and family work for the NHS, and these are my general observations, in order of significance.
1. The biggest problem is underfunded social care. If we took money out of the NHS and moved it into social care, we'd have a better NHS. At the moment, the NHS is full of inappropriate patients with nowhere to go. We also need to consider how we handle the elderly in this country. The idea of having elderly people stay at their suburban homes while the state pays for nurses and doctors to visit is hugely expensive. I suspect caring for your elderly relatives at home is going to need to become more common.
2. The NHS is inefficient BECAUSE there are to too few admin staff. In NHS terms, this includes IT and other similar roles. Currently, my partner spends over an hour a day just waiting to log in on one of her department's three computers. She then spends ages sending emails, following up transfers and doing a whole load of other jobs that should be done by an administrative person. Technology is massively underexploited because investing in technology costs money that we don't want to spend. It's like that death spiral that I'm sure many of us have seen in our careers, where you get nothing done because you spend all day firefighting, and everything eventually grinds to a halt.
3. We need to focus more on preventative care. Right now we largely leave problems until they are much more difficult to treat. This is in large part cultural, and partly due to the firefighting I mentioned before. We have a very unhealthy population (myself included) and more needs to be done to fix that. Other countries have deployed very successful strategies that we've so far failed to apply ourselves.
4. We need to look more at how we handle the end of life process. Sadly, death is an unavoidable reality currently, and we spend a ridiculous amount of resources trying to slightly delay the inevitable. Many of my partner's patients are in their 80s or older, and it seems borderline immoral to be performing such invasive surgeries on extremely unwell elderly people. Interventions continue to get more incredible, but also vastly more labour and resource intensive. Many of these patients may live an extra few months due to these interventions, but we really need to be honest with ourselves and ask whether it's worth it. Currently an intervention is deemed value for money depending on the average QALY added across all patients, but obviously in reality, the same intervention would be usually much more value for money on a healthy 40 year old, and much less on a frail 90 year old. This is an extremely controversial and morally difficult area with extremely challenging issues around every corner, however.
This isn't a problem of funding, either. This is a problem of basic population dynamics. We could throw hundreds of billions more at the problem, but where are we going to get all these new carers, nurses and doctors? Who's going to be left to build their houses and grow their food? If we import all these people from overseas, which is politically unpopular, how are we going to integrate them?
We could look into whether we continue with the Beveridge Model. Certainly some things about it don't work brilliantly. But honestly I don't think the model matters so much as the fundamentals, other than better aligning incentives will make it marginally easier to fix.
Meanwhile the prime minister is on perma vacation and the replacement candidates are focused on banning on shore renewables and squabbling among each other
The replacement candidates are also both sure that the main issues facing the UK public are "woke" politics and trans people[0], and seem entirely unphased about the pending crisis around energy bills and the price of food. And the opposition seem pretty uninterested in taking advantage of this massive open goal. Incredible.
[0] no, not in a nice "let's all remember to treat LGBTQ+ compassionately and with respect" way
> And the opposition seem pretty uninterested in taking advantage of this massive open goal.
Never interrupt your opponent while they are making a mistake.
Right now, Labour and the Lib Dems don't have a particularly credible method to cause an election. Given that, their best _political_ option is probably to allow the Tories to run themselves into the ground.
I'll believe that they have a response to these things when I see it. While I've seen polling putting Labour ahead of the Tories but no big movement on the problems I've mentioned (in addition to some worrying anti-worker sentiment @ party level relating to the rail strikes)
Can't wait for an ideologue to use the situation to push their partisanship into an unrelated conversation by projecting their actions onto their ideological foes.
(Not) Luckily the US healthcare system is already collapsing without social medicine, so it’s not a great talking point. Staffing and supply shortages paint a bleak picture over the next few years.
"the US healthcare system is already collapsing" What do you mean by this, specifically? People not having insurance? Increasing deaths inside the hospital? Large numbers of people turned away from emergency rooms?
I'm questioning this because with the exception of malpractice, the U.S. healthcare system seems to be working quite well, despite the large numbers of uninsured and those who cannot pay.
I just don't buy this argument that the U.S. healthcare system is "collapsing" because if you call an ambulance they will take you to the hospital, and if your life is in danger regardless of your ability to pay, there's a higher chance of surviving in an American medical facility than most places on earth.
People just love to talk about how horrible the US healthcare system is but my disabled daughter has never paid a dime for care in her life (in Kansas, of all places!) via Medicaid. Even her birth was free due to retroactive Medicaid. Her 9 months in the NICU was billed at over $2 million. Thanks taxpayers.
I was having chest pains last week and got triaged within minutes at the ER. I’m pretty sure I “owe” them $500 for a previous ER visit which nobody mentioned during my stay.
My 65 year old uncle hasn’t had insurance in 20 years but when he got cancer three ago the social worker helped him sign up for disability and they got him on Medicare so fast your head would spin. He started chemo basically immediately and while his cancer is terminal the treatment has kept him alive for a long time, even longer than the doctors predicted.
My wife got billed $200,000+ for a visit in the hospital when she had a critical illness and almost died. She ended up paying $2000. This was more than ten years ago and it didn’t ruin her credit and nobody ever came after her for it.
And One more. The hospital messed up the billing for our first daughter’s birth and called us two years later saying we didn’t have insurance (we did). My wife said that was their problem. We never heard from them again or got a bill. I guess they just ate the cost? No idea. But it was over seven years ago and there were zero consequences and we never paid a dime.
We did, through our taxes and insurance premiums and opportunity costs. We paid for average care plus the greatest medical rentier system in the galaxy.
If by "socialized medicine" you mean public option health insurance, then yes it does work. I'm willing to bet, though, that the poster you're replying to only received care from privately run hospitals/clinics, so calling it socialized medicine seems misleading.
> calling it socialized medicine seems misleading.
Outside of the UK, that is how health care in developed countries is organized. It's either that or some version of Obamacare (regulated, private, with price caps and subsidies) or a combination.
American conservatives call them all, without exception, "socialized medicine".
US health is socialized in that the public will pay for it if you're willing to game the system like the uncle in this story, plus spin the wheel of chance to see how much you'll how privately anyway. I don't think the uncle here acted maliciously or TRIED to game the system, but that is what happened and that is what will continue to happen with this shitty half implemented system.
Hah, the world is complicated. I feel like me and my family are the worst case scenario in the health care system and it worked… pretty well aside from them wanting to give my daughter too much care she didn’t need.
The US basically has socialized medicine that scares naive/“honest”/conscientious middle class people into paying up to subsidize it. I suspect if we passed legislation tomorrow to make the US a single payer system it’d all fall apart. But I suppose we’ve managed to trick the US taxpayers into socializing medicine while letting them pretend we haven’t.
Man it just seems insane to me that you are acting like being billed $2 million, $200,000, and having unknown other bills, is somehow a good system.
Let's be honest, overbilling and non-accountability is a huge disaster here. While people like you slip through the cracks in terms of not needing to pay, others slip through the cracks in terms of not getting care at all.
About 10% of Americans don't have medical insurance. That number has been fairly stable for several years, so it's not great but also not a sign of collapse.
Nothing is being hidden. High deductible health plans have been popular, especially among younger consumers. The federal government has specifically promoted those as a way to hold down healthcare expenses, and enrollees receive income tax benefits.
My point with the "hidden" comment was that even though people have coverage they may not be able to use it due to having an unaffordably high deductible, and your first link is showing that there is a rise in high deductible plans and that lower income people don't usually have an HSA to offset the cost. It also points out that 60% of people get their insurance through their company, and that companies are increasingly moving towards the cheapest plans with the highest cost to the individual user.
Is an insurance plan an insurance plan if you can't pay the deductible?
Observation: There's adverse selection at work. People do the economics and look at their expected medical spending with both low and high deductible plans--those not expecting substantial bills generally choose the high deductible plans. Insurance companies observe the results of this--those who choose low deductible plans end up costing more.
I've done the math most years and I have yet to find more than a narrow window where you're better off with the low deductible plan than with a high deductible plan and putting aside the savings. Typically there's no window at all, the high deductible plan is always superior. (Note that this generally changes in situations where you pay a *percentage* of your premium, such as subsidized ACA plans.)
If we want to move away from high deductible plans the only way is for Congress to impose it, market forces will always drive it as high as it can legally go.
I think there are a variety of ways the US healthcare system is collapsing.
One way I experience, relevant to OP, is that even with "good" health insurance, I can't manage to get an appointment with most specialists faster than 3 months, and I can't even see my primary care physician faster than 3 weeks (at best) -- in case of something "urgent", maybe in 2 or 3 days.
This may be especially bad in the region I live in, I'm not sure. When I ask around, many of my friends in other regions have similar experiences. It is not in fact true that those in the US can generally see physicians without long waits for appointments, currently.
Not much groupthink needed to downvote somebody who feels a single short sentence, with no citations or.. anything really, yet one that goes against current mainstream medical and scientific opinions, is worth writing.
If you actually wanted to try to convince anyone that you might be even somewhere in the vicinity of having a point, you've given up before even trying and opted for pre-complaining about downvotes (something which, on HN, almost guarantees you downvotes even if you're saying something people agree with, btw) rather than suggesting a single piece of data that would lead to any reasonable person thinking "hmm, yeah maybe worth investigating further this theory that vaccines are the cause of UK's current high excess mortality rates".
But I suspect you didn't have much choice, if there actually were a compelling argument to make in support of your claim then, well, you'd be making it.
You're right in that I'm being lazy and shouldn't have commented without backup data. There's plenty of data out there, but why try to collect if the HN readership's thinking is so mainstream that they'll reject any such attempts out of hand?
Yes, under a pro-spending, forward-looking government (such as the one we had from roughly 1997 to 2010), staffed public services improved and a trajectory was laid down for future improvements.
Under pro-austerity, myopic governments (such as the one we had from 2010 until now), public services have been rotting from the inside.
It's not difficult to draw a straight line from one to the other. Pouring money into "diversity" is certainly nothing to do with it, and that goes double for our current reigning party.
For what it's worth, it's a testament to the overall resilience of the NHS as a service that it has broadly managed to weather the storm of long-term underfunding and is likely going to continue on track until a forward-looking government is able to come back and breathe life back into it again. Roll on 2024.
> What exactly is the point you are trying to make?
You don't have a clue about what's actually going on in reality. That was the point. Thanks for proving it.
> Pouring money into "diversity" is certainly nothing to do with it
It must be nice to be able to spend the same money twice. Please let us know how exactly to accomplish this feat.
> Overall resilience of the NHS
People dying right now waiting for ambulances. People dying in spates of cancer and heart disease due to delayed screening or missed treatments[1]. "the NHS is so resilient".
> It's not difficult to draw a straight line from one to the other.
So your plan is to put all your eggs into one basket (i.e. state-run health care) and then cross your fingers that no bad politicians (ehm conservatives) ever get into power. That sounds like a very well thought out and forward looking plan.
The numbers you cite represent a real-terms fall after inflation - despite the population growing about 8% in that time - AND a reduction as a proportion of GDP.
> It must be nice to be able to spend the same money twice. [...]
Meaningless.
> People dying right now waiting for ambulances. [...]
Yes, well observed. I do know that. The fact that more do not is frankly miraculous - and the fact that many do right now is more testament to chronic underfunding of other public services, especially elder care and social services.
> So your plan is to put all your eggs into one basket (i.e. state-run health care)
No. You have invented that line of thinking. In the UK state and private healthcare coexist. The only way to put all the eggs in one basket would be to erase the public provision of services which, in case you hadn't noticed, is exactly what the conservatives are trying to do.
You took your time thinking about your excuses. The fact is that you weren't the slightest bit aware of the magnitude or direction of NHS funding. You just assumed it must be down because that's the only reason the godlike public services could fail.
> The numbers you cite represent a real-terms fall after inflation despite the population growing about 8% in that time
Who made the population grow like that? Isn't it usually the same people who tend to champion mass immigration and socialized health care? Have you ever spoken up about the tension between these two issues?
Who made the inflation? Isn't it usually the same people who champion centralized fractional reserve banking with easy money who want socialized health care? Or are you in the inflation threads arguing for limiting inflation to "Save the NHS".
> AND a reduction as a proportion of GDP.
Is that even true? Can you show some math?
And who says health care costs have to keep up with GDP? Are we just supposed run faster in place like we are in a hamster wheel where every bit of increased production is just eaten up by rising costs?
> Meaningless.
Sorry, there is nothing else to say here but that if you are fine with frivolous spending in a funding crisis, as you see it, then you are just an idiot.
Compared to the cesspool that is the US system? The NHS was amazing.
We don’t talk about it, but people still die for non-COVID emergencies because hospitals in the Us are routinely full in 2022.
Privatization of hospital systems in the US have lead to very warped incentives, where C sections are the norm because it’s faster and more money for the hospital and Drs.
Here in the US I had stage III cancer. I was receiving full blown cancer treatment(s) less than a week after I went to the ER with symptoms (chest port + three types of chemo drugs). And that's routine. The US health care failures are mostly the fault of administrators and insurance companies gaming the public. The care is fast + extensive and it's not a cesspool.
And the "full hospital" meme isn't entirely accurate. The US hospital wards are -- by design -- supposed to be full. If 100 beds are allocated for severe flu cases (example) but there's only 25 patients they'll shift the flu ward to 35. Thus they achieve a 75% capacity for the flu beds and allocate the additional beds to other sections. Sometimes the American media (sensationalist by design) will report this as "OH MY GOD THE FLU WARD IS NEAR CAPACITY. 75% FULL!!" without reporting total beds vs flu beds.
While it's nice that you were able to get quick treatment, there are tons of people who never receive any or adequate treatment because they are absolutely terrified of what the cost will mean for themselves and their families.
Hospital capacity depends on the number of staff capable of supporting it. You could have a room with a thousand beds, but if you've got two nurses, your capacity is a tiny fraction of that.
It's laughable to call the US healthcare system bad, but I feel like that sort of treatment should be commonplace and universal for what we pay here. The UK has spent about 10 percent of GDP over the last ten years. The US spends 20 percent. It's going somewhere, but I don't think it's going towards care at quite the same rate as over healthcare systems. Even 15 percent of US GDP would be $3 trillion, or more than the entirety of UK total GDP.
Its 16.77% of GDP for the US currently. Germany is at 11.70%. I think Germany is probably the most reasonably run health care system to compare against since Germany doesn't have the collapse of healthcare issues of UK or Canada we keep hearing about.
> Privatization of hospital systems in the US have lead to very warped incentives, where C sections are the norm because it’s faster and more money for the hospital and Drs.
The US rate of c-sections was 32% in 2017 (and roughly the same for 2020), the same as Switzerland. It's 27.7% in Canada, 33.7% in Australia and 27.4% in the UK.
28% across the OECD, 30% in Germany, 45% in South Korea, 34% in Italy.
Per your own link:
“ Variations in caesarean section rates across countries have been attributed to a number of factors, including financial incentives, malpractice liability concerns, differences in the availability and training of midwives and nurses, and the proportion of women who access private maternity care. For example, there is evidence that private hospitals tend to perform more caesarean sections than public hospitals. In Switzerland, caesarean sections were found to be substantially higher in private clinics (41%) than in public hospitals (30.5%) (OFSP, 2013[1]).”
Sadly, this cynical take is correct in all too many cases.
The solution is to bring more intelligence to the problem of governance and human organization in general, not less. Stupidity has never been the right answer to any problem, yet it seems to be all the conservative side has to offer nowadays. Weaponizing the left side of the IQ bell curve will prove to be a bad idea in the long run.
I don’t buy that explanation. Democracy turned out to be easily manipulatable with large sums of money and media control.
At this point, an average person can’t have much of an affect on how government is acting. Very few people can take a day off to protest, and even if they do, protests tend to be meaningless too.
I’m not saying that average person is blameless but most of the fault lies with the ruling classes.
> At this point, an average person can’t have much of an affect on how government is acting. Very few people can take a day off to protest, and even if they do, protests tend to be meaningless too.
The older I get, the more I believe the only real voting someone can do is with their wallet.
And even that is mostly bullshit, if you don't happen to be flush with money so you can actually afford to throw the weight of your wallet's contents around.
>Democracy turned out to be easily manipulatable with large sums of money and media control.
People being easy to manipulate is feature of humanity, not evidence that democracy does not work.
People are in charge for allowing that to happens, allowing to continue etc. If things go shit under heavy influencing and manipulation it's the failure of the people. "ruling classes" in democracy works is the fault of the non ruling majority.
> People being easy to manipulate is feature of humanity, not evidence that democracy does not work.
Maybe it's both. Much like communism assumes altrustic spherical humans in a vacuum, so does democracy assume that each voter will both bother to vote, and that they are rational enough to vote close to what they actually want without being swayed.
This could be evidence that democracy, much like communism, does not work very well.
I don't think so. Communism has an idea of what should happen next, democracy does not. Democracy is open to change, for whatever people choose, even quitting democracy.
Democracy is always changing, always on move and dangerous. That's why I like democracy. Functioning democracy can even end democracy and choose tyranny.
The founding fathers were heavily against democracy and did everything they could to limit the power of the government without being completely ineffective.
Idea being that individuals create wealth. Government will always become tyrannical.
> The founding fathers were heavily against democracy
Well yes, but this is the UK so the founding fathers would be one of William the Conqueror, James VI and I (that's one person), or George III and his regent, depending on which argument you want to have.
Nahh... when people say "the vote was manipulated" what they mean is "the vote made no sense to me personally, and clearly the voters can't be blamed, so it must have been manipulated".
There are plenty of examples of billions being thrown at campaigns and barely even moving the needle (e.g. Bloomberg's $1B fight for the Presidential race where he didn't even get 1% of the vote).
What I'm saying is that what people see as manipulation of voters (nobody could ever believe that!) is actually just another valid opinion that you so happen to disagree with.
Nobody was deceived. Nobody was manipulated. The voters just don't agree with you on this issue.
This is silly: all kinds of promises were made for Brexit, and if they weren't delivered then those expecting them are at least disappointed, and if there was no reasonable way they could have been delivered and no real effort to deliver them, then they absolutely were deceived.
How did the "£350m for the NHS" bus work out?
> actually just another valid opinion
Some opinions - sky is green, earth is flat - aren't valid.
People who argued about the nature of democratic accountability of the EU, even though I disagreed what them, are not a group I would argue were deceived.
People who believed the UK gave the EU £350 million per week, which is the example the other poster gave, were unambiguously deceived.
If any vote results in voters regretting their vote, I think that counts as voters being deceived.
I don't know (or care, given I left the UK as a direct result of the vote) if there was any significant regret in this case.
(I caveat "significant" because 5-10% of the population will agree with almost any proposition in any opinion poll, no matter how nonsensical the question).
Or maybe a water main breaks during vote counting and everyone is sent home. Except one party that keeps working. But of course nothing suspicious about that.
> Democracy turned out to be easily manipulatable with large sums of money and media control.
Is it, though? Establishment interests spend huge sums of money and often lose. The Republican party was an elite country club party, but when evangelicals emerged as a political force, the party had to jump on that wave, no matter how distasteful the old party elites found it. Then Trump came along, giving blatantly shallow lip service to religion, and now the party is beholden to him. That wasn't in anybody's plan except Trump's, and his personal wealth was paltry next to the Republican Party's resources.
But maybe the elites who do the manipulation are happy to pander on a few issues if they get what they want on the issues that are really important to them. Let's think about that. If there was one core tenet of the GHWB-era Republican Party that its elites would have wanted to protect above all else, what would it be? If there was one core tenet that united all American economic elites, one thing above all others that they would want to instill in voters' heads, wouldn't it be economical liberalism? More specifically, free trade? Well, they've failed at that. NAFTA was a banner achievement for the Republicans. Now Trump calls NAFTA a Clinton disaster and promotes trade war with China, and he runs the Republican Party, because it does matter what the voters want, and you can't outright buy their belief in anything.
We blame voters for being bought and manipulated when someone speaks to them in a way they find compelling but "shouldn't" according to our worldview. We assume that the superiority of our worldview gives us a natural advantage, and we look for special reasons why our views don't prevail. "What's the matter with Kansas?" in other words. What's the matter is that Trump's voters really do care more about Trump licking their wounded egos more than they care about anything else.
Do you think it doesn't apply to the UK? I drew on a US example because it was something I could explain in enough detail. Maybe UK economic elites have mastered control of their voters in a way that US elites have not. Although, you'll have to explain which economic elites in the UK decided that Brexit would be to their advantage and how they stole a march on the UK finance industry.
> Although, you'll have to explain which economic elites in the UK decided that Brexit would be to their advantage
The press.
For a time, Johnson himself was both a minister and a "journalist" for the Times. He was paid more for writing one article a week than for being a minister. Eventually he was forced to give this up. But Brexit is to a great extent a media project, backed by sensational but misleading claims, and supported by the media/politics revolving door.
The Sarah Vine/Michael Gove couple had quite an effect too.
If that's the best answer, I think it tends to show that money didn't buy Brexit. The media doesn't care what circus they're covering, as long as there are plenty of clowns and dancing bears. The people who had the money and motivation to buy public opinion on the issue lost out, and it all happened because some politicians found a message that resonated with voters and kept on it as long as it kept working.
Sounds like an explanation Adam Curtis would approve of. I wonder if he's made a film that's explored this in full yet? I know he's certainly mentioned Brexit.
The UK "establishment" is approximately Oxbridge, the Conservative party, the Queen, and the Church of England. These groups are not quite the same thing as economic elites.
The UK also has much stronger spending (and content) limits on electoral campaigns compared to the US.
Yep it's the people's own fault that they died while waiting in the emergency room. The politicians are sacrosanct and must not be criticized under any circumstances. So, you see, all these excess deaths are really suicides.
More people voted against the conservatives than voted for them, but due to the first past the post system they got a massive majority in Parliament and can do whatever they want.
Watching from next door (we've had STV PR in Ireland since independence), I never got this. PR _wasn't on offer_. Unless you actually preferred first past the post to AV (PR > FPTP > AV seems like a weird preference ranking, but I suppose it might be _someone's_), why on earth didn't you vote for AV?
For those not from the UK there’s a wider narrative at play here.
Any and all government bashing is almost a national sport and pastime at this stage. Throw in some numbers to try to prove your point and you’re going to be well received.
So there’s a lot of misinformation out there. Perhaps this Twitter chap is talking rubbish too.
For the record not saying our government is perfect but holy heck it’s hard to keep up with the negativity
"This Twitter chap" is a journalist at the Financial Times and is a senior fellow at the London School of Economics. He's not just some rando bashing government...
So you're saying as a result of these two positions that he holds he cannot possibly be wrong and I should blindly trust anything he says so long as he shows some workings?
I'm saying that you shouldn't dismiss what he's saying because he posted it on Twitter and/or because (you feel that) people are bashing the government.
He's a journalist at a well-respected newspaper, who has practical and academic experience using and interpreting data for his journalism, communicating his story in accessible way (both accessible in a pedagogical way and because the FT has a paywall). Engage with what he's posted and evaluate it on its merits, not just dismissing it because it's a Twitter thread containing a viewpoint that you don't want to be true.
They're doing incredibly badly despite friendly press support, are leaderless after the misconduct got too much even for the Tory party, and are facing some really serious problems this winter if energy prices match projections. In the meantime they waste time on culture war nonsense. They're not being bashed enough.
I would suggest that the bashing contributed to Boris Johnson being forced (correctly in my opinion) to resign. Not to mention causing many of his former colleagues to read the writing on the wall and finally admit that his honesty was "questionable" (either on TV leadership debates and/or by way of resignation).
If the general public was instead expressing extreme satisfaction with the government, I find it unlikely that this would have happened.
Yeah, extensive bashing has achieved the bare minimum, the resignation of Johnson - but, characteristically, in a half-assed way while a lengthy leadership contest happens and the leadership vacuum remains. We're now moving on to strikes, and if the 70s speedrun continues we're likely to see either energy rationing or a mass non-payment of bills, presumably followed by actual riots, until a general election is finally called.
I don't believe it's going to get quite that bad, but I agree that they need to get a move on and get back to some form of stable government quickly (even if the people in power are not necessarily who I'd choose).
the 12+ hour wait times, the hospital occupancy, the aging population and slashed social spending are all hard data. if you want just ignore everything about the excess mortality, and you'll still get the same picture, it's not gonna look nice anyway you dice it.
healthcare (and education) are both incredibly big outliers in the last decades of technological progress (incredible diminishing returns, just look at US spending, brutal Baumol effect, since almost everything is still manual labor .. every MRI/CT requires more professional labor, every new drug requires more tests and consultations, and so on).
no wonder it's looking worse and worse when compared to total GDP of aging populations.
What if the government allowed private enterprise to open emergency clinics in times of great need? There are probably a lot of people who would be willing to pay out of pocket for medical care, especially in an emergency, if it meant getting seen sooner.
Tell me, if you are having a heart attack or have had a stroke, how likely are you to have the mental fortitude required to realize that not only is there a for-profit emergency service, but you can pay to get seen now?
Probably not very likely. If your emergency is urgent but not actually life threatening, then you might. You might - might - think of it if you have gall bladder or appendix types of pain, if you aren't in too much pain to think about it.
And how, exactly, would this go into place? Would you call the emergency line, who proceeds to upsell you on a premium emergency room that will see you right now if only you pay money upfront? Does this also mean that poor people's lives are worth less since they cannot pay up? How about teenagers, who might be calling the emergency line yet don't actually have money to pay?
I understand you pretty well. But see, the majority of people in this forum are from the USA so most of the scenarios that you draw like "freak cases" are normal day to day things that happen in the USA where most healthcare is for-profit.
For someone that is used to social/universal healthcare (like UK, Norway, France, Germany) the prospect of having to deal with stupid for-profit situations during an emergency are laughable. But for someone living in that hell, it is something normal. Not for anything you read countless of anecdotes of people deciding to stay at home and use some superglue or rolled towels when they have an accident and bleed.
I've had the opportunity of experience the two systems (UK' NHS, Germany´s Gesetzliche Krankenversicherung, Mexico's IMSS for public, and Mexico's private system) and really makes me angry that society is moving toward for-profit privatized systems instead of looking to fix the issues in universal/public systems. (It's like if when we saw that the police or the firefighters were not working, we decided to make law enforcement private... throwing the baby out with the bathwater)
in the states, my experience has been that neighbors will frequently discuss the location of new urgent care clinics or share them in group chats. "hey do you guys know of any good urgent care places? I have a swollen arm from a bee sting" was a recent msg thread that popped up on my phone. Usually the patient is insured but you can (should) also ask for a cash price if needed.
Your strawmam is accurate, stroke survivors will need an ambulance. But you're forgetting that a lot of people get driven to emergency by friends or family. And if those bystanders pass a private hospital on the way to public emergency, they could decide their friend / family members life is worth the extra cost. Of course it wouldn't work for everyone, but it would ease the pressure on a failing system.
Also your tone isn't conducive to a constructive discussion and is not appropriate when responding to someone who is suggesting ways to make the world a better place. Just because you can't imagine someone's idea working doesn't mean it's a bad one.
I drove my father to the hospital when he was having a stroke. To be fair, I didn't know until he told the nurses. Just because someone is being driven by family doesn't mean that it isn't serious nor that there is realistically a chance to call around because of price.
I don't care if you find my tone constructive, by the way. The issues I've raise are real issues, and if you can't explain how you'd get around these and still be sure to have the same quality of care for the poorest of people, it isn't a good plan. Unless, you know, the "separate but equal" (Which rarely works) is your goal.
I didn't suggest anything about seriousness of conditions, and the parent did not suggest having different quality of care for poor people. You are projecting your own politics onto our comments. The issues you have raised are real but irrelevant to the comment "What if the government allowed private enterprise to open emergency clinics in times of great need?" I addressed your first criticism (incapacitated patients) and you responded with a personal anecdote connected to a nonsensical sentence about price. I'm not going to go through the rest of them.
I'm not sure why you are so belligerent, without engagement in each others arguments this is pointless so I'll stop here.
Private enterprises are already running a significant chunk of UK health care at the moment; the Tory government is dismantling the socialized health care in favor of short-term profit. It's not about whether people are willing, it's whether they can afford it or if they have no choice but to go into debt.
Anyway, the NHS has also paid private clinics already because their own facilities are at capacity.
It would get a lot more value from that funding if the Tories (and to be fair, also the last Labour gov a decade and a half ago, though not as much) hadn't been pushing so much of it towards embedding privatisation through the NHS such that profits are pointlessly being taken out at all stages. (Well, obviously not pointless for the shareholders, who happen to often coincidentally be tory party donors.)
A hospital having a 20% bigger budget for their janitorial staff isn't in a better position if it's also been required to move from hiring full time cleaners in-house to contracting an approved cleaning company that has 30% profit margin baked in. An NHS patient isn't helped knowing that 50% more funding goes into paying consultants for the problem they have, if gradually more and more of those consultants are moving to private health companies and having to be rented back to the NHS at a markup that pays both the doctor and the company's shareholders. Etc etc.
Sure, the population demographics are related, but even if we had the exact same population as 20 years ago we'd be in a much worse situation; plus it's the government's job to pay attention to things like demo changes in their population, and to listen to the warnings that have been coming from the medical community for many years, and should have been proactively funding better social care (instead of completely abandoning it to local councils while also lowering their funding) AND making the NHS even better (rather than gradually turning it into an umbrella for private companies who eat up any budget increases).
This is the actual issue, spending isn't keeping up with the demand. I'd agree that "the Tories are to blame" doesn't capture it, but I don't think they're equipped to deal with the problem. Real terms spending per age adjusted capita appears to have been on a downwards trend [0] since they took power. I think this has gone up since the pandemic, but I think it's likely too little too late and will probably be a short term increase.
I'm also skeptical the IFS have managed to accurately estimate the required increase in funding. They don't go into their workings from what I can see, but I doubt they've accurately included the effect of the lifetime allowance on pensions causing doctors to avoid overtime or the £100k tax bracket where you lose your personal allowance not moving since 2009 which more and more doctors will fall into. I'd imagine they've underestimated it, but would be happy to hear evidence to the contrary.
That's not to say that I think any other party has a solution or is properly holding the Tories to account on this.
I'll admit I haven't thought too hard about the problem, but I think the fairest solution would be to make pensioners pay national insurance on their income. It wouldn't affect the poorest pensioners and since national insurance is no longer ring fenced for pensions/healthcare I'm not sure what the justification for a tax break based on age even is anymore.
As someone who intends to subsist on more in retirement that change would negatively affect me, but I still think it's fair. I know that this would be deeply unpopular though, so I don't hold out much hope of it happening anytime soon.
Maybe that isn't the best solution, but I really wish we'd start to have real discourse on how we need to restructure our society as the demographic of the country continues to skew older.
Interesting - nice to have a sensible debate on it. I think your idea is worth pursuing even if it's not perfect.
Young people should not be subsidising old people who no longer work - especially those same young people who don't own house or have savings or a pension.
"What if the government allowed private enterprise to open emergency clinics in times of great need?"
Using what for doctors?
The problem is a supply side shortage of medical staff. Praying to the god of the private sector won't magically cause doctors to appear.
I'll remind everybody again. Primary care in the UK has been in private hands since 1948. It's the lack of capacity in the private part of the NHS that is driving people towards A&E for basic stuff.
This isn't exactly true, nor what the GP is suggesting. Supplementing public service with private is already happening in the UK and very common around the world in even the most socialized, public systems like Canada. Where the US shines is high-end ongoing treatment, for which you do pay big bucks.
Have you tried one? Last time my wife went in there for a broken back, she was told to sit in a chair at 10PM and to wait until 8AM for the doctor to come in.
The last time I was in an urgent care facility, the doctor tried to upsell us on a medical procedure. When he left the room, the nurse assured us the procedure was unnecessary and he just wanted to charge us more. I wish I were making this up.
Emergency care specific private enterprise seems incredibly predatory. I also wonder where the infrastructure and staff for these surge clinics would come from.
Hell no. NHS as a public service is currently fighting for its life. Opening up to private enterprise would accomplish the goal of killing and/or privatising it even quicker.
Without inpatient bed availability, ERs and AMUs can't admit to specialties and everything gums up at the front door.
Let's be clear: we do need many more doctors and nurses, but the existing ones can't do their jobs because their wards have turned into medically-fit nursing homes. They spend half their days trying to send people (who don't have care requirements) home faster than they'd like.
Why? Because central government withdrew funding. Social care is now on the council to fund and many councils have squashed social care, along with libraries and early years provisions. The trap of outsourcing caught many councils out.
Turns out the whole endeavour was yet more myopic, Tory penny-pinching.