NHS breaking point?

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EACLucifer
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Re: NHS breaking point?

Post by EACLucifer » Thu Apr 07, 2022 3:54 pm

nekomatic wrote:
Thu Apr 07, 2022 3:44 pm
monkey wrote:
Thu Apr 07, 2022 12:50 pm
I am not against an insurance based system, it seems to work in other countries who regulate it sufficiently and ensure that everyone has it. But I am unsure that the UK moving to such a system would bring much benefit.
This being my earlier point: it would only bring a benefit if it either persuaded people to spend more on their healthcare than they do now, or persuaded people to accept less healthcare than they get now. People seem to assume that the former would somehow automatically happen, but it’s not obvious to me.
This. We're basically looking at healthcare = funding - inefficiency and bureaucracy.

Adding more internal markets has the potential to increase bureaucracy, as does adding a method for collecting money from patients one way or another, and adding a method to stop that then hitting the poor and vulnerable adds another layer, and that probably won't work with many of the people who need it most, so it will still leave people without care...etc.

The NHS needs more funding and less internal marketisation and fragmentation - the best way to achieve that would be to increase taxes on those who can pay, perhaps by reversing the trend towards taxing unearned income lower than earned income.

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Re: NHS breaking point?

Post by lpm » Thu Apr 07, 2022 4:08 pm

EACLucifer wrote:
Thu Apr 07, 2022 3:54 pm
the best way to achieve that would be to increase taxes on those who can pay, perhaps by reversing the trend towards taxing unearned income lower than earned income.
I'm sure we all agree that would be the best way. But we're not going to get the best way.

What's the second best way?
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Re: NHS breaking point?

Post by Woodchopper » Fri Apr 08, 2022 9:44 am

dyqik wrote:
Thu Apr 07, 2022 1:29 pm
Woodchopper wrote:
Thu Apr 07, 2022 1:02 pm
lpm wrote:
Thu Apr 07, 2022 12:58 pm

What doesn't cause any extra bureaucracy for anyone is not doing the hip replacement. Leave it neglected for years and the paperwork's a breeze. Which is what happens at the moment. The 18 week target is long gone, people are waiting in pain for a couple of years. The queue for this group of operations is half a million people.
Which is an important point. Its easy to point to inequalities and other problems with other means of financing. But they need to be balanced against the current inequalities in which people with chronic conditions can receive very poor quality of care.
I'm already taking that into account. I'm very aware of the problems of access to healthcare. Under your system, people without health insurance or with the wrong health insurance (if the UK was stupid enough to go down the route of multiple providers with separate contracts with providers, and thus preferred provider networks) won't have access to the hip operations.

And the access to healthcare issues are worse under the US system than the UK system. Even the wait times with full health insurance aren't really any better (remember, I have extended family in both countries, and both sides have some complex health issues that they are dealing with now). Of course, other systems exist, but they also exist in a different legal and social environment to either the UK or US, and they have arrived at that set up by a different route than the UK would.

There's also substantial external issues caused by private insurance and access to it. In the US, one of the biggest problems is that private health insurance is inevitably tied to employment as a benefit (as BUPA is now in most cases in the UK), and this leads to labour mobility issues and subsequent low productivity and increased inequality.
I'm not advocating any particular system.

But in general among developed countries the US healthcare is an outlier on every metric I can think of. Of course it would a very bad for the UK or any other country to try to replicate it.

I agree that countries with good healthcare provision partly or mostly via private state subsidized and regulated health insurance have particular legal and social environments. But I suggest that concerning healthcare at least the UK is much closer to Germany or France than it is to the US. Politicians in the UK of all parties at least state that they believe in universal healthcare.

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Re: NHS breaking point?

Post by Woodchopper » Fri Apr 08, 2022 10:37 am

nekomatic wrote:
Thu Apr 07, 2022 3:44 pm
monkey wrote:
Thu Apr 07, 2022 12:50 pm
I am not against an insurance based system, it seems to work in other countries who regulate it sufficiently and ensure that everyone has it. But I am unsure that the UK moving to such a system would bring much benefit.
This being my earlier point: it would only bring a benefit if it either persuaded people to spend more on their healthcare than they do now, or persuaded people to accept less healthcare than they get now. People seem to assume that the former would somehow automatically happen, but it’s not obvious to me.
Its impossible to predict. But I suggest that people might be more willing to pay into a specific health insurance fund rather than higher taxes in general.

If there was to be a UK system similar to that found in Europe - eg compulsory payments into a health insurance fund - then the end result would in practice be very different from taxation. The government would deduct money from people's salaries and as its would be a universal requirement for all taxpayers individual costs can be kept low, and the fund can be subsidized.

So why not just do all that by increasing taxation? The problem with increasing general taxation is that voters tend to be suspicious of politicians and fear that their taxes will be used for things that they don't like. Depending upon someone's political stance that could include things like nuclear weapons, tax cuts for billionaires, or spending on benefit cheats and scroungers.

So people people might be more willing to pay into a national health insurance fund because it would be harder for a future government to use the money for something other than healthcare.

Worries about a private company making excessive profits can be addressed via regulation (eg the regulator setting maximum prices).

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Re: NHS breaking point?

Post by dyqik » Fri Apr 08, 2022 11:31 am

We already address all of that in taxation with National Insurance, or Social Security and Medicare payroll taxes in the US, without getting private companies involved. While I wouldn't suggest structuring a National Health tax in exactly the same way as them (maybe it should be more like income tax), it's entirely possible to make specific earmark taxes.

Usually that's a bit frowned on, because governments want and need the flexibility to move money around as needs change, but NHS funding is one area that's got a solid base level of funds required, and clear ongoing need for capital spending to replace existing facilities and equipment.

Oh, and all private companies (except true non-profits) make excessive profits compared to public bodies. If they are more efficient, then that could be plowed back into services, rather than taken out as profit.

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Re: NHS breaking point?

Post by Woodchopper » Fri Apr 08, 2022 12:35 pm

I think that UK National Insurance is an example of why voters are often suspicious. People pay something called National Insurance, but its just another form of taxation. Governments spend the National Insurance payments immediately and rely upon future taxation to cover benefits etc.

In general, I agree that hypothecated taxes have problems because they reduce flexibility. Its possible that in the future a health insurance fund may turn out not to be the best use of resources. Maybe in 2050 healthcare will be provided by very inexpensive robots.

On the other hand, it seems very likely that the UK and other European states are going to face enormous problems funding healthcare over the next decades. So its probably a fairly safe bet.

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Re: NHS breaking point?

Post by dyqik » Fri Apr 08, 2022 12:43 pm

The US payroll taxes do remain entirely separate though, so it's certainly not impossible to do.

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Re: NHS breaking point?

Post by dyqik » Fri Apr 08, 2022 12:44 pm

Woodchopper wrote:
Fri Apr 08, 2022 12:35 pm
In general, I agree that hypothecated taxes have problems because they reduce flexibility. Its possible that in the future a health insurance fund may turn out not to be the best use of resources. Maybe in 2050 healthcare will be provided by very inexpensive robots.
If this exceptionally unlikely event actually happened, sometime after the porcine space program establishes it's first lunar base, you could always reduce the tax rate.

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Re: NHS breaking point?

Post by snoozeofreason » Fri Apr 08, 2022 1:07 pm

In practice, the problem with hypothecated taxes is more that they do not reduce flexibility. Money is, as economists like to say, fungible, so unless the sum raise by a hypothecated tax is greater than the sum that we usually spend on the issue for which it is hypothecated, it doesn't make any real difference.

If we had a hypothecated tax that raised £200 billion and which had to be spent on the NHS, then that would genuinely limit the flexibility of the government - and reduce it in a way that we would probably approve of - because they would then have to spend at least £200 billion on the NHS, which is greater than the amount currently devoted to it. A hypothecated tax that raises, say, £11 billion and is dedicated to the NHS makes no practical difference, because we are bound to spend more than £11 billion on the NHS, and it is meaningless to ask which part of that money comes from our hypothecated tax, and which from other sources such as income tax .
In six days the Lord made the heavens and the earth, the sea, and all that is in them. The human body was knocked up pretty late on the Friday afternoon, with a deadline looming. How well do you expect it to work?

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Re: NHS breaking point?

Post by snoozeofreason » Fri Apr 08, 2022 1:18 pm

Woodchopper wrote:
Fri Apr 08, 2022 12:35 pm
I think that UK National Insurance is an example of why voters are often suspicious. People pay something called National Insurance, but its just another form of taxation.
It goes beyond suspicion in the Snooze household! Mrs. S works in tax, and also listens to the Today programme in bed of a morning. This is not a good combination, because if NI enters the discussion then I get abruptly woken up by shouts of "National Insurance is a flipping tax you idiot!" (and "flipping" will probably not be her default choice of words because she tends to express herself more robustly than I do).
In six days the Lord made the heavens and the earth, the sea, and all that is in them. The human body was knocked up pretty late on the Friday afternoon, with a deadline looming. How well do you expect it to work?

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Re: NHS breaking point?

Post by lpm » Fri Apr 08, 2022 1:23 pm

snoozeofreason wrote:
Fri Apr 08, 2022 1:07 pm
In practice, the problem with hypothecated taxes is more that they do not reduce flexibility. Money is, as economists like to say, fungible, so unless the sum raise by a hypothecated tax is greater than the sum that we usually spend on the issue for which it is hypothecated, it doesn't make any real difference.

If we had a hypothecated tax that raised £200 billion and which had to be spent on the NHS, then that would genuinely limit the flexibility of the government - and reduce it in a way that we would probably approve of - because they would then have to spend at least £200 billion on the NHS, which is greater than the amount currently devoted to it. A hypothecated tax that raises, say, £11 billion and is dedicated to the NHS makes no practical difference, because we are bound to spend more than £11 billion on the NHS, and it is meaningless to ask which part of that money comes from our hypothecated tax, and which from other sources such as income tax .
The point is we need to persuade people that we should collectively spend more on healthcare.

Putting in a separate Health and Social Care Levy is a way to communicate this. It's meaningless in the real sense but that's not why it's there. It allows for grown-up discussion on what to do about the ageing population and the rising need.
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Re: NHS breaking point?

Post by Woodchopper » Fri Apr 08, 2022 1:24 pm

snoozeofreason wrote:
Fri Apr 08, 2022 1:07 pm
In practice, the problem with hypothecated taxes is more that they do not reduce flexibility. Money is, as economists like to say, fungible, so unless the sum raise by a hypothecated tax is greater than the sum that we usually spend on the issue for which it is hypothecated, it doesn't make any real difference.

If we had a hypothecated tax that raised £200 billion and which had to be spent on the NHS, then that would genuinely limit the flexibility of the government - and reduce it in a way that we would probably approve of - because they would then have to spend at least £200 billion on the NHS, which is greater than the amount currently devoted to it. A hypothecated tax that raises, say, £11 billion and is dedicated to the NHS makes no practical difference, because we are bound to spend more than £11 billion on the NHS, and it is meaningless to ask which part of that money comes from our hypothecated tax, and which from other sources such as income tax .
Fair enough, in my example the problem would be if Britain raised 200 billion per year that could only be spent on healthcare, and due to improvements in technology Britain only needed to spend 50 billion. But as dyqik pointed out, that is a very unlikely scenario (just the only one I could think of at the time).

So if people think that it may be politically feasible to raise a lot more money through a scheme that could only be spent on healthcare that might be a solution. As mentioned, I don't think it would make a lot of difference whether it was European style regulated private insurance with universal payments or some means to hive off a bit of government that couldn't be re-allocated.

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Re: NHS breaking point?

Post by snoozeofreason » Fri Apr 08, 2022 1:31 pm

lpm wrote:
Fri Apr 08, 2022 1:23 pm
snoozeofreason wrote:
Fri Apr 08, 2022 1:07 pm
In practice, the problem with hypothecated taxes is more that they do not reduce flexibility. Money is, as economists like to say, fungible, ...
The point is we need to persuade people that we should collectively spend more on healthcare.

Putting in a separate Health and Social Care Levy is a way to communicate this. It's meaningless in the real sense but that's not why it's there. It allows for grown-up discussion on what to do about the ageing population and the rising need.
You're obviously in a glass half full mood this afternoon. My half empty glass is telling me that, in the hands of our current government, a Health and Social Care Levy might be a good way of subverting such a discussion, because it will be something that they can point to in order to convince people that the need is being addressed, without doing anything that actually does address it.

My feeling is that, if we want government to spend more on health and social care, then we have to get them to commit to doing exactly that. Hypothecating taxes is essentially a game of Find the Lady where the public gets fooled into looking at the wrong thing.
In six days the Lord made the heavens and the earth, the sea, and all that is in them. The human body was knocked up pretty late on the Friday afternoon, with a deadline looming. How well do you expect it to work?

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Re: NHS breaking point?

Post by dyqik » Fri Apr 08, 2022 1:35 pm

snoozeofreason wrote:
Fri Apr 08, 2022 1:31 pm
lpm wrote:
Fri Apr 08, 2022 1:23 pm
snoozeofreason wrote:
Fri Apr 08, 2022 1:07 pm
In practice, the problem with hypothecated taxes is more that they do not reduce flexibility. Money is, as economists like to say, fungible, ...
The point is we need to persuade people that we should collectively spend more on healthcare.

Putting in a separate Health and Social Care Levy is a way to communicate this. It's meaningless in the real sense but that's not why it's there. It allows for grown-up discussion on what to do about the ageing population and the rising need.
You're obviously in a glass half full mood this afternoon. My half empty glass is telling me that, in the hands of our current government, a Health and Social Care Levy might be a good way of subverting such a discussion, because it will be something that they can point to in order to convince people that the need is being addressed, without doing anything that actually does address it.
It's at least a framework that a future responsible government can use to do the right thing with. As opposed to being stuck with a massive private healthcare lobby fighting against public spending and investment in order to protect their rent and profits.

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Re: NHS breaking point?

Post by snoozeofreason » Fri Apr 08, 2022 1:46 pm

dyqik wrote:
Fri Apr 08, 2022 1:35 pm
snoozeofreason wrote:
Fri Apr 08, 2022 1:31 pm
lpm wrote:
Fri Apr 08, 2022 1:23 pm
Putting in a separate Health and Social Care Levy is a way to communicate this. It's meaningless in the real sense but that's not why it's there. It allows for grown-up discussion on what to do about the ageing population and the rising need ...
You're obviously in a glass half full mood this afternoon ...
It's at least a framework that a future responsible government can use to do the right thing with. As opposed to being stuck with a massive private healthcare lobby fighting against public spending and investment in order to protect their rent and profits.
I'd prefer a future responsible government to encourage us to think sensibly about tax. I wouldn't want it to have any truck with hypothecated taxes at all, because they almost inevitably encourage voters to look the wrong way. A responsible government would also completely abolish National Insurance, because it is a regressive form of income tax that applies only to earned income, and which the rich can avoid even more easily than the income tax we actually call Income Tax (I am channelling Mrs S a bit here!).
In six days the Lord made the heavens and the earth, the sea, and all that is in them. The human body was knocked up pretty late on the Friday afternoon, with a deadline looming. How well do you expect it to work?

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Re: NHS breaking point?

Post by dyqik » Fri Apr 08, 2022 2:05 pm

snoozeofreason wrote:
Fri Apr 08, 2022 1:46 pm
dyqik wrote:
Fri Apr 08, 2022 1:35 pm
snoozeofreason wrote:
Fri Apr 08, 2022 1:31 pm


You're obviously in a glass half full mood this afternoon ...
It's at least a framework that a future responsible government can use to do the right thing with. As opposed to being stuck with a massive private healthcare lobby fighting against public spending and investment in order to protect their rent and profits.
I'd prefer a future responsible government to encourage us to think sensibly about tax. I wouldn't want it to have any truck with hypothecated taxes at all, because they almost inevitably encourage voters to look the wrong way. A responsible government would also completely abolish National Insurance, because it is a regressive form of income tax that applies only to earned income, and which the rich can avoid even more easily than the income tax we actually call Income Tax (I am channelling Mrs S a bit here!).
Yeah, the structure of NI is fairly broken. But that doesn't have to be the case for a different tax.

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Re: NHS breaking point?

Post by snoozeofreason » Fri Apr 08, 2022 2:16 pm

dyqik wrote:
Fri Apr 08, 2022 2:05 pm
Yeah, the structure of NI is fairly broken. But that doesn't have to be the case for a different tax.
I wouldn't disagree with that, and I think we have probably got to the point where we have to let this thread get back to it's original topic (unless someone wants to start separate threads on NI and/or hypothecated taxes).
In six days the Lord made the heavens and the earth, the sea, and all that is in them. The human body was knocked up pretty late on the Friday afternoon, with a deadline looming. How well do you expect it to work?

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Re: NHS breaking point?

Post by jimbob » Fri Apr 08, 2022 4:48 pm

jimbob wrote:
Thu Apr 07, 2022 7:05 am
dyqik wrote:
Wed Apr 06, 2022 11:50 pm
monkey wrote:
Wed Apr 06, 2022 11:14 pm


So a bit like the US then? It works really well and it's not at all expensive.

I also really hate that my healthcare is decided by who I work for.


(The US has Medicare for the poor, Medicaid for the old, and the VA system for veterans. Everyone else gets insurance through their employer, by themselves, or through charity.)
And it costs the US government more per capita than the UK government spends on the NHS.

And requires far more labour to administer and to deliver healthcare.
. indeed.

Data in graph form from 1990 Before the ACA, this was simply "public" not "public/compulsory" spending

https://data.oecd.org/chart/60Tt

lpm wrote:
Thu Apr 07, 2022 7:29 am
Now do France, Netherlands, Germany.

Always reaching for US comparisons is Fake Debate.
Fortunately my graph has those countries

https://data.oecd.org/chart/6FMr
2018 data
France 9.352%
Germany 9.672%
UK 7.775%

So I make that the UK is spending roughly 80%-83% of France or Germany in public spending
Have you considered stupidity as an explanation

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Re: NHS breaking point?

Post by WFJ » Fri Apr 08, 2022 5:20 pm

jimbob wrote:
Fri Apr 08, 2022 4:48 pm

Fortunately my graph has those countries

https://data.oecd.org/chart/6FMr
2018 data
France 9.352%
Germany 9.672%
UK 7.775%

So I make that the UK is spending roughly 80%-83% of France or Germany in public spending
From the phrasing "Government/compulsory" I would assume that the German data includes private insurance as well as the legal public insurance system.

In Germany insurance is compulsory, but you can choose whether you want to pay into the public or private system. For a youngish, reasonably well-paid (ie most post-university jobs) person with no children, private insurance will be significantly cheaper than the public system, while offering better coverage. The public system does have additional benefits however*, and the private system becomes more expensive as you get older. Once you move to the private system it is very difficult to be accepted back on the public system.

*free coverage for non-working cohabiting partners and children until they leave school or university. Free coverage when unemployed or retired.

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Re: NHS breaking point?

Post by lpm » Fri Apr 08, 2022 6:07 pm

jimbob wrote:
Fri Apr 08, 2022 4:48 pm
Fortunately my graph has those countries

https://data.oecd.org/chart/6FMr
2018 data
France 9.352%
Germany 9.672%
UK 7.775%

So I make that the UK is spending roughly 80%-83% of France or Germany in public spending
A huge gap to make up. And the insufficient 1.25% tax rise was slammed by both left and right.
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Re: NHS breaking point?

Post by Martin_B » Sat Apr 09, 2022 12:05 am

At the risk of a derail (and possibly worth a thread on it's own), but do any of the USian posters here know much about the Hawaiian healthcare system and whether it is seen as a good thing and economically sound, or a dangerous communist plot?

I understand (possibly erroneously) that emergency care in Hawaii is free (paid for in taxes, like the NHS) with aftercare being either free or private (presumably private gets you better standard of care).

This sounds more like the Australian healthcare system, which is like a BUPA'd up NHS system - emergency care is paid for, but you pay for pretty much everything else (including ambulances!) and then claim it back from your private health fund. But paying for a private healthcare cover also reduces your taxes (3% income tax if you have no cover, 1.5% income tax if you have private cover).
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Re: NHS breaking point?

Post by dyqik » Sat Apr 09, 2022 1:09 am

Martin_B wrote:
Sat Apr 09, 2022 12:05 am
At the risk of a derail (and possibly worth a thread on it's own), but do any of the USian posters here know much about the Hawaiian healthcare system and whether it is seen as a good thing and economically sound, or a dangerous communist plot?

I understand (possibly erroneously) that emergency care in Hawaii is free (paid for in taxes, like the NHS) with aftercare being either free or private (presumably private gets you better standard of care).

This sounds more like the Australian healthcare system, which is like a BUPA'd up NHS system - emergency care is paid for, but you pay for pretty much everything else (including ambulances!) and then claim it back from your private health fund. But paying for a private healthcare cover also reduces your taxes (3% income tax if you have no cover, 1.5% income tax if you have private cover).
Depends who you are asking, I presume. Mitt Romney introduced an Obamacare like thing in Massachusetts several years before Obama ran for president, and it was and remains popular. Hawaii is slightly bluer than Massachusetts, so I expect that it's popular there.

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Re: NHS breaking point?

Post by Millennie Al » Sat Apr 09, 2022 3:22 am

IvanV wrote:
Thu Apr 07, 2022 8:42 am
Interestingly, I always thought that Ireland was a country where you have to pay for health care. The Irish have often told me that the NHS is a reason that many Northern Irish might vote against unification whatever community they come from. Yet the proportion of health care spending from public funds in Ireland isn't very much lower than in the UK - 73% vs 78%.
You were right. See https://en.wikipedia.org/wiki/Healthcar ... of_Ireland which says that free healthcare is provided to 31.9% of the population, with the rest expected to pay at least some of the cost of treatments. Non-mandatory insurance is available to cover these costs, and the average annual cost of basic (whatever that is) health insurance was €1,850 in 2017. From https://en.wikipedia.org/wiki/Health_in ... ted_States I find that workers' average insurance in 2009 was $4,824. And, that probably doesn't cover everything. The USA is a completely useless model for health insurance. The Irish system sounds very like what applies to dentistry in the UK - poorer people get free treatment, while richer people have to pay for themselves, but have the option to get private insurance instead of paying everything as needed.

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Re: NHS breaking point?

Post by Millennie Al » Sat Apr 09, 2022 3:36 am

EACLucifer wrote:
Thu Apr 07, 2022 11:02 am
the private organisation - unless it is a non-profit trust - is taking some of the money out to stick in shareholders pockets.
That is not an inherent property of a private company. For example, Amazon, which was founded in 1994, has never paid a dividend and does not intend to for the forseeable future. All profits are reinvested in the business - just like people claim can only happen with public bodies.
one example I've had personal experience with is in wheelchair provision*, where the body coontracted to provide wheelchairs came up with thresholds based on who needs what that weren't closely attatched to care needs, and couldn't be overridden by medical professionals
If that's what the contract specified, then why do you blame them for doing what they were paid to do? It's like complaining that a taxi driver took you to the wrong place because you gave the wrong destination address. Private enterprise does not work by magic - you specify what you want and what you are willing to pay and then either get that or nothing. If you get something else, that's breach of contract and subject to compensation. The main problem is that governments and public bodies are inefficient and incompetent, so frequently ask for the wrong things. This cannot be fixed by giving them even more control over the process.

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Re: NHS breaking point?

Post by EACLucifer » Sat Apr 09, 2022 3:43 am

Millennie Al wrote:
Sat Apr 09, 2022 3:36 am
EACLucifer wrote:
Thu Apr 07, 2022 11:02 am
one example I've had personal experience with is in wheelchair provision*, where the body coontracted to provide wheelchairs came up with thresholds based on who needs what that weren't closely attatched to care needs, and couldn't be overridden by medical professionals
If that's what the contract specified, then why do you blame them for doing what they were paid to do? It's like complaining that a taxi driver took you to the wrong place because you gave the wrong destination address.
Sure, it was me, the patient, that specified the contract :roll:
Private enterprise does not work by magic - you specify what you want and what you are willing to pay and then either get that or nothing. If you get something else, that's breach of contract and subject to compensation. The main problem is that governments and public bodies are inefficient and incompetent, so frequently ask for the wrong things. This cannot be fixed by giving them even more control over the process.
The main problem is that internal marketisation fragments provision, creating gaps in the service. And as for blaming the public sector for not writing tighter contracts, when subcontracting you end up putting a lot more into bureaucracy - the subcontractor wants to be paid for minimum work, and so employs lawyers to try and find its way to do minimum work, so the contracting party has to then employ lawyers to counter that and keep them on task - the increased bureaucracy means that artificial markets cannot be efficient.

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