You've noted the two key parts of the NHS and both are in big need of reform in my view. We are currently trying to provide a perfect unrationed private system for free and it just doesn't work. Health demand will always be huge so needs rationing. This needs to be tackled through incentives to consumers of healthcare as well as a more honest rationing of the service that can be provided. As for delivery, a mixed economy and attempts at genuine competition between state and private feels like a good place to aim for.

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I imagine some readers were utterly horrified at your suggestion that the NHS should introduce rationing .... But once I'd got over the initial reaction, I found myself asking (1) what (or how) would you ration and (2) doesn't the NHS already have some element of rationing?

On the second of those points, we already have NICE (in England) which decides on treatments that the NHS will or won't provide on the grounds of cost and/or efficacy. This Guardian news article from five years ago lists 17 procedures that were being removed from the NHS (see https://www.theguardian.com/society/2018/jun/29/nhs-wields-the-axe-on-17-unnecessary-procedures).

We also have the GP-as-gatekeeper system which prevents access to a specialist without a referral. That isn't working so well at the moment with GPs overworked and patients turning up at A&E instead.

And so to your first point, what sort of rationing would you suggest? More of the same? Or something different altogether? Would you go so far as to ration patient access to GPs (and A&E) so as to free-up the limited amount of GP time available?

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Had a long chat with a senior NHS consultant friend a few weeks ago on the NHS and a few of your comments are very relevant to his thoughts on what is currently wrong with the NHS which I will come to.

On rationing you rightly note we already have some. You've not mentioned waiting lists which are another form of rationing we currently have and a form that is neither well liked or particularly good for health outcomes. In my comment above I talked about a) a more honest rationing of the service that be provided and b) incentives to consumers of healthcare so it's worth explaining what I mean.

At the moment the expectation from the public is that no matter how small the issue they will be seen quickly and treatment will be provided quickly. However, very rarely is this expectation ever challenged. In fact, politicians focus exclusively on talking about how amazing the NHS is. Such is the religious fervour attached to it, any honest appraisal or criticism is frowned upon. This includes being honest about things like: the gatekeeper role that GPs play, that some treatments aren't economically viable, that we all need to be a bit more responsible about how we use the service because it does need to be rationed.

Talking to my friend it seems that much of the rationing built into the system is falling down right now. Some issues:

- In the litigious age we now find ourselves in the NHS and individual staff are more and more paranoid about accusations of poor care. This makes the individual very powerful and demanding resulting in over testing etc.

- You mention the GP as gatekeeper and I think it's best to quote my friend directly on this "the NHS was held together by senior GPs who would make good decisions for their patients whilst recognising the NHS was free and couldn't do everything. Enter the age of the NHS constitution that basically says everyone is entitled to everything. Those GPs retired and more people are referred to hospital who do more tests. New doctors (some trained abroad) don't speak double speak. It says we don't ration care but in reality we don't give chemotherapy to people who are 100. But nobody says this. We shouldn't give very expensive therapy to terminal patients with very limited life expectancy who will not benefit but these are difficult discussions in a backdrop that continues to say we do."

- Also on GPs "GPs got a level of control back during covid by closing the doors and fixing appointments. They would never want to give this up. Now the overspill goes to hospital (which can and does over investigate simple things)." He also notes that many immigrants don't understand the idea of GPs and are used to turning up at the ED/urgent clinic. They therefore go straight to ED.

- Related to the litigious side of things keeping hospitals compliant has become a big industry of data, governance and management. Back office to pass inspections is immense and with every new body there is more time sucked from clinical staff answering questions.

- On self-rationing "People say they love the NHS but they don't really behave like they value it. I often have conversations at dinner parties where someone bemoans the lack of appointment for something so trivial. They highlight the problem without realising the problem is them with their really low threshold to seek advice"

- 111 is a system that attempts to ration but removes a key piece of the picture "You simply can't design a service that takes personal responsibility for a person's illness but can't see them. It generates chaos. Anything in medicine might be serious!" "In medicine the most important predictor of whether someone has a problem is whether they themselves think they should bother a doctor. With 111 you take that decision making away..... A lot of people I see say 'I didn't think there was much wrong so phoned 111 who told me to come to ED'. I see them after 12 hours waiting in ED! Correct nothing wrong!"

Then there is the incentives side of the piece. I'd like to see the model evolve to put some economic incentives in that make people think more, encourage efficiency and change the relationship between NHS and patient a bit more. I've always liked the Singapore model. Whilst it's evolved some complexity it has some great incentives in place despite still being largely free for most people through use of state provided health accounts to spend on health. In Europe a charge for the first contact is common.

There are also opportunities to improve the incentives internally within the NHS as well. To quote my friend again: "Performance management and incentivising efficiency is non-existent in a socialist structure. You get paid the same if you keep everyone in hospital and do loads of tests as you do if you manage loads more patients by discharging based on sound medical decision making.".

All of the above makes it clear why despite having more staff than ever the system is crumbling. Some other points worth considering:

- There are too many specialists and too few people treating the whole patient. Older people in particular can end up having many appointments and tests with many different specialists for a single issue.

- The beds per capita is too low meaning there is no space in winter and certain surgery grinds to halt with inefficient redeployment of staff.

- Hospitals are about a quarter full of social care with home packages inadequate.

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Thanks for elaborating.

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Simon, without some fundamental re-purposing and re-design, the NHS will surely continue to fail. It is the scale and scope of the change that makes it a nettle that few, if any, politicians will wish to grasp.

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