Tax Rates

Yep. Only when there is a government with such a huge majority and poll lead that they can make the required changes without fear of losing the next election will there be the required change to the NHS. This was the experience of de-unionisation in the '80s - the Conservative government had so much support that they could take on the bodies that constricted the nation at the time. Even if it does come to making the immense changes to UK Healthcare needed it will only be sellable if the apostles of the NHS can be prevented from telling everyone in the UK that the USA model is the only alternative and ignoring the systems of other developed nations.

There also needs to be a run on senior medical professionals along the same lines that senior bankers have. There are a relative few bankers that earn telephone number salaries and I bet the percentage of senior medics that have the kind of earnings that John is alluding to is far higher than the number of trading floor goons (without the monthly fear of being told to fill a black plastic bag with their stuff and go home). Doctors in a lot of other countries are amongst the top earners but they are not deified to the extent the UK profession expects to be. 

The NHS model is good provided it is used by all customers correctly all the time and stays within its remit of general healthcare and support, but as has been said before: no one appreciates or respects something they consider to be "free".

The best chance of change is a through the media. The problem with our media is they seem largely politically motivated and tend to ask questions from the left, that is the questioning is about lack of money and providing more money than how it’s used by the service.
The doctors situation is so misunderstood by the general population that they can get away with murder. Literally in some cases.

I think the ability to take a minimal salary and just get granted stock options which are then used as collateral for loans, that are then re-paid with further loans, to avoid declarable tax income is wrong and needs to be looked at.

There is a very easy solution: go private, get the extra salary and set aside a day a week to do pro-bono work for the NHS to alleviate his "conscience". That way his finances are 320% of their current amount (4x less 20% for the NHS work), from which he can set aside a large amount of pension contribution. If a large enough percentage of consultants did this the finances of the NHS would improve.

However as an A&E consultant there is limited opportunity in the UK in that sector as it's not permitted for A&E patients to go anywhere other an NHS facility. In addition my private consultants are all NHS consultants at St Georges. My appointments and treatments (I have a bulging disc) are all after 4.30pm and the consultants arrive in Cheam having hotfooted it from Tooting.

I'm quite cynical when anyone in any line of work that is classed as a senior consultant complains about any aspect of their remuneration.

The dividend question is easy to answer. Dividends are not a tax deductible expense for the company - they are paid out of taxed income. The understanding that has stood the test of time for 200 years is that if income is taxed in one place it cannot and should not also be taxed in another place at the same time.

The current Government f*cked that one up when they introduced dividend tax and they were just following up Gordon Brown's removal of the tax credit which could give pension schemes and other non taxpayers a refund.. Dividends always used to be subject to higher rate tax with a tax credit being given for an amount roughly equivalent to the Corporation Tax paid on those dividends. If higher rate tax is 40% and basic rate tax 20%, a basic rate taxpayer (historically) paid no tax on dividends because the Corporation tax roughly equated to the basic rate tax already paid. A higher rate taxpayer would pay 40% less the tax credit of 20% = 20%

After 1st April 2023, if a company makes £100,000 profit, they pay corporation tax of £25,000. They then pay a dividend of, say £50,000 to shareholders. If those shareholders are currently basic rate taxpayers they would pay dividend tax of 8.75%, making the total tax take on that £50,000 of dividends £16,875 (£12,500 + £4,375) or 33.75%. If the individual was an additional rate taxpayer (45% tax) they would pay dividend tax at 39.35%, making the total tax take on the £50,000 dividends £32,175 or 64.35%.

If the Govt get rid of dividend tax and replace it with full income tax rates dividends would be taxed twice and the rates would increase even further - it would certainly make running your own limited company a lot more expensive than being a sole trader.

Most UK trained doctors do exactly that these days. We export more than we train and as a result the NHS survives by recruiting from overseas, particularly from developing world countries. This breaks international conventions designed to stop western governments from draining these countries of their human capital.

You could say the same about civil engineers, artisan bakers, motor engineers, metallurgists, research scientist etc. One also has to consider the rest of their lives at whatever point they became disenchanted with their lot compared to their overseas affiliates. If they’re middle-aged, married with a partner with a social circle, kids at school, grandchildren then they’re likely left grinding their teeth. As Michael points out if they’re not there yet they get up and go. 

NHS advocates will tell me the “ah but the Hippocratic oath/ saved us all during Covid / keep us alive / duty” bollocks but my best friend was a key worker during COVID. He’s the Financial Controller of an industrial bakery and feeding people is as important as stopping them being ill. My erstwhile colleagues in the rail sector designed, tested and implemented signalling systems that prevent countless deaths every minute of every day and in my civil engineer sector every time you cross a bridge and don’t plunge to your death below your life has been protected in no less a way than being told by a GP to go home and take a paracetamol. 

S-I-L and B-I-L are a GP and Oncologist respectively in Moravia in Czechia. They have a nicer lifestyle than most around them but they don’t expect to live like the multi-millionaire risk-taking financial sector because to them and all their colleagues the medical profession is just the path they took because it suited them. In other words it’s just a line of work: working on the human body is the same as being the greasy bloke working on a particular marque of classic car: they can diagnose and deal with the problems because experience of doing the same has told them the likely problems. Technology progress has helped them do it better in both cases. 

I think this is the problem with the medical profession at certain levels of seniority: they forgot they are just school kids that grew up and took a job on and not gods that need to be treated differently to check out person at the supermarket that knows how to change the receipt-paper roll.

As was said to me once- Doctors are lucky. They are the only profession that truly gets to bury their mistakes.

I can't fault the treatment I've had from the NHS for my cancer. But that's in a cancer unit that received charitable support over and above what the NHS might be able / want to spend. But, even I could see the waste and inefficiency that occurred in my treatment. Every time I see or speak remotely to people for my follow ups, they have to send a letter to me and my GP telling us what what said, what was discussed, the status and any decisions made etc. I also get a letter to confirm appointments. "Why don't you just email me?". My GP texts me to confirm appointments, I don't get a letter. Not secure was the reply. No less secure than the appointment letter that got lost in the post in my view. I think the excuse of patient confidentiality and security is vastly over-used as an excuse to not face and deal with things that could be done differently.

Two things on the radio today made me see red too. An NHS senior manager was on talking about the length of waiting lists. And of course they started with that political phrase "after 10 years of austerity and then Covid, we can't operate without a lot more money".

And then Jeremy Vine (yes, I know..) had a GP on talking about NHS computer systems and how rubbish they are. Well they may well be, but one of his gripes was how old his IT kit was. Aren't you self employed? If your desktop computer is too slow, just get a new one.

To be fair, the nhs wastes a ton of money every day. Not just the penny mailing stuff.

In addition to that you have to remember a lot of people aren't tech savvy, especially older ones who are most likely to need to use the NHS services.

My mum's 81, has used computers ALL her working life, still uses them for online shopping, etc but it completely useless with a mobile phone apart from making calls.
If she got a text about an appointment she wouldn't know it was there.
What she - in common with a lot of older people - does is sticks the letter up on a board in the kitchen so its clear for her, and me, to see.

The NHS has been subject to so many reorganisations it's no wonder its a mess.
IF the ones done over the past 12 years have been a partial attempt to open the NHS up to private companies maybe it would've been better to be honest about that and do it properly. E.g. provide a list of core services that are protected and free to use and a list of services that are optional. i.e. go on a waiting list for NHS treatment OR pay and go through quicker.
Some sort of properly integrated system like that would probably be reasonably acceptable, especially since the majority of the media has been fairly pro-Tory over the last decade (Mail, Times, Telegraph) so a bit of positive spin to/from them would ease the message.

It's not full privatisation though is it, just some services going out to that.

I have to be honest and say that I have a fairly low opinion of doctors (GPs, anyway) as people.
Quite a lot of the ones I've come into contact with over the years - away from their day job - are not necessarily the type I'd want to spend much time with.
We even have a close friend who is a GP and while he's ok most of the time he has lost some perspective on the wider aspects of life. When he complained about the pension thing I wasn't feeling sympathetic.

It's often said that most doctors marry other doctors or nurses as they are the only other people they regularly come into contact with, who are healthy

Agreed there.

I remember my dad being in hospital a few years ago - after he'd gone into a care home with dementia.
Anyway, he was in a recovery ward for a couple of days and one time I was visiting a large Jamaican senior nurse came across to give me an update.
As she left my dad said "would you look at her", then a pause at which point I wondered what he was going to say next, "her arse is MASSIVE".
I know my dad was never racist but you wonder what effect dementia could have. I've never been so relieved to hear someone point out another person's size.

Pretty much all of the nurses now are chunky. 
When he was in for 3 weeks after a heart attack 25 years previously there were a reasonable number that were attractive but 25 year older me - with consequently lower standards - didn't consider any worthy.....

Thankfully our tax team now do my return for me as a partner, so I try not to concentrate on the vast quantity of tax that I pay.

I should also point out that for all the squeaking about the lowering of the 45% band to £125k, this is offset by the reversal of the NI rise, so someone in my fortunate position or that of John’s OP is actually not in a materially different position from before the latest round of Tory economic mismanagement (sorry Michael but they’ve been awful).

The real damage is in the fiscal drag created lower down the earnings scale by the freezing of the thresholds, and particularly how this interfaces with child credit.

I don’t know the answer with the NHS and I staunchly support the notion of it, but it must need a comprehensive and proper efficiency review.

Italy also has an equivalent of the NHS and I’ll compare and contrast the experiences of my mother and my mother-in-law.

My mother had a knee replacement done in August 2021, having waited over two years in increasing pain, went into Ipswich hospital (about half an hour away) on the day of the op, and was discharged on crutches into my car two days later and largely left to recover on her own.

My mother-in-law was diagnosed as needing a replacement knee earlier this year. She’s being operated on Friday, she goes into the hospital the night before and she is then in for a week after the op until being discharged once they are satisfied with her progress. This is being done on the Italian NHS at no cost to her, but in a private hospital in Rimini (about 40 mins away) to whom the Italian health service has outsourced the operation. Now it hasn’t happened yet and let’s see how it goes, but it sounds a better service on paper at least.

I have to assume that the cost of outsourcing this presumably makes financial sense versus the cost of providing it within the Italian NHS. Yet this sort of public/private partnership seems unnecessarily controversial in this country.