Delayed by the miserable flu-like illness going round.
This post has been a long time coming, hence the old ‘musing on’ title. It’s sat in my drafts as I’ve watched things gradually crumble across the NHS. Things are now so bad I see open discussion in doctor’s forums about futures in private healthcare, and no denial that the NHS has already collapsed (1). Therefore I guess this post will lead into some musing on how the death of the NHS will affect FIRE plans, and what you should do, if anything, about it.
But let’s take it back a bit first. I wrote the first collation of links, draft ideas and title for this post back in 2018. At that time I must have believed the NHS cold be saved, hence the “… long live the NHS” ending. I don’t think that any more. Not in it’s current form, or anything approaching the best treatments for everyone free at point of care. It’s dead wood now. Don’t believe me? Here’s an article and further evidence saying similar (2, 3):
I stood on the picket lines in 2016, arguing for a better contract, as we recognised that we were the first domino to fall before the conservative agenda. Since then below inflation increases to funding have not just impoverished but actively harmed as the populations gets older, fatter and sicker. The British public have been fed an expectation that they can live their life how they want and the NHS will patch them up. Not all have swallowed it, and the sensible continue to take responsibility for their health and quality of life, but for many we are expected to fix the problems of a lifetime of neglect, in a system itself neglected for a generation (4). This is “the national conversation”, that c-suite healthcare managers and politicians are starting to talk about. The NHS and social care system will not be able to support the needs of the coming elderly. It’s going to be a seriously hard lesson for some folks. A bitter pill.

Back in 2016 it probably was saveable. Do you remember in 2017 when the Conservative Party were talking about the “dementia tax” in the run up to the election (6, 7). It was a big thing at the time, caused lots of pushback and was canned because the public didn’t like it. It was exactly the sort of hard thing that needed to happen, which the public wouldn’t like but which would save the system. The issues with the social care system were known then, and the issue was kicked down the road, snowballing as it went. It’s not just the Tories, it should have been reformed in the 90s, but Blair dodged it (6).
The under-funding, under-resourcing and under-supply of social care, particularly for the elderly in the community, backs up the systems into hospitals. Hospitals then have fewer beds available. Since 2020 some of those beds are also taken up with COVID patients (8). Per this IFS report, “the number of beds available for non-COVID activity in the third quarter of 2022 was still lower than pre-pandemic” (8). Additional funds from the government cover only half the increase on costs of inflation. Flow is slower, with people taking longer to discharge, with fewer admissions (they’re just discharging people at the front door who are more unwell) and fewer procedures (8).
The number of staff working for the NHS has gone up by between 8-15% since 2020 (8, 9). Accounting for increased staff sickness that still means more FTE bodies on the shop floor. It’s unlikely to last, as COVID stopped the fairly common practice of junior doctors post foundation year but pre-registrar training jetting off to the antipodes for a few years working R&R. Everyone stayed put as they couldn’t travel, those who were abroad came home to be near family during the pandemix, and doctors just got on with the business of the next stage of training whilst accumulating PTSD from COVID. Now 45% of junior doctors want to leave the NHS (10). Many are planning to leave medicine altogether. The Daily Mail comments (in fact the whole article) on that story is a shitshow: “Nurses and doctors should get free education but contracted to NHS for 10 years or pay for education”; “We need to be recruiting our own people to be doctors and nurses, using health professionals from abroad is not the answer” (11). On the former, most of the money from the government to universities that goes towards our clinical training (by being paid to the NHS for placements) actually just serves to subsidise healthcare. I went to plenty of placements in med school where the clinic time was part funded by my education and I got little learning except as a ward dogsbody. Which is a kind of learning I guess. Some of that payment is still being recouped as my student loan.
On the latter Daily Mail point, finding the people to recruit isn’t always the problem. The gov has increased university medical school places (nice earner for the unis) without increasing the corresponding first year junior doctor posts. Consequently people are graduating medical degrees without a job to go into (12). If you’re lucky enough to get a job, which might be hundreds of miles from family and friends (it was for me), then you can be stuck essentially providing service provision with minimal support for onward training. If you grind through training, paid £12-20/hour to make life or death decisions, then maybe you get to be a consultant. Or you step off the grind, and use the free market economy of locum work to discover your real >£100/hour value (doctors and nurses here) (13). And the NHS wonders why it has a staffing problem (14).
The FIRE bit
Ok, so why does this matter for FIRE. Well if you’re planning for FIRE that should probably include the bit where you get older. That means including old age care, and the chance that you might have chronic illnesses. Something people consistently underestimate, as I wrote about back in 2018. Monevator did an excellent series over the course of 2022 trying to fill in the blanks of how old age social care funding works (15). It’s a big black box of future financial risk that people ignore because it’s scary and complicated. Helpfully the Monevator post does offer a route through, but it’s a messy job.
What happens if the NHS does morph into a different form. It can’t stay as it is, and to make it free for everything everyone wants all the time is going to cost a lot of tax. I suspect we will shift towards the NHS covering urgent/ emergency work, and all elective work being done privately (the lucrative bit anyway). National insurance shifting to covering social care, and an expectation that each individual pays for a hybrid health insurance, like France and Germany. Could or would you cover private insurance in your FI number? TEA and the Mad Fientist kind of discussed this in their chat back in 2021 (16). A sort of self-insurance. If you don’t want to do that, and are as equally pessimistic about the extent to which the NHS will be able to save your bum in the future as I am, then factoring in a degree of flex for private insurance might be an option. In France it seems to be about 40 euro a month, and covers medication and extra services on top of their semi-national health care (17). In Germany it’s 14.6% (+0.9% charge) of your income, though it’s a lot more complicated (18, 19). We don’t want to go the route of the USA, where health insurance is a persistent barrier to FIRE (20). Over there getting sick means debt, financial toxicity (21). I can’t see the UK public stomaching that, although it may insidiously spread.
Ultimately, things can’t stay the same as they are (22):
That means either more tax, or some form of private healthcare. Impossible to predict the future on it, but expect a bigger budget line in the future, and factor in some inflation in FIRE modelling.
Other interesting stuff (usually from Twitter):
Fairly awe-inspiring application of the GPT3 chat AI by Danny Richman on Twitter, which shows what could be done (23).
Graphic from r/dataisbeautiful user u/jcceagle which shows how UK housing is at it’s most unaffordable since the Victorian era (24):
Thread from @CarDealershipGuy on Twitter discussing looming issues in their car market caused by price inflation (and now deflation) and knock on effects (25).
A window into what happens when you go from no COVID to all the COVID, provided by a threat from a Doctor with access to China’s healthcare system (26).
Nils Pratley in the Guardian on Curry’s (27).
November 2022 Finances
Here’s the numbers:


These are taken, as always, from my Beast Budget spreadsheet. I saved an anomalous 60% of my income in November. This figure is actually a bit skewed, as a got a large wodge of expenses paid back, which immediately went into paying off the associated credit card bill (and basically balancing out). I also got backpaid for a bit of private work, so that topped up the regular saver (emergency fund). Some will also get invested in passive trackers naughtiness. My net worth finally bounced back up thanks to paying back that credit card, up 3% this month.
Budgets:
As compared to my four year back-calculated mean monthly spend:
- Groceries: October £330, November £155, budget £220 – Being much more sensible pays off
- Eating out & Takeaway: Oct £105, Nov £160, budget £50 – But also this…
- Transport: Oct £280, Nov £270, budget £330
- Holiday: Oct £10, Nov £0, budget £40
- Personal: Oct £465, Nov £100, budget £120
- Health: Oct £52, Nov £52, budget £150
- Misc: Oct £699, Nov £620, budget £215 – Nursery – a continuous new line on the budget
- Work fees: Oct £394, Nov £135, budget £265 – A reminder this is what I pay each month to be allowed to be a doctor in the UK. I can claim it back via self-assessment tax, but that’s it, big NHS says suck it up.
In the garden:
Digging over compost and general tidying only.
Cheers,
The Shrink
References:
- https://www.reddit.com/r/JuniorDoctorsUK/comments/zaufaq/at_what_point_do_we_conclude_that_the_nhs_has/
- https://twitter.com/KHoulgate/status/1604979026199576576?s=20&t=Hdg5t5XvjkI2iseBXZLtOQ
- https://www.theguardian.com/society/2022/nov/27/stress-exhaustion-1000-patients-a-day-english-gp-nhs-collapse
- https://www.reddit.com/r/JuniorDoctorsUK/comments/zbdcvi/frustrated_with_being_a_sticking_plaster_on_our/
- https://www.ft.com/content/2f1d62ee-bc1b-4eae-bebd-f4e32076bcd5
- https://www.bbc.co.uk/news/health-45750384
- https://www.bbc.co.uk/news/election-2017-40001221
- https://ifs.org.uk/news/nhs-2022-more-funding-more-staff-treating-fewer-patients-covid-impacts-linger
- https://www.gov.uk/government/news/record-numbers-of-staff-working-in-the-nhs
- https://www.businesswire.com/news/home/20220808005334/en/Nearly-1-in-2-Junior-Doctors-Are-Considering-Leaving-Their-Profession-Medscape-UK-Report-Finds
- https://www.dailymail.co.uk/health/article-11579113/Four-10-junior-doctors-plan-quit-NHS-soon-possible.html
- https://www.theguardian.com/society/2022/mar/15/791-medical-graduates-could-miss-out-on-nhs-junior-doctor-training
- https://www.bbc.co.uk/news/health-63588959
- https://www.ft.com/content/3f8c35ed-e7b6-4f96-b965-a2b97bee45cc
- https://monevator.com/social-care/
- https://www.madfientist.com/escape-artist-interview/
- https://www.internations.org/france-expats/guide/healthcare#:~:text=In%20France%2C%20the%20average%20cost,types%20of%20health%20insurance%20plans.
- https://www.academics.com/guide/health-insurance-germany
- https://www.howtogermany.com/pages/healthinsurance.html#brexit
- https://www.reddit.com/r/financialindependence/comments/8zx7iq/health_insurance_as_a_barrier_to_fire_in_the_usa/
- https://www.amjmed.com/article/S0002-9343(18)30509-6/fulltext
- https://twitter.com/ShaunLintern/status/1609895676153925632?s=20&t=QL0jTgTMJFjlHkR2oakn3g
- https://twitter.com/DannyRichman/status/1598254671591723008?s=20&t=RmBfIA8Hg3iFCkEj8D6cug
- https://www.reddit.com/r/dataisbeautiful/comments/zktc6r/oc_uk_housing_most_unaffordable_since_victorian/
- https://twitter.com/GuyDealership/status/1603794722140688384
- https://twitter.com/DrEricDing/status/1604748747640119296?s=20&t=jQjVmvTlJu_8Hfj823eWRw
- https://www.theguardian.com/business/nils-pratley-on-finance/2022/dec/15/currys-no-longer-flavour-of-the-month-in-the-scando-countries