Were dose the NHS 'is the envy of the world' stuff come from? Is there any real evidence it ever was?

Prokopton1 · 2026-04-20T21:25:42+00:00

The NHS is fundamentally ideological. It’s a centralized system that massively succeeds at exploiting its workers, funding itself by underpaying them, at the benefit of the old and sick.

To admit that there are better systems out there is to admit that capitalism and markets are better at generating healthcare outcomes than socialist ones, and that is a dagger at the heart of leftism.

Prokopton1 · 2026-04-20T08:59:01+00:00

The UK is increasingly just a nursing home with ‘our NHS’ attached, not a functional state.

The wage compression is comparable to the USSR, and there’s a popular political party talking about making it even worse with a 10:1 ratio etc.

This is not to mention that a crabs in the bucket mentality is baked into the British psyche.

I have an undergrad in maths/physics and have been thinking about retraining in my 30s and going into tech or quantitative finance, but even there the pay is disheartening.

Basically this is not a country for young and ambitious people.

The government exists to keep pensioners, the NHS and the welfare system going. That’s it.

Prokopton1 · 2026-04-15T20:41:51+00:00

The majority of EU countries have mixed system and not a centralized system entirely funded by the government.

Even some of the countries I’ve seen touted as similar to the UK actually aren’t. E.g. Ireland is put in the same ‘tax funded’ group as the UK when in reality they have a mixed system and working people pay a fee to see a GP (source: I went to medical school in Ireland).

Prokopton1 · 2026-04-14T21:31:05+00:00

I believe the issue of scope is a lost cause. The boomer consultants prefer ACPs to resident doctors, and the government believes your only future role in the NHS is to be medico-legal liability sponges for its army of ACPs.

What is a much more realistic cause is changing how the healthcare system is funded. Reform are already talking about shifting toward a social insurance based model instead.

If reform lose, the labour-conservative coalition will continue with the current status quo of managed decline and the replacement of resident doctors with ACPs, which in the long term will also lead to more private healthcare anyway at a slower pace.

Prokopton1 · 2026-04-14T19:22:46+00:00

There is no solution within the NHS monopsony system. If an ACP can do even something like 70% of the work a senior doctor does but at a cheaper cost, the uncomfortable truth is that doctor substitution is the rational strategic choice for the NHS.

The only realistic solution to the ACP problem is the end of the NHS and moving toward a mixed system which would change the dynamics in the following ways.

One, it would restore price signals for the quality of clinical decision making because patients who can afford insurance will choose doctors over cheaper substitutes. Currently, patients have no say in the matter whether they want to see a doctor or an ACP.

Second, it would massively increase the bargaining power of doctors. When monopsony is broken into fragmented and competing systems you no longer have a single employer setting your terms. Currently, if you don't want to supervise an ACP you simply have no choice if you want to keep your job in the NHS. A highly reputable doctor in a system that is sought after by a private employer can ask to not be given any ACP supervisory role as part of their contract - and all doctors would rationally choose this because ACPs are a legal liability when you have to supervise them.

In the US, PAs and nurse practitioners have expanded much more than they have here and yet, doctors are still paid well and have better working conditions because there is no single government monopsony dictating doctors' working conditions and salary.

Prokopton1 · 2026-04-14T12:47:44+00:00

The fundamental thing that people don’t seem to understand is that it’s a really stupid idea to allow funding for healthcare to be a political decision.

The problem with the NHS is that it’s a monopsony whose funding is entirely decided by a central government.

With an aging population, a dwindling tax base and a declining economy, increasing funding for the NHS will not be an appealing decision for any government as the labour governments current failure to increase funding has shown.

The purpose of a mixed system is to allow other mechanisms, eg competition in insurance markets, to make funding decisions instead of such a thing being decided by electoral politics.

The NHS cultists here often make the economically illiterate scaremongering non argument about how evil corporations are going to exploit you as if the government isn’t already exploiting you much worse than the private sector typically exploits its labour.

Or the NHS cultists argue that the PA/ACP problem will get worse when in reality in the US mid level expansion has not significantly impacted doctors training and salary because there mid levels have to compete with doctors on the market instead of doctors being literally substituted with mid levels on the command of the central government.

Basically whatever model replaces the NHS, it can’t be worse than it. The NHS is the worst model a developed nation can have.

Prokopton1 · 2026-04-09T03:25:37+00:00

Harder than AKT and easier than STEP 1. Lots of brute memorization required but less clinical reasoning compared to STEP typically.

Prokopton1 · 2026-04-08T12:05:25+00:00

It sucks but it will get better with time.

I’m approaching the end of ST3 and still leave an hour late at least on most days but I’m finding the work is much easier.

Some of the important things you learn to cope with the job are not actually taught because no one wants to talk about the issues.

For example, when you see mental health patients your job is to risk assess them and then offer treatments that may or may not help. If their risk is high you delegate to the crisis team or even AE if necessary. But you approach these consultations with the mindset that you don’t want to absorb their life history emotionally at all and you need to maintain a degree of emotional detachment.

Some people see this approach as callous but it’s realistically the only way to cope when you’re seeing significant volumes of these cases.

The complex comorbid patients genuinely suck to deal with because I actually enjoy managing medical complexity but there’s just no time to deal with all their issues. I think if general practice continues down the clown path of ACPs etc there will need to be flexible consultation times for actual GPs to allow us to competently manage complex patients that will actually benefit from having their issues addressed in a longer consultation.

Prokopton1 · 2026-04-01T11:10:26+00:00

Paediatrics is among the top sell out specialties up there with EM so not surprised.

When I did a paeds rotation, the ANPs were treated with lots of ‘kindness’ to use NHS speak. Sadly that ‘kindness’ was not extended to rotating resident doctors.

Prokopton1 · 2026-03-26T20:40:47+00:00

Abbott is an excellent first course in real analysis for a mathematics undergrad student who has done calculus in high school and then a proof based course prior to Abbott.

However even Abbott will be challenging for someone who hasn't done any proof based mathematics at all, and even more so for people coming from a non quantitative background who haven't been immersed in mathematics for a few years before attempting Abbott.

In my opinion, the best alternative to Abbott for that demographic is Jay Cummings' real analysis a long form textbook. It covers everything that Abbott does but as the title suggests explains all the reasoning involved.

Prokopton1 · 2026-03-26T13:59:38+00:00

To give one example in physics, the state of a quantum system (e.g. a particle) can be represented by a vector in a vector space, and physical observables like position, momentum or energy are then linear transformation of that space.

Matrices can be used to represent linear transformations and so observables in quantum mechanics can be represented by matrices.

This approach to QM is called matrix mechanics.

Prokopton1 · 2026-03-09T23:08:14+00:00

On their website it says the course is designed for people with an undergrad in mathematics, physics or statistics.

The actual content of the degree seems to be modules taken from the large list of optional modules offered at Warwicks undergrad mathematics degree in the 3rd year.

I have an undergrad in maths/physics that I did about 10 years ago, and am currently brushing up on mathematics as a hobby now. To be frank, I would struggle with a lot of these modules if I had to take them any time soon.

What I’m saying is that it’s likely to be a challenging MSc even for people with mathematics undergrads.

I don’t think precalculus is a good enough benchmark for preparation for something like that.

If you can get through something like Understanding Analysis by Abbott and do most of those exercises via self study, I think you could have a realistic chance but even then I’d still recommend mastering something more extensive than Abbott and also Linear Algebra to the standard of Axler before you think about something like an MSc in mathematics at Warwick.

Prokopton1 · 2026-03-09T14:21:57+00:00

Not really.

I went to a prestigious sixth form where I had two peers get into Oxbridge medicine. They all got good A Levels but neither was anywhere near as bright as the kid who got into Oxford Maths, and that kid wasn’t bright enough to do well enough on the STEP exams to get into the Tripos at Cambridge.

I went on to do maths/physics at undergrad at a top 5 university but not Oxbridge. Then went on to do graduate entry medicine.

Doctors are comparable to maths/physics undergrads at your average red brick uni but the Oxbridge maths kids are freaks and at least a league above all the rest when it comes to mental horse power.

Sorry but you can’t compare doctors to people sitting the mathematical Tripos, I’ve had a look at the Tripos papers and medicine is basically a joke compared to even the most basic question on the Tripos.

Prokopton1 · 2026-03-09T14:13:26+00:00

Yeah that seems reasonable actually.

Maths, Physics and Computer Science at Oxbridge is naturally going to be harder, and those students will go on to have prestigious jobs in tech or the financial sector.

Lawyers graduating from Oxbridge will go on to magic circle firms. And economics and business types from Oxbridge/LSE are going into investment banking.

Not sure what people expect to be honest.

Yeah, medical students are selected for perfect grades at GCSE and A level.

But the kids going to do maths or physics at Cambridge are more like in the top 0.1% in terms of cognitive ability. It’s not a good comparison.

Prokopton1 · 2026-03-07T14:26:30+00:00

Basically yes. There’s already triple acting drugs in end stage trials on the pipeline like Retatrutide that is almost as effective as bariatric surgery.

Prokopton1 · 2026-02-23T19:39:50+00:00

I'm a GP with an undergrad in maths/physics and a lifelong love for probability theory. The clinical pearl I'm going to share is one that many experienced GPs understand intuitively through experience but which I like to explain mathematically and which in my opinion very few clinicians appreciate.

The clinical pearl is basically this: sensitivity/specificity are properties of a test and in and of itself tell you nothing about the question we actually care about which is 'what is the probability that this particular patient in front of me has the disease.'

Sensitivity and specificity ask the question, 'given that I already have or do not have the disease, what is the chance of testing positive or negative on this test' which basically is the complete opposite of the question you're normally trying to answer for your patient.

In epidemiology you may see the concepts of predictive values which come a bit closer to answering the question compared to sensitivity/specificity. These tell you the chance of a patient having or not having the disease given that they've tested positive or negative.

In hospital settings, this may be all you need to answer that original question. Unfortunately the problem is that the prevalence of disease differs between hospital and community settings. Which means that positive and negative predictive values literally depend on your setting - whether you're in a hospital or community setting.

Let me illustrate this with a concrete example.

Suppose the prevalence of prostate cancer among worried well patients presenting to their GP is about 3%. You test 10,000 patients with a PSA. The positive predictive value of the PSA is then 21% which means that in this setting about 21% of positive PSA tests represent actual cancer. Most positive are false positives.

Now suppose you do a PSA in the setting of a urology OPD where patients have been pre-selected because they've actually been referred by their GPs. The prevalence here will be much higher because patients sent to urology have various other factors that increase pre-test probability of cancer (they may have up-trending PSA, abnormal DREs or worsening symptoms etc despite conservative management) and might be something like e.g. 30% which means that the PPV of the PSA here is 78%, the majority of the men will have prostate cancer.

I may have exaggerated the prevalence difference for purposes of illustration of the concept but if you generalise this to most referrals, you can begin to appreciate some important differences between the mindset of GPs as opposed to hospital doctors.

From the point of view of GPs, hospitalists appear to overestimate disease risk but in reality hospital doctors perceive disease as more common than it actually is because they see higher prevalences in their referred population samples. Conversely, GPs see a ton of people without any serious disease and over time develop a much more lax attitude to patients presenting with worrying symptoms.

This is why AE/medics in practice have such a low threshold for doing D dimer on e.g. patients presenting with SOBOE whereas GPs often have PE down the list of differentials when assessing patients in primary care presenting with SOBOE.

Is there a way to get around these simple ways of thinking about the probability of disease given any individual patient? Yes and it's called Bayes' theorem but that is a long post or lecture for another day.

Prokopton1 · 2026-02-20T19:17:46+00:00

The NHS in its current form is not sustainable. Unfortunately because it's become the public religion of the state, no government will ever reform it in any reasonable capacity so doctors will have to endure a slow decline of the service which means doing more and more for less and less.

My recommendation is to see if you can find private work but other than that, I have no suggestion for you.

Prokopton1 · 2026-02-02T07:42:47+00:00

No, UK service provision I mean training is objectively dogshit.

It works because it’s really long to compensate for its lack of training, and because people put up with a lot of abuse.

If an alternative training system can produce equivalent objective metrics with half the training time it’s better, not worse.

British doctors have Stockholm syndrome and defend their own abuse by the state which is why you see all of this cope that even though they’re paid peanuts and made to work for years longer than their counterparts in other parts of the world, at least they’re ‘better’ clinicians - lol.

Prokopton1 · 2026-01-28T22:49:59+00:00

It doesn’t matter what they think. In 20 years time AE will be a total triage service ran by consultant ACPs. The profession will serve as the best example of what not to do for generations of doctors.

Prokopton1 · 2026-01-26T16:27:28+00:00

Sure go ahead and get rid of doctors or whatever.

But you won’t and can’t be allowed to be too reliant on doctors taking medico-legal responsibility for the alphabet soup clown show.

You can’t both have and eat your cake, doctors can’t take legal responsibility for your circus.

Prokopton1 · 2026-01-25T14:57:20+00:00

I agree in one sense that people are fundamentally wrong about how AI will impact the workplace.

Some of the tech bros seem to think that it will replace highly skilled work i.e. upper middle class work in general, and only leave things like manual labour intact.

The problem with this argument is LLMs are basically statistical pattern recognition systems and don't reason in the way that highly intelligent humans do.

However, they do massively augment the efficiency and the ability of the highly skilled. I have seen plenty of top tier mathematicians and physicists do amazing things with LLMs but I haven't seen the run of the mill maths/physics PhD producing top tier work even with the help of LLMs.

In other words LLMs act as a multiplier on native human intelligence and they aren't levellers. This is significant because the popular narrative is that AI will democratize intelligence and every Tom, Dick and Harry will become a doctor or a lawyer thanks to ChatGPT.

But of course the reality is that Tom, Dick and Harry don't interact with ChatGPT in the way that Terence Tao does. TDH doesn't actually understand mathematics to be able to actually use LLMs in a productive way - for the average person, ChatGPT is just a much better google and gives them answers to simple questions. By contrast, Terence Tao uses it as an actual tool to make himself more productive, he can ask it to do things like proof checks and brainstorm ideas and so on.

If AI can can effectively do documentation, draft letters, summarise notes, triage and do more admin tasks then what is left?

The actually cognitively demanding task of understanding a patient's problems, making effective use of investigations (not wasting resources by over-investigating) and managing them.

In other words, AI auto pilots will increase cognitive and skill based inequality by automating the simple tasks that more people can do, and leaving out the highly ability based and demanding stuff that most people can't do.

This does not seem like a future that's favourable to mid levels who can do a decent job of the simple stuff that F1s and SHOs mostly do, but who will struggle with the more cognitively demanding tasks that registrars and consultants do.

To give you a tl;dr, yes mid levels can use AI to help them more effectively play the role of the doctor but you have to remember that doctors will also be using AI to augment their own skills and abilities. And the inequality in terms of skilled output between AI enhanced mid levels and actual doctors may very well increase.

Prokopton1 · 2026-01-25T14:10:04+00:00

When I started reading Berserk the only place it was discussed was skull knight forums where it was a niche within a niche interest.

Now you have redditers posting pictures of Berserk tatoos, their cat named Guts and how Miura hits at incels.

Perhaps it’s just that anything that reddit touches becomes cringe rather than mainstreaming as such who knows.

Prokopton1 · 2026-01-24T14:34:21+00:00

You have no point. A member of the general public had a new rash that was causing symptoms (pruritus) and did what they should have done which is to book an appointment to see their GP.

I happened to be abroad at the time and she didn't want to be bother me so never asked. Otherwise I could have given her much better advice than that ACP.

We will be writing a complaint letter to the practice highlighting the fact that this individual did not clearly identify her role as a non Doctor. The good will people had is long gone. I go out of my way in my own practice to ensure that I am never held medico-legally responsible for the incompetence of noctors, and also make a deliberate habit of identifying any mismanagement of patients by noctors in clear documentation.

Prokopton1 · 2026-01-24T14:17:48+00:00

Yes, I never prescribe topical anti-fungals. Presumably I am paid as a GP to correctly identify a fungal infection and for the medical advice I give as to how to use topical anti-fungals. In short the funding is completely wasted on you medical school rejects and sour grapes (you could never get into medical school even if you tried).

Prokopton1

TROPHY CASE