Overall investing, especially the accumulation phase: Tim Hale, “Smarter Investing: Simpler Decisions for Better Results”. Goes into plenty of details around why low-cost tracker ETFs are best for building wealth, bonds are best for stabilising the portfolio, and what sort of mix makes sense for you individually.

I’m just reading this one now and would back up that strong recommendation.

Yeah, I’ll believe it when I see it, especially for a safety critical industry.

The problem with “AI” is that the amount of data that’s needed to go from prototype to working model is so large that it’s not possible. Hence no self driving cars, and Babylon Health giving up, and the likely upcoming AI bubble.

@TiRed I don’t think it’s safe or effective to diagnose an infected bite from a photo.

Because it doesn’t work. It never has and it never will. It fundamentally misunderstands the root causes of poor health, and implicitly blames people rather than looking for more effective interventions.

Seems like yet another form of billionaire extravagant potential suicide method to me.

On the news they’re currently talking about how people could help themselves by eating more healthily, exercising and the like.

Ah yes, the old personal responsibility bull$hit.

where do they go?  I don’t think I’ve ever come across an “ex GP” in the outside world

Abroad, retrain in other professions, consultancy, reduction in hours, private sector etc.

And why would they tell you, do you get the full CV of everyone you interact with?

I have lost count how many part-time GPs there are at my practice

I’m part time. I’d love for it to be viable to be full time, because I genuinely love my job. I’m passionate about it (as people can probably tell) and it’s generally a lot of fun and very rewarding.

But it’s not viable to do more than four days a week, and even that’s pushing it, because the workload is so intense.

As Jeremy Hunt himself said, the problem isn’t getting enough doctors becoming GPs, it’s retaining them. At the same time we’re losing some to retirement, but an awful lot of them don’t even become established GPs. Money is an issue, especially when you’re competing for highly intelligent, highly motivated people who are likely to become doctors.

From my point of a view of as a GP, we’ve had ~ 15years of money being taken away from us to give to hospitals and secondary care, they’re doing less and less, we’re doing more and more, including their workload for them, and they’ve just been given a 20% payrise vs my 6%, which, despite Mr Streeting’s protestations, I’ve yet to see a penny of.

The problem with the US system of healthcare is that inordinate amounts of ineffective work is done.

Which is the way we seem to be going in the UK.

@ernielynch I think organisations that get above a size where everyone in the organisation knows the name of everyone else become inherently more complicated to manage.

Get rid of the layers and layers of managers who contribute nothing  but cost large amounts of money.

I believe that the evidence is that, if anything, the NHS overall is undermanaged, not overmanaged.

Again I suspect that the reason that GPs are/were so cost effective was that a small to medium sized GP surgery is a very efficient and agile unit of organisation, at least until we started to be micromanaged.

@bensales what you’re actually talking about there is continuity of care.

Yes I agree that it’s important, see my previous answers. However I don’t think that the one healthcare record is the answer, already GP records are starting to become so unwieldy that they are bordering on unusable. Better design may solve that, but you still have the problem of categorising the information that is put in there, and who is clinically responsible for acting on it.

Again I suspect that it probably would be cheaper and more effective to have a well resourced GP who knows you well who could write a relevant referral letter for other sevices.

 which professionals in secondary care do you think are the problem for inefficiently soaking up all the cash?  Physios, Pharmacists, Nurse Practitioners, Dieticians – I’ve had contact with all of them in secondary care and couldn’t imagine a hospital doctor doing that bit of the care anywhere near as well?

All of them are great in their specific roles. They also tend to get good patient satisfaction, but see also my comments about patient satisfaction being an unreliable indicator of quality.

However when they replace doctor lead clinics in extended roles our experience in General Practice is that they tend to be less productive because they are limited in what they can practice, and anything that is outside their remit they need to refer on which is costly and unproductive. Unfortunately we are starting to see the same thing in specialist hospital doctors too.

More and more we’re seeing patients being bounced back and forward between various specialist clinics in secondary care, without anyone taking clinical ownership of the patient, which is both unproductive and disastrous for the patients.

BUT the concept that some parts of doctors work are either so simple (admin) that they don’t need a doctor, or could be just as well performed by someone who hasn’t learned about every other part of the body and disease etc but is really experienced in this one specialist area actually doesn’t seem too mental to me.

Please see my comments about the ways that GPs add value being through continuity of care (good evidence base), and clinical acumen (anecdotal from my own experience, some evidence to support).

The idea that you can somehow hive off the simpler parts of being a GP, is, I think, one of the biggest mistakes that we are making.

You may argue that I would say that, wouldn’t I, but as far as I’m aware there is good evidence that reasonable access to well resourced primary care doctors is expensive but overall very good value for the system for the above reasons.

@dhague – thanks for that.

@Dickyboy

In my limited experience we seem to waste an awful lot of NHS resources on giving people an entirely undignified death.

We do, and it’s one of the areas where well-resourced GPs who have a long-standing relationship with patients can both improve outcomes, patient satisfaction and save loads money to boot.

@MoreCashThanDash

could you give us some bullet points on how you think reform should look and/or where investment needs to be targeted?

• We need to cut funding to hospitals and secondary care and give it to Primary Care to retain and recruit doctors.
• Primary Care needs to be a GP (doctor) lead service supported by other professions, not replaced by them.
• Secondary care and community services need to support GPs, not the other way round as currently happens.
• In all areas of the NHS we need to stop trying to save money by replacing doctors with other professions, it’s not working and IMV it’s a root cause of the drop in productivity in secondary care.
• We need to look at the training of doctors, it’s gone wrong and we are starting to see a generation of doctors who can only follow protocols and have little practical experience of  clinical decision making and leadership.
• We need to stop trying to get GPs on the cheap and start investing in getting our best and brightest doctors into the position where they can do the greatest good – primary care.
• We need to understand that patient satisfaction is a terrible measure of outcomes, it has little to no correlation with mortality and by prioritising it we inevitably deprioritise patient safety and effectiveness of treatment which are far more important – as shown in the Berwick Report.
• In all areas of the NHS we need to stop focusing on resource efficiency (costs) and start focusing on flow efficiency (outcomes).
• We need to realise that GPs add value through our clinical acumen, continuity of care and ability to effectively gate keep, and that to empower these qualities means compromising in areas such as accountability and resource useage.
• The complaints system needs to be streamlined so that spurious complaints can be dealt with quickly and GPs don’t need to put up with serial complainers, who take up a disproportionate amount of time and resources.
• Now that we’ve separated negligence from compensation, IMV the “prudent patient” standard needs to be replaced.
• Medical leadership at Whitehall and various other agencies needs to come mostly from frontline GPs who are currently both under-represented as a specialty, and over-represented by academics in the few roles that are nominally occupied by GPs.

@IdleJohn

They work in an ice-cream parlour

Before I became a doctor, my summer job was as an ice-cream man. Twas ever thus…

Although I do think it’s become more commonplace.

I feel an essay coming on…

Some quick bullet points:

• I don’t think the characterization of NHS staff as “heroic” is helpful in any shape or form.
• It’s not so much the way that things are funded, as what is funded that makes the difference.
• Historically, increases in funding have been associated with better outcomes in the NHS, and funding has fallen in real terms since 2010.
• There’s no doubt in my mind that secondary care (hospitals and specialist services) have become less productive in the past decade, including community based specialist services such as mental health, despite receiving increased funding.
• GP services have become more productive in the same time frame, but that’s come at the cost of retention of GPs which is a tragedy on many levels.
• Despite those past two points, there is a continued push to try and make GP surgeries work more like miniature hospitals, rather than make hospitals and community services work more like GPs.
• The focus on access is counterproductive and IMO self-defeating because of induced/uncovered demand.
• Despite our productivity, GPs are no substitute for well-conceived and executed public health policies.

I love my Stumpjumper Evo, it’s a great bike, but the only thing I’d say is that you need to be riding steep stuff, bike parks and the alps to get the most out of it. Even though it wasn’t marketed as an enduro bike, that’s more or less what it is, and whilst it’s fine on easier stuff like trail centres, it does make them a little too easy.

4. I’ve put an additional Rockguardz frame protector under the stock one. Set up in bike park configuration (low and slack) this is a bike that you can absolutely hoon down bike park trails and it will throw up rocks what will bounce off the downtube.

My 22 manual says maximum tyre size of 2.5 inches at the rear, but it’s the same frame.

I’ve run it with 2.3 and 2.5. It’s faster rolling with the 2.3, more grip with the 2.5z

Does one look at how the wheels are attached to a car and think it doesn’t make any sense, or how aviation undercarriage works, or maybe they should take down the London Eye as it also makes no sense?

Except that a lefty has a significant torsional force on the suspension component, whereas the others mostly have either linkages to reduce this, or little to no suspension at all.

I’d never buy a helmet off Ebay or Amazon, too much risk of it being a counterfeit.

After 17 years, I think that technically it’s your porn.

@whyterider93

I love my Trek Remedy. But over the winter I got one of the CRC special hardtails. I rode it over winter given all of the slop that we had, and then unexpectedly still ride it for when doing longer rides on the moors which I have come to love. It is more than capable on the trails I rode my remedy on too. It’s now got me thinking that less is more and it’s just being out on a bike with mates and riding that matters more than WHICH bike.alsomakes me wonder why I spend £2k+ on a bike when a hardtails at half the price would do…

Exactly the same story here except with a Stumpjumper Evo rather than a Trek Remedy.

I think Machynlleth is a good call too.

As the proud owner of a “skills compensator” I can indeed confirm that it lets me get away with stuff that my hardtail would not. It’s also amazing how capable a modern geometry hardtail can be and what you can do on one if you choose. As mentioned in another thread, you do tend to get battered though.

When I do uplift, my full sus is excellent.

However for self propelled riding I prefer my 29er hardtail.

Ok, thanks for the answers.

I think it’s hard to activate the D30 by self harm methods?

As for bonds, personally I think they have a place to reduce volatility. We haven’t had a proper sustained equity crash for about 15 years which I think might be making people a little complacent. If you can’t handle seeing your portfolio drop by 40%+, history suggests you probably shouldn’t be in 100% equities.

This is my understanding too.

@andylc

 Index trackers do better even when taking into account market crashes.

Do you have a source for that, I’m genuinely interested?

My understanding was the volatility of index trackers impacted their returns, hence the need for a diversified portfolio and rebalancing.

@MadBillMcMad and do you find that the bike is rideable in the lowest gear, albeit slowly?

Sorry, yes it is a 29er, running 2.3 inch tyres.

That was why I’m asking the question @tjagain.

I don’t  think that the 30t front chainring would be too small, but I do wonder if the 28t would be, so that the bike wouldn’t be rideable.

I used one for the first time today.

I was both very impressed with the effect and very disgusted with the taste (SIS Berry).

Almost instantaneous energy boost which helped me out of the hole I was in.

@Bunnyhop, we actually came through Marple on the Middlewood Way before picking up the Pennine Bridleway. It looked lovely.

@IHN proper Boddingtons on tap, in a great pub. Think it may be Manchester brewery?

@Bunnyhop, I thought you lived in Marple?