The three paradoxes of private medicine

Like many people in Britain I have inherited—and have subsequently nourished—a profound dislike of private medicine. However, it now appears that the reality is much more complicated and disturbing.

We had been told that my daughter would have to wait at least two years to see the consultant as an outpatient, and we felt that this was totally unacceptable. So we made one simple phone call to the private hospital, and she was seen in two weeks.

This much was accomplished without trauma. When we made the appointment it felt like any other—perhaps to see the general practitioner or a school teacher. But the experience began to be qualitatively different when we got there. It began with a feeling of relief that the uncertainty and waiting were over. Then, three things happened that gave me pause for thought.

Instead of the joy of clinical resolution, you are left with a tainted feeling of shameful compromise and guilt

Firstly, the staff were different. They may have had the same job titles and qualifications as staff in the NHS, they may also have had NHS jobs (the consultant certainly did), but they behaved differently. There was a perception of deference to you, the receptionist was caring, they seemed to have more time, the consultation was less pressured (you know that there is no one waiting outside, so you can take as long as you like). So far, so good. But in each of these apples is a worm. Are they only being nice because I’m paying? If so, what do they say behind my back? Do they think I’m as compromised in this Faustian bargain as they are? Is the consultant being pleasant or oleaginous, altruistic or avaricious?

These issues matter because they go to the heart of the encounter: do I respect this person, and therefore do I trust his advice and actions? This is especially important given the manifest perverse incentives, where every additional action means personal income. When he says, “I can see you for the next appointment on the NHS, but it will be a few months,” do I believe him? When he suggests drugs rather than waiting and seeing, could there be ulterior motives? One of the marvels of the NHS is that you can generally trust the motives of the professionals—but here? The result is the first paradox: paying for health care can actually be disempowering.

Acculturation occurs in all societies. Americans generally desire the benefits of private medicine. Most of us read this article with incredulity. I would wonder, I think, as a patient in the NHS whether a decision was being made for financial reasons also. We (the author and I) each distrust the financial motives – he of the private physician, and I of the NHS.

How do we provide the best medical care for the most people? Are we better served by a government bureaucracy or by the profit motive? (As an aside, while certainly some physicians think about profits, I truly believe that most physicians do not consider their income during individual patient encounters.) The profit motive certainly decreases wait times. The bureaucracy may do better in preventive care (although I know of no data).

An editorial runs in the same issue of the BMJ – Why Britons should be grateful for the NHS

If you read Britain’s tabloid newspapers, you would think that Britain’s National Health Service was a disgrace. In this week’s media review, for example, Peter Wilson quotes some of their headlines on MRSA (methicillin resistant Staphylococcus aureus). “Our squalid hospitals: no wonder the MRSA superbug is so rife,” is typical, but the subject can be anything, from stupid managers to uncaring nurses. Moreover, newspapers don’t let the facts stand in the way of a good story. As Wilson says, in their eagerness to paint a picture of MRSA some papers “even include cases of methicillin sensitive S aureus (MSSA), particularly if it happens to involve a minor celebrity.”

But most of the millions of encounters that go on in the NHS each day are not like that: the NHS is not a disgrace. I’ve always marvelled that this complicated organisation—which deals daily with extremes of human emotion, high uncertainty, and technical complexity against a background of politicisation—manages to function as well as it does. In recent encounters I’ve been hugely impressed not only at the standard of care that the NHS provides, and the care that people take, but also at its basic equitableness and decency. Britons should be grateful for it.

So (in my opinion) the BMJ has run two articles to support the NHS. I would argue that these articles are far from objective.

I often rant about the deficiencies in our system. We could certainly use our resources more efficiently. But our system trumps the NHS regularly. Regardless of payor status, if you are truly sick, our system responds. We could do a better job supporting primary care – but even here we trump the NHS (where physicians get around 8 minutes per patient).

So the BMJ’s apologies aside, I will disagree. I am delighted that we have private medicine in this country. We should continue to improve it. We need to better link payment to service, so that patients understand costs. But our system remains the one that I prefer.