A British view of private medicine


Category : Medical Rants

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.

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Comments (22)

The deficiencies of Britain’s system lie in no small part in the fact that they support both a woefully underfunded state health system (the NHS), and a private, for-pay system. That says nothing about the viability of other forms of national health care. We wouldn’t have to make those mistakes.

The nice thing about our system is the patients never have to wonder whether their insurance companies are just trying to make money off them.

They can know it immediately and in advance.

I happened on this article from Canada about their growing problems: http://www.cbc.ca/story/canada/national/2004/09/03/ontariohospitals_040903.html

I’m sure you make links to articles that show any problems in the US health care system too when discussing our system. For example, our trauma center closing here in Las Vegas last year.

What specific lesson am I to draw from this budget battle in Ontario?

Another facet of the beauty of our system is the reluctance of physicians to try to make money off patients.

That “woefully underfunded” NHS system is now the largest employer in Europe, and the third largest employer on the planet Earth.

Number one and number two are the Chinese and Indian armies, respectively.

Unless there’s been another closure I didn’t read about, the trauma center closure in Vegas had to do with the tort system and the cost of malpractice insurance. I think we’ve provided one or two links about that problem on this site.

So … the tort system and malpractice problems aren’t problems with the US healthcare system?

The article linked talks about a budget battle. The reason for the closure of the trauma center here was exactly the same sort of budget battle. The surgeons wanted the hospital to pay their malpractice and the hospital didn’t want to.

The tort and malpractice systems really aren’t the problem, as evidenced by other nations which share common law traditions. Meanwhile, whether or not you want to admit it, U.S. medical malpractice laws have helped advance a lot of initiatives in patient safety and the prevention of maloccurrences.

The problem is the size of the verdicts which come for “future economic damages” – damages which largely vaporize in nations with national health care plans. Even in states with low, rigid caps for non-economic damages, such as Michigan, the “high risk” specialties still tend to pay very high rates for their malpractice insurance.

D.B. – Your commentary should have recognized (overtly) that the UK DOES have private medicine available to its citizens – it’s also part of the system. Great for those who can afford it. But our US system leaves out 45,000,000 who can’t.
And you are wrong to say “Americans generally desire the benefits of private medicine.” Polls have consistently shown that Americans think that their government should provide health insurance to all. See for yourself at kaisernetwork.org where the margin in 1999 was 66% over 30%!

I prefer the poll done in Oregon in 2002, with a 4-1 margin against a single-payer system.

The poll was done on election day, and the 4-1 margin is what you got when the voters saw what a single-payer system would actually do.

As is typical of all the US single-payer initiatives, there was no significant alloowance made for private medicine outside the system.

What’s wrong with a 2 tiered system anyway? We already have a 3 tiered system where I work. 1 tier is those who have private insurance, the 2nd is Medicaid and sometimes Medicare which not all physicians see, and the 3rd is those with no health insurance. What we need is a 2 tiered system that doesn’t have 45 million on the 3rd tier with nothing.

arf, how exactly did the voters “see what the system would do” on election day? Did they all get state-paid medical care on that day, or something? I guess that would result in immediate, long lines at hospitals and clinics as the uninsured and underinsured lined up for care. But really – how did they “see” anything? Aren’t you really describing a voter reaction to sophisticated ad campaigns run by groups who profit enormously from the present system?

Bob, your comments remind me of Sallyann Payton, who announced in the second week of her health law class (in response to a first round of student papers) that we shouldn’t worry about a two-tiered health system. Perhaps if done right, it isn’t a big deal. Britain doesn’t get it right, and hasn’t been working hard enough (or, more accurately, hasn’t been willing to provide the funding to NHS) to get it right. But our nation is backsliding.

uh…….they read the bill

The ballot initiative was polling about 50-50 in Oregon through the summer and early fall.

A few weeks before the election, polling on the initiative plummeted, and the final vote was 4-1 against a statewide single-payer system.

The state has a voter pamphlet that comes out several weeks before the election. It has the language of the initiatives, arguments pro and con.

I for one feel the change in polling and the vote itself reflects the public’s feeling of the idea in theory, and how they feel when the real details are presented to them.

And the complaint that the NHS is underfunded reminds me of John Cleese and the Ministry of Silly Walks:

MINISTER: It’s not particularly silly, is it? I mean, the right leg isn’t silly at all and the left leg merely does a forward aerial half turn every alternate step.

MR PUDEY: Yes, but I think that with Government backing I could make it very silly.


To rail against two-tiered health care is like trying to stop it from raining.

You are going to get two-tiered health care whether you like it or not. That includes Canada, where Jean Chretien was caught getting his health care at Mayo (King Hussein of Jordan died at an inopportune time, causing Canadians to wonder where Chretien was, why wasn’t he at the funeral).

The key is really to create an adequate bottom tier, not to try to tear down the upper tier.

arf, the full text of the ballot initiative is here – http://www.sos.state.or.us/elections/irr/2002/027text.pdf . You actually expect us to believe that Oregon’s voters read that full text, parsed its meanings, and came you share your doom and gloom interpretation of what would follow? (And of course, they did so for the other six major ballot initiatives as well?) While I am reluctant to accuse you of “making stuff up” to advance a position you are unable to support with actual facts, that certainly seems to be your preferred tack.

Your ignorance of the underfunding of the NHS is, like the rest of your positions, quite underwhelming. Who disputes the fact of woeful underfunding? That is, who who knows something, rather than taking your approach of “making stuff up”?

Ah, yes, resort to personal insult.

The position of someone who has lost the argument, and has nothing else to say.


It was a personal insult to point out that you were making stuff up? Heh. I’ll take that as an admission.

Fully aware of the text of the ballot initiative, as I live in Oregon.

I believe that the voters of the state read the ballot, it is detailed on a voter pamphlet, every voter gets it in the mail, and they exercised common sense when they voted.

That’s what we do in Oregon, what you do in Michigan is your busines.

The personal attack is in the language you used above.

What, precisely, have I “made up”?

I thought you weren’t responding any more? Or did you mean, you were going to continue to bicker and make stuff up, but you simply weren’t going to post facts?

Because if that’s what you meant, we already knew that.

You’re right. You’re not worth it. Adios.

Heh. No facts, as expected. You could use Brave Sir Robin’s minstrels.

hey…I’m ready to work 37.5 hours/week. screw working nights. holidays. weekends…the extra stress is not worth the money

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