Canadian Medical Association Journal 1996; 154: 378-381
I know that the debate about private medicine is beginning to percolate in Canada, but the topic is old news in the UK, where about one in six people already has private insurance.
The history of private medicine here offers an interesting story. Until late in the last century, hospitals were used only by the poor because better-off people would be "ill at home," and even underwent surgery there. As medicine and surgery advanced, however, hospital care surpassed home care for the seriously ill and those undergoing surgery, regardless of social class. The major teaching hospitals built special wings with rooms for private patients. Increasingly, the middle classes subscribed to provident societies to pay for medical care and loss of earnings while ill.
Most of the those societies withered and died after the National Health Service (NHS) was born in 1948. It arrived in a wave of postwar idealism in which equality was of over-riding importance. Just as the fire brigade would turn out as quickly for the poorest cottage as the grandest mansion, so the doctor would give the same service to the rich as to the poor. The general practitioner, hospital care and medicines were all free. Doctors were reluctant to join the service, and the health minister, Aneurin Bevan, was accused of "stuffing their mouths with gold" in order to silence opposition.
A raggle-taggle collection of hospitals, most of which were established and run by local authorities, charities or religious orders, lost their autonomy and became "owned" by the new NHS. Patients were cared for in large, open "Nightingale" wards. Outside the metropolis, NHS hospitals kept a few user-pay beds -- usually single rooms in ordinary wards.
There was a handful of truly private hospitals, with rooms and not wards, and these remained private. Typical among them were the London Clinic on Harley Street, and the King Edward VII Hospital for Officers, where ex-military people and the Royals were treated.
In those days the private sector catered only to the very rich, celebrities and a handful of wealthy foreigners who came to England in search of a standard of care unobtainable in their home countries. A private patient in a user-pay bed received the same nursing care as NHS patients, but was given nicer meals and could receive visitors throughout the day (NHS patients were rationed to 30 minutes a day for their own good). The hospital user-pay beds were underused, and were often occupied by terminally ill NHS patients.
The 1970s brought change. Waiting lists for elective surgery had become longer and longer, and it became known that the way to jump the queue was to see the consultant privately. In all probability he would then arrange speedy admission to his NHS hospital ward. Those who could afford it went even further, entering the NHS hospital as private patients. This double standard went down badly with NHS nurses, ancillary staff and porters. From 1974 to 1976 there were dozens of strikes and much political unrest, and when the Labour government tried to get user-pay beds removed from NHS hospitals they had strong union support. Although there were fewer than 5000 of these beds, about 1% of the NHS total, the number was halved and has remained at around 2400 ever since. But the waiting lists got longer and longer, and there were media tales of people laid off work for months for want of a straightforward operation. In 1993, for example, 73-year-old Megan Thompson of Cambridge was offered a 4-year wait to see an orthopedic surgeon. She would, of course, then be put on another waiting list for surgery and might well have died waiting.
The number of private beds operating outside the NHS has risen from 7035 in 1981 to 10 739 in 1990 and 11 681 in 1995. In 1979 only 41% were in for-profit hospitals, but this rose to 63% in 1993 and many of the charity hospitals have brought in commercial management companies.
Of the private medical insurance companies, the British United Provident Association (known as BUPA and pronounced booper), has seen its share of the market fall from 59% in 1985 to 45% in 1994. Private Patients' Plan, second in the field, has grown slightly from 25% to 28%, and commercial insurers that entered the market in the 1980s -- a sure sign that there is money to be made -- now claim about 20%.
The private surgery market is still growing slowly. The 1995 Laing and Buisson's Review of Private Healthcare reports that the amount of private surgery rose 6.9% in real terms between 1993 and 1994. The old provident societies emerged with a new image, insuring people against the cost of being a private patient. They sold their policies to people who were impatient with waiting lists and to employers who wanted bait to recruit senior staff and keep them on the job, not off sick.
American health care companies started building private hospitals, and the provident societies followed suit: the largest, BUPA, now owns 29. The Conservative government, faced with the NHS's burgeoning costs, even encouraged the growth of this private sector and now there are 224 acute private hospitals, mostly small. This means that except in the poorest parts of Britain, there is one private hospital within a mile of every major district general hospital, and this in turn means that consultant surgeons can easily gallop down the road and operate on their private patients. Most beds are in single rooms, with en suite bath and telephone. (To be fair, by 1995 most NHS hospitals had done away with Nightingale wards that were the size of a small aerodrome, breaking them into bays of 4 to 6 beds.)
Concurrent with the development of privatization came the 1970s' fuel crisis. This meant Arab nations became wealthy and many rich Arabs travelled to London, where new private hospitals were built to accommodate them. This sector of the market is dwindling today as Arab countries build and equip their own state-of-the-art facilities.
In 1994, according to independent health care consultant William Laing, private-market hospital care was worth £1.061 billion, with another £641 million paid to surgeons, anesthetists and physicians. There are very few private general practitioners, and together they made only £55m. The few that exist are in the west end of London and in very wealthy districts. Dr. Susan Horsewood-Lee, a Chelsea GP, told CMAJ it is satisfying work: "There are very few time-wasters and none of the NHS form filling to be done, and patients can be referred and investigated promptly, without the delays experienced in the NHS."
Today, 13% of Britons are covered by private health insurance, and that population accounts for two-thirds of all private patients; the rest are an equal mixture of privately paying, noninsured Britons and overseas patients. About 20% of all nonurgent heart surgery and 30% of all hip replacements are done in the private sector, though a few operations are done under contracts from the NHS.
People with expensive long-term illness depend on the NHS; according to the Central Blood Transfusion Laboratory, there is not one private hemophilia patient in Britain. People become private patients for one compelling reason: to avoid the NHS's notoriously long waiting lists for elective surgery. According to health care researcher Professor Alan Maynard, formerly of the University of York and now head of the Nuffield Provincial Hospitals Trust, the mainstay of the private sector is the "three h's" -- hips, hernias and hemorrhoids. Private insurance also covers other elective surgery, particularly in gynecology and ophthalmology, and a small sector caters to fertility regulation and cosmetic surgery, services that are not generally available from private companies.
NHS consultants are based at their hospitals, but private practice is run from consulting rooms at fashionable addresses. Surgery may be scheduled at any of several local private hospitals, the choice often depending on the degree of luxury the patient wants. Most of these hospitals are equipped for elective surgery only, and do not have intensive care facilities or scanners. Many have no doctor on duty around the clock, while others have one full-time junior physician. After the operation is over, medical care consists solely of the surgeon dropping in to see the patient when he has finished his NHS job. Many diagnostic procedures such as computed-tomography scans have to be done in an NHS facility, and postoperative complications, although rare, may require an ambulance ride to an NHS hospital.
The British Medical Association, the consultants' trade union, is adamant that some 90% of consultants fulfil or exceed their NHS commitments and that only 10% may not. But the fact is that Sheffield University's Medical Care Research Unit has shown that although 95% of all consultants' time in normal hours is contracted to the NHS, they perform one private inpatient operation for every seven they (or their registrars) perform in the NHS; according to BUPA promotional literature, the figure is now one in five. Laing and Buisson show that 70% of operations in private hospitals are performed between 9 am and 5 pm. However, the Monopolies and Mergers Commission (MMC) surveyed 556 surgeons and found that most of them managed this by working very long hours.
Full-time NHS consultants' contracts require that they do not earn more than 10% of their income from private practice. However, this has virtually never been monitored or enforced. Maynard thinks it should be; most consultants have maximum part-time contracts, whereby they forgo 1/11th of their salary and in return may do as much private work as they wish, and an unspecified amount of this may be done in NHS hours.
As consultants' earnings are not audited, most estimates of their income are from data provided by private insurance companies. However, in 1992 the MMC investigated and found that only 10% of consultants earned less than £1000 a year from private work; of the 90% who earned more, two-thirds earned £10.000 to £50 000, and a few were earning more than £400 000.
Consultants are expected to schedule between 5 and 7 (out of 10 or 11) sessions to fixed commitments. This leaves 4 to 6 sessions for administrative or other duties, but many doctors, especially those who do a lot of on-call work, feel justified in using this time for private practice. Usually no one monitors whether they do or not.
The most telling point, as Laing and Buisson point out, is that there is no evidence that NHS consultants are short of time to do private work and they do not have waiting lists for private surgery even in London, where the ratio of private to NHS work is highest.
In 1987 the government launched the Patients' Charter, which strove to reduce NHS waiting times, which could be as long as 2 years for hip replacements. Surgeons were instructed to clear the longest backlogs, which they did, often grumbling that more urgent conditions were being pushed to the back of the queue. However, by doing this they reduced their opportunities for private work because the same surgeons operate in both sectors. There are very few consultants in full-time private practice, because there is simply not enough work to go round and the private insurance companies will rarely reimburse the fees of a consultant who has not held an NHS appointment. As well, NHS appointments confer prestige.
The situation, says Alan Maynard, is an unhappy compromise. "The idea of a UK consultant doing private work has some unhappy perverse incentives. The consultants sit in their NHS hospitals knowing that they can earn three times as much for each operation if they do it privately."
No one knows whether surgeons deliberately manipulate waiting lists, but John Yates, PhD, a health care economist at Birmingham University, has demonstrated that the areas with the longest waiting lists have the highest proportion of private surgery. Maynard points out that 50% to 60% of hip replacements in north London are done privately. He strongly believes that hospital administrators should be able to check whether consultants really do keep within the 10% limit; all the circumstantial evidence shows that they do not. "There is no point in having rules if they are not enforced," he says.
Overall, says Maynard, "the problem for the NHS is how far they should go to enforce the present contracts if they are to reduce waiting lists. As Margaret Thatcher remarked in 1989, short NHS waiting lists will reduce the demand for private care." He says there is serious abuse of the NHS by a tiny minority of surgeons, and he thinks they should either pull their weight or resign. "They should either pee or get off the pot, although I'm sure the Canadians would put it more politely. When some orthopedic surgeons are earning six-figure sums from private practice in spite of their NHS contracts, you being to worry about the extent to which they can do their NHS jobs."
Maynard recently spent some time in Alberta, where Dr. Howard Gimbel has been leading in the development of private-sector ophthalmology. "Judging by the British experience, private practice is a major challenge to the Canada Health Act," he says.
Maynard believes that the UK system, in which doctors work in both sectors, holds hazards. "People must be clear about their principles," he said. "The last thing that Canadians want is doctors having dual allegiance."
Yates has long been a scourge of NHS consultants who moonlight in the private sector. His recent book, Private Eye, Heart and Hip: Surgical Consultants, the National Health Service and Private Medicine, argues cogently that the longest waits often occur in regions where there are many private beds, the long-wait specialties are the main private-practice specialities and long waiting lists are sometimes associated with surgeons who do a lot of private practice. In the NHS, he says, insufficient surgical resources are provided, junior surgeons do much of the operating and much private surgery is done at the expense of the NHS and its patients.
Last autumn he telephoned 18 orthopedic surgeons to seek an appointment as an NHS patient; only 4 could see him within 3 months, and for 7 of them the wait was between 6 months and 2 years. He then called as a private patient; 2 did not see private patients but the remaining 16 offered an appointment within 1 to 7 weeks; the average wait was 3.5 weeks, even though some consultants were on holiday.