Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Uneasy in a foreign land
- Dr Steven M Rudolphy (3 September 2004)
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The paradoxical patient
- Rohit Makhija (3 September 2004)
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Hypocrisy, Shock and Embarrassment
- John A Bailey (4 September 2004)
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Bad Health Care Stinks
- Maneesh Gupta (4 September 2004)
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Hypocrisy
- Simon Rose (5 September 2004)
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Paradox
- Paul M Bailey (5 September 2004)
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The tree paradoxes of private medicine
- Stuart Sanders (6 September 2004)
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the real paradoxes
- Roy L Bishop (7 September 2004)
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healthcare funding fundamentalism
- Stephen F Hayes (7 September 2004)
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Service Mentality
- Colin A. Mackenzie (8 September 2004)
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Re: the real paradoxes
- Allison Green (8 September 2004)
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Re: Hypocrisy, Shock and Embarrassment
- Francis C. Rutter (8 September 2004)
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The laddie doth protest too much,methinks.
- N. George Macdonald (9 September 2004)
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The Golden Dustman
- James F R Love (11 September 2004)
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Re: Hypocrisy, Shock and Embarrassment , both sides
- YL Yip (11 September 2004)
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NHS doctors work for money too, don`t they ?
- Eigenmann Franz (13 September 2004)
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Privateering?
- Dominic L McDermott (14 September 2004)
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rapidly responding circles
- Dominic McDermott (14 September 2004)
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Perverse conclusions in a scientific journal
- Michael J Goodman (14 September 2004)
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Re: rapidly responding circles
- Stephen F Hayes (14 September 2004)
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Private medicine and public medicine have delusional-like relationship of infidelity?
- Dr. Naseem A. Qureshi MD, IMAPA, LMIPS, Dr.Ibrahim A. Al-Hoqail, Dean, College of Medicine, MOH, Riyadh, Saudi Arabia. (14 September 2004)
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The Three Paradoxes of Private Medicine
- J Gedis Grudzinskas (16 September 2004)
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private medicine stinks
- James N Hardy (23 September 2004)
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Re: private medicine stinks
- susanne mccabe (27 September 2004)
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Longley's neglected responsibilities
- Michael G Bamber (27 September 2004)
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Utter rubbish
- Aidan Gleeson (16 October 2004)
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a question
- Andrew Montgomery (16 October 2004)
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Sick of UK healthcare
- Jenny L Robertson (16 October 2004)
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Guilt as defence mechanism?
- Adrian S. Blaj (17 October 2004)
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The key issue
- Marcus J Longley (18 October 2004)
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Re: Sick of UK healthcare
- Sumit K Basu, Lewisham High Street. SE13 6LH (19 October 2004)
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Re: Re: Sick of UK healthcare
- Jenny L Robertson (25 October 2004)
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Irrational loathing of the private sector
- Simon A Rogers (29 November 2008)
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I have always wondered about what might have been
- oscar,m jolobe (30 November 2008)
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without co-existence of private medicine, the NHS might, perhaps, have never come into being
- oscar,m jolobe (1 December 2008)
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Dr Steven M Rudolphy, General Practitioner, Snr Lecturer GP Mt Sheridan Medical Practice, Cairns, Australia
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What a strange place Marcus Longley found himself. Receptionists that made appointments easily, receptionists that smile and are nice, unhurried consultations, having the ability to control the resolution of your nearest and dearest medical problems and paying for medical care because you can afford to. Some people come to Australia and can never get used to warm weather, sunshine, under crowding, a smiling populace and want to get back to normality - fabulous August in Britain this year wasn't it? Put your wellies on Marcus and keep wading through public medicine, some people were not cut out to travel. Competing interests: Private Practitioner |
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Rohit Makhija, Surgical Registrar Hemel Hempstead
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Having trained in a different country, one where payment for medical care is an integral part of the care itself, I happen to have slightly different views to the author. Clearly, one gets a different class of comfort and speed in the private sector, as opposed to the NHS. That is an inherent part of the system itself. A quick, relaxed, long and well-explained consultation should be a reason for relief rather than reason for discomfort. While, I do ascribe to the arguement that one should have universal healthcare at great speed, this is not the practical reality.Unfortunately, the state health care system, howsoever good it may be, is limited by resources. Perhaps, private healthcare ought to be best accessed by people able to obtain a sense of relief from it! Most health care staff provide the best medical care they are able to, under the circumstances in which they work. Second-guessing motives is a counterproductive exercise. Paying for a healthcare is no reason to suspect ulterior motives...private care is no brown envelop job! Competing interests: None declared |
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John A Bailey, General Practitioner Whiteladies Health Centre, Clifton, Bristol BS8 2PU
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I read your Personal View column always with interest, mostly with pleasure, sometimes with sadness, but rarely with the mixture of disbelief and anger I experienced from your contributor on the Three Paradoxes of Private Medicine. The opening paragraphs reveal hypocrisy usually heard from Labour politicians who defend sending their children to private schools. So private medicine stinks, but, hey, when it suits my family I am going to make use of it! Secondly, it was hard to believe how shocked your contributor was to be faced with courtesy and politeness by the staff he encountered. What does this say about the NHS! In my general practice we employ thirty-four staff and spend time training them to deal with the general public in a polite and sensitive way, not always an easy task, and I hope not treated with the same contempt your contributor aims at the private sector. Finally, he faced the embarrassment of being asked to pay for private treatment. What did he expect to happen and how did he expect it to take place? Would he have preferred to pass cash across the desk to his consultant, or maybe, as a fellow doctor, he was hoping to be let off. In the same issue there was a deeply moving and thoughtful account of the hardships faced by patients in the south Caucasus. Alongside this your personal view column reeked of smug middle-class angst. Please, no more hypocrisy, shock and embarrassment trivialised in this way. Competing interests: None declared |
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Maneesh Gupta, Consultant Psychiatrist Liverpool
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Paid or free, it is the quality of health care that should be the criteria. If the NHS is unable to provide speed and ease of access, then it stinks. If the NHS is unable to make health care teams work and be accountable for what they do not do, then it stinks. If the NHS consultations are hurried and give the patient a feeling of not having been listened to, then it stinks. Private medicine does what the NHS has failed to do, and that is the reason why people like you use it; and admit to be likely to use it in the future. Use the private specialist, do not abuse him! Competing interests: None declared |
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Simon Rose, Consultant Histopathologist Bath BA1 3NR
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If you chose to spend your income, already taxed at 40%, on a chunk of private healthcare rather than a consumer luxury or a holiday in Florida you should certainly not feel shame. Dr. Longley’s earstwhile socialist private patient does not sell his soul, but once up against the gritty realities, he realises the limitations of the social system he supports in the abstract. Worst of all is to exhibit gross hypocrisy. If something is morally unacceptable to you (say, instead of having a private practice consultation, going drink driving), you don’t do it, say you are going to do it again, but seek to absolve yourself by implicit criticism of the providers and self flagellation in print. Competing interests: Dr Rose has a modest private practice done in addition to and without compromising his NHS work. |
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Paul M Bailey, Emergency Physician Western Australia
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Editor, having read the article by Longley, one suspects that he would have been more satisfied if the receptionist was grumpy, the consultation hurried and any follow up scheduled for 18 months time. What a strange world. Of course, had the above 'welcome' been provided, we would probably have been subjected to a 'private medicine is no better than the NHS' letter. Competing interests: None declared |
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Stuart Sanders, Independent medical practitioner W1G 9PH
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Editor-I was horrified to read Marcus J Longley's distasteful article, and I am surprised that you, the editor, accepted it for publication. In the penultimate paragraph, he uses "you" nine times when he should have written "I", thereby involving the reader in his profound guilt for having "gone private". I have been a private practitioner for forty years and I have a large cohort of grateful patients, untainted by guilt. Private practice does not stink, any malodour emanates from those who are overwhelmed by their guilt. Stuart Sanders Competing interests: None declared |
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Roy L Bishop, Family Practitioner Chico, California 95973
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I read Mr Longley's comments about his reponse to "going private" with some sadness but not surprise. Perhaps we have Psychologists here who could help him accommodate "going private", for a fee of course. The real paradoxes are ; (1) Why is it acceptable that the British people having already been overtaxed have to pay a second time to get a decent level of customer service ? (2) Why should not all patients have the choice that paying with real money brings you ? I'm waiting for the day a British politician has the guts to say that the NHS is a politicised failure, further money thrown at it represents a poor return on investment and that an insurance based system with social safety net is the best answer. Perhaps there are too many vested interests who don't want to face the stark realities of a competitive healthcare market. Until that happens I'll stay here in California where I know my patients have a real choice when they see me and when I refer to specialists, their bills mostly paid for by insurance, but I do keep the credit card machine on the counter to take their copays and deductibles without any embarassment or concealing it ! Roy L Bishop MD Family Physician CEO Argyll Medical Group & Consulting Chico CA USA Competing interests: None declared |
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Stephen F Hayes, freelance GP, GPwSI dermatology Southampton
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'Like many people in Britain I have inherited—and have subsequently nourished—a profound dislike of private medicine. ' And thereby hangs a tale. Dr Longley does a service to the debate about healthcare funding in the above honest opening sentence, the debate that was opened (and immediately concluded with the determination that the status quo was the best of all possible systems) by chancellor Brown 2 years ago. Asking British people to consider alternative methods of funding healthcare is like asking certain faith groups to eat forbidden meats-it is anathema, blasphemy even to talk about it. However, as surely as we medics are told to practice evidence based guidelines, the day surely ought to come when our rulers are forced to evaluate the evidence for the efficacy of our healthcare system against other systems which fund medicine differently and deliver better results. Food, water, clothing, housing-all are more essential to life than medicine. Which fundamental law states that medicine should be provided free at the point of demand if these other goods are not-regardless of the fact that the cost of free-at-the-point-of-demand is perpetual reorganisation and top down command economics? Competing interests: None declared |
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Colin A. Mackenzie, Physician retired 95060
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It is good to have different views about common problems, however, the three paradoxes delineated in Personal View are certainly skewed. Previous rapid responses have ably taken issue with the faulty logic of the three paradoxes and so I won't hammer more on that point. As a Brit having practiced in California for more than 30 years I have often observed on my visits back to the U.K. the all too slow and gradual British adoption of the service with a smile that is complained about by the writer. It has nothing to do with personal financial reward. Besides the NHS the lack of the service with a smile mentality is still seen in the supermarket industry. The contrast in checking out a basket of groceries in California where the clerk stands and makes eye contact with the customer, compares to a similar action in England where the clerk is seated disinterested and disdains to place purchased items in a bag. This is a sign that the Old Country has still a long way to go to rid the country of malaise of the Second World War, when poor service became endemic and was endorsed by the hackneyed phrase of my youth--...don't you know there's a War On!. Competing interests: None declared |
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Allison Green, Senior Research Fellow Addenbrooke's Hospital CB2 2XY
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I was interested to read Dr. Bishop's views on the British attitude to private health and the NHS suggesting that the American-based healthcare system was better. During my postdoctoral years I studied at an Ivy-League medical school in America. An accident at work resulted in almost complete amputation of my little finger and severed tendons in my middle and ring finger. With such a severe injury the micro and tendon surgeons wanted to perform reattachment asap. Unfortunately, the adminstrator refused permission until all the paperwork relating to who would pay for this was complete. This took several hours, in the meantime the surgeons continued to plead with the adminstrator to allow them to operate. In frustration, they simply went ahead even though they were told they would personally be liable for the bill should I fail to pay. The physiotherapy and out-patient care was also subject to delays until payment responsiblity was ascertained. I have the utmost respect for the surgeons, their quality of their work and professionalism was exceptional. However, I can't accept that the 'pay-first' scenario in America is better than the NHS for the vast majority of patients. Instead, both systems have their good points and bad points and I think it is unlikely we will ever develop a healthcare system that is completely 'user-friendly'. Competing interests: None declared |
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Francis C. Rutter, Retired General Practitioner Norwich NR4 7QJ
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Editor, The unease felt by Marcus Longley [Personal View] on using medicine must relate to his own long held feeling that private medicine must somehow be inherently 'bad'. When I suffered a rapidly deteriorating arthritis of the hip I had no qualms about getting it done privately and quickly and I had no feeling that the consultant and staff were anything other than normally professional. The problem with the NHS is not so much one of inadequate care, but rather of getting access to it. One friend was found to have a lung tumour at a routine chest X-ray. He did not see the oncologist for four months and died four months later. I have another friend who was referred with an abdominal tumour on May 19th this year. She finally reached the oncologist on August 9th and started treatment on August 18th - that is 13 weeks after first referral. The first appointment in each case was within the two week target and so, presumably, would be considered satisfactory. That does not make the delay in reaching the right department any easier to bear. As this friend said to me rather wistfully "The oncologist told me that, untreated, I would have about a year to live. Well, I have had a quarter of that already!" Francis Rutter
Competing interests: None declared |
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N. George Macdonald, family physician Warsaw, Indiana, USA, 46580
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I understand the embarrassment that Marcus Longley must have felt when he accessed the private medical system for the care of his daughter. Having practiced in both the public (Canadian) and private (American) systems, I can appreciate the advantages of both. Rationing by the queue,enables the public system to provide cost effective care to the masses. The private system is able to provide more timely consumer orientated care. Instead of shedding crocodile tears about the excellent care his daughter received, he should celebrate the strengths of both systems. Competing interests: None declared |
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James F R Love, Consultant Physician Brisbane, Australia, 4000
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When I was a lad, a visit to the G.P. cost a guinea (Australian), the radio plays came from the B.B.C. (using Australian actors assuming British accents), England was still Home, at least to the older generation, and my reading was all W.E. Johns and Frank Richards. During my studies, Davidson, Hutchinson and Hamilton Bailey painted a world view of Medicine (admittedly somewhat Dickensian) which I absorbed like a sponge and which left me feeling that, somehow, I understood the British way. I thought I knew a bit about the NHS too, but when I read Marcus Longley's lament over receiving some politeness and prompt treatment, I realised that I knew nothing. I was looking into the Heart of Whatness. This is the great British inscrutability. They are Frenchmen with whom we just happen to share a common language. How, I wondered, can one put into words what the NHS means to Longley and these foreigners? And then I remembered that Dickens had done just that, long ago, in the form of Mr Boffin's dust mounds, where great masses of waste and decay are miraculously transformed into gold. I feel much better for having this insight, but I remember also that ultimately the carts arrived and toiled night and day, until the mounds were all gone! Competing interests: None declared |
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YL Yip, Private Practise, Surgeon Hong Kong
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Of all the responses made, I feel Dr.Francis Rutter ,retired general practitioner, expressed a view most similar to mine. "The unease felt by Marcus Longley [Personal View] on using medicine must relate to his own long held feeling that private medicine must somehow be inherently 'bad'." I was in public service for a long time, and Hong Kong , has been under a system very similar to UK, for a very very long time. I also inherit this sense of "public good, private bad; public, for patient sake only, private for doctor's money; public trust worthy; unreliable". And I know that in our public service, many are still thinking like this. I would if I still stay there. At first even when thinking of getting out, I had a guilt feeling of looking for money and forgetting our patients. And friends would ask me even now, 'why, you are not a money minded person, why do you go out there?' or, ' you must be very rich by now?' And when I asked one of my classmate, a hepatologist on her recent research findings, she said, 'it is not useful for getting money from patients, do not use this research knowledge outside,it is not mature yet.' She seems to feel this old friend of hers, once get out immediately become another person, if not a Dracula. Even in our local movies,or TV drama, the public doctor is portraited as an idealistic young man, while the private doctor is portraited as a rich old man,money minded,with poor skill, unless he is the one working in slump district as a crooked filthy old man, with genious ideas, gorgeous medicinal abilities,and despises money, even giving them out to poor patients..........usually a family physician of course. Such a doctor is even the theme in a famous comic in Japan. So this private sector guilt is not only in UK or Mr Longley, it is very universal.... of course, now I have been in private sector for quite some years, and have a totally different view from before, but it can also be biased, albeit from another angle. May be my patients' view are more pragmatic with less fixed concept, like Mr.Longley. They come to private for personalised, speedy , and less beaucratic care.They can choose the one they like and trust or worth the money, and leave the one they dislike, or not trustworthy. They go to public when they can wait,in morbid, urgent situations and when it is going to last a long time, draining money. And of course, when they are not satisfied with either side, they go to the other for a second opinion,or another type of service,like in our place , traditional chinese medicine Competing interests: None declared |
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Eigenmann Franz, Leitender Arzt Gastroenterologie Kantonsspital 5400 Baden Switzerland
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To sum it up Mr. Longley was left with very bad feelings after his daughter had received excellent medical care because he had paid directly for the services. Working in a public hospital where for decades private medicine and services for less affluent parts of the population have coexisted with mutual benefit (although being somewhat threatened more recently) may give some credibility to my comment. Paying for medical services can hardly be disgusting in a capitalist society where most transactions outside the core family are linked to some form to payment. What Mr. Langley seems to forget is that for NHS employees money is a strong incentive too, only it`s called salary. Experience shows that systems like the NHS collapse quickly when salaries are no longer paid. Doctors in the NHS are likely to have to consider their employer`s interests as well their patient`s which may not be identical. In a fee for service system patient satisfaction only guarantees survival and is therefore of paramount importance. Both systems have their strong and weak points and the Swiss experience shows that combinations are possible and useful, perhaps even giving the best practical results in a prosperous society. Competing interests: None declared |
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Dominic L McDermott, Pharmaceutical Adviser Newcastle upon Tyne
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"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." "And then when you go to your GP to collect the results of the blood test so that you can take them to the next private consultation, you find yourself talking in an undertone to the receptionist so that no one else knows you are "private," and you avoid looking at the poor sods in the waiting room who perhaps are only there because they could not afford what you could." Private or Pirate Medicine? Competing interests: Employed by UK NHS |
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Dominic McDermott, Pharmaceutical Adviser Newcastle upon Tyne
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Dr Hayes asked about the difference between healthcare and other essentials: "Food, water, clothing, housing-all are more essential to life than medicine. Which fundamental law states that medicine should be provided free at the point of demand if these other goods are not-regardless of the fact that the cost of free-at-the-point-of-demand is perpetual reorganisation and top down command economics?" No fundamental law that I know of, but some fairly straighforward arguments. In economists' jargon: unequal risk; adverse selection; moral hazard; cognitive dissonance; information asymmetry & supplier induced demand; monopoly power (professional & institutional); externalities; and, most importantly, equity. Or, more succinctly: market failure. Markets for food, water, clothing, housing, energy, entertainment and a variety of other goods essential to a healthy life are all closer to the ideal (perfect information, many buyers and sellers, a uniform product and freedom of entry and exit) than the market for professional healthcare. And, thanks to a less than perfect but nonetheless enviable system of social security, it may be reasonable in 21st century Britain to talk of "demand" for these goods - whereas, even in this age of "lifestyle drugs" and "happy pills", to talk of "demand" rather than "need" for healthcare (with the obvious complications of urgency and unpredictability) in anything other than a strictly technical sense still seems callous. Competing interests: NHS employee |
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Michael J Goodman, Consultant Gastroenterologist Fairfield General Hospital, Bury BL9 7TD
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I was angered to read Longley's Personal View regarding private medicine. He described positive experiences of courtesy, promptness and lack of hurry when his daughter was treated privately. He expresses his inital hypothesis, that private medicine is to be profoundly disliked, he reports his results of his experiment in using private medicine, and then he comes to two conclusions, namely, that he would do it again and that private medicine "stinks", without giving any reasoning behind this latter conclusion. I am amazed that a scientific journal of your stature, and one that is owned by the British Medical Association of which I am a member, sees fit to publish such an article. Is the editor also prejudiced like Longley? Competing interests: None declared |
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Stephen F Hayes, Frelance GP.,GPwSI dermatology Southampton
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>>>Or, more succinctly: market failure. Markets for food, water, clothing, housing, energy, entertainment and a variety of other goods essential to a healthy life are all closer to the ideal (perfect information, many buyers and sellers, a uniform product and freedom of entry and exit) than the market for professional healthcare<<< This is broadly true. Dr Longley states that he took his daughter to a private rather than NHS consultant as the NHS wait was unnacceptably long. The 'market' in UK healthcare is dominated by a single provider, Her Majesty's Government, which ensures that market forces cannot operate normally. If they did, a 2 year wait would be unthinkable. The UK and the USA appear to stand at two opposite extremes of healthcare provision, whereas most sensible countries (such as Switzerland as stated above, and France whose system is consistently voted the world's best) successfully combine social and private insurance and affordable user fees to achieve a larger degree of choice and rapidity of access than is enjoyed in Britain's centralised state system with it's obsession with 'equality'. VAST resources are devoted to the search for equality and the statistics to demonstrate it. This belief that equality is the highest of all goods in healthcare and must be ensured by the state (regardless of distorting effects on the delivery of other goods)is exemplified by the strong antipathy to non- state controlled medicine in the original article, using language like 'Faustian' and 'stinks'. The point is that most developed countries have found ways to combine the demonstrable benefits of real competition and choice with a safety net to prevent the worst aspects of 'market failure'. In Britain we cannot even begin to explore the possibility of moving down this road because of the Doctrinal hostility to 'Private' healthcare, demonstrated with disarming straightforwardness by Dr Longley. If the British people, as our politicians keep telling us, value free -at-the-point-of-demand and State-guaranteed equality above all other goods, then fine. But can we then please re-learn the art of being happy to wait our turn in the queue? Competing interests: None declared |
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Dr. Naseem A. Qureshi MD, IMAPA, LMIPS, Director, CME&R POBox.2292, Buraidah Ment. Halth. Hosp., Saudi Arabia., Dr.Ibrahim A. Al-Hoqail, Dean, College of Medicine, MOH, Riyadh, Saudi Arabia.
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Sir: From medical professional perspective, those of us who have academic interests and pursuits may or may not distaste private medicine. Likewise, those who have exclusively clinical interests and employed in public health institutions again may or may not have unfavourable attitudes against private medicine. On the contrary, those of us who are just private practitioners will have strongly positive and favourable attitudes towards private medicine unless our private medical practice is not booming well, though we may have negative feelings at public medicine. Therefore, attitudes towards private medicine and also public medicine will vary considerably across medical professionals. Individual preferences towards private medicine as reflected in this personal review [1] are robustly plagued with biases and are calling for relevant research in this important field of medicine. Arguably, from health delivery systems perspective private medicine and public medicine are mutually supplementary but consequently tend to widen health disparities between the rich and poor. From both professional and patients perspective, the relationship between private and public medicine is of infidelity. Patients who are ignored and neglected in public health institutions suddenly develop an idea of unfaithfulness and mendacity, which drive them to consult private medical practioners. Similar type of responses emerge from patients when they are incompetently treated and investigated in private medicine. Private and public professionals usually suspect each others motives, which drive them to develop unfaithfulness among themselves. Thus, infidelity resembling the concept of paranoid community pervades medical community invloving private medicine and public medicine. Finally, despite the presence of strong hatred and untrustworthiness between the two sciences, there should be certainly some foolproof guidelines that must protect the rights of the patients, who should not suffer at the hands of public and private professionals. Reference: Marcus J Longley . The three paradoxes of private medicine. BMJ 2004; 329: 579 Competing interests: None declared |
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J Gedis Grudzinskas, Emeritus Professor, Medical Director The London Bridge Fertility, Gynaecology and Genetics Centre, One St Thomas Street, London Bridge, L
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Dear Sir In infertility and IVF practice, the provision of over 75% of patient care is in the private sector and will continue to be so for many years. With over 15 years' experience in both sectors, as Medical Director of The London Bridge Fertility, Gynaecology and Genetics Centre and, until recently, also the IVF unit at St Bartholomew's Hospital, I would like to make the following observations. Working together, the two centres eventually provided well over 2000 treatment cycles a year, becoming two of the largest IVF centres in the UK with livebirth rates amongst the highest in the country. Harmony between the sectors has led to the effective transfer of expertise from the private to the public sector, involving institutions as august as Guy's and St Bartholomew's Hospitals. These activities have resulted in the first Sub-Specialist Training Fellowship in Reproductive Medicine and Surgery in London, situated at St Bartholomew's Hospital, a post which was privately-funded. In addition, up-to-date treatments for male infertility were introduced to the NHS as a result of training and technology transfer from the private sector. Close co-operation between the private and public sectors has also stimulated clinical research activities resulting in publications in peer- reviewed journals, higher degrees and improvements in clinical practice in this field, nationwide and internationally. It would be a pity for these matters not to be brought to Mr Marcus Longley's attention, as well as to others who seem to live in a polarised world. Yours faithfully Emeritus Professor Gedis Grudzinskas FRCOG MD
Competing interests: None declared |
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James N Hardy, GP Principal Bethnal Green Health Centre, 60 Florida Street, London E2 6LL
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Dear Editor, Marcus J Longley is a man after my own heart. His article in the BMJ on private medicine (1) is gloriously disputatious and he has it bang to rights. I received an unctuous letter on embossed paper recently that declared “what a pleasure it was to meet your charming patient Mrs X……..I think she has Y, but for the sake of completeness, I have ordered a number of (expensive) tests and will see her shortly with the results. In the meantime I suggest she takes Zamzam XL and Zipzip MR.” I see Mrs X a couple of days later as an emergency because Zamzam and Zipzip are too expensive for her to buy privately and will I please do so instead (non-generically of course)? I feel angry and manipulated. Two weeks later the second letter arrived. It's been a triumph for Zamzam and the impoverished Mrs X is now to be slotted nicely back into an NHS. It happened again yesterday. 1. Marcus J Longley. The three paradoxes of private medicine BMJ 2004; 329: 579 Competing interests: The NHS |
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susanne mccabe, retired cf 24 3pf
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Ms X has now been labelled 'the charming' and 'the impoverished' by two men with different ideas of practicing medicine. What she is doing herself presumably is attempting to look after her health - but being bounced around the system instead. Ms X needs to read her notes to make sure no perjorative statements are following her around. We have had a similar case in Wales whereby a woman was put on a 17 week waiting list for a scan of suspected breast cancer. After much media attention and input from her MP, the University Hospital of Wales stuck to it's position. The lady borrowed the £150 needed for a private scan, could not afford the further investigation needed, so the private hospital arranged an immediate appoinment at the nearby NHS Glamorgan hospital.Of course it was unfair but they also know how the system is being abused by NHS practitioners too - and did their best for that particular woman. They have done the public a favour in exposing that prefrential treatments are taking place. The outcome is that the MP is furious about the length of time his constituent was told she would have to wait, (she was not referred elsewhere initially either), there is outrage about the manipulation of the NHS - but nobody has yet, in public at least, considered the woman did anything doctors or anybody else would not do to possibly save their own lives. Most shockingly of all the Glamorgan Hospital has now formally and transparently agreed to take a percentage of cases from UHCW. Were they doing this covertly before? Which individuals were involved if so? How were women selected to jump the queque if so? Ms X was not rich, was not one of the 'worried well', she is no more 'charming' than most, no more 'impoverished' than most. She was pluckier and luckier than many - is that a criteria for treatment in the NHS now? Competing interests: None declared |
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Michael G Bamber, General practitioner Colsterworth Medical Practice, Back Lane, Colsterworth, Grantham, Lincolnshire NG33 5NJ
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Dear Sir I am not so enraged by Longley's Personal View as other correspondents, but somewhat saddened. I am quite appalled that he can blithely state that his daughter's consultant said that the next appointment would be on the NHS in "a few months", when Longley had earlier stated that there would be a two year wait to see the consultant on the NHS. This is blatent queue jumping by paying to be advanced on the NHS list, and it is scarcely credible that Longley can compromise the consultant so publicly, and more amazing that your editorial control is so lax as not to perceive this danger and warn Longley. Presumably goodwill is so low in South Wales that colleagues no longer see doctors and their families on a pro bono basis, although I understand the dangers of that situation to all parties. Yours faithfully Michael G Bamber Competing interests: coming from a medical background |
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Aidan Gleeson, Consultant in Emergency Medicine Beaumont Hospital
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I must say I haven't read such a load of nonsense in a long time. One would swear from the author's portrayal of his 'seedy' private consultation and his subsequent guilt that he was recounting how he, a happily married man, got drunk on a golf weekend with the lads and had sex with a prostitute. It is utter nonsense for the author to imply that NHS consultants alter their practice in the private setting in order to line their pockets. In future the author should wait the 2 years for his consultation on the NHS. He should not, however, attempt to dissuade others from using their right to have a private consultation rather than fester on a public waiting list. Competing interests: None declared |
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Andrew Montgomery, locumGP Auckland New Zealand
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I am a locum doctor in New Zealand. I am not so much interested in the relative merits of "public" - government funded medicine vs "private" - largely insurance funded medicine but rather as to the future of both. I believe that insurance funded medicine is rapidly becoming an anachronism in the sense that advances in diagnostic technology will inevitably lead to the death of medical insurance. This should be obvious to your readers without elaboration. It is clear that we are born genetically unequal in every way. The extremes are obvious - there are some who will live to 90 yo in good health despite abuse of alcohol, food and cigarettes (eg my great aunt) and some who lead exemplary lives and die young (eg my father). As diagnostic technology progresses it is inevitable that it will be possible to predict from an early age who will acquire what disease and when - allowing for "health lifestyle" My question is simple. Accepting that the above is true what do your readers believe is fair? Should those who are born with genetic disadvantage be forced to shoulder the burden of their healthcare or should it be the shared responsibility of a nations citizen's? Either way - who should pay? Competing interests: None declared |
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Jenny L Robertson, Journalist London
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I for one am sick of our hypocritical 'healthcare' system which purports to be 'free for all' (no such thing) but in effect breeds a sub- standard, inefficient, corrupt two -tier system in which you have to pay again (if you can afford it) to jump over the trolley-loads of waiting patients and see the self same consultant privately who is then charming to you. Is this fair? Is that what the NHS was supposed to be about? Roy Bishop, from California, summed up the paradox nicely in his response: "Why is it acceptable that the British people having already been overtaxed have to pay a second time to get a decent level of customer service?" I couldn't agree more. The NHS waiting lists are engineered in such a way as to force many, many people - whether they can afford it or not - into paying for private treatment for serious conditions. Yet, and this is the real paradox, people still bleat about feeling "lucky" to have the NHS and feeling "guilty" about paying for private treatment. If patients in the UK are guilty of anything, it is of being too accepting of mediocrity, or worse. "The NHS is over-politicised failure, further money thrown at it represents a poor return on investment and that an insurance based system with social safety net is the best answer." While this solution may not be perfect, it is one that has been adopted by many countries - countries in which I would far rather fall ill than the UK. "Perhaps there are too many vested interests who don't want to face the stark realities of a competitive healthcare market." How true! The current structure of the NHS may well be advantageous to a great many - but not always the patient. I most certainly do not feel 'guilty' about paying for private health care for my family - I just feel intensely irritated that in so doing I am continuing to support a crumbling, beaurocratic, politicised system that is well past its sell-by date. Competing interests: None declared |
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Adrian S. Blaj, Psychiatrist Good Old Chase Farm Hospital, London, EN2 8JL
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Madam: If one tries to analyse Marcus J Longley's private view, he started his letter declaring his 'profound dislike of private medicine' and finishes on the same note 'I still think it stinks'. In the meantime he tells us he overjoyed with a 'feeling of relief that the uncertainty and waiting were over'. Than very shortly becomes suspicious of what those people might say 'behind' his back and continues to carry on with a righteous guilt feeling. I just wonder how a psychoanalyst would interpret this personal view. Defence mechanisms, various envies, coping strategy? What I know is that a bank manager or a lawyer do not harbour a similar guilt if one seeks their help. A visit to a private clinic is no different from going into a contract with a service provider. Most of us are competent adults and able to give informed consent so in my mind purchasing peace of mind is no different from purchasing education for my daughter. Why should people feel guilty for entering in one contract and perfectly happy signing another one? Most recently someone asked about my views on private medicine as opposed to NHS medicine. I replied saying that I do my work in the NHs at standards I would do to private patients. At professional level there should be no distinction between the ways we behave in one or the other setting. The confusion starts when doctors get biased in respect of money and status anxiety and fail to disentangle political/managerial issues from what is expected from them on a professional level. I still believe that the NHS is a wonder of the world which safely coexists with private practice for as long as we all understand not to abuse or misuse the Hippocratic oath. Perhaps Marcus J Longley should look at the bright side: his worries did not prolonged unnecessarily and through his most unwilling act of parting with his money, he helped someone else to gain a place on the waiting list. Competing interests: i love the good old NHS in spite of its failings |
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Marcus J Longley, Senior Fellow and Associate Director Welsh Institute for Health and Social Care, University of Glamorgan, Pontypridd, CF37 1DL
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As the author of the Personal View which sparked this discussion, I wonder whether the key issue is not being overlooked in some of these 30- odd responses. Correspondents have tended to focus (with sometimes withering regard) on the inadequacy and frailties of my personal response to the complex phenomenon of private healthcare - culturally-conditioned as it clearly is. They have perhaps not really addressed the fundamental ethical question which lies behind my personal dilemma, and which is vastly more important: is there not some moral difficulty in a situation where a child's access to timely healthcare depends upon his or her parents' ability to pay? Competing interests: None declared |
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Sumit K Basu, Cosultant Cardiologist University Hospital Lewisham., Lewisham High Street. SE13 6LH
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In the midst of a stimulating and thought provoking discussion I was annoyed to find this frankly offensive rant which is not only inaccurate, dishonest,thoroughly biased but also 'hypocritical','corrupt','substandard' and not at all 'charming'. Furthermore the piece is intellectually lazy and just seeks to propagate all the tabloid stereotypes of a "failing NHS" that we are used to reading about from ideologically and financially motivated journalists. There are so many ridiculous assertions that I do not know where to begin, however, I take particular exception to the insinuation that waiting lists are 'engineered' to perpetuate private practice. Waiting lists are a fact of life in an under-resourced service - but, in my speciality in particular, are declining dramatically with the increase in staff and resources that have happened since the publication of the NSF. As evidence I offer the waiting time for 'Routine' coronary angiography; 6 - 9 months when I started training in my speciality 10 years ago but 4 - 6 Weeks in my hospital today. I would recommend to Ms Robertson that she takes herself off to that country she so admires - where she will discover that the so called safety net has terrifyingly large holes through which the sick and uninsured fall with alarming and predictable regularity especially when they are of Afro- caribbean or Latin origin. I write with some knowledge of the system since I have several first-degree relatives as well as friends from medical school living and working in the US. And finally,I sincerely hope that some day she will learn that 'charming' does not neccessarily equate to knowledgeable or efficient or indeed good for your health! Competing interests: Consultant in the 'Sub-standard' NHS - with no private practice. |
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Jenny L Robertson, Freelance journalist London
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Thank you for your comments, Sumit Basu. My criticisms of the NHS do not primarily relate to the quality of the care offered by the NHS, which can be excellent. There are obviously many, many dedicated talented professionals working within the health service. I would never dispute that. Rather, my criticisms of UK healthcare relate to the difficulty in promptly accessing appropriate healthcare, unless you 'go private'. This point was made very eloquently by a previous respondent whose cancer- stricken friends faced delays in treatment. My argument is: what is the point in having a national healthcare service that cannot be accessed without delay? It's a bit like having a fantastic ambulance service that routinely arrives two days after the motorway pile-up. It's not fair on either the patient, or on those who are working so hard within the service to deliver the goods on time. While the tabloid papers love to publicise horror stories about the NHS, our media generally does not explore the whole issue of healthcare with any great intelligence or depth, in my opinion. Yet without a healthy, rigorous, critical debate how can we move forward? In many instances you can jump the waiting lists by going private - but then you cannot sustain the argument that the NHS is fulfilling what it set out to achieve. However it is very gratifying to hear that waiting lists are being reduced dramatically in some specialties. My other main criticism of UK healthcare is that there is a lack of rigorous INDEPENDENT quality control. Again, I think this impacts negatively on patient care, and is wasteful of resources. You state that: 'waiting lists are a fact of life in an under- resourced service.' Surely this lies at the heart of the debate about what constitutes a good health service. Is it acceptable to have an under- resourced service with waiting lists in the UK in 2004? Don't the British public deserve better? Why is it considered so offensive to ask this perfectly reasonable question? Perhaps I did not make myself clear, but the type of health service I would prefer to the NHS would be a European style insurance system with a social safety net, even if it cost more. Countries such as Swizerland, France and Germany seem to have cracked it better than us. I have lived in France and Switerland, and I know where I would rather be ill, with or without money. Competing interests: None declared |
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Simon A Rogers, NHS Senior manager Cardiff and Vale NHS Trust, University Hospital of Wales, Heath Park, Cardiff, CF14 1XW
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Like those who despise private education and who sneer at those who use it, the author misses the point. We live in a democracy and that involves people making choices. The real issue as with education is that publicly funded health and education needs to learn from the private sector and be more customer focussed and competitive. Only then will truly excellent patient centred care be provided. And only then will people not be forced to use private sources for education and health, but will do so genuinely out of preference. The author sneers at those who use it and then does so himself and somehow releases himself from any guilt by baring his soul and keeping his socialist credentials. The real issue is and it is revealing that the author doesn't ask this - why with all the resources at their disposal cannot public hospitals do this. Why doesn't this happen? Well that is a long and detailed debate. Firstly some do, despite the system, but we discuss the NHS as an amorphous monolith - ie we don't encourage independence or centres of excellence. Some initial thoughts are: 1. If politicians encouraged a culture of positive excellence to develop rather than a negative blame oriented culture, then the NHS would and often does respond in pockets of real excellence. 2. Incentivising excellence and penalising poor quality services through a financial reward system without some of the perverse incentives with the current English Payment by Results tariff based system is also a key lever in making public hospitals more responsive to patients. 3. Devolving reponsibility and empowering both local hospital management and front line senior clinicians is also a key to excellent servuce delivery. Micromanagement by non clinicians clearly never going to lead to excellence in clinical services for patients. Look at leading Foundation Trusts in England and see some of the innovation and quality which is developing under a system of regulation rather than micromanagement. Clinical leadership and empowerment along with being more accountable and responsible for service delivery to patients, ie patient experience such as waiting times is also a clear direction of travel for all public hospital systems. 4. A final piece of the jigsaw is that responsibilities lie also with patients who use public hospitals and that is usually remedied in private medicine (and education) as those who pay generally don't abuse or play the system. Competing interests: None declared |
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oscar,m jolobe, retired geriatrician manchester medical society, c/ojohn rylands university library, oxford road, manchester, M13 9PP
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I have always wondered what the National Health Service might have evolved to, in terms of quality of care and value for money, if there had never been a competing private sector, and if the intellectual elite who had been educated at the state's expense joined forces with the government of the day in the single-minded effort to ensure that year on year the quality of the service would improve and that the taxpayer would get value for money. The Cuban healthcare system has shown that such aims are acheivable, and I do not sincerely beleive that the intellectual elite of their own educational system turn out differently from ours after a stint of being educated at huge expense to the taxpayer. Competing interests: None declared |
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oscar,m jolobe, retired geriatrician manchester medical society, c/o john rylands university library, oxford road, manchester M13 9PP
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At the risk of becoming progressively ungrammatical (instead of "evolved into" I used the phrase "evolved to" in my recent rapid response) my speculation about "what might have been" begs the question of whether the NHS would have ever come into being if the concession had not been made to allow NHS staff to have private practice alongside their NHS commitments. The answer is probably a resounding No! Accordingly, from its very inception, the NHS was never ever going to have the kind of single-minded commitment, from its senior medical staff, that would enable it to realise its full potential to fine tune its performance year on year so that it should become increasingly cost effective and fit for purpose. Instead, fitness for purpose is now purchased at the cost of ever increasing financial incentives, exemplified by doubling of the income of a consultant nurse to £100,000 a year to bring dowmn waiting lists, and payment of an extra £50,000 a year to one doctor to help cut waiting times(1). To a greater or lesser degree, waiting times are, themselves, an inevitable consequence of the fact that a uniquely competent healthcare professional has a limited capacity to divide his time fairly between his NHS work and his private practice. The greater the tension between the two conflicting demands on the doctor's time, the higher the risk of a corresponding increase in waiting times. In a healthcare system such as the one in Cuba, where there is no tradition of an inbuilt relationship between private and public healthcare, clinical competence does not have a purchase price which is dictated by extraneous "market forces". It simply has an intrinsic value which is beyond price and does not need to be factored into the annual budget for healthcare. References (1) Templeton S-K. Revealed: NHS nurse who earns £100,000 Sunday Times No. 9,613 November 30, 2008, page 1. Competing interests: None declared |
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