The case for private practice
MEDICINE JOHN ROWAN WILSON
Last week the council of the British Medical Association took an important new step in policy, by deciding for the first time to 'take all action within its power to encourage par- ticipation by the profession in private practice in Britain.' This is a commitment which the association has always carefully avoided in the past. As the profession's principal negotiator with the Ministry of Health, it has always tended to defer to the ministry's well-known disapproval of private practice and to live on in the hope that one day the National Health Service alone will be able to satisfy all the medical needs of the population. This hope has been dying gradually over recent years and the council's motion means-that the death cer- tificate has now been officially signed.
The consequences of the association's de- cision are not entirely clear at the moment, but there will obviously be increasing attempts to draw private finance into family doctoring, rather in the way that it has been drawn into hospital treatment through such organisations as the British United Provident Association. It should not be impossible, for instance, to finance private health centres in the same way that BUPA has financed private hospitals. There will certainly be further support for the organi- sation known as Independent Medical Services, a scheme set up by the BMA a few years ago to give an opportunity to general practitioners to opt out of the NHS and set up in private practice on a contract basis. IMs has so far enlisted 600 doctors out of the 22,000 Nos general practitioners and the conclusion has been drawn from this that doctors are not really keen on going into private practice. This may be a fallacious conclusion, since the change from NHS to private practice involves leaving a secure pensionable job without any guaran- tee to the doctor that his patients will follow him. It is not surprising that only a small num- ber of brave spirits have dared to take such an irrevocable step.
However, if we are moving towards a salaried service, as so many people seem to believe, this is bound to lead to an increasing polarisation towards government polyclinics on the one hand and individual private practice on the other. This might well be more logical than the present system, which pretends to give all the benefits of a personal doctor to everyone, While in fact doing nothing of the kind. The patient would be left to choose, in the same way as he does with education, whether to have a competent, basic, impersonal service at government expense, or something more leisurely and elegant at his own.
This kind of proposition instantly arouses certain predictable emotional reactions, and perhaps this is as good a time as any to deal with them. First of all, it is said that no self- respecting nation should have 'two different standards of medical care.' This argument is built on the fallacious assumption that treating a patient is like mending an electric-light switch --you either do it properly or you don't. But in fact there are several components to medical care, some of which are basic essentials which should be made available to everyone, and others which must be regarded as luxuries. The luxury elements in medicine are such activities as seeing non-emergency patients at short notice, listening to family problems which have only a marginal connection with illness, and making house visits to patients who at a pinch could attend the surgery. The Health Service simply cannot afford the time and money for such refinements, and it is no use pretending that it can.
It is possible, of course, to say that if we cannot provide certain services for the whole country, they should not be allowed to exist at all, even for those who are prepared to pay for them. This would involve a return to the economic and political philosophy of the post- war years, when Edith Summerskill couldn't tell marge from butter. On this reasoning there is no juslification for luxury of any kind; all quality must be uniform. The one conclusion which emerged when this egalitarian system was tried out was that the British public wouldn't stand for it. Experience showed that people preferred to have the choice to save up their money and buy something a little extra if they had a mind to do so.
But, the argument goes on, we are short of doctors—consequently it follows that anyone who takes up an extra half-hour of a doctor's time must be robbing some other person of medical attention. This might make some sense if we lived in a closed, static world in which there was only just so much of everything to go round. But, as we all know, the Health Ser- vice under present conditions is leaking doctors like a sieve. A survey carried out by the Junior Hospital Doctors' Association a week ago showed that one in two of the young doctors questioned were actively considering emigra- tion. Every year up to 400 doctors leave Britain, mainly for Canada and Australia, where conditions of practice are freer and more favourable. Most of them go because they simply don't fancy practising supermarket medicine. If they can be offered a chance of something better, many of them will stay. We could staff our luxury health centres without robbing the Health Service of a single doctor, by using the men who would otherwise have gone to Australia.
The final argument against private practice is, to my mind, the oddest of all. It is said that if we allow the articulate, educated middle classes to opt out of public services like health and education, we remove a powerful pressure
group which is in a position to insist on the maintenance of standards. As members of this group, I suppose we should feel flattered to be told how influential we are. But personally I haven't seen much evidence of it up to now. Throughout my lifetime this articulate, edu- cated middle class group has lost every battle in which it has been engaged. It has seen its freedoms eroded, its income savagely taxed, its savings demolished by inflation. Its political in- fluence, judged by the amount of notice govern- ments seem to take of it, is obviously negli- gible. But there is one thing it can do, given the chance : it can, by the use of its own money and its own voluntary efforts, keep alive the concept of individual service. And anyone who doubts the value of such a concept need only visit one of those countries in which it has been deliberately destroyed.
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