Tuesday, January 17, 2012

Wachter explains private practice in the UK

Bob Wachter continues to offer thoughtful  perspectives on the British health system.  The latest is about the role of private insurance and private doctors operating in parallel to the National Health Service.  Here are some excerpts:

[F]rom the time of its founding in 1948, the British National Health Service has allowed – and, depending on which party is in power, promoted – a private insurance market. Private insurance in a single payer, government run healthcare system is a funny animal: one part incest, one part conflict of interest, and three parts strange bedfellows. And it’s infinitely fascinating. 

The action in the private world stems from occasionally poor access to specialty care in the NHS, both because of limited numbers of specialists and gatekeeping by GPs. The result of these limitations is the famously long NHS queues. . . . [M]any patients still have to wait longer than they’d like in the NHS. Such patients find the private sector’s shorter waits attractive.

Who are the doctors who provide this private service?

There are few purely “private doctors” in Britain – most private care is delivered by moonlighting NHS physician-specialists. . . . [T]he NHS’s 30,000 specialists have had no cap on the amount of money they can earn from private practice, as long as they clock 40 hours a week for the Health Service.

Hmm, doesn't this create a conflict of attention?  Yup.

The conflicts play out within the specialists’ practices themselves. One London neurologist told me that he might see a patient in consultation for a neurological disorder and offer a follow-up appointment in several months, assuming there is no urgent clinical need. “But if the patient has private insurance, she can see me tomorrow if she’d like.”

The average specialist in the UK augments his or her income by about 50 percent through private practice, but there are wide variations. Specialists operating in the countryside, where few patients have private insurance, may have no opportunity to practice privately. On the other hand, some London specialists double or triple their salaries through private work.

Isn't this unsustainable?

Yet while they differ at the margins, both parties seem content to allow private practice to exist, and sometimes thrive. I wondered why: doesn’t the private sector siphon off resources – both money and providers’ time – from the NHS? I finally had my aha moment when one NHS manager likened the situation to that of US private schools operating alongside our underfunded tax-based public school system. “All the people using the private system have already paid their taxes, so they are siphoning volume out of the NHS that the system otherwise would have to manage,” he said. “The NHS would come to a grinding halt if private practice went away.”

None of this is surprising.  Back in 2007, I wrote about how the US and European health systems will eventually converge.

The health systems in these countries are owned and financed by the government and are often appropriately cited for the quality of care offered to the public. Indeed, in debates here in the US, they are often called out as examples of what we might strive for in terms of universal coverage and a greater emphasis on primary care than we have.

[In a nationalized health system, the] appropriation by the parliament is a politically derived decision. . . .
  In the face of inevitable limitations on the ability of the national hospital system to offer all services demanded by the public, a growing parallel system is emerging, in which private practitioners offer elective therapies and procedures outside of those supported by the national system.
I predict . . . that the systems will start to look more and more alike over time. Pressure in the US for a more nationally-determined approach. Pressure in Europe for more of a private market approach. It shouldn't surprise us to see this convergence. After all, the countries are dealing with the same organisms, both biologically and politically.


Anonymous said...

It would be interesting to see a comparison of the NHS and the Canadian system, where patients have to leave the country to obtain care or procedures for which they perceive too long a wait. (I'm sure such a comparison exists, but I haven't seen it).

I believe the U.S. will inevitably move toward a 'more nationally-determined approach' as you phrase it, Paul. I just wish we could do it in a rational manner, informed by careful study of these other systems.


Barry Carol said...

I think it’s interesting to note that, in the U.S., private school teachers and public school teachers are not the same people. In the UK, NHS doctors, for the most part, practice in both the public and the private system. If the docs are salaried in the public system and the number of patients they see or some other measure of “productivity” is not a meaningful factor in how their salary and bonus, if any, are determined, they have an incentive to see fewer patients rather than more in the public system so they can maximize their compensation on the private side. While the existence of the parallel private healthcare system does reduce the burden on the NHS, there is an inherent potential conflict of interest because the docs presumably earn considerably more per hour of work from treating private pay patients.

In the U.S., I wonder how much easier it would be for Medicare patients to find a primary care doctor if balance billing were allowed, at least for primary care, and if the patient affirmatively agreed to it before services are rendered.

Mike said...

I disagree with the comment “The NHS would come to a grinding halt if private practice went away.” This is simply not true. Private practice in the UK health service effectively deals only with elective or planned hospital care. Everything else is covered by the NHS including general practice. There is also a limited co-payment system for medicines prescribed by general practitioners. And despite what the current coalition government is trying to do to the NHS in England, it remains one of the most cost effective ways of delivering population health care.