HCR -- Private and Public Healthcare in the UK

By John Ballard

Dr. Bob Wachter has put up several posts at The Health Care Blog telling his observations of the NHS, private practice and insurance as they operate in the UK.  Anyone interested in ignoring the fountain of ignorance spewing in the US about socialist gubmint healthcare should take a look at some of his posts.The Awkward World of Private Insurance in the UK is a good place to start.

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. I asked several prominent specialists why they didn�t just ditch the NHS and switch to full-time private practice. The answers varied, but usually included some version of �I take my obligation to participate in the NHS seriously� (this may sound a bit too idealistic for jaded Americans, but I found this credible in the UK, where belief in the NHS can be near-religious) and, more pragmatically, �It is my NHS practice that allows me to be prominent enough to attract patients to my private practice.�

The latter rationale is no doubt true, and it led several NHS administrators I spoke with to bemoan the fact specialists can create a name for themselves in the public system, and then trade on this �brand equity� to enrich themselves� while the public system starves. One CEO told me that the NHS made a major strategic error by allowing a completely independent private sector to spring up. He was enthusiastic about a recent trend � promoted by the Cameron government � to encourage NHS hospitals to tap into the private market; many have responded by building their own private wings. �At least we keep a portion of the income generated by this work, as opposed to it all going to the specialists and the private clinics and hospitals,� he told me. Whether the private facility is freestanding or connected to an NHS building, the amenities in British private hospitals and clinics are more like what we�re accustomed to in US hospitals and boutique practices: fluffy pillows, single rooms, fresh gardenias, and marble floors. It�s the first class to the NHS�s middle seat in economy.

Interestingly, while the care is clearly more patient-centric, it�s not a slam dunk that the quality of care is better in these private facilities (particularly the freestanding ones) and there are even legitimate concerns about whether it�s as good. Sure, the thread counts are nice, and who wouldn�t prefer to stay in a single room rather than the six-bedder typical of many NHS wards. But there have been poor outcomes born of understaffing, the lack of on-site resources to manage critically ill patients, or limited availability of the specialists (who may pop in to see their patients once a day but then rush back to their NHS hospital across town). The accreditation process for private hospitals and clinics has been far more lax than in NHS facilities, though it has tightened up recently. When a patient crashes in a private hospital, he or she is transferred to � you guessed it � the nearest NHS facility.

Of the many things that surprised me about the British health system during my six months in London, this parallel world of private healthcare was high among them. In a system predicated on a communal, tax-based insurance pool, I wondered whether the emergence of a vigorous private sector would threaten the viability of the NHS. It is a perennial worry: in 1983, one analyst fretted, �Will a one-class universal national health care system survive, or is there danger of serious, possibly fatal, mutation?� From what I saw, I�m not too worried. Most people � even patients who have private insurance and doctors who practice in the private sector � believe strongly in the NHS. I met no one � including senior executives at BUPA, the country�s largest private insurer � who felt the UK would be well served by a much larger private sector if it meant a diminished NHS.

He makes a very interesting comparison with the US system of public versus private education.

...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.�

Private schooling in America, -- whether it be home school, upscale private academy or tax-payer supported so-called charter schools -- would fold up like cheap ironing boards if they were expected to educate all our children. When these exclusive environments skim the most promising students from a much larger population of their peers, better outcomes are virtually guaranteed. And like the private hospitals in the UK have the NHS safety net for emergency case patients, private educators in the US deselect students who don't make the grade, tossing them back to public schools in the same way that fishermen pull in a net and sort through the catch.