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October 7, 2015

Dangers lurk in the market

In the last briefing, the reporting of Muhammad Yunus’ view that the pursuit of private profit is wholly incompatible with the values of our sector was not universally well received. Seems there’s a strong belief out there that the market will generally produce the best outcomes.  Frustratingly, the counter arguments to this world view often seem to lack the hard evidence to back them up.   For once though, GP and author Gavin Francis writing in the Guardian, exposes the stark reality of what happens when the profit motive is allowed to encroach into healthcare. 


Gavin Francis, The Guardian

A few years ago I was asked if I’d consider working in a private GP clinic – one of those city-centre enterprises with a sleek logo, an expensive address and an eye on the wallets of bankers. I had a part-time job in the NHS at the time, and was looking for a bit of extra work: I wondered if the clinic would be a rewarding place to do it. At their invitation I went for a look around. The convenience of its location was indisputable, its decor was immaculate and its clinical standards, I was assured, were irreproachable. Towards the end of my tour I asked one of theGPs about their procedure for writing private prescriptions.

The cost of drugs, both to the patient and to the taxpayer, influences the way doctors prescribe. Study after study has shown that NHS GPs are not just conscious of drug costs, they attempt to reduce those costs through a variety of strategies, without compromising the effectiveness of the care they provide. I was interested in the clinic’s attitude to prescriptions because private medicine is different – some doctors in the private sector have even been known to prescribe expensive drugs in the belief that patients have more faith in them (the thinking goes that if a drug costs just pennies, it can’t be any good). The response to my inquiry surprised me “Patients pay the full price of whatever they’re prescribed,” he said, “but we also have an arrangement with a pharmacy around the corner. They charge a private dispensing fee on top of the cost of the drug, and part of that fee makes its way back to us for giving them the business.” I must have looked surprised because he shrugged and became defensive. “It’s all perfectly legal,” he went on, “we’re providing a service, and patients are happy to pay.”

In the middle ages, physicians justified their appetite for gold by using it as a constituent of expensive medication regimes (it is still there in the formulary today, listed between goitre and golfer’s elbow, as an intramuscular injection to ease rheumatoid arthritis). In The Canterbury Tales Chaucer joked about how intimate physicians’ relationship with gold could become: “since gold is a physic in cordial / therefore he loved his gold most of all”.

When Nye Bevan was asked how he had overcome the resistance of hospital consultants to his new National Health Service, he allegedly said he’d “stuffed their mouths with gold”. In getting their agreement, Bevan was obliged to leave the door open for them to intersplice private with NHS work, a concession that 50 years later, when working as a junior hospital doctor, I witnessed causing problems both for patients and for NHS staff. When I started training in the 1990s some consultants couldn’t be contacted when they were doing their private work, even when they were supposed to be on-call for the NHS. I even worked with one who brought his private patients in to have operations in the NHS hospital at the weekend. This could have dramatic repercussions not just for the staff, but for NHS patients: I remember one private patient, brought in for weekend surgery because of the inadequate facilities at the local private hospital, becoming so unwell post-operatively that I had to spend most of my shift at her bedside. Being operated on at the weekend might have been convenient for her surgeon, but it meant the needs of all the other patients on the ward were neglected, and the goodwill and professionalism of NHS staff were exploited.

In my work as an NHS GP the corrupting effect of private practice is less immediately obvious, but through my correspondence with specialists I know it still goes on: scans, arthroscopies and follow-up appointments are all more lavishly recommended when the patient is paying, which makes one wonder about the criteria used to recommend them. Recently an angry father insisted I refer his son for consideration of a tonsillectomy after a couple of episodes of tonsillitis. If I want to refer someone to have their tonsils out on the NHS, my local surgeons won’t countenance seeing them unless they meet certain criteria: seven episodes of tonsillitis in the last year, or 10 over the last two years, or three a year for the last three consecutive years. There are good reasons for this: tonsillectomy risks haemorrhage, infection and leaving you more prone to throat problems in the future. Though we all pay for NHS care through taxation, no doctor in the NHS will now remove your tonsils just because you’ve asked them to – that would be considered a grave abandonment of professional standards, and a flouting of evidence-based practice. But the private healthcare market specialises in treatment on demand, and the rules are different over there. When the father repeated his demand at a private clinic the surgeon’s professional reservations melted away and the operation was scheduled within days. The surgeon’s later correspondence contained a tortured justification for tabling the surgery that was painful to read. It must have been painful too for the patient who went on to need NHS hospital admission to address subsequent complications (bleeding and infection). Several of my own clinic appointments were used to deal with the aftermath. There is as yet no reliable mechanism for the NHS to bill private health companies for the expenses incurred when private procedures go wrong.

Private providers sell an image of excellence and efficiency, but that glossy sheen, in the UK at least, is built on the assurance that whenever a patient becomes unprofitable, or presents too much of a risk, the NHS will step in. This is what some of the private companies taking over aspects of NHS care are beginning to discover: profitability is high if you can pick and choose which patients and procedures you deal with, but drops off when you are confronted with providing a comprehensive service for everyone based on need rather than privilege.

A few weeks ago my clinic was interrupted by a phone call from a concerned psychologist who worked for a large private health company. She had insisted to the receptionist that she speak with me immediately, because she had concerns about one of my patients – let’s call him Walter. “Walter’s here with me,” she said from her upmarket office. “Can I bring him over? He’s desperately suicidal.” “Of course,” I said. “I’ll fit him in.”

When I went to call Walter from the waiting room, he was alone – the psychologist hadn’t waited to tell me more about her concerns. “I’ve no idea why I’m here,” he said as he took a seat in my office, almost embarrassed. “I don’t feel any different today than usual.” He had told the psychologist that he often felt low and had, in the past, contemplated suicide. But he currently had no active plans to kill himself; in fact, he had been consulting with one of my colleagues only the week before, and had follow-up appointments arranged with ourselves as well as the NHS psychiatrists the following week. The private psychologist hadn’t asked about any of this. Walter was bewildered by having been urgently transferred to my waiting room then abandoned – abandoned by a private healthcare system confident that the NHS would take over as soon as he became unprofitable, or began to present a risk.

Private companies benefit by using specialists who are trained and have their professional standards maintained through another body – the NHS. They can, at times, use NHS facilities and NHS staff to care for their sickest patients, when their own facilities are not up to standard. The private sector fails to comply with the highest professional standards of evidence-based practice, as in the case of my tonsillectomy patient, because treatment is often offered on demand rather than according to best evidence. Prices in the private sector are kept artificially low because, in the UK at least, private providers can avoid paying for the fallout of their mistakes – NHS colleagues will follow up any infections and bleeds post-operatively, and if anything goes wrong you can phone an NHS ambulance (in many small private hospitals, they phone 999 if you suffer a heart attack). These factors all mean that private companies can afford to sell an image of efficiency and modernity that in truth they have little claim on, because their success is predicated on the existence of a robust NHS. There is, however, another means by which they benefit from the existence of the NHS: the use, or abuse, of clinical records.

NHS medical records, meticulously gathered over decades to benefit the patient, provide a tremendous resource to mine for risk stratification, enabling private insurers to optimise their own profit margins – they can gain access to these for a small fee and the signed agreement of the patient. I recently finished a long-running correspondence about a patient of mine who had varicose-vein surgery privately, rather than wait for it on the NHS. A company representative, having examined his NHS notes, insisted that a historical reference to leg pain proved that the patient had lied about the exact year his varicose veins began to trouble him. If I would only agree that the “leg pain” entry in his notes represented an early sign of varicose veins, then it would qualify as a “pre-existing condition” and the costs of his vein surgery could be demanded back from the patient. When I argued that the notes said no such thing, and that the earliest moment when diagnosis becomes possible is often a grey area, I was told: “We work with liabilities, there are no grey areas.”

Health is like power, education or money – it confers social advantage according to how much of it you have in comparison to others. In a society that is increasingly unequal, private health companies are booming, while we are told a “free NHS” is unaffordable. The NHS isn’t free – we all pay for it through our taxes, and we will get the service we are willing to pay for. Employers, too, if they want to rely on a healthy workforce, will have to pay for it through corporation taxes.

In Old Scots the word avareis or “avarice” has two meanings: the usual sense of “greed”, evolved from the Latin avarus, but also “a duty or impost on goods; a charge additional to the freight”. There were several reasons I didn’t want to work in the private clinic, but the “avareis” charge arranged between them and their apothecaries was a salient one. I wondered how many other aspects of their practice might be skewed in favour of income generation rather than the best interests of the patient.

More than 2,000 years ago, the authors known collectively as “Hippocrates” were clear on the subject of how money affects clinical practice: it corrupts. As the NHS is denigrated by those in power, and private medicine is promoted as an example of efficiency and consumer-friendliness, it is worth remembering some of them. “One must not be anxious about fixing a fee,” Hippocrates says in the Precepts. “For I consider such a worry to be harmful to a troubled patient … it is better to reproach a patient that you have saved than to extort money from those who are at death’s door.” The theme is elaborated in the series of aphorisms collected under the title Decorum, which contains a meditation on how medical practice should involve the daily exercise of practical compassion and an aspiration towards wisdom. According to Hippocrates, a clinician’s wisdom entails adopting the “right manner” towards money – a manner of generosity, modesty and temperance. He follows this with advice on avoiding ostentation: “Practise elegantly, with reserve. When on a journey use a cheaper case.”

The Roman physician Galen practised several centuries after the Hippocratic writers, but echoed what they had to say: the best clinical decisions are taken when anxieties over money are taken out of the doctor-patient relationship. In a short text called That the Best Physician Is also a Philosopher, Galen reprimanded doctors who are lazy about study, shoddy in their clinical assessments and greedy for fees. We are lucky, writes Galen, to benefit from all the discoveries and systems that our forebears put into place – achievements that were won with great difficulty, and that we should honour and protect. “Philosophy is necessary for doctors if they are to use the Art correctly, when practitioners who are no physicians, but poisoners, are daily before our eyes: lovers of money who abuse the Art for ends that are opposed to its nature.” He is anxious that doctors shouldn’t be asked to double as businesspeople, obliged to practise medicine with one eye on the balance sheet: “For it is impossible at the same time to engage in business, and to practise so great an Art: you must despise one of them, if you are to press on with all speed towards the other.”

The problems with private practice are the same now as they were two millennia ago, but we should know better and, having experienced 67 years of the NHS, be better guarded against them. The clinical attribute with the greatest currency of all is trust: it is essential that we continue to trust our doctors. If private providers with profit as their most fundamental concern are allowed to take over, trust will evaporate. Removing financial questions from the consulting room and transferring them to a central government body was one of the most civilised achievements of the 20th century, perhaps one of the most civilised ideas ever dreamed up by humanity. And if we let our politicians drive profit back into clinical encounters then we haven’t moved on since Chaucer, and we have yet to learn from Hippocrates.