Relations between private practice and the NHS: a personal view.
Authors: D E Bolt
Journal: BMJ (1983)

I have been chairman of the Joint Consultants Committee/ Central Committee for Hospital Medical Services Independent Practice Subcommittee for six years. But, as I have now retired from the National Health Service and private practice, I handed over this role to Mr John Chawner last month. I feel strongly about the importance and legitimacy of private practice in this country and think that this is an opportune moment to record my views on the subject. Some people believe that in a country with a national health service private practice should not exist. If honestly held this view must command respect. Unfortunately, at least some of those who hold such a view will not concede that there is an alternative view that deserves consideration. I believe that the continuation of private practice may be justified on three counts. Firstly, choice is essential in a free society. Economic con? siderations may preclude such a choice for many citizens, but that is a criticism of the financial structure of society rather than an argument against the existence of choice. Apart from the very poor, many people who elect to use the NHS have the means to use the private service but prefer to spend their money on consumer durables or foreign holidays. This is entirely a matter for them: they are merely exercising their fundamental right to freedom of choice. Secondly, it is essential for staff and patients of the NHS that it should not be a monopoly provider of health care. For the staff?especially those whose professions are exclusively applicable to the care of patients?there must be alternative ways for them to earn a living. There must be a market place where an independent valuation may be put on their services, lest they find themselves tied inescapably to an unjust level of remuneration. Indeed, it may be argued that the recent problems relating to the pay of non-medical staff in the NHS, particularly nurses, arose because the NHS is a near monopoly. If the balance between the NHS and private practice was more equal market forces would protect incomes more efficiently than a review body ever could. For patients, the existence of an alter? native to the NHS provides a vital comparison against which the standards of NHS care may be judged. It is, of course, equaUy true the other way round. The NHS provides extremely well for emergency patients and those who are gravely ill and this is a great challenge for the private sector. On the other hand, the private sector provides extremely well for the more routine problems and must always be consumer oriented to a greater degree than the NHS. This competition is advantageous to NHS and private patients. I would not like to see it replaced by a monopoly in health care. Thirdly, British patients who seek private health care have paid their full share in the cost of the NHS. If, either by direct payment or by subscription to a provident association, they pay again for private service they are increasing the total pool of resources for the provision of health care and leaving much needed time and facilities in the NHS for others. It might be supposed that they would be particularly welcome in NHS hospitals on such terms but, sadly, this is often not the case. I see great merits in this arrangement, compared with a system that allows rebate of health contributions to those seeking other methods of insurance. It provides a clear protection against the accusation that the NHS subsidises the cost of private health care.