Private practice--definitely not a zero sum game
Authors: I. Forgacs
Journal: Journal of the Royal Society of Medicine (2006)

In a zero-sum game, one of the participants gains in proportion to the losses of the others. It is a widely held view that private medical practice thrives as (and perhaps because) the NHS declines. Is this correct?

May I start by declaring two conflicts of interest which actually conflict with one another? In 1975, as a final-year medical student, I was a member of MCAPP (The Medical Committee against Private Practice). We, the committed few, used to meet in basement flats in parts of London that then seemed rather dingy but are now almost certainly ‘gentrified’, highly desirable and most unlikely to be affordable by almost any medical practitioner. We plotted, and may have even conspired, to bring about the downfall of private medical practice. The Secretary of State for Health, Barbara Castle, was all for removing ‘pay-beds’ from NHS hospitals. Unlikely as it now sounds, the doctors (that is the 99.98% of the profession that did not belong to MCAPP) proved too powerful a lobby... the rest is history.

The second conflict relates to loss of virginity—and by that I mean the day I first saw a fee-paying patient as a (newly-appointed) consultant physician. A most distinguished colleague phoned me up (for younger readers, just imagine a time when doctors actually spoke to one another rather than sent an e-mail!) to ask me to see Sheikh someone or other. Rather feebly, I reiterated what I had emphasized at my job interview that what I said about wishing to focus entirely on developing the NHS service was true. Anyway I got to about sentence two, word three of my reply when the great man interjected to say he thought I was talking nonsense and, in any case, the patient was already in a taxi on his way to see me. How are the mightily principled fallen.

That violation was insufficient to change my perspective for several years but was sufficient to throw in doubts where I had always been sure. I had always assumed, almost as an act of faith, that those of my colleagues who were really into private practice in a serious way were there for the money. The problem for me was that, right from the start, it was professionally most rewarding to be able to see a newly-referred (three-day wait for an appointment) patient with altered bowel habit on a Monday, diagnose the colon cancer at colonoscopy on the Tuesday, get the biopsy and CT scan results on the Wednesday, and refer the (fully worked-up) patient for surgery within 48 hours of their first appointment.

The new NHS consultant contract is a godsend for those of us whose commitment to the NHS is total but the hours when we are asked to demonstrate that commitment are now very well-defined. In my ‘other’ hours, I enjoy a lengthy run, a swim, or maybe a private clinic. I worry about whether I can get a NHS patient referred with probable cancer through to starting treatment within 62 days. In private practice, I'm just as worried if I can't manage that within 62 hours.

Who loses? Not NHS patients, whose speed through the system has been enhanced not least by DoH targets set as a result of unfavourable comparisons with the private sector, as well as almost anywhere else outside the third world. Not private patients, who get the service they expect and pay for. Not the NHS, who gains by ensuring their consultants work to job plan, and (an old one this but no less true) have patient waiting times reduced by the private patients by-passing the system. And, yes, 'tis true. While I would wish my work to be its own reward, I am most reluctantly obliged as a professional to present a fee for my work. Truly, there are no losers.