Personal View: The three paradoxes of private medicine
Authors: Marcus J Longley
Journal: BMJ (2004)

Like many people in Britain I have inherited—and have subsequently nourished—a profound dislike of private medicine. However, it now appears that the reality is much more complicated and disturbing.

We had been told that my daughter would have to wait at least two years to see the consultant as an outpatient, and we felt that this was totally unacceptable. So we made one simple phone call to the private hospital, and she was seen in two weeks.

This much was accomplished without trauma. When we made the appointment it felt like any other—perhaps to see the general practitioner or a school teacher. But the experience began to be qualitatively different when we got there. It began with a feeling of relief that the uncertainty and waiting were over. Then, three things happened that gave me pause for thought.


Instead of the joy of clinical resolution, you are left with a tainted feeling of shameful compromise and guilt


Firstly, the staff were different. They may have had the same job titles and qualifications as staff in the NHS, they may also have had NHS jobs (the consultant certainly did), but they behaved differently. There was a perception of deference to you, the receptionist was caring, they seemed to have more time, the consultation was less pressured (you know that there is no one waiting outside, so you can take as long as you like). So far, so good. But in each of these apples is a worm. Are they only being nice because I'm paying? If so, what do they say behind my back? Do they think I'm as compromised in this Faustian bargain as they are? Is the consultant being pleasant or oleaginous, altruistic or avaricious?

These issues matter because they go to the heart of the encounter: do I respect this person, and therefore do I trust his advice and actions? This is especially important given the manifest perverse incentives, where every additional action means personal income. When he says, “I can see you for the next appointment on the NHS, but it will be a few months,” do I believe him? When he suggests drugs rather than waiting and seeing, could there be ulterior motives? One of the marvels of the NHS is that you can generally trust the motives of the professionals—but here? The result is the first paradox: paying for health care can actually be disempowering.

Then there is the act of paying itself. The private sector recognises the problem here, and its staff try to be very discreet about money. There are several unwritten rules. The consultant is happy to talk about the cost of drugs, but he doesn't mention how much he will charge for his time—and you somehow know not to ask. The secretary exists for this task, and she delivers the news with a slightly shamefaced and conspiratorial discretion and understanding, laying great emphasis on the fact that the debit will not appear on your credit card statement for 14 to 21 days.

This nicely preserves the hierarchy and the professional ethos; it's almost as though you weren't really paying for the guy's time at all. The hospital bill is settled in a rather pleasant cubicle called “Cashier,” where a third party (unconnected with the clinical element) handles the transaction, and the credit card machine is carefully hidden behind the computer. So, the second paradox is that private medicine does not actually seem to cost anything—or, at least, one can suspend one's disbelief for the duration of the encounter.

Finally, private medicine seduces. Just as inevitably as Faust faced Mephistopheles, the erst- while socialist private patient sells his soul. The first time you realise this has happened is when you find yourself avoiding telling friends and colleagues that you have actually “gone private.” And then when you go to your GP to collect the results of the blood test so that you can take them to the next private consultation, you find yourself talking in an undertone to the receptionist so that no one else knows you are “private,” and you avoid looking at the poor sods in the waiting room who perhaps are only there because they could not afford what you could. No wonder the whole transaction is termed private. Would you want it publicly known?

So, paradox number three: instead of the joy of clinical resolution, you are left with a tainted feeling of shameful compromise and guilt. And now that you have done it once, you know that you are more likely to do it the next time. But worse: while you would rather keep the whole episode “private,” you would vigorously defend your actions if you had to. It feels wrong, but you'd do it again.

And so it goes on, patient after patient, year after year. But don't expect me to endorse private medicine as a concept. I still think it stinks.