Equity, Waiting times and NHS reforms. The privateers speak.

In last weeks BMJ privateers Julian Le Grand and Zack Cooper came to the underwhelming conclusion that “The reforms have not had a deleterious effect on the equity of waiting times for elective surgery in England” On the strength(?) of this they followed up with an article in The Guardian(!), “The NHS can cut costs and still care” followed by letters, including from Peter Fisher, president of the NHS consultant’s association and then a pointed response from Le Grand and Cooper.

Before I summon the energy to respnd to their BMJ article (my baby cryeth upstairs) Here’s my response to an article Le Grand and Cooper wrote in the BMJ news in May:

“As the great sage Jagger said, “You can’t always get what you want!”” House.

According to Zack Cooper and Julian Le Grand, writing in support of patient choice and provider competition in the BMA News in May 2009, “the true test of how a health service is performing is whether patients are satisfied with their care”.[1] It seems extraordinary that this should be the ‘true test’ of healthcare rather than for example, better health. Never mind better diabetic control or better mobility and pain control after orthopaedic surgery, or a reduction in mortality after angioplasty, or any other clinical outcome for that matter. A brief reflection on the parallel system of private healthcare in the UK is explanatory. In the UK people pay for private healthcare in order to have direct access to a consultant specialist, to be seen at a convenient time such as an evening or weekend, to guarantee a private room or for other non-clinical hotel comforts such as carpets or luxury menus. Unsurprisingly the costs of having a specialist at your beck and call and staying in luxury accommodation after your operation vastly exceeds the costs of equivalent NHS care. Satisfaction rates may be higher, but there’s no evidence for any difference in clinical outcomes. At my surgery in Hackney, East London patients have to fill in ‘satisfaction questionnaires’ every year and the responses are one of our ‘performance indicators’ which determine how much we are paid. Frequently there are complaints about our lack of beverage facilities and the quality of reading material in the waiting area. More seriously, of the 26 key performance indicators for Independent Sector Treatment Centres (ISTCs) only 8 are clinical indicators of any kind and only one can be considered a ‘pure clinical outcome indicator’.[2] Whilst I would never deny that I want my patients to be satisfied, I know that quite frequently what they want (viagra) is not the same as what they need (a test for diabetes)

One hundred years ago Bernard Shaw wrote in the Preface to the Doctor’s Dilemma, “Please do not class me as one who “doesn’t believe in doctors.” One of our most pressing social needs is a national staff of doctors whom we can believe in, and whose prosperity shall not depend on the nation’s sickness, but its health”

Satisfaction is the ‘true goal’ of private medicine because satisfied consumers keep coming back for more.

One of the many questions we now need to ask is, are these patients who are being seen quicker, healthier as a result?

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[1] No Turning Back, BMA news May 23^rd 2009 p.15

[2] Player S, Leys C Confuse and Conceal: The NHS and Independent Sector Treatment Centres