Published: 31/01/2002, Volume II2, No. 5790 Page20

There now seem to be five quite different categories of patient who get treated privately. First are those rich enough to pay, some of whom will actually be treated in NHS hospitals. It is estimated that these trusts - mostly centres of excellence - now earn£340m a year from private patients.

1Second are those who can afford private medical insurance, or whose employers buy it on their behalf, though they will still rely on the NHS for any preexisting illness or chronic disease.

Then there is a new group which has been on a waiting list long enough to risk breaching the new waiting-time target of 15 months.

Increasingly these will be offered an operation in a private hospital at NHS expense, assuming the NHS has no spare elective capacity where the money might better be spent - it is not clear what happens to such patients if their trusts run out of cash.

The fourth - and much hyped - group is the small band being shipped to France and Germany at NHS expense. The chief executive of Channel primary care group pointed out: 'We will only use hospitals that are on a par with the best in the NHS.'

2What criteria have been used to make this choice, and does it include mortality, morbidity and outcomes, or where the PCG managed to obtain this data? It is not available to the rest of us.

Finally come people who can ill afford to go private but do not qualify for the NHS paying the bill because their excessively long wait is to see the consultant as an outpatient. That wait doesn't count in trusts' performance targets in the same way.

My sympathies lie with these patients, who are forced to pay for private surgery despite having paid taxes and national insurance all their working lives. A survey of 400 GPs in January this year by Medix UK, an Internet service provider for doctors, estimates they number 100,000 each year.

This does not come as any surprise to the College of Health.

Callers to our national waitinglist helpline over the past 10 years have told us how they spent life savings, mortgaged homes, or borrowed from family and friends for a private operation.

Little, if any, research has been done into the what, why and how of NHS patients who go private, and none I know of into how much they pay. Our own evidence from patients suggests huge variations.We did a study for the Department of Health into the extent to which patients on long waiting lists would welcome choice in where they were referred if it meant earlier treatment. Two patients facing waits of 15 and 18 months for hip replacements had paid£8,000 and£4,500 respectively to have the same operations privately.

3Itis likely that both were operated on by the same surgeon they were waiting to see, and that neither received comparative information about outcomes or costs.

Our founding president, Michael Young, who died this month at the age of 86, explained why we were setting up the College of Health in 1983: 'The reason lies in the present imbalance between medical professionals and their patients.

The former have power, the latter do not. It is also due to the large gap between the knowledge and information of the two parties.

Information, as always, is power.'

4In all the political hype about the private sector's role in the NHS, little attention has been paid to the possibilities for redistributing taxpayers' money within the service. The government is so hung up on not being accused of reinventing the internal market that it has forgotten what existed before.

When the College of Health published its Annual Guide to Hospital Waiting Lists from 198491, any GP was able to refer any patient to any consultant. Our guide acted as a clearing house, pointing patients on very long waiting lists to hospitals where they could be treated much more quickly. There was a system of financial recompense for the hospitals concerned, called crossboundary flow. But patients did not need to know about it - it just worked. Ironically, it was only in 1992 when the government gave us funding to set up the national waiting-list helpline that the creation of the internal market limited patient choice. Things have not improved since.

Our survey found that over 90 per cent of patients would travel if they could get earlier treatment.

Why should they not do so on the NHS? We know the money is there. Perhaps the political will is too bound up with fear of offending the consultants.


1Brown A. Scandal of NHS beds auction. Observer, 6 January 2002.

2Wright G. I would never want an operation in an NHS hospital, says French doctor treating English patients.

Evening Standard, 11 January 2002.

3Rigge M. Telephone survey on patient choice in the NHS.College of Health, November 2001.

4Young M. The four purposes and the six methods. Self Health 1: November 1983.

Marianne Rigge is director of the College of Health.