Wednesday, January 30, 2008

A private function

Your humble Devil has been meaning to flag up this excellent post, by Tom Paine, on the state of medicine—and, in particular, those leaving that profession—for some time. I recommend that you go and read the whole of Tom's post to get the full thrust of his argument.
One of many reasons I never expect to return to the UK is that—after experiencing excellent care from polite and courteous private doctors abroad—I could not face standing in line with bored pensioners filling their days, malingerers looking to be signed off work and others that I would cheerfully pay good money to avoid. All this, just to get five minutes with a GP who would probably not look up from his desk. Yet starting a private service to sell their hard-earned skills for profit simply does not occur to these bright young people.

They are gifted, intelligent and well-placed to serve their fellow man. Their potential for a satisfying, rewarding career is enormous. Yet they feel impotent in the face of state incompetence and bleat like unemployed dockers. Yes it's difficult to compete with "free" services. Yes most people will stand in line rather than pay. But in business you don't need everyone to be your customer; just enough people. A substantial minority would pay a premium for time, attention and courtesy. Why does that not occur to these talented, presumably highly-intelligent individuals?

The problem may be that in choosing medicine in the first place, they had already ruled out a life in business. Their most likely career path was into the socialised health service, so presumably that (to me) grim prospect was appealing? Perhaps they see themselves as "caring" types and are snooty about "money-grubbing." Perhaps, in short, like so many in Britain, their spirits have been neutered by Socialist indoctrination.

Tom quite correctly points out that many people would happily pay to see a GP and, indeed, there are private practices out there (that one's in Scotland, no less). His services do not come "free", but neither are they expensive. In fact, they are rather less than one would pay to a plumber or an electrician. So, why is it that these trainee doctors bleat, as Tom puts it, "like unemployed dockers"?

As Mr Paine points out, those who leave the profession are pissing away an expensive qualification which is, to a great extent, paid for by taxpayers; indeed, as Doctor Crippen consistently points out, it cost some £250,000 to train a doctor. I wonder, would these young medical students be less inclined to throw their qualifications away were we to charge them for the cost of their qualification? Possibly.

Long-term readers will know that, for personal reasons, the idea that a doctor should qualify and then chuck away that opportunity enrages your humble Devil for personal reasons. On a purely philosophical level, that someone should come so far in such a demanding and valuable (both financially and in the matter of potential future earnings and future good that might be done) profession and then quit is quite simply ridiculous.
These unemployed new doctors blistered their brains studying to qualify in a demanding profession. Outside Soviet Britain, it is perhaps the most respected and valued profession of all. If they don't want to cash in on their investment by emigrating, why don't they just "hang a shingle" and offer private services?

Quite. Medicine is a vocation: had I not buggered up Chemistry A Level and had thus entered UCL to study medicine, I would not have left because I felt that the NHS was being fucked up. I was never a big fan of the NHS anyway but, most importantly, I didn't want to do medicine so that I could be looked after from cradle—or university—to grave.

Times have changed since your humble Devil was offered—after interview—three B grades to get into medicine; I sincerely doubt that any medical school will require anything less than three A grades. Minimum. The people who get into study medicine are not stupid.

So why, if they are really wedded to this profession (and however much I may disagree with any of the medico bloggers politically, I admire the tenacity of those still in the business), would they throw away their hard-won career because the state-run NHS is shit.

You are intelligent people: look at other options: go private. Apart from anything else, I feel sure that your NHS compatriots will be joining you in the relatively near future: an intelligent person would see it as advantageous to get in on the ground floor...


Simon Fawthrop said...

£100k a year is an awful lot of money to risk on a step in to the unkown.

Perhaps if they didn't spent their team being brainwashed that private business is somehow morally corrupt we might see a few more setting up in competition to the NHS.

Not a sheep said...

Three Bs at A-level back in 19xx are worth a lot more than three As in 2007/08

Anonymous said...

"You are intelligent people: look at other options: go private."

Intelligence and economic literacy are not synonymous; therein lies the problem.

Devil's Kitchen said...

"£100k a year is an awful lot of money to risk on a step in to the unkown."

Yes, but if your known is not having a job at all...

"Three Bs at A-level back in 19xx are worth a lot more than three As in 2007/08"

FYI, I took my A Levels in 1995. Which means, apparently, that I got the equivalent of 3 As and a B today...

"Intelligence and economic literacy are not synonymous; therein lies the problem."

Ha! Tell me about it...


Mark Wadsworth said...

Taxpayer funded health vouchers, like in other countries. Problem solved.

Anyway, people are very economically literate when it comes to it. If people can choose between being treated like shit by the NHS of toddling off to a private GP (they are technically all self-employed anyway, what's the excitement) and having the bulk if not all your costs covered by vouchers (like in many other European countries) then they will.

Warming to my theme, the bulk of those who stay on benefits do so because they'd be worse off if they took a low paid job. That seems economically literate to me.

Henry North London 2.0 said...

Ah if only you knew devil the trials and tribulations that I have faced in the NHS they are alluded to on my second blog but I am planning on leaving Britain again I already did NZ so this time its South Africa

I'll have to buy a gun and get a few Rottweilers but it will be so worth it.

Roger Thornhill said...

In the far east, good doctors with a vocation to the art have thriving private practices charging top whack and then they do additional out of hours "freebie" or near as damn it low cost work for those who cannot afford it.

The giver decides who gets their charity. The asker decides if they are able to pay the going rate or should they, must they, go to the other sessions. The wealthy pay and have the dignity not to sponge. The poor have dignity too, knowing that even the charity sessions are already quite expensive for them and feel glad and respect the doctors who take time to help them - the act of charity is a way of doctors giving respect to the poor, valuing their health and welfare. Doctors are held in high esteem by ALL sections - rich or poor. They both know the doctor is a valued resource and they are fortunate to get a chance to visit them.

It is all about connecting the giver to the receiver. Of course, Socialists cannot stand the idea that someone gives charity when they choose (how DARE they!) or that people ask for it when truly in need (how "demeaning"!) - they prefer the middle classes to be forced like indentured servants to toil away paying for it all while the poor are dependent and "grateful"*. Socialism hates connecting giver and receiver, as it wants to be the one handing over the cash, the benefits, the keys, the treatment, the charity. IT wants to put itself between every person, every soul, teacher and pupil, doctor and patient and now we see even between parent and child.

God I hate Socialism - it is so inhuman.

* fat chance - something given for free by right is rarely received with gratitude but is eventually snatched out of the hand with contempt. Why? The disconnection, of course.

Anonymous said...

The trainee doctors can't go private- they haven't specialised in anything including "general" practice. That's the rub. I'm a private anaesthetist but it took 10 years of work in the socialist hospitals to get here - there's no alternative.

The Sage of Muswell Hill said...

I believe (and I stand to be corrected) that if you go to a private GP, you are ruling yourself out of any benefits which you might receive from the NHS, particularly "free" drugs. Also referrals from the private GP to a consultant would probably be outside the NHS ie you have to use the consultant's services privately (paid for from your own resources - or health insurance of course - which is effectively the same thing). So it's not just the doctor taking a financial risk - it's the patient also.

Henry North London 2.0 said...

Indeed private prescriptions are payable in full

Anonymous said...

The comments on here are ludicrous. My dad spent his entire career in the public sector: first as an army doc, then as a GP, before finally becoming a paediatric consultant. Many of his med school contemporaries earned a fortune in private practice. How blinkered and, y'know, socialist of him to stay in PICU. I love it when internet punters get so high-minded about jobs they'd never do themselves (HNL aside). You have no fucking idea.

The poor have dignity too...

What sanctimonious shite.

Devil's Kitchen said...

Umbongo & HNL,

Yes, so I see.

"The familiar NHS prescription pad can only be used by NHS GPs. People who are not exempt from prescription charges pay a standard fee of £6.30 per item, no matter the actual cost of the drug to the NHS. Some prescriptions are actually quite cheap – for example 100 paracetamol tablets cost the NHS a basic price of about £0.75 and a week’s course of penicillin tablets for an adult is less than £2.00. On top of the basic drug cost the NHS pays a dispensing fee to the pharmacist, so the final cost is higher, but often still below the prescription charge. The other side of the coin is that many drugs, particularly new ones, are expensive and cost much more than the standard prescription charge for a month’s supply.

As a private GP I must prescribe drugs ‘privately’. This means that instead of an NHS pad I use my own headed notepaper. Instead of a standard prescription charge you pay the pharmacist the true cost of the medicine, plus his dispensing fee. For many commonly used drugs this will end up cheaper than the NHS charge you would normally pay. For more expensive drugs you will need to pay the full cost.

If you need a number of expensive medicines long term then it would become costly to always buy them privately. In those circumstances I recommend that I liase with your NHS GP about what you are taking. The majority of the time it is likely that if your medication regime is working well, then your NHS GP will wish to continue the same medicines."

How much of a problem is this for the average punter? None at all.

The average punter might get a course of penicillin or amoxycillin... what... once every couple of years?


I am not complaining about your father staying in the public sector for years: well done to him.

What I am complaining about is people, such as this chap, pissing away years of work and money because of this weird dichotomy: hating the NHS as its being run, but depressed because they can't get a job in the NHS.

And I take the point about not being able to specialise unless they are in the NHS and would counter with: why should private hospitals not train doctors? Is there any law against it (genuinely interested, by the way, and not being sarky)?

The point of the original article is that doctors expect to be trained by the NHS. They expect the job security and progression that the NHS brings.

In turn, the private hospitals have got used to the idea that, unlike in the US, they don't have to train doctors because the NHS will do it for them.

The whole situation is fucking insane and is wasting capital -- both human and fiscal -- hand over fist.


Henry North London 2.0 said...

DK the private hospitals are not linked into the university deaneries which pay half a trainees salary and who effectively use the NHS as a monopoly organisation to train doctors

You see half the salary comes from the University of the area or the medical school of the area rather than the NHS budget. The universities approve certain training posts in the Hospitals always in the NHS

No one has suggested that the Universities go private because there would be uproar and riots because if a deanery withdraws approval from a post thats it

Its also to do with the royal colleges of medicine surgery etc who basically survive through examinations fees and membership fees so that you can put letters after your name with a postgraduate qualification which costs money which the royal colleges control

That and the GMC which is heavily biased towards NHS medicine

The NHS is a monopoly employer has been since its inception

Private work exists to mop up those who are willing to pay and who wish to have instant treatment.

Private hospitals have grown up through the years and are affectionally called the local nugget

You cant be a consultant in those places unless you have the right to be a consultant in the NHS

Plus if any tom dick or harry doctor sets up without royal college membership or other Consultant grade qualifications there is regulation to prevent them from doing so and the GMC start to get interested and theres all sorts of problems when they are in the frame post Fred Shipman

Its a fucking nightmare.

I hope that explains why the NHS is such a lumbering problem but there is simply no where else to train as a doctor because it would push the liability insurance for the private providers through the roof making it uneconomical to train them.

Its cost at the end of the day

Anonymous said...

No worries, DK - there was just a red mist, all of a sudden...

And I take the point about not being able to specialise...

HNL sets it out. But remember, too, that certain specialties are more amenable to private practice than others. Put bluntly, neonatal intensive care is not - and never will be - a money-spinner in the way that elective surgery (in the fit & well) can be - and is. I guess my point being that, er, "lost_nurse senior" knew full well what he was doing - and why. It's rather crass to put it down to state indoctrination and his apparent inability to understand basic marketing skills.

For sure, there are broader issues about the NHS and medical training - but I agree entirely that NuLab has wasted valuable investment in time and money. Given the present shortages in acute care, it's utter madness that the UK is losing rookie medical staff. But it is not surprising.

ps. re: sticking with the job... it's none of my business, obviously, but I was rather struck that said junior doc was looking forward to being a management consultant. He will probably end up being seconded to DoH (shudder).

Anonymous said...

ps. I meant to add:

"Times have changed since your humble Devil was offered—after interview—three B grades to get into medicine..."

There's still time to become a nurse. And "Memoirs of a burger flipper" suggests that you'd be pretty good at it. Join us...

Hear that, Dr Crippen? :)

Anonymous said...

i am just wondering where medical undergrads sign up to worship the NHS ?

surely, if trained medics go off to do something else, this is the market operating and a good thing ? Why should we see a job in the NHS as the source of all salvation ?

strikes me there are a number of folx who have left medical careers and done rather well elsewhere...

Henry North London 2.0 said...

In order to get registered by the GMC you have to do 12 months in the NHS

A lot of people get disillusioned in the first year because as a student you are treated like royalty the moment you become a junior house doc you are the last of the slave labour

Time was I earnt less out of hours than the cleaner on an hourly rate

My initial take home in 1994 when I qualified was £1000.89 I used to work an average of 82 hours a week for that. You do the maths its now less than the minimum wage or not very much more than it now.

Anonymous said...

I'm in NZ where there is socialized medicine- but Jim, not as we know it! It's a world class health system, no fault compensation for patients so they always get a pay out if something happens even if it's not the docs fault, and the docs can't be sued and dragged through the mud so morale is high. Working hours are sweet, salaries good in the public system, and waiting lists? Nope, not here. Training is excellent and employees are valued. They even reimburse your MPS membership and Medical Council Registration fees! socialised medicine does not have to be all bad-it works here reall really well.

Roger Thornhill said...

lost_socialist: "The poor have dignity too..."

What sanctimonious shite.

Oh, so you think they do not, or that I am being disingenuous? What is sanctimonious about the truth? Have you SEE IT WITH YOUR OWN EYES? I have. I sat alongside people who paid a fraction of what I did to see the very same doctor because he chose to donate his time TO THEM. He chose to give, not the government who chose to tax me to pay him for it.

I suspect you prefer the latter. The real sanctimony is the idea of redistribution by coercion and force to give the pretence of benificence.

Anonymous said...


Give me a break, you victorian ideologue. Across vast swathes of this world, "the poor" often die for want of cheap drugs and inexpensive treatment. Not because they didn't get the chance to queue for Dr Kindheart from Harley Street.

Roger Thornhill said...

Give me a break, you victorian ideologue. Across vast swathes of this world, "the poor" often die for want of cheap drugs and inexpensive treatment. Not because they didn't get the chance to queue for Dr Kindheart from Harley Street.

And in the UK and other Socialist hell-holes people die too, rationed and 'normalised' by a state imposed monopoly.

It has nothing to do with 'victorian' - what an absurd label. Explain why you think such a term has any basis in fact. I note your envy and class hatred swipe at Harley St, btw. My wife had to go there to get a check done because of NHS rationing, but we could only afford a not-for-profit registered charity doing extensive and highly regarded research in the area in question. In the UK, we were in our own turn "the poor" who got the benefit from someone who could have charged us 10x what they can.

So, you cannot accuse me of "ideologue" either. I have seen it from both sides of the coin and also as I am not imposing my ideals onto others, just explaining the ideals other free people practice for themselves. Again, you appear like someone who can't stand that, but want YOUR ideals thrust upon all others by force. If there is an ideologue here, it is not I.

Anonymous said...

I note your envy and class hatred swipe at Harley St, btw.

Come off it - "Harley Street" is universal shorthand for private practice. And I'm all for charity - whether it be MSF, cancer research or Great Ormond St. Nor I am ignorant of this country's pre-NHS heritage. But heady talk of the marvellous gift of giving is often so much (thin) cover for political diatribe.

Lumbering as the super-structure is, please explain to me why NHS emergency and critical care should be dismantled - today, right now - in exchange for doffing one's cap to the super-rich in the hope that a few antibiotic-saturated crumbs fall from the table. That's pretty much the impression I got from your first comment - which was couched in bizarrely sentimental language about what it means to be a member of the dignified poor*. I'm not entirely sure what's relative about it - "poor" means dying from pre-eclampsia because you can't even get hold of magnesium sulphate and simple IV fluids.

*It has nothing to do with 'victorian' - what an absurd label.

The rich man in his castle,
The poor man at his gate,
He made them, high or lowly,
And ordered their estate.

To be fair, I was pretty angry when I replied. I suspect we clash less than you might think - but that's the internet for you.

Roger Thornhill said...

That's pretty much the impression I got from your first comment

Then you were utterly mistaken.

I will refrain from replying to all the various class war, victoriana, dismantling etc. as it is based I suspect on your misunderstanding, but I leave you with this:

I wonder how rapidly you'd complain if healthcare professionals are not respected? I'd wager you complain already and rightly so. We see armies of the undignified crashing into A&E, hogging the resources. Far from doffing a cap or even giving respect, you and your colleagues get sworn at, spat at and sometimes lamped into the bargain.

It is a basic human psychological truth that things given for free with no strings are rarely appreciated, often taken for granted and aggressively so. The NHS is not reformable, as it is systemically dysfunctional.

Anonymous said...

Far from doffing a cap or even giving respect, you and your colleagues get sworn at, spat at and sometimes lamped into the bargain.

Maybe so - although I have to say that I've taken more punches from confused patients than any other demographic. The best placed being from an 88 year old ex-bantam weight champion boxer.

Henry North London 2.0 said...

I have to stick my two pennorth in here

I have worked in the forensic setting

There the respect for doctors and the amount of courtesy given by those people locked up is immense in fact when I was working on a private medium secure unit for the mentally disordered offender I used to hear Good morning Doctor good evening doctor

Things that I hadnt heard in the NHS

It made me stay in medicine because my faith in human kind was restored

I may as well add that in ten years of practising Psychiatry and coming up to 11 in March I have never had a patient suicide on me whilst at work or under my care. Nor have I ever been hit by a patient.

Take from that what you will but I tell you respect given really can make a difference to your life

The NHS has none and gives none

I remember my colleague who had been an English teacher before coming to medical school and becoming a houseofficer saying to me they treat me like dirt This wasnt what I expected I got better treatment from the kids

He had to have a month off with stress

The NHS certainly needs a damn good overhaul

Anonymous said...

What an interesting set of comments! Thanks for bringing my original post to a wider audience, DK. It seems to me that even the most widely-separated views here could be accommodated if the BMA did its job of representing the profession and campaigned to remove the restrictive practices which prevent doctors from qualifying other than via the NHS. Even failing that, these talented young unemployed people could surely go abroad to complete their training and then return directly into private practice? The alternative: a massive waste of talent seems to me quite shocking.

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