Boom in private healthcare piles pressure on GPs
BMJ 2022; 379 doi: https://doi.org/10.1136/bmj.o2115 (Published 06 October 2022) Cite this as: BMJ 2022;379:o2115
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Dear Editor
Sally Howard raises important issues, particularly regarding private assessments for ADHD. As an NHS GP, and a psychiatrist who ran an NHS ADHD service, and executive members of the UK Adult ADHD Network (1) we feel we must respond.
While it is important to resist the transfer of inappropriate work from secondary (private or NHS) to primary care, it is unfair to imply that patients seeking care for ADHD are similar to those having ‘commercial’ health checks or treatment for ‘minor conditions… such as warts and lumps and bumps’. ADHD is not an optional inconvenience -- it is often serious: untreated ADHD is associated with a 12.7 year reduction in life expectancy(2). This is similar to the impact of Type 2 diabetes in middle age.
Many patients who realise they are likely to have ADHD can see the damage it does to their education, employment, relationships, finances, etc. It is not that they can afford the luxury of seeking private treatment: it is that they cannot afford to wreck another year or two of their lives untreated. Many patients with undiagnosed ADHD are already receiving care for anxiety, depression, functional disorders, etc. that would be more effectively treatable if the ADHD were recognised and managed. There is potential for NHS services to benefit from these patients getting the correct, and hence more effective, treatment.
Hannah Short is correct that the transfer of care between secondary and primary care is maladaptive, but due to inadequate resource in both primary and secondary care. No GP would complain about a private (or NHS) provider asking them to follow up a patient with new Type 2 diabetes. GPs receive some payment to manage diabetes but not to monitor treatment for ADHD. The primary care contract and its inadequate funding are one of the problems; GPs should not blame the patients for having ADHD, or the specialists who diagnose it. The long waiting lists for NHS assessment are another major problem, discussed with potential solutions, in our recent UKAAN paper(3).
‘Shared care’ agreements are a misnomer -- care is effectively ‘dumped’ on the GP without resources to provide it. Care may be clinically appropriate but is contractually difficult. This is not unique to ADHD: it happens for coeliac disease, Graves’ disease and others. Most GPs accept that some of their work is unfunded, but as total workload grows unsustainably, GPs are more likely to resist additional unfunded monitoring. GPs may be less familiar with ADHD; more patients may receive a diagnosis privately because of the paucity of NHS services for ADHD; ADHD medication may seem expensive compared to prescribing budgets. However, treating ADHD is cost-effective(4), and often rewarding because patients’ lives can dramatically improve. What matters is deploying scarce NHS resources cost-effectively and equitably, and allocating resources to those best placed to provide appropriate care, so that they can. We should not deny patients effective care because they have used private care previously.
1) See https://www.ukaan.org/
2) Barkley RA & Fischer M, Journal of Attention Disorders 2019, Vol. 23(9) 907–923
3) Asherson P, et al BMC Psychiatry. 2022 Oct 11;22(1):640
4) Dijk HH, et al. J Child Adolesc Psychopharmacol. 2021 Nov;31(9):578-596.
Competing interests: Both authors serve on the executive committee of UKAAN (see https://www.ukaan.org/meet-the-executive-committee.htm)
Dear Editor
In his reponse, Santhanam Sundar compares private health screening to routine screening offered by the NHS such as the NHS Healthcheck.
But there is a key difference. While one could argue over the evidence base for the NHS Healthcheck, at least the Healthcheck measures a small number of variables (hba1c, BP, cholesterol) for a clearly defined purpose - that of cardiovascular risk estimation.
There is typically no such clarity of purpose to the bloods offered as part of private screening. I have had patients referred to me by private providers who have identified borderline abnormalities of LFTs, blood count indices, CRP and B12. None of the patients had any clinical features which would have justified testing.
Each of these results causes a dilemma: am I willing to accept the clinical risk of reassuring the patient that these deviations are unlikely to be of any significance? Or am I going to use NHS resources in investigating them further... or worse, in the case of B12, instigating a lifelong treatment programme that is probably unnecessary.
It is hard not to resent the fact that the private company is getting paid to provide this "service" while the NHS picks up the downstream costs.
Competing interests: No competing interests
Dear Editor
The article raises important concerns about Private Healthcare but it is slightly imbalanced as it does not look at the issue from a patient’s perspective. [1].
Firstly, the private health screens are nothing new and they have been offered by corporate employers for decades. Many General practices, in pre-endemic era, offered well-man and well-women checks. These private screening tests are not dissimilar to the well-man and well-woman checks widely offered by the GPs in the recent past.[ 2].
Secondly, Patients who self-pay for private healthcare are often quite desperate. They do not part with hard earned money on a whim. The access to General Practice seems to be universally poor now. Patients are absolutely fed up with the fobbing off by overworked receptionists. Even patients with confirmed cancer wait for many many weeks to have scans done as radiology departments are overwhelmed by increasing demand.
It’s time the medical profession tries to find or propose equitable solutions within the existing funding model rather than waiting for the political masters to impose a top down solution. Overt rationing is far better than the current system of promising everything and then resorting to covert rationing of waiting lists and indiscriminate access blockage. Because patients are so fed up and frustrated with the existing primary care model, the public may be easily persuaded by politicians to try a new system of care that may not eventually bode well for the long term future of NHS .
Finally, Doctors are there to meet the needs of the patients; not the other way around. While some doctors might flinch at the thought of patients being viewed as customers, many patients do expect a prompt service that meets their needs as a customer.[2].
References
1. Howard S. Boom in private healthcare piles pressure on GPs BMJ 2022; 379 :o2115. doi: https://doi.org/10.1136/bmj.o2115 (Published 06 October 2022)
2. What is an NHS Health Check? https://www.nhs.uk/conditions/nhs-health-check/what-is-an-nhs-health-che... (accessed 12/10/22).
3. Costa DSJ, Mercieca-Bebber R, Tesson S, et al Patient, client, consumer, survivor or other alternatives? A scoping review of preferred terms for labelling individuals who access healthcare across settings BMJ Open 2019;9:e025166. doi: 10.1136/bmjopen-2018-025166
Competing interests: I work in a NHS Hospital and in the private sector. Multiple family members are General Practitioners
Dear Editor
The authors highlight an important aspect of the increase in private health care post pandemic in the face of a health service that can hardly be said to have survived. Namely, the knock on effect on other healthcare professionals, especially GPs.
The patient’s GP remains pivotal in the safe provision of all health care to their patient by ensuring private procedures are recorded in the patient’s NHS health record and ensuring the private consultant is aware of the patient’s past medical history, as they would with an NHS referral.
However, in Bristol, GPs refuse, quite rightly, to remove sutures and provide direct NHS aftercare for private surgical episodes, including ‘routine’ prescribing. That is, quite rightly, part of the private episode of care, especially for the immediate aftercare of surgical patients, which should be provided privately by the private consultant and the private hospital. That is, unless the GP has agreed at the outset of the episode of care to provide their practice’s NHS care for the patient. If not, GPs appear to have the absolute right to politely decline such requests from the private consultant and should do so. It is, indeed, inappropriate for private consultants to use hard pressed GPs as their junior staff, as suggested by one contributor.
Yours faithfully,
Nigel Mercer
Competing interests: No competing interests
Re: Boom in private healthcare piles pressure on GPs
Dear Editor,
We would like to add comment to the author’s findings as a provider of proactive health screening programmes to businesses in critical industries.
The article states that the number of corporate employers offering health checks is on the rise, with “four in 10 jobs advertising private healthcare as an employee benefit.” Businesses taking responsibility for their employees and investing in their health is a welcome development at a time when the UK’s workforce is statistically the sickest in the developed world. Encouraging companies to take a proactive approach to health in the workplace will lower demand on the NHS and provide (part of) the answer to its long-term sustainability.
However, in the short-term we recognise that the private sector can do more to take the strain off our primary care colleagues. Yes, there will be a slight spike in people seeking care - publicly and privately - as we transition to active screening from a retrospective health model but what is key is how we manage that spike.
For example, before a company offers a private healthcare plan to its employees, there must be proactive engagement to ensure the local primary care network that may receive follow ups, is properly briefed. The creation of Community Health Programme Boards around the UK will aid this communication by bringing together employers and private testing companies with representatives from primary and secondary care, local councils, and charitable organisations.
This level of public, private and third sector collaboration, can also reduce GP workloads through the alternative non-clinical referral pathways offered by a Board e.g. third sector support services, social prescription services and ancillary services with local trusts. The health journey shouldn’t stop at the health assessment; rather, it is looking at sectors, both locally and digitally, that can provide the individual with the resources and support to facilitate their care.
For many operating in the private sector, it is not about “offering reassurance” to “the affluent” for financial gain but finding ways to unite health providers at a local level and reinvesting profits into local communities to address health inequalities.
Competing interests: No competing interests