Private Pay Beds. NHS Hospitals, England and Wales, 1950-68 Analysis of benefits paid, Hospital Contributory Schemes, 1968 Page 4 10 14 Number of new subscribers, lapses and net change. BUPA, PPP 14 Number of subscribers joined under individual and group schemes 15 Subscription Income Group and individual subscribers BUPA, PPP Age and social class composition. B UP A membership sample 16 16 18 Foreword This broadsheet is the result of a short study of the private sector of medical care, sponsored by the Department of Health and Social Security and undertaken by PE P. No s The aim of the study was to estimate the size of the private sector, its rate of growth and its scope in relation to the public sector, and to Priva explore the relationship between the two sectors and examine various hypotheses that have been put forward in public debate on this issue. Although the scope of the study did not allow for original research the data which have been obtained and their assessment provide enough that is new to encourage PE P to publish the results in this broadsheet. The work was undertaken for PEP by Mr. Michael Lee. He is a consultant economist and a member of the editorial board of the Office of Health Economics, formerly its Deputy Director. PEP and Mr. Lees are indebted to individual members of the medical professions and the BMA for their advice and assistance, to the executives of provident schemes, and to members of the administrative staff in the Hospital Service and the Department of Health and Social Security. I The Private Sector No sharp dividing line separates the private from the public sector of medical care. These two facets of comprehensive medical care intermingle.1 Simple changes in definition can produce wide difference in estimates of the scope, size and growth of the private sector. A working definition of the private sector is a first requirement. *Private expenditure The commonplace division between the public and private sectors is in terms of expenditure, where the private sector entails direct personal spending as distinct from the drawing on public funds. This simple distinction, however, does not carry analysis of the private sector of medical care far. There are first, many areas of direct personal expenditure on medical items, which fall outside the formal structure of medical care, yet may be significant in a comprehensive definition of private medical spending. The largest item is personal expenditure of non-prescription household medicines, which in 1968 totalled some £88m, rising from £45m ten years earlier.2.3 A comprehensive definition of the private sector could well include this expenditure-as its largest part-although there may be dispute about the appropriateness of allocating this as part of medical care. Whatever the merits of the broad argument, expenditure on household medicines aptly illustrates the problems of definition particularly in the way public and private expenditures on medical care can inter-relate, and how private expenditure may complement or act competitively with N H S medical care. The use of non-prescription medicines to control symptoms of influenza involves personal expenditure, reducing calls upon the N H S. 1 Mencher, S., Private Practice in Britain, Occasional papers in social administration, Number 24, Bill, 1967. 2 There exists an interesting parallel here to the growth of the private sector of medical care generally. Originally, it was expected that, with comprehensive NHS facilities, both would wither away. 3 Without Prescription, Office of Health Economics, 1968. 1 It is officially recommended policy during epidemics to free the general practitioner for serious cases. A similar pattern exists with chronic minor conditions, like migraine, where non-prescription analgesics supplement NHS prescription treatments. Also, it appears common for most to treat symptoms with household medicines at their first appearance. The general practitioner is consulted when the symptoms recur or persist. In this way, the use of household medicines acts as a sieve for minor ailments, and the substantial volume of personal expenditure here forms a gateway into the formal structure of medical care. Similar examples can be found with other services. The General Ophthalmic Service provides for a unique combination of public and personal expenditure with opportunities for combining NHS sight tests and lenses with private frames. As with the Pharmaceutical Services, the definition of public and private spending is obscured here by the incidence of NHS charges. The total N H S spending on the General Ophthalmic Service reached £16m in 1968: charges to patients amounted to an additional £10m. But beyond this a further £24m was spent by patients on private frames, tests and lenses. In all, the total expenditure amounted to £50m, with £34m, or two-thirds of the total. represented by personal expenditure.' The incidence and the level of charges can affect non-N H S persona spending. A minor medicament, costing less across the counter than the prescription charge, is better bought privately. The charges for the Ophthalmic Services improve the prospects for sales of private frames since the difference between NHS and private purchase is reduced Similar consideration may apply to the charges made for NHS Dental Services. The interaction and the problems of definition of private and public expenditure on medical care reach further to involve less direct costs A domiciliary confinement results in different amounts and divisions of cost between the public and private sectors compared to hospita confinement. The cost of subsistence at home falls in the private sector whilst identical items in the hospital, assuming it is not a private bec are public sector costs. Throughout the range of patient care, construction of a precise ard meaningful definition in terms of sectoral expenditure poses difficul problems. Private resources The alternative is to distinguish the sectors with regard to the resources or the supply of medical care. But, here too, the problems of definition are extensive. 4 • Ophthalmic Service, Office of Health Economics, 1970. |