The major physical resource for medical care constitutes hospital ds. At the formation of the NHS some 300 hospitals, mainly small, mained outside the Service. These hospitals, many of which strictly Peaking were nursing homes, were predominantly run by religious ders or linked to special bodies or institutions such as the Royal asonic Hospital. Although precise figures are not available over a ng period, it appears that their number has declined. The largest of ese private hospitals, although by definition in the private sector, ovide medical care in some beds for NHS patients under contract #th Regional Hospital Boards. The major resource for private practice, Owever, are beds in NHS hospitals designated for private treatment nder Section 5 of the 1946 Act. The number of staffed beds allocated nder this section totalled 6,402 in 1950 (England and Wales), falling 5,595 by 1960 and to 4,424 by 1968, a decline of 25 per cent over the years. Occupancy rate by paying patients, however, was low in the arly years: the average daily number occupied totalled 2,801 beds in 955, and 2,787 in 1960, falling to 2,689 by 1968 (Table 1). In that year, e figure represented no more than 0.70 per cent of the total average aily number of all N H S hospital beds. The central point with pay beds that so far as the supply of medical facilities is concerned, the private and public sectors are institutionally linked.

The status of physical resources for the supply of medical care outde the hospital service is even more difficult to disentangle. The eneral practitioners' premises although servicing the NHS patient re a resource in the private sector, similar to the retail chemists' harmacies. However, loans and grants for improvement of the surgery re available from public funds. If the general practitioner functions in group practice based on a health centre, the facilities are provided holly from public funds.

The principal resource in medical care is formed by the body of ualified manpower. The medical professions do not divide into distinct ublic and private sector groups. With general practitioners only about ne-third practise exclusively in the NHS without any private patients." The remaining two-thirds have private patients but rarely more than 20 ach. Only one in twenty general practitioners have over 100 private atients. This pattern appears stable with little change over the years." Vithin the hospital service medical staff, consultants particularly, divide heir time between NHS and private patients. Precise figures are not vailable on the extent to which this occurs. The division of time by

5 Section 5 of the 1946 Act was subsequently replaced by Section 1 for private inpatient and Section 2 for private out-patient treatment of the 1968 Act. The old erminology 'Section 5 beds' still persists in general use, however.

Cartwright, A., Patients and Their Doctors, Routledge Kegan Paul, 1964.

Mencher, S., op. cit., review of studies, p. 16.

doctors in either hospitals or general practice again illustrates the intermingling of the sectors. It also raises problems of measurement. Common practice is to separate the sectors on a time basis. However, it is as logical to divide the sectors on a case load basis. From this, differences in estimates can arise depending upon which method is adopted.

Beyond the formal structure of medical care, there exists a variety of resources which could well be included in the scope of private care. The situation is similar to that with personal health expenditure. A major concentration of resources is found in industry with the facilities ranging from simple first-aid kits to industrial health centres with qualified nursing staff and a few with full-time qualified medical personnel. In addition, there has been a growth in recent years of specialised health facilities in the private sector, either linked to particular sectors of the community, such as the Institute of Directors, or providing new aspects of care such as automated screening. There are also disease group clinics linked to charitable private research bodies like the City Migraine Clinic operated by the Migraine Trust. These organisations illustrate the extent of the problem of measurement and definition of the private sector in terms of supply.

Opting out of the NHS

It is difficult, therefore, to provide satisfactory definitions of the private sector which embrace all its facets and distinguish it satisfactorily and meaningfully from the public. Recent concern and discussion of private medical care have, however, concentrated upon a specific narrow area of the private sector, particularly the area and process embodied originally in Section 5 of the 1946 Act.

To analyse the issues involved, it is necessary to adopt an empirical definition of the private sector which differs from the conventional distinctions in terms of expenditure or supply.

The main concern has centred upon specific issues such as the usage of pay beds and their availability, the division or diversion of consultants' time between the NHS patients and those who pay, the speed of admission to hospital, and the prospect that dual standards exist or may emerge in treatment of patients with similar

conditions.

The heart of the matter lies in a patient's opting to pay for a service which is otherwise and more commonly provided under the NHS. For present purposes the private sector can be defined in these terms, as arising from a decision or series of decisions by the patient to opt out from the National Health Service for a medical episode and so paying for medical care, more commonly provided under the NHS. It is a narrow definition describing a behaviour pattern or a decision not to

use the N H S. It differentiates a minority who decide for any of a wide variety of reasons not to use the NHS for part or whole of a specific medical episode.

It is necessary to examine the process of opting out, or deciding not to use the NHS in detail. Its profile tends to follow these lines. Initially before and apart from any specific medical episode a decision is made to make financial provision for opting out if the need arises. This decision underlies the growth and development of Provident Schemes. In the past, the decision depended much upon individual initiative and attitudes. Increasingly, however, the provision to opt out arises from employment status and fringe benefits, in a similar fashion to occupational pension schemes.

With the occurrence of a medical episode symptoms are presented to the general practitioner, normally under the NHS, although the option for private care may be exercised from the start. The condition may be capable of treatment at this initial stage and the medical ep sode closed without the question of private practice arising. Alterna tively, the condition may need referral to a consultant, opening up the main point of decision to opt out of or to remain within the NHS Depending upon a wide variety of factors including the nature of the condition and likely treatment costs relative to insurance cover, the patient opts for private or NHS care. With the former, a series o options remain for different aspects of care, such as for x-ray, labore tory services and subsequent post-operative domiciliary treatment to produce a combination of N H S and private medical care. Regulations place some limit over the extent of these combinations within the hos pital services. The one specifically excluded by Section 38 of the NHS Act is for private general practitioner treatment and NHS pharma ceutical supplies. During the course of any medical episode, sinc patient care is the paramount consideration, if the condition worsens c recurs and possible costs mount, the option always remains open revert back to NHS treatment.

The private sector of medical care therefore does not constitute distinct and separate population or group within the community. The option to move out of or back into the NHS may be exercised for eac episode as it occurs and at different stages of each episode. The NH provides unlimited cover and bears all risks: the private sector repre sents an option to leave the NHS for a given episode or part of a medical episode. The growth and nature of this process, and implications, are the main concern of this study.

Abortions are excluded from the definition, and the growth of this procedure not reviewed here. Its examination is more properly a subject for social medicine th for economic analysis of the private sector of medical care. (A forthcoming PEP broadsheet will present the findings of a survey of women who have experience abortions, and review the working of the Act.)

II Scope and Size

The financial institutions which support the private sector provide the best source for review of its scope, growth and size, since their perations constitute the major source of continuous and comparable tatistics. But even so, their coverage is partial. The individual who pts out of the NHS and finances private treatment wholly from ersonal expenditure is excluded. At this stage, it is difficult to assess he extent of this behaviour, but for major items, given the recent rowth of provident schemes, it is unlikely that many now remain ninsured for major private sector treatment. Incurring of costs against ersonal income would itself provide a strong incentive to insure in the uture. It follows, however, that some part of the growth of private nedicine schemes includes a transference from individual to insurance isk bearing.

The function and development of the insurance systems for the rivate sector can best be reviewed following the natural sequence of atient care from the general practitioner to the hospital and specialist ervices.

General practice

nsurance schemes providing financial support for private treatment in eneral practice have had a chequered history. The main provident nstitutions offer insurance for this aspect of private treatment, but articipation in these schemes is low. Few subscribers to the large rovident associations, little more than one in twenty, cover for private eneral practitioner costs. Also, it appears that only the same proortion of the public at large would seek private general practice if they ould afford it."

The principal institution which sought to specialise in coverage of eneral practitioner private treatment costs was originated in 1965, nitially under the sponsorship of the British Medical Association

'Cartwright, A., op. cit., p. 11.

7