PMI or private cover? Should GPs ask patients if they have private health insurance? Putting the patient in front of you at the centre of your concern – includes asking about attitudes to non state options..

“Would you like to discuss non state provided options?” This, or a similar question SHOULD occur more frequently in many doctor consultations.. in Hospital or the Community. It is only in emergency care that the private provision is lacking, and in cities this is changing..

It is concerning if a colleague rejects to offer or to even discuss or offer options outside of the Health Service locally. The first duty of a doctor (GMC) is to “put the patient at the centre of your concern”, and this makes no reference to the state provided health services. Your duty is not primarily to the state, and where the interests of the state and the patient differ, a doctors duty is to their patient. It may be a GP aware of long waiting lists, or an oncologist aware of treatment exclusions – and covert rationing.

And the patient has also got the choice to pay directly. Monthly payments of £300 amounts to nearly £12,000 over 3 years, which covers most joint replacements and a lot of physiotherapy. Just because somebody looks poor, or lives in an impoverished area, does not mean their doctor should assume that they have no savings or insurance. Increasing their options with an honest discussion could be good for their health. Telling the truth is a virtue – even if it includes saying a patient is obese.

Putting the patient in front of you at the centre of your concern includes asking about PMI  (Private Medical Insurance) or direct payment if the local service puts them at risk. It does not imply that the doctor makes the choice as to whether to use said insurance (what is the excess? )or to pay directly.

What is shameful is that for 60 years only 10% of the population chose to have PMI, but in the years ahead it may rise well above this, and a two tier system will become de facto.

If patients ask you for recommendations that is another matter. You might refer them to a broker, or to Benenden which promises to cover everyone (but with important exclusions including heart disease and cancer). Benenden advertises at £8.71 per month per person!

There is no harm in asking. The decision to pay is different to asking the question, and being honest about ALL the options is part of the duty of a doctor. You might also wish to point out the difference in the Perverse Incentives: to undertreat in the one system, and over treat in the other.

Fortunately, as yet, different Post Codes are not being charged different premiums, but they may be. Where there is less choice there should be more demand for private services (Wales) and premiums here may rise.

As communities realise the deficit in their potential care, they could group together. PMI is much cheaper for groups and communities. Perhaps a whole town may decide to have a policy. Once again this will favour the richer suburbs., and increase the health divide. But at least they would all know what was excluded, unlike todays covertly rationed health services.

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Charlotte Alexander asks in Pulse 27th October : Should GPs ask patients if they have private health insurance?

YES

I do not see anything wrong with asking patients whether they have private insurance if it helps to create some much-needed slack in the NHS. A recent scheme in Mid-Essex has seen private referrals increase by 6% since the start of the year, which suggests that health insurance is being underused. It may be that people forget to use it or have a ‘no-claims bonus’ attitude towards it, resulting in a pick-and-mix approach to the NHS. Whatever the reason, I do not think most would object if they were gently reminded that they could see the most senior person available more quickly if they did use their cover.

I know some people think this is an inappropriate way to try to save money, but with a dwindling pot can we afford to be so high-minded? Which is worse, trying to increase uptake of health insurance with those fortunate enough to have it, or having to save money by banning non-urgent procedures such as vasectomies, sterilisations and ear syringing?

Some people have said it puts unfair pressure on patients to refrain from using NHS services that are within their rights, but GPs could exercise judgment about who to ask. For example, for those who have used private healthcare before, it is not a huge leap to ask them whether they would like to again. Premiums may go up as a result, but the person will choose to pay it or not. It is not denying them care they are entitled to, it is offering them a choice to use NHS or other services, like the choice between a state or a private school for their children.

Some say that asking patients about their private healthcare insurance compromises the impartiality of the consultation. Actually, we already do that with the QOF, prescribing certain medications because they are cheap and having personal stakes in private companies providing NHS services.

People will also say that this approach lets the Government off the hook as it will continue underfunding the national system. This may be true, but what is the alternative when there is no extra money? While we are living in this time of unfettered corporatism and very high societal inequality I see nothing wrong with redressing this slightly by asking people to use their insurance if they can. The NHS is staggering under the weight of demand and cost cutting. Unless we do everything we can to preserve the cash flow, it won’t get up again, even after multiple infusions.

Dr Charlotte Alexander is a GP in Addlestone, Surrey

NO

On the surface, asking patients about private healthcare insurance may appear to be a positive move; I am sure I’m not the only GP who finds themselves apologising for ever-increasing waiting times for outpatient clinics and elective operations. However, not only are GPs constantly apologising for problems that are beyond our control, we are now being put in the difficult position of asking patients to forfeit the NHS care they deserve as much as the next person. This could potentially put the patient-doctor relationship at risk, and could even jeopardise a doctor’s ethical or moral standing if the patient disagrees with the principle.

It could be suggested that encouraging patients to use their private insurance will take pressure off NHS waiting lists by filtering some patients out. But in reality, it creates a two-tier system, further broadening the gap between the rich and poor and exaggerating health inequalities. While those who can afford either private care or health insurance will find themselves being seen and treated quickly, others who rely on the NHS may be at risk of their health conditions deteriorating while they wait ever-increasing amounts of time.

Asking about private health insurance would also produce geographical health inequalities. Affluent areas will benefit more, not only from a larger number of the population accessing private care, but from the higher number of patients filtered out of NHS waiting lists, freeing up more appointments and improving services in the area. But conversely, in deprived areas, where fewer people have access to private healthcare, NHS waiting times will continue to remain above what is acceptable, further widening regional differences in care.

A final issue is that schemes such as this free the Government from the responsibility for their funding cuts. The NHS is currently in dire straits, and the solutions lie with our Government and the way it funds the NHS, not with alternative solutions such as pushing patients towards the private system. This merely patches up the system while the Government continues to slash funding to public services. It would be more prudent for local health boards or CCGs to fight for more enduring, appropriate solutions, rather than taking us one step closer to an unfair insurance-based healthcare system.

Dr Rebecca Jones is a GP in Hastings, East Sussex

Putting the patient in front of you at the centre of your concern – includes asking about PMI

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This entry was posted in A Personal View, Consultants, General Practitioners, Perverse Incentives, Post Code Lottery, Professionals, Rationing, Stories in the Media on by .

About Roger Burns - retired GP

I am a retired GP and medical educator. I have supported patient participation throughout my career, and my practice, St Thomas; Surgery, has had a longstanding and active Patient Participation Group (PPG). I support the idea of Community Health Councils, although I feel they should be funded at arms length from government. I have taught GP trainees for 30 years, and been a Programme Director for GP training in Pembrokeshire 20 years. I served on the Pembrokeshire LHG and LHB for a total of 10 years. I completed an MBA in 1996, and I along with most others, never had an exit interview from any job in the NHS! I completed an MBA in 1996, and was a runner up for the Adam Smith prize for economy and efficiency in government in that year. This was owing to a suggestion (St Thomas' Mutual) that practices had incentives for saving by being allowed to buy rationed out services in the following year.

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