Private inpatient psychiatric care A two tier system is developing in Britain Private inpatient psychiatric care for profit is a bull market. Over the past five years the number of acute private psychiatric hospitals has doubled to 34 and the number of beds has trebled to 2054.' 2 The Priory Hospital Group, a United States company, entered the British market in 1980 and is now the largest provider of private psychiatric beds. Its operating surplus has risen by 130% since 1984.2 Although there are still just more voluntary non-profit beds than private for profit beds, all of the recent entrants to the market have been for profit organisations.2 The trend is towards smaller hospitals catering for what are seen as "market niches"-for example, eating disorders, impotence, alcohol or substance abuse, and stress reactions. Few people are benefiting from these changes-only the minority (11% of the British population) with private health insurance3 and those who can pay fees directly. Even among the most commonly insured group-middle aged professional men-only one third have cover. But even for this minority cover is limited. The growing range ofinsurance policies often exclude treatment for psychiatric disorders and those of alcohol and drug abuse, especially when they are long term.4 The British United Provident Association does not cover preexisting conditions; the Private Patients Plan has a low premium for its family health plan that excludes psychiatric care; Western Provident pays for only 28 days in any five year period; and Bristol Contributory Welfare excludes treatment of alcohol or drug dependency. The minority is also defined geographically: two thirds of private psychiatric hospitals in England are sited in the four Thames health regions, which contain under a third of the population.25 Evidence for the efficacy of psychiatric services (both private and public) is lacking. Unfortunately, neither private nor public psychiatric hospitals issue enough useful information on recovery rates to allow direct comparisons between different settings. In their absence consumer choice depends more on impressions of the care provided than on any evaluations of outcome. Private providers market comfort, convenience, and privacy; reduced waiting times; more intensive treatment; and respect for the patient. All these are qualities that could be improved within NHS facilities.6 Some of the predictable effects of increasing the availability of private inpatient psychiatric care have already become clear in the United States. One is that deregulation can both stimulate private growth and lower standards of minimum care. In the United States responsibility for service provision is moving to the private sector, which has more than trebled its market share to 35% over the past 15 years (compared with 6% in Britain). The most rapid growth has been in states that have relaxed inspection of the quality of care.7 8 Furthermore, many private hospitals have no contractual control over consultants' renting office facilities, the consultants being neither employees nor responsible to an ethical committee. Private hospitals usually fragment care by transferring patients with chronic diseases who are relatively expensive to public hospitals.' And multihospital corporations (which now own three quarters of private beds in the United States) are reported to be less responsive to local needs.8 Britain can expect to follow the same path. The white papers on hospital and community services9 10 encourage 892

pluralism in service provision at a time when the number of NHS psychiatric beds is being reduced." Business analysts are identifying "growth opportunities" for an expanding private sector, both in tendering for NHS contracts and in providing separate services.2 Properly managed contracted out services can offer facilities that are poorly provided by the NHS -for example, for young patients with brain damagebut if separate services proliferate on the open market this may raise problems. They are likely to cater mainly for that minority of patients who are voluntary, are insured, have acute conditions, and are from the home counties.'2 Long term patients and those compulsorily admitted will probably continue to occupy less than 10% of private beds. 2 Moreover, despite encouraging exceptions'3 most private hospitals will continue to enjoy indirect subsidies by employing staff largely trained within the NHS and will also fail to invest adequately in research.8 Demand is not synonymous with need, as the demand for cocaine shows. The strength of a market in health care is that it will respond to consumer demand. Its weakness is that it may offer perverse incentives to deliver excessive or inappropriate services. Indeed, many people with psychiatric problems are particularly disabled in choosing care appropriate to their needs. Another difficulty is that those with a long term or frequently relapsing condition may soon reach their insurance limits and become ineligible for further reimbursement; and their disorders may cause downward social drift to the point where premiums are no longer affordable. Such patients are often likely to require local services with continuity of care rather than contracted out services at distant sites. Private facilities have no overall responsibility for providing comprehensive care for the population within a defined catchment area. The bull market in private hospitals is threatening the catchment area concept and seems to be producing a two tier system of psychiatric care in Britain. ISAAC MARKS Professor of Experimental Psychopathology GRAHAM THORNICROFT Honorary Lecturer

Institute of Psychiatry, London SE5 8AF 1 Fitzhugh W. The Fitzhugh directorv of independent hospitals and provident associations financial infi)rtnation 1987. London: Health Care Information Services, 1987. 2 Fitzhugh W. The Fitzhugh directorv of independent hospitals and provident associations finiancial

infortnation 1989-1990. London: Health Care Information Services, 1989. 3 Griffith B, Rayner G. Commercial medicine in London. London: Greater London Council, 1985. 4 Anonymous. Insurance coverfor psychiatric conditions. London: Independent Hospitals Association, 1990. 5 Anonymous. 7he directory of independent hospitals and health services 1988-89. London: Iongman, 1988. 6 Wilkinson G. Psychiatry: private and public provision. Br Med 1988;2%:479. 7 Laing W. Laing's revziew of private health care. London: Laing and Buisson, 1988. 8 Dorward R, Schlesinger M. Privatisation of psychiatric services. Am 7 Psychiatry 1988;145:543-53. 9 Secretaries of State for Health, Wales, Northern Ireland, and Scotland. Working for patients. ILondon: HMSO, 1989. (Cmnd 555.) 10 Secretaries of State for Health, Social Security, Wales, and Scotland. Cartngfior people. CommuntOt care in the next decade and beyond. London: HMSO, 1989. (Cmnd 849.) 11 Thornicroft G, Bebbington P. Deinstitutionalisation: from hospital closure to service development. Brj Psvchtatrv 1989;155:739-53. 12 Brandon S. A subversive foray into prisate practice. Bulletin of the Roval College oJ I'svchiatasts 1987;11:23-4. 1 3 Kelly D. Private sector psychiatric services. Bulletin oJ the Royal College olj 'svchiatnsts 1989;13: 199.

BMJ

VOLUME

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7 APRIL 1990