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* No letter should be more than 400 words. * For letters on scientific subjects we normally reserve our correspondence columns for those relating to issues discussed recently (within six weeks) in the BMJ3. * We do not routinely acknowledge letters. Please send a stamped addressed envelope ifyou would like an acknowledgment. * Because we receive many more letters than we can publish we may shorten those we do print, particularly when we receive teveral on the same subject.
Private inpatient psychiatric care SIR,-Professor Isaac Marks and Dr Graham Thornicroft in their editorial on private psychiatric health care comment that the bull market in private hospitals is threatening the catchment area concept. ' This concept was not introduced for the benefit of patients but to allow mental hospitals to refuse patients whom they did not wish to admit. In the main it is a way of excluding difficult patients rather than an attempt to provide good care. It is with shame for the health service that I see patients with relatively meagre means spending their hard earned savings in order to avoid the lunatic asylum. (It is a mistake to think that it is only the wealthy who avail themselves of private care or send their children to private schools or, indeed, go on holidays abroad.) It is not unusual for patients to refuse an admission to their local hospital or to discharge themselves after a few hours having viewed the poor conditions and having had their worst fears confirmed on seeing the high levels of disturbance found therein. This dismal picture is being aggravated with the drive to community care and the general promulgation of the view that admission is undesirable and is acceptable only for those with highly disturbed behaviour. In contrast with catchment area psychiatric hospitals, where the criterion for admission is increasingly behavioural disturbance due to psychosis that is not containable in the community and suicidal risk, the reason for admission to a private psychiatric hospital is additionally the notion of treatability in terms of reducing both the length and the severity of distress. Unless the NHS sector changes its philosophy of care there will indeed be a two tier system of psychiatric care, but this will be the result of a poor and ill thought out and managed public service and not of the private hospitals to which patients are increasingly being forced to turn.
The ideology of centralised state control has been rejected even in eastern Europe but evidently still prevails in Denmark Hill. In all, 15% of the population pays out of its own pocket for fees or insurance to cover what the state falsely promises to deliver free. In developing 12 private psychiatric facilities since 1980 I have been astonished to see the proportion of cash paying clients (versus insured clients) soar from 15% to 35% of referrals. You need only to talk to the customers to understand why. They perceive public psychiatric services to be inattentive, uncaring, and-equally important to them and their mental states-unclean. These perceptions defy scientific analysis and are therefore ignored by those academics entrusted with charting the future direction of clinical practice. They are not ignored by either the customer or the marketplace, hence the embarrassing spectacle of an army of 50000 patients each year marching away from free public psychiatric services. There is more to come. Independent psychiatric provision, which doubled in the 1980s, may double again in the 1990s, as reformed NHS services are obliged to expose their true operating costs, which before the white paper were concealed carefully. This may open the floodgates for contracting for long term care, which has hitherto been largely neglected by the independent sector as chronic illness is a costly, uninsurable risk that must inevitably be paid for by the state. The authors are quite correct in stating that a two tier system is evolving; but this is no bad thing. Given fair standards for measuring clinical care and hard figures to assess the financial impact, the NHS's near monopoly position in both acute and chronic care will continue to be eroded. 'rhis will enable the independent sector to serve a broader segment of the population. JOHN C HUGHES
Cygnet Health Care, London SW 13 9LB 1 Marks I, Thornicroft G. Private inpatient psychiatric care. BrMed3r 1990;300:892. (7 April.)
A C WHITE
Queen Elizabeth Hospital, Birmingham B15 2TH 1 Marks I, Thornicroft G. Private inpatient psychiatric care.
BrMedJ 1990;300:892. (7 April.)
SIR,-Professor Isaac Marks and Dr Graham Thornicroft miss the boat when they say: "The bull market in private hospitals is threatening the catchment area concept."' The fact is that independent psychiatric hospitals are meeting the inpatient and outpatient needs of over 50 000 Britons each year precisely because the statist "catchment area" concept has proved unworkable.
1136
SIR,-Professor Isaac Marks and Dr Graham Thornicroft are correct in observing the emergence of a two tier system in the treatment of patients with acute psychiatric illness.' Of the two tiers, I am assuming that they mean that the private tier provides the better service to the patient. In my experience this would be a valid observation. What I fail to understand is, having observed the two tiers, why the article concentrates on the negative aspects of the "better" of the two. Some insurers do indeed limit benefit for psychiatric treatment, though I am not certain how this observation supports the general argument. In point of fact, about three quarters of medical
insurance policies include benefit for psychiatry. The market share of those insurance companies that exclude such benefit is not materially important, though such exclusion is somewhat surprising as the likelihood of being referred to a consultant for a psychiatric problem is over four times greater than a referral for heart disease. Luckily, most citizens seem to realise this and continue to insure themselves against the unfortunate possibility of acute mental illness. I perfectly understand the need fully to evaluate efficacy and outcome. The absence of such a full evaluation does not, however, invalidate the clinical work that is carried out in NHS or private hospitals. In the private hospital one element in determining the efficacy of service, both clinical and "hotel," is the number of patients referred. Clearly, if the treatment offered is below standard consultants admit their patients elsewhere. This is not a choice open to consultants or patients in catchment areas. Many of the lessons from the United States are not strictly relevant here; it is mere assertion to say that "Britain can expect to follow the same path." For example, it may be that private hospitals have flourished in those states that have relaxed their inspections: in Britain private hospitals alone are subjected to external inspection. We now have the bizarre spectacle of health authority inspectors stipulating minimum requirements for private facilities that NHS units in their own authority do not meet. I do not see why private facilities should be responsible for comprehensive care. Health authorities have this responsibility. Surely the role for private hospitals in a catchment area, health district, or whatever arbitrary geographical areas we end up with is that they are there as part of the overall provision. In the future the decision the consultant, general practitioner, and patient will have is whether the referral is to a private hospital or an NHS one. Surely the factors to be considered in that decision are clinical efficacy, comfort, cost, availability, and convenience. Given roughly equal costs between two facilities, one NHS and one private, would it not take a pecularly hairy shirt to recommend a patient is admitted to the "lower" of the two tiers? FREDERICK STAPLETON London SW3 2QW 1 Marks I, Thornicroft G. Private inpatient psychiatric care. BrMedJ 1990;300:892. (7 April.)
SIR,-Economy with the truth is an effective way of drawing opposite conclusions to those that are supported by a more objective view of the facts. Professor Isaac Marks and Dr Graham Thornicroft provide a classic example of this in their editorial on private inpatient psychiatric care.'
BMJ VOLUME 300
28 APRIL 1990
* No letter should be more than 400 words. * For letters on scientific subjects we normally reserve our correspondence columns for those relating to issues discussed recently (within six weeks) in the BMJ3. * We do not routinely acknowledge letters. Please send a stamped addressed envelope ifyou would like an acknowledgment. * Because we receive many more letters than we can publish we may shorten those we do print, particularly when we receive teveral on the same subject.
Private inpatient psychiatric care SIR,-Professor Isaac Marks and Dr Graham Thornicroft in their editorial on private psychiatric health care comment that the bull market in private hospitals is threatening the catchment area concept. ' This concept was not introduced for the benefit of patients but to allow mental hospitals to refuse patients whom they did not wish to admit. In the main it is a way of excluding difficult patients rather than an attempt to provide good care. It is with shame for the health service that I see patients with relatively meagre means spending their hard earned savings in order to avoid the lunatic asylum. (It is a mistake to think that it is only the wealthy who avail themselves of private care or send their children to private schools or, indeed, go on holidays abroad.) It is not unusual for patients to refuse an admission to their local hospital or to discharge themselves after a few hours having viewed the poor conditions and having had their worst fears confirmed on seeing the high levels of disturbance found therein. This dismal picture is being aggravated with the drive to community care and the general promulgation of the view that admission is undesirable and is acceptable only for those with highly disturbed behaviour. In contrast with catchment area psychiatric hospitals, where the criterion for admission is increasingly behavioural disturbance due to psychosis that is not containable in the community and suicidal risk, the reason for admission to a private psychiatric hospital is additionally the notion of treatability in terms of reducing both the length and the severity of distress. Unless the NHS sector changes its philosophy of care there will indeed be a two tier system of psychiatric care, but this will be the result of a poor and ill thought out and managed public service and not of the private hospitals to which patients are increasingly being forced to turn.
The ideology of centralised state control has been rejected even in eastern Europe but evidently still prevails in Denmark Hill. In all, 15% of the population pays out of its own pocket for fees or insurance to cover what the state falsely promises to deliver free. In developing 12 private psychiatric facilities since 1980 I have been astonished to see the proportion of cash paying clients (versus insured clients) soar from 15% to 35% of referrals. You need only to talk to the customers to understand why. They perceive public psychiatric services to be inattentive, uncaring, and-equally important to them and their mental states-unclean. These perceptions defy scientific analysis and are therefore ignored by those academics entrusted with charting the future direction of clinical practice. They are not ignored by either the customer or the marketplace, hence the embarrassing spectacle of an army of 50000 patients each year marching away from free public psychiatric services. There is more to come. Independent psychiatric provision, which doubled in the 1980s, may double again in the 1990s, as reformed NHS services are obliged to expose their true operating costs, which before the white paper were concealed carefully. This may open the floodgates for contracting for long term care, which has hitherto been largely neglected by the independent sector as chronic illness is a costly, uninsurable risk that must inevitably be paid for by the state. The authors are quite correct in stating that a two tier system is evolving; but this is no bad thing. Given fair standards for measuring clinical care and hard figures to assess the financial impact, the NHS's near monopoly position in both acute and chronic care will continue to be eroded. 'rhis will enable the independent sector to serve a broader segment of the population. JOHN C HUGHES
Cygnet Health Care, London SW 13 9LB 1 Marks I, Thornicroft G. Private inpatient psychiatric care. BrMed3r 1990;300:892. (7 April.)
A C WHITE
Queen Elizabeth Hospital, Birmingham B15 2TH 1 Marks I, Thornicroft G. Private inpatient psychiatric care.
BrMedJ 1990;300:892. (7 April.)
SIR,-Professor Isaac Marks and Dr Graham Thornicroft miss the boat when they say: "The bull market in private hospitals is threatening the catchment area concept."' The fact is that independent psychiatric hospitals are meeting the inpatient and outpatient needs of over 50 000 Britons each year precisely because the statist "catchment area" concept has proved unworkable.
1136
SIR,-Professor Isaac Marks and Dr Graham Thornicroft are correct in observing the emergence of a two tier system in the treatment of patients with acute psychiatric illness.' Of the two tiers, I am assuming that they mean that the private tier provides the better service to the patient. In my experience this would be a valid observation. What I fail to understand is, having observed the two tiers, why the article concentrates on the negative aspects of the "better" of the two. Some insurers do indeed limit benefit for psychiatric treatment, though I am not certain how this observation supports the general argument. In point of fact, about three quarters of medical
insurance policies include benefit for psychiatry. The market share of those insurance companies that exclude such benefit is not materially important, though such exclusion is somewhat surprising as the likelihood of being referred to a consultant for a psychiatric problem is over four times greater than a referral for heart disease. Luckily, most citizens seem to realise this and continue to insure themselves against the unfortunate possibility of acute mental illness. I perfectly understand the need fully to evaluate efficacy and outcome. The absence of such a full evaluation does not, however, invalidate the clinical work that is carried out in NHS or private hospitals. In the private hospital one element in determining the efficacy of service, both clinical and "hotel," is the number of patients referred. Clearly, if the treatment offered is below standard consultants admit their patients elsewhere. This is not a choice open to consultants or patients in catchment areas. Many of the lessons from the United States are not strictly relevant here; it is mere assertion to say that "Britain can expect to follow the same path." For example, it may be that private hospitals have flourished in those states that have relaxed their inspections: in Britain private hospitals alone are subjected to external inspection. We now have the bizarre spectacle of health authority inspectors stipulating minimum requirements for private facilities that NHS units in their own authority do not meet. I do not see why private facilities should be responsible for comprehensive care. Health authorities have this responsibility. Surely the role for private hospitals in a catchment area, health district, or whatever arbitrary geographical areas we end up with is that they are there as part of the overall provision. In the future the decision the consultant, general practitioner, and patient will have is whether the referral is to a private hospital or an NHS one. Surely the factors to be considered in that decision are clinical efficacy, comfort, cost, availability, and convenience. Given roughly equal costs between two facilities, one NHS and one private, would it not take a pecularly hairy shirt to recommend a patient is admitted to the "lower" of the two tiers? FREDERICK STAPLETON London SW3 2QW 1 Marks I, Thornicroft G. Private inpatient psychiatric care. BrMedJ 1990;300:892. (7 April.)
SIR,-Economy with the truth is an effective way of drawing opposite conclusions to those that are supported by a more objective view of the facts. Professor Isaac Marks and Dr Graham Thornicroft provide a classic example of this in their editorial on private inpatient psychiatric care.'
BMJ VOLUME 300
28 APRIL 1990
