Private life
More and more UK doctors are working privately, and
the Scottish National Party has proposed golden handcuffs to retain doctors
in the state system. Katie Reid asks medical students around the world if they feel a
duty to serve the public
The Scottish National
Party last month raised concerns that Scotland is training doctors who go
to England and often end up working in the private sector. Fiona Hyslop,
member of the Scottish National Party, told members of the Scottish
parliament that the answer might be “golden handcuffs” to keep
doctors in Scotland and the NHS. The policy would bind junior doctors to a
minimum period of service within the Scottish NHS.
“The idea of the golden handcuffs is
simple—if you’re getting the benefits of a high quality
Scottish medical education, we want you to give something back to the NHS
in Scotland,” shadow health minister Shona Robinson said days before
the meeting in the Scottish parliament in January.
The proposal, which might not be legal under
European law, is not the answer according to Pauline McNeill,
Labour member of the Scottish parliament. “I don’t support it.
I don’t think it is really practical to hold doctors here. I think we
need to make the job attractive enough for doctors to remain here and
because we have so many English students they will want to go
home.”
The proposal of golden handcuffs leads to questions
about how much freedom doctors should have to choose where they work. It
costs the government £67000 ($126381; a97329) to educate each medical student in Scotland. Do
doctors have a duty to serve the taxpayers who helped to finance their
education?
Leigh Bissett, chairman of the BMA’s Medical
Students Committee, believes that there are no ethical reasons for a doctor
not to do private work. “In the UK you can only enter into private
practice when you are a consultant. By this time a doctor will have been
paying taxes and working in the public sector for up to 10 years. By the
time a doctor can do private practice they will be paying income tax at
40%.”
Piers Benn, a lecturer in medical ethics at Imperial
College, London, agrees: “Many doctors work in both the private
and state sectors. If private practice helps to shorten the queues for
those who cannot afford private care then it is good—particularly
when people are faced with long waiting lists for things like hip
replacements.”
But he added there are some problems when resources
are undermined and asked whether the NHS is needed at all.
Katherine Morton, a consultant pathologist from
Stirling said that patients who choose private care have paid their
taxes and have also helped to pay for medical training. “Very few
people go into private practice straight from medical school,” Dr
Morton added. “They need the NHS to get into private practice and
most people need to build up a reputation first. You also find that most
people do both private and state work,” she said. But some experts in
ethics were reluctant to comment on this complex issue.
Recent statistics have shown that there has been
increase in the number of doctors doing private work. An estimated 40000
doctors across the country work for the private sector, and half of those
are working for private practices on a regular basis, according to the
Independent Doctors Forum.
Four hundred general practitioners left the NHS to
work privately in 2004, Rachel Whitelegg, a spokesperson for the
Independent Doctors Forum, said. Revenues of independent hospitals and
clinics rose 8.5% in 2001-2, and the private patient revenue from NHS
Trusts in NHS hospitals is reported to have been £3.388bn in 2002-3,
a 7.9% increase.
Despite this burgeoning industry, figures from the
Scottish Health Executive have shown that the number of doctors within NHS
Scotland grew by 14% in 1999-2003. Currently, Scotland has more doctors per
head than England and Wales and a retention programme is under review by
the executive.
In the UK as a whole, the government has increased the
number of places at medical schools by 55% since 1997. And the Department
of Health has said that NHS investment in education and training has
doubled in the past eight years.
The freedom to decide where to work affects doctors
around the world. Below medical students from more than 15 countries
describe whether they feel obliged to work for the state.
LP WOODS
Turkey—Eray
Atalay feels indebted to the taxpayers who made his degree possible and
believes everyone in Turkey should have access to a free health service.
“We all know how hard it is to provide medical education. It requires
a lot of expensive equipment, qualified personnel, and special
laboratories. Medical students and doctors owe a lot to the people who have
contributed to their education, so they should at least show their loyalty
to those people and serve them. The people living in the poor regions of a
country also have the right to receive health services.” But a
compulsory health service may not be popular and the introduction of a
voluntary health service which should target new doctors. He said that the
government should offer incentives for doctors.
Brazil —Bruno
Monnerat also believes that health care should be free for all. He and many
of his classmates want to get a job in the state system. But he admits that
his motives are not entirely altruistic: “Most of us can’t find
a better job fresh out of college.” He added that a third of his
income will go to the government, and although he does not take his state
education for granted, he does feel that it is his right.
Serbia and Montenegro—Makro
Bukurov fears that medicine is vulnerable in a world of profit and
market competition. “Medicine is a profession that should have a
special and noble position within our civilisation. The private sector
and its tendency to make a profit out of human suffering should not
exist.”
Egypt—Ahmed
Ibrahim is faced with another dilemma in Egypt. He feels he is obliged to
pay back the system that provided him with free education and
training, but is hampered by the low salaries that the state pays doctors.
“Doctors seeking an average standard of living will have to either
shift to private sector or work extra hours. This can be hard for junior
doctors, who also have to study for their degrees, and they end up less
motivated and disillusioned and prefer the private sector.”
Lithuania—Matas
Morkevicius is faced with a similar problem: financial constraints on
doctors mean that the private sector is often the only way for doctors to
support their families. “A doctor’s salary is the same as a
worker in a beer factory; working in a state run hospital is ridiculous.
Maybe it is not fair for the patients, but when doctors have a hard time
supporting their families, at a certain point you stop caring about what is
fair and what is not.” The government is encouraging doctors to go
into private practice as it is unable to support the national health care
system, he added.
Australia—Some
student doctors feel that they are under no obligation to work in the
public sector. “We should have the freedom to choose after our
respective training programmes. From our first year out as interns right up
to the last year of being a registrar, that would be at least seven years
of giving back to society,” Allan Lee from Australia argued. “I
am quite sure that whatever financial debt we owed those who contributed to
our academic success would be paid back by then,” he added.
New Zealand—Emma
Hannay said, “Doctors will spend their working lives paying more
taxes simply by being a high income earner. This debt is paid off many
times over.” She also added that students have to pay up to one third
of the cost of their course in fees, which can result in crippling debts.
United Kingdom—“The
state must be prepared to ensure that the welfare of doctors is
safeguarded so that the inclination to leave for the private sector is
decreased,” Christopher Chew said. He argued that doctors should have
the freedom to decide where they worked as long as they had spent a number
of years doing NHS work.
Katie Reid, freelance journalist,
Email: katie_reid59@hotmail.com
Information about paying for healthcare and medical education around the world is on studentbmj.com
studentBMJ 2005;13:89-132 March ISSN 0966-6494
- References
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Responses published this month
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Articles
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Responses
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LIFE
Private Life
Katie Reid (March, 2005)
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Lui Wilson
(March 18, 2005)
Read this response
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LIFE
Private Life
Katie Reid (March, 2005)
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Lui Wilson
(March 18, 2005)
Medical student (year 4), The Chinese University of Hong Kong s017861@cuhk.edu.hk
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With only publicly avalible universities avaliable for medical education in Hong Kong, the situation is much the same here - having the taxpayer to subsidise the training of a medical student.
Personally, I would love to serve in the public sector which is a satisfaction to help the needy. But most stay for the specialist training provided only in the public sector. I also agree that some sort of standard most be reached before being allowed to practice privately in the interest of the public.
However, the current atmosphere in general is also a disappointment. Low moral in those working in the public service and insecurity to students, especially with the economical downturn since the 1997 financial crisis in asia, the Hong Kong government in serious debt every year since has been very keen to cut down on expenditure. So despite the clear lack of manpower in the public sector they chose not to take in all the gradutes and also encourage the more senior ones to leave - doing quite the opposite of "golden handcuffs to retain doctors in the state system".
We currently do not have strict guidelines as to whom could practice in the private sector - of course the better equiped the better the chance of a successful practice. But fresh graduates coming out to work in the private sector is not uncommon. With more and more (HMOs) health managing organizations recruiting young doctors, it has never been easier to work privately.
As noted in other places worldwide, the private sector has a much better pay than working in the public with general less workload.
As a result, those who want to work for the government may not be able to do so!! Therefore, having a "private life" is not all up to us doctors but also the planning and administrative policy of the government.
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