Consultants should think first about what is best for their patients,

Our health service could be streamlined and cost-effective if all us professionals got our act together, with only a little help from the politicians. Yes, we undoubtedly need a graduated increase in cash-injection, but we also require a revolutionary re-orientation of emphasis towards patient benefit rather than staff careers and convenience.

Consultants have done much to hinder the development of a universally fair health system. They required their mouths to be stopped by gold before they allowed Nye Bevan's inspiration of a public national service to go forward. They have perpetuated a two- tier service since then in the shape of private practice on which, contrary to public perception, the best is not always, or even usually, available in the private sector. As a body we can sometimes lose sight of the patient's perspective in concern for our own careers, prestige and specialties.

I have no doubt that my colleagues who take private patients are as professional and ethical as any others, but the public ought to understand that the primary motive for taking on this additional responsibility is extra income for the doctors. Any business has as its core raison d'tre a profit motive. Where that exists, it will always over-ride any other consideration.

There is nothing morally wrong with a profit motive except where it masquerades as moral philanthropy. And profiteering sits ill besides dedicated service provision.

Ideologically, Public-Private Partnerships (PPP) are supposed to benefit the public in some magical osmotic acquisition of cash, presumably by spontaneous generation. It certainly won't happen by spontaneous generosity. In fact, the gradient always goes the other way. It is in those specialities monopolised by the private sector (ENT, orthopaedics, plastic surgery) that waiting lists accumulate on the public side.

Then by a double hit, consultants in those same specialties can profit by waiting list initiatives - that irrational marker of government obsession - which means that non-urgent surgery at weekends displaces urgent cases, like elderly ladies with fractured necks or femurs who have to wait over until Monday for their operations.

In London hospitals, where overseas patients supply large tranches of private income - both for the service and for consultants' pockets - the ordinary taxpaying Londoners get relegated to second place.

Meanwhile, all low-paid public sector health workers - nurses, porters, secretaries, lab staff - are expected to do their usual stuff for these privileged patients without any personal gain. The goodwill of these less influential staff is exploited and they never benefit from any postulated "trickle-down" effect.

Part of the professionalism in a public service is training young hopefuls in tandem with the daily routine. In my laboratory, it takes six months' input into trainee scientific staff before they are capable of giving back any useful work. In the past five years we have made this investment in six individuals, only to have them attracted away by bigger salaries in a neighbouring pharmaceutical research company, Quintiles. This company thus has ready access to staff ready-trained, courtesy of the NHS, courtesy of the public purse, without themselves investing a bean in the process.

One of the most avaricious businesses to rub shoulders with the NHS, and which has a formidable and far-reaching influence on medical practice, is the megalithic pharmaceutical industry.

Since I was a medical initiate I have been interested in the service/profit paradox, and I have collected over the years files of news cuttings which show unequivocally that in this multinational business setting, profit-making takes precedence over ethical matters, safety, unmet need, or any other patient-related issues. If our government could grasp this simple truth with all its implications about human nature, they would drop PPPs like so many hot potatoes. This is not misty-eyed idealism, it is harsh reality.

Over the past few years, I have been approached on three occasions by drug-reps with offers to finance me on trips to prestigious scientific meetings abroad. To their consternation I refused on the grounds that such support is unethical. My patients do not want to think that their treatment is influenced by those drug companies who provide freebies and junkets, even if it's under the guise of research and education.

A service whose objective is the public good can only be funded from public funds if perverse incentives are to be minimised. The consultant body, in spite of my strictures, are almost all staunchly motivated to do their best for their patients. They should collaborate with government by backing a policy of tax increases explicitly to fund the health service with the maximum of openness and accountability. They should undertake to commit either to the health service or to private practice but not both.

Newly-appointed consultants should be obliged to commit to the health service for a given period in order to pay back their publicly funded training. Private concerns who employ NHS-trained staff should be charged a fee as a contribution to the costs of training, even if retrospective.

Consultants should also dissociate themselves from all interactions with drug companies - whether sponsorship, research, information provision or teaching - which are sophisticated forms of advertising.

Finally, the consultant body should press very hard through the Royal Colleges to regulate and openly debate with the public the issues of rationing (which are already covertly happening) and core health provision.

Copyright 2002
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