Nicki ThorogoodPrivate medicine: 'you pay your moneyand you gets your treatment'

Abstract This paper looks at the issue of private health care from theperspective of black (Afro-Caribbean) women in Britain. Theresearch on which it is based (Thorogood 1988) indicates thatthese women have a particular relationship to health care, oneaspect of which is their use of private consultations with GeneralPractitioners. This is, I suggest, a consequence of their historicaland contemporary experiences.

Introduction

Literature on 'health and race' is limited, and much of it has been based onnotions of ethnicity and culture (Pearson 1986). These works draw on thetheoretical base of cultural pluralism which supposes that all 'cultures'meet on an equal footing. This neglects any consideration of the structuralmanifestation of power inequalities, that is, racism, and reduces everythingto the shortcomings of individuals or their cultures (Henley 1980; Khan1979; Littlewood and Lipsedge 1982). Ouite apart from this it takes theconcept of culture to be unproblematic, stripped of its social context. Thus'ethnic health' research has focused largely on the more 'exotic' seeming'problems' of non-English speaking 'Asian' communities (mainly thewomen); black women's fertility more generally (for example the mosttranslated HE A leaflets are on contraception; the Training in Health andRace initiative focused almost exclusively on maternity services) or onpsychiatric disorders, mainly located amongst Caribbean men. Whilstthese works are not intentionally racist (indeed they are usually at pains tostate the opposite) they neglect to consider the social and political contextin which they are produced. One notable exception to this is Donovan'sethnography (1986), We Don't Buy Sickness, it just comes, a study of theexperience of illness amongst Black people in East London.

In contrast, the use of private health care in Britain has been the subject

Sociology of Health & Illness Vol. 14 No. 1 1992 ISSN 0141-9889

24 Nicki Thorogood

of much discussion during the last decade (Griffith 1985; Higgins 1988;Iliffe 1988). Little attention has been paid, however, to the role of generalpractice in the private sector, or indeed to the role of private health careamongst ethnic minority populations (McNaught 1988).

Sample and method

The following discussion is based on in-depth interviews with 32 womenliving in Hackney, East London. The sample was drawn equally from twoage groups, (16-30 years and 40-60 years) and from two locations. Thefirst group were selected from the GP's waiting room of a local healthcentre, the second by word of mouth recommendations in the local area.Thirty-one of the interviews were conducted in the women's own homes.The remaining interview took place in my home at the interviewee'srequest. All the interviews were tape recorded and then transcribed, eachlasting an average of three hours. The older women had all been born inthe Caribbean and had moved to Britain during the late Fifties and earlySixties. Whilst this group had, all except one, had a similar ruralupbringing they emigrated variously as single women and married women,some without children and some leaving them behind; one came as adaughter with her parents and a mother came with her five children to joinher husband after several years. The children 'left behind' were sent for,often one at a time, as soon as circumstances permitted.

Amongst the younger age group, half had been born in Britain and theother half in the Caribbean. These young women had, for the most part,been left in the care of their aunts or grandmothers in rural settings similarto their mothers' own childhoods. They had then been 'sent for', coming torejoin their mothers (and sometimes fathers and 'new' siblings too) at agesranging from four to 14 years.

Thus many of the women interviewed had experienced health care in theCaribbean and all of them, even those born in Britain, referred to it as'back home'. It is this 'ideological' allegiance to a place, a style of life, ahistorical past, which, I suggest, interacts with their contemporaryexperiences to produce their 'culture'. In this paper I am seeking to avoidviewing 'culture' as a static, homogenous entity and instead to construct itas a dynamic process or resource (Gilroy 1987). Following Giddens (1979)I suggest that resources are not simply inert materials possessed (or not) byindividuals but are part of a socially structured set of relations. In this wayresources can be seen as both the consequence and the expression of aperson's class, race and gender position.

It is clear that the sample group were both black and female. Ascribing aclass position is more difficult, in terms of both race and gender. Tlierelationship and overlap between the categories is complex and has beendiscussed in depth elsewhere (Gilroy 1987; Thorogood 1988). However,

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for the purposes of this paper it can be noted that none of the women held'professional' jobs (Class Ilia or above by the Registrar General'sdefinitions), nor were they the partner of any man who did. In this respect,and in many others, these women could be defined as 'working class'. Theydefined themselves variously as 'poor' or of the 'lower classes' or indeedunemployed. No-one used the label housewife. 'Culture' is therefore alsostructured through race, class and gender experiences. Culture in this senseis a structural property, both enabling and constraining like any otherresource (see Gabe and Thorogood 1988; Giddens 1979) and differentiallydistributed or valued.

This paper seeks to analyse only one aspect of the relationship betweenblack women in Britain and their management of health, that is, their useof private medicine. This, as we shall see, largely takes the form of privategeneral practice. Other facets of black women's management of health inGreat Britain are discussed elsewhere (see, for example, tranquilliser use(Gabe and Thorogood 1986), their experience of the NHS (Thorogood1988), their use of 'bush' and other home remedies (Thorogood 1990).

In discussing the relevance of their Caribbean experience I am lessconcerned with the 'fact' of that experience than with the way in which thisheritage is used to construct a cultural attitude or response to thecontemporary management of their health in Great Britain. The experiencefor women brought up in the Caribbean was of a private health service,with a GP covering a locality (a number of villages in the rural areas) and ifnecessary a recourse to the Public Hospitals, which had poor reputations,in the cities. For these women 'bush' and other home remedies wereimportant and widely used. Nevertheless 29 of the 32 women had used'bush' regardless of where they grew up. As Wickham (1988) points out,histories are important not because they construct 'the reality of the past',but because they form a crucial part of the experience of the present.

It is this interaction of specific historical and contemporary experiences,this culture, which informs any group's response to aspects of social life.

In this paper I examine the attitudes towards and use of private healthcare amongst one group of black women in Britain in the light of theircultural experiences and identities. How far is this generalisable to allAfro-Caribbean women in Britain? Perhaps it can be suggested that this ispossible in two ways. Firstly, other work which relates Afro-Caribbeanwomen's experiences of life in Great Britain would seem to tell us similarstories (Bryan et al 1985; Prescod-Roberts and Steele 1980). Secondly, theresearch took an explicitly feminist theory and methodology. Feministresearch does not aim for 'predictability', but is about deconstructing thoseprocesses through which the world is constructed by studying them at thelevel of experience and meaning. It is this detailed understanding ofpersonal experience which allows a more precise understanding of itsrelation to the wider social, political and economic sphere (Webb 1983). Itis by focusing on the individual's experience of the world that the structural

26 Nicki Thorogood

relations are made apparent. What is it about this group of women whichconstructs their particular discourse of health? What are their beliefs abouthealth and health care which lead them to make such unusual use of theprovision?

Experience of private medical treatment

Most of the women interviewed held the commonsense view that illnesswas no respecter of class, that rich people still get sick. However, it wasequally clear that having money widened the scope for health care. Onlyone woman saw this in terms of a changed life-style: better food or a newbed, for example: the others saw it in terms of the ability to pay fortreatment. Twenty-one women said they thought private health care was ofa better quality than the NHS. This is supported by findings amongst agroup of working-class women documented in Calnan (1987).

There were data for 29 women (14 young and 15 older) regarding theiruse of private medicine. Fifteen of them (six young and nine older) hadused it and 14 (eight young and six older) had not. However, of those 14who had not used private medicine, five of the younger women said thatthey would if it were necessary or if they could afford it.

This then leaves only nine women (six older and three younger), amongthose who were asked about private medicine, who had not considered it,although at least one had been taken as a child. (It should be noted that Iam here only referring to their experiences in Britain). Thus, 20 of these 29women felt private medicine appropriate for them.

The type of private treatment under consideration is very specific. Everywoman, with two exceptions, meant by 'private doctor' a privateconsultation with a General Practitioner. It is clear then, that it is notspecialist skills or expertise which are being sought. The two exceptions,both young, single parents, made one visit each to a Harley Street'specialist', one of whom was a homeopath. Neither was the question'Have you ever been to a private doctor?' ever taken to refer to a privatehealth insurance scheme. Only one woman, herself a SEN, was seriouslyconsidering joining BUPA. For the most part, what is under considerationis a paid-for consultation with a General Practitioner, used in tandem withthe NHS.

For many of these working-class black women private medicine was arational, if reluctant, choice. No-one suggested a completely privatesystem would be preferable: indeed, many said that they would like to seethe NHS revived. The politics of private medicine were very much to thefore in the accounts both of women who had used it and women who hadnot. Use or non-use was no guarantee of their approval or disapproval ofthe system; ideas and practice remained discrete. Arguments both for and

Private medicine 27

against private medicine, some of which I shall consider here, were putforward by both users and non-users, sometimes simultaneously.

Reasons for not using private medicine

Of the nine women mentioned above three did not use private medicine onprinciple, three due to cost and three because they had not thought aboutit. Myrtle, Remelda and Audrey thought that NHS hospitals were just asgood. Indeed, Remelda commented that:

A private doctor is just the doctor you seeing when you go to hospital.

Myrtle actually felt that the NHS hospitals had more scope:

You get a better care in a hospital than you get from your doctor . . .because there is more doctors in the hospital to see what's wrong withyou. It's true.

Neither did she see private doctors as a viable long term option:

The day you don't have no money you can't go to him, you still got to goto the hospital, so I don't believe in them.

These views did, however, conflict with those of her husband:

My husband believes in private doctors. He thinks if you pay yourmoney you are going to hear the truth.

Neither did Audrey 'believe in them', but perhaps for more explicitpolitical reasons:

. . . with all that money they pay to go to a private doctor they could takethat money and put that money to good use . . . you know, those starvingkids abroad and things . . . or open more nurseries . . . I think giving it toa private doctor is really a waste of time.

[a clear example of the interchangeability of time and money].However, none of these three appeared inherently averse to the idea ofprivate medicine, even if they themselves are excluded on financialgrounds. Indeed, Sandra went on to say:

I think they are just the same [as NHS doctors]. I think they treat youbetter because you pay for it and then, it's not too demanding, therearen't so many people, so they have more time with one person and theypay more attention. And they give you your money worth, of course . . .NT: Who do you think goes?Sandra: The rich. People with money. Unless you're a person who, youknow, is not rich, but you want to get proper treatment [my emphasis].

This seems to me to be a telling phrase and is an aspect I shall return to.

28 Nicki Thorogood

However, it seems significant that there were only three women for whomprivate medicine was outside their conceptual framework:

Clara: No, I haven't been. I have no need to, my doctor is quite good.NT: Have you ever thought about it?Clara: No.

Of the remaining three women who had not used private medicine,Evelyn, when I asked if she had thought of checking her GP's diagnosis (orrather lack of it), privately, replied:

I never thought of t ha t . . . I just thought, wel l . . . I pay a full stamp . . .

Lucille was not even aware that private doctors, with the possibleexception of Harley Street abortionists, existed in Britain, despite havingfrequently used private medicine 'at home' in the West Indies. So insummary, three women did not believe in it, three could not afford it, andthree women had never heard of it.

Finally, as mentioned earlier, there were five young women who had notused private medicine but who did not rule out the option. They felt theywould use it if necessary, for example, to compensate for the inadequaciesof the NHS:

Debbie: Nothing's got that serious that I need a private doctor, anyway.

Or perhaps to avoid certain aspects of the NHS:

Ann: I don't think that's true but there are certain times when I've sortof thought it might be better to go to a private doctor rather than sit inthe surgery for ages . . .

Perhaps most significantly, as well as avoiding a long and potentiallydangerous wait, they would use private medicine to procure better qualitytreatment:

Arlene: If it so happened that I had a problem that I thought any of thesedoctors couldn't cope with. I feel that, you know especially if it came to akind of operation and you may have to go on a waiting list, andsomething like that.

These are the views of those who had not yet sought private treatment, butit is clear that it is a strategy they considered available to them and onewhich other members of their family use.

Reconciling the contradictions between private medicine and the NHS

It should be bome in mind that implicitly and sometimes explicitly thesewomen feel private medicine undermines the NHS but that despite orperhaps because of this, many believe private doctors are a necessary evil.

Private medicine 29

As we have seen, Audrey felt that private medicine existed at theexpense of the NHS and for that reason (amongst others) would notconsider using it. Ann had not used it either, although as we have heardshe sometimes considered it. But she too felt that at some level the privatesector detracts from the NHS, which she expressed at a straightforwardeconomic level:

NT: You feel that you are kind of suffering at their expense o r . . .Ann: Yes, I think sometimes because, as I say, if a doctor has to choosebetween sort of a patient who is going to pay like say £50 for aconsultation, and a patient he gets £4 something for from theGovernment. I mean, in all honesty who would blame him if he goes forthe £50 patient? So I suppose that draws a lot of doctors and there wouldbe more doctors available really, and it would make life easier for theones who stayed, because they wouldn't have so much work to do.

There were others who felt equally strongly about private medicine'sdetrimental effect, but used it nevertheless. Interestingly, Beryl, thewoman who seemingly made most use of a private GP, offered the mostcritical political analysis:

Beryl: I think that in the past we have all taken doctors... patients,have all taken the Health Service for granted. I think the Government isdeliberately trying to run the Health Service down, that's for sure. Sothat they can bring in private medicine. Privatisation is her middle name,isn't it.NT: Do you think that's a good thing or a bad thing?Beryl: You should always have a system whereby you can't say you aregoing to privatise the Health Service 100% because there will always bepeople who will never be able to afford to pay for private medicine. Soyou must have an efficient system left behind that will serve the peoplewho need this sort of treatment.NT: Do you think there's room to have both?Beryl: Yes.

However, she also went on to say:

. . . these private surgeons or whatever, they are using the NationalHealth facilities for half their patients and what they pay theGovernment back is not even a spit in the ocean compared with whatthey are putting in their pockets. That annoys me . . . and most of thesesurgeons they have all their training from the Health Service and nowthey are putting money in their pockets. That's what annoys me aboutthat.

Yet others who had consulted privately were critical; not simply ofspecific occasions or practitioners, which they sometimes were, but more ofthe system which makes it necessary for them to waste their money in this

30 Nicki Thorogood

fashion. It is perhaps surprising that more was not made of the point thatwe have after all already paid for the NHS. Particularly since this was sostrongly felt with regard to the way in which the NHS was run.Nevertheless, four women brought up the point (three of whom hadconsulted privately).

Thus, only three (Evelyn, Lucille and Clare cited earlier) out of 29women had no relationship to or knowledge of private medicine in Britain.Of course, of the remaining 26 women only 15 had actually used privatemedicine. But at least five of those who had not, would, and still others feltthat private medicine is qualitively 'better'. The lines are not easily drawn.

From their accounts it is apparent that private medicine is not taken upin an uncritical manner. This is perhaps best summed up by Cora, a regularuser of private medicine, speaking about local hospital services:

Cora:. . . you know Hackney, Hackney's getting terrible.NT: Why do you think it is?Cora: I don't really know, I don't know if it's because of this BUPA. Ithink that's spoiling things.

What do private GPs ofTer?

Given these opinions the interesting question is, why do these womenconsult privately? What do they expect; what do they get; what does itmean to them?

It seems that, with the (aforementioned) exceptions for BUPA andHarley Street, the women were paying for an alternative to their GeneralPractitioner. Indeed, there is a taken-for-granted assumption throughoutthat 'hospital private medicine' is different from the sort available to them(and of course, it is, it is far more expensive) unless it is achieved throughprivate health insurance. Thus, it would seem that, so far, private healthschemes have not needed to appeal to the black consumer market, relyingfor the most part on employment-related schemes. This is confirmed byGriffith et al (1985) who, in their report on commercial medicine inLondon, show that private medical insurance is the third most importantemployment perk. Nevertheless, it appears that the initial rate of growth inprivate medical insurance has considerably tailed off and: 'The insurancemarket today - though numbering around two million subscribers - is stilltiny by comparison with the NHS.' (Griffith et al 1985:15). Interestingly,this report made no mention of private practice by General Practitioners(see also Higgins 1988). Commercial medicine, as addressed by this reportin terms of private medical insurance and specialist consultations, was notusually considered appropriate by these women.

Specialist treatment was not apparently what most women sought fromtheir private consultations. Instead they seemed to be extending the

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services of their own GP. Every woman who consulted a private GP gaveas a reason either getting a second opinion, e.g.:

Cora: I always like a second opinion, and if I decided to have theoperation I would go to a private doctor for a second opinion, I wouldn'tjust agree. I've always done that.

or a second diagnosis:

Ann:... I went to my doctor once and he told me that my haemoglobinwas low. So I was on iron tablets and they wasn't doing me any good, so Iwent back to see this private doctor, someone recommended him to me.

Another frequently-cited reason was for a 'good going over':

Pearl: Well, they certainly quicker to examine you and they seem to bemore thorough, but then again, it depends what kind of [NHS] doctoryou have.

Firstly, there seems to be a requirement, not just amongst these womenbut amongst people generally, for routine 'check-ups' in much the samemanner as having a car serviced (Fowler 1985). This is an area of publicconcern which has been tapped by private insurance schemes amongst thewhite population, and seemingly by private GPs amongst these blackwomen (Weightman, 1977).

Beryl: If I feel I want a complete check-up, I go to see my private doctor,and I have him make all the tests, even for sugar.

In addition to a check-up which acts as a 'body service' there seems to bean element in these women's accounts which suggests 'proper' diagnosiscannot be made without physical examination. This harks back to thedoctors 'back home', those 'old-fashioned family doctors' that were part ofan idealised past (see eg Cornwell 1984; Balint 1957):

Beryl: Because this is the way we have doctors back in the West Indies.NT: What, do you pay for them, or . . .Beryl: Not only pay for them but they give you a thorough examination.Not just sit there, three yards away from you. How can he know whatyou are suffering from? I had a doctor [NHS] for years and didn't knowhe had a little back room there with a couch for examinations!

A third reason for consulting private GPs was because they gave youmore time. It was generally recognised that this was because they had farfewer patients than an NHS GP, but the consequence was that you receivedbetter treatment.

Beryl: But at least you can spend up to an hour there with him.

and more explicitly, Marie said:

32 Nicki Thorogood

Well he [private GP] examined me and did more or less the same thingwhat was done [on the NHS] but still I got that by paying and getting hisindividual attention. Because don't forget your family doctor, he's got somuch to do, so many people waiting behind him to see him.

These reasons were also given by three of the five women who had not yetconsulted privately, although Ann also said about NHS GPs:

they are a bit rushed, but at least they don't have time to give you a lot ofwaffle.

Apart from accounts of two individual bad experiences, this way the onlytime that the notion of unsatisfactory treatment from a private doctor wasmentioned. Otherwise, it seemed they were literally buying time andattention, rather than particular skills:

Rosalind: I don't know if it's because you are paying for the service thereand that kind of thing, and he takes a lot more time with you, and heseems more interested in you and your illness than just getting on with it.

This is very much in line with Silverman's (1984) and Strong's (1979)findings. Indeed, what are highlighted by these accounts are the kinds ofexperience that these women have of the NHS. As Joy said regarding hermother joining BUPA:

. . . I would prefer to pay for the operation, because I think the doctorsin the National Health are so run down and tired, and overworked, halfthe t ime. . . . I don't think they remember what they are doing. Or whowhich patient is, because of course they are seeing double the amount ofpatients. So they can't remember each one individually like you wouldlike them to.

All the private GPs consulted were local to the women's home (at thattime). Most women has been recommended to a private GP by a friend(eight), the others by their mothers (four). Interestingly, one doctor wasmentioned particularly often, and although not every woman had visitedhim, almost all had heard of him. It would seem that he was Irish, had oncebeen a gynaecologist in a London teaching hospital and currently had anNHS practice as well as his private surgeries. Amongst those who hadheard of him it was common knowledge that he was popular with blackpeople:

NT: Do you think you get a proper check up from him?

Beryl: Of course, yes. Most of his clients are black people. Most of them.

Note, too, her use of 'client' and not 'patient'. Rosalind said of him:

. . . it's ridiculous, his surgery, everybody just goes to Dr. N.Thus, the question we are left to ask is why is it that everyone just goes toDr. N? Or more generally, what is it about the character of a private

Private medicine 33

consultation with a GP which addresses the experience and meets theneeds of these women?

The role of money

What is it about the health needs of black women in inner city Britainwhich is expressed by this relation of women and private GP consultations?I would suggest that much of the ambivalence of the women's relationshipto the NHS both as workers and as patients is countered in the role ofprivate patient by the act of handing over money. This action encapsulatesthe whole character of the relation of black women to private medicine,and by extension to health care provision in general.

Obvious though it might seem, the difference between private and publictreatment is that the former is expressed by a visible and direct exchange ofmoney. This inevitably allows the patient some control over the situation ata number of levels; for example, as Strong says:

. . . in the private format patients assumed and were granted somemeasure of competence to judge the service they received. (Strong1979:81)

Briefly, Strong suggests, firstly, that a client is buying a service and to thatextent is able to determine which service is wanted, eg blood test, check-up. X-ray, etc. Secondly, that the client has some control over the formatof the consultation, eg its level of formality, making the opening andclosing remarks, etc. Thirdly, the client has financial power in the sensethat if you do not like the service you can take your custom away. In a waywhich is impossible within the NHS doctor/patient relationship, the privatedoctor is theoretically dependent upon you for his livelihood. This wassummed up by Beryl:

If he's horrible he won't get any patients, any private patients, and hewon't be able to make any money on the side. And if he's good you tellyour friends. Because I have sent about half a dozen people up there tomy private doctor.

When the relationship is expressed like this, however, in material terms,the women's sense of poweriessness within the NHS is also reconstructed.Strong (1979:90) discusses options for power and control in the NHS interms of the politeness ethic, concluding that it is indirect political powerwhich ensures politeness to patients in the NHS:

In this situation doctors are still dependent on their patients' goodwill,but in a somewhat different manner. Since they are not paid directly bythe individual... [but] are under direct political management and arethemselves a political issue, it pays doctors to be polite to the great massof their patients. (1979:215)

34 Nicki Thorogood

However, these women were well aware of the political and financial basesof the NHS, and also their relative inability to see it organised in a way theywould like (Thorogood 1988). Indeed, as patients they were, again asStrong (1979:8) has described, almost put into a position of beingrecipients of charity. TTiis characterises the NHS doctor/patient relationship -benefactor and beneficiary (preferably deserving), and perhaps thetensions implicit in this are more keenly felt by black women. They aremore sharply aware of the economic framework of the NHS and morelikely to feel that they have paid for it and have a right to it. Being blackwomen they are more likely to be perceived by doctors as powerless andthus they will be, doctor and patient, at the extremes of the continuumStrong characterised as a 'charitable' relationship.

This is neatly avoided by paying for the service as it is used. No long-term commitment is involved that distances the economic relation, and thepatient is reconstructed as the client, who, although still dependent on thedoctor's skill and expertise, is theoretically no longer dependent on hisgoodwill. Indeed the reverse is true:

. . . since the patients could take their money elsewhere, the need tomarket a distinct product subtly influenced all aspects of theconsultation. Personal touches paid. (Strong 1979:207)

This then, is an economic means for at least temporarily redressing animbalance in power.

This economic control also underpinned their expectations of goodservice (see Beryl's comments above) except that in the case of thoseHarley Street clients who were quickly aware that their economic powerwas diminished by not being important customers. This too demonstrateswhy it is the GP consultation which is most sought after, for in that smaller,local sphere their particular customer is much more valued.

Private GPs are a resource both available and appropriate to thesewomen and they are used in tandem with the NHS. The women appear tohave an instrumental approach to their heath care, 'shopping around'(Strong 1978:79) for the most suitable treatment. NHS GPs remain usefulfor diagnosing 'ordinary' complaints, i.e. those for which the patientusually knows what to expect, such as for antibiotics or for sicknesscertificates. And, should a GP fail to live up to these expectations, it islikely that they will change their GP. Private doctors are used in addition,to provide services which the NHS appears either unable or unwilling toprovide: that is, time, attention, personal service, second opinions,politeness and a degree of patient control (the 'client' relationship). Afeature of private medicine. Strong (1979) argues, is that its emphasis is onthe doctor as an individual, in contrast to the NHS where doctors aretheoretically interchangeable, each being as competent as the next. Thisagain accords with these wonien's consumer attitudes, enabling them todiscover a GP who meets their requirements, that is, one who is like an

Private medicine 35

'old-fashioned family doctor', who gives you a check-up, etc. Interestingly,the 'race' of the GP (private or NHS) was apparently not important.Although the (white) doctor mentioned earlier was felt to be 'popular' andsympathetic to black people, more frequently mentioned was a preferencefor a woman (Thorogood 1988).

There is a notable lack of (structural) criticism of private GPconsultations. They are centred on individual personalities, and outside ofa health insurance scheme, there is no broader structural framework.Private GPs are simply a series of individual, unconnected experts andcriticism of them remains at the level of individual experience. It is also atthis level that control is exercised - you take your business elsewhere.When we consider the relationship of these women to the NHS, privateconsultations with a GP appear as a rational manner in which black womencan extend their control over their own health care.

Conclusion

If, then, it is reasonable to assume that a private consultation with a GPallowed these women to buy back some equality, to regain some power andcontrol in this area of their lives, the question remains as to what sort ofequality they felt they were buying. Was this 'politeness' a consequence ofoverriding 'race' or gender or class inequalities?

Firstly, it is clear that there is a class dimension. As I have shownelsewhere (Thorogood 1988) these women are aware that black people inBritain are, for the most part, in the 'poor' or 'lower' classes; that moneyshould not affect health but that in fact, it does; and that the serviceavailable free (at the point of use) is second-rate, being mn down and as aconsequence used only by poor or lower class people. This is, of course,generally true of inner city areas such as Hackney (Tudor Hart 1971).One response to this has been to buy back those missing elements.(Strong 1979:209).

Secondly, there is a clear gender dimension to their actions. Whilst thispaper has only anecdotal evidence regarding black men's use of privatemedicine, women are primarily responsible for the routine maintenanceand reproduction of the family (Thorogood, 1987). On a day-to-day basisthis involves not only for most women paid work outside the home anddomestic labour within it but also the emotional labour of 'caring' for afamily, i.e. maintaining and reproducing their sense of health and well-being. Thus health is of prime concem to women, not only that of theirchildren (for whose health they are responsible) but also their own in bothfunctional, instrumental and emotional senses. It has been frequentlynoted that women take prime responsibility for family health (Graham1984a, Comwell 1984). If we extend the concept of health to include thematerial and emotional reproduction of the family we can see why it is that

36 Nicki Thorogood

these women seek out private GPs. For it is here where their family isknown and remembered. Their own bodies are 'serviced', hopefully toavoid any breakdowns in the future (which would disrupt their workinglives), and diagnosis and treatment is obtained quickly (so avoidingamongst other things, loss of earnings, which is of course both class andgender related).

Finally, there is also clearly a 'race' dimension: for structural reasons,black people in Britain are more likely to experience the worst conditionsand services in health, housing, employment, etc., and so will benefit mostby being able to buy some small part of the kinds of services which areapparently available to others.

It is when these three aspects of experience, race, class and gender, arecombined, however, as they surely are in these women's daily lives, thatthey produce the experience which is more than just their sum. It is this,the experience of being black working-class women in Britain's inner cities,which is addressed by private GP consultations. It is impossible to separateout the experiences of 'race', class and gender in practice, but we have seenhow the private doctor/client relation overcomes aspects of all threeexpressions of inequality. For the women themselves these inequalities areexpressed through wealth. The impression they had that, as a consequenceof the poor service the NHS offers, the rich seek private treatment,suggested that by buying private treatment, they could in some wayoverride class inequalities. However, as we have seen and as theythemselves take for granted, the reason these women find themselvesamongst the 'poor' class are precisely because of their 'race' and genderand the way in which these are socially structured. Thus, whilst theirunequal relation to the NHS is a consequence of the combination of theirexperiences of being black, female and working class, the womenthemselves experience this relation as being expressed through money.

The class and gender dimensions of this would also apply to their whitepeers. Yet we see very little evidence of white working-class use of privatehealth care, particularly outside of insurance schemes and charitableabortions. What is apparent amongst this group of black women is a veryparticular response to their needs. Equal and appropriate treatment (bothmedical and personal) cannot be taken for granted by them but must besought out. Black people's exjjeriences of the State, particularly its'welfare' arm, have not led them to believe it acts in their best interests(CCCS 1982; Bryan et al 1985). Doctors are no exception. Therefore if youdo not get what you want, it is your responsibility to do something about it.The historical and cultural knowledge and experience of black people, Isuggest, lessens the 'grip' of the ideological and allows them to holdalternative and contradictory attitudes and ideas. In health care thisincludes what is suitable treatment from a doctor. When this does not meettheir expectation, black women, in contrast with their white peers, do notconsider it a failing on their part (to explain themselves properly, to be

Private medicine 37

making a fuss about health) but a failure of the doctor to treat them equally(either in the medical or social sense). Their experience tells them it isthey who must take action.

Most women felt that they were unlikely to get all they were entitled tofrom the NHS, but that they were personally unable to influence anystructural changes (Thorogood 1989). Their realistic appraisal of thecircumstances leads them to the conclusion that improvements in thefuture are unlikely and that for them private medicine is a practicalalternative.

City and Hackney Young People's ProjectLondon Nl 5LZ

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