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We, the Clients

How public health care turned citizens into petitioners and responsibility into paperwork

  July 7, 2026  |  also in polski pl
A photograph of a large concrete hospital with a blue SZPITAL sign against a hazy, smoggy city skyline with smoking chimneys

The problem with public health care is not only underfunding, poor oversight, or the absence of yet another audit. The problem is a model in which society pays, doctors and facilities increasingly operate as market actors, and the patient is left in the role of a petitioner who can, at most, file a complaint. Before we point to the guilty, however, it is worth seeing something less theatrical: this system is blind. It does not add up who it pays and what it pays for, so it cannot distinguish honesty from the appearance of honesty. Perhaps it is time to democratize it.

It is July 7, 2026. Poland has already gone through several changes of political scenery: the social right of Law and Justice, the liberal center gathered around the Civic Coalition, coalition compromises, cabinet reshuffles, promises, and repeated attempts to fix the system. Yet public health care still looks like a place where everyone talks about procedures, while few can point to the person responsible for the outcome. Such a state of affairs demoralizes both sides of the desk: some doctors and their clients alike. In a badly designed arrangement, both sides lose.

I write “clients” deliberately, because the word “patient” has been marked in this system by helplessness. The patient waits. The patient asks. The patient does not understand, because they lack the expertise. They will leave and close the door behind them.

The patient may file a complaint, which someone will review when they have time, provided they are not on duty, in a committee, on a contract, on a board, on television, in a second hospital, or in a third company. The client is a different figure. The client pays and can say: “thank you, we no longer wish to work with you.”

In the public health care system, however, the client is not just one person, but the community paying contributions: taxes, health insurance contributions, private co-payments, time, nerves, queues, and sometimes its own life. In this picture, the NFZ (National Health Fund) is not a benefactor, but a representative of the clients, that is, of us.

In the space of three weeks we saw a series of cases that work like a cold shower. Not because they prove that “all doctors are bad.” That would be a foolish generalization. We saw something more important: an arrangement in which a combination of private forms of operation, public payers, diffused responsibility, and asymmetry of power creates a niche for serious abuse.

We do not even have to assume bad faith on the part of every participant. A poorly designed mechanism is enough. Demoralized individuals driven by low instincts will settle into it and use it for their own purposes, muttering under their breath: “if there is a cow, it should be milked.”

Symptoms

Let us begin with facts and allegations, not to stage a festival of outrage, but to see one recurring pattern in them: a system that does not see, and pays for what it has not checked.

Unrealistic hours

It began with the case of the Southern Hospital in Warsaw. Media outlets described a physician-politician who, in 2025, was said to have earned about PLN 1.6 million, and in that facility alone reported 3,976 hours of work, or an average of 331 hours per month. Zero.pl described schedules, public appearances, and situations in which that doctor was supposedly on duty according to the documents, even though he should have been somewhere else. The hospital checked the number of hours, the doctor was dismissed, and state authorities and the medical professional self-government took up the case. It remains ongoing, but as a systemic signal it is clear: documentation can impersonate reality.

Bilocations

Around the same time, the word “bilocation” began to appear more often. The deputy minister of health announced that the state wants to have data on the actual presence of medical personnel in a specific workplace, in order to limit overlapping hours and simultaneous work in several places. Termedia captured it with a concise headline: “The end of doctors’ bilocation.” The point is that if, in 2026, the state is only now building the ability to check whether a person was where they were supposed to perform a service, we are not dealing with a subtle regulatory problem, but with the absence of an elementary meter at the boundary of public money.

The neurosurgeons’ company

At the same time, Wirtualna Polska described the case of neurosurgeons and the company Spine in hospitals in Mogilno and Miastko. According to journalistic findings, doctors were to receive 65 percent of what the NFZ (National Health Fund) paid for a procedure, perform series of short procedures on Saturdays, and report more expensive procedures in the documentation. Figures appeared at the level of PLN 26,000 per hour and more than PLN 300,000 for a day of work, along with an NFZ penalty for the hospital in Mogilno exceeding PLN 2.6 million, and a thread examined by the CBA (Central Anti-Corruption Bureau) and the prosecutor’s office. A regional consultant was said to have pointed to documentation that looked like an assembly line.

Illegal price lists and desecration

Then came reports about the mortuary of the Southern Hospital. Onet described an illegal “price list” for releasing a body, preparing remains, embalming, and directing families to specific funeral homes. According to findings based on accounts from people in the funeral industry, someone was even said to have urinated on a body in the mortuary of the Southern Hospital. That thread later entered the prosecutor’s preliminary checks.

Kronika24, in turn, quoted a prosecutor’s office statement about checks concerning the collection of undue fees and benefits for directing families to a funeral home.

It is hard to imagine a more literal metaphor for a system capable of turning human helplessness at the end of life, and the helplessness of the family after death, into a toll point.

Paper staffing

WP abcZdrowie described allegations concerning the SOR (Hospital Emergency Department) in Torun: gaps in the schedules were allegedly patched with doctors from other departments who were formally on duty elsewhere, and whistleblowers were said to have been intimidated. The management rejects the allegations, so again this is not about issuing a verdict on the basis of an article, but about naming the failure model: paper staffing may look better than real patient safety.

A parasitic disease

The symptomatic culmination of the incidents described above is the almost normalized, in public awareness, issue of private entities feeding on the public system: queues, referrals, admissions out of sequence, and penalties for waiting lists. Rzeczpospolita described a penalty of almost PLN 300,000 imposed on UCK WUM (the University Clinical Center of the Medical University of Warsaw) and allegations that patients with referrals from one doctor’s private office were being admitted much faster than patients from the hospital outpatient clinic. The NFZ (National Health Fund) audit did not confirm all allegations, but it did find irregularities in waiting lists.

All this is a map of symptoms of one disease: a system that does not see whom it pays and what it pays for.

Money grows, trust does not

The website zarobkilekarzy.pl has gathered what is most important in this debate in recent days: the gap is not that someone does not know the hourly rate in one contract, but that the public system has not been adding up remuneration by person, by license-to-practice number, and by the real beneficiary of the money flow. According to the site’s summary, about 73 percent of specialists work on B2B contracts, and the published medians concern single contracts, not the combined income of one doctor from multiple facilities.

In practice this means that the same person may receive income in different places from different sources, such as a contract, on-call shifts, and an outpatient clinic, which only changes the full picture after being added up. A statistic of individual contracts may therefore describe correct numbers while at the same time understating the real flows to one person.

This is not a bookkeeping detail, but a data-model error: a source blindness from which many other symptoms grow. If a publicly financed system does not know the sum of public payments to a person operating inside that system, then it has no tool for distinguishing honestly high earnings from a structure spread across many contracts. If the same system does not see each person’s working time, it does not see fatigue, overload, or fictitious presence. Further still, if it does not see conflicts of interest, it does not see when a private office begins to control the pressure in the public water mains.

That analogy matters. When someone says that the problem of private visits will disappear if the NFZ (National Health Fund) buys enough services, it sounds as if they were saying: if people took more water from the tap, they would stop buying bottled water. Except that in our example, the employees of the bottled-water companies are sitting at the water-main valves at the same time.

The problem is not the private nature of a service itself. The problem is coupled interests, which make shortage on the public side a fuel for demand on the private side. And the most important component of this arrangement, the process of the human person and the personal property connected with it, is excluded from real agency.

The state responded with a statutory change allowing remuneration data for medical workers to be linked to a PESEL number (Polish national identification number) or a PWZ number (license to practice medicine). The Ministry of Health wrote that AOTMiT (Agency for Health Technology Assessment and Tariff System) had not previously had a legal basis for processing such identifying data, which limited the completeness and precision of analyses. This is a necessary step, but it is still only a meter. Such an indicator is not a brake, a steering wheel, or the client’s right to ask a dishonest contractor to leave their own house.

Fairness requires giving the other side a voice. Some of this opacity has entirely innocent roots: personal-data protection, the flexibility of contracts that keeps the system working at all, and the real difficulty of measuring something as soft as trust. More than that, transparency is in doctors’ own interest, because an honest specialist gains when their name stops disappearing into a collective suspicion directed at the whole group. The point is not to expose an enemy, but to make sure that everyone - those who pay, those who are treated, and those who treat - stops being held hostage by the same problem.

Why audits are secondary

More money? Yes, if we want real access. More oversight? Yes, if we want less fiction. More audits? Of course, if we do not want to pay for services that never happened. But these are secondary measures: necessary, yet primarily protective against consequences.

The first problem is scale. In a small community, responsibility is still partly personal. Someone knows who treated whom fairly, who was drunk, who cheated, who helped, who caused harm. In a large system, responsibility is replaced by a procedure, schedule, form, questionnaire, protocol, and contract. Procedure is needed, but procedure has no conscience. It can be a corridor for responsibility or a smoke screen for its diffusion.

The second problem is the hybrid we have built without carefully accounting for its effects. Medical professionals can act like companies. Companies can contract services. Subcontractors can perform fragments of tasks. Foundations, consortia, sole proprietorships, and limited-liability companies can enter chains of care. At the same time, the payer is the NFZ (National Health Fund), that is, the representative of people who do not personally negotiate terms and cannot personally choose the contractor in the time, place, and quality that would meet their needs.

The third problem is sealing. Private legal forms exist to separate assets, risk, function, and responsibility. That is normal in business. But when capital enters the space of the common good, it begins to dissolve responsibility in layers: the doctor says it was the facility; the facility says it was the contract; the contract says it was the subcontractor; the subcontractor says it was the documentation; the documentation says everything is correct; and the patient, family member, or whistleblower is left with the feeling that they saw something obvious that the system cannot name.

In the normative documentation of my hobby project for building distributed artificial intelligence, I call this accountability without dissolving into procedure: the more layers, roles, and processes mediate between a decision and its consequence, the easier it becomes for every participant in the chain to say: “it wasn’t me.”

For a moment I wondered whether a special “health voucher” might improve the situation, because money would follow the patient. After thinking about it, however, I concluded that it is somewhat naive to believe that a free-market simulacrum would solve the problems described here. After all, no one would allow a local clinic or hospital to collapse when patients no longer want to use it, because it is not the hospital or clinic that will bear the health consequences of such a situation.

So I think it would become another layer with the potential to hide problems behind capital: a form of clientelism that cannot hold the actual service provider accountable for intention. In health care this is not an abstraction. It is a human body in the emergency department, a child in a queue, a family beside a corpse, an elderly woman in pain, and an invoice issued somewhere along the way.

The doctor is armed, the patient is alone

The doctor has an institution, a professional chamber, knowledge, documentation, expert language, a professional environment, sometimes a company, sometimes a contract, and sometimes even political contacts. Often they can also leave for another facility. The patient has pain, fear, a queue number, and a complaint form.

Of course, doctors can also be victims of the system: overwork, poor organization, long shifts, managerial violence, staff shortages, sick pricing, and detached politics. We do not need to pretend that doctors are a caste of villains. But a profession of public trust has asymmetric accountability precisely because it has asymmetric power. The greater the power over another person’s body, documentation, time, suffering, and death, the greater the accountability and the stricter the consequence of abuse.

Today there is no counterweight. There are medical chambers, courts, prosecutors, the Rzecznik Praw Pacjenta (Patient Rights Ombudsman), the NFZ (National Health Fund), and audits. Each of these elements is needed, but none is the voice of the clients of the public system: clients who could say in plain language that we no longer trust this person, this company, this facility, this model of operation, and therefore we do not want to finance it from the common purse. We do not want to wait for a criminal judgment to decide whom we entrust with a public service.

This is not about vigilantism or revenge. It is about ordinary agency: the kind owed to the community that pays and is treated.

The hairdressers’ chamber and public money

Imagine an ordinary situation. We go to a hairdresser in a chain of salons. We are not satisfied with the service. The hairdresser cut our hair badly, was inattentive, cheated on the price, worked too long and made a mistake, or simply treated us as an obstacle between them and the end of the shift. We can leave and never return. We can tell family and friends that we do not recommend them. We can leave a review and warn others.

Does some chamber of hairdressers then raise the alarm that only it has the proper knowledge to assess the quality of the haircut? No. An expert may assess the technique of cutting, but the client can assess the relationship, trust, honesty, comfort, safety, and their own willingness to use the service again. They do not need to explain themselves to a professional corporation for not wanting to pay someone a second time.

In public health care it should be similar, only stronger. Because this is not about a haircut, but about health, life, dignity, and the body. If a community does not trust someone, that person does not have to be paid by the community. They may work privately, provided they have the right to practice and do not violate other laws.

Access to public money is a contract with us.

Patient Councils

Yesterday evening I had an idea that could improve the problem of asymmetry: Patient Councils, at the county and regional (voivodeship) levels. Not as another office, but as a missing layer of client representation.

We do not need a Chamber of Patients, because patients are not a professional corporation, nor a Patients’ Commission, because commissions usually write minutes. We need democratically elected bodies representing the clients of public health care, able to oblige the NFZ (National Health Fund) to refuse financing to people and entities in whom the community has lost trust.

A Patient Council would not decide whether a suture was made perfectly, whether the best surgical method was chosen, or whether a clinical decision was optimal in a given minute. That is the role of experts, court-appointed specialists, medical audits, chambers, courts, and disciplinary proceedings. The council would decide something else: whether a person, company, facility, or chain of subcontractors has preserved the minimum conditions of trust necessary for using public money.

In practice, such a council could:

  1. examine cases of abuse in public health care: fictitious shifts, dishonest settlements, queue manipulation, conflicts of interest, intimidation of whistleblowers, and violations of patient dignity;

  2. demand from the NFZ (National Health Fund) and facilities the documents necessary to assess a case, with medical-data protection and anonymization where necessary;

  3. hold public hearings, unless the patient’s welfare requires part of the material to be closed;

  4. issue decisions binding on the NFZ (National Health Fund) to temporarily or permanently prohibit contracting services connected with a person or entity;

  5. extend the prohibition to indirect workarounds: companies, foundations, sole proprietorships, consortia, and subcontractors, all those elegant gloves through which one might try to touch public money.

Today there is no one who can say such a sentence. We are missing a voice that could sound roughly like this:

We, the clients of the public health care system,
by decision of a democratically elected Patient Council,
oblige the NFZ (National Health Fund) to suspend financing of services linked
to the indicated person for a period of five years.

That would be a real client voice. Not a comment on X or Reddit. Not private revenge or a people’s court. An institutional, public, procedural voice of the community of system users.

Boundary conditions

Of course, the mechanism described above can itself become a tool of abuse. It is therefore worth naming the boundary conditions immediately.

First, Patient Councils must remain external to local arrangements. The smaller the community, the greater the risk of personal ties and retaliation. Therefore, in locally heated cases, the adjudicating panel should be mixed: partly local, partly drawn from other counties or voivodeships. It is a simple way to reduce the suffocation of a small arrangement.

Second, the decision must have a justification and an evidentiary trail. “We do not like the doctor” is not enough. One must show a pattern: fictitious presence, dishonest documentation, confirmed queue violations, conflicts of interest, abuse of advantage, harm to a whistleblower, humiliation of patients, refusal to cooperate with an audit.

Third, an appeals procedure is needed. First, the protection of the public interest; then a quick appeal to a higher-level council or an administrative court. In roles of public trust, the threshold for activating safeguards should be lower than the threshold for final condemnation. This is normal: when an airline pilot raises serious doubts, we do not wait for a crash before removing them from the controls.

Fourth, one must distinguish a ban on public financing from revoking the right to practice. A Patient Council does not have to revoke a PWZ (license to practice medicine). It may say: in our public system, we do not pay this person. This is a different sanction, more like a client’s decision to end cooperation than a criminal sentence.

Fifth, all conflicts of interest of council members must be public. If someone sits on a council and has family in a hospital, a contract with a facility, a relationship with a professional chamber, or a stake in a medical company, it does not automatically mean they are guilty of anything. It means that the information must be public, and in some cases such a person should not vote or should face strict criminal consequences.

Pillars of repair

Patient Councils are a pillar of agency, but not the only element that could help. A minimal repair package would include, among other things:

  • a public register of total payments from public funds by PWZ number (license to practice medicine), summed by person rather than by contract;
  • a public register of conflicts of interest: private offices, companies, subcontractors, managerial functions, and family ties where they enter contracting;
  • mandatory reporting of actual working time and presence, with detection of overlapping shifts;
  • whistleblower protection as infrastructure;
  • transparency of disciplinary proceedings as the rule, with exceptions to protect the patient;
  • a ban on public financing through intermediary chains for excluded people and entities;
  • money following the patient where it is safe and sensible;
  • the possibility of recording selected administrative-service contact points, with the patient’s consent and data protection, just as in other high-risk professions the course of an intervention is recorded.

Better allocation of money is not enough, because the problem is sometimes cheating and concealment. Procedure has no power to stop a thief if the thief knows how to fill it out. We therefore need not only procedures, but also living responsibility, reputation, transparency, and the community’s right to withdraw trust.

The broader context may also include the democratization of judicial and prosecutorial functions in local cases, the participation of lay judges, and proceedings concerning professions of public trust that remain external to local professional networks. That, however, is a topic for another text. Here it is enough to say one thing: public trust without public control is an empty phrase legitimizing abuse.

Regaining agency

The wrong answer to the present crisis is: “the system must be sealed.” Of course it must. But sealing is the language of a plumber, not the language of a citizen. The second answer is: “funding must be increased.” Perhaps. Yet more water in a leaky circuit still does not restore the client’s voice. The third answer is: “we need more audits.” Yes, but auditing without patient representation merely moves power from one desk to another.

So the question is not only: who will add money? The more important question is who will guarantee access, spending audits, transparency of conflicts of interest, and an end to private paths feeding on the public system.

I do not want health care in which the patient is raw material flowing between a facility, a contract, a company, a form, and a private office. I do not want health care in which an honest doctor has to work among schemers and then explain themselves for the whole group. I do not want a system in which a deceased person’s family reaches the hospital basement and meets a man with an unofficial price list. Finally, I do not want health care in which the state discovers after years that it might be useful to check whether one person is working in several places at once.

We need a system in which public money has a public trace, a public role has public responsibility, and the public client has public influence.

We are not petitioners. We are clients of a system we finance ourselves, and that client is also the honest doctor who does not want to lend their name to other people’s abuses. And such a client, even when using a shared service, has the right to say: we no longer trust this arrangement.

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