Private practice

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Applicable

The National Health Service in the United Kingdom provides free health care to each and every eligible person living in UK free at the point of delivery. Patients can see their General Practitioner, Accident and Emergency or Hospital Consultant and undergo various diagnostic and surgical procedures without paying a single penny. However there are times when patients feel that they should be able to receive earlier attention by a doctor of their choice, perhaps at a place of their liking. This is possible when the patients are willing to pay medical expenses from their own resources. Patients can see some general practitioners privately. This is a distinctly minority service, with notable exceptions, including "The Street", which is an area around London's Harley Street. Most of the information on this page relates to specialist medical services. There are a number of private health care providers in the UK who can be used by the patients capable of self funding. A number of health insurance schemes are available, with uptake often by corporate workers in large multinational institutions, but also well off individual patients. Private practice in UK is generally open to Consultants in the NHS who register themselves in Private Hospitals close to their NHS hospitals. The private practice committee in the local hospital and/or its operating company enrol the new consultant as one of the recognized specialists. As such institutions are now registered under the Care Home Act and are independent of the NHS such enrollment is likely to involve an annual bureaucratic check of the Consultants continued fitness to practice independent of the NHS process.

Contents

Issues around Private Practice

  • Private practice of clinicians has a bearing on the performance of the NHS in a number of ways. These include:
    • Allows more flexibility in prioritisation of NHS resources
    • Allows an easy way of separating uncontrolled emergency demand from predictable elective demand. Indeed much NHS elective provision is likely to be provided by private providers
  • Is orientated to elective rather than emergency presentations. Insured patients with an emergency presentation, but insured, may actually get a better medical assessment of an acute problem on the NHS, and indeed often have to accept this route as most private providers work at high elective bed capacities to maintain profits.
  • Well regulated private practice should benefit the patients, clinicians and the NHS. It often provides standards more consistent with individual and clinician aspirations than the NHS can provide.
  • Private practice could be run on a no profit no loss basis by charities. This is certainly how the hospice movement started.

Private treatment from GPs

For NHS GPS, the GP (GMS) contract regulations, Part 5, Para 24 (2) state:[1]

The contractor shall not, either itself or through any other person, demand or accept from any patient of its a fee or other remuneration, for its own or another's benefit, for -
(a) the provision of any treatment whether under the contract or otherwise; or
(b) any prescription or repeatable prescription for any drug, medicine or appliance,
except in the circumstances set out in Schedule 5.

The important word there is treatment. That would exclude GPs providing any treatments including cosmetic treatments to any of their own registered patients.

It is no longer considered be acceptable to offer a private prescription for treatments that are available on the NHS.[2]

Schedule 5 delineates those exceptional situations where GPs can charge their NHS patients.

How much GPs can charge

For some items that are chargeable in NHS general practice there are fixed prices set by e.g. government departments. Some pieces of work must be done - they are part of the contract; others are optional. If the price is set by others, you have the choice of doing it for the set price, or declining to do the work.

Many chargeable items have no set charge, however. In this situation practices can charge whatever they feel is reasonable - although, of course, it is good practice to agree the charges in advance. Some would recommend agreeing to provide, for example, reports to insurance companies only once payment has been received; others might feel this is unnecessarily awkward in the first instance (although it is probably sensible if whoever you are providing the report to has failed to honour agreements promptly in the past, or where they are not well known to you). The BMA provides advice on fees that may be charged here. They used to recommend rates for specific private services; but these recommendations were deemed to be anticompetitive. According to the Office of Fair Trading (since replaced by the Competition and Markets Authority):[3]

"In its simplest terms, a cartel is an agreement between businesses not to compete with each other. The agreement is usually secret, verbal and often informal.

Typically, cartel members may agree on:

  • prices
  • output levels
  • discounts
  • credit terms
  • which customers they will supply
  • which areas they will supply
  • who should win a contract (bid rigging).

Each of the above types of agreement is prohibited by the Competition Act and Article 81 of the EC Treaty. In addition, the Enterprise Act makes it a criminal offence for individuals to dishonestly take part in certain specified cartels, essentially those that involve price fixing, market sharing, limitation of production or supply or bid rigging.

Cartels can occur in almost any industry and can involve goods or services at the manufacturing, distribution or retail level.

Some sectors are more susceptible to cartels than others because of the structure or the way in which they operate. For example, where:

  • there are few competitors
  • the products have similar characteristics, leaving little scope for competition on quality or service
  • communication channels between competitors are already established
  • the industry is suffering from excess capacity or there is general recession.

It is clear from this that there is scope for illegal cartels in general practice - and indeed, they could arise quite inadvertently, if one practice asks a neighbouring practice, professional group, or medical forum for advice on how much they think they should charge for a particular service. Private surgeons have been fined for breaching competition law.[4]

DNUK cannot provide legal advice, but it seems likely that while it is probably an offence to advise others as to what they should charge for a particular service, there is nothing wrong in publishing what you charge, and providing this information to others on request - as long as the information is in the public domain. It is probably unwise to provide this information to others (other than clients or prospective clients) if it is not in the public domain.

Examples of information provided by practices on fees and charges

Benefits

  • Private practice enables the consultants to gain greater experience and practice in an environment of greater clinical freedom. For example they may recommend and be able to put into practice promptly the best treatment for an individual while the NHS is more likely to have agreed the best treatment for a group of individuals, or have a bureacracy involved in approving such treatment leading to delay.
  • The skills gained in private practice can be put to use in the NHS Hospitals and have motivated change in NHS services
  • Private practice can be an incentive for junior doctors to pursue a training career, improve skills and experience and become an unsupervised health professional (consultant) with incomes compariable to peers in industry and other professions, rather than lagging behind as tends to be the case in the public sector.
  • Private practice reduces the burden on the NHS by taking away a good number of financially well off patients, who continue to contribute to the NHS through National Insurance. These patients often have expectations with regard to non medical care that the NHS is not resourced to provide (eg single carpeted en suite rooms, fair quality catering and cleaning services)
  • The private health companies invest in the NHS for various diagnostic facilities and building programmes and so increase the hospital infrastructure.
  • Private patients get continuity of care and can almost always guarantee to see their consultant every day. In the NHS this is a distinct rariety as the European Working Time Directive applies(limiting hours of work).

Disadvantages

  • Private practice might treat patients as commodities, and illness as income generator. This is a particular risk where group contracts with say an insurer or the NHS occur.
  • Private practice issues may spoil the emotional atmosphere in some departments and lead to a charged atmosphere. Not all consultants may wish to do private practice, or those that do may be competing against each other outside their NHS practice.
  • While well organised private practice, in which all the consultants share work equally or as fairly as they wish, improves the atmosphere, a disorganised setup spoils the working relationships.
  • Consultants may devote more attention to their private work at the expense of the NHS work.
  • Cover arrangements in private hospitals tend to be thinner, both because of small size of institution, lack of resident on call staff or single resident on call doctor, or need for cover by consultant from home.
  • While all consultants are treated equally in the NHS, the Private practice earnings are dictated by market forces. There is a huge disparity in incomes between specialists from different specialties.
  • The consultants can get organized into self interested groups, working for the benefit of those loyal to them.
  • Patients can actually be electing for care that is known by randomised controlled trial evidence to be poorer. One example is stroke care, where specialist acute or rehabilitation units ofter better health outcomes than general medical wards. Only a few private providers can offer in the UK the critical mass to make such private units sustainable.

Private practice tips

For Surgeons and Physicians

They are known to the community through

  1. Word of mouth from the patients
  2. Advertisement by the private hospital and on the internet.
  3. Local and national newspapers reports
  4. Television programmes locally and nationally
  5. The referring GPs will know by a feedback from the patients and other GPs
  6. Liason with other specialists in the hospital
  7. Through medical community activities such as CME for GPs etc

For Anaesthetists

  1. A well organised group practice creates a conducive atmosphere and increases the profile of the department as a whole.
  2. In the abscence of a group practice individual anaesthetists have to develop rapport with the surgeons. It is good to get in touch with the newly appointed surgeons and announce your availability and interest in the particular type of surgery.
  3. Establishing private practice gets easier if you undertake departmental responsibilities such as Clinical director or clinical lead.

For other specialists

If you are a solo specialists for a particular field, a simple notification to local GPs and admission rights at the local private hospital is the first step to establish practice. The private provider masy well do some work for you.

Problems to individual clinicians from private practice

  • A good private practice actually usually follows a good NHS practice, not the other way around

QuotationMarkLeft.png Private Practice is for the second Jaguar QuotationMarkRight.pngPlastic surgeon, Aylesbury

  • Established practice has the advantages as the incumbents are known to local GPs
  • Private practice will erode into the leisure time and can effect the quality of life.
  • It is an extra commitment in addition to the NHS
  • Private practice may prove addictive and typical signs of withdrawal (depression etc) may develop when there is a halt to the practice from litigation etc.
  • It may well mean foregoing the financial awards implicate in NHS work of merit or working for national development of a speciality
  • Indeed you may overextend your own lifestyle and committments assuming your private practice income is a given
    • Do you have sickness/life insurance ?
    • Have you made pension arrangements for your private income ?
    • Might a divorce make you a slave to private practice ?
  • It requires administration support that is transparent (and sometimes does not exist !) in the NHS. You will require
    • To practice as a small business
    • Secretarial support
    • Perhaps to become an employer in its own right which imposes considerable potential burdens
  • Will require an accountant
  • Will require professional insurance, whose rates will reflect both your income and risk of your area of practice
  • Requires fair knowledge of business regulation (eg to prevent cartels - thats all your colleagues you reach an understanding with on how much to charge patients), the Inland Revenue (take care that a subcontractor who provides a service to you might not be seen as an employee by the IR...and VAT registration rules could catch you increasingly for some forms of private practice)
  • Take care for potential fraud against the NHS (by borrowing their resources, undertaking elective private work in NHS time, treating former private patients preferentially on the NHS).
  • Not declaring a potential conflict of interest.

References

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