Private practice in internal medicine in the UK
Good for straightforward, low-risk problems and procedures
The role of private practice in health provision has long been prominent in UK national politics, never more so than now with the NHS under such stress.
Apart from a few paragraphs toward the end of this post I will however leave discussion of the politics, economics and ethics of private practice to experts in those fields.
Instead I will confine myself to what I learned in my 32 years of private practice in rheumatology alongside my NHS work.
Private practice in internal medicine
Basic requirements of the private practitioner
The Three A’s (Affability, Availability and Ability) are the fundamental requirement of any practitioner in private practice in the UK.
Private practice requires consultants to perform many roles that in the NHS they would delegate to their juniors.
Thus consultants who don’t suffer fools gladly, who rely on their status in the NHS hierarchy, and who don’t like to see extra patients inconveniently at the end of long clinics will find private practice hard work in any speciality .
Which internal medical subspecialities are best suited to private practice?
Private outpatient consultations in nearly all internal medical specialities generally work well for both patient and doctor, for reasons that I’ll explain later.
However for anyone considering private practice it’s important to be aware that there is unlikely to be enough private work in any non-surgical speciality outside London and a few other large UK centres to allow any but a small number of physicians to undertake fulltime private practice.
Additionally, for any level of care beyond outpatient consultation, private practice works best for specialities with easily-costed activities, such as those specialities that offer low-risk interventions or have well-defined boundaries. Examples include surgical specialities, radiology and anaesthetics.
Some “wire- and pipe-pushing” internal medical activities are suited to private practice as long as they are performed in an appropriate environment. These include several areas in cardiology, as well as diagnostic and therapeutic endoscopy in gastroenterology and respiratory medicine. Dermatology also offers low-risk practical procedures.
Patients with complex medical conditions and multiple comorbidities
In my experience it is extremely difficult to deal with complex diagnostic and clinical management problems outside the NHS.
This applies particularly to patients with multiple comorbidities who require the continuing input of other specialists and of junior medical staff, specialist allied health professionals and specialist nurses. I tried to avoid such work in my private practice.
Partnerships
Groups of private practitioners working in the same speciality sometimes pool their resources and expenses in limited liability partnerships, some of which own their practice premises.
These partnerships exist mainly to share expenses and duty rotas but the collaboration involved in the partnership sometimes helps to tone down potentially-toxic rivalries between specialists in their private practices that can blow back into their NHS speciality departments, causing huge damage.
Advantages of private practice to the physician
From the physician’s viewpoint private practice in an internal medical speciality offers:
outpatient consultations that are under less time pressure and are subject to fewer distractions such as staff entering the consultant’s room to discuss cases or to ask what to do when a patient has turned up unexpectedly in the clinic for a previously-postponed appointment!
independent practice, away from the inevitable restrictions and frustrations of a large NHS hospital.
predictability and comfort – cancellation and curtailment of clinics due to staff shortages are very unusual, physicians are made to feel welcome when they arrive to do their clinics and are well looked after, with good quality hot drinks and sandwiches readily available.
income additional to that from their NHS employment.
Advantages of private medicine to the patient
These include:
Much shorter waiting times for appointments and treatment compared with the NHS.
Comfortable waiting and consulting rooms, with personal needs catered for.
Personal medical attention – patients see the consultant they want to see every time they attend, while longer, less-pressured consultations allow adequate time for their questions. Any in-patient care is provided directly by the consultant.
Disadvantages of private practice to the physician
Medical insurers scrutinise the invoices of private specialists closely. If specialists’ fees are higher than those of their peers, insurers may not reimburse them fully. A physician will thus find it difficult to charge much more for a particularly complex, lengthy new patient consultation than for a more-straightforward consultation.
A growing number of uninsured people are using private medicine at the moment. Uninsured patients often have to dig deeply into their savings to pay for consultations, many unaware that their treatment (and costs) may be open-ended. That may lead to pressure on specialists to charge different rates for uninsured and insured patients. Many physicians feel uncomfortable offering private medicine in such circumstances unless they are able to offer an opinion or treatment that cannot be obtained through the NHS.
Setting up and running a private practice is costly and can be hard work. Significant research may be needed to find suitable consulting premises, a secretary and to set optimal consultation durations and charges, which will depend heavily on what insurers allow.
Most physicians have to pay for their consulting rooms and secretaries even when they are on holiday or not seeing patients for example because of personal illness.
The private specialist is never off call, including nights and weekends, and has to find someone to cover their private patients when they go on holiday.
When private patients need to transfer to the NHS at short notice for more-complex treatment than the private sector can provide, the private practitioner is reliant on the goodwill of NHS colleagues for a smooth transfer. The goodwill shown to the private practitioner on such occasions depends on their involvement and reputation in the NHS.
Private practitioners also have to keep a ledger of their expenses and of patients seen and charged, as well as separate bank accounts for their private practice. They have to include the high cost of the often-complex work by their accountants involved in preparing their accounts for HM Revenue and Customs (HMRC) as well as the cost of secure storage of patient notes (unless they use a hospital-based electronic patient record [EPR]).
If one’s private practice is based in a large private hospital many of these expenses are included in the (usually considerable) consulting room charges. Practitioners who own their own premises have to organise everything themselves.
For all these reasons, as the volume of my private practice declined in my later years in clinical practice I decided to retire from private practice and take up my NHS hospital’s offer of an extra NHS clinic. That clinic yielded a net income that was more than I could earn from the equivalent amount of time spent in the private sector, without any expenses.
Disadvantages of private practice to the patient
Patients attending private hospitals for consultations or single defined procedures are usually delighted with the ambience of the hospital, the ease of the procedure and its outcome.
However there is some evidence (awaiting confirmation) that the increase in outsourcing of care from the NHS to private providers between 2013 – 2020 corresponded with significantly increased rates of treatable mortality “potentially as a result of a decline in the quality of privately-provided health-care services [compared with the NHS]”.
Patients with private health insurance
Patients with private health insurance should be the mainstay of private practice. However the proportion of the UK population with any type of private health insurance, although fairly steady, is low - 12.4% in 2008, around 11% by 2014 and possibly around 13% this year, compared with over 50% in Australia.
Comprehensive private medical insurance is very expensive unless it is provided as a perk by employers.
Uninsured patients
Medical conditions that the patient suffered before the start of their private health insurance are often excluded from cover.
The rapidly growing proportion of uninsured patients who see private specialists in the UK are sometimes unpleasantly surprised to discover that if they cannot afford the whole course of private treatment they will have to be re-referred by their GP to rejoin the NHS queue along with other patients with their condition. However having bypassed the early stages of the NHS process, they might in some cases be able to join the NHS queue further along than if they had sought NHS treatment from the start.
A crisis for the patient and their specialist occurs when uninsured patients who are ineligible for NHS treatment (ie those who are not “ordinarily resident” in the UK) cannot afford to continue private treatment and cannot transfer to the NHS. To avoid this risk the private specialist should establish the patient’s NHS eligibility before offering any treatment.
The relationship between private hospitals and the consultants who work in them.
The representatives of private healthcare will argue with justification that they provide an important public service. I would add that the public service that they provide is conditional on its profitability to their business.
This may mean that private providers don’t always welcome practitioners in relatively low-earning specialities. More than once managers of private hospitals have made clear to me that they favoured consultants in other specialities who sent far more business their way than I ever could.
Who employs the specialist?
With few exceptions consultants who work in private hospitals are not employed by those hospitals; the private hospital acts as a contractor supplying services to specialists and patients.
That can create a very complicated division of liability when things go wrong. Many private providers are Designated Bodies and so have a Responsible Officer and provide appraisal to doctors whose main work connection is with them. However there have been allegations that the disavowal by private hospitals of full responsibility for what medical practitioners do in their facilities makes them susceptible to exploitation by ill-meaning or incompetent doctors and leaves patients at risk. Those making these allegations hold that Care Quality Commission (CQC) inspections, however thorough, do not have the power to directly address this vulnerability.
The Private Healthcare Information Network (PHIN) is a publicly-accessible information resource funded by a levy on each private hospital patient, but also does not appear to address the private hospital’s role in specialist governance and liability.
Conclusions
From the private physician’s viewpoint
Private healthcare in the UK is expensive for both patients and for physicians, who need sufficient turnover to cover their large costs.
Although private practice may suit consultants who like to work alone, it can be professionally isolated, seldom offering the support of formal private-sector multidisciplinary meetings.
Certainly outside London the private sector relies on back- up from the NHS to deal with the complex open-ended clinical problems, clinical uncertainty and expensive investigations that characterise unstable chronic disease.
That’s why most physicians in private practice offer only outpatient consultations and straightforward low-risk procedures, and transfer their patients with complicated problems to the NHS.
Healthcare as part of a country’s infrastructure
From a practical, utilitarian point of view good quality healthcare, like clean water, is an integral part of the basic infrastructure of any effectively-functioning country. Effective healthcare whether provided by the state, the private sector or by combinations of the two benefits the whole community.
From that it follows that government has a key role in health provision to ensure that the whole population is able to receive uniformly-competent treatment when they need it, regardless of their personal financial circumstances. That allows people to get on with their lives and jobs, helping to generate the wealth that provides pension contributions as well as the tax that helps to pay for the country’s infrastructure.
This also applies to medical and social care for the elderly whose support requirements might otherwise draw some younger care-giving family members away from the workforce.
Privately-provided healthcare can never be a truly price-competitive business because medicine and nursing are monopoly professions providing complex, expensive products. It is not surprising that the UK Competition and Markets Authority after a two year investigation into private healthcare in the UK concluded that certain features within private healthcare markets were leading to adverse effects on competition.
In healthcare quality trumps all. Thus if only minimal price competition is possible between well-regulated private practitioners because they all have similar costs, competition between healthcare providers, other than that based on the standard of their facilities, must centre on convenience to the patient, including shorter waiting lists. That is highly-desirable but could only be achieved with much larger numbers of healthcare staff than at present.
Many more-straightforward aspects of health care such as outpatient consultation and many routine procedures could probably be provided to the population as effectively and equitably by the private sector as by the NHS - if costs were kept no higher than in the NHS.
It’s worth repeating that private sector provision is often not fully-independent; private healthcare providers rely on the NHS to train large numbers of their staff, while many receive at least some funding from the NHS and fall back on the NHS when necessary. They are thus contractors to the state who need to be subjected to the same close, even-handed and consistent regulation as the NHS.
Privatising the NHS
The best health systems around the world offer universal coverage, are well-regulated, well-equipped, well-staffed and well-funded, often from several sources.
Privatising the NHS wouldn’t come cheap, and certainly no cheaper than the NHS.
Until the understaffing in the total UK health workforce is corrected it’s hard to see how any privatised system could offer much more to the British population than the NHS does at the moment. To rectify understaffing will take years, even decades.
An insurance-based health service would cost more to administer than the current NHS. For example healthcare fraud worldwide (much of it committed against insurers) is estimated to causes losses of 3%-5% and possibly more than 10% in some cases; its prevention is costly. Inspection and regulation of many more private practitioners than at present is also likely to be expensive.
Private companies providing comprehensive health services in the UK have struggled to stay the course in a time of austerity because of their difficulty in providing unprofitable essential services in the face of restricted financial support from the state.
Taking all these these things into consideration, attempts to privatise the NHS other than possibly in a few areas around its edges would, for the moment, appear to be pointless. The money would be better spent on improving social care to ameliorate delayed discharge of patients from NHS hospitals.
Difficult to disagree with a single sentence written by my earnest & insightful colleague. Good luck to those who venture into independent practice.