Feature BMJ Investigation

A sixth of hospitals in England have expanded private patient options this year, the BMJ finds

BMJ 2013; 347 doi: http://dx.doi.org/10.1136/bmj.f4524 (Published 17 July 2013) Cite this as: BMJ 2013;347:f4524
  1. Gareth Iacobucci
  1. 1BMJ

As hospitals look for ways to boost their income, Gareth Iacobucci discovers that some are taking advantage of the rationing decisions being made by hard pressed clinical commissioning groups

A BMJ investigation shows that NHS hospital trusts in England are increasingly turning to income from private patients to generate additional funding, as cost pressures tighten restrictions on some services in the NHS.

Just a week after NHS England warned that the NHS might face a funding gap of £30bn (€35bn; $45bn) by 2020,1 the BMJ has shown that one in six hospitals have introduced new private treatment options this year.

A growing number of hospitals are introducing a new category of private patient, known as the “self funded” patient. Tariffs for this new category are based on estimates of what it costs the NHS to treat these patients and are considerably lower than the traditional rates charged to private patients.

John Appleby, chief economist at the healthcare think tank the King’s Fund, described the difference between the two categories as immaterial and the new category as a euphemism. “It is essentially paying privately to get some healthcare provided by the NHS. It is a private scheme.”

The BMJ investigation, which obtained data from 134 acute hospital trusts in England through requests made under freedom of information legislation, found that:

  • 119 trusts (89%) now offer private or “self funded” services

  • 21 (16%) added new self funding or private treatment options for 2013-14, and

  • 17 (13%) now allow patients to pay for one or more services at notional NHS rates, under the self funding scheme.

In the past year acute hospital trusts across England have added procedures in areas such as ophthalmology, radiology, and varicose vein surgery to their roster of services that patients can pay for at cheaper rates rather than the traditional private patient rates (box 1).

Box 1: What types of treatment are patients self funding at NHS hospitals?

  • Fertility services such as IVF

  • Ophthalmology services such as ranibizumab injections and cataract surgery

  • Radiology services such as magnetic resonance imaging and chemotherapy delivery

  • Screening for hereditary diseases, such as liver testing

  • Varicose vein removal

  • Treatment for carpal tunnel syndrome

  • Knee arthroscopy

  • Ganglion cyst removal

  • Inguinal hernia repair

  • Minor skin procedures

  • Vasectomy

  • Blepharoplasty

  • Circumcision

  • Dupuytren’s contracture treatment

  • Bunion surgery

The BMJ reported last year that a handful of trusts had begun offering NHS patients the choice of “self funding” for treatments and services that were subject to restrictions from commissioners or to lengthy waiting times on the NHS, such as in vitro fertilisation (IVF), bone scans, cancer surgery, and screening for hereditary diseases.2

The latest analysis provides new evidence of the options being offered and marketed by NHS trusts across England—and shows that the range of treatments available through self funding is expanding as cost pressures force tighter restrictions on the availability of some NHS services.

The leading private provider Care UK has also begun marketing self pay options at its NHS funded treatment centres for patients who “do not meet the threshold for NHS treatment.”

The findings come against the backdrop of clinical commissioning groups (CCGs) in England introducing new restrictions on referrals to secondary care, as documented in the first part of the BMJ’s investigation last week.3

Providers operating self funding schemes told the BMJ that the schemes allowed patients to access restricted treatments at a cheaper rate than in the private sector, making care more accessible.

A spokesman for NHS England, said, “Access to NHS services is based on clinical need, not an individual’s ability to pay. NHS trusts and foundation trusts are permitted to offer private services to patients, provided that any such services do not interfere with their obligations to NHS patients.”

But critics have said that the growth of self funding has muddied the waters between private care and the NHS and could undermine the founding principle of the NHS by creating a two tier system, particularly in combination with government rule changes that allow hospitals to raise up to 49% of funds through non-NHS work, removing the cap of around 2% set by the previous Labour government.4

NHS hospitals that offer self pay options

Among the hospitals to have introduced new options for patients in the past year include Warrington and Halton Hospitals NHS Foundation Trust, which recently began offering patients the opportunity to purchase varicose vein surgery for cosmetic purposes at “NHS rates” through its MyChoice service.5

Advertising the service on its website, the trust said, “There are some treatments provided in the past that may no longer be accessible through local NHS funding. However, the trust has been contacted by patients who still want to have these procedures. In order to give patients choice around their care, they have developed the MyChoice service. This allows patients to pay (self-fund) to have these procedures at the hospital at the standard NHS price.

“The fee they pay also goes directly back into patient care at the hospitals.”

Epsom and St Helier University Hospitals NHS Trust, one of the first to offer self funding for IVF patients, has now expanded its offering to allow patients to self fund transient elastography of the liver (FibroScan), vitreoretinal surgery, and ranibizumab (Lucentis) injections for wet age related macular degeneration.

Elsewhere, the Princess Alexandra Hospital NHS Trust in Harlow, Essex, now allows patients to privately fund a range of direct access and outpatient diagnostic imaging services, chemotherapy, and external beam radiotherapy at NHS prices.

Many trusts that the BMJ contacted, including Princess Alexandra, said they did not differentiate between “self funded” and “private” care. But some hospitals do make a distinction. In its marketing for its IVF service, Epsom and St Helier said, “We describe the treatment as ‘self-funded’ rather than ‘private’ because the treatment is exactly the same as for patients funded by the NHS. The charges we make are non-profit-making, i.e. they are at cost price. All income from self-funded patients is put back into the IVF programme.

“Some [commissioners] do fund IVF, but usually to a limited extent. Others do not fund IVF at all. The [commissioners] set their own criteria for treatment to which the assisted conception unit at St Helier Hospital must adhere. Sadly there is currently a significant waiting list for NHS treatment.”

Homerton University Hospital NHS Foundation Trust in east London, which offers self funding options to patients who “do not meet the eligibility criteria for NHS funded treatment or do not want to wait for NHS funding to become available,” differentiates between self funding and private care on the basis that private care offers the patient “exclusive single consultant-led care.”

But the King’s Fund’s Appleby said that, regardless of price, care was still being funded from patients’ own pockets and was driven by cost restrictions.

“Some say this is not private because they are providing the same service [as the NHS],” he said. “But if you then go on to say you will provide it if your local commissioner has taken on some sort of rationing decision, such as they will only provide a certain number of cycles of IVF or they have age limits, then of course you are buying something extra, you are buying access to the service.

“You are also jumping a waiting list as well. The ‘NHS rates’ is neither here nor there really. That’s just their pricing strategy.”

Critics have argued that self funding not only blurs the lines between NHS and private care but could also disadvantage NHS patients. The concern is partly driven by the fact that—unlike traditional private patients—self funding patients are often treated in the same premises as NHS patients.

Defining the difference between self funding and private patients

David Lock, a barrister and QC at No 5 Chambers, London, said that adherence to the law against people “topping up” their NHS care with private care, which used to be very clear cut, had been compromised in recent years.

“It is plainly unlawful to make NHS treatments contingent on a person purchasing additional private treatment. However, it’s never that straightforward. The idea that there used to be—of a [patient having a] completed consultant episode on the NHS and then a completely different consultant episode privately—has been blurred. The Department of Health guidance says you can top up, particularly with cancer drugs. This is a problem of NHS rationing.”

Does self funding adversely affect NHS patients?

Paul Flynn, chairman of the BMA’s Consultants Committee and a consultant obstetrician and gynaecologist in Swansea, said that the association feared that self funding schemes could adversely affect NHS patients.

He said, “The BMA has concerns about self funding, as it could create a two tier system whereby some patients can get treatments that others can’t because they can afford to pay for it. This undermines the principle of equity that should be at the heart of the NHS.

“We wouldn’t want NHS [hospitals] to be taking on significant numbers of self paying patients, as this could impact on the services offered to NHS patients.

“We would also be concerned if self paying patients jumped ahead of NHS patients due to the fact that they are paying for treatment.”

Care UK’s self paying options at NHS centres

The lines are arguably being blurred even further by a new scheme from the private provider Care UK, which recently introduced a new self pay option at four of its 11 NHS funded treatment centres across England. Here, patients can pay for treatments such as knee arthroscopy, treatment for carpal tunnel syndrome, and inguinal hernia repair at a cost described by Care UK as “less than similar services at a private hospital.”6

To promote the scheme, Care UK has produced leaflets marketing its services to GPs and patients. In its leaflet to patients it says, “If you require treatment, but cannot access it through the NHS, you may choose to opt for Self-Pay. This way, you’ll benefit from prompt medical care at a time that’s right for you—and with Care UK it may cost less than you might imagine.”7

Nicholas Hopkinson, a consultant chest physician in London, said he was concerned that private companies would position themselves through self funding to market their “premium” services to patients and said he opposed self funding as it could lead to an “inferior service” for those not paying.

“Inevitably, if you have a two tier service you will end up with an inferior service and a queue jumping service,” he said. “Once the private providers have integrated themselves into NHS provision, they’ll be in a position to offer people their premium service as well.”

A spokesman for Care UK said that NHS patients were the “over-riding priority” at its treatment centres, which currently see 70 000 NHS patients each year.

He said, “The small number of optional procedures offered to private patients equate to under 0.1% of our treatment centre services.

“Self pay patients will not be prioritised over NHS patients in any Care UK treatment centre. Virtually all of the services Care UK provides are for NHS patients and are free at the point of use.”

Getting round restrictions on IVF

Another NHS trust to introduce new self funding options for patients is Mid Cheshire Hospitals NHS Foundation Trust, which recently began offering “self funded” cycles of IVF and intracytoplasmic sperm injection for patients who have used up their NHS funded cycles of treatment of IVF.

Lynda Coughlin, the trust’s clinical lead for obstetrics and gynaecology, said the scheme was designed for couples whose NHS funded treatment cycles had been unsuccessful and who wished to “continue with ‘self-funded’ treatment through a team with which they have an existing rapport.”

She said, “Self funded treatment will provide a convenient, high quality package of care at a competitive price with the private sector.”

Patients choosing this option at Mid Cheshire are seen at NHS based clinics, but Coughlin said that self funded patients received “the same level of treatment as NHS funded patients” and “are not prioritised.”

She added, “We have the capacity in our clinics without any detriment to our NHS patients. Currently there is no NHS waiting list for IVF.”

The option is currently limited to couples who are already patients at the trust and have had treatment; but, if capacity allowed, Coughlin said that the option could be expanded in future to include patients who failed to meet the eligibility criteria for even one NHS funded cycle of treatment.

Need for transparency

Appleby said that although self funding options were not new, the expansion of what was being offered meant it was crucial they were strictly governed and separated from NHS care.

“Many NHS consultants and other healthcare workers in the NHS do private work. But the rules around it need to be completely open and transparent,” he said.

“The concern has always been how you demarcate between the private and public service. To what extent does a patient who is, say, paying for IVF somehow dip in and out of public and private within the same hospital? Does this start to muddy the provision of public-private healthcare within the NHS?”

Appleby said that trusts that operated self pay schemes must be able to show that NHS patients were not being adversely affected.

“If it has any negative impact on the NHS and patients, then clearly that’s not right,” he said. “My argument would be there must be no ‘opportunity costs’ falling on NHS funded patients. I think the hospital needs to positively demonstrate clearly that there is no worsening of waiting times, for example, and that the service NHS patients are getting is completely unaffected. There should be an onus on trusts to show that.”

Expanding the self funding category

The Foundation Trust Network, which represents NHS hospital foundation trusts in England, said it understood the concerns that NHS patients could be adversely affected by self funding but added that most trusts had systems in place to stop paying patients “queue jumping” ahead of NHS patients when being treated in the same facility (box 2).

The network’s regulatory policy consultant, Frances Blunden, said that the network expected more treatments to be available to self funding in the future, with the potential for NHS funding to be restricted for any treatment deemed to be of limited value by the National Institute for Health and Care Excellence (NICE).

She said, “We already know there are a lot of procedures undertaken on the NHS that NICE has identified as of minimal value, so potentially all of those could become part of that [self funding].”

Box 2: Arguments for and against “self funded” care

For

Frances Blunden, regulatory policy consultant at the Foundation Trust Network, said it acknowledged concerns that NHS patients could be adversely affected by “self funders” but said that most trusts had systems in place to stop paying patients jumping the queue ahead of NHS patients when being treated in the same facility.

“In most circumstances they [trusts] tend to run self funded and NHS alongside each other, so people don’t queue jump—which must be the great concern—and people who are self funding get the same structures around waiting lists and so on,” Blunden explained.

“When you consider that these [treatments] may well be things that commissioners are not funding, that there is demand from the public, and the public is prepared to pay to get them, then we don’t see that it’s necessarily going to have a significant impact on NHS treatment.

“At the moment, a lot of it [the concern] is about people taking an ideological stand about whether it is a good thing or a bad thing. In that respect we are totally neutral. If it’s providing good patient care and is in the interests of patients, then we would be supportive of it.

“You would have to rely on the integrity of the organisations and that they are fully committed to the NHS and to providing good patient care.”

Against

David Hunter, professor of health policy and management at Durham University, said that self funding schemes, whether run by private companies or NHS trusts, could prove to be “the thin end of the wedge” and pave the way for “a two tier or multi-tier system which is both complicated and inequitable.”

He told the BMJ, “For a start, care is not free at the point of need in all cases, and such schemes are hardly equitable in their likely impact across the population and all social groups. They also get the public used to the idea of ‘top-up’ payments over and above what they already pay in taxes.”

Hunter also warned that self funding schemes could lead to commissioners and providers focusing their energies on more lucrative procedures.

“It opens the way for ‘gaming’ and possibly introducing perverse incentives among commissioners and providers as a result of regarding such schemes as offering opportunities to raise additional funds through such means rather than by offering the service through the normal NHS route,” he said.

Notes

Cite this as: BMJ 2013;347:f4524

Footnotes

  • Competing interests: I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: None.

  • bmj.com Feature: GPs put the squeeze on access to hospital care (BMJ 2013;347:f4432, doi:10.1136/bmj.f4432)

References