Private practice is unethical—and doctors should give it up
BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h2299 (Published 05 May 2015) Cite this as: BMJ 2015;350:h2299
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Thanks for this post. You are fully in line with my own convictions.
The dual practice is a treat for the Whole NHS. And in LMIC, this is much more visible.
There is a huge and urgent need to call for a reform of the status of health workers at Worldwide Work Office to tackle this issue in a much more systemic way.
Thanks one again.
Competing interests: No competing interests
I have read with great interest the responses to my article on line at bmj.com and on the newspaper websites.
Opposition from the medical profession to my article seems to take two forms; firstly (and most commonly) there are those who believe it is perfectly possible to behave ethically in private practice. They almost all accept that conflicts exist and can name doctors who have abused the system, but it does not happen to them. Many express either pity or scorn for me that I lacked the moral fibre (which they hold in spades) to resist the substantial financial incentives.
Secondly, there are a few who simply cannot understand my misgivings. Private practice is a business. And like any business, the name of the game is to make as much profit as possible. As long as the police and the GMC are not interested in your affairs, what’s the problem? Go ahead and make as much money as you can.
I do not hold strong views on healthcare models in other countries apart from the general comment that anyone who consults a doctor working on a fee for service basis faces a dilemma, whether the doctor’s main focus is on the patient’s health or their chequebook. This statement is often greeted with outrage but it seems self-evident to me. I accept that most patients across the globe face this dilemma.
Also I am not unduly concerned about doctors who devote all their time to private practice. My main point is that it is difficult to work in both the private and public sectors at the same time. There are two further reasons why I believe this to be unethical, but did not have space to mention in my article. Firstly, it divides the profession, splitting us into the ‘haves’ and the ‘have-nots’. Is it purely coincidental that the specialties that have the greatest recruitment problems are those where the opportunity for private work is very low or non-existent? And yet these disciplines (emergency medicine, geriatrics, acute medicine, palliative care etc.) are exactly those that desperately need more doctors to cope with the ever-increasing tide of emergency admissions to hospital and care for our aging population.
Secondly, it divides the medical profession from the allied professions (nurses, radiographers, ODA’s etc.). A consultant carrying out a private procedure in an NHS hospital will receive a substantial fee, whereas the team assisting him will be paid standard NHS rates, even if this procedure is done outside normal working hours. A bag of doughnuts doesn’t really address this imbalance.
My comment that private practice ‘…is largely a con’ has proved particularly inflammatory, I cannot see why. For sure, if you want to have your piles fixed in a facility with a private room where you can order a bottle of claret with your evening meal, you will not get this on the NHS. But if you really believe that private hospitals offer safe, quality care I would urge you to read the CHPI report (http://chpi.org.uk/wp-content/uploads/2014/08/CHPI-PatientSafety-Aug2014...) and think again.
Competing interests: No competing interests
Sir
It is unfair to classify private practice as unethical. I work as a private medical practitioner without getting any funds or help from the NHS, DOH or the community. Time after time, successive governments have tried to tear apart private practice through regulation and revalidation. I have to pay rent, rates, staff, MDU, utility, expenses for Revalidation/GMC fee, CQC fee, liability and premises insurance, costs for participating continued medical education and business promotion.
Why do people still cling on to the NHS? Why could they not take risk, like me, of entering into full time private practice, and if they are talented enough they can make a satisfactory living not under the umbrella of anyone and obeying guidelines on budget and targets? As you accuse I have never sent a patient for unnecessary investigations and I have never had any sneaky pact with pharmaceutical companies, or private hospitals.
Take this as a challenge!
Dr.C.J.George FRCS
Competing interests: No competing interests
Your article by Dr John Dean emphasises the economic motives for NHS consultants also doing private practice..
I would emphasise that there are deeper problems involved.
This two-tier health system arose before the introduction of the NHS in July 1948. Aneurin Bevan faced 85% opposition from the BMA. He, therefore, allowed private beds to remain in the nationalised hospitals. Thus Bevan was both the best and the worst of all health secretaries.
In my first eye position in the NHS I served under two excellent eye surgeons. Apparently they had not spoken to each other for twelve years as a result of competition for private patients. This problem is still present today with NHS consultants not cooperating fully with their colleagues.
One of our local consultants recently retired from the NHS. His wife explained to us that his NHS colleagues were broadcasting widely that he had retired in her view to diminish his private practice.
A few years ago the Lancet published a paper demonstrating the increased breakup of long-standing marriages because of the time spent away from home doing private work on top of their NHS duties.
The conscientious do not escape either. My late father, Norman Jory, ENT surgeon at Barts and with a modest Harley Street practice was always the last to leave his NHS clinics. He died from heart failure at the age of 69 from overwork.
When I returned from Canada, after 18 years as an eye consultant, I was asked to look after Salisbury because of the ill health of the incumbent, John Ogg.
I followed my father`s practice of always being the last to leave my NHS clinic. At this stage I was not in a fit state to see private patients in the nearby private hospital.
Because of my many contacts with government in Canada I have been advising them not to allow this double standard of health care. In my opinion, it prevents the NHS from being the finest health system in the world. So far they have taken my advice. Consultants should choose either NHS or private practice.
Yours sincerely
William Jory FRCS(C) FRCOphth
General Council of the Canadian Medical Association 1972-1984
Past President of the British Columbia Medical Association 1976-77 and 1982-83
Romsey, Hants.
Competing interests: No competing interests
We would like to respond the letter by John Dean, titled: "Private Practice is Unethical – and doctors should give it up" (BMJ 2015; 350:h2299).
Affluent people in China have some other concepts about the treatment of their illness no matter acute of chronic. They need the directors of department and experts for their treatment at any cost either by gift or invitation of dinner. In Chinese, public hospital's outpatient departments are mostly run by experienced doctors, and the procedure is done by a team where the respective experts intervene for a particular subject’s irrespective of their financial status. Equality is given to each and every patient. However, rich patients need that the ‘head of department’ should care for him all the way until discharge. From a patien'st point of view, it is justified that they need the senior most doctors for treatment. What about the experts, those who have served decades and have the pressure of department and administrative work? How should they cope with this all meshed together? Taking all of this into account, the government has made a good arrangement for every class of people, whether they are rich, middle class or the poorest one.
In China, Public hospitals are considerably better and well equipped than private hospitals and clinics. Government has provided a lot more facilities to the patients for their treatment and insurance policy. For the rich people, there are VIP clinics in public hospitals where they could have their meeting with desired physicians and have the better consultation they seek. Not for patients, has the government considered the expert doctors as well, by providing them with many financial benefits rather than their junior doctors.
It does not mean that there is bias in the treatment according to financial conditions. In China, public hospitals provide the good facility, and all the patients are considered first priority according to their ailment. However, there is certain grading of patient's ward and charges such as VIP clinics and expert outpatient charges. We assume this is much fairer to the patients and doctors too to get their actual value of money and time.
Yes, we favor private practice in some circumstances if someone needs home treatment such as daily injections, Physiotherapy exercises, surgical dressing, etc. And that should be up to the discretion of the patient and their relatives. Every patient has different concepts and financial conditions. Considering the choice of people, doctors and nurses could entertain such patients while they are off duty. This is my opinion.
Specialized assistance, having access to tests and devices and hospital care tends to be much better in Chinese public hospitals in contrast to the private hospitals. Private hospital care facilities could possibly be less satisfactory with respect to the staff members, required health apparatus, and suitable interventional team, as well as the nursing care unit as the government hospitals possesses, in China.
In public institutional hospitals students and junior residents have the chance to learn a lot, and this is much important for better treatment to patients and also for the medical discipline. Specialist could cure someone while in private practice, nevertheless, the trend of the treatment of particular illness will probably be restricted up to them only. On the other hand, junior doctors have no privilege to learn about those specific things. Yes, there are a few sectors where private consultation could play a vital role in the patients such as nursing, psychiatry treatment and physiotherapist guidance, etc, where the patient could get better service at their home or private clinics and get substantial benefits.
Finally, it would be imperative to consider which sort of disease needs attention in which sector Private OR Public.
Competing interests: No competing interests
I left the NHS because it was unethical!
Resignation came after 25 years in the Service and 8 years as consultant surgeon at a University Hospital.
My departure was driven by the loss of command and control of (my) patients’ journey from community to hospital and back.
I was stopped from seeing new patients for more than a year because of the number of referrals generated. A system where surgeon A saw new patients, surgeon B operated on them and surgeon C reviewed them, was endorsed.
Is that professional or ethical?
Profit?! Well, doctors in the NHS are addicted to a salary and pension. Like their patients, few precisely appreciate the high costs of care. They don’t have to! It’s not their business. Independent practitioners are acutely aware of outgoings. To survive they have to be effective in both service and performance. Nowadays outcomes are under rigorous scrutiny. Charlatans may fool some of the people some of the time but not all of the people all of the time!
I now work in an independent practice, which I finance and manage. My patients are funded by insurance schemes, their savings, or the State. Someone has to pay for health. The sooner Society gets that clear, the better.
The monopoly of the NHS needs to be challenged to improve. We simply cannot afford not to.
Competing interests: No competing interests
Editor
The responses to this article form a very interesting melange with advocates on both sides, though a fair amount of self-justification from people who clearly have an interest in or record of private practice. The anti-brigade don't perhaps feel the need to write in and justify something they aren't engaged in in the first place.
Many respondents are from countries where even if services are state funded, universal and free at the point of delivery, the doctors nonetheless operate as independent contractors on a fee for service basis and where huge pay differentials exist between specialities - often driving doctors into those where most money to be made and not into those specialities and areas where they are most needed - increasingly those with complex comorbidities, frailty etc.
Its important to remember that in large parts of the UK where levels of social deprivation are high, where private health insurance among the population is rare and in many acute specialities (emergency medicine, acute medicine, geriatric medicine, trauma surgery, stroke, acute paediatrics) or others such as palliative care there is little market in any case. In a UK context, if people are acutely ill or medically complex or in need of a hospital with full ICU/team of on call specialities, etc they come to public hospitals. And when people in private hospitals do become ill, they are generally shipped back to the NHS pronto. Private hospitals here are set up to deal with outpatient work, diagnostics and elective procedures, which can make money for the hospitals and for the doctors working in them. Not the bulk of the medically complex patients who form the bulk of hospital inpatient activity.
I feel bad for Dr Dean that he felt the need to publish a quasi retraction. He is entitled to express his opinion in the BMJ (though of course anyone publishing here should realise it has a high profile) without being made to feel like a pariah by colleagues.
I am astonished by the assertion of Mr Dickson that Private Practice improves NHS care because only those doctors who provide excellent care to NHS patients will gain a significant private practice income. Contorted and reprehensible, speaking volumes about instrinsic motivation and insulting the thousand of NHS consultants who have no intention of carrying out private practice but are committed nonetheless to their NHS patients
Moving on to the doctor whose son is an engineer and yet doesn't feel his state-subsidised education must be used in the public sector, there is a material difference. Doctors trained in the UK four nations have received not just their University education but also all their clinical training in publicly funded institutions. It is the NHS that delivers all the training and it is the NHS that provides the majority of health care (around 93%). This is not analogous to engineering and of course the cost of education and training for doctors is far higher, with student fees only covering a fraction of the real cost and then postgraduate training in practice all being NHS -funded. Most doctors doing private practice rely on the NHS for their ongoing CPD, appraisal, revalidation, mandatory training, and for the credibility and profile that allows them to practice privately. The private hospitals where they sometimes work don't have to bear any of this.
The suggestion that teaching, college work, advisory work, training, research, etc also distract from day to day NHS patient care or that doctors might be just as tired from a night on call in the NHS as from a Sunday in the private hospital, is also disingenuous. All those activities are helping to train and support and revalidate NHS staff and improve care for NHS patients - which is not quite the same as increasing ones own income by working privately.
We also have the argument advanced that private practice is ethical because it provides treatments which the state will not - but many of these treatments probably shouldn't be carried out in the first place, however much patients are prepared to pay. And when it comes to jumping statist waiting lists . we need to reflect that those waiting lists might be shorter if the doctors providing the private sessions were tackling the same lists within the public sector. Until the government in the UK imposed targets to reduce waiting times, we were utterly complacent about waits for elective procedures or even assessments to be put on those lists. Our professionalism was compromised by respect for private practice income in many cases.
I wouldn't argue for one moment that doctors should be banned per se from practicing privately. However, given that very few of them in the UK could actually make the same living if they left the NHS altogether, we should certainly question whether the status quo of allowing doctors trained by the NHS and with their primary employment and support coming the NHS to do private practice alongside their NHS work should be allowed to continue.
There is no way, even if it is in job plans that some doctors can commit fully to the NHS when they are earning half as much again (or more) from private income as from their "day job".
Should we stop them altogether? Maybe. But should a doctor feel able to repent in public about his former fixation with private income without being judged. You Bet
David Oliver
Competing interests: No competing interests
Having read the responses to this Personal view there seem to be several themes.
For instance, “Doctors are trained for and paid for by taxes and should therefore work for the NHS”. My son was equally funded by the taxpayer for his engineering degree, earns more than a medical graduate of similar age and experience, and works significantly less hours. He has not been required to work for any nationalised engineering service.
Or “it distracts from NHS duties, including non-availability to interact with patients or relatives”. No one pointed out this could be said of College activities, management duties, BMA committees or being knackered after a night on call with no junior support.
Or “ if they were more committed to the NHS there would be no need for private practice” No mention of the 48 hour limit on NHS duties, often ignored by consultants. It has been shown that consultants regularly exceed the notional 40 hour week by between 8 and 10 hours, often unpaid. How many more hours must they do? Ironically it is those very specialties in which consultants have been shown to do the most number of NHS hours that have the biggest opportunity for private practice.
Or “it’s not fair for patients who cant’ afford it” That’s true of people who can’t afford a Series 7 BMW and have to drive a Golf (or those poor souls who have to drive a motorbike), but we don’t suggest that cars should all be the same. Allied to this is that it’s unethical to treat patients for money, as if anyone would work for the NHS for free. We all get paid at the expense of our patients misfortunes, it’s no different if they pay us via taxes or a cheque.
There are, of course, individuals who do private practice who behave unethically and who can be criticised for exploiting the worried well. There are also NHS doctors who are lazy, unproductive, incompetent and dangerous. We don’t suggest scrapping the NHS because of them. We take steps to try and identify them and resolve the underlying problem. The private system actually tends to reward consultants who have busy NHS practices who serve their referrers (GP’s) well and have good reputations for ability and efficiency.
One theme that hasn’t been explored is the almost Stalinist tendency of the NHS to restrict the scope clinical practice to the detriment of groups of patients. Without access to non NHS clinical care these patient are effectively being denied appropriate management. I am not referring to NICE guidelines, although there’s a whole world of opportunity there, but decisions not to fund effective treatments for certain conditions. I have recently had funding for a clinical service I introduced and developed arbitrarily withdrawn because savings needed to be made. It wasn’t a life saving service, but very effective and relatively cheap. And very popular. Now those patients have no choice but to opt for private treatment. In order not to be accused of profiting from this situation, despite no one else in my region seeming to be interested, I have opted not to take private referrals for this service. Is this ethical of me?
Peter Ramsay-Baggs
Consultant, The Ulster Hospital
Competing interests: I work in the NHS and have a small private practice. I sometimes do WLI work. I have been Chairman of Medical staff at the Ulster Independent Clinic in the past.
Private practice is as bad or as good as you make it.
When done in competition with other paid responsibilities, the temptations may be much but not insurmountable.
As in all other areas, self discipline is crucial to maintain balance. The same self discipline that is required for the academic who may be tempted to cut down clinical and teaching responsibilties for which he is being part paid in favour of paper publications to advance his academic career with the result that he is hardly seen by students or patients whom he is paid to handle.
It is always about disciplined choices and constructive restraints when faced with such scenarios as the author describes.
And there are many advantages to providing options of private care to patients who so wish and can afford, including freeing up slots on the public lists for less wealthy sick people.
It is a bit of a generalization to characterize private care in 'greedy-needy' terms.
I have found that there is in fact greater direct accountability between doctors and their patients In private settings than in the 'crowded teams' of public settings, where passing the buck often rears its ugly head amidst staff with grossly unequal commitments to any one case.
Competing interests: Run a private hospital
Adding oil to the fire: is this another attempt at stimulating discussion or is it self-justification in defence of what was alleged?
Dear Editors
I am uncertain of the intent of Dr Dean from his latest rapid response but I would naturally understand if even more doctors would be outraged by his latest input to the discussion in addition to those already incited by his original article.
I am sure that there will be some readers who will be less than impressed by his first rapid response which included an attempt at apologising to his immediate cardiologist colleagues and stating that his “arrows were aimed at more distant professional acquaintances”. Certainly I think this remark could very be misinterpreted (or rather correctly construed as the latest response reflected) as painting the entire cohort of doctors working in the private sector (part-time or full-time) with same brush of tar.
Dr Dean repeated his assertion that the whole business (of private practice) is “largely a con” and is yet surprised that this statement is particularly inflammatory. Any high school student would be able to offer reasons why any statement calling any group of working people can naturally be considered as inflammatory. Try doing that to public servants sometimes.
Dr Dean wrote that “Also I am not unduly concerned about doctors who devote all their time to private practice. My main point is that it is difficult to work in both the private and public sectors at the same time.”, but what does any reasonable person conclude when you again call private practice largely a con in your closing statement. What is the reader suppose to believe?
Seriously, Dr Dean, let’s not play games here.
You used the CHPI report Patient Safety in Private Hospital as a pedestal of evidence to justify private medicine as “largely a con”. Perhaps you should look at the latest Care Quality Commission report “The state of health care and adult social care in England 2013/4” where 65 out of 82 acute NHS hospitals (79%) are assessed as requiring improvement or inadequate and only 78% NHS acute trust is rated as aligned with overall provider rating. Of course the government funded CQC cut the NHS some slack for this result by repeatedly stressing that they have started to used a stricter inspection process, the same process which will be applied to the independent (private) hospitals which in 2013/14 93% of services was assessed as meeting standards in safeguarding and safety (in 2012/3 NHS and private hospitals has ratings of 87% and 92%).
It makes one wonder what data the authors commissioned by the independent CHPI is using and how can the CQC get it so wrong? Perhaps the NHS should hire the CHPI researchers to help formulate the next state of health care report!
I also cannot let his 2 new assertions pass without commenting on them.
Dr Dean claimed that having private practice “divides the profession, splitting us into the ‘haves’ and the ‘have-nots’”. Perhaps he wants to nationalise the legal professionals and even the accountants while he’s at it. He did not think the difficulty in recruiting trainees to certain specialities is not just because of the lack of access to independent (I won’t call it private since it seemed to be a taboo word to some) practice, but also the fact that they have been susceptible to political football game playing. Emergency medicine, geriatrics, acute medicine, palliative care.... yup.... remember 4 hour target, Darzi Clinics, Liverpool care pathway. If any junior colleague decided to chose another speciality training program because of these fiascos, I can totally understand why.
Dr Dean also thinks it “divides the medical profession from the allied professions” because “a consultant carrying out a private procedure in an NHS hospital will receive a substantial fee, whereas the team assisting him will be paid standard NHS rates, even if this procedure is done outside normal working hours.” Yes, I agree that if staff is called back from being call (not actually on duty on site as rostered after hours) they should be renumerated properly, doctors and support staff. However, we should help by supporting their fight for better pay in this situation, not by denegrating the doctor’s ability to charge a fee, however large or small. If the NHS feels so strongly about this, they are welcomed to refuse to have a private-paying patient treated on NHS facilities, along with any premium fees the trust normally charges the patient or health insurance for allowing that.
Unfortunately in his argument and points of contention, Dr Dean reveals more about himself than the health professionals in the private practice business he calls “largely a con”. I am unsure what more I can say to moderate the fervorous views of a born-again public servant. It's more of a dilemma than that of the private patient Dr Dean suggested.
Perhaps I should give up (no, not my right to private practice, but believing there is a middle ground for Dr Dean's view).
Competing interests: I support the right of any doctor to have a private practice