Will private practice remain an attractive career option for doctors?BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j1258 (Published 16 March 2017) Cite this as: BMJ 2017;356:j1258
New ways of working, changes to competition rules, and stricter requirements for competing interests are changing the options for doctors considering a move into private practice. Anne Gulland reports
Private practice is evolving, and gone are the days when many doctors would set up on their own, employing their own secretary or nurse. Changes in the insurance market and new competition rules are making it expensive for doctors to work independently, says Ray Stanbridge, an accountant who specialises in advising doctors in private practice.
“There are around 25 000 consultants registered with insurance companies to do private work, but around 80% of the work goes to just 5000 people,” he says. “The cost of dealing with a lot of consultants who don’t do a lot of work is quite high, so insurance companies are increasingly dealing with groups of doctors working together.”
Groups of specialists come together to work in what are akin to barristers’ chambers. They work as little or as much as they like, sharing a profit in the business. Doctors pay to become part of the group: as much as £20 000 or £30 000 for some of the bigger groups, says Stanbridge.
One such group is the London Orthopaedic Clinic, set up by three surgeons in 2008 and now expanded to 19. Sean Curry, one of the founding partners, had been working as a sole trader but wanted to collaborate with other surgeons. They formed a limited liability partnership, found premises, and now share the running costs.
Some of the doctors are full equity partners and some are associates. Associates have less of a say in how the business is run, but “it doesn’t make a huge difference in the day to day running of the business,” Curry says. “We have monthly meetings where we all meet up and discuss things.”
Curry works only at the clinic, but some of his partners do private and NHS work. He says he would not go back to working as a sole trader, partly because working in a group means that he can share running costs with the other partners, but mainly because of the opportunity to collaborate with other doctors.
“I like the ease of cross cover. If I’m away for a week I can ask one of my colleagues to cover for me. But the opportunity to work with peers and discuss things from an educational and management point of view is also very important,” he says.
He says that more such groups are setting up, with some doing it solely for marketing purposes, whereas the orthopaedic clinic is run more like an NHS department. “We look after our own governance, we collect data. I can pool my data and benchmark against colleagues. I also keep up to date. It’s a bit like working in an NHS orthopaedic department—the only difference is that we’re in the private sector,” he says.
One of the reasons he left the NHS was because he became frustrated at management and government interference. He enjoys the autonomy the private sector offers, though he does miss the opportunity to train junior doctors. The clinic cannot employ juniors or trainees because of indemnity exclusions. “That’s the one thing I miss about working in the NHS and the reason some of my colleagues still work there,” he says.
Despite Curry’s upbeat overview of the sector, Stanbridge thinks other things are working against private doctors. Competition and Market Authority rules that came into force in 2014 cracked down on private hospital providers offering financial incentives to doctors to encourage them to use their services.
“There used to be sweetener deals: someone who joined a hospital might get free rent for the first six months,” he says. “But consultants have big costs from day one—anything up to £30 000.”
The healthcare market intelligence provider LaingBuisson’s annual survey of the private acute healthcare sector shows that the market is strong.1 Private acute medical care was worth £5.57bn in 2015, 4.4% up from the previous year. And the market has nearly doubled in the past 12 years, from £2.63bn in 2003. The analysis says that despite the economic gloom precipitated by the UK’s decision to leave the European Union the market is set to grow in coming years.
It points out that an overstretched NHS is a good thing for the sector. NHS waiting times are high and still rising, encouraging people and employers to look at private alternatives, it says.
Stanbridge reports a boom in private GP services, although actual figures are hard to come by. Babylon, a private GP service offering remote consultations for a fee, has teamed up with 60 employers to offer the service, and a year ago it said it had 150 000 registered patients.2
Doctors who wish to do both NHS and private work need to be aware of various things. New rules on conflicting interests coming into effect in June state that clinical staff doing private work should declare where they practise, what they practise, and when they practise.3 NHS England has also emphasised a ruling in consultants’ contracts that doctors must also declare all private practice on appointment to a post and any new private practice when it arises.
Clinicians must also ensure that their NHS work takes precedence over their private work and that there is no conflict of interest between the two. They must seek approval from their NHS employer before taking up any private work. Doctors must not accept direct or indirect financial incentives from private providers other than those allowed by Competition and Markets Authority guidelines. Unsurprisingly, doctors must also not attempt to sell their private services to NHS patients, nor should they ask other staff to do this for them.
NHS England had also threatened to make doctors declare their private income but reneged on these plans. NHS England’s concerns about private practice could all be part of a perception that medicine is a vocation and that UK doctors, who have been trained in a taxpayer funded system, shouldn’t be seen to abandon the system that nurtured them.
Curry believes that the perception that doctors somehow have a debt or an obligation to the NHS has been eroding over the years. “More doctors will leave the NHS over the coming years, as they no longer feel that obligation,” he says. “They feel they have been exploited and not looked after or appreciated. They are disillusioned and feel no compunction in leaving the NHS if a better job offer comes along.”
The perception that doctors somehow have a debt or an obligation to the NHS has been eroding over the years