Boom in private healthcare piles pressure on GPs

Private care piles pressure on GPs

Despite the public perception that patients who self-fund in the private sector ease pressures on the NHS, GPs warn that the trend is increasing their workloads—particularly in the case of one-off specialist appointments that are referred back to NHS GPs for interpretation, or because the patient cannot afford continuing private care. One-off private tests can also offer false hope, and be perceived as queue jumping by doctors or other patients.

“There are a few problems at play here,” Oxford GP and BMJ columnist Helen Salisbury3 tells The BMJ. “There is the market in commercial health checks, which often give rise to a whole load of blood tests with bits in red that patients bring to their GPs for interpretation; there are the patients who can only afford one appointment with a specialist, which is then referred back to their NHS GP; and there is the matter of private diagnostic providers in areas in which the NHS is under-resourced, such as attention deficit hyperactivity disorder (ADHD) assessment, who transfer lot of work into general practice in the form of shared care agreements.”

Marcus Baw, a Yorkshire GP with an interest in improving NHS systems, says that patients who ask to be referred to a specialist for a one-off appointment to expedite treatment, in particular, add to GPs’ workload. “Once the patient has been seen initially the consultant will often ask us to re-refer the patient to that same consultant on the NHS,” he says, “Which is extra work, as well as being morally dubious in that the patient has paid to jump the new patient queue.”

He adds that in cases where patients baulk at the cost of private prescriptions and ask GPs for prescribables from the NHS, “considerable time can be wasted in trying to get written confirmation of exactly what the consultant wanted to be prescribed.”

Additionally, Salisbury points out that GPs are being enjoined to practise outside their competence as GPs. “We are being asked to request tests we are not confident to interpret, to prescribe drugs of which we have no experience,” she says.

ADHD and shared care

It’s understandable that patients facing lengthy queues for particularly pressured NHS specialisms such as ADHD—which has waiting times over a year long in some trusts—might resort to private providers.

Tens of private ADHD assessment clinics—bricks and mortar and online—have sprung up in recent years, with private clinics who have a contract with a trust somewhere in the UK also leveraging choice rules to pick up remote patients across the country paid for by the NHS. Patients refer to these private operators as “right to choose” clinics.

Liz Hope, a 23 year old woman from Huddersfield who was diagnosed with ADHD by a private provider in Lincolnshire and now has a shared care arrangement with the assessor and her GP, believes that by going private she was taking pressure off the NHS. Hope was told in January 2022 that she would have to wait up to a year for an ADHD assessment.

“By going private I managed to get an ADHD diagnosis and now I have care,” she tells The BMJ. “The way I see it, those that can afford it should pay and take pressure off the system, including by not bugging our GPs because we’re still on a waiting list.”

Shared care arrangements involve NHS GPs prescribing drugs suggested by specialists. In these cases the legal responsibility for prescribing lies with the doctor who signs the prescription.

Chris Preece, a GP in Harrogate, is troubled by the rise of assessors whose models operate on the basis of shared care arrangements with patients’ GPs. “They promote themselves to patients elsewhere in the country very aggressively but are unable to provide proper patient care remotely,” he says. “This leaves GPs to pick up testing and monitoring around medications.”

A GP in Solihull who did not want to be named is angered by the impact online only ADHD clinics are having on her practice. “Online ADHD assessors demand GPs act as their house officers: performing heart and cardiovascular examinations and electrocardiograms and collating all the tests and emailing them back to them,” she told The BMJ. “Reputable ADHD clinics would arrange their own clinical tests but these cowboy outfits dump workload onto GPs.”

Preece is sympathetic to patients who turn to private providers in a climate of rapidly increasing referrals and overstretched NHS systems. “ADHD referrals nationally are phenomenally high and there’s an absence of better solutions,” he says.

Commercial health checks

Commercial health checks are another growth area of private healthcare, advertised directly to consumers with the promise of “preventing future health problems” and “taking control of your health.” The number of corporations offering health checks as an employment perk is also rising, with four in 10 jobs advertising private healthcare as an employee benefit.4

Shan Hussain, a Nottingham GP and ambassador for doctors’ mental health charity Doctors in Distress, says that it is common for patients to present in his surgery with the results of private blood tests, electrocardiograms, and audiology investigations for GP follow-up. “While I have no problem with companies offering private health checks, I feel it’s important that these organisations arrange their own follow-up for their consultations,” he says. “Instead, we receive communications from these companies with words to the effect of: ‘start this, stop that, arrange this, refer there.’”

One of the leading providers offers checks for heart disease, cholesterol, glucose levels, liver and kidney function, digestive disorders, bowel health, and anaemia with an “entry level” testing package costing £129. Salisbury believes there is little proof of these commercial health checks’ benefits. “They are being touted as an answer to pressures in healthcare but there’s very little evidence they’re useful,” she says.

Gillian Davidson, a GP and primary care network director in Derbyshire, believes the rise in private health testing reflects a market capitalising on “massive post-lockdown health anxiety” and that at their best these tests “can offer reassurance,” as they reduce pressure by preventing the affluent worried well presenting to their GP.

In a 2019 position statement, the Royal College of General Practitioners said that it does not support non-evidence based screening which has not been approved by the UK National Screening Committee or the National Institute for Health and Care Excellence or their counterparts and that the organisations initiating these screenings should fund follow-up and not assume that GPs will deal with the results.5

“Maladaptation” to lack of provision

GPs can refuse a shared care agreement if they are not happy with the burden of responsibility it puts on them, and they can refuse referrals back to general practice from private specialists. In a post on Twitter, Toni Hazell, a GP in a deprived area of London, recommends setting clear boundaries: “I’m happy to assess my patients from scratch, or refer them privately if they want: if the latter then they sort all the tests privately. I’m not the private consultant’s house officer.”

Hannah Short, a private doctor specialising in menopause and premenstrual disorders, sees her role in the private sector as providing specialist input then discharging back to the NHS with a care plan as “that’s what most private clients want.” Short would like to work for the NHS but says NHS specialist menopause clinics and posts are being decommissioned.

“Patients come to see me as they can’t access specialist help on the NHS and are feeling desperate,” she says. Short is careful not to overpromise to patients and is wary of adding to NHS GPs’ workload but says the private-to-NHS model is a maladaptation to a situation where there isn’t enough provision in the NHS.

“Patients often ask if their GP can do any recommended tests and provide prescriptions and I explain that I can always ask, but there is no guarantee and we cannot expect this,” she says.

Amina Albeyatti, a GP in Surrey who works in teleconsultations in the private sector and as a locum in the NHS, believes the NHS is facing a perfect storm of increasing expectation from the public of the services it provides and the speed with which this will be provided, and growing need. Albeyatti is sanguine about a future in which affluent patients pay to see specialists for more minor conditions as the NHS is seen as a “life saving vessel.”

“If patients want to pay for the warts and the lumps and bumps and the non-life threatening stuff, they should,” she says. She adds that medtech launches such as Medical Chain,6 who seek to encrypt patient data and make it easier to transfer between healthcare providers, could usher in innovations that enable records to be more readily shared between NHS and private systems.

“Some GPs are taught that the private sector is the dark side and shouldn’t be engaged with, and I think that’s a shame because if a patient’s willing to pay for, say, blood tests, and these come seamlessly back to their GP, where’s the problem?” she says.

Conversely, the rise of one-off paid appointments amid a cost of living crisis raises the risk of patients who cannot afford to pay for private specialists doing so and failing to progress on waiting lists. Patient watchdog Healthwatch England warns of “widening health inequalities” as going private “simply isn’t an option” for many.7 Others might take out loans and resort to crowdfunding to pay for private treatment.8

Salisbury doesn’t think that communication between NHS GPs and private providers is the crux of the problem. “Sometimes there’s a problem with not getting the paperwork that one needs, but on the whole private providers are keen to pass it on,” she says. “The problem is that there is a generated workload that wasn’t there before and that this workload falls to GPs.”