Education

In the past it was quite usual for a majority of newly appointed consultants to opt to enter private practice, often taking over that of the colleague who had preceded them in post. With the expansion of consultant posts over the last 25 years this is, in many areas across the country, no longer the case. Many newly appointed consultants particularly outside the M25 are choosing not to start a practice. Often because they have no desire to, some feel it would interfere with their work/life balance, feel adequately paid by the NHS, or would do some waiting list work if more income was needed.

Deciding to enter independent practice is not something to be undertaken lightly. Apart from getting your name out there to encourage referrals from GPs and optometrists, there are the significant costs involved – renting consulting space, secretarial help, creating an online presence and of course indemnity insurance. Once you have decided to start a private practice you will need to consider the format that you will adopt. The options will be discussed below.

The simplest approach when setting up a private practice is as an independent practitioner. To do this you will need to decide where you will carry out your outpatient work and also your surgery. Unless you are in London or major cities like Birmingham or Manchester, where you may have your own consulting rooms, this will probably be in a private hospital. In order to do this you will need to get practising privileges at the hospital of your choice. This usually requires an application to the chief executive of the hospital followed by a discussion at the Medical Advisory Committee. You will already have demonstrated amongst other things that you have indemnity insurance, that your revalidation is current, that you are Hep B immunised and that you are not a criminal. Having obtained your practising privileges you will need to rent consulting room space and acquire a secretary to help run your practice. Initially, this may only be part-time. To help build your practice a website will be required. Also, you will need to engage with the Private Healthcare Information Network (PHIN) once you start surgery to validate your data about your practice. This is mandatory as part of the remedies following the Competition and Markets Authority (CMA) report on the private healthcare market. Further, you will need to post your outpatient and surgical fees on the PHIN website. There is also an opportunity to create a personal profile on the PHIN website which is meant for patients to help their consultant choice.

It may be that in the hospital of your choice, there is already an established group, who are a legal entity like an LLP. This has advantages in that there will be an established referral process of which you will become part. A further alternative is to become an employee of a private hospital like the Cleveland Hospital in London. You will be paid a salary and your indemnity insurance will be covered as well as other expenses. Whichever route you choose you will need to become eligible to treat patients with private medical insurance (PMI) policies. This will require you to apply for so-called recognition by the insurer. Since a decade or so ago, in order to be paid to treat patients of the major insurers Bupa, Axa, Vitality and Aviva, you needed to sign a contract agreeing to be fee assured. This means that the insurer dictates the maximum you may charge for your services. It is a great deal lower than that for consultants who began practice 12 or more years ago. It means that you may not charge patients a shortfall above the PMI rate. Patients who opt to fund their own treatment are not subject to these rules and you may set your own fees. You may not discuss fees with colleagues this is considered anti-competitive behaviour. However, if you look on the PHIN website you can see the range of colleagues fees across the country and judge what is appropriate to charge.

In recent years because of the way that NHS waiting lists for elective surgery have ballooned trusts are using the private sector more and more to speed throughput of NHS patients. At the same time, patients are able to get themselves referred to private hospitals that carry out NHS work to avoid long waits at NHS hospitals. For many consultants who do not wish to carry out private work but like to have a source of additional income this can be a useful approach. However, it is important when undertaking this work to have a clear idea about whether you need your own indemnity insurance or if the NHS hospital commissioning the work covers this. 

Obtaining proper surgical consent is a critical aspect of patient care that requires careful attention to the 2020 GMC guidelines on decision-making and consent. It’s essential to engage patients in meaningful dialogue, tailoring discussions to their individual needs and priorities. Providing comprehensive written or video-based information on surgical options, including their advantages, disadvantages, and potential complications, both before and after the consultation, can significantly enhance patient understanding and decision-making capacity. This approach allows patients to review information at their own pace and formulate questions. Following the consultation, it’s highly beneficial to send a written summary to the patient, outlining the key points discussed, the chosen surgical option, and its potential complications. This practice not only reinforces the information shared during the consultation but also serves as a valuable reference for patients and documentation of the consent process. By adhering to these principles, consultants can ensure properly informed consent, improve patient satisfaction, and potentially reduce the risk of litigation. Remember, consent is an ongoing process, not a one-time event, and should be revisited as necessary throughout the patient’s care journey.

Maintaining meticulous clinical records is paramount to ensuring high-quality patient care and protecting oneself professionally. The critical importance of keeping detailed, accurate, and contemporaneous records cannot be overstated, particularly in documenting all discussions surrounding consent and proposed surgical procedures. It is essential to thoroughly document every aspect of patient interactions, including the specific potential complications discussed, the patient’s understanding and responses, and any questions or concerns raised. This comprehensive approach to record-keeping serves several purposes: it ensures continuity of care especially if a consultant is ill or on leave and provides a robust defence in the event of medicolegal claims. Always bear in mind the time-honoured adage in medicine: “If it’s not written down, it didn’t happen.” This principle underscores the legal and ethical necessity of documenting all significant clinical decisions, observations, and patient communications. In the context of surgical consent, detailed records should include the specific risks explained, alternative treatments considered, and the patient’s expressed preferences and decisions. By maintaining such thorough documentation, consultants not only safeguard themselves against potential litigation but also demonstrate their commitment to transparent, patient-centred care.

Why do you need malpractice coverage?

Malpractice coverage is fundamental for medical professionals and a GMC requirement under their Good Medical Practice guidance. To obtain a medical licence, professionals must ensure they have adequate and appropriate malpractice coverage in place. As a medical professional, you are responsible for the health and well-being of your patients. However, even with the best intentions, mistakes can happen, and patients may suffer harm or injury. This is where the medical malpractice cover comes in.  If a patient suffers harm or injury due to your medical services, they have the option to file a malpractice claim. Malpractice cover provides essential financial protection in the event of such a claim, ensuring that you are adequately covered and supported.

MDO vs MedMal Insurance

There are two main types of malpractice coverage available to medical professionals: Medical Defence Organisation (MDO) coverage and medical malpractice insurance.MDOs are mutual non-profit organisations that provide indemnity policies rather than insurance. These policies are offered on an occurrence basis, meaning they respond based on the treatment date rather than the date on which matters escalate. MDO policies are discretionary, meaning the MDO can choose not to pay a claim. Despite being discretionary, these policies are generally more expensive than insurance due to the breadth of the coverage. Being mutual and owned by the members, big claims can affect all the members’ premiums as these pay for the claims.

On the other hand, medical malpractice insurance is a type of insurance that is contractually bound to guarantee coverage by law as long as the policy terms and conditions have been complied with. Insurers and brokers are FCA-regulated, which provides greater financial security that a claim will be paid. Medical malpractice insurance policies are on a claims-made basis, meaning they only cover claims made during the term of the policy. These policies are generally cheaper as premiums are not subject to large claims by other policyholders but are relative to the risk. Run-off cover is required when you retire but may be built into the policy.

What else does cover provide?

In addition to assistance with financial claims, malpractice cover provides other benefits. These include assistance with investigations by the General Medical Council (GMC) into your fitness to practice, and assistance with internal disciplinary procedures, inquests and fatal accident inquiries.

GMC guidelines for communicating information about your services

When advertising your services, you must follow the regulatory codes and guidelines set by the Committee of Advertising Practice.

You must make sure the information you publish is factual and can be checked, and does not exploit patients’ vulnerability or lack of medical knowledge.

Your marketing must be responsible.19  It must not minimise or trivialise the risks of interventions and must not exploit patients’ vulnerability. You must not claim that interventions are risk-free.

If patients will need to have a medical assessment before you can carry out an intervention, your marketing must make this clear.

You must not mislead about the results you are likely to achieve. You must not falsely claim or imply that certain results are guaranteed from an intervention.

You must not use promotional tactics in ways that could encourage people to make an ill-considered decision.

You must not provide your services as a prize.

You must not knowingly allow others to misrepresent you or offer your services in ways that would conflict with this guidance.

The Care Quality Commission (CQC) significantly impacts private medical practice in the UK by regulating and inspecting independent doctor and clinic services. From April 2019, the CQC began awarding quality ratings to these services, aligning them with NHS standards. CQC inspections are designed to assess whether services are safe, effective, caring, responsive, and well-led. Poor ratings can lead to reputational risks and necessitate improvements; failure to comply may result in enforcement actions, including registration cancellation. This regulatory framework is designed to ensure patient safety and influences public perception of private healthcare providers.

CQC ratings may significantly impact the reputation of private medical practices in the UK. High ratings can enhance a practice’s reputation, attracting more patients by demonstrating compliance with safety and quality standards. Conversely, poor ratings can pose reputational risks, potentially deterring patients and affecting the commercial viability of your practice. The ratings also influence public perception by providing transparency and allowing patients to compare services. Practices with lower ratings may face challenges such as reduced patient trust and difficulties in securing contracts or financial support.

The CQC focuses on several key areas during inspections of private medical practices:

1. Patient Safety: Evaluating risk management, infection control, and incident response.
2. Quality of Care: Assessing patient experience, communication, and treatment effectiveness.
3. Leadership and Management: Reviewing governance, staff oversight, and compliance with regulations.
4. Staffing: Ensuring appropriate training and management of personnel.
5. Regulatory Compliance: Checking adherence to specific healthcare regulations and standards.

If a private medical practice fails to meet CQC standards, it may receive an “inadequate” rating. The practice is then given a specific time frame (usually up to six months) to make improvements. During this period, the practice is placed in “special measures” which involves increased supervision and support from relevant agencies. If the practice fails to improve within this timeframe, the CQC may cancel its registration, effectively closing the practice. Practices can appeal against CQC decisions if they disagree with the rtaings or judgements.

Recently, Wes Streeting, the UK Secretary of State for Health and Social Care, has criticised the CQC, calling it “not fit for purpose”. He highlighted issues such as inconsistent safety ratings, delays in provider registration and inspections, and a lack of expertise among inspectors. He emphasised the need for immediate reforms to restore trust in the CQC’s ability to assess healthcare quality effectively. Suggested reforms include the appointment of new leadership, improving transparency, increased oversight and a review of patient safety organisations. Whilst these reforms are implemented, their impact will not in anyway reduce the necessity for private practices in the UK to remain observant of CQC regulation.