Working for private providers that have been commissioned to provide services to NHS patients, or undertaking extra work through NHS waiting list initiatives (WLI) can often be seen as a good way of taking a first step into private practice. It might even seem at first glance that this is the simplest option of exploring private practice. There are, however, elements that clinicians need to consider carefully.
Indemnity
By the time you reach consultant level, you will be aware that you require separate indemnity for clinical negligence claims when seeing private patients, as this does not fall under state-backed indemnity schemes. However, when NHS patients are seen in private practice, things become more complicated. You should not assume that indemnity for claims arising from NHS patients treated in private practice, including WLIs, will lie with the state.
The provider commissioned to undertake WLI or NHS patient care in the private sector may have entered into an arrangement for protection against claims from the relevant state-backed clinical negligence scheme, but this is not guaranteed. It is imperative that you check your individual contract for this work to understand what the indemnity arrangements are and whether you are required to arrange your own individual protection for claims. If this is the case it is important that you contact your medical defence organisation (MDO) or insurer prior to commencing the work.
I would also recommend that you retain all relevant contracts as you may need to rely on them in the future should a claim arise. Even if indemnity for claims is provided by the state, it is worthwhile remembering that state indemnity is unlikely to provide assistance with disciplinaries, regulatory investigations, inquests or criminal investigations which are challenging to manage and costly to defend. All the more reason to ensure that your MDO or insurer is aware of all of your different roles and responsibilities, so that you can request assistance with a range of medicolegal issues should you need it.
Patient safety
Several press articles have recently raised concerns about the quality of care and patient safety in private health organisations providing care for NHS patients, with the Department of Health and Social Care potentially investigating. As per the GMC’s guidance, you should always make the care of patients your first concern. Prior to commencing work at a new private healthcare facility, take a look at their most recent CQC review, patient satisfaction data and speak to consultants working there to understand their experience and any concerns. You might also want to ensure the technical elements are of a standard you are used to and happy with, and that good processes are in place for all elements of clinical care, including pre and post op care. Ultimately, is this a place where you feel you would be able to provide high quality care to your patients?
Delegation
Becoming a consultant in private practice brings with it different responsibilities in relation to delegation of care than might ordinarily be seen in the NHS. This change in responsibilities arises from differences in hospital systems, clinical team structure, patient expectations and your personal availability. The GMC’s Delegation and Referral guidance is helpful, and advises that you should be confident that the colleague you delegate to has the necessary knowledge, skills and training to carry out the task, or that they will be adequately supervised to ensure safe care.
It also states that “You must give clear instructions when delegating, including about what needs to be done, by whom and by when”, and advises that you must encourage colleagues to ask questions, familiarise themselves with protocols and guidelines regarding escalation, and to seek support or supervision if they need it at any point. When you delegate care, you are responsible for that decision to delegate and the instructions you give. While the individual you delegate to is accountable for their own actions, you as the consultant are still responsible for the overall management of the patient.
Working within private healthcare organisations can provide a different challenge in relation to delegation as the structure of your healthcare team may be vastly different to the team you are used to in the NHS. You may not have had the time to build up rapport and trust with the clinical team, understand their processes, and the only doctor available when you have left the premises may be an RMO. In view of this, when starting a new post it is important to take the time to meet the team, understand their ways of working, and try to meet the RMOs individually if possible.
Clinical handover
Clinical handover is a crucial communication point in the patient journey and research shows that one quarter of handovers are associated with handover-related care failure, with surgical patients being particularly at risk. Medical associations, surgical colleges and the World Health Organisation all offer guidance, but there is little evidence-based training and no gold standard exists to date.
In a recent study by the Royal College of Surgeons in Ireland, funded by the MPS Foundation, 85% of SHOs and senior registrars reported that information received during handover was missing or incorrect some of the time, and one third of respondents reported that a near miss had occurred as a result of handover within the previous three months. Reported barriers to handover from this study included negative attitudes, a lack of institutional support and competing clinical activities.
When considering handover of duties when you start private practice, the following points may be useful:
- Use a standard process for every handover to ensure no critical elements are missed and your team become familiar with your process and documentation.
- Document and communicate a clear management plan with clear details regarding expected frequency of review and escalation triggers.
- Ensure clarity over where responsibility lies for specific tasks: this doesn’t just apply to the acute setting but can be crucial at discharge as well.
- Ensure your contact details are clearly displayed, with clear contingency plans if you are not available for any periods of time.
- Encourage questions from your team, make it clear there is no ‘stupid’ question and that you are happy to be contacted if they have concerns or questions about patient care.
Availability
As mentioned above, continuity of care and contingency plans take on a different light in private practice. The GMC clearly states in Good Medical Practice that “when you are on duty you must be accessible to colleagues seeking information, advice or support”. In private practice, when you have in-patients, it could be considered that you are always on duty, so it is important to consider your availability whether that be due to periods of leave, or when balancing your NHS and private roles. What happens if you are in the middle of an NHS ward round or in surgery and the RMO contacts you about the private patient you operated on yesterday advising that a return to surgery is needed?
When considering this scenario, you must ensure the needs of both your private patient and NHS patients are met. The NHS consultant contract states that you must ensure that your private practice or fee-paying services do not result in a detrimental effect on NHS patients or services, nor diminish the public resources that are available for the NHS and that there must be no conflict of interest between your NHS and private work. It also states that you are obliged to disclose any private practice commitments to your employer. It is worthwhile reading The Code of Conduct for Private Practice as this sets out additional obligations relating to scheduling arrangements and best practice.
It would be prudent to consider, before committing to both private and NHS work, how to prevent or mitigate a clash by pre-emptively arranging cover in the event that such a situation was to arise. This could, for example, include reaching an agreement with another colleague who holds privileges in the same private hospital, so that you cover each other’s private patients should an emergency arise. You could also arrange for your NHS colleagues to cover your NHS duties were you to be urgently called away to the private hospital. You should ensure that your NHS lead approves any cross-cover arrangement and keep proof of the agreement.
It would also be prudent to ensure your contract or terms of engagement with your private patients makes clear that in the event of an urgent problem or emergency, another clinician would need to be involved if you are not available. Further, you may to wish to consider whether it would be appropriate to request changes to your NHS job plan, or to your scheduled times at the private hospital, to minimise any disruption that may be caused to your NHS work should there be a complication arising from a procedure you have performed privately. This might, for example, mean adjusting your timetable so that you do not have NHS clinical commitments at a time when it may be more likely that complications would occur in your private patients.
Summary
Working in private practice can be rewarding but it is important that you consider the different responsibilities that come with it. My key takeaway messages are:
- Take time to understand the indemnity arrangements, review your contract and make sure you contact your MDO prior to starting any new role.
- Make patient safety your first concern. Undertake the appropriate checks to ensure that this is a place you can deliver high quality care.
- Be aware of your GMC obligations in relation to delegation and referral.
- Take time to get to know your clinical team and their existing processes and protocols.
- Ensure you have a clear, consistent handover procedure that is well documented.
- Consider how you are going to balance your NHS and private roles and work out the practicalities of cover in advance, don’t leave it until an urgent response is needed.
Dr Sarah Townley is Deputy Medical Director at Medical Protection.
