Is the demonisation of private practice unhelpful?

The vast majority of healthcare in the UK is provided by the National Health Service (NHS). However, in recent years there has been increased use of private heath facilities, much of it driven by dissatisfaction with the NHS.¹ Yet private practice is negatively perceived by the media and politicians.

As the current configuration of both private consultant practice and the GP independent contractor status both have their origins in the foundation of the NHS, I would argue that, rather than being mutually exclusive opposites, they could work together more for public benefit.

I will also detail three factors likely to drive an increase in private practice, these being the falling remuneration for NHS work, areas of poor performance within the NHS, and the fact that UK medical graduates are a highly diverse cohort likely to be tempted by options outside the NHS.

Historical perspectives

Prior to the founding of the NHS in 1948, all medical practice in the UK was private. Effectively, an unwritten social contact prevailed, whereby the poor were treated for free, and a sliding scale of fees applied depending on one’s means, with the principle of noblesse oblige ensuring the wealthiest paid most. For centuries, from William Harvey to John Snow, and from Elizabeth Garrett Anderson to Hamilton Bailey and hundreds of thousands of lesser-known foot-soldiers, pre-NHS doctors had no guaranteed income. Hospitals and GP practices were strategically sited to ensure that at least some of the catchment area was affluent enough to ensure viability.

Yet it appears that the system worked well; indeed, when Clement Attlee’s post-war Labour government proposed the NHS, the overwhelming majority of doctors bitterly opposed it, and tough negotiations with the BMA ensued. Matters were eventually concluded when the Health Secretary at the time, Aneurin Bevan, reached key compromises with each of the two main wings of the profession. For consultants, a fixed salary linked to their NHS hospital post applied, but with license to practice privately in their spare time. For GPs, independent contractor status was given, encouraging a degree of entrepreneurialism as well as flexibility to adapt their practices according to local need. Through all the many ensuing reconfigurations of the NHS, these core working models have remained firmly in place.

Negative perceptions of private practice

Despite this, it is striking that discussion of private practice, whether in the medical or general press or in political debate, invariably seems to be negatively framed. As far back as 2000, Tony Blair’s otherwise business-friendly government briefly debated whether consultants should be prevented from practising privately,² though that came to nothing.

A paper that initiated my interest in the matter was published in 2015 by John Dean, a now-retired cardiologist from Devon.³ His article candidly recounts his negative experiences of private practice, the paper’s title calling it unethical and urging doctors to give it up. He said: “I could not escape the fact that I was involved in a business where the conduct of some was so venal, it bordered on criminal – the greedy preying on the needy.”

Yet there are sanctimonious elements to the paper, such as stating that he never hankered after a Maserati, and was more content with a chicken balti than fine dining. In Dean’s view, NHS and private practice are, by dint of conflict of interest, mutually exclusive for an individual practitioner.³

A similar view is held by the Glasgow GP and highly entertaining medical journalist Des Spence. In his Bad medicine anthology, he targets private practice,⁴ arguing that it would be most unusual for any other industry to have staff working for their arch competitors at the same time.⁴

In 2020 Jessica Arnold, an NHS commissioner, wrote an article correctly summarising what ails NHS staff – longer hours, increasing workload, wage stagnation and colleagues leaving without being replaced, but argued that those leaving to work in the private sector, and patients opting for private care, exacerbated problems within the NHS.⁵

Threats to general practice’s independent contractor status

My own specialty of general practice has not escaped its independent contractor status – a perfectly good working example of social democracy – coming under fire. The current Shadow Health Secretary Wes Streeting recently said he would tear up the GP contract and make us GPs salaried employees of the NHS.⁶ Interestingly, former Conservative Health Secretary, Sajid Javid, just a year previously, proposed the same.⁷ The fact that Streeting and Javid are at diametrically opposite ends of the political spectrum yet espouse identical views suggests that where general practice is concerned, pure, unadulterated socialism is the aim.

Streeting and Javid are both personable and erudite men, and both have risen from humble backgrounds to prominent positions in public life. But they have made terrible miscalculations that show a lack of appreciation for how much we do, and how cost-effective our service is. Are they really, for the dubious benefit of paying me and my remaining GP partner colleagues a little less than we currently earn, pledging to pass the cost of staff and utilities to the taxpayer? Would they cut out incentives such as the enhanced service for minor surgery, for patients with cysts, skin tags and frozen shoulders to sit out a long queue for elective surgery which, when it happens in hospital, will cost five times more than in primary care?

And what they would do with services whose tariffs have slipped under the NHS radar, like cremation forms and teaching students, if indeed we were to be banned from all private work? In practice, I believe that either their stance would soften, or there would be a brutal political fight that they would lose, for the medical profession possesses far more power than it usually wields. It also damages the profession by effectively telling the public we are being paid more than we deserve.

Financial realities of private practice

At an individual level, the main argument for private practice is, of course, financial. This has, if anything, been accentuated by falling pay in real terms, which has accelerated sharply since the financial crisis of 2008. Indeed, the BMA calculate that over a consultant’s career, anything up to £ 1.5 million may be lost compared to if pay had just kept pace with inflation;⁸ not a propitious situation for those starting out.

Indeed, were any medical graduate to maintain friendships or a flat share with peers in law, accountancy, advertising, the media or real estate, they would quickly be aware of the superior starting salaries and faster pay progression of the others, even in the current economic climate. Medicine is also a late-starting career, with six years at medical school followed by at least as long in poorly-paid postgraduate training.

It is also an expensive profession, with membership exams to fund, and subsequently, college membership annual fees as well as GMC registration, all of which have risen at a far higher rate than members’ pay. Finally, a rarely mentioned fact is that as it takes, typically, to the mid-30s to secure a consultancy of become established as a GP, and the physical and emotional toll of medicine means that many reduce clinical commitment around a decade before retirement, our peak shelf life lasts only around 20 years, a figure comparable to professional sport.

A struggling NHS

The public’s sentimental attachment to the NHS needs a sharp reality check, for it has been struggling for years, and has been savaged by the Covid-19 pandemic. Hospitals have evolved into de facto emergency-only services,⁹ and reasonable provision of emergency, obstetric and cancer care cannot mask the dreadfully soporific throughput of elective care, which has led to a waiting list of 7.2 million.¹⁰ This in turn has damaged the relationship between primary and secondary care,¹¹ with the latter further strained by rejected referrals and requests from patients to chase or expediate appointments.

Beyond just financial considerations, the attraction to all clinicians of spending at least some time in the more sedate environment of private practice is clear. I do not share the polemical views of Dean,³ Spence⁴ and Arnold⁵ that private practice is a predator denuding the NHS of talent; rather, properly embraced, it could benefit the latter by selling some of its spare capacity, which to some extent has happened, particularly for elective surgery.

I further disagree with the view that doctors will be ethically compromised if they work in both sectors. NHS trust managers closely monitor consultants’ outside activities, and the BMA sets a reasonable ethical framework for private work.¹²

There are numerous examples of eminent doctors who have had no conflict of interest. The pioneering cardiothoracic surgeon Sir Madgy Yacoub of the Brompton and Harefield Hospitals, Victor Lewis of Watford General Hospital who did much to advance laparoscopic and endoscopic gynaecological surgery as well as fertility services, and the late John Studd of King’s College Hospital and later the Chelsea and Westminster Hospital, a leading figure in HRT research, all had large private practices. But they all also gave yeoman service to the NHS, within which they also conducted their research.

Demography of UK medical graduates as a driver of private practice

Emigration has always served as a strong indicator of dissatisfaction with one’s environment, and the UK, historically an importer of doctors, now loses around 4% of its registered practitioners to emigration annually, with financial considerations the main reason overall.¹³ Though there has, in recent years, been much written about this, I fear that the publicity is often badly handled.

Pictures of expatriate doctors grinning on Australian beaches and Canadian mountains is perfect fodder for those who wish to portray our profession as idle and pleasure-seeking. Our climate is no more the sole reason for people leaving than it is the main attraction for oligarchs and financiers who flock to London; we must grasp the real issues.

The pull of other English-speaking countries is obvious; however, given that UK medical graduates are a hugely diverse cohort, with many coming from entrepreneurial South Asian, Chinese, Jewish and Middle Eastern backgrounds, I predict that two further potential exit routes from the NHS will evolve.

Firstly, other countries may feature as likely destinations. As a hypothetical example, a UK graduate of Lebanese or Iraqi origin who speaks Arabic may or may not feel compelled to work in their troubled homeland, but a career in a wealthy Gulf tax haven is possible. Secondly, they could become drivers of an expansion of independent practice within the UK. It is puzzling that government ministers fail to see how globally marketable UK medical graduates are.

Limitations of private practice

Whenever the NHS outsources to the private sector, there is often hysterical fear that it is about to become privatised. To be fair, the record of public-private partnerships has been patchy. Capita, recruited to manage GP support services including pensions, has performed poorly and should not have been rewarded with the 3-year extension given.¹⁴ During the pandemic, the Test and Trace system’s deal with Deloitte paid senior staff £ 6000 per day, but failed to deliver.¹⁵ Yet patchy is not always bad; for example, Physiological Measurements Ltd. provide an excellent ultrasound service in my area of West Herts.

The shortcomings of private medicine in its current form must also be acknowledged. Geographically, it is skewed to London and the Home Counties, and specialty-wise, it is skewed to surgical fields and investigation-dependent physician areas such as cardiology and gastroenterology.¹⁶ It is also expensive, as is insurance, with the latter often limited by exclusion clauses. However, were provision to expand, the unit cost of procedures should drop, in line with usual commercial practice. Insurance companies may also decide to tap into hitherto poorly covered areas such as mental health and general practice.

Conclusion

Private practice is not without its faults or limitations, but it is not the devil incarnate either. Whatever one’s political persuasion or ethical misgivings, the constellation of an NHS that is struggling in many areas and keeping people waiting dangerously long for elective care makes it inevitable that private practice will expand. As does a cohort of highly trained medical graduates facing financial uncertainty due to falling remuneration within the NHS, but whose diverse backgrounds make them potentially mobile across the globe.

The generally negative press it receives is unjustified, and rather than being seen as competitors, the NHS and private sectors should consider working together more for both public benefit as well as their own.

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Edin Lakasing, GP, Trainer and Tutor, Chorleywood Health Centre, Hertfordshire

[email protected]

Competing interests: none.

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References

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