Interface between NHS and private treatment
Guidance from the Ethics Department
February 2004
Issues for consultants
Can patients receive part of their treatment within the NHS and part privately?
Dilemmas can arise if patients choose to seek part of their treatment privately and part on the NHS. A common scenario is where a patient seeks private investigations in order to obtain an earlier diagnosis and then switches back to the NHS for any subsequent treatment. Provided patients are entitled to NHS treatment they may opt into or out of NHS care at any stage. Patients who seek private investigations may subsequently be placed directly onto the NHS waiting list at the same position as if that consultation had been undertaken within the NHS (assuming the treatment in question is provided by the NHS).[Go to reference 5] Patients do not need to have a further assessment within the NHS before receiving their treatment nor do they need to be referred back to their general practitioner. Some doctors are unhappy that patients who can afford to pay for private investigations are able to effectively jump the queue for treatment by reaching the waiting list earlier than those who wait for investigations and diagnosis on the NHS. Others argue that because some people seek their investigations privately, the NHS waiting list for investigations is reduced and therefore other patients are seen more quickly. There is undoubtedly an advantage to reaching the waiting list sooner but, nevertheless, NHS patients whose clinical need is greater may join the waiting list later but could still receive their treatment earlier if they are categorised as needing more urgent treatment.
May NHS consultants advise patients about the option of being seen privately?
When patients are referred to a consultant within the NHS it is not unusual for a doctor to provide a diagnosis and recommended care plan, but to advise that the waiting list for non-urgent treatment may be many months. Although some patients may subsequently opt for private treatment rather than waiting for treatment within the NHS, it is not appropriate for consultants to use their NHS patient lists to initiate discussion about their private practice. It is not acceptable, therefore, for doctors to suggest to patients, who are placed on a waiting list for NHS treatment that the treatment could be provided more quickly on a private basis. It is also inappropriate for consultants to raise the issue of private practice obliquely, for example by handing the patient a business card containing the address of both the NHS hospital and the doctor’s private consulting rooms or adding the private clinic address to NHS letterhead. The codes of conduct for private practice in England, Scotland and Wales state explicitly that consultants should not, in the course of their NHS duties, initiate discussions about providing private services for NHS patients.[Go to reference 6]
The BMA believes an exception to this general rule is where treatment is available but is not funded within the NHS. In such circumstances, patients should generally be advised of this option in order to make an informed choice about treatment (see BMA guidance on the duty of candour).[Go to reference 7] It could be argued that the same principle should apply to patients being given the choice between NHS and private care. Arguably, patients should be given sufficient information – including the availability and price of private treatment – in order to decide whether to join the NHS waiting list or seek private treatment. It is possible, however, that this could put pressure on patients to seek private treatment, particularly where the patient is very sick and potentially vulnerable. There is also a fundamental difference between these two scenarios, which justifies treating them differently. Patients are generally aware of the availability of private treatment and so the option is always open to them to enquire. Where there is a new treatment available that is not provided on the NHS, patients cannot be expected to know about it. It is, therefore, appropriate to provide balanced and factual information about the treatment, although this too needs careful handling to ensure the patient or the family do not feel pressure to choose the private option.
How should consultants respond to questions from NHS patients about being treated privately?
With the limited exception given above, consultants should not spend time discussing private treatment with patients during NHS consultations. It would be inappropriate for them to pressure or encourage patients to transfer from NHS to private care but, in practice, patients themselves frequently raise questions about the availability of private treatment. This can put doctors in a difficult position where they could be perceived as having a conflict of interest. It might be suggested, for example, that patients have been put under pressure to seek private treatment or that doctors are using their NHS consultations to promote their own private practice. In order to avoid this perception, there should be a clear separation between NHS and private treatment. Views about how consultants should handle such direct questions, however, differ. Some people believe that where patients raise the option of private treatment during a NHS consultation they should be directed back to their GP for a separate private referral. Where the patient expresses a clear preference to see the same doctor privately, however, insisting on a separate referral from the GP can seem to the patient to be unnecessarily bureaucratic as well as adding to the workload of GPs. There may, however, be some circumstances where a referral back to the GP is the most appropriate course of action, if, for example, something unexpected is discovered during the consultation and referral to a different consultant is needed.
It is for individual consultants to decide how to respond to patients’ questions about private treatment within the terms agreed locally. Some consultants prefer not to discuss their private practice at all during NHS consultations and refer all enquiries to their private secretaries. Consultants may, however, briefly answer factual questions about the availability of private treatment and there is no requirement for the patient to be referred back to the GP (although the GP should be kept informed of any change to the patient’s care plan). A consultant in this position should make a contemporaneous note on the medical record, and inform the patient’s GP, that the patient has requested information about private treatment. Patients should be informed of the option of seeing a different doctor for private treatment and some patients may wish to discuss the options with their general practitioner before making a decision.
How should consultants respond to patient requests for a second opinion in the private sector?
Requests for second opinions should generally be complied with unless there are good reasons to justify a refusal. A second opinion will usually be provided within the NHS (see CCSC guidance on second opinions[Go to reference 8]). Some patients, however, may specifically request a further opinion on a private basis. This might be because they believe that further treatment options will be open to them that are not funded within the NHS or because they believe they will receive better quality care. Patients are entitled to seek a second opinion, on a private basis, and the treating NHS consultant should facilitate this where possible or liaise with the patient’s general practitioner about arranging a private referral. The same general principles apply to private patients seeking a second opinion.
Can consultants involve NHS staff in the treatment of private patients?
NHS staff are sometimes asked to clerk in and look after private patients on the ward on behalf of consultants who are being paid privately for the treatment. The consultants’ guidance on private practice is clear that consultants may not use NHS staff for the provision of private services without the agreement of their NHS employer.[Go to reference 9]