This guidance provides information to SAS doctors considering or undertaking private practice both in the NHS and in private settings. It sets out the rights and responsibilities of SAS doctors in relation to private practice.
Can SAS doctors carry out private medical practice?
SAS doctors can undertake private practice; however, in reality, the opportunities to do so can be limited.
To treat patients in a private hospital, doctors must obtain practising privileges or admitting rights from the private hospital. Practising privileges are a matter between the doctor and the hospital concerned - taking into account the individual practitioner’s clinical abilities, experience and references - and are generally approved through the hospital's MAC (Medical Advisory Committee).
Some insurers use the concept of 'specialist recognition' to decide who may treat their subscribers. Recognition is usually granted to individuals who hold, or have held, a substantive consultant post in the NHS or who are on the Specialist Register.
SAS doctors wanting to undertake private practice may want to consider applying for a Certificate of Eligibility for Specialist Registration (CESR). Unfortunately, while a small number have gained recognition, on an individual basis, insurers are becoming increasingly firm in only recognising individuals that have held a substantive consultant post. The BMA has raised this issue several times with insurers.
Private practice and NHS contracts
The 2008 Specialty Doctor and Associate Specialist Terms and Conditions of Service (TCS) (Schedule 10 for Scotland, England and Northern Ireland and Schedule 7 for Wales) outlines SAS doctors’ contractual right to undertake private practice and contains contractual provisions dealing with the relationship between NHS and private activity.
The contracts state that:
- SAS doctors should inform their employer of any regular private commitments, which should be noted in the job plan
- NHS commitments take precedence over private work and there should be no significant risk of NHS commitments disrupting private work
- SAS doctors should not undertake private work while on call for the NHS apart from in cases of emergency or, with the agreement of the employer, when on a high frequency and low intensity rota
- SAS doctors can only use NHS facilities and staff for private work with the employer’s agreement
- private patients should normally be seen separately from scheduled NHS patients
- SAS doctors should not initiate discussions about private practice and should only provide agreed information when approached by a patient
Additional PAs (programmed activities) and pay progression
Under the 2008 SAS contracts, there is no obligation for a SAS doctor to undertake PAs in excess of the standard 10 per week for a full-time worker.
However, one of the criteria for achieving progression through the pay scales is that SAS doctors should accept an additional paid programmed activity in the NHS, if offered, before undertaking private work.
If you were to refuse an additional PA offered by your NHS employer, and then chose to undertake private practice anyway, the employer can defer your pay progression for the year in question.
Any additional PAs offered must be offered equitably between all SAS doctors in that specialty; if a colleague takes up that work there would be no detriment to pay progression for the other doctors in the group/department/specialty.
If you accept any additional PAs, there is a three-month minimum notice period for termination of the additional PAs on both sides.
Code of conduct for private practice
As part of the 2003 consultant contract negotiations, a new code of conduct for private practice was agreed, which applies to all doctors (including SAS doctors) working in the NHS.
The aim of the code was to minimise the risk of a conflict of interest arising between a consultant’s private practice and their NHS commitments. Scotland has its own code of conduct which is Appendix 8 of the 2004 Scottish consultant terms and conditions of service.
Both codes mirror the provisions governing private practice in the 2008 SAS TCS and cover issues including disclosure of information, scheduling of work, delivering private care in the NHS, and information about private care for patients.
Compliance with the code is another requirement for pay progression in a given year.
Assisting consultants treating private patients
Training grade and SAS doctors are required to assist the consultants to whom they are responsible with the treatment of their private patients within an NHS hospital in the same way as their NHS patients.
The charge paid by private patients to the hospital covers the whole cost of hospital treatment, including the salaries of nurses and all medical staff.
Private prescriptions in the NHS
Doctors may provide patients with private prescriptions. These are sometimes written because they are prescribing a particular drug that has restricted availability or because of doubts about clinical efficacy.
The doctor may consider that there is a chance the patient could benefit from the medication, but it would not be funded by the NHS. Where a drug is unlicensed, the doctor would have to take full clinical and legal responsibility for the prescription.
In cases where a private prescription has been issued, both an employer and a doctor can charge the NHS patient a separate fee, the employer for the cost of the drug prescribed and the doctor for the issuing of the prescription. The Health and Medicines Act 1988 provides for NHS employers to set their own charges for private prescriptions on what they consider to be the appropriate commercial basis. The writing and issuing of a private prescription to any patient by a doctor does not form a written undertaking that the patient has become a private patient.
A doctor cannot write an NHS prescription for a private patient unless it is for a separate condition than that for which the patient was admitted.
SAS doctors should be aware that the NHS indemnity scheme does not cover private work, either in the NHS or in private hospitals.
SAS doctors should ensure that they have appropriate indemnity with a medical defence body to cover them for private practice. Indemnity for private prescribing will depend on the individual circumstances. Doctors should seek advice from their medical defence organisation.