Perhaps due to the UK’s essentially socialist healthcare system, or the lack of business education in medical school, many new consultants arrive in their first post not even considering private practice. Others will desire to set up privately, but do not want to be seen as avaricious having only just arrived. Some see it as unusual for new consultants to start practising privately at the same time as commencing their NHS consultant career.
A common approach encountered at this earliest of stages in an NHS consultant’s career is a desire to concentrate on your NHS career for six months, before considering private practice. Reasons for this include personal insecurities regarding your abilities, the understandable desire to concentrate on establishing a solid NHS practice, and often the understandable desire to avoid upsetting colleagues.
While naturally onerous at times, the NHS also functions as one of the greatest marketing tools that you have at your disposal. Every time you see a patient, or write a letter to a colleague, publicity for your personal medical practice is generated; if the patient’s experience was good, and the letter carries good news (as simple as you can help in some way), then so much the better. Many private patient encounters are generated as a result of your name within the NHS, be they patients trying to bypass waiting lists, or new referrers simply looking for a name to refer to.
It is important to realise that actively turning down private referrals early in your consultant career may lead to a major hindrance to referrals at a later stage. If a very privately-minded GP tries to refer to you early in your career, but is met with a negative response (no matter how polite!), they will - through necessity - develop an alternative referral pathway, which may be impossible to tap back into at a later date. Saying ‘no’ at any early stage may perhaps be even more damaging to non-medical referrers, for example physiotherapists and optometrists, who may exist solely in private practice.
Probably for some very good reasons, many consultants do not start practising privately until many years into their careers. Attempting to change the label that ‘they have never and do not accept private patients’ will naturally be extremely difficult. In such a situation, it may be worthwhile for the consultant to leave the area in order to succeed privately; a new consultant untainted by turning away referrals may potentially be more successful at generating referral pathways.
For new NHS consultants who wish to succeed in private practice, but perhaps wish for a slower start, another option might be to accept all referrals and NHS-to-private practice transfers, but to avoid actively marketing their practice. This avoids sending negative messages to referrers, runs a low risk of upsetting colleagues, and is simple to build on when the time is right. On the down side, it is all too easy to sleep walk into an inefficient private practice, perhaps with the incorrect choice of administrative support, and often the wrong business vehicle (e.g. sole trader, rather than the alternatives).
The key principle for NHS consultants is that your private practice should not interfere with your NHS practice. Most NHS Trusts have private practice codes of conduct, to which you should ensure you adhere; declaring that you do so is increasingly routine as part of annual appraisal, and hence revalidation. Not adhering to some local policies may constitute fraud and lead to potential disciplinary action.
You should avoid any conflict of interest between your private practice and NHS work. In practice, this means that – with the rare exception of the provision of emergency care – practising privately should not disadvantage NHS patients or services; agreed NHS commitments, typically as part of your job plan, should take precedence over private work.
Your NHS consultant contract
The new NHS consultant contract (2003) defines work in terms of units known as Programmed Activities (PAs), which are broadly split into direct clinical care (DCC) and supporting professional activities (SPA). Most new full time consultants are appointed on 10 PA contracts, typically with a 7.5 DCC / 2.5 SPA split. DCC includes all clinical work, on call, patient-related administration and meetings, as well as travel between NHS sites; SPA time includes continuous professional development, educational and research roles, management activities and preparing for appraisal and revalidation.
Extra PAs?
Under the terms of the 2003 contract, when a consultant on a 10PA contract wishes to start undertaking private practice, the employing Trust may offer an additional PA of DCC to the consultant’s group of specialists (for part time consultants, an additional PA above their contracted number). If this offer is declined, then the Trust has the right to decline the consultant in question pay progression for that year. There should be a minimum of a three-month notice period on either side for increasing or reducing your PAs. In practice, the extra PA stipulation is certainly not always imposed, as many managers are very reasonable and most Trusts are keen for consultants to be employed on 10 PAs contracts, due to financial constraints.
The timing of your work
Every NHS consultant needs to have their own job plan, within which you will need to schedule your private work. In many cases, onerous on-calls and long NHS days lead to regular, compensatory time off during the working week, which may be utilised for private work. Agreeing a job plan - in partnership with your clinical director - that allows you time for private practice, is a recipe for harmonious relationships with your colleagues.
SPA time, such as preparing for revalidation and CPD, can often be scheduled flexibly, or in the evening, allowing time during the working week for regular private practice. Many employers now require that consultants are present on site for at least some of their SPA time, although this is extremely difficult to enforce and is often of questionable benefit to the Trust, as many SPA activities need to be carried out flexibly, almost by definition. Examples of this are the need for specific IT facilities, which may not be provided by the NHS and the facility to watch surgical videos online, which are often blocked by Trust firewalls. Journal subscriptions may also lead to journals being delivered to you home, rather than the Trust.
Evenings and weekends are favoured by some as an obvious time for private medical activities, but such activity again needs to be considered during NHS job-planning, particularly in light of government proposals to increase NHS weekend working. When setting your private fees, it is worth considering that private hospital fees (e.g. rental of consultation rooms) are typically higher in the evenings and at weekends and you may thus wish to charge a premium.
You should not schedule private work when you are on call for emergency work for the NHS. Clearly, if you can arrange appropriate cover from a colleague for on call work while you are carrying out your private practice (for example if a private operating list overran into an on call period), then there is no conflict of interest, however, it would be wise to ensure that such cover is arranged prospectively and ideally with an associated audit trail. Maintaining good working relationships with your NHS colleagues is naturally key to allowing such flexibility in your work.
The evolution of your private practice
If your private practice grows and you wish to be able to devote more time to it, you may wish to consider changes to your NHS job plan to allow this. There are many options:
• If you are working more than 10 PAs, then you have the right to reduce to 10 PAs after giving your Trust three months’ notice. Exactly how this reduction is achieved is for negotiation between you and your clinical director, but job diary data will be useful to help guide decisions. Most Trusts are keen for their consultant staff to be working 10 PA contracts, but of course they have the right to request an extra PA of DCC from the department, as above.
• A change in timetable. In order to free up an afternoon, for example, it may be preferable to take on either an evening or weekend session within the NHS setting. It is worth considering that a PA during ‘premium time’ is currently only three hours, not four, which may be beneficial.
• Going part time. You do not have a right to start working part time, but organisations must consider such requests. Departments are often looking to expand but need justification for this; if a business case for 7 PAs, for example, has already been achieved, then reducing your commitment by 3 PAs would potentially allow the department to advertise for a full time 10 PA colleague.
• Job sharing. This is the equivalent of going part time, but with a similarly minded colleague, and is often easier for a department to factor in.