Private practice: is it unethical?
In an article published on 5 May 2015 in the British Medical Journal, a consultant cardiologist in Exeter, Dr John Dean, has hit out at the pernicious effect of private healthcare on the NHS, branding it as unethical:
There are plenty of any reasons why patients choose private healthcare treatment, from avoiding lengthy NHS queues and to being able to have a second opinion. For example, private medicine may provide:
- Quicker access to treatment than on the NHS, which experiences long waiting lists and delays in the provision of non-emergency treatments;
- A choice of consultant or specialist, who may not be local;
- A choice of when a patient has treatment;
- A choice of where a patient has treatment, for example in a private hospital which may be more comfortable, quieter and more convenient than an NHS hospital; and
- The option of having a treatment that is not available on the NHS or, for a course of treatment, only available for a limited number of times.
More and more patients now have private healthcare because their employer will offer private health insurance as part of their contract of employment, although many people remain self-funding, and it has been well documented that the NHS is increasingly relying on the private sector to supplement or provide its services, with the argument that more patients going privately will help ease some of the burden on the NHS.
However, the flip side to this is that many consultants work in both the NHS and private sector, the latter to supplement their income from the former, and this private work can reduce the amount of time that those consultants are able to dedicate to the NHS. Dr Dean remarks that “time spent in the private sector deprives the NHS of a valuable resource”. But it is not only this, as Dr Dean goes on to describe private practice as “the greedy preying on the needy” and argues that it “encourages doctors to make decisions on the basis of profit rather than need”. He considers that “private practice creates a perverse incentive to increase your NHS waiting times – after all, the longer they are, the more private practice will accrue” and further notes that “Jealousy over private income is a major source of conflict between consultants in many hospitals”, which could, of course, be divisive. He points out that emergency patients are safer in the NHS. He concludes by suggesting that being able to work in both the NHS and private practice perhaps should be abolished in its entirety.
Whilst there can be little doubt that the points raised by Dr Dean are strong and controversial such that there will be disagreement from some private consultants and patients who have been satisfactorily treated in the private sector, there will also be support. It is fair to say that in certain quarters there has always been an underlying disquiet about consultants working in the private sector because there is an inherent, unavoidable potential conflict of interest due to the fact that the health professional has a financial incentive in offering treatment: therefore, the patient relies upon the doctor not compromising their ethics by taking advantage, to any degree, of this financial incentive.
In the Responses to Dr Dean’s article, Dr David Evans, a consultant cardiologist at St George’s Hospital in London, remarks: “I completely agree that there are some doctors who exploit this privilege with avarice beyond description. Unnecessary tests, too many tests, quack treatments … I have seen it all.” Dr Oliver, a consultant physician at The Royal Berkshire Hospital in Reading, is of the view that doctors are salaried public servants who “shouldn’t be coming into a public sector job with some mind-set that we should be paid like a commercial lawyer or accountant in the City of London”, that “those doing private practice are dependent on their NHS contacts, NHS status and steady NHS employment as a bed rock for their private work” and that private practice “is bound to distract from the ‘day job’ which is already a full on commitment”.
In contrast, the British Medical Association points out that, as part of their NHS employment contract, doctors must prioritise their NHS work over their private work, and there should be no conflict of interest between the two. Over the years, I have personally heard a number of private practice doctors argue that the points raised by Dr Dean points are simply not true, as they would not dream of compromising their ethics and they fulfil a necessary and important role wearing both their NHS and private hats. Dr Evans also remarks that, “Most (but not all) cardiologists I know do not overindulge their interests in private practice.” He cogently argues against some of Dr Dean’s points, pointing out that not all private consultants succumb to the temptation of more money, private patients are as well informed as NHS patients, the insurance industry is heavily regulated and “queue-jumping” is not permitted. Ultimately, he claims that, “the charlatans, quacks, mountebanks and the frankly dishonest are usually found out. Eliminating private medicine to rid it of these types would punish the honest practitioners. Personal integrity should negate any conflict between the ‘business of medicine and the practice of medicine’.”
However, having spent some time (albeit many years ago) working as a doctor in both the NHS and the private sector, my experience at that time was that there were some doctors who considered that the combination of poor NHS pay (in comparison to their peers in other professions) and the excessive hours they worked in particular as a junior doctor gave them some sort of entitlement to work in the private sector to supplement their NHS income. Dr Dean is brutally honest in his reasons for doing private practice: “So why did I do it? To begin with, I decided that I needed the money to renovate the house, educate the children, and so on.” And how many private practice doctors could, with their hand on their heart, say their primary motivator was not something similar?
I cannot comment from personal experience on what may have changed since I was in medical practice all those years ago, but some of what Dr Dean is lamenting now does not seem to me to be so different; and, if anything, I wonder that things have in fact worsened. I can, however, comment personally on what I see in my day-to-day claimant clinical negligence legal practice in which I have a particular interest in private healthcare cases. From my own personal experience of such cases, many of Dr Dean’s criticisms and concerns ring true: a private hospital not being the place to be in an emergency; consultants not being available when required (both of which were problems I personally experienced as a private hospital RMO); unnecessary treatments being offered or procedures being carried out; standards of care not being consistent with or as up to date as NHS counterparts; shoddy consent processes and informed consent not being properly obtained; experimental treatments being tried out; aggressive marketing practises; and the list goes on.
Is the abolition of private healthcare the answer, as Dr Dean posits? Arguably it may be. But even if not, there can be little argument that there needs to be sufficient regulation of the private sector and those practising within to ensure that both unethical practices and professionals who prey on the needy are weeded out, that legally acceptable standards of care and ethics are attained and maintained, and that there is access to appropriate redress for patients when things do end up going horribly wrong.