Where to practise?
To the uninitiated, the answer may seem glaringly obvious: at the private hospital! Granted, local private hospitals are likely to represent the easiest location to start your private practise, however, there are many other possibilities that you should consider, all with their own pros and cons. You may ultimately want to open your own clinic.
Always remember the business aspect of private practice; from a private hospital’s perspective, you – the consultant – are the principal client and as with all forms of business you may be able to negotiate yourself and your patients a better deal by shopping around. There is a myriad of possibilities regarding where you might choose to practise. These include: your local private hospitals, within your NHS hospital, at an NHS community or peripheral hospital, within a private ‘high street’ facility, your colleagues’ chambers, within your own facility, at the practice of an associated paramedical colleague (e.g. a physiotherapist’s or optician’s practice), and of course, even virtually on the internet.
Clearly there will be some aspects of your practice which you will only be able to practise in certain locations, however, this does not stop you marketing your entire practice in all the venues that you practise at.
Let’s now look more closely at the pros and cons of working in one or more locations.
Advantages of working within a single private hospital include:
• Simplicity. For many, working in a single private practice location is easy and minimises the potential hassles of working in multiple locations.
• Many private hospitals now offer the option of collecting all fees for you, including for outpatient consultations, reducing the difficulties associated with billing and potentially making accounting and book-keeping easier for you.
• It is normal for private hospitals to offer you secretarial services, such as basic clinic administration and typing, and as a result you may not need to employ or find your own secretary. This will potentially work very well for you if your practice is confined to the same hospital.
Disadvantages of the single hospital arrangement include:
• Remember that as the client in the relationship, if you are restricting yourself to a single provider you will not be able to shop around for a better deal. While you should have the absolute right to charge what you see fit, you might potentially find this difficult to achieve while maintaining a reasonable overall charge to the patient.
• Quality. There will be many occasions when you find the quality of the service to your patients is left wanting. Unless you have the option of diverting patients to a higher quality provider, it will be more difficult to address the problem. Organisations – just like the NHS – respond far better to financial arguments (i.e. a sudden lack of patients and associated income stream) than simple arguments regarding quality.
• You may be restricting your potential business growth by limiting your geographical appeal.
• You may be restricting your potential business growth by limiting your availability to the times that the single private hospital can accommodate you.
• You may be restricting your business to certain insurers only. As insurance rebates for some procedures continue to fall, some private hospitals are finding that it is simply not worth their while to offer certain procedures for some insurers. Other insurers only have arrangements with certain hospitals.
• Depending on the facilities that you have on offer, you may not be able to carry out certain procedures, even though you are eminently qualified to provide them.
• Beware the intermediaries’ legislation (IR35). Some of the most important aspects of being self-employed are the very different arrangements for taxation. While there are many angles of IR35 to consider, working in a single location and being remunerated by a single large organisation on a monthly basis does begin to sound rather like employment… this is potentially particularly true for NHS work in private facilities, where crucially you have not generated the work yourself, all associated secretarial work is paid for at source, etc.
At the end of the day, this is your private practice and it is likely that a number of other factors will lead to you making your decision to fit with your lifestyle and available time.
Working privately within the NHS
Most NHS hospitals are keen to allow private practice to occur on their premises as it represents additional income in largely cash-strapped organisations. Generally speaking, consultations and procedures need to occur in a fashion that does not affect the provision of NHS care. Thus, you might find that you will need to schedule care over lunch times, evenings or weekends, after open and explicit discussion with local managers. Alternatives may also include fallow theatre lists as a result of colleagues’ – or even your own – annual leave.
The individual arrangements for billing for private work will vary between different NHS facilities. Broadly speaking, there are two aspects of the total cost to the patient, the clinician’s fee and the facility fee. The author recommends that you maintain absolute control over the clinician’s fee, as you may wish to change this as your business sees fit. For procedures, many NHS hospitals use the NHS PBR tariff as the facility fee for the private procedure – the additional profit being the fact that they have not had to pay the consultant out of this fee. Other facilities will have very different price lists and you will need to be aware of these costs before fulfilling your obligations to inform patients in advance of the likely total costs.
In some cases, the standard of nursing care within the operating theatres of some NHS hospitals may be higher than in some private hospitals. Private hospital theatre staff have to accommodate many different specialties and hence are not always specialists in, e.g. complex ENT surgery, and you may therefore feel more comfortable in the NHS environment for more challenging procedures. Conversely, you may find the more intimate working environments in many private hospitals leads to better relationships with your nursing staff and hence better care for patients. Ideally, you should exploit these differences to achieve the best possible care for the end customer, the patient, and only you will know what the best environment will be.
In many cases, the hospital fees charged are extremely different to private hospital fee splits, representing excellent value for patients, a business opportunity for you, or both. When setting your fees, do consider whether it would be entirely appropriate to charge more than you would at the private hospital. As an example, some private hospital chains provide a guarantee that all costs arising from the procedure, including complications and their management, will be explicitly covered by the patient’s procedure bill. If such a complication were to occur in the NHS setting, charging more at the outset to cover such an eventuality (an in-house guarantee, if you like) would be an entirely reasonable justification for a differential fee structure.
The private hospital
Depending on your local geography, you may find that there are several potential options for you. In almost all cases, you will need to apply for practising privileges / admission rights to each separate hospital, your application being considered by the hospital director and / or the hospital’s medical advisory committee. The outcome of your application will depend on a number of factors, such as clinic room / theatre availability, the services that you offer, your availability for emergencies arising from procedures, as well as your application.
The hospital will typically carry out a number of important functions for you, including providing a governance structure for you to work within, offering some marketing for your services, providing secretarial services (for a fee) and supporting you with complaints. Some may also collect patients’ fees on your behalf.
In the current culture, it will be expected that your clinical practice at the private hospital mirrors your NHS practice, although there are obviously exceptions to this rule (e.g. cosmetic work not being possible within the NHS setting).
It is obviously crucial that you arrange to meet with clinic nurses in advance of your first clinic, and with operating theatre staff before booking any cases, in order to ensure that the facilities meet your expectations.
The high street ‘facility’
Within the world of ophthalmology, there are a number of different brands that now provide eye treatments – most commonly refractive / laser eye surgery – in a high street location, all of which are heavily marketed and all of which depend on ophthalmologists working for them. As should be expected, given that the brands generate the patient load through their own marketing exercises, you will have little say in determining the fees that you will be allowed to charge for your work. The fees that you receive for your work – and in some cases a salary as an employee - may be less than more established colleagues and this should not come as a surprise: this is the world of business, with supply and demand – not NHS-style parity – being key principles. You should consider carefully the benefits of work (quick start to private practice, likely heavy patient load) in such an environment as well as the downsides (you are growing someone else’s business, with little autonomy). Many clinicians find a short-term relationship of benefit, helping the individual to build confidence, pending development of their own brand.
NHS community / peripheral hospitals
Patients love the convenience of being seen close to their homes and while the contemporary glitz of private hospitals has an appeal, distance of travel is an increasingly important consideration as one’s time on the planet increases. If you are able to offer private consultations in a local setting, patients often find it immensely helpful.
You will need to have a frank discussion with the manager of the hospital, who should know what the arrangements are for billing of the patients, as well as ensuring that your medical manager is aware of this aspect of your practice; probity is vital in maintaining a long and successful private practice.
In some cases, you will be able to provide surgical services for patients in these environments too. In many cases, the fees charged are extremely different to the hospital fees charged by larger NHS Trusts and private hospital fee splits, representing excellent value for patients, a business opportunity for you, or both.
Paramedical colleagues’ facilities
Examples would include dental practices, optometrists’ stores, physiotherapy practices, GP practices, audiology practices, beauty salons, podiatrists’ practices, and so on.
Not only will you almost certainly be providing a service closer to the patient’s home, but you should most likely establish an excellent working relationship with new potential referrers. Your paramedical colleagues will typically enjoy the relationship as they will: (i) earn money from your presence; (ii) glean a benefit from being able to discuss tricky cases with you, without necessarily referring; (iii) potentially enjoy the kudos of having a specialist consultant working in their practice and may even wish to market your presence; (iv) you may provide on-site training as part of the relationship.
Do ensure that what you are proposing to offer is appropriate in that setting, bearing in mind the CQC (in England) and its regulations.
Colleagues’ chambers / their own facility
Ok, you have significant competition. Make sure that you understand completely the financial arrangements in play here, as well as who’s brand you are growing. Initially, you will likely be paying a fee for use of the facilities, much like you would at a private hospital. With time, however, there may be an opportunity to buy into the facility too; in such a situation, you would then need to declare to patients your financial interest in the facility.