Getting back to work

Accountant Ian Tongue

With the NHS and some private hospitals moving towards triggering the de-escalation clause to allow some private work and NHS elective surgery, Ian Tongue sets out key issues for independent practitioners to be ready for.


Income for all practitioners has taken a huge hit in the last few months and this will continue over the coming weeks.

New protocols to deal with patient consultations, investigations and procedures will mean fewer patients can be seen, investigated and operated on within the time span compared to pre-Covid-19 days.

This means less income unless fees are reassessed upwards.

The private hospitals, by way of the NHS block-booking of their facilities, effectively received a subsidy to assist them over the three-month period that, in most cases, saw little use of their facilities.

They will be acutely aware of the huge list of NHS patients needing treatment and will, no doubt, seek contracts to treat them for the NHS. This will provide an opportunity for additional private work – but at what rates?

Insured v self-pay

There will be a surge of patients wishing to use your services.

In the past, the health insurers wielded great power in restricting the level of fees that consultants could charge for consultations and procedures.

In the Covid-19 era, their power to restrict fees may be somewhat less, as their insured members are less attractive to both the private hospitals and consultants. The amount they are willing to pay will not reflect the supply and demand generated by Covid-19 and the additional cost of both theatre and consultants’ time.

Certainly, relatively new consultants who, for recognition purposes, had to limit fees will wish to look towards self-pay patients.

The insurers’ business model and subscription charges for members will have to change.

Competition among consultants

You will be keen to start up again in private practice and hopefully attain similar levels of activity as pre-Covid-19. This may be difficult due to new protocols, as stated above, and fees may have to be reassessed upwards as a consequence.

Pressure will be placed on space for waiting areas and investigative equipment cleaned after use each time, with operating theatres similarly requiring cleaning particularly for aerosol-generating procedures.

Everyone will be keen to kick-start their private practices, but space and time will be rationed to begin with. This may be acutely felt if the hospital has contracted to deal with the backlog of NHS patients, so you may have to discuss these practicalities with colleagues and hospital management.

You may find that you are encouraged to discuss pricing with fellow colleagues and hospital management, but be careful not to fall foul of the Competition and Markets Authority (CMA), which penalises practices who are deemed to be non-competitive by dint of forming a cartel.


The largest expenses of any practice are staff, defence cover and premises. The Government has extended the furlough scheme to the end of October 2020 with the option to bringing staff back on a part-time basis. If needed, use this support.

The defence bodies and insurers need to be contacted to determine whether there is any scope for reduced subscriptions. Be careful of changing to any new provider driven by cost alone, as you must ensure that the policies are comparable. 

First check out their excesses, roll-on cover, what happens if there is a claim and the level and experience of their team to assist you. You do not want in this post Covid-19 period to find that, for reduced subscriptions, you have access to the most junior person at the indemnity provider or their advisers for support.

Check what happens to subscription levels if a claim is made and also check roll-over cover should you decide to cease private practice.

Your premises and their suitability for consulting with patients will need to be reviewed and, if need be, altered to meet distancing protocols. The cost will be tax-deductible.

Patient pathway

The patient pathway from consultation through to recovery will alter drastically. Hospital protocols, together with your own, will be needed to ensure safety as far as possible for the patient, your staff and you.

You will need to check and follow the patient pathway from beginning to end, noting any areas of concern and indeed any area that may cause anxiety for patients themselves. It would do no harm to have a lay person, family or friend test run the pathway.

Dental practitioners offer an opportunity for you to review what they have in place and provide a good base to see in practice their protocols and any issues faced.

A review of consenting and follow-up procedures will be needed and there is an abundance of guidance from your professional bodies.  

It is likely that defence bodies/insurers will look to exclude Covid-19 from claims by patients and therefore you will need to review consent procedures to ensure that it is included within the risks of a procedure taking place in this new world we find ourselves in.  

No doubt, the private hospitals will be working on this and will communicate their policies, but it is important that you review your own procedures in this area. 

Staff and administrative systems

Most consultants’ secretaries either work within the private hospitals or remotely. Some will have been furloughed and you will need to check how they are upon returning. They will be ‘rusty’ to begin with, getting up to speed from where they left off.

What will be important is a review of your administrative systems to ensure they are capable of working in the new environment.

In an ideal world, you would want a single package that:

  • Deals with the patient pathway at all stages;
  • Acts as a database of contact details and templates;
  • Allows remote access and remote consultations;
  • Allows the patient to interact, say, with booking an appointment;
  • Deals with all the financial side, say, taking payment remotely in advance.

Some packages have this; others require some bolt-ons.

Ian Tongue is a partner with Sandison Easson medical acccountants