Re-opening is not that simple
There is a cost to financial recovery for independent practitioners trying to get back to ‘open for business’. Dr Sara Sreih and Dr Lucy Hanington highlight some important considerations.
The effects of the Covid-19 pandemic have impacted many patients but also the private practitioners who rely on this work to maintain their livelihoods.
In the first wave of the pandemic, the provision of privately funded healthcare fell by up to 84%. The impact of this hit varied between specialties, with fields such as trauma and orthopaedics and ophthalmology being relatively more affected.
However, there is reason to believe that any detrimental effect on private practice should be short-lived.
The reduction in private practice income showed a rapid recovery to almost pre-pandemic levels by the second lockdown.
A UK survey of over 1,000 individuals also found that, since the pandemic, 27% are now considering paying for treatment or taking out private medical insurance, compared to just 15% prior to Covid-19.
As the pressure on the NHS gradually eases, and hopefully continues to do so, there may be a temptation for private practitioners to throw themselves into their private work.
This could be to recover from financial loss, meet the increase in demand from patients and future-proof their businesses. But there are key issues to bear in mind when navigating a return to, or increase in, private practice.
Ethical and medico-legal risks
It is likely that there will be pandemic-related disruption to patient pathways for some time to come.
Practitioners should review their services regularly in this changing environment.
Redeployment and shielding may continue to mean that key team members are less available than before. There may be delays in accessing scans or in the processing of laboratory investigations. Patient expectations will need to be carefully managed if complaints are to be avoided.
More disruption
Potential delays should be factored into clinical decision-making and patients will need to be safety-netted appropriately.
There remains the possibility that the emergence of a further wave of Covid-19 could result in yet more disruption to healthcare services and impact both existing patients currently receiving care, as well as any new patients who wish to be seen. Where possible, contingency plans should be made.
Independent practitioners may be keen to ramp up their clinical work as soon as they are able to, but should consider their capacity, that of their team and the service as a whole.
High workload
Attempting to undertake too high a workload can result in a drop in clinical standards and increase in clinical errors, leading to adverse clinical outcomes.
This, in turn, can also lead to an increased risk of complaints, claims and other investigatory processes, adding further pressure onto staff.
Patients may come to the private setting with a set idea of what investigations or treatment they require, particularly given the potentially significant wait they may have endured.
The wishes of patients and the reasoning behind them should be explored and it is essential to ensure that clinical objectivity is maintained and usual guidance or evidence is followed when providing clinical care.
If a patient is asking for treatment that the clinician does not believe would meet the patient’s needs, then this should not be offered. However, this should be explained, alternative options discussed and the patient reminded of their right to seek a second opinion.
Of course, it may be that the clinician chooses to seek a second opinion themselves to provide an objective viewpoint on the clinical reasoning.
Good communication and documentation, as well as adhering to the principles of informed consent – in line with the GMC’s guidance on shared decision-making – are key in such situations.
Conflicts of interest
Any potential conflicts of interests, or perceived conflicts of interests, should also be considered.
For example, clinicians working in both the NHS and private practice would need to be mindful of any conflicting commitments with regards to their time when taking on additional work and take care not to conduct any private work when scheduled to be working in the NHS.
Even if the time in the NHS is not being used to see NHS patients, conducting private clinical work during this time would be an issue of probity and fraud.
The potential for (perceived) conflict also exists when an NHS patient seeks privately funded treatment or follow-up.
There is detailed guidance from the GMC on how to handle such issues and it advises that if there is doubt as to whether there is a conflict of interest, you should act as though there is one and seek advice on the implications of any potential conflicts.
Health and well-being
The pandemic has taken its toll on many in society, not least healthcare staff who have worked relentlessly in challenging environments and witnessed great suffering first-hand.
Many healthcare professionals have spent time volunteering or have been redeployed in other clinical areas to assist in the most recent wave and so may be returning to their private work already exhausted.
Indeed, the BMA has reported that almost 60% of doctors in England, Wales and Northern Ireland are suffering from anxiety or depression and 46% reporting a worsening since the pandemic.
It therefore becomes a balancing act between the wish to see and treat many private patients and needing to ensure that the workdays are not so long and stressful that they negatively impact one’s health.
Patient safety
Many clinicians will be familiar with the idea that poor well-being and burnout has been found to affect patient safety.
Burnout was an issue globally among clinicians in the pre-Covid-19 world, with calls for policy changes to address the concerns high on Medical Protection’s agenda. The pressure of the pandemic will only have added to the toll on staff.
Being stressed, tired and short on time can also impact communication with patients during consultations.
A survey we commissioned in 2017 showed that manner and attitude was the top reason for GP complaints, with three out of the top five reasons relating to communication. Most complaints to the NHS between 2013 and 2014 related to poor communication.
Many patients may begin their journeys having already waited to be seen or treated, enduring a prolonged period of suffering with symptoms, and so extra care and attentiveness to their experiences and needs is recommended.
How much is too much?
Care must be taken in considering what is a manageable, acceptable and safe workload in one’s private practice setting. Allowances must be made for the challenges created by the pandemic.
Robust clinical governance systems and regular service evaluations will help to ensure patient safety in ever-changing circumstances.
Clear communication with patients and the managing of expectations are key in avoiding adverse medico-legal consequences.
But most importantly of all, doctors must prioritise their own well-being and that of their teams, so that they are able to continue to meet the demands placed upon them effectively and safely.
Dr Sara Sreih (left) and Dr Lucy Hanington (right) are medico-legal consultants at Medical Protection