Not all private units can do critical care

Increasing demand for private healthcare brings with it some more risks for doctors in private practice, warn Dr Beth Walker and Dr Sophie Haroon.

Driven by historically long NHS waiting lists, more and more people are accessing healthcare in the private sector through medical insurance or self-funding. 

Waiting list initiatives are also resulting in some NHS patients being referred to private providers for treatment, funded by the NHS.   

Here are some of the statistics:

 News reports suggest nearly 500,000 new customers took out private health insurance in 2022 with three of the largest insurance companies in the UK.

 Self-pay admissions are down from their record post-pandemic peaks, but are still approximately one third higher than pre-pandemic levels. 

 A record 820,000 inpatients and day-case patients were treated in 2022 in the private sector, with data from 2023 on track to exceed this again.

 According to a recent market update from the Private Health­care Information Network (PHIN), the top five procedures undertaken in the private sector in 2023 were: cataract surgery, chemotherapy, diagnostic upper-GI endo­scopy, diagnostic colonoscopy and primary hip replacement surgery.

In a poll published in 2023 by the Independent Healthcare Providers Network, the most common factor for people deciding to use private healthcare was being unable to get an NHS appointment quickly enough, with 46% of all respondents citing this. 

The Institute of Fiscal Studies recently published a report predicting that it is very unlikely that NHS waiting lists in England will reach pre-pandemic levels by December 2027, even in a best-case scenario.

So with the above in mind, it seems unlikely that the increasing number of people turning to the private sector for elective treatment and procedures is going to relent in the near future.  

This increase in volume, together with a likely increase in more complex and more frail patients seeking to undergo a procedure in a private hospital, will present additional factors for doctors in private practice to consider.  

Considering suitability for a procedure in a private unit

In the vast majority of private hospitals, there are significant differences in HDU and ITU resource and capacity compared to NHS hospitals, as well as differences in the level of resident junior doctor cover and senior cover out of hours.  

The Royal College of Surgeons of England (RCSE) provides helpful guidance on this in its document Working in the Independent Sector. It advises that the consultant performing the procedure will usually be responsible for the care of the patient, including ensuring they receive appropriate postoperative management.   

The college also states that surgeons should be satisfied that ‘operations are performed in a facility that is appropriate for the level of risk involved in the procedure. 

‘Facilities should be appropriately staffed and equipped to manage possible complications and emergencies and sufficient protocols should be in place for managing complications and emergencies that may arise during the procedure or in the immediate postoperative phase.’ 

This will be a case-by-case consideration dependent on the individual circumstances and risk factors for each patient and the individual facility where the procedure would take place. 

Limits of care 

A recent Healthcare Safety Invest­igation Branch investigation into surgical care of NHS patients in independent hospitals highlighted the same factors.  

In Good Surgical Practice, the RCSE advises that surgeons working in the private sector should ‘make clear to patients the limits of the care available in any independent hospital used, such as the level of critical care provision and the qualification of the resident medical cover’.  

It also advises that surgeons must make arrangements for the continuity of care of private inpatients.  

If the surgeon is not personally available in the postoperative period, formal arrangements must be made with an alternative, named and suitably qualified person in the event the patient experiences complications outside normal working hours.  

These arrangements should be made in advance, where possible, and made known to the patient and relevant staff at the independent hospital. 

Like the consent process for the procedure itself, this exchange of information is a crucial part of the explanation and dialogue between the surgeon and the patient.

Several inquests and GMC matters investigating incidents have questioned whether a private hospital was an appropriate setting for the surgery and postoperative management based on the individual patient’s condition and comorbidities.

Case study 

In our hypothetical case study, 78-year-old Mr A was keen to have his total hip replacement surgery carried out privately due to the NHS waiting list.  

He approached Miss B, a consultant orthopaedic surgeon, directly as a self-paying patient with no GP referral. Mr A had a history of a previous coronary artery stent, COPD which he described as well controlled, osteoarthritis and chronic kidney disease stage three.  

He was not aware that the private hospital did not have high dependency or intensive care facilities and this was not discussed by Miss B. 

She and the anaesthetist Dr C reviewed Mr A pre-operatively, but did not have access to Mr A’s NHS records, where there was more detailed information regarding his COPD and kidney function.  

Mr A’s hip replacement went smoothly and he returned to the ward. But 24 hours later, the resident medical officer (RMO) was called overnight to see Mr A due to a raised temperature and increased secretions. 

Mr A was prescribed antibiotics for a suspected chest infection and Miss B was updated by phone.  

The next day, Miss B was caught up with her NHS practice. The RMO was busy covering the wards and managing another sick patient, but was able to briefly review Mr A amongst this. He appeared relatively stable, and antibiotics and IV fluids were continued.  

That night, Mr A became profoundly hypoxic, hypotensive and oliguric. The RMO called Miss B who discussed Mr A with the on-call medical and orthopaedic teams at the local NHS trust. 

Mr A became increasingly confused and his blood pressure remained low despite all ward-based interventions. 

An ambulance was called for an urgent transfer and Mr A was eventually transferred to the NHS hospital the following morning.  

He was diagnosed with a chest infection, sepsis and acute kidney injury. Mr A was admitted to the intensive care unit with multi-organ failure, where he sadly died three days later.  

Mr A’s family submitted a complaint to the GMC regarding Miss B. 

They alleged she had failed to identify he was too high-risk a patient for surgery in the private hospital without the necessary critical care facilities should a postoperative complication like this arise and that she did not inform him of the lack of these facilities.

Learning points

As the volume of patients seeking to undergo procedures and treatment in the private sector increases, there is the potential for frailer patients and those with complex comorbidities to present and seek treatment in this setting too. 

More complex private patients add an extra element of risk to their management in the private setting, which needs to be considered.

These considerations include the suitability of the facility for the patient in the event of them developing a complication related to their comorbidity and the proximity to higher levels of care in an NHS facility, including transfer arrangements and times. 

Consider whether further information is needed, such as from the patient’s NHS records, with their consent, to accurately assess their suitability for a procedure in that private setting, particularly with direct self-referrals.

Privately practising surgeons should include in their discussion with patients any limits of the care available in that private hospital setting, such as the level of critical care provision and staffing cover.

Discussions should be carefully documented in the medical records together with the clinical justification for undertaking the surgery privately and the appropriateness of doing so in this setting in each patient’s case. 

If there is uncertainty about the patient’s suitability to be operated on in the private setting, then this should be discussed with others at that facility, including the medical director. 

Giving consideration to these wider elements of private care could help avoid a GMC investigation, criticism at an inquest or even a claim of clinical negligence.

Ensure you have appropriate and adequate indemnity protection for the types of work you are carrying out, so you can seek assistance with a range of medico-legal matters. 


Dr Beth Walker (left) and Dr Sophie Haroon are medico-legal consultants at Medical Protection