The BOA and the independent sector (private practice): ensuring best care, identifying concerns and representing our members

Andrew Manktelow and Mark Bowditch

The relationship between the National Health Service and the independent sector (IS) has rarely been more complicated. Historically, there was a relatively clear delineation, as colleagues spent one part of their working time in the NHS and another ‘elsewhere’. Many were clear and definitive in separating these two clinical aspects of their practice. Many will have experiences and apocryphal stories of how boundaries were blurred.

More recently, many aspects of care in the IS have changed. Traditionally, it was those who had insurance cover, individually or collectively through work, alongside those who could afford private care, who chose to utilise the ‘private’ independent sector. This ensured they were able to access a certain clinician, at a time they chose, to reduce delays and perhaps enhance the softer side of their experience. With longer waiting times, even pre-COVID-19, an increasing number of patients sought private care.

Subsequently, the NHS Choice framework has enabled provision of care by ‘any qualified provider’, leading to NHS patients accessing IS facilities for routine NHS treatment and procedures. With COVID-19 exacerbating pre-existing delays, there has been a significant increase in patients seeking treatment within the IS. Against that backdrop, it should be appreciated that many private providers acted in support of challenged NHS facilities, to deliver care as part of the response to COVID-19. Various models were utilised and in many areas, the provision of NHS cancer services during the COVID-19 pandemic were strongly supported by the IS. During the same period, some elective orthopaedic surgery was carried out – within and outside existing job plans – in the IS to maintain clinical activity. With a significant part of the NHS COVID-19 backlog recovery plan involving the utilisation of IS capacity, this is likely to increase. The financial, governance and practical complexities of the relationship that exists between IS and NHS care will continue.

The requirement to comply with the Competitions and Markets Authority (CMA) Ruling of 2014 has been dealt with recently within this journal [1]. The effect of the ruling on how surgeons practise in the IS continues to develop, though it is perhaps important to recognise that much of the information clinicians are required to provide is reasonable. Many of us – wherever we were seeking care – would look to understand and be aware of the likely outcomes and clinical experience, when choosing one surgeon or facility over another. Similarly, few of us would feel comfortable accessing that service without a clear understanding of what the costs involved would be. Clinicians providing services within the IS should ensure that their practices, services and costs are presented accurately. Those responsible should ensure that data is presented accurately within their patient-facing facilities.

The Bishop of Norwich Report on the Paterson case has identified the important role of a multidisciplinary team (MDT) in the clinical decision-making process. It has been detailed that those who practise within the IS are fully appraised and revalidated, and that their practice is reviewed fully, with any limitations in NHS activity highlighted. As part of that appraisal, an update on IS activity is required. As detailed previously1, the importance of surgeons validating their data will become increasingly important with a drive toward presumed publication. With improvements to the Private Healthcare Information Network (PHIN) patient-facing website and with additional Patient Reported Outcome Measures (PROMS) data available, patients will increasingly have access to information from that facility. It is the surgeons’ responsibility to ensure that data is accurate and reflects their practice.

Private medical insurers (PMIs) have changed their processes and practices in numerous ways. Patients have seen a steady increase in the costs of their subscriptions. Despite increased technical complexity, governance and outcome scrutiny, the rates of remuneration for the doctors – upon whose activities the entire IS is based – have been static for many years. Patients would perhaps be surprised that increases in their subscription rates have not been reflected in higher remuneration for their doctor. Indeed, in some cases there has been a reduction in physician remuneration. Many would argue that the existing rate of remuneration do not reflect present costs levied for secretarial and hospital facilities, insurance premiums and assistant support, all of which have increased significantly.

Geographical variation exists with local arrangements that will reflect market forces. However, with a fixed rate of remuneration available, with no ability to reflect experience, expertise, outcomes and technical complexity, many surgeons have felt disenfranchised with existing arrangements. Increased costs with static fees have resulted in a functional reduction in income. Many have felt it necessary to increase their fees to reflect increased expenses. This then leaves many surgeons enforcedly disenfranchised by PMIs, with terms such as ’unrecognised’ used when patients seek to access that specific surgeon in the IS. The situation has deteriorated to a level that the Federation of Independent Practitioners Organisation (FIPO) reports that more recently, appointed colleagues would seem less keen to look to practice within the IS.

Interestingly, with the stated aims of the CMA being to improve patient care – to improve patient choice and to ensure that a clear representation of the costs involved is made available to patients – much of what has happened more recently, with PMIs increasingly determining patient referral pathways, could be seen to have left patients less able to seek out the specific clinician they might wish to be treated by. As such, it could be argued that the net effect of the present arrangement leaves patients with less choice than they have had previously.

How doctors’ views in matters that pertain to the IS are represented is complicated. Discussions that relate to fees and costs are seen to be anti-competitive. As such, colleagues can feel exposed and isolated, with no one able to represent their views and support their interests while maintaining the best care for patients in the IS. More specific to this article, how BOA members are kept informed and how their views are best represented is unclear. A member of the BOA Council represents the BOA in discussions with FIPO. The BOA, among other specialist societies, contributes funding to that organisation which was established in 2000, specifically to represent doctors’ views within the independent sector. Similarly, the BOA has representation with PHIN. The BOA Orthopaedic Committee and Council receive regular reports from that FIPO/PHIN representative member.

There remains a disconnect regarding how that information is communicated to BOA members and from there, how BOA members’ thoughts, issues and suggestions can then be returned to those with influence. The remit of BOA Orthopaedic Committee does include private practice. The BOA can feed in to the BMA Private Practice Committee, but perhaps orthopaedic views are diluted.

With recent publications in the JTO and communication via the website, the BOA has sought to increase the information available and to seek input from its members. It would be helpful to understand a little more about how BOA members see activities within the IS and what topics they would like the BOA to address. It is important that the BOA understands whether its members would wish to see the organisation more active in the area. Caring for patients, delivering the best possible care while supporting surgeons wherever that care is delivered, fits securely with the BOA’s mission.

We invite and encourage BOA members, plus other colleagues to be in contact with their thoughts and experiences in this area. Any suggestions as to how the present arrangements could be improved, made more relevant to BOA members and effective for our patients, would be very gratefully received.

References

1. Private Health Information Network (PHIN) and complying with the Competitions and Markets Authority Order: An update for members. JTO Vol 11 Issue 1. March 2023. www.boa.ac.uk.

Andrew Manktelow is a Consultant Orthopaedic Surgeon working within Nottingham University Hospitals NHS Trust, with a specialist interest in primary and revision hip surgery. A past President of the British Hip Society, Andrew has been on the BOA Council since 2019. Contributing to the Orthopaedic Committee, Andrew reports to BOA Council on matters relevant to the independent sector.

Mark Bowditch is a Consultant and Divisional Clinical Director for MSK & surgical specialties at the East Suffolk and North Essex NHS Foundation Trust. Mark’s specialist interests are in surgery of the knee and all levels of surgical education, and he is currently the Head of School of Surgery in the East of England.