Private Practice Activity

Introduction

Traditionally almost all surgeons did private practice. The old consultant  contract arrangements  allowed for NHS consultants to carry out private practice activity in addition to NHS activity by taking what was called a ‘maximum part time contract.’ By relinquishing 10% of their NHS salary surgeons were allowed to carry out private practice. In practice most surgeons organised to do one day a week in the private sector, doubling their overall income with additional expenses – indemnity and administration support amounting to between 10 - 15% of their gross additional earnings.

This arrangement continued after the introduction of the new contract, which allowed time in the week for ‘supporting professional activity’ (SPA’s), time used by most surgeons, myself included, to make up their salaries to the levels now paid to senior NHS managers (in excess of £150k).  (I presume that some surgeons may have earned more than this but to do so requires a commitment to the private sector of more than one day a week in my view.)

In my case 9% of admissions under my care were private at the time when I opted out of this system. These were cases that were either admitted to Frenchay or to one of two private institutions, the Nuffield St Mary's Hospital in Bristol and the BMI Bath Clinic. For the record the following is the list of the procedures with their codes that I did perform privately in order of their frequency. 

1. Spinal cord stimulator insertion - A4830
2. Lumbar microdiscectomy – V3370,V3470
3. Posterior lumbar decompression – V2530, V3410
4. Anterior cervical discectomy – V2940, V2950, V3040, V3050
5. Craniotomy for Intrinsic brain tumour – AO200, AO300, AO400
6. Laminectomy for Intradural tumour – A4500, A5110, V4980
7. Craniotomy for extrinsic brain tumour e.g. meningioma – A3810, L7510, A3680
8. Posterior cervical decompression – V2200, V2300, V2280, V2380
9. Upper cervical decompression / fusion – V2980, V3730, V0390
10. Burr hole procedure – AO300, A2210, A1250
11. Skull surgery – V0110, VO510,
12. Carpal tunnel decompression – A6510, A6580
13. Trigeminal neuralgia surgery – A3200, A5160
14. Insertion of motor cortex stimulator – AO900, AO300
15. Craniotomy + lobectomy for epilepsy – AO110, AO300
16. Thoracic laminectomy – V2400, V2430, V2410, V2431
17. Insertion of peripheral nerve stimulator – A7010

A number of factors came together to change my views on private practice, which led to my ceasing operate in the private sector altogether:

Firstly I have always had an emotional and political loyalty to the NHS. My reasons for starting private practice at all were both professional and commercial. When I started as a consultant in 1991, the setting up of a private practice was part of establishing oneself professionally, while the additional earnings paid for the trappings of middle class life – school fees, holidays and reasonable real estate (my senior colleagues had been able to fund life in ‘the big house on the hill’ – that option not easily available to my generation of surgeons)

Secondly and importantly it made less and less commercial sense to continue operating privately. By the time I ceased, my administration costs had increased to 30% of my gross private earnings (£40k out of £120k) in an environment that was becoming more and more restrictive with constant downward pressure on earnings for surgical activity.

Thirdly it was becoming increasingly difficult to organise safe practice in the private sector. Private operating at Frenchay had become a non starter. Although the hospital had fully equipped theatres for both intracranial and spinal surgery, with resident anaesthetists and junior surgical staff on hand to manage postoperative complications if they occurred with ventilation and ITU facilities if required, the disadvantage of the lack of ring fenced beds and the poor staff availability for additional activity made it impossible to plan ahead and offer private patients the flexible service they demanded.

Facilities in the private sector were also deteriorating, the reason being the increasing commercial pressures built into the private healthcare model of low turnover – high return that was and still is practiced in the Bath / Bristol area. I found that my operating times were no longer guaranteed, making it impossible to plan family life around work.  Specialist expertise at all levels was being diluted with theatre and nursing staff offering general experience only without specialist training. Supporting medical services, like anaesthesia and radiology had become organised into cartels that functioned in a way that did not support the kind of specialist activity that I wished to carry out. Finally I discovered the hard way the lack of clinical governance in the private sector. Simply stated, it is a brutal truth that with all the business models of private healthcare available today when something goes wrong, commercial imperatives predominate over any clinical governance issues. In short the ‘blame’ for any mishap is laid firmly at the door of the surgeon with a commercial legal infrastructure, paid to minimise the financial exposure of the private institution itself. (The case in question for me was one where a patient suffered a serious, disabling but rare complication of surgery which ended up with my indemnity insurers taking the full brunt of a multi-million pound claim.) I finally had to admit to myself that safe practice was not possible in the private sector.

What happens when things go wrong?

For reasons of patient confidentiality, I am unable to refer to the above mentioned case in detail but considering the implications of a case like this is worthwhile. Neurosurgery is a ‘high risk’ activity. Like an elite athlete who has to perform to the highest standard, day in day out, any surgeon has to organise his or her life to offer the patient the best of themselves. Most of the time we get it right but occasionally we don’t. This is rarely due to a single catastrophic event but usually a series of small events that compound to produce a poor outcome. This in neurosurgery is usually life changing or a patient dies as a result. However well informed a patient is of the risks of surgery, poor outcome after surgery always comes as a shock. Living with permanent neurological deficit is difficult and costly and as we do not have a system of ‘no fault compensation’ in the UK, funding that increased cost can only come through making a successful medicolegal claim. In simplistic terms a successful claim is usually constructed around one of three things – lack of informed consent, performing an operation that was not consented for or substandard surgery and or aftercare deemed to be negligent by being carried out in a way that would not be followed by a reasonable body of surgeons

For operations performed in the NHS, it is the institution that is liable, not the individual surgeon. The many factors that contribute to poor outcome are more commonly taken into account. The lack of governance in the private sector (a blanket refusal of the institution backed by a powerful legal team to admit any liability) means it is the surgeon that, in effect, takes sole responsibility for poor outcome. Experienced specialist medicolegal firms know this and will work to reduce complex issues to a single issue of surgical competence. When successful, settlements can be enormous – in my case seven figure payouts to both client and lawyers. The process involves vilifying the individual surgeon in a way that if taken personally would bring most people to their knees.

I survived for four reasons. Firstly I was aware of ‘the process’ so tried not to take things personally.  Secondly I received incredible personal support from my defence union - the Medical Protection Society (MPS). Thirdly I received unanimous support from my colleagues without which I wouldn’t have been able cope psychologically. My case was referred to the General Medical Council (GMC), who, bowing to considerable pressure applied by the claimant’s lawyers invited me to accept a sanction. The MPS challenged this and my colleagues were given less than 24 hours by the GMC to write character references on my behalf. All 12 wrote what were, in effect ‘present tense obituaries’ supporting me professionally and personally. This resulted in the complaint against me not being upheld and my being allowed to continue to practice unimpeded. (There can’t be many surgical departments so cohesive!) The fourth factor was having another patient with the same pathology that I operated on around the same time whose problem was more complex but who did very well.

Nevertheless I had to make considerable changes to my life to ensure that a similar thing didn’t happen again – getting divorced, reducing my workload by a third ( I discovered that over work is no defence when things go wrong) and giving up all private operating, to name the main ones. I am now, in the words of a clinical psychology friend of mine, ‘the last man standing’ and as such am really enjoying the contribution I am able to continue to make. Kipling got it when he wrote in his poem "If" – “If you can meet with triumph and disaster and treat these two imposters just the same....”

(The postscript to this adverse incident was a final settlement out of court where the private provider accepted liability for 20% of the damages paid - some acknowledgement at least of shared responsibility)

Medico – legal practice

After I gave up operating in the private sector, I continued to assess patients for surgery for a while, referring them on to colleagues with the appropriate specialist expertise. Now I only assess patients for medical legal purposes. I believe, perhaps from my own personal experience that it is important that practicing clinicians should be involved in this process. I aim to give as balanced a review of a case as possible. The Woolf reforms have made this so much more straightforward in ensuring that an individual expert’s responsibility is to the court and not primarily to the appointing solicitor. My recent activity has consisted of:

                                                                   Claimant    Defendant    Joint      Total

1. Personal injury cases -                                       162                   3                   3            168
2. Clinical negligence cases -                                  121                 10                   3            134
3. Screening reports -                                                                                                         64
4. Court attendance -                                                                                                            1