Hospital in focus: the role of private healthcare within Imperial College Healthcare
The role of private healthcare within the NHS has never been without controversy. And increasingly, as episode two of the latest series of BBC Two’s Hospital shows, the choice between NHS and private may not always be black and white. Here, the Trust’s director of private healthcare, Nick Fox, explains the role that private care has played in the NHS since it was founded in 1948 and, specifically, how private care is being managed and developed at Imperial College Healthcare.
While the NHS provides by far the majority of healthcare in the UK, there is a sizeable private sector. Around 11 per cent of the UK population have some form of private health insurance and they account for just over half of private healthcare revenue. A small number of other UK residents choose to pay for treatment out of their own pockets. And there is also healthcare demand from overseas patients. Around a quarter of overall private healthcare revenue comes from the NHS paying private providers to boost capacity by treating NHS patients – at the same prices charged by NHS hospitals.
An important income source for NHS services
To add to this complex picture, many NHS trusts also have some form of private healthcare arm. Imperial College Healthcare NHS Trust brings in around £50 million a year through its private division, equivalent to just under five per cent of its total revenue. Set against a planned deficit for the Trust this year of £41 million, this is an important factor in reducing the amount of efficiency savings that our NHS services need to find.
Private and NHS links go back to 1948
The inter-connections between private and public healthcare go back to the foundations of the NHS in 1948. One of the terms agreed by founder Nye Bevan was that consultants were permitted to continue with their private work alongside their commitment to NHS services. This condition remains in place today, with consultants able to split their time between working for the NHS and for private services, albeit with stringent rules in place to avoid conflicts of interest. Around half of NHS consultants are estimated to undertake some additional private work for which they are paid an agreed fee directly.
Likewise, our hospitals precede the founding of the NHS and we have continued to maintain and develop a private arm. This enables us to ‘keep’ private income generated by our consultants undertaking their private work in our facilities within the NHS. As our private division is fully part of our organisation, all of the income comes back into the Trust and helps support NHS services.
Managing potential conflicts of interest
The income also maintains our dedicated private facilities. As well as enabling us to offer the higher specification accommodation that private patients expect – and pay for – this means that, as far as possible, private services do not need to share NHS capacity. We have the Lindo Wing at St Mary’s – probably best known for the births of many members of the royal family; the Robert and Lisa Sainsbury Wing at Hammersmith; the Sir Stanley Clayton Ward at Queen Charlotte’s & Chelsea; The Thames View at Charing Cross; and a dedicated private unit at the Western Eye.
There are occasions when private work takes place in NHS facilities, such as some operating theatres, but this will be scheduled around NHS lists. Emergency cases, whether under private or NHS care, are treated exactly the same and only clinical priority is taken into account. We do have some sharing of resources going the other way too – if we are very stretched for capacity in our NHS services, we are able to bring into use spare beds in our private facilities, without any additional charge to the NHS.
Although our private healthcare arm is a commercial business, the principles and values of the NHS are very much apparent throughout the organisation. There are strict rules around how our consultants manage their time between NHS and private work. Our consultants must ensure that their NHS work takes precedence over their private work. And they must also never attempt to sell private services to NHS patients, or ask other staff to do so.
As an NHS organisation, with many world-renowned consultants and a strong research focus, the make-up of our private income is quite different to the average for the private sector. Around a quarter of our income comes from overseas patients, who are not eligible for NHS care. A small proportion comes from self-pay patients and the majority from health insurance. We do not undertake any NHS work from other NHS hospitals.
Managing emerging dilemmas at the frontier of innovation
Episode two of the second series of BBC Two’s Hospital shows a relatively new strand of self-pay work – still small but growing. This is for providing aspects of care for NHS patients that are not available on the NHS, because the treatment is so early in its development that it is not yet fully proven or is not deemed affordable by the National Institute for Health and Care Excellence (NICE) when taking into account effectiveness, cost and existing alternatives.
In the programme, we see Glendon, a 51-year-old man with an aggressive brain tumour, who has researched an immunotherapy drug that is beginning to be trialled for his type of cancer. But, as the evidence for its effectiveness is not strong currently, it is not licensed for this use and so is not available on the NHS. Undeterred, Glendon wants to self-fund a course of the drug and comes to Charing Cross Hospital’s private wing to see one of our consultant oncologists who has a particular interest in this treatment approach.
As his story unfolds, it’s clear that there are real dilemmas here, for Glendon and his clinicians. While the Trust adds no mark-up on the drug and charges only a small fee to cover costs for its administration, at up to £30,000 per dose, the cost of the drug itself is high. With little empirical evidence to go on, does a potential improvement in Glendon’s life expectancy or quality of life justify the financial expense and potential side-effects?
Clinicians working privately in our Trust are governed by the same rigorous clinical standards and supervision and appraisal processes as they are in their NHS work. We see Glendon’s oncologist discussing treatment options with his divisional director and with other colleagues in order to arrive at the best possible recommendation for his patient.
Looking to the future
The proportion of private income generated by the Trust has not grown much over the years. It is currently nearly five per cent. We think there are sensible options to grow it further in some areas – where there is demand and where we have particular expertise and capacity. This is particularly important when NHS funding is constrained as it helps us maintain investment in our NHS services. We’re also very proud of the private care we offer to UK and overseas patients across our hospitals. Ultimately, though, we are clear that our core business is NHS care and that will always be our main focus.