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The times we are working in now need a great deal of accelerated change and there must be no negotiating that down. So my mission statement for this part of my consultancy career is to be clear that there needs to be and will be a lot of change from the work that I do with individuals and organisations and if organisations don’t want that, then it is probably best to go somewhere else.

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Private sector health care and payment for training

Filed Under (GPs, Private Sector, Resources) by Paul on 27-07-2011

Education and training in the NHS use a great deal of our public resources. This investment plays not only a very significant role in developing the NHS, but also plays a much wider role in developing our society. The fact that tens of thousands of teenagers in every generation work hard to get into clinical education demonstrates the central role that the NHS plays in people’s lives.

As with education we have a mixed system of providers of health care – some are private and some publically owned – and, just as with private schools, privately owned health providers gain from training that has been paid for from the public purse. Off and on, over the 60 years since the inception of the NHS, the issue of gain by private health companies of public resources has been raised.

The argument goes like this.

A private company employing doctors and nurses, trained using NHS resources, makes a profit from that training – that was paid for from the public purse. The argument is that there should be some recompense to the public purse from this private profit.

There are a number of parallels in our wider society that are problematic here. Insofar as a subsidy is paid out of public resources for any undergraduate education (and under the present cuts this will reduce to £3.2 billion) there is a public resource subsidy for all higher education.  That suggests that every private sector company that employs a graduate of the English Higher Education system should in some way repay the cost of the public subsidy for that graduate from their profits. Following this line of reasoning an accountancy graduate going on to work for a private sector company should have the subsidy that was paid for their higher education repaid from the profits of the company that employs them.

If profits from health care should be used to repay the public subsidy for higher education – then surely so should those from other companies? But as we shall see (in a later post) the public have a different attitude toward profit from health care than they do toward profit in other industries.

Benenden Healthcare Society recently carried out a study that found that 57% of adults stated that if an NHS trained doctor goes on to treat patients privately, they should have to pay back at least some of the cost of their training1. .

A third of those questioned (31%) said that doctors should not have to pay back their training costs, so long as they continued to do their fair share of NHS work.  Just under one in eight (12%) of adults believe that as doctors pay tax on their private earnings they should not be expected to pay back any of their NHS training costs.

25% of those polled said the entire cost of a doctor’s training should be paid back if they treat patients privately, 19% said it should be up to half, whilst 13% believe it should be between 50-100% of the cost.

Those working in the public sector are equally as likely to believe that doctors should pay back training costs as those in the private sector (59% v 62%).  Attitudes vary more greatly across the country.  In Scotland and Wales two thirds of people (66% and 64% respectively) think training costs should be paid back, whereas in London and the West Midlands, this falls to one in two.

With the NHS spending on average over £200,000 training each doctor, a repayment programme by doctors working in private practice could result in at least £744 million being returned to the NHS2.

This is of course a very significant amount of money and one of the reasons this issue is resurfacing at the moment is because of a growing realisation that the NHS is going to have a very, very tight few years in terms of the increased demand for health care. Over the next few years the public will be looking for a return on all of its investments.

Very soon after this research was published I was on a platform for a breakfast discussion about the role of the private sector in English health care. This issue was raised a couple of times and the two representatives of private sector providers on the panel were very calm about it.

Above all they really wanted their organisations to have the opportunity to play as full a role as possible in the training of junior doctors and nurses. They felt that they provided a very good learning platform for doctors and nurses in training and some of them were starting to be used for the annual rotation.

Given the fact that about 200,000 NHS patients will be having elective operations carried out within private sector provision, it makes sense for providers carrying out NHS work to be a full part of the training for NHS staff. The private and public sector would gain if all providers were able to play as full a part in the training of staff as possible.

1 – Research carried out by Populus amongst 2059 UK adults between 24th and 27th June 2011.

2 – Based on 41,439 GPs with an average of 9% of income from outside NHS: and


3 Responses to “Private sector health care and payment for training”

  1. While some training programmes rotate into the Independent sector (Plastic surgery & Orthopaedics come to mind immediately) because the volume of cases carried out is so great, we are currently cutting the numbers of trainees overall.
    Since trainees give as much service as they receive training, any more moves to the public sector whill of necessity take a trainee out of an NHS hospital and deprive them of the service element.
    Obviously the trainee needs to follow the curriculum opportunities wherever they arise and there is no doubt that in a small number of cases these will be be in the private hospitals.
    But the far more complex cases and the sickest patients are still in the NHS hospitals.

  2. You just mention doctors’ training in your piece – what about nurses and physios who go to work in the private sector ? Doctors in training spend a bigger part of their working lives providing service than physios or nurses. I agree (as do most) that If the private sector wants a piece of the NHS pie, they should contribute somehow to training and associated costs.

  3. There are some other issues that you do not mention.

    The first is the “level playing field”. If you read the impact assessment for the Health and Social care Bill you’ll see that KPMG claim that the private sector are disadvantaged by 14%, that is, things like NHS pensions and NHS liability insurance means that there are lower costs for the NHS than the private sector. My response is “good, it proves the NHS is cost-effective” but that is not the response of Lansley who talked about making a “level playing field”, which was interpreted by some as being a charge to NHS providers for these services. The problem was, of course, KPMG did not include training, nor the extra costs involved in running A&E and a *comprehensive* set of services, nor the extra costs of PFI. This is the reason why the costs of training came to the forefront.

    Another issue that few people point out are the effects of MPET and SIFT on the incomes of hospitals. My local hospital is a medium sized DGH; MPET and SIFT make up one quarter of the salary budget. This is significant and any attempt by this government to make “providers pay for training” will have a serious effect on their income. In fact, if that funding is removed, then the hospital will go bankrupt.

    So the issue of private providers paying for training is fraught with difficulties. Perhaps Lansley should just leave it alone and concentrate on the far more important task which is the Nicholson Challenge.

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