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Private Parts - An editorial by Ian Culligan

ACPRC's Vice Chair and Healthcare Change Manager at Bupa, Ian Culligan discusses private respiratory physiotherapy.

Respiratory Physiotherapy: Private Parts

Walk through the door of many of London’s private hospitals or clinics, and you could be forgiven for thinking that you have just walked into a 5-star hotel lobby. With a dedicated concierge team to accompany you to your ward, light and spacious waiting rooms filled with the scent of freshly ground coffee, and state of the art facilities in every consulting room/treatment area, it becomes quickly apparent that these organisations view their clientele not just as patients, but customers as well.

Providing these facilities in areas such as Harley Street or the 6th floor of the Shard in Central London doesn’t come cheap, and the majority of private healthcare is funded by health insurance companies such as Bupa, Aviva, Axa and Vitality. Approximately 10% of the UK population have private health insurance either through their employer or a personal policy, with costs dependent on age, lifestyle, medical history and postcode.

For those without health insurance, private healthcare is becoming increasingly available on a self-pay basis, but with consultant fees of around £200 per 20-min visit and diagnostic tests often running into the hundreds, it can be an expensive undertaking for anybody who needs to use healthcare services regularly.

There are a number of vocal critics of private healthcare in the UK - many citing issues such as making profit from ill-health or cherry-picking the profitable services - but few would disagree with the fact that if private healthcare provision disappeared overnight, the knock-on effect on the NHS would be crippling.

Furthermore, one could view the current model of CCGs using taxpayers money to fund local NHS services as not entirely different to the model of insurers using customers premiums to pay for private services. With CCGs cutting back on services being funded (think vasectomy / minor surgical procedures etc), the cherry picking seems not to be limited just to the private sector - a key the difference being that if an insurer loses £135m in one year for overpaying for too much treatment then it may cease to exist. Whilst one approach adheres to the mantra of ‘giving based on ability / taking based on need’ the other favours a more ‘give and take based on ability to pay’, and whilst it would unwise - even impossible - to simplify and debate the relative merits of private v public healthcare in less than 1,000 words, physiotherapists should at least have an awareness of the different models of care available to their patients.
Respiratory Physio Context

When it comes to private physiotherapy services, respiratory services often play 2nd or even 3rd fiddle to MSK and Neuro. Out-patient provision dominates the private respiratory physiotherapy sector, and recent trends have shown that the number of private respiratory services are growing, with patients increasingly willing to part with their hard-earned cash to be seen more quickly and at a time that suits them. However this model of care may not always be in the patient’s best interest, whether that be due to the lack of integration with other services or the failure to divert specialist resource where it can have the greatest effect. The following challenges also need careful consideration:

Challenge 1 – Chronic Conditions
With respiratory conditions requiring more ongoing appointments compared to an acute MSK injury - and the majority of health insurance policies not covering chronic/pre-existing conditions – private respiratory physiotherapy struggles to attract volumes anywhere near its MSK relatives.

Respiratory physiotherapy patients are nearly always self-paying, which poses both a service design and moral challenge for disease groups such as COPD, which are often associated with lower income, employment challenges and long-term disability. Providing services based on people’s ability to pay always sparks the debate about a two-tier system and whether we should be rewarding positive health behaviours or attitudes (i.e. healthy get healthier) or focusing attention on those with more negative health behaviours and attitudes to raise the ‘minimum standard’.

Challenge 2 – Inpatient Care
With the majority of UK Respiratory Physiotherapists working in specialist inpatient settings, the opportunities to treat patients in private settings compared with MSK colleagues are significantly limited. A number of private hospitals do not have 24/7 critical care facilities, and as a result this can limit the amount of exposure (and subsequently experience) that inpatient physiotherapy teams get treating complex respiratory patients. The smaller size and scale of private facilities can often result in complex patients being moved to an NHS hospital, which may further limit the opportunities for development and growth in inpatient respiratory care.

Many NHS hospitals now have ‘private wards’ where patients with Health Insurance are admitted, regardless of their diagnosis. Some private 24-bedded wards (normally all side rooms) will cater for 24 specialties all at the same time, with teams such as respiratory physiotherapists providing outreach as part of their caseload which itself poses challenges around integration and a seamless care journey.

In some units, the financial value placed on respiratory physiotherapists by insurance companies can also cause problems where the reimbursement for specialist physiotherapy teams is insufficient and benchmarked at a lower grade than the individuals providing care. This can cause a financial headache for managers who are grateful for the additional income, but acknowledge that the other services may suffer as a result.

Challenge 3 – Integration
As the NHS moves towards increased collaboration and integration through the recently launched STP programmes, private providers remain on the periphery and risk missing out on system-wide integration which is centred around the individual patient. One could argue that integration of services is in direct conflict with the commercial nature and market dynamics of private services, and if a private provider stands to lose out financially due to ‘integration’ then the likelihood of them engaging is limited – even if this is for the greater good.

In the private sector (as with the existing NHS model of commissioning) there is all too often a scramble to attract patients to specific facilities because increased patient volume = increased revenue. As a result, the difficult conversations which are taking place in NHS boardrooms re: STP integration/mergers are also being had across the private sector as a whole, because integration will come at a cost whichever form it takes.

Challenge 4 - Customer Service
The Department of Health defines ‘Quality Care’ as being safe, clinically effective and a great customer experience. The private sector certainly place greater emphasis on customer service and experience compared to the NHS, but the first two must still remain higher priorities.
Working in a MDT everyday with unrestricted access to specialist colleagues, and treatment informed by up to date research and best practice are clearly key drivers behind delivering safe and effective care. This is normally (but not always) easier to achieve in organisations like large NHS trusts, but that is not to say that these ambitions are not achievable by private sector workers.

However, when you consider the ‘customer service’ that some patients experience in an NHS hospital from expensive parking and a poorly-signed maze of corridors, to unhealthy food in cafeterias and lengthy waits in uncomfortable waiting rooms, the question of whether NHS services are doing all that they can to make healthcare a positive experience needs to be asked.

As members of the public ourselves, if we experienced this from John Lewis or Pizza Express then it may seriously question whether we would want to return. Our patients may not have another option so the onus is on all of us to put this back on equal par with safe and effective.

So What?
For the private respiratory physiotherapists providing treatment independently of the NHS, real efforts now need to be made to formally link in with NHS services including GPs, secondary care and support services. Tough questions need to be asked about what is best for the patient whether they are willing to pay or not, and whilst working privately comes with a number of benefits for both physiotherapist and patient, a balance must be struck and compromises reached to ensure that where possible, all patients receive care that is safe, clinically effective and a positive experience.

For example, if research were to find that one to one pulmonary rehabilitation was less effective than group-based PR, would private physiotherapists to consider their service offerings and models? Furthermore, if a NICE description of best practice care of respiratory patient includes an MDT approach, this can be harder to achieve privately than in the NHS and therefore a concerted effort will need to be made to integrate appropriately and not just as a tick box exercise.
Finally, a quote that has stuck with me for a number of years is “if we chase perfection then we might just catch excellence”. Regardless of whether we work in the public or private sector, we need to move away from a mentality of accepting mediocrity, and move towards designing systems and processes which enable quality care to be delivered every time. Striving for perfection drives continuous improvement, and if we fail to aim for this then we risk falling even shorter.