Private Patient Policy. Documentation Control

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1 Documentation Control Reference Date approved Approving Body Trust Board Implementation Date July 2009 NUH Private Patient and Supersedes Overseas Visitor Policy Private Patient Advisory Group, Consultation Undertaken Directors Group, Operation Group, LNC, Staff Side All staff involved in the delivery Target Audience of care and services to private patients in NUH. Management of Private Patients Supporting Procedures Procedure Review Date July 2012 Lead Executive Mark Mansfield Author / Lead Manager Further Guidance / Information Helen Wilkinson Helen Wilkinson, Private Patient Business Manager - Ext /

2 CONTENTS Paragraph Title Page 1. Policy Statement 3 2. Equality and Diversity 3 3. Introduction 3 4. General Principles 4 5. Finance 5 6. Function of Private Patient Office 5 7. Responsibilities of Clinical Directorates 8. Responsibilities of Practitioners undertaking private work on NUH premises Private Outpatient Appointments Private Inpatients / Day Cases Professional Liability Cover Private Top ups to NHS Care Transferring from Private to NHS Care Monitoring Arrangements 15 2

3 1. Policy Statement 1.1 NUH welcomes private patients and uses the additional income generated for the benefit of all patients within the Trust. NUH will have in place streamlined and simple systems for managing private patient work so as to encourage the development of private patient activity within NUH so long as there is no adverse impact on our core NHS business. 1.2 All NUH staff carrying out private work in the Trust must adhere to this Policy and the associated procedures. 1.3 For the purposes of this Policy, private patients are defined as those patients receiving private clinical care and who give an undertaking to pay charges to the Trust for accommodation and services. The policy also covers patients undergoing clinical assessment for medico-legal purposes. 1.4 NUH currently has no dedicated facilities for private patients. Should this change, this Policy and the associated procedures will be amended as appropriate. 1.5 Standards of clinical care, courtesy and confidentiality should be the same for all NUH patients, whether they are NHS or private. Private Patients will have comments, feedback and complaints dealt with via the same Trust mechanisms as NHS patients. 2. Equality and Diversity Employees will not discriminate in the application of this procedure in respect of age, disability, race, nationality, ethnic or national origin, gender, religion, beliefs, sexual orientation, domestic circumstances, social and employment status, gender reassignment, political affiliation or trade union membership. The Trust will assess the potential effects of a policy on particular populations in a rigorous way by undertaking an equality impact assessment. 3. Introduction This Policy has been written with reference to: 3

4 3.1.1 NHS Act 1977 (as amended by the Health Service Act, 1980) A Code of Conduct for Private Practice Guidance for NHS Medical Staff (Department of Health, 2003) BMA Code of Practice for Private Patients (2006) NHS Finance Manual (2006) NUH Secondary Employment Policy (2007) Terms and Conditions - Consultants (England) (2003) NUH Consultant Job Planning Policy (2009) 4. General Principles 4.1 The basis for private patient services in NUH is the generation of additional income which can be re-invested at directorate level to improve NHS services. Private work should therefore generate a level of income that exceeds total costs. If at any time private patient activities are found to be running at a loss, then the Trust may act ultra vires and cease this activity as not to do so would mean that commercial activities are being subsidised by NHS funds and potentially diverting resources away from the care of our NHS patients. 4.1 Similarly, if we are unable to negotiate prices with an insurance company that cover our costs and provide a reasonable element of profit the Trust will cease to carry out private work for that insurer. 4.2 The Trust is legally debarred from undertaking private services in a manner which compromises our ability to deliver services to NHS patients. The provision of services for private patients must not therefore prejudice the interests of NHS patients of the Trust or disrupt Trust NHS services. 4.3 All directorates must adhere to the broad principles and procedures described in this policy. However, managers will also need to establish local arrangements to ensure that the policy works well in practice at directorate level. 4

5 5. Finance 5.1 NUH charges for private patients will be reviewed annually and a new tariff will come into effect on 1 st April each year. The Private Patient Business Manager will conduct negotiations annually with private health insurers in order to agree the annual tariff. The tariff will be simple, competitive in relation to other providers and will include an element of profit for the Trust. 5.2 The basis of the NUH Private Patient Tariff will be the BUPA Schedule of Procedures which identifies procedures by OPCS code and then groups these by level of complexity. NUH procedure prices will be based on these levels of complexity i.e. a single base price across the Trust for all procedures regardless of the specialty, with additional charges for implants and certain consumables and a price differentiation between inpatients and day cases. 5.3 Directorates should not set their own prices for individual procedures as insurance companies may refuse to pay as these will not have been agreed in the annual round of negotiations. 5.4 The Private Patient Office will dispatch an invoice within 7 days of the patient s discharge, as long as all information relating to the patient s stay is available. 5.5 Self funding patients will be required to pay in full in advance for their treatment. There will be no facility for payment by instalments. This applies both to private patients and to NHS patients wishing to top up their care / treatment. The Trust is able to accommodate various payment methods including cash, cheques, bankers drafts, BACS, credit / debit cards and on-line via the Trust website. 6. Function of the Private Patient Office 6.1 The Private Patient Office has bases on both campuses and provides support and advice to Directorates, maintains a database of private patient activity and income, generates invoices, takes and chases payments and liaises with insurance companies and patients as required. 5

6 6.2 The Private Patient Office can advise directorates and patients about appropriate payment methods for self paying patients. 6.3 The Private Patient Business Manager will work with directorates to identify opportunities to increase private patient income. 7. Responsibilities of Clinical Directorates 7.1 Private patients bring additional income to directorates. Simple but robust systems must be in place at directorate level to enable consultants to see and treat private patients in a timely manner, in an appropriate environment and with appropriate support. 7.2 Directorate systems should facilitate the capture of all private patient activity and the provision of prompt and accurate information about the services and care provided to individual private patients in order that invoices can be raised and dispatched in a timely manner by the Private Patient Office. This will include length of stay, diagnostic tests, prostheses used, OPCS code(s) etc. 7.3 Directorate management teams should have a clear view of how they see private patient activity contributing to directorate income and this view should be communicated to the directorate. 7.4 Each directorate must have a nominated Private Patient Lead who co-ordinates the administration of all private patient activity in the directorate. The Lead will be the primary point of contact for consultants wishing to undertake private work and the link between the directorate and the Private Patient Office and other departments as required e.g. Theatres. 7.5 Directorate managers should ensure staff understand that private patients are not seen instead of NHS patients and that the income generated benefits not only individual consultants but also the directorate and Trust as a whole. 7.6 Directorate managers should, with guidance and support from their Directorate HR Manager, ensure that non medical staff involved in the delivery of private patient activity outside their normal working hours are paid appropriately usually overtime recorded on the monthly summary sheets. Directorates must ensure staff are aware that they should not accept payment from 6

7 consultants for supporting private activity carried out during their contracted hours. 7.7 Directorates should not make any additional payment to consultants or any other staff for private work undertaken in contracted hours as this would constitute double payment. Where a consultant sees private patients during programmed activities the consultant must remit the fee to NUH or timeshift activity. 8. Responsibilities of Practitioners Undertaking Private Work on NUH Premises 8.1 Detailed guidance for consultants on the management of private patients in NHS hospitals is laid out in A Code of Conduct for Private Practice - Guidance for NHS Medical Staff. Responsibilities are also outlined in consultants Terms and Conditions of Employment. Consultants who choose to practice privately within Trust facilities must comply with the Code of Conduct, with their Terms and Conditions and with this Policy and associated procedures. 8.2 The key principles that all practitioners must adhere to are: There must be no real or perceived conflict of interest between private work and NUH NHS work. Practitioners must declare in writing to the Trust Secretary any business or professional interest or other non Trust work which may directly or indirectly give rise to or may reasonably be perceived to give rise to any conflict of interest. With the exception of the need to provide emergency care, NHS commitments in the Trust always take precedence over private work where there is a conflict or potential conflict of interests Practitioners may only see patients privately within NUH facilities with the explicit agreement of the Trust. For medical staff, agreement of job plans that include an element of private patient work can be taken as the express agreement of the Trust. 7

8 Practitioners should not use NUH NHS staff or facilities without the express permission of the Trust. Entitlement to use Trust staff and facilities is at the Trust s discretion and this entitlement can be withdrawn if a practitioner consistently fails to follow procedures. Under no circumstances should any practitioner make payments directly to NUH staff for work carried out on NUH premises as this potentially contravenes the Trust Secondary Employment Policy. Where an NUH employee provides support to private patient activity that brings additional income to a directorate, the directorate will make appropriate arrangements to remunerate that employee (via overtime). Where an NUH employee provides support to private patient activity that occurs outside the Trust and brings no financial benefit to the Trust but does so on NUH premises (e.g. an NUH medical secretary who provides administrative support to a consultant s private practice for another organisation), this arrangement must be approved by the directorate and the consultant should be charged for that employee s time and use of Trust resources and facilities. If it becomes clear at any point that NHS services are being compromised as a result of the arrangement, the Trust may withdraw its permission. The practitioner responsible for arranging to see or admit a private patient on NUH premises must inform the Private Patients Office and / or their Directorate Patient Lead of the patient s status. While this task may be delegated to someone else typically a medical secretary the practitioner remains ultimately responsible. 9. Private Outpatient Appointments 9.1 Practitioners Roles and Responsibilities Practitioners must inform their Directorate Private Patient Lead of any arrangement they make to see private patients on NUH premises, including confirmation of whether this is likely to be for consultation only or for chargeable 8

9 procedures / investigations. The process for doing this will be subject to local arrangements Under no circumstances will a practitioner cancel a Trust NHS patient s outpatient appointment to make way for a private patient Consultants seeing and / or treating private outpatients in NUH will be charged for the use of Trust facilities, equipment and staff. The charge will include a contribution to Trust overheads. This arrangement will ensure that NUH meets its statutory duty to recover all costs relating to the provision of private work NUH will invoice patients separately for procedures and / or diagnostic tests undertaken on an outpatient basis e.g. Minor Procedures, Endoscopy, Pathology, Radiology, Audiology etc Consultants are encouraged to use outpatient facilities for outpatient consultation and medico-legal work. If a consultant decides to use their office for private outpatient consultations they must inform the Directorate Private patient lead and will be charged for the use of Trust facilities, equipment and staff. 9.2 Directorate Responsibilities Directorate management teams must ensure that robust and locally appropriate systems are in place to facilitate private patient outpatient activity as long as this does not interfere with NHS outpatient activity and in particular achievement of waiting times targets The Private Patient Lead will agree mutually acceptable arrangements with each practitioner wanting to see private outpatients in directorate accommodation. This will include clarification of when and where patients will be seen and what nursing, administrative, secretarial and other support is required A private patient should never be given a slot in a clinic reserved for an NHS patient unless that slot would otherwise be left unfilled; if a consultant only sees small numbers of private patients directorates should usually 9

10 agree to additional slots at the beginning ( e.g. over lunchtime ) or end of the consultant s normal clinic. Such activity will not count towards the consultant s PA Private Patient Leads will ensure that self funding patients pay for any outpatient procedure in advance or on arrival. 10. Private Inpatients / Day Cases 10.1 Consultant Responsibilities It is the medical practitioner s responsibility to ensure that the directorate Private Patient Lead has all the essential details relating to a private patient prior to admission. This will include an authorisation code from the insurance company if appropriate. Some insurers will not routinely fund admissions to NUH; consultants must always advise patients to contact their insurer for an authorisation code. Forms submitted to the Private Patient Office without an authorisation code when one is required will be returned Consultants will typically book theatre slots for private patients via the directorate Private Patient Lead or the person to whom this task has been delegated e.g. a waiting list co-ordinator Private patients should not be listed on a consultant s NHS theatre list without the express agreement of the Private Patient Lead Consultants may negotiate to timeshift an NHS theatre session used wholly or in part for private work or agree to remit their fee to NUH Consultants may wish to include their professional fees in self pay prices. These should be charged in line with the BUPA Schedule of procedures. Consultants will be reimbursed within 28 days, by cheque. Consultants who choose to admit self payers before payment has been received by the trust will not be paid until the Trust has received payment from the patient. 10

11 10.2 Directorate Responsibilities Directorate management teams must ensure that robust and locally appropriate systems are in place to facilitate private patient day case / inpatient activity as long as this does not interfere with NHS day case / inpatient activity, in particular achievement of waiting times targets If the patient is self funding, directorates must ensure that payment in full for treatment is made before admission. Self payers should be given written information as to the likely cost of the planned treatment / procedure. A payment will be taken based upon the estimated charge and if the actual charge is greater, the balance will be paid on discharge. 11. Professional Liability Cover 11.1 Consultants or clinicians who are personally taking a fee for service are required to have up to date indemnity insurance from a recognised defence organisation and should be able to provide evidence of this on request Consultants and clinicians will be deemed personally responsible for the care they give to patients when they are paid a fee, even if they opt to place that fee in an NUH account Consultants and clinicians providing top up NHS treatments funded by patients but with the agreement of the Trust will be covered by NHS Indemnity. A full guide to NHS Indemnity is provided at Appendix Where junior medical staff, nurses or members of professions allied to medicine are involved in the care of a private patient in NUH, they will normally be doing so as part of their NHS contract and will therefore be covered by NHS Indemnity. 12. Private Top Ups to NHS Care From March 2009 patients wishing to top up or supplement their NHS care have been able to do so 11

12 without losing their entitlement to ongoing NHS care. This will mainly have an impact on a small number of patients with cancer who are now able to enhance their NHS care by paying for drugs which are not currently funded by the NHS. This section of the describes the approach which will be taken to Top Ups within the Trust in response to guidance from the SHA and Department of Health. A detailed local procedure describing how (and where) co-payment treatment will be delivered and charges raised and collected is currently being produced. There are some clear key principles: Individuals who choose to access private healthcare now retain the right to access NHS healthcare which is normally funded by the patient s PCT on the same basis as any other individual; NHS care should not therefore be withdrawn simply because a patient chooses to buy additional private care. The NHS must not subsidise private care. Therefore where a patient wishes to top up their treatment with medicines not normally funded by the patient s PCT, the patient must pay in full for their purchase, preparation, administration and all other associated costs of the private treatment, including additional treatment needed for the management of side-effects. Clinicians and directorate managers should exhaust all reasonable avenues for securing NHS funding before suggesting that a patient s only option is to pay for treatment privately. NUH clinicians should make all care options available to patients, including those not offered by themselves or by NUH, in line with GMC guidance.. Clinicians should not make assumptions about the information a patient may want or need. This includes deciding whether to tell a patient about all available treatment options based on an assumption of their financial circumstances. Consultants should also continue to comply with the Code of Conduct for Private Practice which states that: - consultants should not initiate discussions about providing private services for NHS patients, nor should they ask other NHS staff to initiate such discussions on their behalf. However, 12

13 there is a difference between providing information to patients on all of the treatment options available to them, including a top up drug, and advertising private practice to NHS patients. If a patient seeks information about a top up drug, consultants should provide full and accurate information about the drug including the costs and the potential benefits, risks, burdens and side effects. A brief record should be kept of all discussions with patients about care not routinely funded on the NHS in the patient s NHS medical notes. There should be as clear a separation as possible between private and NHS care. The top up element of the patient s care should be carried out at a different time and place. Facilities ( such as side rooms or treatment rooms ) and equipment can be temporarily designated for private care. Departing form these principles of separation should only be considered where there are overriding concerns of patient safety. Such decisions should usually be agreed in advance with the Medical Director. Where a decision has to be made without gaining prior approval from the Medical Director on the grounds of clinical urgency, the Medical Director should be informed as soon as possible afterwards. A record should be kept of all decisions to depart from these principles. Where NUH decides to provide additional private care as one of the services we offer as an organisation, staff including consultants will be covered by NUH indemnity as they will be providing private care in the course of their NHS employment. In this scenario the expectation is that the patient will be treated in the consultant s NHS time and no fee will be levied Patients wishing to pay for additional private care must be informed in advance of the likely costs of the treatment, An Undertaking to Pay form should be completed and signed and payment in full taken before the treatment is given, month by month if required. Top up medicines will be given on a strictly pay as you go basis; payment by instalment will not be permitted. 13

14 12.3 Some patients will only have the resources to fund the top up drug for a limited period. It is vital that patients have complete understanding of: The costs of the treatment (including additional charges that may be made in the event of the patient needing treatment for side effects) The Trust Terms and Conditions (i.e. payment in full up front) The NUH position in the event of the patient being unable to continue funding their treatment i.e. NUH can only continue to provide and administer the drug as long as they can pay for it, regardless of how beneficial the drug turns out to be 12.4 In all cases an exit strategy must be agreed by all parties. 13. Transferring from Private to NHS Care 13.1 Patients who choose to be treated privately are entitled to NHS services on exactly the same basis of clinical need as any other patient. Where a patient wishes to change from private to NHS status, the following principles apply: A patient cannot be both a private and an NHS patient for the treatment of any one condition during a single visit to the Trust. Any patient seen privately is entitled to subsequently change his or her status and seek treatment as an NHS patient. However, the patient is still liable for the cost of treatment already received privately. When a patient is seen privately and they make a request for their care to be transferred to the NHS, a new referral to the NHS must be arranged by the patient s general practitioner. This allows the patient to choose their NHS provider and allows the Trust to recover the full cost of their care. 14

15 A consultant may not refer a private patient directly to the NHS for investigation, treatment or follow up unless the patient is need of immediate care (initiation of investigations or treatment within 24 hours). 14. Monitoring 14.1 Private Patient activity will be monitored to ensure that all the income due to the Trust is recovered and to identify trends and potential opportunities. Reports will be produced regularly to allow the Private Patient Manager to monitor income and debt recovery The Income section of the Finance Department will provide the Private Patient team with the following information on a monthly basis: List of all private patient invoices raised Analysis by consultant, insurance company and OPCS code Notification of what invoices have been paid Aged debtor s analysis including status of debts being managed by Debt Collection Agency Theatres will send a monthly list to the Private Patients Office of all private patients seen in Theatres (extracted from ORMIS) and this will be cross referenced with invoices sent out to ensure that no activity is being missed All practitioners carrying out private work in the Trust will be required to complete a quarterly private patient return declaration which will enable the Private Patient Office to check that all private patient activity has been invoiced. Helen Wilkinson Nigel Beasley Simon Linthwaite May

16 EMPLOYEE RECORD OF HAVING READ THE POLICY Title of Policy/Procedure: I have read and understand the principles contained in the named policy. PRINT FULL NAME SIGNATURE DATE 16

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