SPEAKER_03 0:00

You're listening to Confidence to Thrive, a podcast for ambitious healthcare practitioners and entrepreneurs, brought to you by Alicity Advisors. Welcome to Confidence to Thrive, the podcast helping growing practitioners and healthcare entrepreneurs navigate the challenges and risks of regulation while building brands that matter. Every episode we tackle a different issue facing healthcare practitioners or entrepreneurs, or we interview a guest who is working on the leading edge of private healthcare, building something that matters in their sector or profession. My name is Jody Rainsford, and on today's episode I'll be discussing with Christopher Cloak Brown and Roger Houston, directors at OLISTE, about a particular case study in relation to the challenge of growing a healthcare business and navigating the NHS private interface. This case revolves around a functional medicine client who has been assisted with an NHS England complaint and is particularly relevant to those practitioners or entrepreneurs who have or are starting a new functional medicine practice and trying to find new patients early on. Let's go over to Chris and Roger to go into the details. So, Christopher and Roger, what was the specific complaint that you were asked to assist with?

SPEAKER_01 1:04

So we've had it from two angles. So let's deal with the NHS England complaint first. So the circumstances were partner in a GP practice, considering treatment, an existing patient treatment journey within the NHS, for perfectly sensible reasons, mainly on waiting, not scope of treatment. It was waiting time, suggested that a particular patient might want to consult that same doctor privately for something that you could broadly label as functional medicine. That was a complaint to NHS England on the basis that the patient could have been given the same treatment in an acceptable time frame under the NHS and three at the point of delivery. NHS England doesn't exist anymore, but the same broad ethics do under the GMC. So interestingly, this was an NHS England complaint only. I think it was triggered by another partner reporting this person to the NHS for breach of their GP contract. So that's what triggered it. So the patient wanted to be brought back into the NHS fold on the basis that the treatment they thought wasn't and the time limit wasn't worth the money. So there was that aspect of it. The practice wanted to jump all over the individual GP for having the temerity to, as they see it, appoach patients from their list. NHS England wanted everyone to be friends as NH England did. So that was an interesting one. GMC, the emphasis is on guidance, adherence, and discipline. If there was a suggestion that you failed to meet the expected standards, so that's where guidance becomes wholly writ, as we said in the other podcast, interestingly enough. NHS England is about education and self-reflection. Yeah, it was like the medieval equivalent of being confined to a monastery for prayer and self-reflection, which was interesting. So that was a particular aspect to say this particular practitioner is now fully familiar with their contractual obligations and has learned and is now a better person. There was interestingly enough, no criticism about the scope of treatment. No one says she was a bad doctor from a clinical point of view. Her her grievous crime was to be vaguely entrepreneurial, but there we are.

SPEAKER_03 3:46

So from a case basis, that's what happened. What happened in in practice then, just to understand it from the individual level?

SPEAKER_01 3:54

From the patient, they they effectively had the same treatment with the same doctor at the same location, they just didn't get a bill at the end of it.

SPEAKER_03 4:02

Okay, and so the patient raised this with the clinic, and then the clinic they investigated it and and with their colleague partner to NHS England. And does that mean that the they had no protocol in place for potential referrals, or is that such it is that a no-go? Is there any kind of sign that the client was unaware that this would be viewed in a way to register even a complaint?

SPEAKER_00 4:31

Yeah, I think it is an interesting one, Jodie, and it expands. So it's a common problem where you have uh effectively an NHS practice, and let's say for the arguments of some, but one of them decides to set up their own, let's call it a private GP for now. Very often the private GP is going a little bit away from standard NHS practice, and they like the functional medicine, they like spending time, they like getting to the root cause. That's very much a driver for GPs to set up a private practice needs to get out of this sort of you've got six minutes to work out which pill to give your patient. That's we're trying not to do that. So, in some ways, when you you set up a business, you're used to the NHS and you have this nice long list of patients in the NHS and potential clients in your private business, you can see the temptation. There's sort of two things to understand is the NHS contract specifically says that you can only offer private services to patients that you cannot offer under your NHS contract. And secondly, one way people think of that they can get round of it is what happens if my colleagues refer their patients to me. I won't refer my patients because clearly that's unethical, but I've got all these lovely colleagues with lists of patients too. So we looked at that. This we've looked at it a few times for a few people. The contract is normally with the practice, so the patients are a patient of the practice. It just happens that the practice decides to split those patients into different lists for different GPs. So again, that's a no-go. The contract says you cannot refer the patients to the practice, so any other GP cannot refer those patients because they're patients that are practice and can't be referred. So I think our very clear advice is as tempting as we can see it is, just stay away from it. It is a whole world of hurt. If you get into the weeds and the detail, there are things that you could possibly do, but you rarely are for the amount of benefit, the risk in the world of hurt that might await you, is just not worth it.

SPEAKER_03 6:36

Does that does this mean that this was the first instance this has happened at this clinic, or is this the first instance that had caused this particular issue? Were there other other doctors with private practices who Yeah, there could have been Jodie.

SPEAKER_01 6:49

Our involvement and the trigger for this was the patient complaining. There may have been other patients that went through a similar journey that didn't complain and therefore didn't trigger anything. So yeah, he was a fairly switched-on patient. He was well researched, which many of them are, and he was basically saying this is available free on the NHS. Yes, you've told me about the waiting list and issues. I accept that, but I'm prepared to deal with that. So why did you take me out and why are you wanting to charge me?

SPEAKER_03 7:18

Okay, so this was before anything was charged. This was this happened.

SPEAKER_01 7:21

No, it was it was yeah, there had been some invoices raised and what have you. So had that gone to the GMC, there would have been an allegation that you were prescribing treatment for financial gain, which is a very serious allegation, and one that would have been very hard to rebut. In some ways, this this individual, in quotes, got off lightly by just having to contend with an NHS England complaint. Had that gone to the GMC, it would have been much more serious.

SPEAKER_00 7:50

I think it's it's an interesting thing, Jodie. And so the the lists is one way, but actually the whole sort of as we keep discussing, the NHS isn't really set up commercially at all. It's not a commercial organization, so as is problematic that interface where you're interfacing anything commercial with it. And we had another practitioner who said they were doing just pure functional and diet exercise lifestyle supplements. And in the world of supplements, there's sort of good ones and bad ones, so the quality varies massively. So they actually set up a supplement provider, and their motivation was to ensure that they only offered the good quality, the high-grade supplements to their clients, and there was a clear source to get those supplements. But again, they had a patient who bought it was several thousand pounds worth of supplements from them and then decided that they weren't doing them any good, and it was all a bunch of rubbish, and made a complaint. And effectively, we advised her to refund because again, you it was just a bit too close to home, and you don't want a GMC complaint. And as Roger says, the clear complaint is that you are trying to profit off your patients rather than treat them, and you need to be very careful in that in all aspects of healthcare. So, yeah, it's interesting that some doctors are only fairly good, caring people, that's why they go into the profession and they do a lot of things for the best of motivations. But you need to step back sometimes and have a sort of slightly sceptical view on things as to how it can be interpreted if it goes wrong.

SPEAKER_03 9:24

Before I want to come back to something Roger said there about anyone doing anything vaguely entrepreneurial, because that really goes to the heart of what this podcast is about. But before I do that, can we just cover the area of dentistry? Because I think that was another element worth mentioning in in this part of the discussion, and particularly around the situation of dentists coming from abroad and not fully understanding the NHS private interface and that causing issues.

SPEAKER_00 9:48

Yeah, so in the UK, the NHS is fairly unique, and then whilst there is increasingly less NHS dentistry in the UK, there is is still some, and they are still NHS patients. Now, abroad, the it's pretty much all private. So you get, and we've seen this with an extremely experienced, extremely well-qualified dentist who came to the UK from Germany. So they would assess their patients in the NHS part of their practice, say, This is what I think you need, this is what your treatment plan is. Where aspects of that treatment plan would fall outside what was available on the NHS. So it fell into a into the private practice. And at the end of the treatments, the patient we presented with a bill which was far higher than anticipated, would go through and go, What's all this? Why did you do that? You could have treated me in the NHS, I'm an NHS patient, and that in his first 18 months, two years generated him about six or seven complaints, yeah. So until he worked out what the NHS was, what treatments were available on the NHS, and so on. And then you can explain the difference. Uh, I'm not sure what the situation is today, but in those days it's the difference between having an amalgam filling with mercury in it and a white filling. And so there is a debate as to whether those amalgam fillings are dangerous with the mercury in them, so he would do white fillings. But at that time, at least wasn't an NHS treatment, so they were getting the bigger bill for it. So he thought he was doing from Germany good dentist, great track record. I'm providing quality treatment here, and all of a sudden he's got six, seven complaints.

SPEAKER_01 11:30

Yeah. Yeah, and at least in the title is National Health Service. So people within it that don't do private work think of it as a service. No different from the police or fire ambulance service. The idea is service, not business.

SPEAKER_03 11:48

I suppose that goes back to the the point you were making about God forbid anyone do anything slightly entrepreneurial. We've talked about a couple of cases there of someone seeing that and with the supplements as well, offering something that that is that they see as beneficial that because they understand all those kind of differences. Is there a a way of doing it that doesn't cross the line? If you were going to suggest how exactly someone might be able to navigate the interface in the right way without potentially triggering complaints, without potentially causing issues like this, is it possible or are we still in an area where it is just unlikely that anyone would be able to use the interface in that way in order to grow a business that they almost have to leave and separately set something up?

SPEAKER_01 12:38

Yeah, so I think the irony in all of this is that where all this comes from is a perception of an inadequacy that's what's available via the NHS. So I think again, it's all about definition, isn't it? What you want to do, what's available on the NHS, and say that there's a private option, the cost is this, and give the patient the choice. What you cannot assume is that they will agree to private treatment at a cost that they don't know about in advance. The onus is very clearly on the physician to say that acting in your best interests includes counter to my financial interest, which is why they take this whole treatment for financial gain thing so seriously if it ever gets to the GMC. So you need to be a position, it's just another view, it's a commercial reality or prime, it's just another form of informed consent. Here are your options, here's the price for each. What do you want to do? So it's possible, it's extra work, but again, the people we speak to, they know what's available locally on their practice, they know what the NHS waiting list is for various things, they know what they want to do, they know why they want to do it. That's the other thing, isn't it? It's quite a lot of work if you do it in six-minute time slots under the NHS, but the NHS don't require a whole range of things. So you need to change the way you think. It's probably a half-hour consultation that you're going to have to live with, and you're going to have to set out the options, a bit like a menu with a price. Think of it, they're dining a la carte with you. They're not in McDonald's under the NHS, and therefore they need this proper menu. Leave the choice to them.

SPEAKER_03 14:08

In those couple of examples you used, the the question around that is to whether I imagine is whether the similar treatment on the NHS would be and how that compares with the treatment being suggested. So, in the first case, the big case we're talking about, the wait time wasn't seen as significantly long enough to warrant it being different. And in the supplements case, the quality of the supplements, I imagine in that was they weren't seen as vastly superior enough in terms of the NHS alternative. So, how does that kind of sliding scale work? Is that just a case-by-case basis, or how do you assess that?

SPEAKER_01 14:43

It's whether the patient thinks you're ripping them off.

SPEAKER_03 14:45

Okay.

SPEAKER_01 14:46

That's the litmus test.

SPEAKER_00 14:48

I think, and your defenses have presented you with the options. There is a sales bit to say if you want this, if you want the sale, you've got to convince them of the benefit, but you can't you can't stretch the truth because you could be subject to an awful lot of scrutiny. But yes, so that's the the the awkward part.

SPEAKER_03 15:07

Because surely that's quite that's a difficult thing to do. The way that NHS waiting times work is that you don't really know how long you're gonna have to wait until until you're referred. So how can anyone make that judgment as to whether something is going to be sure or not?

SPEAKER_01 15:22

So lots of people we deal with still have a foot in the NHS locally and they know what the waiting time is for a blood test, for example.

SPEAKER_00 15:30

But I think that's and again that goes back to our sort of overall advice, which basically says it is very difficult to interface between a personal NHS practice and a private practice. It is much better that your private practice is independent from your NHS practice, and those patients and those clients choose to go privately and come from other sources. I think a lot of these problems happen, and again, in the dentists, it's it's the dentist who walk in with they have an NHS piece of their business and a private practice, so they have their NHS list, they don't understand the NHS list, and they've effectively chosen that NHS, so they're offered the treatments with within that. They don't want the private dentistry for whatever reason. You treat your NHS patients as I offer them these treatments within this world, and my private patients as I, you know, I offer them these treatments within this world, but it's that blurring of the two that generally causes people problems.

SPEAKER_01 16:29

Yeah, it's interesting. I had a very tricky dentistry case where a foreign qualified dentist thinking he was being helpful, genuinely thinking he was being helpful, ended up signing a finance agreement to fund dental treatment on behalf of a patient. Yeah, exactly. You can imagine how that went. So it's interesting that it comes out in various guises, but the trigger for all this is candidly the patient thinking that we're taking advantage of them. And the way to deal with that is to refer to the treatment schedule and the menu of options, including cost. It's very difficult for them to subsequently complain if they've consented to the procedure, even if that procedure can't guarantee an outcome at any particular point, and no sensible medical plan can, and anyone that any plan that says it can is not really a medical plan. So it's certainly achievable, it's just the way of thinking, it's not like all this information is not available or not readily available. They're serious medical players, these people. It's not like they can't do it, it's just that they don't set it out in the right way, and they typically don't do that because they don't feel that they can charge for their time to do it properly. That's a commercial decision that you need to do it, and they come from a background where it's largely not required because of the NHS way in which it works. So you're going from providing a service to charging for within a business context, that's the difference. And lots of foreign doctors don't have a problem with that. When we go to Ireland, we never get this, do we? We never get it, it's only here.

SPEAKER_03 18:18

So cultural and process.

SPEAKER_00 18:20

Yeah, yeah. But point of delivery, but it's free on the basis of we'll offer what we offer when we get round to offering it. So it's uh as Roger says, it is just a completely different thing. One is a health service, and the other is a health business, and they're not the same thing, and they clash.

SPEAKER_03 18:38

And so, based on what we've discussed, then almost like the safest route would be to uh set up a separate business with patients coming to that separately, and almost it's like a Chinese wall between NHS patients and the patients coming into your business. I suppose if they find another way there, that's that that's their thing, isn't it?

SPEAKER_00 18:59

The ones who do it successfully, and then if you like the sort of the in GP lands, norm most GPs have mainly decided to be NHS or private. So I would say it's probably a more recent thing where you get these people a little bit of a foot in both camps, and that's part of a sort of shrinking availability of GP service and people feeling that they need to have a private capacity to even just offer some stuff. But if you go into the world of surgeons and surgery, they've always had this sort of um 80-20 contract, so 80% of their time they spend in the NHS, and then 20% of the time they can do what they want, and that's when they do their private business. But that is completely separate to the NHS. It is normally going through private hospitals, so they get practicing rights at private hospitals. The private hospitals go out there and market to the patients and attract people who have got insurance or want self-pay is increasing these days, but chosen the private route. And it is a completely different set of patients with completely different activities. Often in the days when there was weight loss surgery, that wasn't particularly offered on the NHS. So the people who did the weight loss surgery privately didn't do so much of it in the NHS, they just did the more general upper GI surgery, and then their private practice was all the bariatric weight loss surgery. Hips and knees is offered in the NHS. People spend all day doing hips and knees in the NHS, but then as I say, it will be completely different people, completely separate to their practice, all sourced through the spas and boopers and all the private hospitals of the world. So very separate, but the issues come where you're trying to balance the two.

SPEAKER_01 20:39

Yeah, I think the other thing I would say that I've noticed over the years is initially quite a lot of sort of private GPs morphing into functional medicine were moneyed people who were effectively the worried well. So quite a lot of the treatments, tear and sympathy without being unkind. Now I see it morphing into far more a cohort of people that have got serious long-term problems that are looking for a solution. And it's not uncommon now to have patients where the family have rallied round to support, produce a pool of money to go off and get Auntie Betty her treatment because they all love Auntie Betty, she's been suffering for years. They understand that something might be done now, but Auntie Betty can't afford it. So the hat goes round at Christmas, and all of a sudden we've got 10 grand and off we go. It's a totally different thing from someone who's flying in from abroad in Harley Street that's got plenty of money, who is effectively there's nothing wrong with them, but they're worried. And increasingly that, which is great because it's getting into doing some serious good in population, that's great. But the the attitude to financial risk versus cure is vastly different with those two cohorts, and you've got to recognise that.

SPEAKER_03 21:54

And that's where it's lacking at the moment that there is not that. Awareness of that shift.

SPEAKER_01 22:01

Yeah, yeah, and that's at the risk for the at one time. People would have clubbed together for Auntie Betty, eight grand for a hit, we can deal with that. But it's far more nuanced to saying she's really not recovered. I think last holiday she was bitten by a tick and she's got Lyme's disease, the NHS doesn't all that kind of stuff, and she's lethargic and she's God, is it early onset dementia? Who knows? That's far more nuanced. So the whole cost benefit when you don't have money to burn and the family have supported it and they're clubbing together to try and help out. That's a totally different thing.

SPEAKER_03 22:36

And again, the answer to that in terms of ensuring that you are correctly protected is clarity, communication, and being honest as to the various likelihood of things working.

SPEAKER_01 22:50

Yeah, and being brutally fiscally honest to say the first two grand is going to be test to decide what I need to do. So don't expect anything material to improve for your first two grand. It's as granular as that, it's as potentially financially as obnoxious as that for the for the GP, but unless you're wired into how these people will look at it, and yet they do wonderful things. We were speaking to someone the other day that that says we had two or three patients come to me four months ago, these youngsters, in a wheelchair.

SPEAKER_00 23:26

Yes.

SPEAKER_01 23:26

Now they're no longer in a wheelchair. If that isn't a modern biblical parody, I don't know what it is.

SPEAKER_00 23:34

That's the issue, is it that? And then you can looping back, you you can see that going to the papers and those in a wheelchair, and then you know, go and see these people, and six weeks later, as you say, it's almost biblical. You can imagine Jesus there in the in the background or in the forefront, no doubt, and so on. But then that creates expectation. So everybody says, Oh, I can do that, it doesn't work for everyone.

SPEAKER_01 23:55

Yeah, or I've read it in the paper, and it sounds like I've got exactly what they've got. Yeah, bear in mind this has been reported by a son reporter or something, so it's not really clinically particularly cogent. Yeah, it said here they couldn't walk, I can't walk.

SPEAKER_03 24:09

Yeah, so yeah, I know the thing in terms of the nuance there is the cost of diagnosis where you know finding out exactly what the problem is when the NHS is funding it. Yes, it's annoying that it takes longer, but you essentially but it's also Joe this this difference of approach.

SPEAKER_00 24:26

So the end is is this symptoms-based, still this medicine too in Peter Attius' term symptoms-based diagnosis and so on. So that is more this list of symptoms, walk, pain in left thigh, slightly yellowy skin, whatever the list is, and out of that tick-tick, I've got 65%, so you've got this. So you immediately go from what is quite often a fairly short diagnosis into this, that's what's wrong with you, or with the NHS, we don't know what's wrong with you, in which case you get pinged around forever. We most likely don't find out. Well, you end up with a diagnosis of exclusion, yeah, or a diagnosis for something different, and you end up getting loads of treatment that that does you no good, or there's a variety of things. It is that big difference where in the functional medicine world, medicine three, it's it's delving right into the details. I just I can't emphasize enough the level of detail and sophistication that these people go to. These hundreds of markers, and it's looking at precise levels and precise levels versus other markers and all sorts of things. I think I've said on on on previous podcasts, but I I keep coming back to this example with gut health. The general advice is oh, you can improve your gut health by eating these kinds of foods and entered foods and you know fermented yogurts is a sort of classic, and that's all sold as marvelous health food for your gut in the supermarkets. Whereas when I sat in the Nordic Labs conference, they were not just talking about specific gut microbes. So they were saying we identified that this person was short on not just these two specific gut microbes, but actually they looked at the DNA of the gut microbes and it's these two gut microbes with these DNA profiles.

SPEAKER_01 26:13

I'll tell you what was interesting. We had, as you well know, I won't mention his name, but we had a whole IoT shenanigans last autumn, and one of the allegations supported by a really misdirected uh breach of duty report from uh I'm gonna say a jobbing GP, which sounds disrespectful. I don't mean it to sound disrespectful, fielded by the GMC, was criticizing where the lab investigations were done because it was in Eastern Europe, but too far east to be respectable. And the reality is that they were testing a whole range of markers that were simply not available and not tested in the UK.

SPEAKER_02 26:55

Yes.

SPEAKER_01 26:55

So there is this intellectual arrogance within medicine here that it's because it's British, it must be best because we've been doing it longest than all the rest of it. It simply isn't true, not for functional medicine, certainly. So again, it comes down to informing consent. The reason why I'm going to have a blood test and send it to Ubekistan or somewhere is because they will test for this and this marker, which I think is relevant for this and this reason, and that facility is not available in the UK. Now, needless to say, that GMC allegation didn't land, but it was certainly made and needed to be rebutted through a fairly tortuous process, as we both know. So again, it comes down to communication. So we can head off again. We've got quite a nice body of scar tissue with some of these issues. That if someone wants to ring and say, actually, what we're not doctors, but we do have some experience of when things go wrong. And we're I think we're reasonably well attuned to pitching the dialogue with the patient. The reason why I'm charging you two grand for this case is not because I'm ripping you off, because I can't send it to a lab in the UK or in Western Europe that will look for this marker that I need to know because I need to know this and this. You say that to anyone, even the family that's funding Auntie Betty, and they'll get that and they won't complain. It's when they don't know that and they're thinking, Christ almighty, two grand and you've done nothing. That's the trigger. It's not medical, it's financial.

SPEAKER_00 28:20

Yeah, but it's interesting, and then again, maybe this is another podcast, actually, if you like in the evil worlds of commercial, there what is emerging is there is all sorts of health inf misinformation that has emerged. So the whole idea that cholesterol blocks your arteries is is quite highly contested these days. And that came about from I was going to say the 1920s, but it's probably later than that. I think it was about the 1950s or something. Kellogg-sponsored research to try and work out what blocked your arteries. And the researchers basically looked at artery disease, arterial disease versus diet in 48 different countries, and they found for nine advanced economies that there was a high correlation between the consumption of meat and arterial disease. So they published the results of those nine. They didn't publish the remaining 41, which showed no relationship at all between the two.

SPEAKER_01 29:23

All challenges are worried about is it wasn't related to corn flavor.

SPEAKER_00 29:26

So though so that was the point. That's when the fry-up became your sausages and bacon and became bad for you. That caused cholesterol, that caused heart disease. And so therefore you should have cereal for breakfast. Now, the thing about cereal is those grains are and so you just have to watch my youngest son at breakfast, they need some quite serious amounts of sugar on them to make them palatable. And if you read the contents of a lot of these cereals, they are very high sugar content. What's emerging is arterial diseases actually, when you get into these biochemical mechanisms, it's actually sugar, which is the culprit, and all that's emerging. So actually, it's interesting that there's layers and layers of misinformation here. And what's really interesting, exciting about this, with these sort of people driving this new version of medicine and medication is they're getting right into the details, and you can go right back for years with all sorts of misinformation which has been fed to people for years through press and all sorts of stuff. And I think because people are interested and understand this stuff in a lot of detail, is the classic. I don't think they understand how poor the understanding is in the general population. So things that would be entirely obvious to them are absolutely not obvious at all. If I've got cholesterol or if I've got high blood pressure, it's cholesterol, everybody thinks it's cholesterol. I troop off to the doctor, I get you know statins, which is a multi-billion-pound pharmaceutical industry, and it's nothing to do with the three tons of sugar I put on my cornflakes every morning.

SPEAKER_03 30:55

I think that's a a great place to end the discussion. Like I say, we can there's several aspects in there that we could probably turn into further podcasts. But for the time being, thank you very much, and I will see you on the next podcast.

SPEAKER_01 31:07

Yeah, thanks, Jesse.

SPEAKER_03 31:08

Thanks soon. Thank you for listening to Confidence to Thrive. Before you go, please rate, review, and subscribe to Confidence to Thrive on your preferred podcast platform and help us spread our message to others who are making a difference in private healthcare. This podcast was brought to you by Our Litity, insurance advisors who support your business ambitions. Our litity advises practitioners, owners, and entrepreneurs of healthcare practices on mitigating risks so your business can thrive. Learn more about how OurLity can support you by finding the link in the show notes or visiting ourty.co.uk