GP fact file - Private medical insurance

This GP Fact File was written by Dr Louise R Newson, GP, West Midlands

How many people have medical insurance?
In 2008, over six million people in the UK were covered by either personal or corporate private medical insurance (PMI). A further one million were covered through healthcare trust arrangements, where employers invest to cover their staff's medical expenses. Many companies invest in PMI because it often allows their employees to return to work after illness or injury sooner. Despite the recession, there has been an increase of nearly 3% in the number of people covered by PMI compared to 2007.

What are the benefits of PMI?
Although waiting times for outpatient procedures have improved dramatically in recent years, many patients still prefer to be seen and treated in private hospitals. Some reasons for this include:

  • Personal choice.
  • Ability to be seen by a consultant rather than a junior member of the medical team.
  • Longer clinic appointment times.
  • Appointments and treatment are still usually faster when compared with the NHS.
  • Convenience of being able to plan an operation more easily.
  • If an inpatient stay is required, this is usually in a private room and there is no restriction on visiting.
  • Lower risk of meticillin-resistant Staphylococcus aureus and Clostridium difficile infection in private hospitals.

Treatment in a private hospital or clinic does seem to reduce a patient's chance of contracting a hospital-acquired infection. This is mostly due to lower bed occupancy, and the risk of cross-infection is substantially reduced by the majority of patients having their own private rooms with ensuite bathrooms.

The infection rates for hip surgery in private hospitals in the UK range from 0.98% for low-risk patients to 1.99% cent for high-risk patients. This compares with rates of up to 4% in some NHS hospitals.1

Are patients taking full advantage of their PMI?
It is very common for patients to forget to inform their GP during the consultation that they have PMI. Many patients do not realise that even very minor procedures are often covered by their health insurance. In addition, they may not know that some private hospital services can be accessed directly without a GP referral, including health screening, physiotherapy and some pathology tests.

What should patients consider when choosing a PMI plan?
Private health schemes vary tremendously in what they cover. It is important that a patient checks the details of their policy carefully before attending for private treatment.

Some plans offer core cover for operations, procedures requiring overnight stays and treatments such as chemotherapy and radiotherapy. The schemes then allow people to add on extra services depending on their need and requirements, for example physiotherapy or acupuncture.

Alternatively, some people may choose to pay a voluntary excess for their treatment. This may mean that they choose not to use their insurance for some treatments, especially if there is a short waiting time in a local NHS hospital.

Some insurance companies offer patients incentives linked to healthy living. For example, discounts are applied if the patient is a non-smoker, attends regular health screens and exercises regularly.

What treatments are usually excluded?
It is important for patients and doctors to be aware that PMI is not designed to replace all services offered by the NHS. PMI usually excludes pre-existing conditions, GP services, cover for a long-term, chronic illness and A&E admissions. It may exclude treatment for self-inflicted injuries, HIV/AIDS, infertility, uncomplicated or routine pregnancy, cosmetic surgery and sex change.

What are the advantages of referring a patient for private hospital investigations?
Private referrals can reduce the number of referrals to the NHS, relieve some of the workload and may allow for budget savings. Because patients want to be referred  promptly, any investigations that would normally be done prior to an NHS referral, for example blood tests and X-rays, are arranged in secondary rather than primary care. This reduces the workload in primary care. It may be preferable to note PMI status in patient records. This will save asking patients each time they need a referral.

What are the disadvantages of referring a patient for private hospital investigations?
Some patients can ask for a referral without having a medical indication, or have a minor complaint that could be managed in primary care. GPs may feel embarrassed writing a referral for a complaint that does not warrant a specialist referral. However, it is very difficult to decline a private referral of this nature. It is often appropriate to note in the letter that the patient requested the referral. These consultations can affect the doctor-patient relationship and impact on future consultations.

Referrals can also prolong consultations if the patient wants to know the actual waiting times for an NHS referral or treatment before deciding whether or not to use their PMI. Many feel that they will incur an increase in their premiums if they claim; this is not the case for many policies and patients should be advised to check.

Occasionally an NHS referral is made only for the patient to cancel it later or not attend, instead requesting a private referral when they have checked their policy after the consultation. It may be worth deferring making the NHS referral in these cases and wait until the patient has checked with their insurer.

1.Wilson J, Charlett A, Leong G, et al. Rates of surgical site infection after hip replacement as a hospital performance indicator. Infect Control Hosp Epidemiol 2008;29:219-26.


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