How UK consultants divide time between NHS and private practice

A surprising number of people who have worked with a UK consultant in the private sector do not realise the consultant is also, in most cases, a full or part-time National Health Service (NHS) employee. The consultant running a private Tuesday-evening clinic in a central London hospital is very often the same consultant running NHS theatre lists on Monday morning in the same specialty, sometimes in an NHS hospital half a mile away.

This dual-role pattern has been the design of UK hospital medicine since the NHS was founded in 1948. This article sets out how the rules work, how a typical consultant's week is structured, what the contract allows, and what the boundaries are between NHS and private patient care. Sources are at the end.

The 1948 compromise

When the NHS was set up, Aneurin Bevan famously said he had "stuffed their mouths with gold" to persuade hospital consultants to join the new service. The gold took two forms: salaried employment inside the NHS at a level that was attractive by 1940s standards, and explicit permission for consultants to maintain a parallel private practice.

The dual-role design is not an accident or an oversight. It was a negotiated compromise that made the nationalisation of UK hospitals politically achievable in 1948, and it has persisted through every subsequent NHS reform. Both the UK private hospital sector and the UK NHS consultant workforce are structurally shaped by that compromise today.

The national consultant contract and programmed activities

NHS consultant employment in England is governed by the national consultant contract (2003), introduced in 2003 and amended several times since. Earlier generations of consultants were employed on variants of the 1948 and 1988 contracts, some of which remain in use for pre-2003 consultants.

Under the 2003 contract, NHS consultant working time is measured in Programmed Activities (PAs). One PA is four hours of contracted NHS work.

• A full-time NHS consultant job plan is typically 10 PAs per week: 7.5 Direct Clinical Care (DCC) PAs and 2.5 Supporting Professional Activities (SPA) PAs. DCC covers patient-facing clinical work. SPA covers training, appraisal, audit, research, governance, and teaching.

• Part-time consultants work a reduced number of PAs, scaled down from the full-time pattern. A six-PA consultant is working roughly 24 hours of contracted NHS time per week.

• Extra Programmed Activities (EPAs) are additional NHS sessions worked beyond the standard job plan, typically to cover on-call, waiting-list initiatives, or specific service demands. Each EPA is paid at a higher hourly rate than standard PAs.

Job plans are formally negotiated with the employing NHS trust annually and are the contractual basis for what a consultant actually does, how much they are paid, and what time remains outside the NHS week.

Private work rules

The 2003 contract includes specific rules about private practice. The headline rules are as follows.

• Full-time consultants can carry out private work outside their NHS commitments. The traditional rule (inherited from earlier contracts) was that private work could not exceed 10 per cent of the consultant's NHS earnings, calculated on specific formulas. The 2003 contract reformed this, allowing more flexibility in exchange for certain undertakings about NHS availability.

• Part-time consultants have greater scope for private work, with their NHS time defined by the PAs they hold.

• Private work must not take place during NHS contracted time. A consultant is not permitted to do private work during the hours they are contracted to do NHS work. Private clinics run in the consultant's own time.

• Priority to NHS work in commitments. If a clinical need arises during NHS time (an emergency, an on-call commitment, a specific theatre list), the NHS takes priority.

• No queue-jumping. The consultant's NHS patients cannot be given faster access to the consultant's NHS list by paying privately. The patient is either an NHS patient being seen in the NHS queue, or a private patient being seen in the private queue. The two queues do not overlap.

• No overlap of the same clinical episode. The consultant cannot see the same patient privately for the same condition they are simultaneously treating NHS, except under specific transitional arrangements.

The rules are intended to keep the NHS and private practice as clearly separate activities, carried out by the same individual consultant at different times and under different funding arrangements.

Typical patterns of weekly work

In practice, consultant work patterns fall into a few broad shapes.

• Full-time NHS with a small amount of private work. The consultant works 10 PAs of NHS time across Monday to Friday daytime, and adds one or two private evening clinics a week plus some weekend operating in private hospitals. Private work is supplementary; NHS is the main employment. This is a common pattern in areas of medicine where the private market is modest (for example most paediatric subspecialties, intensive care, public health).

• Full-time NHS with substantial private work. Same NHS commitment, but private work is on a larger scale: two or three clinics a week, significant private theatre time, and a meaningful share of income from the private sector. More common in specialties with large private markets (orthopaedics, cosmetic-adjacent surgery, dermatology, fertility, cardiology).

• Part-time NHS with substantial private practice. The consultant holds a 6-PA or 7-PA NHS post rather than the full 10, using the remaining days for private practice. This has been a common pattern among consultants at the later stages of their career or with significant private workloads.

• Almost entirely private (minimal NHS). A smaller number of consultants hold minimal NHS commitments (for example one or two PAs a week in a teaching role) or have left NHS employment entirely. This is a minority pattern.

• No private work at all. Some consultants do no private work on principle or because their specialty has no meaningful private market. This is also a minority pattern in most acute specialties.

Historically, part-time NHS consultants derived on average about a third of their total income from private practice. That figure has varied over time and by specialty, and individual patterns vary widely.

Where the private work happens

Consultant private practice is carried out in several settings.

• Independent private hospitals. The consultant uses operating theatres, clinic rooms, and inpatient beds provided by the hospital, which is paid a facility fee by the patient or insurer. The consultant receives their professional fee separately.

• NHS Private Patient Units (PPUs). Many large NHS teaching hospitals operate dedicated private-patient facilities. The consultant can see private patients in the PPU alongside their NHS work in the same hospital. Income generated by the PPU flows back to the NHS trust.

• Specialist consulting rooms. Consultants lease sessional time in consulting rooms in Harley Street and equivalent districts, running outpatient clinics without needing hospital admission facilities.

• Independent Sector Treatment Centres (ISTCs) and Community Diagnostic Centres (CDCs) which, although private-sector-owned, deliver a substantial volume of NHS-commissioned activity. The same consultant may operate on an NHS patient in one session and a private patient in the next, in the same facility.

The mix of private venues varies by specialty. A consultant orthopaedic surgeon typically needs a theatre-equipped facility; a consultant dermatologist can often do most private work from a single consulting room.

The fee structure on the private side

On the private side, a consultant is paid either by the patient (self-pay) or by the patient's private medical insurer. Fees are set by the consultant individually, within the constraints of insurer-approved fee schedules. Insurers maintain recognised consultant networks with agreed fee structures; consultants can choose to be on or off those networks, and some insurers operate tiered fee systems.

The Private Healthcare Information Network (PHIN) publishes procedure-level consultant fee and outcome data as a result of the CMA Private Healthcare Market Investigation 2014. This is the primary public-facing source for patients comparing consultant fees and outcomes.

Regulation and the fitness-to-practise implication

Private work is subject to the same regulatory framework as NHS work. A consultant doing private practice must:

• Hold full GMC registration with a licence to practise.

• Be on the Specialist Register for the specialty in which they are practising.

• Hold professional indemnity for the private work, separate from NHS indemnity. Most consultants hold this through one of the main medical defence organisations.

• Comply with GMC Good Medical Practice standards, which apply equally to NHS and private work.

• Be subject to the CQC inspection framework of the facility where they work.

A fitness-to-practise concern arising in private work is investigated by the GMC in the same way as one arising in NHS work. A consultant who loses their GMC registration loses their ability to practise in both settings.

Why this structure matters for patients

For a patient choosing whether to see a specialist privately, the dual-role pattern has several practical implications.

• The consultant is very often the same person. A patient choosing a private cardiology consultation will, in most cases, be seeing a consultant who also holds an NHS post in the same specialty. The clinical training, standards, and regulation are the same.

• The letters after their name mean the same thing. GMC Specialist Register entry, MRCP or FRCS or equivalent exit qualification, and royal college membership apply equally to NHS and private work. There is no lower bar for private practice.

• The facility is often different. Private care is usually delivered in an independent hospital, a PPU, or a specialist consulting room rather than an NHS ward or NHS clinic room. Facilities, staffing, and amenities differ. The clinical medicine does not.

• What you get is a different kind of service experience, not a different doctor. The same consultant, in a different setting, with a different fee structure.

This is the honest frame for thinking about private consultant care. It is how the UK has been set up to work since 1948.

The summary

UK hospital consultants are permitted, by the design of the NHS since 1948 and by the national consultant contract since 2003, to carry out private practice alongside their NHS commitments. Programmed Activities define the NHS commitment; private work happens outside those hours, subject to specific rules about queue-jumping, clinical priority, and separation of the two patient populations.

Most UK consultants work in some mix of NHS and private, with the balance varying by specialty, career stage, and individual choice. The same regulatory framework applies to both sides, and the same letters after the consultant's name qualify them for both.

This is what the UK has always meant by a parallel private sector: a group of facilities where the national consultant workforce also works.

Sources and further reading

• British Medical Association, Consultant contract (2003) England. The national consultant contract governing most NHS hospital consultants.

• NHS Employers, Consultant contract resources. Employer-side guidance on the consultant contract.

• British Medical Association, Private practice guidance. BMA advice for doctors in private practice.

• General Medical Council, gmc-uk.org. Regulator of UK doctors.

• GMC, Good Medical Practice. Professional standards applicable to all UK doctors.

• GMC, The Specialist Register. Public register of UK specialists.

• Care Quality Commission, Independent healthcare services. Regulator of private hospitals and independent providers.

• gov.uk, Private Healthcare Market Investigation. CMA investigation and remedies.

• Private Healthcare Information Network, phin.org.uk. Consultant-level and procedure-level performance and fee data.

• NHS England, NHS history. The 1948 settlement.

• Medical Defence Union, themdu.com. Example medical defence organisation for private-practice indemnity.

• Medical Protection Society, medicalprotection.org. Example medical defence organisation.

About the author

Dr Seth Rankin qualified in medicine at Auckland School of Medicine in New Zealand in 1990 and worked as a junior doctor across New Zealand, Australia, and the UK before qualifying as a Member of the Royal College of General Practitioners (MRCGP) through the London Deanery in 2004. He was Managing Partner of Wandsworth Medical Centre from 2006 to 2016 and served as a Board Member of Wandsworth Clinical Commissioning Group for nine years. He is the founder of London Travel Clinic, London Doctors Clinic, London Medical Laboratory, and LoveMyLife.

Read more about Dr Seth Rankin.

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