Expanding Horizons: How can private sector involvement be leveraged to enhance opportunities for orthopaedic trainees?

By Lorena Brasnic
University of Aberdeen

Introduction

Private sector involvement can be strategically leveraged to expand the training, skill, and career opportunities of orthopaedic trainees while enhancing the quality of healthcare. Orthopaedic training has traditionally been anchored in the public sector, but increasing service pressures, rising medical graduate numbers, and advances in surgical technology require a rethink of this paradigm. In the UK, 6.2% of elective NHS cases are now delivered in the private sector, with this proportion projected to rise [1]. In Orthopaedics specifically, 25% of hip and knee operations are carried out in the private sector [2]. This discrepancy between where patients are treated and where trainees are trained highlights an untapped potential to expand trainee opportunities.

The current landscape

Public hospitals remain the main training environment but are increasingly dominated by emergency and complex cases. Meanwhile, case numbers logged by UK orthopaedic trainees are falling due to service pressures within the NHS, creating concern that trainees are not receiving sufficient exposure [1]. Training opportunities are also still recovering from the disruption caused by the COVID-19 pandemic, where cessation of elective surgeries and the increased reliance on non-surgical trauma management significantly reduced trainee operative time [3]. Expanding training into the private sector could therefore address both the problem of declining case numbers and the growing need for workforce capacity.

Opportunities for trainees

Private sector provides several distinctive opportunities for trainees. One of the most important one is the expansion of case mix and case load. Incorporating exposure to high-turnover elective procedures into curriculum would allow trainees to experience the full spectrum of orthopaedic practice, and in some cases, access procedures that may not be routinely funded in public hospitals [4]. Worldwide, effective interplay of these two sectors already exists. Australian models that combine public and private placements have demonstrated that surgical exposure can be doubled without any reduction in the quality of supervision [4]. Theatre lists characterised by low-risk, high-turnover cases would enable trainees to consolidate core surgical skills and build confidence in performing procedures under supervision. Outside the theatre, private sector offers valuable ward-based opportunities to gain experience in perioperative care associated with short-stay, enhanced recovery pathways. The technical abilities and intrapersonal skills acquired could translate into the increasingly complex caseload in public hospitals [1].

Beyond gaining clinical experience, engaging trainees in the private sector offers them opportunities to lead quality improvement initiatives and maximise the research potential in a more homogenous patient population. Trainees could facilitate the enrolment of private hospitals into national registries and research databases, enhancing evidence-based orthopaedic practice.
Private sector also provides a fundamentally different educational environment. Rotating through private sector would expose trainees to the entrepreneurial side of orthopaedics, cultivating entrepreneurial thinking and economic literacy, skills that are seldom emphasised in the public setting. This fosters the skills of resource management and adaptability to evolving healthcare models. With innovative implants, equipment and robotic surgical systems being more accessible in the private sector, trainees would gain early exposure to novel surgical technology and device development, fostering innovation and preparing them to lead future advancements in patient care. Additionally, these rotations would introduce trainees to cultural and operational differences in private practice, equipping them with a holistic understanding of healthcare delivery.

Opportunities for healthcare system

Embedding trainees in private sector could also benefit the wider healthcare system. Trainees could provide support to consultants working in relative isolation and in that way, enhance clinical governance and postoperative care standards [1]. Recent report has already demonstrated that patient outcomes in the private sector are comparable to those in the NHS [2] suggesting that introducing trainees would not compromise patient care and safety.

Private sector rotations could increase the number of training posts while addressing the growing gap between surgical service supply and demand. Dual engagement of trainees in both sectors would ensure a steady pipeline of skilled surgeons, strengthen workforce capacity and enhance the overall sustainability of surgical services. Ultimately, incorporating private sector into the training program would provide a contingency for any future events where elective work is suspended, without compromising operative experience or training progression.

Strategies for implementation of private sector into training

Implementing private sector rotations requires careful planning to overcome administrative, logistical, and cultural barriers while maintaining quality and equity. One of the primary challenges is the administrative burden associated with trainees moving between sectors, as providers must demonstrate compliance with regulatory standards such as the Care Inspectorate in Scotland or the Care Quality Commission in England. Coordinated information sharing between NHS trusts, training bodies, and private providers would streamline duplicate paperwork and expedite trainee placement allocations. Similarly, shifting a current culture of short-notice allocations to a structured rota would allow employment and governance checks for private sector to occur in parallel with the NHS processes. Funding presents another key consideration, as having trainees can increase operational costs for private sector. The NHS could commission elective training lists in private hospitals, covering operational costs. Where private sector manages a mixture of NHS and private patients, shared funding models could offset the additional training burden, with private providers contributing towards training costs in exchange for the service provided by trainees [4]. Supporting private providers with accreditation is essential to incentivise participation. Providing clear guidelines, online training courses by JCST and ISCP would ensure that the educational quality is transferable to the private sector. Small-scale pilot rotations in select private hospitals would further help identify practice barriers and refine the implementation strategies before nation-wide rollout. Regular dialogue between the sectors and inclusion of trainees in the design and evaluation of the new program are the most valuable strategies to ensure that educational, operational and patient healthcare outcomes are optimised.

Conclusion

Training should be reimagined as an interplay between public and private domains, preparing orthopaedic trainees for the realities of modern practice. Private sector involvement should be embraced as a catalyst for innovation and opportunity. It is the crucial next step in creating competent and adaptable generation of surgeons that is equipped to lead in an ever-evolving healthcare environment.

References

1. Fletcher, N. & Barker, J. (2022). Training challenges in the independent sector. Anaesthesia, 77(9), pp.1001–1003.
2. Bottle A, Browne J. Outsourcing care to the private sector: some reassuring evidence on patient outcomes. BMJ Quality & Safety Published Online First: 22 October 2021. doi: 10.1136/bmjqs-2021-014349
3. Dattani, R., Morgan, C., Li, L., Bennett-Brown, K., & Wharton, R. M. H. (2020). The impact of COVID-19 on the future of orthopaedic training in the UK. Acta Orthopaedica, 91(6), 627–632. https://doi.org/10.1080/17453674.2020.1795790
4. Watters DA, D'Souza B, Guest G, Wardill D, Levy S, O'Keefe M, Crowley S. Training in the private sector: what works and how do we increase opportunities? ANZ J Surg. 2009 Mar;79(3):138-42. doi: 10.1111/j.1445-2197.2008.04830.x. PMID: 19317778.