Private patient fee disputes

A patient attended my private clinic requesting treatment for acne scarring. I performed laser treatment after careful examination and a detailed history-taking. Before the procedure I told the patient that laser treatment was commonly performed and generally safe but there could be side effects and potential complications which I outlined in detail. I documented this discussion in my notes as usual and the patient signed a consent form that mentioned the potential complications. The procedure was uneventful and I arranged to see the patient for follow up ten days later. On routine review, the skin appeared to be healing well and the patient did not express any concerns so no further follow up was arranged. However, three months later, I have now received a letter of complaint from the patient stating that she is dissatisfied with the aesthetic results including some persisting redness in the treatment area and a slight change in her skin pigmentation next to the treated region.

She has requested a refund of the cost of the treatment. I initially contacted the patient to say I would be happy to review her again in clinic to assess the pigmentation and discuss whether it could be rectified.

The patient has declined my offer and reiterated her demand for a reimbursement of her costs. What should I do?

It may be helpful to offer the patient an explanation of the treatment she received and consider apologising for the fact that she is dissatisfied with the results. Although the NHS complaints procedure does not apply to independent practice, we advise members to apply the central principle, namely that patients who complain should receive a full explanation for the care they received and an apology where appropriate. Furthermore, paragraph 61 of the GMC's Good Medical Practice guidance (2013) states that 'You must respond promptly, fully and honestly to complaints and apologise when appropriate. You must not allow a patient's complaint to adversely affect the care or treatment you provide or arrange'.

Complaints about cosmetic procedures are more common than complaints about other surgical procedures, possibly in part because of unrealistic patient expectations. It is important to ensure that patients have a realistic idea of the potential results before treatment. Some patients who are dissatisfied may go on to request reimbursement of their costs.

In this case, the decision as to whether to refund costs is a matter of personal discretion for the private surgeon concerned. This type of payment is known as an ex-gratia payment, which is a payment made as a goodwill gesture, without admission of liability.

It is important to ensure careful wording of any correspondence and we can assist you with your response.

It may reassure you to know that the Compensation Act 2006 makes it clear that an apology, offer of treatment or other redress does not of itself amount to an admission of negligence or breach of duty. It should be noted that, even if you make an ex-gratia payment to the patient, there is unfortunately no guarantee that this will prevent the matter from proceeding to a claim for alleged negligence.

Detailed and contemporaneous notekeeping and careful documentation of the consent process, such as information given and questions asked and answered, could be very helpful in mounting a robust defence if a claim were made.