LAUSR

According to health economics, physicians who respond to ‘third-party payers’ for healthcare are expected to establish a ‘principal–agent relationship’ with patients, which implies mutual trust. Physicians’ dual practice, a combination of public and private practice, may raise potential conflicts of interest in this relationship. It might even lead physicians to ‘predatory behaviours’, in which self-gain is pursued to the detriment of colleagues and/or patients, while at the same time de-legitimising public services and jeopardising the population’s trust. Dual practice has long existed in most healthcare systems around the world, regardless of a country’s wealth. Canada is the only highly developed country where it is strongly discouraged, and even forbidden in some provinces. It is widely accepted that dual practice plays very different roles in lowand highincome countries, since, in the former, governments can hardly manage universal coverage for health and thus are unlikely to play a dominant role in healthcare provision and regulation. A common feature in countries where dual practice flourishes is that public employment is remunerated with fixed compensation (usually wages), while the private sector offers tailored incentives (mainly fees). The potential for dual practice varies a lot according to a physician’s specialty, and experience too. The relationship with patients may be stronger for medical and surgical specialties, which ‘have patients’, rather than for support ones like pathology or radiology. Thus, dual practice is likely to be practised more in the former (e.g. cardiology, dermatology, orthopaedics, obstetrics and gynaecology). Since it takes time for a physician to build up a good reputation and attract patients for private practice, dual practice is usually also related to a physician’s age. Here we summarise the historical background to dual practice inWestern European countries, focusing on doctors employed in the public sector. Then we analyse the main critical issues of dual practice in Europe and discuss it in a global perspective, finally offering a very simple proposal for debate.