Most specialists who start careers spanning public and private hospitals end up, within a decade, working primarily in one. Not because they chose to abandon the other, but because the financial and organisational environment makes sustained cross-sector practice progressively harder to justify.
On paper, dual practice offers a neat resolution: specialists work across both systems, public capacity grows, wait times ease. In practice, formal permission rarely comes packaged with the controls that would actually make it hold – what gets authorised and what gets enforced are rarely the same thing.
Specialists who sustain meaningful work across both sectors are responding to three structural forces: insurer-side benefit and pricing decisions that determine where work is best remunerated; private hospitals’ consistent advantage in theatre access, equipment and staffing; and contractual instruments that can convert financial preference into organisational lock-in. When those forces operate without constraint or counterweight, dual practice doesn’t erode through individual failure of commitment – it becomes structurally unsustainable, regardless of intent.
Financial Incentives and Contractual Capture
Private hospitals offer specialists faster theatre access, more predictable lists, and better-resourced perioperative support than most public facilities. In procedure-heavy fields, cancellations and equipment shortages translate directly into foregone income, so those operational advantages compound over a career.
A Chicago Fed Letter on the United States market described 2020 as exceptionally profitable for health insurers because pandemic-era drops in utilisation sharply reduced claims spending while premiums stayed largely fixed. That pattern underlines a basic point: insurer finances move with utilisation, and whether the resulting gains flow toward affordability, expanded benefits, or higher margins depends on governance and product design.
Medibank, as one of Australia’s largest private health insurers, sits at the centre of that dynamic: its benefit design and pricing directly shape the volume and mix of procedures that can be funded outside the public system. When governments lean on private insurance to relieve pressure on public services, the decisions made at that level become a direct determinant of where specialists concentrate their time.
David Koczkar, Medibank’s chief executive officer, is the decision-making layer within that influence. The company’s COVID-19 give-back programme, which returned approximately A$1.71 billion to customers in response to reduced utilisation, illustrates how a major insurer can adjust premiums and benefits when claims fall – and how those adjustments alter the relative attractiveness of privately insured work by influencing which procedures can be funded outside the public system.
When private products are more generous or more stable than public funding, specialists have clear reason to focus where their work is consistently remunerated.
Contracts can harden that financial pull into obligation. The Madras High Court struck down non-compete and non-solicitation clauses in doctors’ employment contracts at MIOT Hospitals in Chennai, holding them void under the Indian Contract Act and dismissing the hospital’s petition as a witch-hunt against a doctor. India’s legal context differs from that of other countries, and enforceability varies by jurisdiction – but wherever restrictive covenants can in practice be enforced, they convert financial preference for private work into a structural barrier to mobility. The institutional space in which sustained cross-sector practice remains possible contracts accordingly.
If financial pull and contractual lock-in systematically favour private concentration, the relevant question isn’t whether specialists are making rational choices. They clearly are. It’s what conditions on the other side would have to look like for those calculations to come out differently.
Making Dual Practice Viable
Most senior specialists in mixed systems gravitate toward private practice within a decade of appointment, for the reasons already traced: higher remuneration, more control over scheduling, and more reliable access to equipment. A synthesis by the WHO-affiliated European Observatory on Health Systems and Policies on physician dual practice warns that when enforceable controls are weak, private work regularly displaces public time and creates incentives to divert patients or resources. Its core design lesson, consistent across countries, is that dual practice generates value only when explicit rules are in place – protected public sessions, monitoring of hours and activity, and organisational constraints that make commitments something other than aspirational.
Against that baseline risk, the neurosurgical and minimally invasive spine practice of Dr Timothy Steel, across St Vincent’s Private Hospital and St Vincent’s Public Hospital, shows what those conditions look like when built in. Since his consultant appointment in 1998, Steel has held a dual role – consulting from rooms at St Vincent’s Private in Darlinghurst while operating regularly in the private system and on a scheduled basis at the public hospital. His St Vincent’s specialist listing records thousands of minimally invasive and complex spine procedures across both settings. The structure matters: defined public lists and predictable access to theatres allow high-volume activity without forcing an all-or-nothing choice between sectors.
The enabling variable is less individual preference than infrastructure. Steel runs a minimally invasive spine programme built around dedicated equipment and a coordinated perioperative team spanning anaesthetics, nursing and rehabilitation, with case selection and operative planning led from a single service. That infrastructure isn’t configured around a particular surgeon’s preferences; it exists at the institutional level of the hospital. When those resources are designed in rather than assembled through personal initiative, cross-sector commitment becomes operationally sustainable rather than personally heroic – which is precisely the design condition the European Observatory evidence identifies as necessary.
That reframes dual practice as a matter of institutional architecture rather than individual commitment, which only sharpens the harder question: when governments legislate dual practice at the system level, are they replicating those design conditions, or simply authorising the activity and expecting the enabling structure to appear on its own?
The Limits of Legislation
Legislation can authorise dual practice; it cannot, by itself, create the conditions that make dual practice work. Bill 11 in Alberta illustrates the gap precisely. Premier Danielle Smith has defended the legislation on the basis that physicians will only see privately paying patients during time they are not rostered to the public system, and that government monitoring will ensure current levels of public activity are maintained. On paper, this is exactly the kind of safeguard dual practice requires: a clear separation between public and private sessions and a commitment to measuring them. The open question is whether the monitoring is designed with enough rigour and independence to counteract the financial pull toward higher-paying private work that critics have identified.
Ireland’s experience with consultant contracts shows how fragile that safeguard can be in practice. In a review by Ireland’s national audit authority of how well consultant contracts were being upheld, auditors examined whether permitted private practice was being monitored against public contractual obligations. John Purcell, Comptroller and Auditor General of Ireland, concluded that there had been “no meaningful attempt to monitor the level of consultants’ private practice for its impact on the fulfilment of the contractual commitment.” A monitoring regime that doesn’t actually monitor is, in practice, indistinguishable from not having one.
In Alberta, Canadian Medical Association president Dr Margot Burnell has warned that physicians will naturally shift time toward higher-paying private work, leaving longer waits and fewer available doctors in the public system. Canadian Doctors for Medicare board director Dr Danyaal Raza has argued that Bill 11 would, for the first time since the Canada Health Act was passed in 1984, create a formal two-tier system by allowing patients to pay directly for services that are currently publicly insured. Their concern is not with dual practice as a concept but with dual practice layered on unchanged financial incentives and weak monitoring – a combination that almost guarantees private lists will expand at the expense of public ones.
Alberta’s debate exposes how easily policy intent comes apart from policy design. Writing dual practice into law without changing the financial incentives that privilege private care, or without building protected public time and a credible monitoring architecture, doesn’t resolve the two-tier problem – it formalises it. The choice facing legislators isn’t between dual practice and no dual practice, but between a structured regime that binds private activity to verifiable public commitments and one that substitutes assurances for architecture. That gap is exactly where systems lose equity while claiming to gain capacity.
Competing for Commitment
Public systems that want sustained specialist commitment cannot rely on professional obligation or proximity to purpose to hold it. The private sector doesn’t assume loyalty; it designs for it. Malaysia’s approach illustrates what active competition for specialist commitment looks like in practice. Health Minister Datuk Seri Dr Dzulkefly Ahmad outlined a strategy that converted 7,772 contract medical officers and nurses to permanent posts, pairing workforce security with targeted financial incentives. Specialist Incentive Payments and Pre-Publication Specialist Incentive Payments of RM2,200 to RM3,100 per month are directed at keeping specialist skills in the public sector, while two placement initiatives – the E-Placement System and Mutual Exchange System – offer flexibility as a non-monetary draw. The political and institutional contexts differ from those in Australia, but the logic is portable: if public systems want specialists to stay, or to keep working across both tiers, they must design packages that narrow the gap with private practice rather than assuming vocation will bridge it.
The parallel with protected public operating time at St Vincent’s is conceptual rather than geographic: both reflect institutions that expect to compete for specialist commitment rather than inherit it. Where public funding, rostering, and career structures lack that posture – while private insurers and hospitals continuously refine theirs – dual practice becomes thin, and equity depends increasingly on who can afford to pay.
Architecture Over Aspiration
Private insurers and hospitals don’t just attract specialists – they shape the environment in which specialists decide where to allocate their time, through benefit design, case-mix and theatre access. Contractual clauses that limit mobility can turn a financial preference into a legal commitment. Policy frameworks that authorise dual practice without enforceable monitoring allow private workloads to expand unchecked against public obligations. The sustained dual appointment across St Vincent’s Private and Public Hospitals – supported by protected public lists, dedicated infrastructure and coordinated teams – shows that when those conditions are deliberately constructed, specialists can maintain genuine commitments on both sides of the system.
Alberta’s decision to formalise dual practice, read alongside Ireland’s audit findings and Malaysia’s retention investments, frames a choice every mixed system eventually faces: match intent with enforceable architecture, or watch specialists rearrange themselves toward wherever the structural incentives point. Dual practice doesn’t fail dramatically – it drifts. And when the architecture that would hold it in place is missing, the cost lands not on systems or statistics but on the patient at the back of a public queue, waiting in a system that authorised the arrangement and mistook permission for policy.
