Late last year, the Alberta Government announced healthcare legislation that will allow physicians to provide care to patients in public and private settings. The move improves choice for patients and brings Alberta closer to better-performing universal health care systems in Europe.
However, some critics argue that this will lead to physicians leaving the public system.
The reality is that it does the opposite – it ensures physicians can deliver private care to patients without being forced to sacrifice their public role. These include patients who would otherwise leave Canada to receive more timely care in a different country, as well as those who may otherwise join the thousands of Canadians who die on wait lists every year.
So why the controversy?
First, it’s important to understand that physicians in Alberta (and indeed most of Canada) were always able to opt-out of the public system. However, to do so, they had to give up their public role entirely. Presented with this binary choice, physicians historically opted to stay within the public system, but that may not always be the case.
For instance, in 2014, the Calgary Herald profiled how a retired nurse from Alberta (Marlene Driscoll) and a Calgary-based surgeon travelled together to Turks and Caicos so that the latter could perform surgery on the former, as such a private transaction was not allowed in Alberta. The article also notes that one Alberta surgeon, Dr. Hollinshead, eventually made the difficult decision to opt-out of the public system entirely so he could treat patients like Ms. Driscoll in their hometown in the future. Other provinces that have clung to this approach (like Quebec) are also now seeing an increasing number of physicians opting out.
Alberta’s government understands that the old approach doesn’t work and in fact risks physicians like Dr. Hollinshead abandoning the public system entirely. This is why it introduced dual-practice legislation to offer physicians a more flexible option – allowing them to participate in the private sector while continue serving patients in the public queue.
But what’s to stop physicians from simply reducing their hours in the public system?
Bill 11 includes language that empowers the Minister of Health to dictate the circumstances and conditions under which dual practice is permitted, including restricting the types of services offered.
While the specifics are yet to be worked out, it’s worth examining guardrails in other universal health care systems that allow dual practice for their physicians. Analysts Krystle Wittevrongel and Conrad Eder examined universal health care in Germany, France, and the UK. These countries regularly outperform Canada on international comparisons of healthcare performance, allow dual-practice, but expect physicians to prioritize public sector responsibilities.
| Regulatory Features | United Kingdom | Germany | France |
| DISCLOSURE AND TRANSPARENCY | Private practice must be declared and documented for public National Health System (NHS) planning. | Written authorization for any secondary employment must be obtained, and approval can be refused if it impairs duties or legitimate employer interests. | Each practice method must be declared to the relevant professional body and Caisse Primaire d’Assurance Maladie (CPAM). Secondary activities require prior written authorization. |
| PRIORITIZATION OF PUBLIC DUTIES | Private activities cannot be scheduled during times scheduled for the NHS, ensuring that public activities take precedence. Where a conflict exists, NHS commitments must take priority over private work. Before undertaking private work, spare professional capacity must first be offered to the NHS and a failure to do so can impact pay progression. | Minimum of 25 hours to be used to treat public patients. Private patient consultations and additional services cannot be conducted during these mandated public hours. Secondary (private) activities cannot be detrimental to the interests of the principal (public) employer. If there is a negative impact on primary (public) interests (i.e., primary job is impacted by supplementary/private work by overexertion) then disciplinary action is likely which can include dismissal or the obligation to surrender earnings to the primary employer. Secondary activities outside hospitals should generally not exceed 20% of working time within the maximum 48-hour limit for total working time. | Physicians seeking to practice in the private sector must first complete a minimum of 24 months in the public sector. Minimum amount of hospital working time set at five half-days, and physicians whose public practice covers between 50% and 90% of their working time are able to offer off-site private activity. Private practice activities cannot exceed 20% of the physician’s weekly public hospital service hours. Garot Law (2025) has been adopted by the National Assembly but not yet passed into law that would regulate where self-employed doctors can establish practices and mandates participation in on-call duties, reinforcing obligations toward the publicly financed system. |
| CONFLICT-OF-INTEREST MANAGEMENT | Private activities cannot be offered to public (NHS) patients. NHS patients’ appointments cannot be cancelled to accommodate private patients except in genuine emergencies. Use of public resources, staff, and facilities for private practice are also prohibited without prior formal agreement. | Physicians can be allowed to conduct privately billed activity within the public hospital provided they pay a percentage of their private earnings back to the hospital to compensate the hospital for the use of infrastructure, equipment, and staff. | Public patients cannot be referred to doctor’s private practice or facility. Practitioners whose working time is at least 50% may be prohibited from entering into paid activities in direct competition with the public health establishment they primarily work in. Specialists may see patients on an in-patient basis but they must pay a percentage of remuneration to the hospital. |
Sources: Bill 11; Health Care by Country 2024 Report | Commonwealth Fund; Consultants and private practice; Consultant part-time and flexible working; Guide_to_consultant_job_planning.pdf; NHS England » Managing conflicts of interest in the NHS; pdf; Merkblatt_Nebentaetigkeit_TV-AErzte_ENG.pdf; Quellenmaterial; Nebentätigkeit – was muss ich beachten? | ÄRZTESTELLEN; Part-time jobs in the public sector: What applies to several jobs | University of Applied Sciences for Public Administration and Finance Ludwigsburg Home office for doctors – VOELKER & Partner mbB; Quel cadre réglementaire; Public and private sectors for doctors in France: | Euromotion Medical encadre l’exercice mixte en médecine générale de proximité ?; Le cumul d’activités des praticiens hospitaliers – MACSF; France | International Health Care System Profiles | Commonwealth Fund Policy and regulatory responses to dual practice in the health sector – ScienceDirect Dual practice of hospital staff doctors: hippocratic or hypocritic? – PMC; Dual Practice in the Health Sector: Policy and Regulatory Respons; TVöD Nebentätigkeiten; 34; Dual practice of hospital staff doctors: hippocratic or hypocritic? – PMC; Updates
For example, dual-practice physicians in Germany must commit to working at least 25 hours for the public system before they can provide private care. In France, the requirement is five “half-days” and private activity is capped at 20% of physicians’ public activity. In the United Kingdom, doctors who have contracts with the public National Health Service (NHS) must generally prioritize their duty to the public hospital. They must disclose private activity to their public employer, not discuss private treatment during a public consultation, and ensure no conflict of interest – specifically that their private practice does not “result in a detrimental effect on NHS patients or services, nor diminish the public resources that are available for the NHS.”
Common elements across these three systems include mandatory authorization and disclosure/transparency, explicit rules to ensure that public obligations take precedence, clear limits on private practice time, and strict prohibitions on the use of public resources or public patients for private gain. Taken together, these safeguards demonstrate that dual practice can be compatible with strong public systems when it is carefully designed.
It’s important to remember that many of these countries consistently outperform Canada on indicators of timely access to health care. For example, whereas 58 percent of Canadians waited longer than 2 months for scheduled surgery, that number was 49 percent in the UK, 32 percent in France, and just 20 percent in Germany.
With thoughtful safeguards in place, informed by these international examples, Alberta can increase capacity, shorten wait times, and reinforce, rather than weaken, the public system.
Of course, dual practice is simply one tool in the government’s arsenal to tackle wait times and must be complemented by additional reforms – many of which are either being tested, or currently under consideration. You can read more about them at HealthReformAlberta.ca
This blog post was written by SecondStreet.org Research Director, Bacchus Barua.
