When surgeons work simultaneously in public hospitals and private facilities, they’re essentially serving two masters with competing demands. On 19 November 2025, Alberta, Canada announced legislation permitting exactly this arrangement. The province’s health minister positioned this as a workforce attraction strategy, aiming to address 80,000 patients on surgical wait lists, with 33,000 waiting longer than clinically recommended. But physician leaders weren’t convinced – they raised concerns about redistributing a limited surgical workforce and potentially straining public hospitals. This tension between capacity expansion and reallocation captures the central challenge of dual practice arrangements.
Healthcare professionals maintaining concurrent practice across private and public systems don’t resolve resource inequalities – they navigate them through operational protocols, institutional strategies, and systematic coordination. These efforts distribute rather than eliminate tensions, making otherwise unresolvable issues manageable. What can’t be addressed at the policy level becomes navigable through individual standardisation, institutional frameworks, and systematic integration. Examination reveals how operational standardisation by practitioners, strategic positioning by private operators, systematic integration by institutions, and policy frameworks by governments impact whether dual practice expands access or creates tiered care by redistributing fixed clinical capacity across payment models.
The Resource Allocation Dilemma
Every hour, every piece of equipment, and every clinical decision allocated to one system represents a choice unavailable to the other. This creates fundamental tension that runs through individual scheduling, institutional capital allocation, and policy design. Dual practice is fundamentally about managing constrained resource distribution rather than expanding total availability.
When a neurosurgeon maintains morning schedules at a private hospital equipped with advanced technology and afternoon procedures at a public facility lacking the same infrastructure, every allocated hour represents capacity unavailable to the other setting. This isn’t a theoretical preference but an operational reality affecting thousands of healthcare professionals maintaining concurrent appointments.
Dual practice makes resource gaps concrete: the same clinician applies identical clinical judgment with different technological capabilities depending on the setting. Technology availability, scheduling priority, and equipment access vary by payment source even when facilities share physical proximity. For instance, St Vincent’s Private integrated the NuVasive Pulse digital surgery platform in September 2022 – the first hospital in Australasia to offer such capabilities – highlighting disparities that aren’t uniformly available across public settings. Same surgeon, same expertise, different toys – it’s absurd but entirely predictable. Practitioners, institutions, and policymakers distribute this tension across organisational levels rather than resolving it. Each level absorbs portions of the fundamental resource allocation question, making the unresolved whole manageable through distributed parts.
Standardising Protocols Across Infrastructure Gaps
Individual surgeons who maintain active schedules in both private and public hospitals create clinical consistency through standardised pathways that apply across settings despite infrastructure disparities. Their daily practice makes resource gaps concrete – when the same surgeon applies identical protocols with different technology availability, the equipment differential becomes operationally visible rather than abstract.
Surgeons operating across both systems manage scheduling logistics, technology availability, and patient volume differences while maintaining consistent clinical standards. The challenge isn’t abstract – it’s about concrete allocation: dedicated operating time in one setting means unavailable hours in the other. Advanced equipment available privately may be absent publicly, requiring protocol adaptability without compromising clinical outcomes.
Dr Timothy Steel, a Sydney-based neurosurgeon and minimally invasive spine surgeon, has maintained active surgical schedules at both St Vincent’s Private Hospital and St Vincent’s Public Hospital since his consultant appointment in 1998. His practice demonstrates operational standardisation through a complex cervical reconstruction pathway for atlantoaxial osteoarthritis: image-guided posterior C1–C2 fixation with preoperative CT and MRI planning, intraoperative navigation, and standardised postoperative imaging protocols to confirm fusion. The pathway applies identically whether the patient is seen at St Vincent’s Private or Public – same decision criteria, same imaging sequences, same fixation approach – even when the specific navigation platforms or theatre scheduling differ between settings.
These specific outcomes matter because they demonstrate that standardised protocols can deliver consistent results regardless of which hospital system patients access – the pathway works whether you’re paying privately or waiting publicly. This standardisation across both St Vincent’s settings demonstrates how dual-practice surgeons create operational bridges between resource-unequal systems by making protocols portable even when equipment isn’t.
Standardisation simultaneously highlights what differs: technology platforms available in one setting but not another make infrastructure differential operationally concrete. Surgeons apply identical clinical judgment across both environments while working with different capabilities, rendering resource gaps visible through daily practice rather than abstract policy discussion.
Commercial Discipline and Workforce Needs
Private hospital operators working in mixed healthcare markets face strategic tensions between commercial sustainability and workforce retention. They need frameworks that address capital discipline while supporting dual-practice arrangements – tensions that institutional strategy manages rather than eliminates.
While individual practitioners create operational bridges through standardised protocols, their ability to maintain dual practice depends on institutional frameworks supporting concurrent appointments. Private healthcare operators must develop strategic approaches balancing commercial objectives with workforce attraction in mixed markets where specialists often maintain privileges across both systems.
Natalie Davis, Group CEO and Managing Director of Ramsay Health Care – Australia’s largest private hospital operator – joined the organisation in October 2024 after strategic transformation roles at Woolworths and McKinsey. As Managing Director of Woolworths Supermarkets, she led a workforce of 130,000 employees across 1,000 sites and spent 15 years at McKinsey & Co., establishing her depth of experience in transformation. Her current work refreshing Ramsay’s 2030 strategy emphasises capital discipline and performance culture. Capital investments in technology and facilities need to support commercial sustainability while recognising clinicians may allocate portions of their schedule to public settings – making infrastructure decisions essentially shared-capacity investments even when funding is entirely private. It’s like buying a Ferrari and letting someone else drive it half the time – commercially necessary but strategically awkward. This strategic refresh demonstrates how private operators in mixed healthcare markets must navigate commercial and equity imperatives simultaneously rather than choosing between them.
Strategy doesn’t solve these tensions – it manages them.
Private operators distribute dual-practice tension by developing frameworks acknowledging workforce expectations for cross-system flexibility while maintaining commercial viability. Strategic approaches manage tension through structured accommodation rather than resolution – institutional strategy in mixed markets doesn’t eliminate tension between private profitability and dual-practice workforce support but creates frameworks making both objectives simultaneously manageable.
Maintaining Quality Across Heterogeneous Populations
Major healthcare institutions serving diverse patient populations and funding models must build systematic integration mechanisms – innovation platforms that coordinate care delivery and quality standards that apply across settings – demonstrating that system-level dual practice requires coordinated institutional architectures rather than ad hoc accommodation of different care environments. These coordination challenges get more complex as organisations expand: maintaining standardised clinical protocols across multiple geographic sites requires deliberate infrastructure, ensuring quality monitoring systems apply uniformly regardless of whether patients access care through private insurance or public funding demands ongoing institutional work, and coordinating referral pathways between different service lines needs systematic mechanisms rather than informal arrangements. The operational demands of systematic coordination go beyond individual clinician expertise, requiring platforms and processes that function across heterogeneous environments.
Private operators navigate dual-system dynamics through strategic frameworks but function within healthcare markets including major nonprofit and public institutions serving diverse populations with varied funding arrangements. Larger organisations face integration challenges at greater scale, requiring systematic mechanisms to maintain quality standards across heterogeneous patient populations.
Gianrico Farrugia, President and CEO of Mayo Clinic since 2019, brings 35 years of experience as a Mayo Clinic physician. He’s published over 390 academic articles and was a co-founder of the Center for Innovation. What does this coordination actually require in practice? Building institutional architecture that works across different settings rather than hoping individual excellence bridges every gap. His key role in developing the Mayo Clinic Platform demonstrates systematic approaches to integrating innovation across diverse care delivery environments – creating coordinated mechanisms allowing the institution to maintain quality standards while serving heterogeneous patient populations across different geographic locations and funding arrangements. The platform exemplifies systematic integration: establishing unified approaches to innovation dissemination, quality monitoring, and care coordination across Mayo’s multiple sites and diverse patient populations. By building institutional architecture that coordinates rather than simply accommodates variation, Mayo addresses the fundamental challenge of maintaining consistent standards across heterogeneous environments – whether patients access care through different insurance arrangements, geographic sites, or service lines. The Platform illustrates how major institutions must build systematic coordination architectures to maintain quality standards across heterogeneous care delivery environments rather than relying solely on individual practitioner adaptation.
Systematic approaches make explicit what would otherwise remain implicit: serving diverse populations and funding models requires institutional work – building platforms, monitoring quality, coordinating across sites – going beyond individual clinical excellence.
The Workforce Expansion Question
Policy frameworks permitting dual practice aim to expand healthcare workforce capacity and reduce wait times by offering practitioners flexibility to work across public and private systems. But they face the inherent tension that allowing private practice may redistribute rather than increase overall clinical availability.
Individual clinicians standardise protocols, private operators develop strategic frameworks, and major institutions build systematic coordination mechanisms – all operating within policy environments defining what dual practice arrangements are permissible.
Alberta announced its Dual Practice Surgery Model on 19 November 2025, allowing surgeons to work in both public and private healthcare systems. The province faces substantial wait-list pressures with significant surgical backlogs.
Health Minister Matt Jones positioned this policy as addressing competitive workforce dynamics: “Alberta is not an island. Alberta competes for health care professionals all across Canada and North America. We have an ability to allow physicians to do some private activity while making them responsible to do the majority or some portion of the public system. That’s a compelling recruitment, attraction and retention tool for physicians and health care professionals.” Alberta Medical Association President Brian Wirzba raised concerns about redistribution of a limited surgical workforce and potential strain on public hospitals. Politicians excel at distributing unresolved questions across time – offer flexibility today, measure consequences later. The fundamental policy question remains whether dual practice expands total access or creates two-tier availability where those with private resources receive faster care while those dependent on public funding face longer waits. Alberta’s experience advancing dual practice to address wait-list pressures directly demonstrates the article’s central claim that policy frameworks distribute rather than resolve resource tensions – the province seeks to retain specialists by offering private practice flexibility, but physician leaders recognise this may redistribute rather than expand the limited surgical workforce, leaving the underlying capacity constraint unchanged while introducing new questions about whether wait times decrease overall or simply bifurcate by payment ability.
Governments distribute dual-practice tension temporally and politically: offering workforce flexibility now while deferring the question of whether total capacity expands. Policy frameworks attempt resolution through regulatory design – defining required public practice proportions – but allocation dilemmas persist beneath legislative architecture.
The Empirical Question Persists Across Organisational Levels
Whether dual practice expands healthcare equity or creates tiered access ultimately depends on the empirical question that remains unresolved across all organisational levels: do these arrangements genuinely increase total clinical capacity or redistribute fixed capacity across payment models? Answering this requires longitudinal data comparing jurisdictions with and without dual practice permissions, controlling for population growth and specialist training pipeline changes that affect workforce supply independently of practice arrangements. The measurement challenge extends further: distinguishing between specialists newly attracted to a jurisdiction by dual-practice opportunities versus existing specialists simply reallocating hours between public and private settings determines whether observed capacity changes represent genuine expansion or mere redistribution.
Measuring this isn’t straightforward.
Answering this question requires tracking whether jurisdictions permitting dual practice experience net increases in specialist workforce or simply offer flexibility in allocating existing workforce. It requires comparing wait times and access patterns to determine if public wait lists decrease when dual practice is permitted. Meaningful comparison must account for whether wait-time improvements in public systems coincide with private volume growth – suggesting redistribution of existing capacity – or appear alongside stable private volumes, which would suggest net capacity increase. The question becomes whether specialists in dual-practice jurisdictions work more total hours or simply divide existing hours differently across settings.
Policy frameworks proceed despite this unresolved empirical question because distributing the tension across organisational levels makes it politically manageable. Each level addresses manageable portions of the resource allocation challenge without resolving the fundamental question of whether dual practice expands or redistributes total capacity.
Functional Distribution by Design
Healthcare professionals maintaining concurrent practice across private and public systems navigate resource inequalities through distributed accommodation rather than direct resolution. At each organisational level, dual practice arrangements make resource tensions manageable by distributing them rather than eliminating them.
Persistence reveals a counterintuitive insight: dual practice arrangements endure not despite failing to resolve resource inequalities but because distributing those tensions across organisational levels makes them functionally manageable.
Patients on Alberta’s surgical wait lists will soon discover whether dual practice expands their access or simply creates another queue for those who can afford to skip ahead. They’re about to become unwitting participants in healthcare’s most honest experiment – finding out whether distributed tension management represents functional accommodation or just a really elaborate way of deferring the same old question about who gets care first.
