UK hospital service approved for Jersey psychiatric patients

A hospital in Dorset providing a specialised psychiatric service does meet the needs of patients in Jersey, the States has said. The Minister for Health and Social Services has designated St Ann's Hospital in Dorset as an "approved establishment" for islanders to receive the specialised service which cannot be provided locally. The approval means patients initially transferred to the Psychiatric Intensive Care Unit (PICU) can be transferred to other wards if clinically appropriate.The service will be subject to monitoring by the Jersey adult mental health services, the States said.
'Appropriate and adequate'
It said: "The minister has responsibility to approve establishments or premises for the purpose of care and treatment of patients. "Governance checks have confirmed that the service is appropriate and adequate to meet the needs of service users who require this service, which cannot be provided locally in Jersey due to the specialised nature of the service and the PICU environment."The decision also affects patients transferred to UK hospitals through the criminal justice system, as any hospital must be designated "an approved establishment" under Jersey's mental health law.The most recent Care Quality Commission report rated the trust's acute wards for adults of working age and psychiatric intensive care units as good.

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The Guardian

2 days ago

• The Guardian

‘These deaths are not inevitable': state gun control laws reduce children's firearm deaths, study shows

Guns have been the leading cause of death among US children since 2020. A new study shows a clear path to addressing this scourge and saving kids' lives: state gun control laws. The study, published this month in Jama Pediatrics, reveals that states which enacted stricter gun control measures following the 2010 McDonald v Chicago supreme court ruling – a landmark decision that struck down Chicago's ban on handguns and, in effect, expanded the second amendment nationwide – have seen a relative decrease in firearm deaths among children aged up to 17. By contrast, states that expanded gun freedoms have seen a notable increase in kids' deaths from gun violence, including by homicide, by suicide and from accidents. This means that commonsense gun policies make a difference when it comes to keeping kids safe, said Nick Suplina, senior vice-president for law and policy at Everytown for Gun Safety. 'This study sends a message that lawmakers that refuse to take action or who further loosen gun laws are putting kids' lives in peril,' he said. 'That's a very powerful outcome for an academic study.' To conduct their study, researchers divided states into three categories – least permissive, more permissive and most permissive – based on the strength of their gun control laws. They then used data from the Centers for Disease Control and Prevention to look into individual states' rates of pediatric firearm deaths (deaths from gun violence among children ages 0-17) over a 12-year span. What they found was a striking degree of overlap among states based on legislation enacted. In more permissive states, such as Mississippi and New Hampshire, pediatric death rates rose substantially more than expected, especially among children of color. '[We saw] so many excess deaths over and above what would have been expected,' said Jeremy Faust, an emergency room physician and assistant professor of medicine at Harvard University, and the study's lead author. But in states that passed stricter laws – such as background checks, permitting and safe-storage requirements – rates either stayed stagnant or fell. That finding surprised Faust, who anticipated that every state would see at least some increase since the number of kids killed by guns in the US has risen so sharply over the past decade. California, New York and Maryland, all of which have assault weapon bans and safe-storage laws, saw decreased rates of pediatric firearm mortality. And Rhode Island, which requires would-be gun owners to pass a firearm safety course to buy a handgun, saw a 60% drop in gun-related deaths among children. 'These deaths are not inevitable,' said Shriya Bhat, a second-year molecular biology student at Harvard and an author of the study. 'Policy choices matter, and we can learn from the places that have kept kids safer.' Gun policy experts say that research like this, which treats gun violence as a public health concern and considers the impact of on-the-books legislation from a scientific perspective, is desperately needed. 'The insights of the medical community are vital to educating policymakers and the public about the need to address the public health crisis fueled by unregulated access to firearms,' said Nick Wilson, senior director for gun violence prevention at the Center for American Progress. (The White House recently removed former surgeon general Vivek Murthy's advisory on gun violence as a public health issue, and has also slashed funding for gun violence research.) Experts also stress the need for lawmakers to translate knowledge into action. That means prioritizing measures that keep all of society safe from gun violence, such as universal background checks, as well as laws that protect kids specifically, such as safe-storage regulations. 'We really need policymakers to step up,' said Kelly Drane, research director at the Giffords Law Center. Suplina added that moving the needle on policy would require dampening the influence of the country's for-profit gun lobby, which perpetuates the narrative that guns make a society safer – a myth he hopes this study can help dispel. 'Literally the exact opposite is true,' he said. 'If more guns made us safer, the US would be the safest country in the world by far. Instead, we have a homicide rate that's 25 times that of our peer nations.' Sign up to Headlines US Get the most important US headlines and highlights emailed direct to you every morning after newsletter promotion But a lack of gun control legislation doesn't mean individuals can't change their own behaviors to keep kids safe. Parents who own guns can safely store their firearms and ask other parents whether there are guns in the house before permitting a playdate, said Drane, much like a parent might ask if another family has a fence around their pool. 'It doesn't have to be a conversation about whether or not it's OK to own firearms, but just knowing that there's a plan in place to keep kids safe in the home is really important.' Nonetheless, researchers and experts are hopeful that political gulfs can be crossed by focusing on how policies can save the lives of children. 'We've seen a lot of public health successes that have been bridged by focusing on the impact of public health threats on children,' said Drane. 'I'm hopeful that research like this can help change minds.' For Faust, who witnessed children die from gunshot wounds first-hand while training in a Queens, New York, trauma center, addressing the epidemic of gun violence is deeply tied to his work as a physician. 'I am interested in how choices we make as a society can have a massive impact on the way we live and die,' he said. 'When you save the life of a kid, think about the decades of life you are giving back.'

BBC News

2 days ago

• BBC News

What next for troubled Nottingham NHS trust after £1.6m fine?

The NHS is largely funded by public money paid for through taxes and national February, one of the busiest and biggest NHS trusts in England was given a record £1.6m fine over maternity failings in connection with the deaths of three University Hospitals (NUH) NHS trust is already at the centre of the largest maternity review of its kind in the NHS, following hundreds of baby deaths and injuries. When it was fined at Nottingham Magistrates' Court, the judge said the trust was operating at a deficit of about £100m, and added there was "no money to pay any substantial fines without requiring the trust to make further cuts".District Judge Grace Leong considered other court judgements and guidelines for comparable offences before handing down the why was an already struggling, publicly-funded service given such a large fine, and what justice did the fine bring for the families the trust let down? The details of the case Adele O'Sullivan died on 7 April 2021 - just 26 minutes old - Kahlani Rawson died on 15 June at four days old and Quinn Lias Parker died on 16 July at two days old. NUH pleaded guilty to six counts of failing to provide safe care and treatment to the babies and their mothers, in a prosecution brought by the healthcare watchdog, the Care Quality Commission (CQC). The court heard there were similar failings in all three cases, including a failure to expedite the delivery of the babies, not recognising serious conditions, communication issues and staff not being equipped to interpret anomalies in foetal heart monitoring. It was the second time the trust had been prosecuted by the CQC for maternity failings. In 2023, the trust was fined £800,000 over the death of Wynter Andrews, who died shortly after her birth at the Queen's Medical Centre in 2019. Until this year, that fine was the largest handed down for maternity failings. NUH prosecutions make up two of five maternity-related criminal prosecutions brought by the CQC. The watchdog gained powers under the Health and Social Care Act 2008 (Regulated activities) Regulations 2014, in prosecution by the CQC is separate from any prosecution that could arise from a corporate manslaughter investigation, which was opened earlier this 2 June, Nottinghamshire Police said it was examining whether maternity care provided by NUH had been grossly negligent. How did the judge decide on £1.6m? In her sentencing remarks, District Judge Grace Leong said she would have to fix a "significant financial penalty" to mark the gravity of the offences, but also had to strike "a delicate balance"."I cannot ignore the negative impact that the fine will have on services to patients at a time when the NHS continues to face unprecedented challenges both in terms of insufficient funding, the backlog of patients waiting for treatment and the demands placed upon the trust's services from an ageing population," the judge was no ceiling to the level of fine the judge could meant the sentence was a matter of discretion, with the judge considering other sources of guidance - such as any High Court or Court of Appeal judgements - and other sentencing guidelines for comparable was reduced from a starting point of £5.5m, as the judge took into account the financial implications on the public body and its guilty pleas. How could the fine impact services? In response to the BBC, a statement from NUH chief executive Anthony May said: "We fully accept the findings from court, including the fine handed down by the judge. "The mothers and families of these babies have had to endure things that no family should after the care provided by our hospitals failed them, and for that I am truly sorry."We will work to ensure to minimise the impact of the fine on our patients, including ongoing efforts to improve our maternity services."NUH did not want to put anyone forward for interview, and did not wish to detail how the fine might impact services. Roy Lilley, former chairman of the old Homewood NHS Trust in Chertsey, Surrey - which later merged with Ashford and St. Peter's Hospitals NHS Trust - and now an independent commentator on health service issues, said some impact on services would be "inevitable". "Clearly a chunk of money like £1.6m is going to have an impact on the trust's ability to operate."The day-to-day running of the trust is, of course, difficult enough with all the financial pressures but to have this kind of money taken out of its revenue balances, it makes it even more difficult," he said. Mr Lilley - who has not worked for NUH - added: "It will certainly slow down some of the plans that they had in terms of improvements.""Generally it has a very bad effect, a big impact on the trust's ability to respond," he said. Mr Lilley said it was possible for trusts to seek loans from the Department of Health of Social Care (DHSC) in the face of financial difficulty. The BBC understands while NHS trusts are expected to meet their legal and financial obligations - including prosecution fines - they can access loans in some instances. The trust's annual budget is £1.8bn. What does the fine mean to the families? The families affected by NUH's maternity failings have consistently called for the sentencing, solicitor Natalie Cosgrave - representing the parents of baby Quinn - said in a statement that the prosecution was "the only system that exists" to obtain Simpson, an associate clinical negligence solicitor who represented the families of Adele and Kahlani, told the BBC the trust's guilty plea was "some level of accountability, but it's only one part of a much bigger picture".To the bereaved families, it is individuals who should be held accountable, not just the trust as an organisation, Ms Simpson Simpson has also represented the families of Adele and Kahlani, as well as others, in civil claims against NUH. At each stage of the various investigations and proceedings they have endured - including inquests, internal reviews and court hearings - the families have called for more change and scrutiny. Ms Simpson said: "The judge was very clear that a fine is the only sentence that she can impose, and no fine is ever going to be enough when you've lost your child." During the sentencing in February, the earlier case of Wynter Andrews - who died 23 minutes after being born - was referenced several parents Sarah and Gary Andrews watched the hearing from the public gallery "as concerned parents", but did not know their daughter's case would be mentioned "quite so prominently". "I think for us it's important to highlight that this process is the only avenue that families have to get some accountability," he said."The judge is in a really difficult position, I feel, but we're counting pennies over babies' lives." Where does the money go? The fine is paid to HM Treasury - the government's finance ministry which controls public spending - as with any prosecution affected in this case will not receive any of the money from the trust was also told to cover prosecution costs of £67,755.23 and a victim surcharge of £ costs in this case will be paid to the CQC. The victim surcharge - which is imposed on offenders to ensure they hold some responsibility towards the cost of support victims and witnesses - goes to a general fund and not directly to those involved. That money provides a contribution towards Ministry of Justice-funded support services for victims and witnesses. The £1.6m fine is separate from the tens of millions of pounds the trust has paid out in damages for civil claims in relation to maternity care. What next for the trust? Nottinghamshire Police's investigation into the trust's maternity services - called Operation Perth - has seen more than 200 family cases referred to it so the separate maternity review by senior midwife Donna Ockenden is currently examining the testimony of more than 2,000 cases. The review began in September 2022 and closed to new cases at the end of May. Ms Ockenden's final report of findings is due to be published in June last week, the trust announced plans to cut at least 430 jobs in an attempt to save £97m in the next planned job cuts follow the government's instruction to all trusts to reduce the size of their corporate and support services, and were not as a result of the record fine, the trust said.

Reuters

13-06-2025

• Reuters

Health Care Non-Competes Practical Law The Journal

The enforceability of non-compete agreements has long been the subject of civil litigation and arbitration between contracting parties. Non-competes are agreements that limit a worker's ability to engage in certain post-employment activities. Traditional non-competes restrict workers from engaging in competitive activity for a designated time period, typically within a specified geographic area. In recent years, federal and state legislatures and regulatory agencies have more broadly targeted non-competes and other restrictive covenants for reform or even elimination. Non-competes create an inherent tension between an employer's need to protect legitimate business interests, such as trade secrets, confidential information, and client relationships, and employees' rights to earn a living and work in their chosen profession and location. Non-competes with health care professionals present unique challenges and considerations. The enforceability of these agreements may be influenced by: Patients' rights to access, choose, and continue to receive treatment from specific health care professionals. The lack of available care in certain areas. In recognition of these public policy concerns, many states have enacted laws restricting or prohibiting non-competes with certain health care professionals. Health care employers often use other restrictive covenants in addition or as an alternative to non-competes. These include: Non-solicitation agreements, which restrict health care professionals from soliciting certain patients for a period of time. Non-treatment agreements (also known as non-acceptance or non-service agreements), which prohibit health care professionals from treating certain patients for a specified time period (see Non-Treatment Agreements below). This article discusses the interplay of law and policy considerations regarding non-competes and other restrictive covenants entered into between: Health care employers, including: hospitals (both for-profit and non-profit); private medical practices and partnerships; and staffing agencies. Health care workers, including: doctors; nurses; physician assistants; home health aides; and other non-physician health care practitioners. This article also summarizes select state law provisions regulating non-competes in the health care industry and discusses the challenges of enforcing non-competes with health care professionals, including those providing telemedicine services. (For more on post-employment restrictive covenants, see Non-Compete Agreements with Employees and Restrictive Covenants Toolkit on Practical Law; for a model non-compete, with explanatory notes and drafting tips, see Employee Non-Compete Agreement on Practical Law.) The Legal Framework Governing Health Care Non-Competes Despite recent efforts to ban most post-employment non-competes, there is currently no federal law specifically addressing non-competes, non-solicits, or non-treatment agreements for health care workers (for more on the latest efforts to ban post-employment non-competes, see FTC Non-Compete Clause Rulemaking Tracker on Practical Law). The enforceability of these agreements therefore depends on the applicable state law. Although state non-compete laws vary dramatically, with regard to health care professionals, they generally can be categorized as: Blanket non-compete bans. Several states, such as California, Minnesota, North Dakota, and Oklahoma, effectively ban most non-competes, with limited exceptions. These non-compete bans apply equally to health care professionals. Health care-specific statutes. More than 20 states have enacted statutes prohibiting or otherwise limiting the enforceability of physician or health care worker non-competes. These laws often impose additional or more stringent limitations on the use of non-competes in the health care sector than in other industries. General state non-compete regulations. In all other states, health care non-competes are governed by either: a statute governing non-competes generally, without any health care-specific restrictions or requirements; or a common law reasonableness analysis, if there is no generally applicable non-compete statute. (For a chart providing an overview of laws governing non-competes in the health care sector, see Health Care Non-Compete State Law Chart: Overview on Practical Law.) Specific Health Care Non-Compete State Statutes Many states have enacted statutes specifically regulating the use of non-competes in the health care context, which may help to: Preserve patient choice. Improve access to health care, especially in rural communities (see Health Care Deserts below). Allow for continuity of therapeutic relationships between patients and health care providers. State Statutes Banning Certain Health Care Non-Competes Several states have statutes containing outright bans on non-competes with particular classifications of health care workers. For example, state laws generally prohibit non-competes in: Arkansas with: physicians and surgeons licensed under the Arkansas Medical Practices Act (Ark. Code Ann. § 17-95-201); and osteopathic physicians licensed under Ark. Code Ann. § 17-91-101 (S.B. 139 (adding a new section to Ark. Code Ann. § 4-75-101(k)) (effective July 15, 2025)). Indiana: with primary care physicians who practice family medicine, general pediatric medicine, and internal medicine (Ind. Code § 25-22.5-5.5-2.5(b)); and for agreements originally entered into on or after July 1, 2025, between all physicians and any hospital, hospital parent company or hospital affiliated manager, or hospital system (Senate Enrolled Act 475, adding a new Ind. Code § 25-22.5-5.5-2.3). Massachusetts with: physicians (M.G.L. c. 112, § 12X); nurses (M.G.L. c. 112, § 74D); psychologists (M.G.L. c. 112, § 129B); and social workers (M.G.L. c. 112, § 135C). New Hampshire with: Rhode Island with licensed physicians (R.I. Gen. Laws § 5-37-33). Wyoming with physicians (S.F. 107 (codified as Wyo. Stat. Ann. § 1-23-108(b)) (effective July 1, 2025)). State Statutes Limiting Health Care Non-Competes Most state laws do not completely ban non-competes in the health care industry. Indeed, there are countervailing policy considerations that can weigh in favor of allowing health care non-competes, such as the health care employer's need to: Protect confidential information, for example, patient records and business plans. Ensure the stability of a sufficient number of health care providers within an existing practice group. Preserve patient-practice relationships, which may promote continuity of care. Sustain revenues and profitability. States that restrict non-competes for certain health care workers, without imposing outright bans, take various approaches. The laws may, either alone or in combination: Focus on certain specialties or positions. Limit the duration of enforceable restrictions. Limit the geographic scope of enforceable restrictions. Declare non-competes unenforceable if a health care worker was terminated without cause. Allow for or require notice to patients of a health care worker's departure. Encourage patient choice and therapeutic continuity by allowing the patient-authorized transfer of medical records. Invalidate non-competes for health care workers who earn less than a minimum annual compensation threshold. Maryland Maryland recently enacted a statute restricting non-competes for certain health care professionals. Effective July 1, 2025, non-competes in Maryland are void with: Under this new law, non-competes are only enforceable against health care employees earning more than $350,000 annually if the restrictions do not either: Tennessee Tennessee law imposes restrictions on non-competes with covered health care providers, including podiatrists, chiropractors, dentists, optometrists, physicians, osteopathic physicians, and psychologists, but not physicians specializing in emergency medicine. Non-competes with covered providers are enforceable only if: The agreement is in writing and signed by the provider and employing or contracting entity. The temporal restriction is for two years or less. The geographic restriction, if any, does not exceed the greater of: a ten-mile radius from the provider's primary practice site; or the county where the primary practice site is located. If there is no geographic restriction, the provider can only be restricted from practicing their profession at any facility where the employing or contracting entity provided services while the provider was employed with that entity. (T.C.A. §§ 63-1-148 and 63-6-204.) Additional conditions apply in Tennessee to non-competes with certain employing or contracting entities, including: Hospitals (T.C.A. § 63-6-204(f)(2), (3); see also T.C.A. § 68-11-205(b)(2), (3)). Renal dialysis clinics (T.C.A. § 63-6-204(g)(2), (3); see also T.C.A. § 68-11-205(c)(2), (3)). Faculty practice plans (T.C.A. § 63-6-204(h)). Nursing homes (T.C.A. § 68-11-205(f)(2)). Texas In Texas, a non-compete with a licensed physician is enforceable only if it: Other States In addition to other restrictions, several state laws render physician non-competes unenforceable under certain circumstances when the employing entity terminates the employment relationship without cause. This type of restriction exists in states such as: Connecticut, when the employer terminates the employment without cause (Conn. Gen. Stat. Ann. § 20-14p(b)(2)). Indiana, when the employer terminates the employment without cause or the physician terminates the relationship for cause (Ind. Code § 25-22.5-5.5-2.5(b)). However, for agreements originally entered into on or after July 1, 2025, Indiana renders void and unenforceable all non-competes between physicians and a hospital, hospital parent company, hospital affiliated manager, or hospital system, regardless of the circumstances of the employment termination (with limited exceptions for the sale of a business) (Senate Enrolled Act No. 475, adding a new Ind. Code §§ 25-22.5-5-2.3 and 25-22.5-5.5-1.4(b)(3)). Pennsylvania, which generally bans non-competes with health care practitioners, but includes an exception for covenants of no more than one year in duration, provided the employer has not terminated the employment relationship (35 P.S. § 10324(a), (b)). Sale of Business Exceptions Several state statutes that restrict the enforceability of non-competes with certain health care professionals include exceptions for covenants related to the purchase or sale of a business or partnership interest. For example, Tennessee's statute, which sets temporal and geographic limits on enforceable health care non-competes, also provides that non-competes made in conjunction with the purchase or sale of a health care provider's practice may restrict the provider's right to practice if the temporal and geographic scope of the non-compete are reasonable. The statute creates a rebuttable presumption that the temporal and geographic limitations agreed to by the parties are reasonable. (T.C.A. §§ 63-1-148 and 63-6-204.) Rhode Island's statute provides that non-competes for physicians and advanced practice registered nurses are generally prohibited but are enforceable in connection with the purchase or sale of a practice if the non-compete restriction is no longer than five years (R.I. Gen. Laws §§ 5-37-33 and 5-34-50). Pennsylvania's statute also has exceptions for the sale of a business. The Pennsylvania Fair Contracting for Health Care Practitioners Act provides that non-competes with covered health care practitioners generally are enforceable only if both: The non-compete restriction is no longer than one year. The health care practitioner was not dismissed by the employer. Under the statute, covered health care practitioners include: Medical doctors. Doctors of osteopathy. Certified registered nurse anesthetists. Certified registered nurse practitioners. Physician assistants to an osteopathic or medical practice. These restrictions, however, do not apply to covenants connected to: The sale of a health care practitioner's ownership interest in an entity or all or substantially all of the entity's assets. Transactions resulting in the sale, transfer, or change in control of the entity. An ownership interest in the business entity. (35 P.S. §§ 10321 to 10325.) Other states with sale of business exceptions to health care non-compete bans or restrictions include: Indiana, regarding physician non-competes with hospitals, hospital parent companies, hospital affiliated managers, and hospital systems, provided the physician owns more than 50% of the business entity at the time of sale (Senate Enrolled Act No. 475, adding a new Ind. Code §§ 25-22.5-5-2.3 and 25-22.5-5.5-1.4(b)(3) (effective July 1, 2025)). Montana (Mont. Code Ann. § 28-2-724(3)). South Dakota (SDCL 53-9-11.2). West Virginia (W. Va. Code § 47-11E-4). Buyout Provisions Some statutes addressing health care non-competes allow physicians the right to buy their way out of the non-compete. For example, Texas's statute provides that a non-compete with a licensed physician is not enforceable unless, among other requirements, the agreement provides an opportunity for the physician to buy out of the covenant at a reasonable price or, at the option of either party, as determined by a mutually agreeable arbitrator. If the parties are unable to agree on a reasonable price or the selection of an arbitrator, a court-appointed arbitrator will determine a reasonable price. (Tex. Bus. & Com. Code Ann. § 15.50(b)(2).) The failure to include the required buyout provision renders the agreement unenforceable (LasikPlus of Tex., P.C. v. Mattioli, 418 S.W.3d 210, 219-20 (Tex. App.—Houston [14th Dist.] 2013, no pet.) (holding that the court had no authority to enforce or reform an agreement lacking a buyout provision)). Under Tennessee law, when a physician sells their practice, any employment agreement or medical practice sale agreement restricting the physician's right to practice after the sale must both: Allow the physician to void the restriction on the physician's practice by buying back the physician's practice either: for the original purchase price of the practice; or if the parties agree in writing, at a price not to exceed the fair market value of the practice at the time of the buyback. Not require the physician to give more than 30 days' notice to exercise the repurchase option, provided that this does not otherwise affect any contract termination notice requirements. If the buyback provision is dependent on determining the fair market value of the practice, the contract must specify the method of determining fair market value by independent appraisal, if the parties cannot agree. (T.C.A. § 63-1-148(b).) Liquidated Damages Provisions Although many states allow for liquidated damages provisions in health care non-competes, the damages generally must be reasonably related to an actual injury. For example, under Delaware law, non-competes between or among physicians restricting a physician's right to practice medicine in a particular location or for a defined period of time after termination of the employment agreement are void. However, Delaware law contains an exception to this blanket ban, which allows for the enforcement of a reasonable liquidated damages provision. Specifically, the law states that provisions that 'require the payment of damages in an amount that is reasonably related to the injury suffered by reason of termination of the principal agreement' are enforceable and that these '[p]rovisions may include, but not be limited to, damages related to competition' (6 Del. Code Ann. § 2707). Arizona also applies a reasonableness requirement for liquidated damages provisions under common law. For example, in Tortolita Veterinary Services, PC v. Rodden, the court held that liquidated damage provisions in veterinarians' non-competes may be enforceable if the provisions: Are intended to compensate the non-breaching party, rather than penalize the breaching party. Approximate the loss: anticipated at the time of contract creation; or that actually occurred. (498 P.3d 125, 129-132 (Ariz. Ct. App. 2021).) Generally Applicable Non-Compete Statutes In recent years, states have increasingly passed laws that limit or restrict the use of non-competes and, sometimes, other restrictive covenants, such as non-solicits and non-treatment agreements. In states without a specific health care statute, the general non-compete laws typically govern non-competes with health care workers. Several states have enacted laws invalidating non-competes for certain workers or imposing other requirements on the enforceability of non-competes by, for example: Setting a maximum duration for non-competes. Invalidating non-competes for employees or contractors who earn less than a specified minimum annual compensation threshold. Imposing notice requirements, such as requiring that the non-compete be disclosed to the employee before employment begins or at least 14 days before the employee signs the non-compete. Requiring that compensation be paid during the non-compete period. Mandating that the employer advise the employee of their right to consult with an attorney before signing the non-compete. Common Law Reasonableness Analysis In states without any non-compete statute, courts typically apply a common law analysis to determine the enforceability of non-competes. While the analysis starts with the premise that non-competes are generally disfavored, courts typically enforce non-competes when they are narrowly tailored and reasonably necessary to protect an employer's legitimate business interest without unduly restricting an employee's ability to earn a living or harming the public interest. Courts have applied these principles when determining the enforceability of physician non-competes in common law jurisdictions (see, for example, Glascock v. Covenant Med. Ctr. Inc., 2022 WL 2824734, at *2-3 (Iowa Ct. App. July 20, 2022) (enforcing a 25-mile, 18-month non-compete against a bariatric surgeon); MetroHealth Sys. v. Khandelwal, 183 N.E.3d 590, 596 (Ohio App. 8th Dist. 2022) (modifying and enforcing as modified a two-year, 35-mile non-compete against a burn surgeon and the director of a burn center); Weber v. Tillman, 913 P.2d 84, 89-90 (Kan. 1996) (upholding a physician's non-compete because it was reasonable and not adverse to the public welfare)). Courts often find that a medical practice's relationships with its existing patients constitute legitimate business interests that are worthy of protection (see, for example, Surgery Ctr. Holdings, Inc. v. Guirguis, 318 So. 3d 1274, 1280-81 (Fla. 2d DCA 2021) (holding that patient goodwill within a 25-mile radius was a legitimate business interest warranting enforcement of two-year non-solicit provisions against departing physicians); Ansaarie v. First Coast Cardiovascular Inst., P.A., 252 So. 3d 287, 291-92 (Fla. 1st DCA 2018) (enforcing a five-mile, two-year non-compete prohibiting a doctor from providing or soliciting competing cardiovascular services); Healthcare Servs. of the Ozarks, Inc. v. Copeland, 198 S.W.3d 604, 613 (Mo. 2006) (finding that patients were a protectable interest and enforcing a non-compete against a home health care provider)). Courts also have held that hospitals have a legitimate interest in protecting confidential business information, such as patient lists, patient referral lists, and the hospital's investment in training its physicians (Cmty. Hosp. Grp., Inc. v. More, 869 A.2d 884, 897 (N.J. 2005) (enforcing a physician non-compete as modified to reduce the geographic scope)). Some courts have held that physician non-competes, while not per se unenforceable, require stricter scrutiny than employee non-competes in other industries because of strong public policy and ethical considerations (see, for example, Valley Med. Specialists v. Farber, 982 P.2d 1277, 1283 (Ariz. 1999) (finding that 'the doctor-patient relationship is special and entitled to unique protection' and holding that a pulmonologist's three-year non-compete for practicing medicine was unenforceable)). Non-Treatment Agreements Non-treatment agreements are another form of restriction imposed on health care practitioners' professional activities. Non-treatment agreements can be either stand-alone agreements or, more commonly, provisions within non-competes. They differ from non-solicits in that they prevent health care professionals from treating a former patient even if the patient requests continued treatment from that professional. Some states: Disfavor non-treatment provisions as a matter of public policy. For example, the Arizona Supreme Court held that a non-treatment clause prohibiting a physician from providing medical care or assistance to former patients for three years within five miles of any of the employer's offices was not reasonable. Among other reasons, the court stated that a patient's right to see the doctor of their choice is entitled to substantial protection and that the covenant violates public policy because of the sensitive and personal nature of the doctor-patient relationship. (Valley Med. Specialists v. Farber, 982 P.2d 1277, 1285 (Ariz. 1999).) Prohibit non-treatment provisions for certain types of patients. For example, Texas law requires restrictive covenants to provide that a physician will not be prohibited from providing continuing care and treatment to a specific patient or patients during the course of an acute illness even after the contract or employment has been terminated (Tex. Bus. & Com. Code Ann. § 15.50(b)(3)). Ethical Concerns With Physician Non-Competes In addition to the challenges of enforcing non-competes generally, imposing non-compete restrictions on physicians may raise ethical issues for practitioners. According to an American Medical Association (AMA) ethics opinion, non-competes 'restrict competition, can disrupt continuity of care, and may limit access to care.' The opinion states that: While the AMA ethics opinion may raise legitimate concerns about health care non-competes, it merely discourages, but does not prohibit, these agreements. Although a court tasked with deciding a contract dispute may consider the opinion as a factor when balancing the equities, the opinion is not legally binding. In addition to the challenges of enforcing non-competes generally, imposing non-compete restrictions on physicians may raise ethical issues for practitioners. According to an AMA ethics opinion, non-competes 'restrict competition, can disrupt continuity of care, and may limit access to care.' Most courts addressing the issue have not found that the AMA ethics opinion (or its predecessor versions) renders physician non-competes per se void (see, for example, Mohanty v. St. John Heart Clinic, S.C., 866 N.E.2d 85, 94 (Ill. 2006) (explaining that the opinion discourages but does not prohibit restrictive covenants in physician employment contracts, is not the equivalent of a statute or rule of professional conduct, and does not render physician non-competes per se void); see also Skaf v. Wy. Cardiopulmonary Servs., P.C., 495 P.3d 887, 897 (Wyo. 2021) (finding, before the state enacted a statutory ban, that nothing in the opinion renders physician non-competes per se void)). At least one court has relied on the AMA ethics opinion in concluding that most physician non-competes violate public policy (Murfreesboro Med. Clinic, P.A. v. Udom, 166 S.W.3d 674 (Tenn. 2005)). However, that case has been superseded by Tennessee's health care non-compete statute, which allows physician non-competes under certain circumstances (see Tennessee above). Other Considerations Regarding Health Care Non-Competes Several unique issues impact the use and enforceability of non-competes in the health care sector, including health care deserts, telemedicine, staffing agencies, and applications for injunctive relief. Health Care Deserts The use and enforcement of non-competes with health care professionals is further complicated when they restrict a physician's ability to provide services in a health care desert. Health care deserts (or medical deserts) are areas where access to health care services is limited. Patients may be unable to access the care they need or may experience long wait times between the request for an appointment and a consultation with a physician. This may be explained by any number of factors, such as: Scarcity of health professionals, particularly specialists, in a region. Limited health care facilities. Disproportionately high costs of access. A court tasked with determining the enforceability of a health care non-compete within a health care desert may consider public policy arguments regarding the effect, if any, of a non-compete on patients' access to medical care. For example, in Aesthetic Facial & Ocular Plastic Surgery Center, P.A. v. Zaldivar, the court held that a non-compete restricting a physician's practice of a sub-specialty of oculo-facial surgery was unenforceable as against public policy (826 S.E.2d 723, 728-30 (N.C. Ct. App. 2019)). In reaching this conclusion, the court evaluated the risk that the physician non-compete presented to the public by considering: The shortage of specialists in the field in the restricted area. The impact of establishing a monopoly in the restricted area, including fees and availability of doctors for emergencies. The public interest in having a choice in the selection of a physician. (Aesthetic Facial, 826 S.E.2d at 727.) Telemedicine E-commerce has made geographic boundaries less relevant for many businesses, including health care practices engaged in telemedicine. Telemedicine enables health care practitioners to provide diagnostic, treatment, and monitoring services to their patients remotely, often allowing patients to connect with physicians and other health care providers beyond the area or state where the patients reside. It is especially useful in providing greater access to treatment and services for individuals in health care deserts, such as rural or other traditionally underserved areas. (For more information, see Telehealth: Overview on Practical Law.) The use of telemedicine expanded dramatically during the COVID-19 pandemic and continues in the post-pandemic environment. The fact that physicians engaged in telemedicine may treat patients over a broader geographic area (potentially in multiple states) than in traditional medical practice raises practical and policy considerations when assessing the enforceability of non-competes. This is especially true regarding the reasonableness of a covenant's geographic scope and the application of appropriate state law. Employers and others drafting non-competes, non-solicits, and non-treatment agreements for health care professionals should consider the possibility that the workers subject to those restrictions may provide competitive services via telecommunication, rather than in person. For example, imagine a doctor who resigned from a position treating patients in person at a Virginia medical practice and who is subject to a post-employment non-compete that prevents the doctor from working for a competing practice or soliciting former patients within a designated region of Virginia. If the doctor lives in Maryland, it is unclear whether providing telemedicine services from Maryland to patients in Virginia would violate the non-compete. While there is little case law addressing the impact of the location of a telemedicine practice on the enforceability of non-competes, guidance from medical regulatory boards in the context of licensing requirements suggests that the location of the patient, rather than the physician, is likely to be controlling. For example, the Virginia Board of Medicine states: 'The practice of medicine occurs where the patient is located at the time telemedicine services are used, and insurers may issue reimbursements based on where the practitioner is located. Therefore, a practitioner must be licensed by, or under the jurisdiction of, the regulatory board of the state where the patient is located and the state where the practitioner is located.' (Virginia Board of Medicine Telemedicine, Guidance document 85-12 (revised June 24, 2021, effective Aug. 19, 2021); for a chart on telemedicine requirements for providers in all 50 states and the District of Columbia, see State Telehealth Requirements for Private Payors Chart on Practical Law.) Another issue to consider is the degree to which a telemedicine health care employer can enter into a reasonable non-compete or non-solicit with a physician who treats patients remotely over a broad geographic area. While the health care employer may have a legitimate business interest in restricting the physician from practicing anywhere the physician had treated patients, depending on the size and locations of the employer's roster of patients, a multi-state or nationwide restriction may be overly broad and unenforceable if it realistically prevents the physician from practicing medicine. Staffing Agencies Many hospital health care workers, such as nurses, anesthesiologists, and radiologists, are employed by employment or staffing agencies. These workers commonly enter into contracts with the staffing agencies that restrict them, for a specified time period after the contract's termination, from working for the agencies' clients (that is, the hospitals or other institutions where the workers perform medical services) or for competing agencies. Staffing agencies also often enter into agreements with hospitals and other client institutions prohibiting the institutions from directly hiring those workers for a specified time period following the termination of their employment with the agencies or their assignment with the client institutions. Some state statutes prohibit or limit the staffing agencies from entering into these agreements. For example, Iowa has a worker-friendly statute prohibiting a health care employment agency from entering into a contract with an agency worker or health care entity where the contract: Restricts the employment opportunities of an agency worker by including a non-compete provision. Requires the payment of liquidated damages, employment fees, or other compensation if the health care entity later hires an agency worker as a permanent employee. (Iowa Code Ann. § 135Q.2(3).) Kentucky has a similar statute regarding temporary direct care staff contracted with or employed by a health care services agency. It prohibits health care services agencies from: Restricting the employment opportunities of an agency employee, including by using contractual non-competes or buyout clauses. Requiring the payment of liquidated damages, employment fees, or other compensation if the institution where the agency employee worked later hires them as a permanent employee. (KRS 216.724.) Courts also have grappled with the issues raised by medical staffing agency non-competes. For example, in St. Joseph's Hospital Health Center v. American Anesthesiology of Syracuse, P.C., the plaintiff hospital sued staffing companies that had assigned their employees (anesthesiologists and nurse anesthetists) to the hospital. The hospital and staffing companies had entered into an agreement that prohibited the hospital, for two years after the termination of the agreement, from soliciting employees or taking action to cause employees to end their employment with the staffing companies. The staffing companies also had entered into non-competes with their employees. (2024 WL 4930688, at *1-2 (N.D.N.Y. Dec. 2, 2024).) After the hospital terminated the agreement, it extended employment offers to many staffing company employees, claiming that this action was necessary to hire enough anesthesiologists. The hospital sued the staffing companies, claiming that they engaged in antitrust violations (an unreasonable restraint of trade and unlawful monopolization). The staffing companies counterclaimed for breach of contract. The court denied the staffing companies' motion to dismiss the antitrust claims, advising the parties that non-competes and non-solicits would be carefully scrutinized and that public policy favors access to medical professionals. (St. Joseph's, 2024 WL 4930688, at *3-6; see also Magtoles v. United Staffing Registry, Inc., 665 F. Supp. 3d 326, 347-49 (E.D.N.Y. 2023) (refusing to enforce a staffing company's nationwide non-compete with nurses, noting that it would be 'plainly harmful to the general public if dozens of licensed nurses and practitioners were prohibited from contributing their services to an industry as valuable and important as nursing').) Applications for Injunctive Relief Non-compete litigation often involves applications to courts for injunctive relief, such as a temporary restraining order (TRO) or preliminary injunction (PI). Among the factors considered by the courts in granting or denying the requested relief is a balancing of the equities, namely, the harm to the employer if the court denies the relief weighed against the harm to the employees or the general public if the court grants it. In the case of health care non-competes, the public harm may be significant, especially in health care deserts and other less populated areas, because the court's order may impact patient choice and health care access. For example, parties seeking enforcement of restrictive covenants may seek a TRO or PI prohibiting medical professionals from engaging in the practice of medicine or a given specialty within a defined geographic region. This in turn may prevent these medical professionals from: Working for competitors or opening a new practice in the area. Soliciting their former patients. Treating their former patients and therefore disrupting continuity of care. Conversely, health care employers have legitimate business interests in protecting: In the case of health care non-competes, the public harm may be significant, especially in health care deserts and other less populated areas, because the court's order may impact patient choice and health care access. Many factors impact courts' decisions on applications for equitable relief involving health care non-competes. As with other non-competes, these determinations involve a fact-specific analysis. Courts may be more hesitant to grant injunctive relief regarding health care non-competes given the possible effects on patients' access to adequate health care (including specialty care) and patients' ability to see the medical professionals they choose. (For a collection of resources on injunctive relief generally, see Injunctive Relief Toolkit (Federal) on Practical Law.) Best Practices for Using and Enforcing Health Care Non-Competes For health care professionals and the entities that employ them, regulatory and policy issues may affect the enforceability of health care non-competes. These issues apply to non-competes entered into in connection with the purchase or sale of a medical practice, although these situations are often addressed by statute. The applicable laws vary widely across jurisdictions and are changing rapidly. Health care employers and their counsel should follow certain best practices when drafting, implementing, and enforcing non-competes. For example, they should: Continue to monitor changes in federal and state law that may affect health care non-competes, including changes to general non-compete laws in jurisdictions where health care non-competes are not specifically regulated, and consult with counsel for the latest developments. Implement annual reviews of health care non-competes to assess their continuing enforceability, and revise, replace, or revoke the non-competes as appropriate. Consider alternative protections for confidential information. Patient lists and other information can be protected as trade secrets or confidential information if the employer takes sufficient measures to preserve confidentiality, such as by: If considering litigation to enforce a health care non-compete, counsel should gather evidence, strategize, and realistically assess their chance of success before proceeding (for more on litigating restrictive covenant and trade secret cases, see Preparing for Non-Compete Litigation, Trade Secrets Litigation, and Employment Litigation: DTSA Claims on Practical Law).