A View of the NHS from the private sector health care

A View of the NHS from the private sector health care - A Personal Perspective:

by 

Joe Karthikappallil

Whenever there are more than one solution to solve one problem  its safe to assume that  none works satisfactorily .

Healthcare for all free at the point of delivery is a commendable dogma which has made the UK a privileged population.  The staff including doctors who are appointed to the NHS enjoy reliable employment with a decent pension provision and great  perks with no pressure, obligation, or motivation to a  target orientated work ethic or to eliminate the waiting list of patients - apart from their goodwill.  

My experiences in the NHS are limited to ophthalmology and it would be reasonable to limit my comments to this speciality. Others may be able to comment on their speciality.  Lengthy waiting lists in Ophthalmology in the 90s and 00   were the result of a healthcare monopoly. Lack of competition and assured employment caused the incumbent surgeons to become inefficient. The result, lack of essential healthcare for the needy. 

Monopoly kills competition and stifles viable alternatives. Lack of competition causes creeping inefficiencies. Choice is important to maintain efficiency and keep costs down. Capitalistic market forces are not ideal but it delivers results. Private healthcare had to be roped in to reduce the massive waiting times in a fully funded NHS. How this could be achieved was a lesson that the NHS needed to learn.

The private sector quickly realised that efficient use of surgeons who are an expensive and scarce resource is key – something the NHS has still not taken any notice of. Five days a week and sometimes more - surgeons were utilised to perform surgical operations.

All other activity involved in the patient pathway could be serviced by staff who were trained e.g. preoperative assessment, biometry preparing the patient for operation, consenting and all postoperative care. This was a concept which the NHS was resistant to. Doctors were involved in organising all the above activity.

It was customary for all cataract surgeries to be performed under GA in the NHS whereas surgeons elsewhere were performing the same surgeries under topical anaesthesia. Compared to an average NHS list of 4 to 5 patient who required inpatient care due to GA, the private sector could treat 25 cataracts without anaesthesia cover as outpatient procedure. These efficiencies were lacking in the NHS due to the lack of competition.

A huge outcry was raised by the incumbent surgeons pointing out safety and cherry picking of patients. But evidence based medicine and audit of the outcomes paid put to these baseless allegations.  Kicking and screaming, efficiency in the NHS was improved.

Today the constant threat of funding following the patient compels the NHS to find efficiencies and failing surgeons and departments are shut or amalgamated.

The NHS is a monolith as far as procurement is concerned. Huge efficiency can be achieved if standardisation of use of capex products. In Ophthalmology departments the number of high tech equipments purchased and serviced runs in to billions of pounds.

The private sector buys standard equipments in large orders and thus drive prices down form suppliers. For instance the lenses and surgical instruments used in cataract surgeries, eye drops used can be standardised and prices can be a fraction of the current price if all orders are generated centrally. Similarly servicing charges for equipments are enormous and could be mitigated by  a dedicated NHS team of service engineers  - the private sectors do this currently.

These are just a few ways efficiencies of scale can be achieved. To the trained eye the NHS seems to be riddled with inefficiencies and in this age of technology, where there is a will, a way can easily be found. This is a relentless everyday process of discovering and upgrading efficiency.

In various other fields of British life, partnership between the private sector and the public sector is acceptable. The famous nuclear deterrent of the cold war was built on private public partnership.

There are build and operate private and public enterprise in constructing  hospitals  but not  healthcare delivery systems.

Not long ago NICE came along with recommendations regarding laser vision correction that made a mockery of available evidence base. All it achieved was a loss of credibility and a diminished its status as an institute of excellence. To lay out clear guidelines to the effect that although there is clear evidence to suggest that laser vision correction for myopia and hyperopia which is safe and effective there is no case for this to be available on the NHS would have been an elegant  stance to take. 

Such procedures  are performed and the public who have done their research are availing of such services but the animosity that this generates between the  surgeon community each trying to  undermine the other is unbecoming of an  erudite community of health professionals.

Aneurin Bevan in 1946 conceived and dedicated to the nation the NHS on the premise that services were provided free at the point of use. Advances in technology, extension of life expectancy, changes in the nation’s demographics and the longest recession in living memory are some of the forces testing the resolve of the British Isles - it is a challenge if such a health service or any health service conceived on the premise of free delivery at the point of care can endure any longer.

The people of the nation, if not the politicians are determined, that the NHS, the envy of the rest of the world shall endure. Take care of the pennies the pound will take care of itself. You shall find efficiency or efficiency shall be thrust upon you. A strong resolve alone is not sufficient to ensure that this generation and many generations to come shall continue to benefit from the high ideals of our fore-fathers.

Author of this post:

Joe Karthikappallil, FRCS Ophthal, is a consultant ophthalmologist in the private sector working in the northwest of England. The views expressed are his personal views and does not represent the views of any organisation, individual, associates, businesses, etc. 

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I thank Joe for his contribution to this blogsite. 

M. HEMADRI

©M HEMADRI

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Deliberate Redundancy and Intelligent Management

DELIBERATE REDUNDANCY AND INTELLIGENT MANAGEMENT MAY BE THE NATURAL WAY FORWARD FOR HEALTHCARE SYSTEMS 


Redundancy (slack in the system) is normal in the human body. Nature has provided the human body far too much capacity than what is needed for day to day living. Most of the capability of the human body lies unused for most of the time. Human anatomy is full of many muscles all doing small parts of the same movement and/or many muscles doing same or nearly same movements. There is often two of many organs. Two eyes may be needed for depth perception but two nostrils, two breasts, two ovaries, two testicles cannot be explained within the logic of efficient systems. It is also not just the anatomy, the way the anatomy works also reflects enormous over capacity of human systems. About one eighth of the kidney or one seventh of the liver is adequate for normal living. Similarly much lesser length of colon or much lesser sperm counts will still be abundantly compatible with digestion or reproduction. The scope of the surplus is truly amazing, for instance every part of the body is pain and pressure sensitive – we are used to it but is that needed or if we were building a system would we not consider that as wasted resource. There are many ways of providing energy and and many ways to eliminate end products. Well amazing is probably and understatement.

It is normal for the human body to have excessive capacity with only part utilisation at most times - i.e. functioning as though it was an inefficient system for the majority of the time. Even after doing so the human system needs significant amounts of rest and recovery at regular intervals at low utilisation levels and certainly much higher rest and recovery when systems are stressed (achy muscles and joints even after exercise and worse effects after fever, or surgery etc)

Interestingly that is how the rest of the nature is. There is more water than needed, more sun than needed, more air than needed, one could even argue that there is more food than needed (though it is distributed unevenly and too much is wasted).


My argument is that such a pattern is actually essential for healthcare systems. There is a lesson for healthcare professionals on how to manage healthcare systems which care for redundantly built humans. We should not be averse to a system with significant redundancy deliberately built into it and managed intelligently.



High reliability, high efficiency, narrow variation is valid for system architecture, system performance and output delivery in mechanised or electronic or technology based systems (i.e. machines). Humans dealing with healthcare will almost never be high reliability, high efficiency or narrow variation - they only give the impression of being so. In other words healthcare systems with human beings showing high 'efficiency' may well turn out quite simply to be an illusion. It is simply anti-natural, anti-anatomical, anti-physiological and anti-biochemical - humans are not built to perform that way. Well, most of the humans anyway with the few exceptions of outliers such as high end sports persons, highly narrow specialists, etc – even they need much 'down' time.




However, it is imperative to insist that a high redundancy system simply cannot mean that delivery, output and/or outcome can be all over the place in healthcare - that would to put it simply - kill the ill; apart from causing significant morbidity.



So while the overall infrastructure is 'poor' by technology standards the output performance by humans delivering healthcare has to be pretty slick. A 'poor' 'system' (with high level of redundancy/slack, over-capacity and similar) has to deliver 'great' results. That is exactly what the human body does for us human beings - poor 'systems' delivering 'great' results.



That can only be done by building deliberate redundancy, planned slack in the system, over-capacity by design with specific high intelligence management. A large system which only uses small parts of it most of the time to deliver great results. A large system which kicks in fully only occasionally to cope with specific pressures and then goes to rest again. A large system that under extreme crisis shuts off most of its activity and concentrates on the vital few to survive and once it survives goes back to its normal (for human) inefficient (as per technology definitions) self.

This will require a completely contrary understanding to the one that we currently possess, We will need a new kind of intelligent management that may be non-existent right now. We need to learn from nature about the need for redundancy and over-capacity to live a normal life. Any one who is unable or refuses to learn from nature will be defeated by it – we cannot afford that in healthcare as our failure will affect our patients more than us.

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