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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My mini e-book 'Standardised Management Conversation' is available - click http://www.amazon.co.uk/Standardised-Management-Conversation-Hemadri-ebook/dp/B018AWBJTU 
till 31 December 2016 all my earnings from the sale of this book will be donated to charity  http://successinhealthcare.blogspot.co.uk/2015/11/standardised-management-conversation.html

Warning: Legality could be injurious to health

This particular blog post is fictional. Any resemblances to any person living or dead or incidents current or historical are purely coincidental.

Warning: Legality could be injurious to health

It was the saddest day of his life.

Let us start from the beginning. Bill was a brilliant student at A levels, he was also a stickler for formality, rules and process. This stood him well and he was very highly thought of as a scrupulous, proper, law abiding young man. He went on to study medicine, completed junior general training and got into specialty training – all very smoothly. His specialty also involved working in the operating theatres.

Bill found within a few weeks of into his registrar job that his work never ever finished at 5 pm.  Bill being Bill, thought he will simply leave at 5 pm as long as there was no patient he was directly dealing with was acutely ill. He did that for a week. Bill then found his training was getting adversely affected. Consultant ward rounds continued after 5 pm, if he did not join in he cannot learn. Patients for elective surgery were admitted after 5 pm, if he did not see them he will not be ready for them for the next day. Theatres routinely over ran easily to 7 pm sometimes longer, if he was not there he will lose out on the training.

Bill discussed this with his consultants who looked at him as though he was an alien zombie. When he insisted on resolution they told Bill that he is free to leave at 5 pm if he wished to do so, some of them insisted that he leave at 5 pm so that he did not breach his hours. Bill’s logical argument was very simple, substantial training happened after 5 pm so to take consultants’ advice and leave at 5 pm means that he will never get the training he deserved. So Bill refused to leave on the grounds of training needs and claimed payment for extra time on the basis of actual time spent working at the hospitals. Boy, this was resisted by the management. Bill was born different, his documentation was perfect, they had no choice but to pay him. The managers gave the consultants a hard time because of this issue; the consultants did not take it lightly.

The time came to ‘assess’ and ‘report’ on Bill which were used at annual progress meetings. These used to be called RITAs before now called ARCPs. Bill’s numbers, performance, success rates, patient feedback and anything clinical were spot on average. Bill’s consultant reports were full of masked vitriol on how his attitude, behaviour, cooperation, et al were not compatible with a surgical career. This was pointed out to him and he made tremendous efforts to improve. Every time he was assessed externally he had no issues on any of the ‘soft skills’ assessments. But he would not stop claiming for staying after contracted hours. Every hospital that made him work after 5 pm paid up; the consultants from the hospital wrote badly about his approach to life.

After 6 years of completed training with same average clinical rating as his peer group, Bill was denied his completion of training certificate due to five reports that faulted his attitude. Bill cannot get into the specialist register; Bill cannot be a substantive consultant in the NHS. His colleagues with his level of performance and achievement and some with lesser performance and achievement were signed off.

All because he followed the country’s law and the NHS rules. The message his colleagues got from their seniors was that people who followed the law can be severely, career damagingly punished. The message other trainers and managers got was that they can break the rules and law with impunity and use their power to penalise the person who caught them out. Bill can go to employment tribunals and the like but when he has at least half a dozen consultants who have already written badly and a dozen managers willing to write badly – he faces a lost cause. In a world where the subjective decimates the objective - he is a lost soul.

Has he learned his lessons that legal and rule based behaviour does not win and not submitting to the whims of the powerful was harmful? We do not know yet. This sounds like a case of operation successful, patient died; only here it will be training successful, career died. Bill hit the target, its the ricochet and the debris that maimed him.

Bill is at a crossroad waiting to change careers.

Oh by the way he also happens to belong to a minority ethnic group.

I think this quote from John le Carre (in his book The Constant Gardener) will probably be very appropriate here "Nobody in this story, and no outfit or corporation, thank God, is based upon an actual person or outfit in the real world. But I can tell you this; as my journey through the pharmaceutical jungle progressed, I came to realize that, by comparison with the reality, my story was as tame as a holiday postcard."

©M HEMADRI 

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PS: The loose ends such as throwing in the ethnic minority, etc are there to be filled in, if and when I get to write this story in full

Examinations for doctors - time to think differently

I wrote the article below in 2006. I was not blogging at that time so it just lived in my computer. When you read it please be in a 2006 frame of mind. The article 14, the new rules for surgical exit exam, the impeding new contracts for doctors especially for SAS doctors and so on.

Once you have read it, cross reference it to the recent GP exam results.

We need an end to the monopoly of examination providers for post-graduate doctors. We need a plurality of avenues to demonstrate knowledge.  Why should every university in UK not have a knowledge test for specialist doctors?

The link to the intercollegiate website cited in the article will not work, you may want to search their website for the current link or otherwise check with them.

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THE EXIT EXAMINATIONS: IS IT TIME TO HAVE A DIFFERENT THINKING?

The surgical royal colleges have decided to allow any candidate who is able to muster the references of two consultant surgeons to take the intercollegiate exit examination. The colleges would see this as a response to the changes in the rules that have happened due the PMETB to allow a fair opportunity to anyone who wants to demonstrate their proficiency in surgical knowledge. The General and Specialist Medical Practise Order that created the PMETB was passed in April 2003 and there have been wide consultations before and since. It has taken three years to arrange a new format which is likely to change again very soon, in view of the MMC reforms.

While it is clear that the 'standard of knowledge' should be the same for surgeons entering the specialist register one has to question if the actual examination should also be the same. Whether different formats for differing groups/sub-specialties were considered is not known. Whether any surgeons who are not in training were consulted before these changes is not known. If any of the 'mediated entry' candidates who have taken these examinations in the past were consulted is not known. A close look seems to reveal the need to have some radical, new and different thinking about who should take which examinations and who should offer them.

HISTORY OF WHO PASSED AND WHO FAILED

The point about consulting the past candidates is rather important. The evidence for the importance lies in the figures available in the Intercollegiate Speciality Boards website (http://www.intercollegiate.org.uk/html/results.html) where between 1998 and 2001 the overall pass rates in the intercollegiate surgical exit examinations was 70% for mediated entry candidates, 76% for type two trainees and 96% for type one trainees. We should keep aside the issue of mediated entry candidates for just a moment and look at the glaring difference of pass rate between type 1 and type 2 trainees. Most type two trainees worked to similar rotas in similar hospitals with similar consultants and mostly for similar number of years. Some differences do exist in their pathways such as type one trainees spending more time in teaching hospitals and type one trainees having experience in some research, while many type 2 trainees also have such exposure not all of them do. Opportunities for courses, learning etc are all similar. However, when it comes to examinations type 2 trainees did not do well. It begs many obvious questions, the foremost of which is why trainees with such similar pathways did not fare similarly at the examinations. If type 2 surgical trainees had equivalent training to type 1 trainees, as an admission to the examination implied till recently, why did they not do well? If we accept that the examination was a true reflection of their training and knowledge then was the process that selected them was wrong? If we accept that their pathways were not as similar as described here then why were they allowed into the examination on the basis of ‘end of training’ ‘exit’ examination? Knowing that type 2 candidates fared badly what changes were made to address that situation? If they were genuinely poor why were they selected into specialist registrar posts, if they continued to be poor why were they not stopped from progressing through their training which enabled them to take the examination?

When so many questions exist in the issue of type 2 registrars, there are even more for mediated entry candidates of the past and especially possibly for non-training post holding candidates of the future.

THE DEBATE IS INTERNATIONAL AND ABOUT THE FUTURE

The debate is not simply about the present UK based SAS doctors, FTTA, LAT and LAS posts who intend to take these examinations under the new regulations. The future also demands some answers. Some of the colleges have taken upon themselves to hold these examinations in many parts of the world. The demand for such examinations exists. Would the colleges allow non-training doctors from abroad to sit the intercollegiate exit examinations? This opens an even wider debate whether surgeons not in non-training posts from anywhere in the world would be allowed entry in to the specialist register partly on the basis of a test of knowledge that UK Royal Colleges offered. That is not to say that such surgeons should not be allowed but to wonder if the GMC, PMETB and royal colleges have the resources to probe the credentials of such candidates so thoroughly that the British public can be assured of quality in real time practise and not success in a paper work exercise. Perhaps the easy way out is to ‘rule’ on application, that the applicant is in need of further training, which is in reality will be difficult and expensive to challenge by overseas applicants.

INTENTION VS REALITY

The law in the form of the PMETB rules allows for various types of demonstration of knowledge, specifically to enable a variety of suitable candidates to enter the specialist register. The surgical colleges instead of taking the cue and innovating, have changed the entry criteria and the format to allow non-training surgeons to sit the same examination. Instead of exploring and enabling diversity that the law demanded the situation is now quite simply similar to tying the hands of a challenger and then putting him into the boxing ring. The example of an SAS doing excellent breast work for years taking the exit examination as an opportunity and achieving a predictable failure can be foreseen very clearly. To state that it is the responsibility of the candidate to ready themselves in all aspects before appearing for the examination sounds very reasonable but in reality very cynical. To then retrain the candidate due to a PMETB refusal or an examination failure and on the successful completion of 'training' and/or 'examination' only to be employed to the same job but possibly a higher title seems bad logic and an extreme waste of resources.

There is also a general perception that the current format of the new examination could be interpreted as being that of a different standard than the recently expired one. There is a suspicion that the goal posts are set differently in preparation for the MMC changes.

MONOPOLY

In the UK there is only one form of test of knowledge. There is only one body that provides it. This situation may be appreciated as offering uniformity. On the other hand it could also be considered as a monopoly of provision. The general view of monopolistic provision is that it is unhealthy. The intercollegiate format could also be perceived as cartelisation of sorts. The reality of a very small number of people involved in taking these examinations may prevent such a thought stream from developing into meaningful progress.

Surely the royal colleges have huge experience in designing examinations and though a challenge could devise a range of 'fit for purpose' examinations which would be of equivalent standards to enter the specialist register. The law allows it though does not require the colleges to do so. Coming from a different angle would it not be logical to wonder why a breast specialist has not taken a specific exit examination in breast surgery and so on? The urologist does.

More and more of assessments are being delegated and devolved to local deaneries who then sub-delegate to individual trusts and consultants in the form of in the work place assessments. As a logical futuristic extension some consideration may be given to decentralising the test of knowledge to be provided by a range of alternative providers. This may be not only a great market opportunity but also an opportunity to demonstrate leadership and vision, for universities and private educational systems to device such tailored high standard tests of knowledge as they have already done in the CME/CPD areas.

CONCLUSION

No one argues the need for good knowledge before entering the specialist register; it is no doubt a must. The entire debate is about the demonstration of that knowledge. The intercollegiate surgical exit examination is one of them but it is probably suited only for the current type one trainees. That examination's suitability for others including type 2 trainees and their derivatives, the future MMC defined ST post holders, SAS surgeons, MMC generated non-training post holding surgeons, overseas non-training post holding surgeons is unclear, though many will take it due to lack of alternatives. There may also be reluctance on the part of the ‘higher’ authorities to accept alternatives.

It is time to realise that 'similar' and 'equivalent' do not have to mean doing the same things or taking the same examinations. It is possibly the time to wonder about the paucity of alternatives to demonstrate knowledge. With the large increase in the number of medical students and the possibility of expansion of ‘consultant’ numbers, it is time for the good and great of the medical profession, though the surgical example is illustrated here, to lead in thinking, policy and practise rather than to react and respond as shown repeatedly with some of the glowing examples such as Calman, EWTD, PMETB and MMC amongst many others, with many issues arising from them still remaining unresolved.

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©M HEMADRI 

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