Saturday, 9 April 2016

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:
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. 

I thank Joe for his contribution to this blogsite. 


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