Feature

Operating in the public interest?

Waiting times for appointments in many NHS specialties are increasing — yet the same consultants can be seen privately within a few days. John Yates asks why nobody seems interested in solving the problem

Surgeons, politicians and even managers claim that the needs of the patient always have the highest priority in their thinking. Politicians of all major parties support equality of access to healthcare. In its statement of primary values the Institute of Health Services Management argues that in making decisions and taking actions, managers and organisations should ‘strive for accessible and effective health care according to need’. The motto of the Royal College of Surgeons is ‘Skills for the benefit of all men’.

Recently all these professionals have been faced with evidence that ought to challenge their thinking and their action. In January this year the Channel 4 television Dispatches documentary and report Serving two masters argued that these three professional groups must urgently re-examine the system that they work in.¹ The research work presented was seen as controversial, both in the methods used and the results obtained, but within two months the Audit Commission had published a report which confirmed some of the findings.²

Data from these two studies, which investigated the activity of over 400 consultant surgeons in Britain, shows that they are now performing an average of five or six operations per week in the NHS. About a fifth of surgeons do three or less operations per week, the majority (three-fifths of surgeons) do four, five or six operations per week and the remaining fifth do seven or more per week. An examination of the actual time spent on each operation shows that the average time per operation is only a little over an hour. These results are not a surprise to many, given that few surgeons have access to more than three operating lists per week. The 10½ hours that these three lists provide have to be shared with junior staff and thus a consultant would routinely only have five or six hours personal operating time and four to five hours supervising his or her junior staff in theatre.

This evidence of a relatively low operative workload in the NHS does not sit easily with the following facts:

• Paying for a private outpatient appointment guarantees speedier access to healthcare than is available in the NHS. Specialties like orthopaedics and ophthalmology have an average waiting time in the NHS for an outpatient appointment of 20 to 25 weeks, whereas in the private sector it is one to two weeks. In orthopaedics, 96 per cent of patients seeking an outpatient consultation in the private sector receive one within one month, whereas in the NHS only seven per cent do so.
• Paying for private inpatient treatment guarantees speedier and more frequent admission to surgical beds. Although only 11 per cent of the population are covered by health insurance, 20 per cent of all elective (non-urgent) operations are now performed on private patients and for some operations, like hip replacement, as many as 30 per cent of the population now receive their healthcare privately. In recent years the proportion of the population covered by healthcare insurance has stabilised, but the proportion of operations which are private continues to rise.
• Some of the most commonly performed operations in this country are the subject of considerable dispute in the medical journals regarding the appropriateness of the surgery. For example, the gynaecological procedure dilation and curettage is the fourth most common procedure in Britain, and yet has been described in the British Medical Journal as ‘diagnostically inaccurate and therapeutically useless’.³ There are doubts about the effectiveness of five of the top ten most common procedures.
• The majority of surgeons are paid on a ‘maximum part-time contract’. Consultants are said to work a fifty hour week in the NHS and yet it appears that only 10 per cent of a consultant surgeon’s time is spent personally operating in the NHS. Surgeons commonly spend two or three half days per week in the private sector during the working day.

Politicians, surgeons and managers are reluctant to consider this evidence. A few retreat to the moral high ground, claiming that the criticisms are totally unjustified. They argue that the vast majority of surgeons are hard-working and spend many more hours working than their NHS contract requires. This defensive reaction comes with little convincing evidence. In the main, it is merely asserted that the contrary evidence collected by researchers and auditors is inaccurate, unrepresentative or out of date. The majority of the medical profession, politicians and managers are more subdued in their response.

For example, the BMA and the Hospital Consultants and Specialists Association argue that one can interpret the regulations and advice about job plans and consultant contracts in such a way that consultants can legitimately spend up to four half days per week working in the private sector. This argument is made despite the fact that those same regulations state consultants should devote ‘substantially the whole of their time’ to the NHS and give it priority on all occasions. The medical profession emphasises the low level of health care expenditure in Britain, which leaves the UK with less doctors per population than most other European countries. They describe the enormous problems arising from financial shortages and show that surgeons are frequently not given the resources to enable them to do the job. The medical profession point the finger at politicians and managers.

In turn, managers feel constrained by professional advice and financial difficulties. Professional advice often suggests that there should only be two or three operating lists per week (e.g. ophthalmology, ENT, trauma and orthopaedics), and financial constraints mean that managers are often unable to offer even the number of operating lists recommended by the professional body. Managers are reluctant to examine the workload of individual surgeons, and often do not know the level of activity performed by individuals. They lack clear guidance on contractual rules and see the problem as lying with the medical profession and the politicians.

Lastly, politicians and civil servants argue that these problems are not to be tackled by the Department of Health. They are issues that should be handled by trusts, in negotiation with the profession. The level of resources provided are greater than ever before, the number of surgeons in post are higher than ever before and these issues should be dealt with locally by doctors and managers.

Whichever group is approached, it points the finger elsewhere. The patient and the Treasury are left on the outside, bemused by the fact that the surgical services on offer in the country too often give priority to those who can afford to pay (with due acknowledgement to the improvement in long waiting times for inpatient admission), and that we seem to be making so little use in the operating theatres of some of the most highly trained surgical personnel in the world.

Hundreds of surgeons are now doing four or less operations per week and hundreds of surgeons are routinely spending three or more sessions per week in the private sector while on maximum part-time contracts. There is some overlap between the two groups, but they are no by no means identical. Is it unreasonable to suggest that this evidence is sufficient to call for an independent inquiry to examine whether there is a problem and to establish the size of that problem? The reluctance of politicians, managers and the medical profession to agree to such an inquiry inevitably creates the suspicion that they have something to hide.