News from nowhere

The concordat between the NHS and commercial medicine may be necessary and useful, but it conceals as much as it clarifies. At waiting list level what matters is the micro-economics of private practice, because that determines both the backlog of work and the commercial sector’s capacity to meet NHS demand.

But the reality of private practice is carefully hidden behind professionals’ insistence on ‘freedom’ and managers’ fear of rocking the boat. NfN moles have been burrowing away beneath the camouflage, and have brought succulent morsels to the surface.

The reluctance of surgeons to clear waiting lists because this will reduce the size of their private income – easily £20-40,000 extra a year in most parts of the UK, and up to £70,000 on top of the NHS salary for the most successful – is well known. Less public are the cartel arrangements that reduce the flexibility of local hospitals in meeting demand, and the ways in which appointment of new specialists is influenced to minimise market disturbance.

Flexible working in surgery becomes a problem for hospital managers when surgeons refuse to work with anaesthetists in training, or those in staff grade or associate specialist posts, insisting instead on specific consultants. These are the consultants with whom they are likely to work in the local private hospital, so the bond is maintained by both parties. Since anaesthetists and surgeons control their own work rotas in most hospitals, managers are unable to deploy staff to maximise activity.

The growing backlog of NHS work needs to be done, so more specialists are hired. Those in post cannot easily prevent new appointments that might dilute their private practice, but they can influence the choice of candidate or the working practices of the newcomer. Appointing a weak candidate to a new post is one way to delegate the routine NHS work while minimising the impact on the local economy of commercial medicine. New anaesthetists may find their rotas controlled by the incumbents, who ensure that they don’t get to work with the surgeons who supply private cases.

Hospital managers know all this, but usually feel powerless to do anything about it. Sensibly enough, they keep quiet about what could be a major embarrassment. Not so the Modernisation Agency and the other new quangos tasked with shaking up the NHS. Sooner or later they will have to confront the restrictive practices of surgeons and anaesthetists, so watch out for the coming assault on professional misconduct – after the general election, no doubt.

Commercial medicine even touches the Alder Hey scandal, not because of the sale of body parts, but because NHS post-mortems are hard to come by. NHS pathologists are hard at work dealing with tissue samples from surgery, and seem unwilling to undertake post-mortem work – unless they are Coroners’ post-mortems, which attract a fee, of course.

The Department of Health listed successful bids for Personal Medical Services pilot status in a press release in mid December 2000, but at least one region did not inform the relevant Primary Care Groups for four weeks. Fortunately the BMA told the general practices involved, taking the opportunity to warn them of the risks they were taking. So this is what is meant by the ‘command and control’ structure of the NHS! Sadly the BMA did not warn GPs about one immediate risk – being kept out of the picture by an incompetent administration.