Published: 10/01/2001, Volume 112, No. 5787 Page 30 31
The term 'public-private partnership' represents a relatively new concept for the health service.
Some would credit it to New Labour, while others would date it to the Thatcherite revolution. In fact, it was probably invented by Old Labour. It appeared at the time when Aneurin Bevan was negotiating with doctors about the design of the NHS. Despite the tide of emotion concerning the establishment of a service 'free at the point of delivery', the 1946 legislation provided a very diluted version of the high ideals of equity. From the outset the NHS has allowed its hospitals to charge for private healthcare, and permitted its consultants to undertake private work in both NHS and private hospitals. In effect it established in law a public-private partnership, but in so doing produced an inherent conflict of interests.
As a result of the 1946 version of 'partnership', maximum part-time surgeons have contracts that require them to 'devote substantially the whole of their time to the NHS', yet permit them uncontrolled activity in the private sector. On the basis of current legislation and regulations, consultants are required to have between five and seven fixed sessions a week in the NHS. The schedule in figure 1 conforms to those rules and to professional advice. On alternate weeks there are either five or six sessions devoted to operating, outpatient clinics or ward rounds.
The blanks in the schedule are for flexible commitments such as training, teaching, research, clinical audit, management, administration, committee work and on-call rota requirements. The flexible commitments, however, do not necessarily need to take place on weekday mornings and afternoons, and many consultants perform some of these duties in the evening and at weekends. This is particularly the case for those who also undertake private practice during the normal working day.
The schedule in figure 1 is based on the timetable of a surgeon who chooses to fill all of the blank spaces with private work. Such a high level of private practice inevitably results in very long working hours or the sacrifice of some NHS activity.
The conflict of interest underlying this schedule can be best illustrated by comparing possible earnings in the two parts of the week. For the five to six fixed NHS sessions and the additional flexible commitments, a maximum part-time surgeon will receive a basic salary of£50,810 to£66,120 per year with discretionary points that could take the earnings to£87,280. A few might also have additional distinction awards. For the four to five sessions spent in the private sector, some surgeons tell me that they have an annual income of£250,000. Once established in private practice, there is little incentive for a surgeon to give up a private practice session to perform an extra NHS operating list for no additional reward.
This case study is an example of working practice for one individual, but how typical is it of all surgeons?
Given the enormous waiting times faced by orthopaedic patients, a number of studies have been undertaken to gather information about the balance between NHS and private sector activity. Private sector data in the past has been difficult to obtain, but has become easier with the introduction of Internet sites which provide such information. Selecting the 242 surgeons who were listed as working in the 15 shortest-wait and the 15 longest-wait trusts in England, we can see that:
ninformation on private-rooms sessions was available for 132 of the 242 consultants selected.
these 132 consultants offered an average of two rooms-sessions per week in the working day, ranging from nought to six sessions (see figure 2).
sessional commitment to rooms was slightly higher in long-wait trusts (2.1) than in short-wait trusts (1.8).
Note that the consultants with four, five and six sessions per week may have had part-time contracts.
The results were very similar to three others studies (figure 3), and it is interesting to see that in the past few years commitment to working-day private practice has increased in both England and Wales.
Most of these studies simply collected information about time spent in private consulting rooms only, as data for operating time was difficult to gather.
But the 2001 Welsh study reported on the Welsh S4C current affairs programme Y Byd ar Bedwar followed up the web search with telephone enquiries about operating sessions.
Just over half of the secretaries contacted were able to answer the query and in every case they stated that private operating sessions were held during normal working hours, Monday to Friday. It confirms previous research findings that where two or more sessions per week are devoted to private-rooms sessions there is usually one additional session a week of private operating time. In orthopaedics it appears that, on average, three out of 10 available weekday sessions are devoted to private practice, and consequently NHS flexible commitments must be forced into evenings and weekends. Is this the best time to undertake teaching, training, audit, and so on?
Work in the private sector is yet another factor (along with reduced doctors' hours, shortage of resources etc) contributing to the reduction in NHS productivity. While more time is being devoted to private practice, productivity in terms of new outpatients and finished consultant episodes per consultant continues to fall - and there is no improvement in NHS waiting times.
Last month this column suggested that a radical change in government policy would be needed if waiting-time targets were to be met. The government's latest proposal is certainly radical. It offers patients who have waited over six months for an operation the opportunity to have their surgery in the private sector. Some practical details need to be ironed out. Is there sufficient spare capacity in the private sector? Which surgeons will be performing the surgery? How can we be sure they are given adequate resources to enable them to do a full week's operating in the NHS before they move across to the private sector? Without tight control, the proposals are in danger of simply transferring activity from the NHS to the private sector, at overall increased expense, with decreasing NHS efficiency.
Politicians, surgeons and managers tell us that the NHS has more money, more audit, more teaching, more patient choice, higher salaries and shorter working hours. All that the patients see is increasing evidence that waiting times are worse now than in March 2001. If we are going to have yet another 'public-private partnership', can we please ensure that extra funding for the NHS and its surgeons is tied not simply to treating more patients, but to increased productivity and reduced waiting times?
Professor John Yates is director of inter-authority comparisons and consultancy at Birmingham University's health services management centre.