Published: 04/04/2002, Volume II2, No. 5799 Page 25
Long waiting times in any single location are traditionally explained by one or more of five factors: inaccurate and unvalidated lists, shortage of resources, inefficient use of resources, inappropriate referral or admission criteria and the potential conflict of interest for consultants working in the private sector and the NHS. The government is trying to address most of these issues, though the proposal to stop consultants doing private practice for the first seven years of their careers has met fierce opposition.
Negotiations on the consultants' contract continue in traditional trade union versus employer mode - behind closed doors, leaving most interested parties in the dark. Bureaucrats try to produce an acceptable package that costs the Treasury the minimum, promises the earth and ensures that few people lose face.
The British Medical Association's negotiators take an unashamedly partisan stance. 'Our priority is to get it right for consultants, ' they told Hospital Doctor on 14 March. The danger is that the outcome will be like 1948, when the consultant contract was created, and its revision in 1990, when job plans were introduced. In both cases, the resulting contract did little for the equitable treatment of patients. The rich still get treated before the poor.
In recent years, time spent on clinical work has come under increased pressure. Reductions in direct clinical time are brought about by the need to fill the week with important, but clinically indirect, activity. Research, teaching, clinical governance, audit and management have to be squeezed into the week, but mean working longer hours or a decrease in clinical time. Add private practice work, and the week becomes very long or NHS clinical commitments are squeezed even further.
Coupled with the fact that the NHS frequently fails to provide surgeons with one or more key resources (theatre lists, support staff or hospital beds), the result is a decrease in clinical time per consultant and, in some specialties, a fall in productivity as measured by the number of patients treated per surgical firm.
Younger consultants, in fairness to their families, sanity and many private patients' wishes, are less and less prepared to work in the private sector at weekends.
Their private practice mainly occurs on weekday mornings and afternoons. Little wonder that the secretary of state favours restricting consultants to no private practice for the first seven years of their career.
From the consultants' point of view, this would cause a serious loss of potential income. Those who are forced, or choose, to decline the private-practice option will deserve and need a substantial pay award.
An alternative to the seven-year option is to restrict private practice to out-of-hours - at times not set aside for teaching, research, audit and the recovery time required after strenuous on-call duties. Hospital consultants work in a technically and intellectually complex environment. They can no longer 'leave the day job' for one or two days a week to earn extra revenue elsewhere. Professionals should be paid properly and fairly and commit themselves to their critical role in delivering a service to patients, regardless of their incomes. Those who wish to work in the private sector should be free to do so, but only by leaving the NHS or working in the evenings and at weekends.
While the negotiations continue, patients' needs appear completely ignored, though their taxes pay the wages of the doctors and managers who continue to fail to deliver an equitable service. To reduce waiting times, the current two-sided debate may have to include the third, most important, party. Currently patients are only heard through the occasional intervention of politicians, who have made some interesting promises. First, they say, the NHS is going to receive performance-changing sums of money.
Second, they are committed to equitable access and third, there are going to be radical reductions in waiting times. A contract is needed that commits three sides rather than two (see table).
Professor John Yates is director of inter-authority comparisons and consultancy at Birmingham University's health services management centre.