APPENDIX 8
Memorandum by Professor Donald Light (CC16)
TESTIMONY ON ITS INQUIRY INTO CONSULTANTS'
CONTRACTS
I am writing this testimony as an international
expert on waiting lists and an advocate of private practice. Every
patient in a health care system should have the right to seek
private services of consultants, GPs, nurses, and other clinicians.
Such services should be supplementary to a nation's national health
service, however, and they should not be organised in ways that
invite manipulation or exploitation of the NHS or its patients.
When in the UK, I have used private services, and there are many
reasons for doing so; but it should be between consenting adults
over and above the services of the NHS.
There are few, if any, scientific studies on
the "accountability, effectiveness and efficiency" of
the NHS consultants' contracts that would pass the research standards
that would be applied to other human activities, because so much
of what consultants do cannot be observed or their effects well
measured. British consultants have made it extremely difficult
to observe and measure what they do, so that terms like "effectiveness"
and especially "efficiency" are nearly impossible to
apply to their work. The point is that, aside from the careful
work of a few researchers, like John Yates, who can provide Members
of Parliament with some basic counts of hours and the like, the
Committee and MPs should focus their stated charge on the structural
effects, accountability and impact on the NHS. If you do not,
you will end up by calling for more empirical studies, like the
ones called for time and again over the past 15 years, thereby
not making a clear structural decision about the terms on which
the Government and the nation want to engage the services of medical
specialists. And if you call for more studies, the researchers
will do their best, but under very unfavourable circumstances
of little access to what consultants actually do and say, and
of poor data on effects and impacts.
Parliament and the Government can steer behaviour
through setting rules, contract and regulations. Therefore, the
questions which the Health Committee has set for itself are best
approached (and can largely be only approached) from a structural
point of view: are the consultants' contracts designed to provide
substantial or optional levels of accountability and effectiveness?
(Efficiency cannot be determined until one states one's goals:
"Efficient for what? To what ends?") Do the contracts
set the right terms for the desired impact on the NHS?
The NHS consultants' contracts are a formalised
version of a gentlemen's agreement. They set a low level of fixed
sessions and work done and a low level of accountability. Effectiveness
is, to my knowledge, not addressed at all. Given the steady stream
of revelations of dangerously low and tragic quality or effectiveness
since the Bristol case, and given that lack of accountability
has lain at the heart of most of these cases, the Committee and
Parliament may want to alter the contracts in these regards. If
they do, there is extensive experience and evidence in the United
States about types of contracts with specialists, how well or
poorly they work, and what kinds of changes in clinical work they
entail. The Committee and Parliament may want to draw on this
considerable body of material.
Behind these issues, behind the large variations
in how doctors with the same training treat similar patients,
and behind large variations in quality and cost is a paradigm
shift in professionalism. American purchasers concluded about
20 years ago that gentlemen's agreements with physicians had failed,
because physicians do not, and cannot, monitor themselves in terms
of quality, effectiveness and cost-effectiveness. Since then,
research physicians have worked with US purchasers to establish
evidence-based, clinical standards of effectivess, "efficiency"
and accountability.
Where this work has been carried out, unnecessary
hospital admissions, bed-days, operations, prescriptions, and
tests have dropped significantly, as has their variation in treating
patients with the same kinds of clinical problems. More important,
clinical errors and tragedies have dropped. It is now routine
to track what specialists do so that one can produce comparative
profiles.
In short, we have concluded that doctors need
systematic and comparative feedback on their work, just like any
other group of highly skilled technicians in fields where judgement
plays a considerable role. American specialists were outraged
when this revolution happened, but the evidence (which you have
as well) was clear, and the purchasers were firm in asking, "Why
should we be paying for the specialists at the high end of testing,
prescribing, operating and admitting patients to hospitals, when
there is no evidence their patients do any better than the specialists
at the low end?" The issue was (and is) not "efficiency"
(an unclear term) but value for money.
There are similar variations in how efficiently
clinicians run their practices or manage their waiting lists.
Waiting times, for example, vary by three-fold within the same
area (eg Birmingham) for the same sorts of patients. Why? Even
aside from the possibility that the consultants with long waits
are nurturing their private practice, consultants vary as much
as politicians in how well they run things. I know that in the
United States there are politicians who work very hard but are
constantly behind, and there are other politicians who get a great
deal done and have time to spare for golf and social events. Perhaps
in the UK, political candidates all pass an efficiency test before
they run for office; but otherwise I suspect politicians vary
as much as clinicians in how well they run their office, even
among hard-working conscientious ones. This is a major reason
why I have recommended since 1990 that all referrals from GPs
and consultants be run by an independent Waiting List and Booking
Office that would manage the logistics of assigning and allocating
patients among consultants in a geographical area.
If we turn to the maximum part-time contract
and other part-time contracts for 9/11th or 8 or 7/11th time,
we turn to other serious problems. These contracts contain structural
conflict of interest, independent of evidence about how many consultants
exploit that conflict of interest. Consultants lose a portion
of their income, or conversely, pay several thousands pounds,
for a contract that allows them to build up a private practice
on the base of their NHS practice. We will never know just how
much, and in what ways, consultants indicate to patients that
there will be quite a wait for their treatment, "but of course
I could take care of your problem next week if you like."
My point is that it does not matter. What matters is whether the
Government and Parliament want to continue to put temptation in
harm's way, whether they want to have this conflict-of-interest
in their contracts with consultants.
The powers and perks that the NHS gives to building
up a private practice are as well known as they are denied. One
consultant who wrote into the BMJ in response to my recent article
on government policy and waiting lists (attached)[3]
emphasised that the NHS offers no perks, like a company car. Yet
his private practice (worth far more than any company car or expense
account) depends utterly on his appointment and position in the
NHS. The perks are the appointment of consultant itself, the network
of referrals from GPs and other consultants, the NHS resources,
control of the waiting lists, and legitimacy that enable a private
practice to be built up. As Barry Jackson, President of the Royal
College of Surgeons, told Ms Toynbee of The Times on 7
June, once surgeons leave the NHS, their private practice "dries
up quickly and many have been very disappointed men. GPs soon
stop referring patients to surgeons not attached to a good NHS
hospital."
The structural problem is that, according to
a source who knows the claims records of a large UK insurance
company, most consultants do a modest amount of private work,
but about 1,500-2,000 consultants bill for very large amounts,
indicating that they are exploiting the NHS and its patients for
their own gain. Almost all of these are surgeons and anaesthetists.
Does this imply that contracts with these two groups should be
written differently from contracts with other consultants?
The consultants claim, on one hand, that they
work far beyond their contractual obligations, out of a spirit
of duty and commitment to the NHS and to patients. To replace
the current contracts with more specific terms of productivity
would kill this spirit, they claim, and they would work "to
the contract". Costs to the NHS would zoom. Is this an accurate
picture of work and motives? We do not know. Actual studies or
actual work, outside of surgery, are uncommon, and all the rest
is self-reported. But for a summary of the evidence on surgeons,
see my reply to the BMJ letters (all attached). In surgery, the
Audit Commission's studies give us a sad and very different picture,
one that has been further substantiated by subsequent studies
by Yates. Surgeons average between a half-day and a day a week
operating on NHS patients. Half operate even less. This is shockingly
low, and the Audit Commission also reported that a large portion
of surgeons were not present at obligatory fixed sessions—a
serious lack of accountability. On the other hand, some surgeons
operate two days a week (four sessions), which is close to a full-time
load of actual operations. Probably most of these surgeons hold
full-time contracts with the NHS. If four sessions of operating
became the contractual standard, waiting times would plummet from
several months to a few weeks.
What do surgeons do the other four days? Research
has documented that they spend about 10-14 hours a week in clinic.
Administrative work and supervision may take up another 10-14
hours a week. On-call duty involves a large number of potential
hours of work but very little actual work. Few do much or any
research. These figures add up to 25-38 hours a week, though they
claim they work 60. After 15 years of research (such as is possible),
what they do beyond these hours is not known and they are not
accountable.
I have come to conclude that consultants' contracts
constitute one of several governmental policies that maximise
waiting times and maximise the number of patients going private.
Enclosed is my recent BMJ article that describes that six elements
of the "two-tier syndrome" underlying the so-called
waiting lists. (They are not lists and to call them "lists"
is to play on the public's good will to "wait their turn".
From the raft of letters written in response to this article I
realise I left out an element that I would actually put near the
top of the list: the Nobody's In Charge structure of hospital
contracts and budgets. Nobody's In Charge implies that what the
Government and Parliament need are not so much contracts with
consultants for their personal compensation, as contracts with
consultants for running an entire service, with strong measures
of accountability, effectiveness and value for money built into
them. For as things stand now, even the most dedicated surgeon
has no control over cancelled sessions, too few theatre nurses,
not enough recovery beds, insufficient intensive-care beds, and
discharge planning so that the entire surgical service can be
efficient and productive. Nor does anyone else have such control
or reponsibility, right up to the Chief Executive.
Nobody's in Charge is also the major obstacle
to establishing much more cost effective services in the community
and near patients' homes so as to minimise the costly use of acute
hospitals. This is the major barrier to developing integrated
intermediate care, and I am working out a solution that should
be drafted by July. The core problems, in short, are (1) writing
commercial licences (maximum part-time contracts and loose part-time
contracts) that provide very strong financial incentives for consultants
to "work" the NHS and patients for private practice,
(2) having the same consultants manage their thousands of waiting
lists according to undocumented and unaccountable criteria in
a blatant conflict of interest, and (3) running NHS hospitals
so that consultants' teams do not have real organisational and
financial responsibility for all related staff and resources to
run their services effectively and efficiently. Consultants understandably
say, "Don't blame me. I'm a victim of these circumstances."
What the Government needs are service contracts that put consultants
(whether in geriatrics or general surgery) in charge so that the
buck stops at their desk.
June 2000
3 Attachments not presented. Back
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