What role do consultants play in health service waiting lists?

Seanin Graham’s exclusive in the Irish News “Desperate Patients Pay for Eastern Europe Opshighlights a persistent problem in our Health Service; lengthening waiting lists.  She focuses on the use by local patients of surgical services in other European states and identifies the lengths some will go to improve their situation.   She has identified the problem and, for very few patients,  an expensive solution, and where this is a useful reminder that as a population we deserve better, she fails to consider why we have unacceptable waiting lists in the first place.

The HSCB knows only too well the complex interactions of factors that make waiting lists grow.  Lack of investment certainly is one with our HS needing about 4% uplift year on year to keep steady which means that perhaps £1 billion of funding was not invested between 2010 and 2017 due to government cut backs and with that lack of funding you can expect problems in the service.

Our HS is far from a simple system but in simple terms; patient suffers symptoms, goes to GP, GP refers to a consultant, consultant assesses patient and, if deemed necessary, gives treatment – a surgical intervention perhaps.  Each step of this pathway has its problems and complexities.  The patient, for example, may fail to see the GP early and the problem is then more difficult to manage; ironically left on a waiting list this has the same outcome.   Or, for example, you cannot get a patient out of their recovery bed after surgery because a care package is not in place at home, the patient cannot go home and the bed is blocked.  Health Service managers struggle to manage and transform the system, and in some specialities, a transformation has proved all but impossible.

But a key factor few are willing to identify never mind tackle is the all-powerful medical consultant.   These are the experts who sit atop the medical hierarchy and can be difficult people to manage.   Their brilliance makes them almost untouchable, certainly formidable and for too long, in some specialities at least, the service appears to be run for the convenience of the consultant rather than the patient.

I have a good friend, a professional woman, who using BUPA medical cover visited a consultant for a private consultation one week after seeing her GP.   He assessed that she needed a hip replacement and offered her an operation at a local private clinic the following Saturday.  She was taken aback with the speed this happened but decided to go ahead and found she was one of four patient who the consultant operated on that Saturday.   This level of efficiency were it to exist in the Health Service, would see a big impact on waiting lists.   There is a glaring perverse incentive in the contractual relationship medical consultants have with the Health Service yet no government seems capable of tackling this.

Off course most medical consultants are hard-working, dedicated professionals, and in some specialities, we do not have significant waiting lists.  And that is not to say where waiting lists exist the consultants are primarily to blame, far from it.  But some medical specialities stand out as problematic.   Perhaps waiting lists are a poor measure of quality in that they quantify the problem but do not allow sufficient insight to what needs to be changed.   Above all, we must make our health services accessible to all dependent on clinical need rather than the ability to pay for private medical insurance.

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  • Kevin Breslin
  • Reader

    Kevin Breslin: Another thing Brexit will destroy.
    Our local politicians might have to fix the NHS instead of outsourcing it?
    There are alternatives to Lithuania though. E.g.
    “More than 70,000 Britons already fly abroad each year for private surgery, with many choosing to head to India.”
    From :
    http://www.dailymail.co.uk/news/article-2400693/NHS-patients-sent-India-cut-price-surgery-Former-Labour-health-secretary-says-doctors-sent-India-treat-locals-bid-raise-money.html
    There’s a whole world out there.

  • Kevin Breslin

    Oh Reader, Reader quite contrary
    How does your Brexit grow?
    With magic spells, and fairy tails,
    And trade deals lined up all in a row.

    Fair play to India, and for people can afford the travel and the visas.

  • whatif1984true

    I was hoping the writer was going to answer the question posed in the title. CLICKBAIT.

  • NI GP

    Yes of course there are greedy consultants who manipulate and milk the system but they are few and far between.

    The problem is (as depressingly frequently in NI) is political failure.

    We have a (by UK standards if not international ) reasonably well funded health system but we waste our money primarily by funding too many inefficient hospitals.

    Belfast has four hospitals. Why?

    Lagan Valley, the Down, Daisy Hill, Causeway? ??

    These dilute our resources both in terms of staff and finance so the whole system is absurdly inefficient.

    Some consultant surgeons are now appointed to jobs where they only have one operating session every fortnight because there aren’t enough theatres or recovery beds because the money is being spent on keeping these hospital relics of a bygone age open. Being surgeons they want to operate, it’s why they became surgeons so of course they work in the private sector where they can usetheir skills to help patients albeit only those who can pay

    At least four but possibly five reports have pointed this out in the past 20 years. All have been ignored by our spineless politicians and put in the “too difficult , let’s just hope it goes away ” tray.

    Result, mismatch in staff, insane locum bills trying to keep unsustainable buildings and rotas going and spiralling waiting lists.

    And given our current fixation with stoking up our sectarian divisions to increase our mandates to do anything rather than govern, things will only get worse

  • Brian O’Neill

    Indeed. People want a school, factory and hospital at the end of every street.

  • SDLP supporter

    Informative piece, as always, by Dr. Maguire. Any party which might get the Health portfolio in a future Executive would do well to retain him as a Special Advisor. There are few people here with his breadth of oversight and vision.
    The SDLP made a big mistake in 1998 when it funked out of taking the Health portfolio. It is absolutely crying out for a young-ish, savvy, dynamic Minister.

    I agree with the point about consultants having the status of demi-gods. They are undoubtedly for the most part intellectually brilliant people but that might

  • Brian O’Neill

    Why do you think a Magee school will help matters? What’s to stop Magee graduate doctors taking themselves off to Australia?

  • SDLP supporter

    Difficulties with all options, Brian. One is to stick students with the full economic costs of their education. I know of two paediatric neurologists in the US who had combined debts of $1.5 million at the end of their education. That works through to high fees charged by medics there for a not particularly stellar medical service.
    Another option is to make a commitment to the NHS post qualification as a condition of entry to medical school.
    I recall reading a paper by a QUB academic doing a comparative study of the health services of NI and Cuba. NI was ahead, but not by much, and the cost in Cuba per capita was a fraction of that in NI.

  • Theelk11

    There there is a school of thought which would reimagine the ” relics” as hospitals where if you are acutely unwell and/or elderly you could be treated locally with efficiency and quality. With acute medicine and outreach into the community to avoid unnecessary admission.
    Limited ” cold” medical services which are easy to do and have a defined stop point such as hernia repairs hip replacements etc could theoretically be performed in one elective centre for the region.
    Anything more complicated such as cancer resection will need on site ICU facilities which would be difficult to organise , who is going to be responsible for the patient in such an institution described above if they bleed post surgery and need to go back to theatre? I cannot see anything replacing a full blooded DGH or the Royal for that stuff.
    It’s not political failure I fear but half assed self interested thinking.
    Forgive me if I am wrong but I presume from your moniker you are a GP? You probably need to look a bit closer to home for problems that need resolving.

  • Zig70

    Good piece and the thought process that puts doctors above patients needs challenged. The whole private use of nhs facilities by consultants at a cost to the tax payers leads to a disillusionment with the moral authority of doctors.

  • Zeno

    Cuba?
    The average Cuban physician receives 1,400 Cuban pesos (€46) per month, and faces restrictive rules allowing them to leave the country meaning few can travel abroad unless sent on state-sponsored missions abroad.
    http://www.thejournal.ie/cuba-healthcare-system-2668448-Mar2016/

  • NI GP

    You are indeed describing the proposed solution advocated by all the Expert reports – fewer Acute DGHs, more services nearer the patient with less separation between primary/community care and hospital/secondary care.

    The “relics” could provide step down beds for recovering patients no longer needing acute care but ready to go home. Intermediate care teams could treat less severe illnesses either in patient’s homes or in less expensive community hospitals.

    Most agree that this is the way forward but can only happen by transferring money out of the hospital sector into primary/community/intermediate care. And that is where it is blocked.No politician is willing to support a hospital in his patch being downgraded or closed even if it would allow better care for the population.

    As regards GP in NI, don’t get me started. It is about to collapse due to underfunding, lack of GPs and indifference from politicians and Department.

  • NI GP

    Hopefully nothing to stop Magee graduates going anywhere they want but the experience with graduate entry medical schools has been that they (obviously) produce slightly older doctors more of whom have families, homes, commitments and more of whom tend to stay and work locally.

    And if we have a new medical school it needs to be in the West as QUB has failed to provide doctors beyond the Greater Belfast area.

    Hence the millions spent by the Western Trust on locum hospital doctors and the collapse of general practice particularly in Fermanagh

  • Laurence Rocke

    Can you give some current examples of consultants using NHS facilities for private patients?

  • Old Mortality

    ‘Another option is to make a commitment to the NHS post qualification as a condition of entry to medical school.’
    You would need to offer some financial incentive such as waiver of loan repayments or the stick of no loans for individuals who fail to make a commitment to the NHS. I also doubt that such a commitment could be confined to the NHS in NI.
    We need to get away from the idea that studying medicine is anything more than learning a trade, however brilliant some of its practitioners may be, and not financed on the same basis as purely academic study.

  • SDLP supporter

    Doesn’t mean to say that their medical personnel aren’t well-trained. I hold no brief for Castro, his thuggery and the totalitarianism of his regime but his revolution did make real advances in universal healthcare and literacy.

    Same thing in East Germany. A report after the 1989 re-unification found that on certain key measurements the former East German system scored better than the former West German model.

    I don’t think you can leave public benefits like healthcare and education solely to market forces.

  • Reader

    I thought I had replied to this one. I’ll try again.
    People travel to India because the overall cost to the individual is less than a private operation in the UK. Or in Lithuania.
    So why does the NHS choose Lithuania over India? EU protectionism?

  • Kevin Breslin

    The NHS has no jurisdiction in any other EU state but the UK, I suppose they could refer a child down to Dublin for heart surgery but that’s down to convenience.

    The fact is that it’s not EU protectionism that reduces costs to someone travelling to Vilnius or Kaunas but the freedom of movement of people.

    Even to Austrian scholars it’s very clear that migration control is a form of protectionism i.e. a non-tariff barrier.
    https://mises.org/library/mises-protectionism-and-immigration

    So it’s very clear that one of the United Kingdom Union’s main protectionist areas is going to be about controlling its borders to people … including labourers, consumers, service providers etc. etc.

    So if the United Kingdom does go down that route, the reasonable reciprocation is the denial of free European healthcare to Britons on the same discriminatory basis as Britons would deny healthcare to EU nationals.

    Then again that is Protectionism Brexit style.

  • Theelk11

    Yep.
    Demographics are the threat and the opportunity.
    Elderly patients use up an increasing number of hospital beds days. The profile of acute admissions from this group continues to get older year on year.
    Emergency department attendances from this demographic rise year on year. The current hospital system cannot cope. I fear this winter already.
    The opportunity is to reimagine what a local hospital is and does. To close the doors on them is not an option,that would break the system. They will do a lot of things differently and some things not at all but not close. That is the message the MLAs should push instead of wanting a all singing DGH in their parish.
    General practice needs to decide what its future looks like. I agree it’s in trouble.