Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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missing the point
- benjamin dean (19 November 2005)
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Independent treatment centres, success or failure?
- Dr Payam Fazel (21 November 2005)
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Is there no medicine in the future NHS?
- A Ewen MacKinnon (21 November 2005)
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The NHS and the private sector: the real story
- Rachel Aldred (21 November 2005)
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Treatment centres and their effect on surgical training
- Catherine Guly, Richard Sidebottom, Kim Hakin, Keith Bates. (22 November 2005)
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Questioning challenges of private provision in the NHS
- Mark J Ashworth (22 November 2005)
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Re: Questioning challenges of private provision in the NHS
- Nicholas Timmins (22 November 2005)
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question
- benjamin dean (23 November 2005)
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Timmin's references
- James D Woodcock (24 November 2005)
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Re: question - Answer : Yes, of course.
- L S Lewis (24 November 2005)
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answers
- benjamin dean (25 November 2005)
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Re: answers
- L S Lewis (26 November 2005)
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Seeing cataracts clearly
- Simon P Kelly (28 November 2005)
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Mind the gap.
- Richard G Richards (29 November 2005)
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Surgical training in independent treatment centres
- Simon E Gilbert (3 December 2005)
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Author's reply to four responses
- Nicholas Timmins (5 December 2005)
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you can't measure complex care
- Sebastian Kraemer (12 December 2005)
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benjamin dean, sho australia
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I think these artciles all miss the point entirely. It is unimportant as to whether current new government strategies are consistent with the founding principles of the NHS. This is because the founding principles of the NHS need to be questioned themselves, why should these principles be adhered to and not questioned- when there is so much evidence that they are misguided and flawed. It can be argued that a good standard of healthcare cannot be sustainable delivered if it is delivered free at the point of use. The arguments from the likes of Nicholas Timmins are deeply flawed. It is claimed that 'competition' from private providers will help improve the system for all. The problem with this argument is simply that there is no genuine competition between public and private providers. Fixed quotas of operations are sold off to private providers and these operations are then performed. I fail to see where the so called 'competition' is. The private companies make their money while the NHS waiting lists fall, as the NHS does less work. This can lead to massive ineffieciency as NHS surgeons have free theatre time with no operations to perform. Also there are many other implications of private providers- where is the countinuity of care if all their complications have to be dealt with by the NHS? what about surgical trainees, who are already getting less operating with the working time laws? I could go on. It is claimed also by Mr Timmins that "independent treatment centres have had a much bigger effect on waiting lists than can be accounted for by the number of procedures they performed". If this is true then maybe it is because the government are fudging the figures to make it appear that their private providers are a runaway success. This was an explanation not considered by Mr Timmins. We need to address the fundimental principles of the NHS and introduce payment at the point of use, this is the only way forward for healthcare. This is another debate entirely though. Introducing private providers who cherry pick the easy profits, while NHS providers struggle with the unprofitable chronic heathcare problems, is not an efficient means of improving healthcare. There are also numerous downsides to this strategy which include continuity of care and training issues. Has anyone thought about what happens to surgeons who work for the NHS? I very much doubt it. These non-UK surgeons are working in the UK, doing solely private work and getting paid handsomely for it. Will this result in further discontent amongst NHS staff and a continued exodus to other careers/countries? Overall I think the introduction of private providers will no nothing to improve our healthcare system efficiently, while creating yet more problems at the same time. It's funny how Nicholas Timmins' article concentrated solely on the unproven benefits while not mentioning many of the possible negatives. Yours, Dr Benjamin Dean Competing interests: None declared |
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Dr Payam Fazel, Specialist Registrar in Public Health Medicine Leeds LS6 2ET
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We need to pose a few questions that merit answer before labelling the independent sector treatment centres with success or failure. We will then translate those questions to an answerable research question that could test the policy using appropriate and cost-effective methodology. 1) Effectiveness: Does the introduction of independent treatment centres reduce waiting lists? Do independent treatment centres increase the diversity of patient choice? 2) Efficiency: How do independent treatment centres cost-compare with the already existing services? Is the input (work force, money,structure) minimised for maximisation of the output (reducing waiting list, increasing patient choice)? Are there any more efficient ways to deliver this service (opportunity cost)? Do ITCs not impose significant parallel administrative and structural costs? 3) Acceptability: Does the new service, conform to expectation of the ITC patients, all patients, and the wider public? Is it what the health professionals think that the public need (demand versus need: wants vs. capacity to benefit)? Is the policy demand driven or need responsive? 4) Utilization and access: Are ITCs dispersed according to the population needs? Can people travel back and forth to the ITCs for examination, operation and post-op complications? 5) Equity: 6) Relevance: Is the overall NHS/ITC mix pattern and balance of services the best possible design, considering the needs and demands of the wider public? Is uninformed patient choice really a sound and desirable objective? 7) Quality: Are there any governance measures in place to safeguard quality of the ITC services? Are outcomes (right things done: reduction of waiting lists/”increase in patient choice”) the best measure of policy success? Are processes (things done right) not as important in quantifying success? Is process mapping and evaluation possible with confidential commercial care pathways? 8) Organisational and financial sustainability: Is this pattern sustainable in the long run? What is the long-term policy impact on the existing structures and workforce Research Question. We will not try to second guess the answer to all of the above questions here but endeavour to raise a sound research question that could help examine the introduction of independent sector treatment centres. Thinking of the current demand driven model the question would be: Do ITCs reduce waiting times and increase patient choice efficiently compared to pre-existing services? A combination of multidimensional qualitative and quantitative research methods possibly using triangulation and/or complementarity and development, are needed to answer the above question. We need a combination of cross sectional studies (to quantify costs),prospective and retrospective longitudinal studies in which timing of the policy introduction is compared with the impact on waiting lists and patient’s choice and quality of care; and cost benefit analysis of introduction of the ITCs. There are a few practical issues. The studies will look at different objectives and might produce results that are in different directions, it is extremely difficult to choose an objective at the expense of ignoring the other . The evaluation could be quite costly and the final recommendations can be very debatable considering that different sorts of bias can be introduced by carrying out several studies that are influenced by a multitude of different factors. The alternative would be to translate the objectives of the current demand driven model to objectives of a need responsive approach. Here the question/s would be: Does introduction of the ITCs increase quality adjusted life years (QALY)/per unit cost? (U/C) OR: How does the unit cost per quality adjusted life years (QALY) generated by the ITCs compare with the existing structures?(C/U) To answer the latter questions we need to carry out a robust cost utility analysis that needs to: 1) Quantify the unit cost of an average case mix standardised unit of surgical intervention in the ITCs and the NHS hospitals. 2) Quantify Quality adjusted life years (QALY) generated in a given period of time. 3) Measure the rate of QALYs generation by the ITCs and the NHS hospitals and cost comparison it with the existing structures. PS: With gratitude, I hereby acknowledge information, advice and communication with the following colleagues in the process of preparing this response: Karen Bloor, Lucy Hainsworth, Carol Propper, Julie Reynolds, Joan Kennedy. Competing interests: None declared |
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A Ewen MacKinnon, Consultant Paediatric Surgeon Sheffield Children's Hospital, Western Bank, Sheffield S10 2TH
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Professor Timmins sets out some pointers in relation to the future of the NHS and its relation to private provision of services. He only discusses surgery. Does he think that there will be no medicine in the future? Numbers of operations are easy to count, and to some extent so is their outcome. Medicine does not lend itself to the same analysis but why should it be left out of NHS planning? Competing interests: None declared |
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Rachel Aldred, Researcher Goldsmiths College, University of London, London SE14 6NW
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Nicholas Timmins’ argument that the NHS has never been exclusively ‘public sector’ is misleading. While technically true, it obscures the astonishing growth and concentration of corporate power in the health sector. When the NHS was created, pharmaceutical companies were in their infancy, whereas today they rank among the most powerful corporations in the world. As the NHS becomes more and more fragmented, this will increase the power of such companies relative to NHS bodies. It is true that throughout the NHS’s history, most GPs have been independent contractors. However, the BMA’s survey of GP opinion in 2001 showed that most GPs now see themselves as part of the NHS and do not want a greater role for private companies in primary care. Even ‘entrepreneurial’ GPs are hardly in the same league as multinational private firms. Government policy means that we are likely to see individual GP practices replaced by franchises or branches of profit- making companies, along the lines of McDonalds or Tescos. The involvement of big business is already damaging the NHS. The private finance initiative (PFI) and its latest incarnation, Local Improvement Finance Trust (LIFT) hand over control of hospitals and surgeries to private consortia, which view them not primarily as health facilities but as opportunities to make money. Even many supporters of PFI have begun to concede that it is inflexible. NHS staff can no longer, say, put up shelves for extra equipment; the buildings do not belong to the NHS and can only be changed by negotiating with and paying the private consortia. The NHS’s power to redesign and change buildings and services is much reduced. As large private companies take on more and more NHS services, they are likely to want to find additional revenue by increasing user charges (just as PFI has led to charges for hospital patients receiving calls, or watching TV). Greater private provision will come to undermine public funding through taxation. The government wants PCTs to become purely commissioning bodies, purchasing health care on behalf of a defined population. This makes them effectively ‘social insurers’, and it may not be long before private insurance companies are invited to compete, perhaps justified by reference to EU trade rules. PFI providers will increasingly link up with the private health care companies now running ISTCs, creating giant monopolies, complex subcontracting chains, and deals shrouded in ‘commercial confidentiality’. As this happens it will be extremely difficult for the public sector to intervene even when public safety may be at stake, as shown by the recent safety alert on part-privatised London Underground’s Northern Line. The planning function of the NHS will be eroded as not only will it be fragmented, but its hands will also be tied by long-term, immensely complicated contracts. The BMJ has a responsibility to take a position on what may be the slow death of the NHS. References: BMA (2001) National survey of GP opinion, available from http://www.bma.org.uk/ap.nsf/650f3eec0dfb990fca25692100069854/ 80256b140033ce0780256b1a004e0211/$FILE/ATT0GTSX/uk.pdf, pdf file, accessed 21/11/2005 Competing interests: None declared |
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Catherine Guly, SHO Ophthalmology Taunton & Somerset Hospital, Musgrove Park, Taunton, TA1 5DA, Richard Sidebottom, Kim Hakin, Keith Bates.
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EDITOR - Timmins, in his series of articles on health care in the market place, questions whether the benefits of using independent providers for health care outweighs the risks. He notes the tendency for treatment centres to take on simpler cases, leaving the NHS to deal with complex surgery,1 but brushes over the devastating effect this is having on surgical training.2 Cataract surgery is the most common operation performed by treatment centres. It is easy to trivialise an operation which can be performed in 15 minutes under local anaesthetic as a day case, but it takes intensive training to become a good cataract surgeon. It is usually possible to predict which cataract operations are going to be difficult or high risk when the patient is seen pre-operatively.3 In our department these complex cases are listed as ‘consultant to do.’ The remainder are listed as ‘any surgeon to do’ and it is these low risk patients who may be suitable for training. Since Netcare, a mobile treatment unit, and the Shepton Mallet treatment centre began operating in Somerset, we have noticed a dramatic reduction in cataract surgery training opportunities. The number of ‘any surgeon to do’ patients on each consultant list has halved from 3 patients per operating list in 2003 to 1.5 patients per list in 2005. Given that there is more than one trainee per list, and that not all low risk patients are suitable for training, it is not infrequent that trainees are unable to operate because of a lack of suitable cases. The deleterious effect of treatment centres on cataract surgery training will affect all ophthalmic training grades, but particularly senior house officers (SHO) as they require the most straight forward cases to learn cataract surgery. There has long been concern that SHO surgical training in ophthalmology is inadequate. A survey in 2000-1 found that half the UK ophthalmic SHOs were not receiving adequate basic surgical training.4 In the conflict between budgets, waiting times and surgical training, it is the latter, which is not subject to government targets or financial penalties, which becomes the lesser priority. A reduction in low risk cataract operations in the NHS and increasing competition from treatment centres will only compound this problem. There is a real danger that NHS ophthalmic units will operate only on complicated cases, and that trainee ophthalmic surgeons will not operate at all. Fielder and Watson, noting that Action on Cataracts had failed to consider surgical training, made some excellent suggestions about how training could be improved. Their ideas of high volume service and low volume training surgical lists, with blocks of intensive surgical training seem eminently sensible.5 It would appear that the demand for surgery was overestimated when planning treatment centres.1 Could this excess capacity now be utilised by the NHS in the form of low volume surgical training lists? Given that £52m has been set aside for the cataract care pathway programme,5 it does not seem unreasonable that there is some investment in training the next generation of ophthalmic surgeons. The assertion that the private sector can (and will) provide surgical training recognises that training comes at a price,2 but it is difficult to visualise how such a plan could be successful. If treatment centres had been intended for training, why was our local treatment centre built 40 miles away, and why was there no collaboration with our ophthalmic unit when it was set up? Cataract surgery is just one, albeit important, part of ophthalmic training and we are uneasy at the thought of training being split into components and sold to private companies. Quite apart from the logistical difficulties of travelling to and from treatment centres, we have specific concerns about the quality of teaching, continuity of training and erosion of team working in the NHS, should the private sector become involved in surgical training. Treatment centres have been implemented because of the increasing demand for cataract surgery in the NHS. It seems very ‘short sighted’ that while the number of cataract operations performed in the UK is increasing, the future of cataract surgery training is under threat. Catherine Guly, SHO Ophthalmology
Taunton and Somerset NHS Trust 1. Timmins N. Use of private health care in the NHS. BMJ 2005;331:1141-1142. 2. Timmins N. Challenges of private provision in the NHS. BMJ 2005;331:1193-1195. 3. Muhtaseb M, Kalhoro A, Ionides A. A system for preoperative stratification of cataract patients according to risk of intraoperative complications: a prospective analysis of 1441 cases. Br J Ophthalmol 2004;88:1242-1246. 4. Watson MP, Boulton MG, Gibson A et al. The state of basic surgical training in the UK: ophthalmology as a case example. J R Soc Med 2004;97(4):174-8. 5. Fielder AR, Watson MP, Seward HC et al. Action on Cataracts should influence surgical training. BMJ 2000;321:639. 6. The Royal College of Ophthalmologists. http://www.rcophth.ac.uk/public/cataract.html Competing interests: None declared |
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Mark J Ashworth, Orthopaedic Consultant Torbay Hospital, Torquay, Devon, TQ2 7AA
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I do not wish to comment on the politics of the argument put forward for the introduction of treatment centres. However, I believe the financial argument proposed is flawed if one closely examines the costing put forward in the article. 'Long before 2000' we are told the cost per case is between £1,250 and £1,667 (£100m divided by 60-80,000 cases). With the new contract we are told £500m buys 200,000 cases per year, i.e. £2,500 per case, and that this is 'much lower than the NHS was paying before'. I calculate that over a 5 year period of spending £500m per year the new contract will deliver between 500,000 and 1m FEWER operations for the same cost. Even allowing for a subsequent reduction, from this initial 15% above tariff price, these figures can never add up to any saving at all. Perhaps the 'rip off' referred to in the article is now and not then. But that could just be one political view. I welcome an explanation of the figures from the author. Competing interests: None declared |
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Nicholas Timmins, Public policy editor Financial Times, London SE1 9HL
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It's a neat calculation, but it doesn't work. The range of 60,000 to 80,000 quoted is a range because there are/were no absolutely accurate figures on how many procedures the NHS was buying prior to the ISTC contracts. There were figures in NHS returns, and figures collected by the then Independent Healthcare Association. The two never matched, often being out by 10,000 or more, and I don't think either side had any real idea who was right. The £100m is also an estimate. In other words both the numerator and denominator of that part of the sum are heavily rounded. The figures provide a sense of scale, not something on which detailed sums can be built. Second, to make the comparison between cost per case before ISTCs and cost per case in ISTCs you need to know the case mix, which may well be very different. For reasons explained above, that isn't available for the pre-ISTC contracts. What we do know, is that the NHS for a wide range of individual operations was paying up to 40 per cent and more above tariff. And that the department claims the ISTC contracts are around tariff +15 per cent, and the G-Supp contracts are at, or in some cases, below, tariff. Competing interests: None declared |
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benjamin dean, sho australia
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I would just like to ask Mr Timmins a question if possible. Is it possible to have genuine competition in a state funded system? If it is not possible then you cannot use the advantages that competition brings to drive the system forward. There are a number of different paths forward that the NHS could take potentially. The system could remain entirely state funded and state run, however I think history has shown this is not sustainable. The current track offered by the government has the pretence of competition, without there being any actual genuine competition. The government is tricking the public. You cannot have a competitive free market of healthcare if it is funded with people's taxes! Thus the 'competitive market' Mr Timmins talks about is merely a figment of his imagination; true, there may be private providers competing to make a profit at the tax payers expense- but a genuine competitive market where the consumer can choose where to take his money, no way. The point I am trying to make is that you cannot have both a state funded system and a competitive marketplace! They are contradictions in terms. If a competitive market is desired then the only way to do this is to empower the individual consumer, so that they individually choose where to take their trade. Thus we have a choice- either stick with a deteriorating state system or try to generate a genuine competitive marketplace. The current reforms will be of no benefit to anyone but the private providers. Competition will not come unless people have genuine choice, and genuine choice will not occur unless healthcare is payed for by the individual. Currently the only competition is between the private providers to secure lucrative contracts from the government. To quote hayek "This is not a dispute about whether planning is to be done or not. It is a dispute as to whether planning is to be done centrally, by one authority for the whole economic system, or is to be divided among many individuals. " The same principles can be applied to healthcare. Yours benjamin dean Competing interests: None declared |
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James D Woodcock, Researcher London School of Hygiene and Tropical Medicine
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I would like to ask why Timmin's references no academic articles on this important subject? Does he claim there is no relevant academic work of merit? In fact 13 out of 16 references are to his own newspaper column. Competing interests: None declared |
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L S Lewis, GP Surgery, Newport, Pembrokeshire, SA42 0TJ
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Is it possible to have genuine competition in a state
funded system? In 25 years as a GP, my answer is most certainly ,YES. Of course it is 'managed' competition, but it really has worked - Patients choose their preferred GPs ( from a limited local range, I grant ) whilst GPs were paid by a mix of 'capitation', and 'item of service' tariff fees. Latterly, GPs are paid a new range of rewards, mirroring 'payment by results'.. The government is tricking the public. You cannot have a competitive free market of healthcare if it is funded with people's taxes! Why ever not ?? No markets are entirely ‘free’. All economies are more-or-less mixed. General practice IS funded largely from people’s taxes, and some ‘private’ fees - HGV, passport and insurance examinations, for example. It seems to me entirely possible to sustain a tax-funded NHS , virtually free to patients ( barring arcane prescription cost rules ) according to need, funded by progressive taxation according to ability to pay. This is my preferred definition of socialism ( or is that ‘social market’ these days ? ). Questions as to who owns the premises, and how the practitioners organise their accounts, who is private, and who is public, are entirely immaterial… let the state-funded NHS purchase health-care wherever it can get, and equitably sustain, value for money. My concerns are :
Concerns re: volume, productivity, training, sustainability, purchasing power, etc. thus remain the relevant and central domain of NHS national and locality Commissioners. Dr Sam Lewis Competing interests: None declared |
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benjamin dean, sho australia
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just in response to Dr Lewis' response. I beg to differ in that I do not see 'managed' competition as genuine competition. There is really only a very minimal amount of competition between GPs. To suggest otherwise is strecthing the truth a little. If competition is 'managed' as it is as regards GPs in a top down fashion by the state, then GPs simply learn how to exploit the payment system in order to profit maximally. Payments are based on achieving fixed targets and quotas that are set by the state, I do not think this constitutes competition. Anything that is not included in the payment system will become unimportant and will be ignored, as the GPs are reacting to state imposed directives- not any demand from their customers/patients. So services, maybe as an example podiatry and physiotherapy, have massive waiting lists despite a big demand. There are many examples of areas of need that are not being serviced, this is because there is no genuine competition- thus the health service does not react automatically to demand of patients. If a health services is based on the patient and there is genuine choice and competition, then supply will react to demand. The only way this happens in the NHS is by the state changing its 'management' of the system- this is an extremely poor alternative to a genuine competitive marketplace. It is a both cumbersome and inefficient way of running healthcare. Can you imagine if the state set the price of beef? Also if there is genuine competition in a system then there would be GP's going out of business, which there aren't. A competitive system that is driven by patient choice would drive up the quaity of healthcare, as opposed to the stagnated state monopoloy we have now. There is really very little competition in the NHS, and 'managed' competition is not genuine competition. It is like saying communism is state managed capitalism. No markets are entirely free, true, however this isn't an argument that we should not try improve the freedom in the heathcare market. Also it was stated that "the NHS is virtually free to patients"- I don't think this is true given the amount of taxes that go towards paying for the NHS. Near the end also "let the state-funded NHS purchase health-care wherever it can get, and equitably sustain, value for money." A nice idea but in practice unworkable for many of the reasons I have mentioned. If the state is left to purchase all healthcare, it means the demands of the state are met- not the demands of the consumers/patients. This results in the system being incredibly inefficient as the state must keep adapting its policies to try to meet the demand of the consumer. It is a completely unneccessary loop. The more the state tries to improve efficiency, the more inefficient the system becomes- as central planning is not the way forward. Your concerns are also very valid, however a system controlled by state planning will not meet them as well as a system that allows the individual the freedom to choose where to spend his own money directly. You also mentioned autonomy, ie how can it be best sustained in a free society? The more the state controls our lives, the less freedom we have. If you want a genuine free society and autonomy then this goes against having a state controlled NHS. Our autonomy is being impinged upon as the state decides everything for us. Socialist ideas have good intentions but do not work in practice. They try to make all people equal rather than treating all people as equals. The more the state controls, the more the freedom of individuals is impacted upon and the more wasteful state organisations become ( as we have seen in the blossoming of NHS management staff- I'm sure there were good intentions behind this ). "The part of our social order which can or ought to be made a conscious product of human reason is only a small part of all the forces of society." This quote sums it up well, we should be leaving the ball in the court of the consumer and then genuine competition can be left to sort itself out. The control freak tendencies of the state as we stand will help to improve nothing, most likely making things worse. The new reforms will not introduce genuine competition, the funds are still state controlled. Roll on 1984. Competing interests: None declared |
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L S Lewis, GP Surgery, Newport, Pembrokeshire, SA42 0TJ
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I think I understand exactly your point of view, and it seems entirely valid hypothesis- first put about by Adam Smith in earlier days - that a free truly competitive market should serve people's needs best... Two centuries later only those blind and deaf to the exclusion of the global masses of poor people from health can sustain that belief - If you really believe the USA is a better model for healthcare provision than the NHS then you are welcome to it. I don't. I think it self-evident that the poor ( and the chronic sick, and the elderly - unless they have savings.. ) will never get effective healthcare in any truly free market competition... We must inject altruism as well as efficiency. 'bye. Competing interests: need vs greed, conscience vs. wallet |
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Simon P Kelly, Consultant Ophthalmologist Bolton Hospitals NHS Trust. BL4 OJR
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Mr Timmins is accurate in noting that ministers' claims of a "massive" effect of Independent Sector-Treatment Centres (IS-TCs) are hollow, especially in relation to cataract surgery. (REF 1) For example when the Secretary of State announced “the first wave of IS-TCs has already brought down the waiting times for cataract operations to three months, a target achieved four years earlier than promised” (REF 2) acknowledgment to the achievements of NHS staff in such improvements was neglected. It is NHS staff and not Wave 1 IS-TCs who have delivered improved service to cataract patients. Improved care is now being achieved from the Action on Cataract scheme which promised that by “concentrating on areas with low rates of cataract surgery, the NHS would increase the rate of cataract surgery from 170,000 cataract operations in 1998/99 to an expected 250,000 operations per year by 2003.” (REF 3) Improved capital funding and quality improvements to care pathways has empowered NHS hospital eye services to increase cataract surgery capacity and exceed this numerical target in England before Netcare’s mobile units opened in 2004. (REF 4) However, Netcare it seems may have to be paid for many cataract operations in contracts guaranteed over 5 years regardless of whether surgery is carried out, or not, or even wanted by NHS commissioners, regardless of demand or uptake. In a recent example in Oxfordshire £255,000 has had to be paid for cataract activity that should have cost £40,000 and was opposed by local commissioners from the start, but overruled from the centre. (REF 5) NHS cataract care is probably the best example of targeted NHS investment policy by government reaping rewards. Such policy brings benefits to training of future staff, improves patient access and uplifts staff morale rather more than do IS-TC schemes using overseas clinical teams. 1 Timmins N. Use of private health care in the NHS. BMJ 2005; 331: 1141-1142. 2 Hewitt P. Labour's Values and the Modern NHS. Fabian Society Lecture. July 2005 http://www.fabian- society.org.uk/documents/ViewADocument.asp?ID=112&CatID=52 3 Department of Health 2000. Local schemes for better cataract services published Press release 2000/0388: London; Department of Health. http://www.dh.gov.uk/PublicationsAndStatistics/PressReleases/ PressReleasesNotices/fs/en?CONTENT_ID=4005048&chk=9yEnDc 4 Kelly SP. Recurring policy errors: blind spots over cataracts. Lancet, 2005; 366: (9498) 1691. 5 Mooney H. ITC gets 600pc mark-up. Health Services Journal. 2005 Nov 24. Competing interests: I am employed in an NHS ophthalmology department that benefited from the NHS 'Action on Cataract' targeted capital funding. These observations are my own personal views only. |
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Richard G Richards, Director of Public Health Newark & Sherwood PCT, 65 Northgate, Newark NG24 1HD
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Timmins points to the evidence that patients are moving from the private sector into the National Health Service for their healthcare. The implications of this are that some of the increased funding of the NHS is providing services not previously delivered, whilst not increasing the health of the population through the healthcare it is providing. Those who previously themselves paid for their healthcare, or their employers, will however become richer and therefore healthier. Less of the extra NHS resources will be available to address existing inequalities. The gap in wealth and health between the rich and the poor will widen yet further. Competing interests: I am deemed responsible for reducing health inequalities (and wish to do so). |
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Simon E Gilbert, Senior House Officer, Basic Surgical Training Rotation Medway Maritime Hospital, ME7 5NY
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Guly is correct to highlight the threat to surgical training with increased use of independent treatment centres.(1) Although the point has been raised that depriving juniors of ‘bread and butter’ elective work will slow the development of their surgical skills, there has not been much discussion on possible solutions. One answer would be to allow the private sector to offer training attachments for surgeons at the appropriate level of training. In return for providing guaranteed operating / training lists the centres would get an SpR or appropriate SHO who could cover on-calls and assist in theatre. Allowing trainees to spend some time in dedicated elective surgery units would be fantastic for their training, as they would have the time and continuity of trainer uninterrupted by general admitting on call work (they would be on call to cover post ops etc probably). Who would pay for this? The current systems of deanery funding could be adapted so that money follows the trainee to their posting in the private sector, perhaps in the form of a ‘voucher’. Trainees could use this voucher to choose from several training posts (NHS or private) at each stage of their training. This system would ensure that the jobs that provided good quality training would keep their funding, and those that simply concentrated on filling a service need would have to improve or lose the training post altogether. This would raise standards and help moderate the problems caused by reduced training time and the European Working Time Directive. References: (1) Guly C. Treatment centres and their effect on surgical training. BMJ 2005;331:1338. (3 December) Competing interests: None declared |
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Nicholas Timmins, Public Policy Editor Financial Times
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Re: question
I don't know quite where to begin. In answer to your first long reply I think if you re-read the pieces you will find most of the things you say I have not addressed are in fact addressed, although not necessarily answered. Can you have a competitive market with state funded health care? Yes, of course. See Dr Sam Lewis's reply. The distinction you are failing to make is between the demand side and supply side of a market. It is is possible to keep the demand side state run - the NHS pays for treatment out of taxes - while potentially having a highly competitive market in the supply of care. Could I suggest, with due deference, that you re-read your Adam Smith? Re: Is there no medicine in the future NHS? I wrote about independent treatment centres and therefore surgery because that is what I was asked to write about. I think you will find that I did point out that elective surgery is only a small part of the NHS's business. Re: Timmin's references I am sorry if I have upset you with the references. They are not meant to be to my "work" in the academic sense. They are bits of reporting on what has been a fast moving story, and would provide more detail on the points referred to for those who are interested. Perhaps unsurprisingly, the Financial Times has followed developments in more detail than most newspapers. If there is genuine academic work out there on the development of treatment centres (ie some real research which sheds light on the issues) I would be delighted to see it. At present all I am aware of is the initial study of outcomes which was published too late to be included. Re: Independent treatment centres, success or failure? Dr Fazel asks all the right questions. I just hope someone funds him to provide all the answers (some of which may be technically somewhat difficult to construct). I look forward to reading the results. Competing interests: I wrote the articles in question! |
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Sebastian Kraemer, consultant child and adolescent psychiatrist (paediatric liaison) Paediatric Department, Whittington Hospital, London N19 5NF
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As some correspondents have noted, surgery is the model used by Timmins (and many others) for the supply of NHS services, yet the majority of patients do not have surgery, and many have chronic or complex disorders. If I had to sell my labour it would be impossible to work out know which patients were mine, as we not only see those referred but also support the treatment provided by paediatric and other colleagues. A team approach to NHS care makes bean counting irrelevant. Competing interests: None declared |
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