It sounds like a marvellous idea—a cross between John Mortimer's Rumpole of the Bailey and James Herriot's All Creatures Great and Small. But are medical chambers a pipe dream or a serious way forward for the NHS?
Since the BMA produced a discussion paper on setting up medical chambers last May, some consultants have begun collaborating in private practice under formal partnerships and limited companies, while continuing on 10/11ths NHS contracts. But how far do such part time collaborations go in testing the private chambers concept, and what effect would private chambers have if they did spread across the NHS?
According to the BMA's concept of medical chambers, consultants would become self employed, free standing practitioners, working from private chambers with fellow clinicians, who charge the NHS per service supplied. The beauty of it would be more independence, possibly higher incomes, and no more management or administrative duties unless one opted into these (and charged accordingly).
Part time private collaborations among doctors who sell their services to the NHS are widespread across pathology and anaesthetics, and there is talk about setting up such arrangements in cardiothoracic surgery, ophthalmology, and orthopaedics.
Pathology is suitable for the group approach because of severe skills shortages—nearly a quarter of consultant vacancies remain unfilled—and because work can easily be packaged up into manageable chunks.
Nottingham based company Pathlore runs a triage (or “remote locum”) service for trusts undergoing a staffing hiatus. Routine work is split into one hour chunks of 20 samples; each pack is couriered to a relevant specialist from Pathlore's list of 41; and the results are returned within five days. To maintain standards, consultants work only within their area, from a list of 16 subspecialties. The consultants all received permission from their trusts before they signed a contract for services with Pathlore, a limited company in which they each have a stake.
Consultant pathologist at Nottingham City Hospital Dr Ian Ellis set up Pathlore in March last year as a subsidiary of the equipment and diagnostics group Medical Solutions. He believes it is a practical way to find spare capacity in an overstretched specialty. Members can do their private work more efficiently—they simply come into hospital an hour or two early—at a fraction of the usual cost.
“We're looking at this in quite a scientific way—‘how can we do our jobs so we’re more efficient and happier with it?' It's 5-10% of what you'd charge for a private case because we can provide people with a work package, receiving £10-£15 [$14.30-$21.45; €16.40-€24.60] per case,” says Dr Ellis. “We're doing something we feel is important, but we're facing a lot of criticism because we're backed by a commercial organisation.”
Other consultants have chosen the less contentious partnership route. Four urologists from the Royal Berkshire and Battle Hospital Trust in Reading have gone into partnership, so that they can stick to their subspecialties in their private work, share overheads, and conform to clinical governance requirements, including audits.
The partners have been asked on an ad hoc basis to do elective surgery such as prostate surgery on NHS patients, designated as “long waiters.”
One of the urologists, Mr Derek Fawcett, says that their decision to team up, in September, has safeguarded their standards in private practice and relieved pressure on them as individuals.
“It's jacked up the quality. And we can share on-call rotas in private practice. We can become ill and maintain our private income, and we can possibly take sabbaticals from private practice without losing income,” he says.
Shared private practice also gives consultants a psychological boost by offering an escape route should NHS working conditions deteriorate unacceptably. “We would be in a position, if we wished, to negotiate with the NHS—if we thought it was appropriate in the future,” says Mr Fawcett. “But we have no desire to leave the NHS at the moment.”
Collaboration in private practice is also widespread among anaesthetists because as individuals they have felt vulnerable and reliant on good relations with a particular surgeon to get private work. The Oxford Anaesthetics Practice is over 40 years old, and now has 25 full partners. It has secured NHS waiting list initiative work for partners, through a private hospital.
The advantages, according to senior partner and honorary treasurer Dr Michael Ward, include lower overheads and increased clout—often with six partners attending private operations at the same time.
Dr Ward says that practising as a group helps him to plan his schedule so he can deliver his NHS commitment better.
“I know, for instance, that I'm not going to get phoned up tonight to say I've got to do a private appendectomy,” says Dr Ward, a consultant anaesthetist from the Nuffield department of Anaesthetics at the Oxford Radcliffe Hospitals Trust.
But just like working in the NHS, group private practice means compromising, going with the majority vote, and adhering to clinical governance—which could frustrate some lone-wolf consultants.
“You have to be certain that you all agree on what each member can and can't do—so they aren't tempted to work outside their specialty,” says Dr Ward. “And if you get invited to give a lecture somewhere you have to ask the partnership if you may have that day off. It's like a small department in that sense.”
But some experts in public- private partnerships are sceptical that the chambers system in its purest form will ever work. Research fellow at the King's Fund Anthony Harrison believes that creating networks of specialists is an excellent move, but the private chambers model could stoke up animosity between clinicians and health service managers.
“If we know one thing about the legal system, it's that it was tremendously badly organised and time wasteful—now they're turning judges into managers to sort cases out,” he says.
“Chambers is going the wrong way. We should do what many parts of the profession are already doing—that's being more involved in management of patient flows, and not treating the management as the opposition.”
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MAGGIE MURRAY/FORMAT
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