Below is the latest in our series of talking point pieces under the heading of “Breakfast Chat”, intended to provoke thought and discussion.
A medical consultant’s thoughts on the Guernsey health system
First some history. Forty years ago in Guernsey, primary and secondary healthcare (ie general practitioners and specialists) were combined in several private medical practices. This was perhaps an unusual solution, in view of the size and remoteness of Guernsey.
It was an entirely private system funded by the patients themselves, often through various health insurances such as Oddfellows, and Foresters, and the more usual commercial insurers, such as BUPA. The States of Guernsey helped those on social benefits.
All private practising doctors covered the emergencies at the Hospital by a rota system through what was then called the Receiving Room – which went on to be called “A and E”.
That system made life very varied and interesting for practitioners and it worked well. It was also relatively cheap to run, with sharing of costs and overheads. Patients were also seen much more quickly, because referrals were within the same structure. The only real difficulty with this model was the expense of major surgical procedures for people who chose not to take out insurance (or were unable to do so and yet not on incomes low enough to entitle them to states benefits). They were in a minority, though, and of course could make arrangements with their practice to pay the bill over time, or the bill would sometimes be waived, and thus the losses were shared.
In the early 1990s, the States then effectively intervened and insisted that specialists and GPs should separate, and that the specialists should form their own private practice. They said that their aim was to provide a “more balanced” service. They were also concerned to limit the number of consultants who could practise.
The Medical Specialist Group was therefore formed, in effect, at the behest and the insistence of the States, with the agreement (although reluctantly in some instances) of the specialists of each practice. The States did not, however, provide land or accommodation for the new specialist group, and the doctors themselves, therefore built the specially designed MSG building.
Approximately two years after the MSG was formed, the States resolved to introduce a compulsory insurance scheme for secondary care. However, they were unable to find a reasonably priced, inclusive, insurance company provider and so they chose to fund the system themselves, as they have been doing ever since.
This was arguably a mistake; the Board of Health lost the chance of a better system when they concentrated only on secondary care, and making that free at source.
A contract was concluded between the Board of Health and the MSG, renewable at regular intervals with reviews on performance criteria as to waiting times for appointments/operations etc. However, within the contract there was no consideration given to criteria to monitor the clinical outcomes of this system. This seemed strange. However, this contract has soldiered on over the years. It is now past its sell-by date and there needs to be a total review of both primary and secondary care systems.
Primary care has been largely ignored by politicians to date, and the GPs have been able to develop their practices, largely without any States involvement. The current contribution made by the States to each patient consultation fee is now wholly unrelated to the actual cost, so that the actual patient contribution is way above that of the States contribution.
The initial MSG contract put extreme pressure on the consultants to see new patients speedily and within set time frames. However the GPs did not act as efficient gatekeepers, and there was no real incentive to them to do so.It was probably easier for them to pass patients over to a specialist, even though their treatment was well within the GPs’ own capabilities. The GPs were no doubt also under pressure from the patients themselves to be referred to specialists, as that was entirely free to the patient. The actual referral rates were therefore extremely high, compared to other systems like the NHS. This also, would tend to lead to some GPs becoming de-skilled in the management of conditions that would, historically, have been managed by them – as they were and have continued to be in the UK.
The time is long past to get to grips with the entire system of primary and secondary care.
The States of Guernsey, through the Board of Health, gradually became increasingly directive of the MSG, and this has gradually eroded the consultants’ incomes. This has led to the extraordinary situation under which primary care doctors, remaining entirely private, have been left alone to charge what fees they want, whilst consultants have been subject to constraints. It is believed that the result has been that GPs now earn significantly more than consultants.
The States appears to have been trying to develop a system which resembles the NHS. This is sad and misguided, as the NHS system itself has real problems, and is deeply flawed. There is a common pattern in Guernsey, to follow many years behind trends in the UK, but then to ignore the flaws which have come to light through experience, and blindly just decide to follow in the UK’s footsteps. The way in which the education system has been changed is yet another example of the States failing to take into account the outcomes and demonstrated problems of systems tried by others, and from which they have the opportunity to learn.
Sadly, and in the same vein, there has been a vast increase in the number of administrators in the health system in Guernsey over last 40 years, with all the attendant bureaucracy, resulting in decision-making being slow and unwieldy. Members of the medical profession who were dealing with States officials came to spend an inordinate amount of time in committees, discussing the same thing month after month, without leadership or effectiveness from the Department of Health. One example is that specialist obstetricians tried to discuss the problems which they saw in the midwifery service with States officials, but were firmly reminded that this was not their business, as the system was run by the civil servants. Scant regard was paid to the views of the specialists; the officials seemed uninterested in the views of the actual professionals. We all know what happened, then. A predictable and avoidable incident caused the Department of Health much heartache, expense, resignations and political upheaval.
The result of that incident sadly being the death of a baby, the States then decided to introduce a very expensive, UK type system of overarching regulation, when, frankly, a simpler, more appropriate, less expensive and “Guernsey friendly” solution should have been introduced. This has arisen because the people who were engaged by the States to look into the problem and come up with a remedy, were commissioned from the UK, and therefore, having only the experience of the NHS, they come with both a lack of wider imagination and a predisposition to think that only the NHS systems, which they are used to, provide the answer. They ignore and overlook the different needs of a small island, and what is really appropriate here.
As regards the future, it would be good to see:
- More input from the medical professionals into health care, and less micro-management from politicians. This has been a common negative feature of various committees over the years.
- More investment into private care (eg expansion of facilities for private patients/more private rooms and care/separate theatres for private patients). This could be be funded either by the States, or by private investment – and it could surely be a very good income generator for the island.
- The encouragement of private health insurance by giving tax breaks for premiums and to reduce cost to the States.
- A recognition that if the system continues to erode the standard of living of consultants, there will inevitably be more problems with recruitment and the standard of service and the calibre of consultants will fall.
- Consideration being given to a method of taking more control of GP practices to bring down costs and to save States money by ensuring that there are no inappropriate referrals to “free” specialists.
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