Teaming up with UK unit would mean more-specialist healthcare

Specialist health care universally is becoming extremely expensive. The provision of high-quality secondary health care at an affordable price is a dilemma that the Guernsey politicians will have to wrestle with. Medical care is much more complex and specialised than in the past and more so year on year, reflected by dramatically improved clinical outcomes but at a heavy financial cost.

Life expectancy is increasing, resulting in a greater proportion of older patients, compounded by the general population's increased expectation for the best treatment, irrespective of cost. This medical burden is a challenge for larger communities. Guernsey and other small communities are particularly vulnerable. A 60,000 population in isolation is not medically viable. UK hospitals have catchment areas of half a million or more. Small units have been integrated into the larger units not only on cost grounds but more importantly on results.

Regrettably, the day of the general physician and general surgeon are over. Originally, a general surgeon was trained to cover multiple specialities. As surgery advanced, surgical specialisation developed, for example, musculo-skeletal disease was treated by orthopaedic surgeons rather than general surgeons. In response to the need for full-time specialist surgeons in Guernsey, in 1992, health care separated into primary and secondary care. Specialist surgeons were appointed in orthopaedics and ENT. It resulted in a better and more modern service but was not welcomed by many senior doctors at the time.

It has served its purpose and allowed the appointment of consultants in a number of medical and surgical sub-specialities. But now with a mushrooming of sub-specialities and best practice encouraging surgeons to work in teams to improve outcomes and not in isolated, single-handed practice, the same valid arguments arise. This and the increasing costs of health care are demanding a further major evolution in the delivery of specialist services locally.

Today, the surgical training programs are training very specialised surgeons. In orthopaedics, in single-joint surgery, for example hip surgery, knee surgery, foot and ankle surgery etc. They are trained to a very high degree in advanced techniques and their consultant practice is confined to a very narrow area. Furthermore, in larger units, surgeons can work in teams with all its benefits to both patients and surgeons rather than in isolation. This is not just confined to the surgical specialities but to the medical and paediatric specialities as well.

A recent seminal paper, 'Getting it right first time', by Professor Tim Briggs, at the time president of the British Orthopaedic Association, emphasised that not only was that the goal of every surgeon and the desire of every patient but failure to achieve it resulted in costs many times greater.

Not only is revision surgery itself expensive, it is compounded by additional costs for community services, sick pay and loss of productivity. The same is true in the medical specialities – the cost of treating the complications of treatment is staggering.

Specialist organisations are now publishing lists of recommended surgeons for specific procedures. There is an abundance of evidence that high-volume units achieve superior results than low-volume units. In a recent edition of 'Bone and Joint 360', June 2014, it stated '... despite the accumulating data that complication rates are surgeon and unit volume dependent, there continues across all regulated healthcare economies to be no regulation on a minimum safe surgical volume. We wonder here at 360, with the ongoing publication of articles like this, how long it can (should) be before health care regulators act on the growing volume of information supporting the desirability of high volume specialist surgeons.'

What is a safe volume remains difficult to quantify but working in specialist teams with daily peer review enhances and shares experiences. The medical insurance companies recognise this with their approved-surgeons lists and medical indemnity providers limit who they cover in certain high-risk specialities. Doubtless these providers of health care and medical indemnity will impose their regulations if the medical profession does not.

Guernsey has always sought and has been provided with a high standard of secondary care, delivered promptly and by a 'familiar face'. With the spiralling costs and increasing sub-specialisation, has the time come for Guernsey's consultants to be fully integrated into a mainland centre of excellence?

A bold step, not immediately attractive to an independently-minded Guernsey resident. But the reality is that a 60,000 population in isolation is no longer viable, either medically or economically, to provide affordable, high-quality, modern, specialist care.

Guernsey has a second-to-none hospital with excellent support services, including nursing, physiotherapy, imaging and laboratory services. A facility that any centre of excellence would be proud to work with. Integration is required at medical consultant level. It would bring with it many advantages, both to the profession, para-medical services and patients, and to the States' finances.

There would be the opportunity to expand the on-island consultant services with the appointment of more-specialist surgeons. This would be achieved by split appointments between the mainland centre of excellence and Guernsey. This is a common situation presently in the UK with surgeons working at multiple sites and not without precedent in Guernsey. Two Guernsey surgeons have had a weekly clinical appointment in the UK for many years, one in the NHS and one in the private sector. It overcomes the problems of isolated practice. Surgeons welcome the opportunity to work with similar-minded specialists and be fully integrated as active members of a dedicated team of sub-speciality surgeons.

Ad-hoc attachments without clinical responsibility fail to provide the same clinical benefits or governance. The difficult case is easily shared and by concentrating on their sub-speciality, they and their patients can have the benefit of being part of a high-volume unit.

Mainland surgeons working in Guernsey would be part of the resident team and fully committed, when safe, to provide surgical services on island in the PEH. Patients would be able to obtain advanced, modern, sub-speciality treatment on island rather than having to travel to the UK with the additional cost to the state. Integration with a single UK unit at consultant level would still give patients a service provided by a familiar and accountable consultant face locally. Furthermore, the States travel budget would be greatly reduced as the travel cost of one consultant is considerably less than the travel costs for a whole clinic of patients to go to the UK.

Standardisation of best-practice treatment protocols would be rapidly established and monitored with enhanced cost savings. The introduction of new, expensive procedures would be controlled by peer review. Clinical practice would evolve as new techniques were introduced by the speciality teams and old procedures discarded. If certain specialities were no longer required or appropriate on island, that specialist could be relocated to the base hospital.

Vascular surgery is an example of this. Years ago, two vascular surgeons on island were appropriate. With a change of practice, the workload on-island no longer justifies a full-time vascular surgeon. With integration into a large unit, consultant vascular sessions on-island could be reduced and substituted easily and earlier for the expanding specialities without waiting for retirements or accepting very expensive over-staffing.

With the present arrangement of full-time, on-island specialists, it is inevitable that there is over staffing for daytime needs in order to provide sufficient consultants for night cover. Split appointments increases the pool of specialists available for night cover at no additional cost. The current and appropriate trend is to reduce excessively long working hours. This is legally enforceable at non-consultant level in the UK. Inevitably this eventually will apply to consultants in Guernsey. The appointment of additional full-time consultants would be an extremely expensive solution with daytime redundancy, and it would lower surgical volume rates, exactly the opposite as to what is desirable.

Integration with a UK centre of excellence with split consultant appointments is a 'win win' situation for all, above all for patients, who would receive treatment by a senior member of a dedicated team of sub-specialists on-island. Guernsey specialists would be able to develop their specialist skills and be active and clinically responsible members of a sub-speciality team with all the advantages of increased work volume, regular peer review, clinical conferences, involvement in the introduction of new techniques in a team setting and clinical governance.

'Guernsey Limited' would have reduced manpower costs and be able to maintain the present high quality of medical services in the future, in spite of the increasing complexity of medicine demanding increasing sub-specialisation. Hopefully also benefitting from Professor Briggs' mantra of 'Getting it right first time'.

To contain costs but not at the expense of care, in tandem with assimilating Guernsey consultants into a UK centre of excellence, elderly care must be prioritised.

Demographics are rapidly changing, with fewer people of working age supporting an increasingly elderly population.

Health prevention, regular assessment of the elderly, provision of both hospital and domiciliary rehabilitation and hospital-in-the-home services, along with adequate short- and long-term accommodation, need to be increased. It is cheaper to prevent than treat and it is cheaper to treat early than late.

This service can be provided by a consultant-led service rather than an expensive consultant-provided service. Non-consultant-grade physicians should be appointed along with an expansion of nurse consultant specialists, occupational therapists (historically, in Guernsey, hopelessly under resourced), extended-role physiotherapists and above all by carers, all of which cost considerably less than a third of a million each.

The current situation of specialists carrying out junior tasks on the ward and in clinics is a total waste of their skills and States money.

These services are better provided by non-consultant medical staff and paramedical specialists.

This would free up a considerable amount of their time and would allow Guernsey's high-quality senior physicians to concentrate on consultant sub-speciality work. This, along with split appointments, would enhance the specialities covered on-island at no additional cost and avoid over-staffing needed to provide night cover.

Guernsey has an excellent secondary healthcare system as a result of the split into primary and secondary healthcare in 1992. Evolution and change is essential if Guernsey wishes to maintain an affordable, high-quality service for all that is free at the point of delivery.

As always, Guernsey will devise its own, unique solution, but it must exclude vested interests, as did the courageous reformers in 1992. A challenge to the politicians that I do not envy.

DAVID PRING,

Consultant orthopaedic surgeon.