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Commentary |
Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Massachusetts General Hospital, Boston, MA 02114, USA
Correspondence: Dr Giles Boland, Department of Radiology, White 270C, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA. E-mail: gboland{at}partners.org.
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Abstract |
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The founders of the National Health Service (NHS) intended that it was the responsibility of government to provide free healthcare to all British citizens at the point of delivery. However, they could not have foreseen the dramatic medical innovations over the last 50 years, nor their cost. Nor could they have predicted the massive increase in demand for these services. Whether they would have advocated the same mandate with this knowledge in hindsight is open to debate, but the relentless and increasing demands on clinical services have undoubtedly demonstrated profound weaknesses in the structure of the NHS. While this is true for most clinical services, radiological services have been particularly exposed. Massive increases in demand have meant prolonged waiting lists for essential radiological services, with some patients having to wait months for basic diagnostic and therapeutic procedures [1]. The Audit Commission in 2002, for instance, demonstrated average waiting times for outpatient MRI at 20 weeks and for CT at over 6 weeks [1]. Although waiting lists for these services are coming down, most consider waiting lists for radiological services within the NHS to be unacceptably long. Worse, the demand for services continues unabated due to an ageing population and because patients and their doctors see an ever increasing value from these radiological services. Newer and better imaging techniques combined with newer imaging applications means that imaging is now increasingly used as a primary diagnostic tool [2, 3]. This in turn has raised the stakeholder expectations from radiology for hospital administrations, referring physicians and patients alike. However, as the number of radiology investigations performed today cannot meet demand (and is likely to deteriorate further), an unsustainable tension has arisen between the NHS providers of radiology services (radiologists and radiographers) and their customers, the referring physicians and patients.
The cause of this crisis within radiology, however, is not so clear. Many stakeholders, particularly the providers, advocate that the NHS has been significantly and chronically underfunded, leading to too few radiologists, radiographers and equipment (i.e. resources). Undoubtedly there is some truth to this despite the recent expansion in the number of trainee radiologists [4]. Britain has some of the fewest radiologists per head of population when compared with other Western nations, approximately half that of Germany and one quarter that of France, although it is interesting that Britain also has one of the fewest number of examinations performed per head of population in Western nations, suggesting it would need fewer radiologists (the UK performs 52 investigations per 100 head of population annually compared with a European annual average of approximately 100 investigations per 100 head of population) [5]. Furthermore, government itself has recognized that the NHS has been underfunded and is currently injecting massive increases in cash into the NHS in order to bring its expenditure on healthcare in line with other Western European nations [6, 7]. In England, the cash budget for the NHS has doubled since 1999 [6] with large increases to radiological services. However, the real and sometimes perceived lack of resources is too often used as the explanation for much of the NHS' problems in general, and particularly for radiology, due to the high cost of its resources. Indeed, attempts by recent governments and others to seek better value out of existing resources have often been met with resistance [8, 9–11].
However, without precise data to benchmark the utilization of current resources, it is not realistically possible to accurately argue one way or the other. The Audit Commission of NHS radiological services in 2002 gave some insight as to what analysis of existing resource utilization might show – that a significant component of the shortfall in radiological capacity is due to the poor use of its resources. This report demonstrated major differences in the hours of operations of existing equipment and of radiologist productivity [1]. Most CT and half of MRI scanners were operational for less than 9 h day–1 and examination throughput for the same scanners can be less than 50% of that seen in the USA [12]. Productivity rates for radiologists (the number of investigations they interpret) vary significantly, with some consultants being three times more productive than others [1]. It has also been demonstrated that other clinical services within the NHS also fail to use their resources effectively [8]. As more accurate data become available it will be increasingly evident to most informed healthcare professionals (and probably the public) that public sector NHS reform is desperately needed. Such data will likely continue to point to marked variations in resource utilization. It will therefore become increasingly hard to deny the widespread inefficient use of existing resources, an unacceptable situation considering the high cost of these resources and that they are ultimately paid for from public funding.
What is controversial, however, is what reform is required, who should pay for it and what are the goals, incentives and achievable outcomes? Since the 1980s there has been a number of significant government policy agendas that have attempted to address this problem, but many have either run their course or been overturned by succeeding governments. However, the general concept of NHS reform and particularly market reform have stuck, and the current government has been actively seeking means to reduce waste and increase capacity through more efficient use of limited resources [6, 7, 13, 14].
This in turn has led to further tension amongst healthcare providers, particularly the clinical staff, as reform in healthcare is usually viewed with suspicion [8–11]. Reform inevitably requires an evaluation and measurement of current practices to establish the strengths and weaknesses of those services. National Health Service physicians have been generally resistant to having their practices measured [8]. Not only have they seen themselves historically as autonomous professionals, some may fear that any measurement of their services may expose significant discrepancies (either personal or organizational). Indeed, some may argue that one of the primary reasons why such little data on resource utilization is available is because it might expose such discrepancies and therefore give the doctor's adversaries the data they need to force change.
All this is, of course, understandable considering the organizational structure of the NHS. It is generally understood that it is not the role of doctors to measure resource utilization including their own productivity; rather it is left to the myriad of hospital managers that have sprung up over the last 20 years [7, 9]. Furthermore, if confronted with productivity data by their managers, physicians may feel that these managers do not fully understand the clinical issues that drive the healthcare process and therefore consider their data of little relevance. The result is that a situation of general mistrust and lack of morale pervades the system, whereby physicians feel over appraised and over inspected by professionals who either do not have their interest at heart, or more importantly, do not have the patient's interest at heart [8]. A relative stalemate has therefore arisen over the last 10 years whereby the interests of physicians do not necessarily meet those of other stakeholders, particularly managers and government civil servants. Interestingly, both sides passionately feel that they are defending the interests of the patients.
This lack of clear vision from NHS doctors to engage and address the variances in resource productivity and utilization in the public sector has forced the government to address the problems for them. The government has embarked upon an ambitious attempt to enforce better utilization of its resources, which in turn is hoped to increase the value of its healthcare system to its population. First, the government insisted on a new physician contract (albeit agreed to with significant difficulty), which was partly an attempt to align productivity with incentives [7, 8, 11]. Now it is attempting to reduce waiting lists by outsourcing large swathes of low risk outpatient surgery and diagnostics to the independent sector, either through development of specialized Treatment Centres currently under construction or directly to existing independent providers [15]. Indeed, the NHS is planning to purchase £1 billion of diagnostic services directly from the independent providers and hundreds of thousands of MRI services are already being outsourced to independent providers [6]. It is predicted that as much as 15% of the NHS funding may be shifted to the independent sector over the next 2–3 years as the government attempts to meet its political objectives [7, 8].
Perversely, these events may initially be strongly welcomed and encouraged by NHS healthcare providers, both managers and physicians alike, as they attempt to manage the prolonged waiting lists and meet the government targets imposed to help reduce patient lists. Some physicians may actually feel that this scenario may be a vindication of their position after all – namely, the government is effectively agreeing to their long standing opinion that more resources are needed – and bolstered by the fact that the government has now provided the necessary funding, albeit partially to the independent sector.
While these beliefs may bring satisfaction to some doctors in the short term, they may find that the government has the "last laugh". Unless physicians are willing to critically and objectively look at their organizations and departments and make significant attempts to work collaboratively to improve performance and productivity, their influence and even income may be marginalized. Under the government's proposals, the funds to pay for these clinical services will follow the patient to the institution that provides the services – the independent sector [7]. If the government's intentions are played out, a large proportion of outpatient imaging (perhaps up to 15% or more) may be outsourced to the independent sector. While this may ease the current waiting list crisis within hospitals, it will inevitably deprive these hospitals of much needed income down the road.
The effect of these government initiatives will equate to competition in the conventional business sense. A potential outcome for public sector hospitals that do not undergo significant reform and compete may be loss of valuable market share, which in turn will lead to lost revenue. In any traditional business, competition, which threatens its survival, is usually countered with restructuring and reform in order to become more productive and in turn provide similar services or products for less cost (i.e. they become more competitive). Ideally, in the process, restructuring may yield an increase in quality or value in the services, a very favourable circumstance. Within radiology, witness the impact that voice recognition technology can do to replace traditional transcriptional services. Within a few months of implementation, the financial costs are significantly less, but the value of the radiologist services (the ability to deliver a timely report) has greatly increased [16, 17]. The result is that customers (i.e. patients and referring physicians) have now gained a better product for less cost. It should come as no surprise to anyone within the NHS that this is exactly what the current government is trying to do. While many healthcare professionals may not like to think of themselves as conventional businesses, it is now increasingly evident that they need to think and act that way.
While any changes may be good news for patients, they may not be good news for many doctors. Through an idiosyncratic historical contractual arrangement, doctors have been able to earn significant income outside their primary work place (the NHS) within the independent sector [18]. Indeed, this contractual arrangement may be seen by some as having presented a conflict of interest to senior doctors in the NHS, in which longer waiting lists in their NHS practice served to increase the likelihood that those patients who could afford to (an increasing proportion) would move to their more lucrative private practice. However, this potential opportunity is under threat. If the government's reforms are successful, NHS waiting lists may start to shorten significantly. This could adversely affect many doctors who perform private practice. Doctors are likely to see a dwindling of their private practice revenues as more and more patients are either treated or evaluated in the government sponsored independent sector institutions or existing independent providers (paid for from government revenue). Any doctor thinking that they may benefit from the newly outsourced business to the independent sector is likely to be disappointed. The government has stipulated that most of the new opportunities in the independent sector may not be available to NHS employees or if they are, there will be significant limitations to the opportunities.
What are radiologists and other doctors to do in this unpredictable environment? One option is to do little, assuming that this is yet another government attempt at healthcare market reform that will run its course. While this is possible, the evidence is against this outcome. The government has allocated vast new sums of money towards this agenda and is determined for it to succeed. Those doctors who fail to respond creatively and positively risk being left behind. Not only will the doctor's influence be marginalized, it may be too late for them to save their private practice income should the government reforms be successful. Besides, even if the government initiatives fail, positive action by doctors to improve productivity and efficiency in the public sector should bring strong benefits to their organization and therefore the patients they serve. No one can argue that delivering timely efficient high quality healthcare to patients is not something worth striving for.
A more sensible option therefore would be for doctors to rapidly understand what changes are happening, why they are happening and what they can do to respond to these changes. First and foremost, they need to recognize and accept that this is a serious effort by the government to increase the value of the healthcare system to its population. While doctors may not necessarily agree with these initiatives, they need to replace their ambivalence and inertia by recognizing that health systems in 2006 effectively have to act along efficient business lines. Those who remain entrenched, believing that clinical care and business do not mix, may have a lot to lose. Doctors need to rapidly gain an understanding of the business fundamentals required to efficiently operate their specialty. For radiologists, it is vital they develop an understanding of effective resource utilization and mechanisms to improve departmental productivity. After all, they are partly responsible for managing and operating some of the highest cost items of capital equipment within their organizations. Typically this will require analysis of their existing assets to determine current operational productivity. Once this is known, it should then be possible to benchmark their operation against the best practices in the industry. The analysis will inevitably require operational changes to increase productivity from their existing assets, i.e. greater patient throughput. While some additional resources may be needed to make this happen, the costs are minimal compared with the overall benefit to the organization. For example, in radiology, two radiographers can perform more than twice as many CT scans as a single radiographer (and possibly even three times) [19, 20]. The number of patients scanned each day per CT scanner could increase from approximately 25 per day to over 90 patients per day (current volume of the busiest scanners at the Massachusetts General Hospital, Boston, MA). The cost of an additional radiographer is minimal compared with the thousands of additional CT scans that can be performed annually. Furthermore, increasing operations into the weekend and evening hours will further increase capacity and help to significantly shorten waiting lists. Analyses of many other parameters should also be performed including length of waiting lists, time to perform the procedure, report turnaround time, radiologist's productivity and costs per examination, amongst others [19].
Such an analysis of the operations will then permit radiologists to devise strategies and the tactics to counter the new threats and position their organization to compete with the independent sector. While radiologists may prefer to delegate analysis of their operations to their managers, there is unlikely to be broad acceptance by doctors for any changes that are recommended by other groups. Besides, because doctors are on the "front line" of the healthcare delivery cycle, they should be intimately involved in developing solutions to improve their operations. Doctors therefore need to become more business-like and understand their operations through careful data analysis and then cooperate with managers to maximize capacity and utilization of their fixed assets.
Inevitably this will require physician leadership, which will in turn require greater knowledge, which for many will require further education and training. It should not, of course, be assumed that managers understand appropriate asset management either and further training may be needed by them to understand how they can help maximize their organization's resources (staff and equipment). Doctors and managers will both need to learn to better cooperate with each other to improve the productivity and efficiency of their department, thereby creating a more valuable product for their organization. While this process is not easy (and typically change for some doctors has been difficult), it is essential that physician leaders respond to the challenge and convince their peers that it is in their best interest to change. This will require particular skill, particularly as many radiologists will immediately demand to know who is going to read the additional studies generated by any increase in productivity, particularly due to the relative shortage of radiologists.
The answer to this conundrum is not at all clear given the current contractual arrangement within the NHS. There has structurally been little incentive for doctors in the NHS to work towards increasing productivity and services within the NHS. Some may, of course, argue that this is one of the NHS' strengths; a system that provides financial incentives to doctors to perform more investigations on a fee for service basis is likely to be more costly [21]. However, it is extremely hard to significantly change organizational behaviour without offering some form of incentive. Unfortunately, attempts by some NHS physicians to help improve productivity and services have frequently been met with resistance from their managers who fear the increase in costs that may occur, even if marginal. However, Trusts are becoming more financially autonomous, so it is quite conceivable that radiologists could negotiate additional pay for the additional studies interpreted, perhaps on a modified fee for service basis. Besides, this financial arrangement has existed in the independent sector for many years. Furthermore, radiologists will be unlikely to participate in a service improvement program without some form of incentive, even if it is the right thing to do. It is therefore strongly recommended that managers seriously consider incentive schemes for radiologists who add value to their organizations and help to shorten patient waiting lists.
In summary, in order to bring greater value from the health service to its citizens, the British government is actively creating a publicly funded independent or part-independent sector that is likely to directly compete with the public sector NHS. A likely intention by the government, perhaps covertly, is to force public sector NHS organizations and particularly doctors to adapt to this new competitive threat. Those doctors who ignore or even resist these changes may have a lot to lose both in influence and financial reward. However, those doctors who respond creatively with knowledge, skill and leadership to maximize the productivity and value of radiology services within their organizations are likely to receive greater respect, recognition and probably financial reward. This in turn should increase the value that radiologists bring to their department, their organization, but most importantly, to the patients they serve.
Received for publication February 13, 2006. Revision received May 25, 2006. Accepted for publication June 14, 2006.
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