How would you feel if you had had an operation or treatment that you thought was necessary and then found out that you never needed this treatment? If you were told you had cancer but you never had it? Pretty let down I would think, even if the operation were “successful”. Think of all the unnecessary worry, the discomfort, sometimes pain, the interruption to your schedule, the insult to your body and body image. If there were complications you would feel devastated. So when I read of the surgeon who was convicted recently for doing just that, I wondered again about his motivation.

It is easy to see why a surgeon might perform extra operations in the private sector – money. The surgeons are paid directly for each operation they perform. They can decide for themselves which operations to do and which not to do, and are constrained only by the concept of “good medical practice”. This is decided and promoted by the Royal Colleges of each speciality, and doctors at the top of their tree, well-respected consultants, look at the evidence for each operation or new therapy. Guidelines are issued, and doctors are expected to follow them, under threat of GMC action if they transgress. However in the private sector they are less constrained by NICE guidance, which gives advice on what would be cost effective for the NHS. So as we have seen, this doctor did not follow the consensus of his peers, and persuaded patients to undergo operations for various reasons. Some of them were told they had cancer when they didn’t – how evil is that? Some of them were persuaded to have operations that he liked to do such as the “cleavage sparing “ operation, despite the lack of evidence. Some of them presumably didn’t mind the inconvenience and discomfort and had operations, which they were told would improve their looks. What ever the reason patients parted with their money, and he assaulted them, banked the money and spent it.   Wicked, criminal behaviour.

But this surgeon in fact did most of his unnecessary operations on the NHS, and it is more difficult to see the motivation there. A surgeon is employed by the hospital on a salary, which is set in stone, and he does not get any extra for working harder. The only way of getting more money is through the “merit” system which gives a bonus to those doctors who are considered to do the best quality work in their speciality. Some heavily criticize this system because it is biased towards those in teaching hospitals, but no one can say that doctors getting these awards do not follow guidelines to the letter. On quality you cannot fault the system. It does not reward doctors who have the heaviest workloads, or do most of the routine operations that are boring for the surgeon but are most helpful, and sometimes life changing, for patients. So why would an NHS doctor deliberately persuade patients to have more operations when it will increase their workload for no more money?

Having worked in hospitals and as a manager, as well as being a GP, I can understand the temptation. In a profession such as medicine the route to success, prestige and power is the development and expansion of your speciality and your reputation amongst other doctors. For several years I worked with consultants on a scheme to improve the quality of referrals from GPs, to make sure that each referral made was to the right specialist; for a condition that was according to up to date guidelines; and where all investigations had been done to ensure that the diagnosis was correct. One of the aims was to reduce the vast variation on referral rates from different GPs and so to save patents from having unnecessary treatment. There was also a hope there might be a cost saving for the NHS by making sure that NHS money was only spent on doing essential treatment.

I had naively thought that consultants would be extremely keen on the scheme because everyone expected it to reduce their workload, and make the referrals they got much more focused. I was amazed to find quite early on that some consultants, especially orthopaedic surgeons, were actively against the scheme and would not take part. I had to work extremely hard to get any to turn up for our joint meeting with GPs despite the fact that they had time set aside in their schedules (and therefore paid for) to do so.   Yet orthopaedic surgeons had the longest waiting lists, and more unnecessary referrals than any other surgeon, and worked very hard as a result. Why did they not want to reduce referrals?

I eventually realised that waiting lists were far from a problem for the surgeons, but more a source of power. If a surgeon had a much longer waiting list than others it meant that they had more clout with managers whose responsibility it was to clear the waiting lists. They were likely to get more junior staff to help them, and do many of the routine operations while they could concentrate on the bigger more challenging stuff, and more resources that would further develop their speciality. A large proportion of patients referred to them are never likely to get an operation because the solution to their problem is much simpler – lifestyle advice, physiotherapy, podiatry, etc. But if their outpatient clinics weren’t full of patients like these there wouldn’t be a waiting list at all. That would result in managers deciding to put any available extra cash elsewhere, and they might get fewer junior staff in their department. They would lose some of their importance and prestige.

Crucially it would also impact their private practice. If a patient who needed a hip operation could be seen within a few weeks there would be no incentive for them to “go private”. Most private consultations in all surgical specialities result not in a private operation, but in being put on the NHS waiting list, sometimes quite far up the queue. It is perfectly legal. So the patient would pay £150 for a private consultation and would get a quick NHS operation which would have otherwise cost thousands. In our area we found that when the waiting lists came right down in the last years of the labour government, the number of private referrals nose-dived. That did not go down so well.

There were also a few consultants in our area who honestly thought that everyone should be seen by a consultant, even if they did only need a physiotherapist, because only a doctor would be able to pick up on the rare condition that needed further treatment urgently (mostly rare cancers). This is a very old fashioned view now as most physios, podiatrists and other professions allied to medicine are themselves very well trained and know when to refer on. But old habits die hard, and some consultants were very against GPs doing a better job of screening their patients and sending them to the right professional rather than making them go through the hoop of seeing a consultant and then a physio or someone outside their speciality.

I must add that only a few consultants actively obstructed our work and most specialists, especially those with managerial roles, were very keen to help.  Breast surgery is also a slightly different case as most breast clinics are tightly managed,, so it has always been more difficult to overtreat. But the culture 10 years ago was very much that consultants would fight for power, prestige and resources, and accurate referral to their speciality was not high on their list of priorities. I doubt if things are much different now.

So this surgeon working extra hard by doing unnecessary operations was not completely outside the mould. He was “shopped” early on by his colleagues who realised that they were all working harder because of his behaviour, but they were probably unaware of how much his work was against patients’ interests. It may have been that the system worked against anyone who really wanted to stop him, and this might have been one of the reasons it took so long to discover exactly what was going on. There must have been other reasons though, and in future the system must ensure that such activity is picked up and stopped immediately it is recognized. The private sector must also be much more tightly regulated so that patients can get recompense as of right. At the moment many of the patients affected will struggle to get any money despite often having been cruelly harmed, as neither the surgeon nor the organisation he worked for had adequate insurance. The NHS has already paid out huge sums, but private patients have no such protection.

This whole sorry tale has an importance beyond one surgeon’s nefarious activity. It goes to the heart of the “privatization” battle in the NHS. The concept of a wholly public NHS, with doctors concentrating entirely on their NHS work, has never worked, and can never work, as private treatment has to be allowed.  Where patients are paying either directly or through insurance for their treatment there is little incentive for doctors and private companies not to do operations or provide treatment, even if there is little evidence that patients are actually helped in the long run. This is the main reason for the huge cost of healthcare in the USA – more and more investigations are done, more treatment is provided earlier and earlier and costs rocket. But patients are not better off – in many cases the condition would have got better perfectly well on its own, such is the ability of our bodies to heal themselves if we wait, with much better functional results in the end. A friend in the USA had a series of operations and investigation on his knee, and suffered a lot of pain after them, but in my practice patients with problems like his would get better with physiotherapy – they might have to wait six months but they would not have had to have a painful operation. The overall results of healthcare in the USA are worse, not better, than in other developed countries including the UK because there will always be complications in some cases, and patients’ money is wasted on unnecessary treatment.

There is a big risk we are going this way in the UK with more privatization with big for-profit corporations organizing more and more services. These companies are the reason behind the privatization drive as investors can make huge profits at the expense of patients. The culture in the private sector is that patient choice is paramount so that they can have treatment much more easily if they are paying, but it is imperative that these big corporations are accountable to the patients and shoulder the insurance costs.

My personal view for the future of the NHS is that we should be given a political choice. We can have an increased range of services, with some more risky treatments being allowed if we agree to put more money into the health service. So for instance, we could have a tax on income which would be ring fenced for the NHS, or we could have an increase in national insurance, and with the elderly who use the most services having to pay a graduated national insurance contribution (they do not pay NI at all at the moment.) If the NHS continues to be starved of funds as it is at the moment there will be no option but to streamline treatment so that there is less patient choice, and treatment which is outside evidence based guidelines is completely prohibited. If you are considering a treatment which is only marginally effective in the hope that you will benefit (even though statistically most people won’t) then you would have to pay. At the moment most NHS doctors (and all private ones) will give you the benefit of the doubt, and indeed they have to as they are required to provide “all necessary treatment”, but there isn’t the money available for this to happen at the moment. Unless the general public agrees to pay more, and crucially the government agrees to stop further privatization, the NHS should restrict itself to treatments that are conventional, with an extra fund available for new and exciting developments in a separate income stream. That way those that cannot afford to pay may be ensured that they have unrestricted access at least to those true and tested treatments,

Breast surgeon convicted of carrying out unnecessary-srgery

https://www.radionewshub.com/articles/news-updates/breast-surgeon..