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Sue Smith Interview

This is an interview with Sue Smith, Chief Executive of the Independent Doctors’ Federation, about the challenges facing independent doctors and the independent healthcare sector more widely, how the sector might grow and where we might be in ten years’ time.

Q So how do you view the future of the private healthcare sector?
Well the first thing I would say is that much of what we have today is going to be the same and I think there will also be huge changes. How that will actually affect patient care I think is yet to be evaluated. But it’s a very exciting time.
And predictions are difficult. Predicting the future of healthcare, I think in this day and age with digital technology etc is almost impossible. But it’s an exciting time and I’m looking forward to being part of it.

Q:  And what are the current challenges for private healthcare?
I think the challenges for private healthcare are not isolated. It has to be looked at in context of what’s happening in the wider world, particularly with the public sector, with the National Health Service, but also the pressures that come to us internationally and politically because they do affect what is happening on a day to day basis.

Private healthcare hasn’t really grown that much and much of the private healthcare facilities in fact deal with public patients. And so we’ve seen quite a differentiation of the caseload in private hospitals. In central London it continues to be mostly private, but if you go out of London then you do see a completely different mix of patient workload.

That does have an impact on the perception of the general public about what private healthcare is and of course there is a big dilemma and desire amongst many people that healthcare should not be privatised. But, as we know of course, it is being privatised here and there, particularly in the community, particularly by big players and actually at the point of delivery the customer doesn’t know any different because we are all here to provide the same service which is excellence in healthcare.
But it does have an impact overall and it has a particular impact on how costs are managed. And when you get pressure on cost management, it has an impact on how you deliver the service. So, for example, there is always a downward pressure from the private medical insurers – the PMIs – for hospitals and doctors to charge less. But to provide a better service. So there’s an emphasis on ‘What does a better service look like?’ ‘What is excellence?’ ‘How can we measure it?’ And yet at the same time ‘How can we do it with less resources?’  And that’s a quandary because there isn’t an answer to that and it requires a lot of new types of thinking and new types of interventions. And that’s going to continue. It’s been a feature of the way we practise for at least the last ten years and I see the pace quickening. The pressures on both providers and doctors to adhere to some new sets of rules almost takes over from the base principle of caring for patients.

How we’re going to make the most of that I think is a difficult question. The pressures are coming from every angle.  So we have the pressure of cost, much of which is led by the PMIs. But we also have the pressure of regulation and that does impact the way that doctors work, particularly in the private sector. If they work in a big hospital, the hospital provider takes a lot of the burden away and so, as far as the CQC is taken for example, if you’re a doctor working in a private hospital, you’re guided and directed on how to meet CQC requirements. But if you’re working outside of a big hospital, if you have your own rooms, or if you have your own group, you actually have to become a registered provider. There’s a huge bureaucracy attached to that. And so many doctors who leave the health service, who think they’re going to have more time to care for patients, which is one of the prime motivations, actually end up dealing with as much as, if not more bureaucracy than they faced elsewhere.
They have to take more time to organise their practices. They have to be quite disciplined about recording what they do and not just about the patient care but about how they make decisions and how they can justify those decisions. That is a change from ten, twenty years ago when you could enter into private practice, you could go and operate on your patient and you could go home again.  Actually you can’t do that in the same way today. and so it does bring a new dimension into doctors considering whether or not they will enter private practice.. And I think that’s a challenge for independent medicine. How are we going to ensure doctors have options of how they practise?  But the biggest challenge for them is ‘Can I, with all of the restrictions which are being placed upon me, can I actually deliver the good patient care that I want to and can I provide myself and my family with that supplementary income which private practice has traditionally given me?’

I think doctors need help and support in making those decisions and that support will come from a number of avenues and certainly the Independent Doctors’ Federation is one avenue where our mission, if you will, is to enable clinicians, doctors, all healthcare professionals to provide the best quality care – excellence in healthcare.

I don’t think doctors can do it on their own any more. The day of the lone practitioner has long gone. There is continuing pressure from the private medical insurers. They are beginning to insist that doctors work in groups. And we will find before too long that insurers won’t recognise doctors who work in a single-handed practice. I think if we look ten years hence, that will clearly be the case. So the next generation of doctors are going to have to think very carefully how they position themselves, where they position themselves. Are they going to ally themselves with one big provider? Are they going to form a group and develop a management structure that can manage this for them? That’s a big change in independent medicine if we think back ten or even twenty years.

So we’re going to see private medicine practised differently. As a whole there is a requirement from the general public, from the politicians, to justify what private practice produces. Does it have the same quality?

We’ve seen some very recent adverse press against private medicine and its accountability. I think that sometimes it can be patchy.  But it think that it behoves all of us to work together to ensure that we are able to justify what we’re doing, that we are practising best medicine. The best endeavours of the whole team are essential to make healthcare in the private sector as good, if not better, than you may receive in a public institution.

There is no doubt that regulation has had a huge impact on healthcare and it’s impacted independent medicine as much if not more than public medicine. It may have been less understood quickly enough but today it is an overriding concern for all of us who work in independent healthcare. And this applies to the CQC, the GMC, the RCN, whatever it is. And the impact of the Competition and Markets Authority, who have really dictated the way that we’re going to operate, is important and we certainly need to spend more time helping – particularly the doctors – understand how they can adhere and conform to what is being required of them, but to be able to do it in a time-efficient manner with the best outcomes. Because once patients know more about outcomes, they are going to look around for their choices. And we can no longer take it for granted that just because we have a title, we will be the doctor of choice. So I think that that is going to have an impact.

One of the biggest changes that has occurred in the medical world is the introduction of appraisal and revalidation. There’s a long history about why it was felt necessary to bring in this system in a more structured way. At the IDF we have an appraisal and revalidation service and it’s recognised. We are a statutory, regulatory, designated body and we see some 600 doctors who go through our service. It’s an important service in as much as when you’  re working in the independent sector you do need to have some peer challenges, some peer support in order to ensure that you remain up-to-date, reflective on your practice and in touch with your patients. And that can only be good and it’s not just for the National Health Service. When you work independently, in the private sector, you are actually more on show. You do tend to be focused on for the negatives as opposed to the positives, and appraisal and revalidation can really help you manage your own career if you use it to its advantage and see it as a benefit, not as a burden. And so I would encourage doctors really to use appraisal and revalidation as a tool for their careers. Yes it is a regulatory requirement. But it can be more than that. You can use it to your advantage.

Q What are your thoughts on how the sector might grow?
So obviously I work in the independent sector and I have done for years. And we all want to see private healthcare flourish. We want it to be the best – as good as it can be – and we want the sector to grow. And I think it’s going to grow in a number of different ways. I was recently at a conference when the question was asked whether the NHS was the future of private healthcare. I think the answer to that question is actually no. I think in some sectors – in care homes for example, in psychiatric care – we see more and more public ventures with private providers to deliver that care. But resource is a big issue. Staffing resource is a big issue and Brexit isn’t going to help us very much.

But when we look at the acute care sector we don’t see the same type of relationship with the NHS. And so that, almost certainly, is not going to be where the growth comes. We see a change in the way that healthcare is funded so that the PMI market is relatively static. It’s certainly static for the individual – although individuals are going down and corporates are static. Individuals are turning more to a self-pay option. Now the issue with the self-pay option is of course that patients have a choice. They can choose what they pay for and they can also choose what they’re not prepared to pay for. And so we’ll see a differentiation. Will they pay for the expensive things like a hip replacement? Maybe they will or maybe they won’t. But they almost certainly will pay for diagnostics because people want to know if they’re sick. They don’t want to wait six weeks, ten weeks for an appointment to get an MRI. So I think they will be prepared to pay and I think that the providers have got to make this competitively priced.

Once a person who’s never had PMI, hasn’t been used to the benefits of it, sees the benefits of paying and being able to choose where they go and when they go and how they go, I think private medicine will have a greater appeal. And I think it is up to us in the private sector to actually make that process – that patient journey – easier. To use the technology that is available to us to make it easier for the patient to make a choice about where to go, how much it’s going to cost them. It’s online and I don’t think we should assume that the older generation can’t go online because increasingly we see that they do. And of course, within ten years, going online is natural to everyone. We can book our airplane tickets, we can book our hair appointments and we’ll be able to book our MRI. And we will be able to choose where we go. And that’s an opportunity for the private sector to get it right. And I think that there are so many entrepreneurs in medicine today – doctors becoming businessmen – who  can see the niches and will see where that gap is and provide a solution for those patients.

But what we also see is we’ve had big providers – the Bupas, the Spires, the HCAs of this world. What we’re now beginning to see is that the market is about to become more diverse. We’re seeing new entrants coming into the market, particularly in London. We know that the Cleveland Clinic will be here within three to four years, opening its doors. The Schoen clinic will open its doors more quickly than that. And the Schoen is a good example of a specialist hospital where they focus on one item, which is based in their case around the spine. They have a good track record in Germany, and they’re bringing that example to here. And that’s very much going to be focused on and selling the benefits of outcome measurements and how that can improve patient care. That’s going to increase the market. It’s also going to make the current providers a little bit more nimble in order to keep up. So I think we’re going to see some challenges to current provision, the power of the patient who is going to shop around a bit more, and that in itself will probably bring down costs. It will widen the market. We’re going to see new patients enter the market who weren’t in the market before. So that’s exciting and I think that will grow.

The NHS is under pressure. There is no doubt that they’re rationing care. And patients will need care. We’re becoming older. We have all of the issues with old age be it musculoskeletal or dementia or whatever. It puts a huge burden on the system and so we have to find alternative ways of funding.  So the entrepreneur out there, the medical futurist, has a great future.

I think that as demand outgrows capacity in the health service, if the capacity is going to be taken up by private healthcare, then that requires some really structured thinking about what part of that capacity can the private healthcare provide cost effectively. Obviously people have to make a margin and it has to be a recognised and sensible margin because we are dependent on investment and where the private health sector, particularly in London, has been able to be successful is the amount of investment that has been made. Investment in basic structures but also investment in technology, in equipment which enables patient care to be delivered more effectively. That helps with costs, but it also helps with patients coming into hospital for less time, going out almost ready to go back to work. That change is really well managed in the private healthcare sector and so I think there’s a lot of learn. The NHS actually has things to learn from the private sector. But we have to be quite careful about how we allocate our capacity.

One key change is going to be critical over the next ten years – and it’s happening already – is the focus on wellbeing and preventive medicine. I was CEO at the Portland Hospital in the ‘80s and early ‘90s and when I first went there we did so many hysterectomies that I would have lost count of them, but over the years that changed. It changed because technology changed, drug therapies changed, women started to focus on their health sooner and more efficiently and today we don’t see women having many hysterectomies because they have taken charge of their own health. And so there’s a big market for those organisations that have recognised that already. Promote wellness, promote preventive medicine – and we also see the PMIs cashing in on this particular aspect. But it enables patients to take charge, to be in charge of their own health, and the more they’re in charge, the more that they will dictate how and when or if they need to see a doctor, how they’re going to be treated. So this is a huge and potential opportunity for the private sector. And it’s started already and it will only grow.

Q You mentioned Brexit earlier and your concerns about its impact. Would you like to say something more about that?
We are already seeing the impact of Brexit even though we’re at the very,  very early days –  I think we only started last week in fact. One of the biggest concerns that we all have is what is going to happen to our staffing resource?  We know that it wasn’t that long ago when the number of foreign nurses applying to come into the UK to work could be numbered amongst hundreds if not thousands. At the last record there were only 45 applications for nurses to come and work in this country. And if we don’t allow people here already to stay we are going to be in a desperate position. So that is a key issue when negotiations take place. We have to recognise that we do rely on resources from abroad. And to be honest there’s nothing wrong with that. They bring new ideas, new thoughts to us, they make us think better and differently. So I do hope that the current upheavals may actually work in our favour in respect of a softening round the edges to ensure that we don’t throw the baby out with the bathwater.

So where will we be in ten years’ time? Well I think we’re changing. Everything is changing now. The last five years have been rapid. The last twelve months have been huge. And today, if you go to a conference, somewhere on that agenda we’re talking about technology, digital platforms, how that technology is going to empower, not just patients as I’ve mentioned, but also doctors into behaving differently.

So artificial intelligence can make a difference in our lives. And a challenge we all face – and this applies to doctors, hospitals and patients – is information overload. So we’ve gone from a position as a patient of really not knowing anything, and believing what the doctor said, to now going to Dr Google first and then discussing what Dr Google said with our doctor. That hasn’t always sat very well and what will happen over time is that the doctor and the patient will have a consultation, part of which will be using artificial intelligence, going onto some of the new apps – and I saw one recently which was called safedrugdotbot. And this is fascinating. This is an app or bot that enables a pregnant woman and her doctor to understand the interactions of all of the various medications that she might be taking. And it’s readily available. We don’t have to go to MIMS to look it up. It’s there and so we can say ‘well  we’re taking Vitamin C and we’re taking this drug. Are they going to work together? Are they effective? Is there a better combination? And that could probably be done in two or three minutes. It won’t actually take a doctor’s consultation. We will have virtual consultations and they are already available on the market. And companies like Babylon are really ahead of the market and doing extremely well in that area.

Patients will not have traditional GPs perhaps. We’ll also need someone however to take care of the overall health of the patient. It does need co-ordinating. I think we have not yet reached the position where the patient can be totally in charge of their own health. They would need to be exceptionally well informed to do that. But the merger of artificial intelligence, the benefits of some of the technology that’s available on the internet now is creating a different environment in which people are going to practise. I think doctors have the potential to have more time. To have technology at his fingertips which will actually enhance his ability to work with individual patients, is fascinating. It’s a different world. It’s not going to happen next year in its entirety, but in ten years’ time…..  I think our relationships with doctors will be different.   And I think doctors entering the independent sector will have a whole different paradigm that they’re going to follow. Now how exciting is that? And I hope that an organisation like ours – the Independent Doctors’ Federation – can actually be at the forefront of understanding what those implications can be. We can bring that information and technology to the notice of our doctors, debate with them and with the providers. How can we use that for the best advantage of patients?  How can we use it to make the independent sector more viable? A better choice?  And allow the NHS to focus on those things which it does brilliantly? Emergency care for example, at which it excels. So I think that those areas – the medical futurist – is something that we should definitely keep an eye on and I find particularly exciting.

But patients also are going to have the benefits which we see already of personalised medicine, of immunotherapies, genetic profiling and technology is here to help us in that and that’s going to make a huge difference to the way that we practise medicine. And are we going to see the need for big hospitals? How much more are we going to see hospitals at home? Where in every room of your house you will have a piece of equipment – be it the scales or your toothbrush or the sleep monitor by your bed – helping  you to monitor your own health. Hospitals I think shouldn’t become larger. I think they should become more focused and smaller. That’s going to be really interesting. So private medicine isn’t necessarily about providing care in hospitals. It’s about providing care for patients. Helping them to make informed choices. Really, really important.