South West Imaging Services Ltd
Sadly this section is also of historical interest as far as my current practice is concerned. Running my own healthcare provider business was an interesting experiment that was successful in that it proved the concept of what we were trying to do but was unsuccessful in that we were unable to make the business sustainable. Some of the reasons for this I will outline as the demise of SWIS Ltd illustrates so many of the problems with healthcare delivery inthe UK and indeed our whole economy!
The origins of SWIS Ltd lie in the frustrations of working in a system that had lost sight of its main purpose - to deliver first quality patient centric healthcare.
Reviewing things at the millenium it seemed to me that the NHS had 'lost the plot'. It had become a vast employment agency where the vested interests of individual employee groups were taking precedence over patient care. There was no joint line of responsibility between nursing, medicine and management so there was never a co-ordinated approach to care delivery. Politicians wanted the NHS to work - votes depended on it, so they were prepared to spend large amounts of money to secure those votes. The money they spent went to service a bureaucracy put in place to deliver targets primarily defined by political rhetoric - sound bite medicine! A perfect example was the 18 week target. Someone asked how long it took for a patient to be seen in the NHS. 18 months was the response. "so lets make the target 18 weeks" Not exactly a sophisticated way to plan and fund healthcare.
The private sector, on the other hand was no better. It was and is wedded to a low volume, high cost model of healthcare delivery where baseline costs of healthcare delivery are not known and have never been known. Prices charged are what, historically they have got away with! The end result is that private healthcare was accessible only to a minority of the population (10 - 15%). with decent quality care only available for relatively low cost procedures. Investment in private healthcare was only made available for high revenue business models.
My thinking at the time was that "one should render unto Caesar that that was Caesar's! The NHS should be responsible for first quality emergency care, cancer care, ITU based specialist care and long term care. These aspects of healthcare should all be free at the point of access for all and paid for out of taxation. My vision was for a new clinician led independent sector which should be responsible for elective care delivering a customer centric, value for money, first quality service delivered through separate, dedicated healthcare facilities, where there was no competition for resources between elective and emergency patients and where a 'focussed factory' approach to heathcare delivery could be developed to maximise efficiency and value for money. In short I had defined a need for a system of elective care that assessed poeple promptly offered treatment in a timely fashion thereby getting people better before chronic illness set in, unlike the then current system of elective healthcare where delays created illness instead of curing it!
Im my naivety hadn't accounted for a number of factors that I was to learn about the hard way - the cost of private investment in healthcare, the imposed rigidity of private business models that maximised profit by delivering care only to the wealthy few, the firghtening lack of governance in the private sector, also profit driven and perhaps most difficult to understand, the willful determination of the NHS organisations that I came into contact with not to get their own house in order to provide a viable alternative to private sector elective care.
The SWIS approach
This thinking led to the formation of SWIS Ltd, an ethical company that was clinically led. Its aim was to deliver a first quality integrated diagnostic and treatment service that was patient (customer) centric. It was not a charity. By defining the costs of healthcare delivery very precisely, the company aimed to define a price for its services that allowed for sustainable 'organic' growth in the company (avoiding outside investment) at the same time as offering its customers best value for money - elective healthcare that was chargeable to a credit card not paid for by remorgaging the house! Emphasis wa on the delivery of an integrated service, bringing together all the elements required to complete a cycle of care for a patient in a way that kept the patient at the centre of that cycle. That was the theory anyway!
The SWIS experience would never have happened without the monumental expertise and drive of Mr Arthur Bird, Management Consultant. His unremunerated commitment to SWIS and the principles of what we were trying to achieve, resulted in the company's inception and formation. He was responsible for guidng us through the process of day to day running of the business. Using his expertise we were able to set up business models that reflected our founding principle of organic growth. His negotiating skills allowed us to win contracts and 'punch a long way above our weight' in the field of health care provision. Without his expertise we would never have been awarded the scanning contract by BUPA or the Bristol spinal assessment interface service. From him I learnt the principles of responsible business management. Through him I also received the negative experience of pitching a business case to venture capitalists and investment banks. We tried to diversify by bringing image guided radiosurgery to the UK (Cyberknife), for which we would have needed capital investment. That expereince had a profound influence on my current views on healthcare delivery and funding. Fuelled by a considerable amount of malt whisky, I once asked him why he had committed so muchtime and effort to SWIS for no finacnial return. His reply was "because it has been fun!" "If you dont like someone, dont do business with them" was lasting sound advice.
In 2005, we started by tackling inefficiencies in the neurosurgical and spinal diagnostic service. At that time patients with spinal problems severe enough to prevent them working but nevertheless classified as routine would have to wait up to three years for diagnosis and treatment on the NHS! Waiting times from GP referral to specialist assessment were in excess of 9 months. Informed sugical opinion is only possible with MRI scanning - patients had to wait a further nine months for the scan. A further wait for reassessment by the specialist and then time on an elective waiting list could easily add another 18 months to a patient's wait for treatment and often did. By which time a patient's 'routine' non life threatening problem that, if treated in timely fashion would have had little impact on their lives had changed their lives forever - loss of earnings, loss of jobs, break up of relationships, loss of self esteem with subsequent burden on social services were all commonplace problems that I encountered in the pain surgery clinic at that time.
The private sector service was out of reach of most people. Two attendance at a specialists private clinic and further attendance for an MRI scan resulted in a bill for well over £1000 and an average two month delay. Routine spinal surgery cost in excess of £7500 at that time, prices beyond most of us.
SWIS embodied the concept of the 'one stop shop'. Have a scan, and see the specialist at the same visit for a price that was affordable by most. We started by leasing 'down time' on static MRI scanners, firstly in the private sector and then at Frenchay hospital to prove the concept of an integrated service, charging £400 for the service. We then increased our scanning volumes by bringing a mobile scanner to Bath Racecourse, not everyone's idea of a medical centre but in actual fact ideal for our purposes - a flat surface for the MRI scan lorry, a 3 phase electrical supply, plenty of parking and buildings lieing idle that were easily adapted as waiting areas and consulting rooms. Although a somewhat quirky idea born of a certain amount of lateral thinking, it was quickly adopted by all our clients, the british public recognising quality and service quicker than the institutions that are supposed to serve them. Increase in volume allowed a reduction in our unit price to £350.
The SWIS service was set up initially for self pay patients who wanted to avoid delay for investigation but who could not afford the premium rates charged by the private sector. However the standards set by SWIS also met the rigorous audit standards set by the private medical insurers leading, in 2006, to the company receiving accreditation as an MRI provider by BUPA and then the other medical insurance companies. We were then successful in bidding for an NHS contract for a pilot interface service providing spinal assessment for North Bristol GPs. We delivered this service for 2.5 years, allowing a further reducvtion in unit price to £328. Despite running a fully audited service with nothing but positive feedback form all, the definitive pan Bristol spinal assessment contract was then awarded to the Bristol PCT's in house physiotherapy led service. By this time SWIS had changed practice in the independent sector so much that there was no longer a business for us there - reasonably priced scans were available from all private institutions with the one stop shop model adopted by all private private practitioners - great for patients but no longer for SWIS. Our attempts to diversify into radiosurgery had failed. We offered the SWIS service to North Bristol NHS trust even providing our administration staff to them free of charge on the basis that SWIS assessment resulted in a 50% 'pull through' of cases to secondary care but they declined to take it on, . The reason given was that it was not a service the PCT would support. I therefore had no alternative but to cease trading. In November 2011 SWIS was no more.
Looking back it is interesting to reflect on what we learnt. First and foremost was the fact that the 'do as you would be done to' school of medicine actually works. By defining costs precisely and by not runnning to an overinflated business model, universal health care can be delivered at reasonable cost. The SWIS mobel of a 27% markup aiming at a profit of 10% would have been sustainable at a unit cost within NHS tariff rates for outpatient assessment - £276 with the increased volumes that a pan Bristol service would have produced.
I had no chance to persuade the PCT of this - the political decision had been made to cease outsourcing spinal assessment and no argument that we put forward was going to be listened to. What was more worrying to encounter was the trust position. I was forced to realise that the NHS that pretends to be 'business like' functions in a way that is totally removed from basic business principles. No one in the NHS knows the cost of anything! What is relied on is the price of things defined by the tariff rate. For example, the tariff price of an MRI scan in 2010 was £198. The fact that for four years the unit cost of an MRI scan on the high street ( or in our case, on the racecourse) was less than £100 was completely lost on the Frenchay accountants who were totally unable to see that by establishing the true cost of the one stop shop, it could be delivered at tariff rates with all the secondary benefits to NBT. Define the costs of elective spinal surgery the SWIS way and four cases can be done on a list, paying staff extra to do them, for a cost that is half tariff rate. Instead we now have a situation where most elective spinal surgery does not meet waitng time targets and is taken to the private sector costing the trust money rather than making them a profit. Utter madness!
The SWIS experience has also formulated my views on capital investment in healthcare and indeed in all public services. The profit margins demanded by the city for the loan of money for healthcare are completly incompatible with the delivery of a comprehensive health service that is free at the point of access to all. SWIS achieved this. On one memorable day at the racecourse I remember scanning senior judge, a captain of industry, the golf course maintenance man working next door to the racecourse that stepped off his mower for a scan and a somali immigrant's wife amongst a list of 25 or so people. I remember it was an exhausting day but it was exhilarating. Here we were delivering the same first quality care to a complete cross section of society! The profits city investment demands results in one of two things; prices are so high that only a small perce3ntage of the privileged few can afford them or services have to be paired down so much that the quality is undermined. It seems to me that none of that profit comes back into the system as it is syponed offshore.
The consequences of inviting the private sector to fund the NBT new build at Southmead have yet to be realised. A 30 year loan repayment of £27m a year is 7% of the annual budget for the trust. (I wonder what it would have if Libor hadnt been rigged) The trouble is that is 20% of the non pay budget. There is talk of a 30% in reduction in current staff numbers, which means that so or later services will go. Let's hope we can hold the epilepsy surgery service together at least until I retire!
Whay is need is public ownership of the plant needed for public services with services run to the SWIS business modelm, making a living for those that make the service work but not making profit for the city with a localism agenda that services to be tailored to local needs. How about a three party coalition to make it happen!