Congratulations both to Stubbs et alfor their paper exploring anaesthetists’ remuneration and to Harrop-Griffiths et al for their accompanying editorial: both deal with difficult areas buried within the complexities of national agreements, insurance maxima, professional relationships and unspoken arrangements. I would like to add comment on the differences between NHS and private remuneration and also would like to shed some light on its history.
When the NHS was set up in 1948, the AAGBI played a keyrole in establishing anaesthesia as a recognised clinical specialty, with consultant anaesthetists having the same remuneration for NHS work as surgeons and physicians. This successful battle for equality is well described in Tom Boulton’s History of the AAGBI:it was hugely dependent upon the Association Council at the time, and the support of the Royal College of Surgeons. A consequence of this victory was the establishment of the Faculty of Anaesthetists within the RCS and the Fellowship (FFA) examinations to gain specialty ‘respectability’.
Within the NHS, history is therefore on our side and it seems straightforward to me that in routine, on-call and waiting list initiative activities, all specialties should be paid the same. This also has the massive public benefit that in choosing a specialty career, young doctors are motivated by what they are interested in, rather than what will remunerate them best.
However, the private sector is rather different. I first became interested in private practice in the 1980’s and continued to do private practice until I was 60 yrs old in 2007. This included both working as a sole practitioner and within a group practice. Before establishing myself in the independent sector, I decided to take the advice of an older and rather successful private anaesthetist (since deceased). He advised me on what I should do, how to approach private patients, how to bill and most importantly, how to manage surgeons. He also gave me a history lesson.
In the period between the world wars, anaesthesia was a growth specialty, and there was no NHS. At that time anaesthetists were in increased demand, but often fulfilled other roles as well, such as general practice. Charging for anaesthesia services was variable, and often done indirectly by the surgeon. However, on average, in private practice, one anaesthetist provided services for 2 surgeons. This is the original basis for the fee differential: with the anaesthetist taking a third of the total medical fee for the procedure (i.e. half of the surgical fee), and remuneration between surgeons and anaesthetists was tolerably equitable.
My independent sector mentor had been a friend of Sir Robert Macintosh. He informed me that when Macintosh and his colleagues set up the Mayfair Gas Company in 1933, to provide the first full time specialist anaesthetists and to meet the surgical demand in London’s hospitals, they too used this fee ratio as a guide (unless the patient was very well heeled, in which case special factors came into play). Over the years, the specialty of anaesthesia has spread into other areas such as pre-and post-operative care, intensive care and pain medicine. Unless the circumstances are very unusual, pre- and post-operative care are included in the anaesthetic fee and the fees for intensive care remainderisory. Consequently, as we are now able to undertake a much wider range of activities than when this 1:2 ratio was first established (i.e. some anaesthetists do relative little anaesthesia per se), the overall financial 'cake' available from surgical procedures is reduced for anaesthetists
Harrop-Griffiths et al suggest that a market with patients deciding what they will pay will ultimately determine the return per case. Whilst this is true, it is a situation that needs to be approached with caution. A younger acquaintance of mine who tried to ‘test the market’ found that the patients complained about his fees being outside the insurance allowance to the surgeon, at the 6 week follow-up appointment. The surgeon, not knowing of these fee hikes, felt that it reflected on him and was a threat to patient satisfaction, his unblemished reputation and his continued referral pattern. The outcome was that he used a different anaesthetist.
Consequently, in summary, on the basis of logic, custom and practice, it is entirely justifiable for NHS work to have a uniform cross-specialty remuneration pattern. This must be fought for and maintained and there are good arguments for doing so. Unfortunately, historical precedents and subsequent custom and practice produce differential pricing in the independent sector. This is particularly unfair with the ever-increasing numbers of patients having routine surgery in the presence of multiple pathologies. Moderating fees for anaesthesia under these circumstances is possible, but requires good communication skills, a patient with funds and surgical support and loyalty. In my experience, it is the latter of these which is crucial: without it and a surplus of anaesthetists available to do the work tolerably well, private sector fees will remain static.
Professor Peter Hutton