In my last column I discussed the basic structure of a pain clinic in the U.K. In this column I will elaborate further on the two systems, U.K. and Sri Lanka.
In the United Kingdom over 90 per cent of patients see their pain consultants and consultants in other specialties through the NHS which is free at the point of entry and afterwards. Our state health service is similar to the U.K. National Health Service but with less resources and funding. It’s free at the point of entry. In U.K. the patients will never be requested to purchase their own drugs like in some cases in Sri Lanka. One cannot blame the Health Department in Sri Lanka as it is underfunded due to our economic status as a developing country. In Sri Lanka over 85 per cent of the outpatient consultations are carried out privately according to some audits. This year the health budget in the U.K. was 130 billion sterling pounds. They have allocated 3 trillion sterling pounds as a relief package to deal with the Covid-19 issue.
Even with this kind of government funding the waiting list for a new patient to see a consultant is around four months in U.K. If the patient needs a procedure another 2-3 months wait. For repeat procedures the waiting times are over a year. This was my experience. To clear this backlog the Labour government introduced a 16 week pathway which recommended that a patient should be seen and treated within 16 weeks from the referral date. Mind you, still a four-month wait. This was a costly undertaking for the government. The hospitals which could not honour the 16 week rule were fined even if a single patient went over 16 weeks. The managers would panic when a patient approaches 16 weeks.
The NHS had to employ consultants to work more hours with extra pay. Some Trusts did pay per patient for consultation and procedures. Due to the fact that the state sector could not cope with the volume of patients the private sector was sub contracted to treat the backlog of patients. As the services were out sourced the state hospitals had to spend more money where the debt was accumulating.
The U.K. system
Therefore, some state hospitals were shut down. I was contracted to reduce waiting times and I did carry out over 3,500 procedures in 2010 alone and worked Saturdays and Sundays as well. This made me one of the busiest consultants in my field in the U.K. I paid a price where my aortic valve had to be replaced when I was 48 years due to being over worked I guess. One has to pay a price for everything. Nothing is certain in life other than death and your tax bill.
I am describing the U.K. system as the pain services are not properly organised in Sri Lanka. Some of our doctors in Sri Lanka may not take this statement kindly. But this is the truth.
I had a very senior consultant at the Asiri Central texting me and saying, ‘Dr Namal you have collected enormous wealth in the U.K. and when the folks there realise that you are a spent force now you decide to come to Sri Lanka and serve the country’. This was laughable and I reject his claim. I retired from the NHS at 55 years when the retirement age is 68 in the U.K. My entire schooling at Trinity College and medical schooling (NCMC) was carried out privately thanks to my father. Therefore, I do not owe the state a penny.
When I left U.K. in February this year and came to Sri Lanka on a break I got caught to Covid-19 and was stuck here. While staying for five months I got used to Sri Lanka once again to the chaotic lifestyle having spent 25 years in the U.K. Then I decided to stay and start my pain centre. I did this at the peak of my career in the U.K. and gave up an income of around 25,000 sterling pounds a month which is around Rs six million a month. I sacrificed a huge income to erect a tent here. I sympathise with this senior doctor who is 71 years old. I do not know him in person and have never seen or met him. This is Sri Lanka. That was his way of welcoming me to Sri Lanka.
My family of four are all doctors. We are the only four Dr Senasinghe’s in the GMC UK register. The rest of my family are still in the U.K. and they will not return to Sri Lanka as my children were three and four years old when they migrated to England. But my heart is here. When this article is published I would have left Sri Lanka to the U.K. to see my family and will be back in four weeks if I am alive.
I gather from a few of my Sri Lankan medical colleagues that there are few pain clinics in the state hospitals in Colombo and Kandy. But there is a severe communication issue in Sri Lanka regarding pain and how to reduce pain.
One reason is the lack of information available to the Sri Lankan public. Even when the information is provided there is an issue with grasping the information. This is due to drawbacks in our education system. I would say it is much easier to discuss pain conditions with my English patients compared to the Sri Lankans. May be due to the language.
In Sri Lanka some patients have trust in our Ayurvedic system. Some want answers from me regarding the benefits of Ayurvedic medicine. I explain to them politely that my expertise are in Western medicine but request them to see an Ayurvedic physician and ask them the relevant questions. I usually give a minimum of 15 minutes for my basic consultation and I had a patient telling me about the success of Ayurvedic medicine and he used the entire consultation time to educate me without a request.
At the end I had to tell him politely that he had used the entire 15 minutes educating me rather than discussing his ailment. I simply asked him whether he has done justice to himself which made him blush. I told him to think about it on his way home, saying, “you paid money to give me a lecture”.
The challenges I face in Sri Lanka having worked 25 years in U.K. as a doctor, of which 17 years were as a consultant in pain medicine, are enormous. Materialistic wise I have a fantastic state-of- the-art centre.
People lack knowledge about pain and methods available to relieve them, for example, to see a specialty based consultant, a consultant in pain medicine to treat pain. I was not aware of full time pain consultants in Sri Lanka until I arrived. I hope my colleagues will pardon me if I was ignorant here. Trainees should be properly trained by skilled pain consultants. I gather there is a training program in the country to train pain consultants.
Poor specialty related referrals are an issue in Sri Lanka.
The GP referral system is poorly organised as most GPs run private clinics. In England the GP practices are run by the state and funded by state. Therefore, there is a proper referral system. Every patient should come with a referral from a GP whether it’s a private referral or NHS referral.
Now let me highlight how the private sector works in treating patients. The General Medical Council (GMC) has strict guidelines for doctors. No patient should be treated without knowing the fees prior to the consultation, procedure or surgery. Patients should be given estimated costs for their procedures or surgeries. No patient should be anaesthetised and put on an operating table not knowing what the costs would be. Patients have the right to request for the estimated costs of a procedure. I request all patients to do that.
Fixed price packages
Therefore, in U.K. there are fixed price packages for self funding private patients and BUPA OPSC coding for insured patients. The code will specifically state the hospital fees, surgeon’s fees and the anaesthetist’s fees. You cannot bill patients randomly. If a doctor is found guilty of not following the guidelines he or she would be investigated by the GMC in the U.K. if reported, and sanctions put in place if found guilty.
For example, a consultant breast surgeon was suspended by the GMC for charging money for an extra procedure he had not carried out. The insurance was charged for mastectomy plus axillary node clearance. One can claim 25-40 per cent for a second procedure based on the main procedure. The patient got a copy of the bill and informed the insurance company that there was no scar in her axilla. The insurance company referred the doctor to the GMC. Once the GMC receives a complaint of that nature they will write to the hospital to provide details of patients the doctor has treated and a full enquiry done. If found guilty the consequences are serious. I follow this practice in Sri Lanka and I give all my patients an estimated cost for the procedure. When the patient wakes up he or she will not be in for a rude shock.
To be continued next week