In the U.K. neurosurgery is based in National Health Service hospitals that are funded by income tax and thus are free to all U.K. residents. There are 34 neurosurgical units and for the most part, each of the 240 consultant (fully trained) neurosurgeons practices in only one hospital within the NHS. An NHS position is salaried, although there are some incentive-pay supplements.
Given that the U.K. population is 60.9 million, the number of trained neurosurgeons is one of the lowest per capita in the developed world: 1 neurosurgeon per 254,063 people. Despite a government strategy that foresees healthcare delivery provided directly by fully trained surgeons, the U.K. is well short of the ideal minimum of 360 neurosurgeons suggested by the Society of British Neurological Surgeons. European law restricts working hours, adding to the strain on the U.K. neurosurgical workforce. It may be inevitable that a significant increase in the number of neurosurgeons is initiated within the next year.
Selection into university for medicine is directly from high school graduation and demands the highest grades. Of those graduates selected into neurosurgery, the majority choose neurosurgery by the end of their undergraduate years, to which many choose to add an extra year in neuroscience. Currently, neurosurgery appears to be attracting highly motivated and well—qualified young doctors. However, despite reduction in on-call hours, surgery in general and neurosurgery in particular is failing to attract women—who represent 60 percent of medical school graduates—in significant numbers.
Postgraduate training in medicine is undergoing radical change in the U.K. Recently taken over by a government committee from the medical and surgical Royal Colleges, arrangements are in a state of flux. Currently, medical school graduates enter a two-year probationary period of which a four-month module of neurosurgery is very occasionally included. Neurosurgical training starts after this and takes eight years. Trainees currently work an average of 56 hours per week, a number that soon will be reduced to 48. Annual assessments and two exams certify successful applicants as Members of the Royal College of Surgeons then as Fellows of the Royal College of Surgeons (Surgical Neurology).
The public’s access to medical care has been speeded considerably by recent government changes. All nonemergency care must be provided within 18 weeks, counted from the initial referral by the family practitioner, who is the gateway to nonemergency care, to initiation of definitive treatment. However, 60 percent of neurosurgical cases are urgent.
There is a significant but small private healthcare sector running parallel to the free NHS service. Depending on geographical area, between 7 percent and 20 percent of the population has private health insurance for the purpose of speeding access to trained specialists and time to treatment. Most neurosurgeons have a small private practice in terms of patient numbers; the fees generated significantly supplement their NHS salaries. At some NHS hospitals, hospital management encourages private practice and there are wards for fee-paying patients.
Malpractice insurance is related to type of practice and age. Surgeons who have no private practice are covered by Crown Indemnity. There are virtually no surgeons practicing exclusively in the private sector, with the exception of a few after their retirement from the NHS, usually in their 60s. The cost of private malpractice insurance for neurosurgeons is related to net private fees per annum, but premiums remain significantly below those in the United States. Indemnity insurance for surgery is not extended to those over age 70.
Medical litigation has steadily increased in the last two decades. However, because cases are held in the High Court by senior judges and without juries, and with strict reforms in litigation rules, the situation does not dominate U.K. medical practice. Furthermore, lawyers paid by contingency fees are not permitted. Poor litigants are funded by the Legal Services Commission.
Michael Powell, FRCS, FRCP, is a consultant in the Department of Neurosurgery at the National Hospital for Neurology and Neurosurgery, London, U.K. The author reported no conflicts for disclosure.