So, first of all, could you each introduce yourselves for me? Yeah, I'm Sean Carend, and I'm one of the orthopedic surgeons in Nobles Hospital. I've been there since 1996, and I've been there through the transition from the old Nobles up to the present site up in Braden. It's a long history then with the old others. Exactly, yeah. And yourself? My name is Prakash Thiagarajan, I'm a consultant pediatrician and neonatologist. I have been in Nobles since 2005. I'm here in my role as chairman of the Eilofman Medical Society, and Mr. Crayron is the president elect taking office in two weeks' time. That's right. Of the Eilofmanics Society. Already busy talking to us. Already busy. Yeah, we're easing me into it. Yes, that's it. Okay, perfect. So, we're talking today about this decision from ManxCare that's come about, and has been made public really through a ten-world written question regarding elective surgery and a cut to the theatre lists in that regard. I guess, first of all, before we get into this, in layman's terms, because you kind of explain what an elective surgery is. In layman's terms, surgery is divided into two major categories. We've got emergency surgery and elective surgery. Emergency surgery is surgery that has to be done, from my point of view, as an orthopedic surgeon, it would be people who maybe have broken a leg or broken their hip, and it's done as an emergency. Elective surgery, on the other hand, is surgery that's planned. In other words, if some person needs a hip replacement or a knee replacement, or any of that, that isn't an emergency, then we can plan that surgery and organise for that patient to come in on a particular day at a particular time. So, that's the big division between elective surgery. So, elective surgery is planned surgery, and emergency surgery is unplanned. We can't forecast it, so to speak. It's kind of been rushed in, versus, yeah. Exactly. Yeah. And obviously, this cutting list, they've mentioned, would affect things like general surgery, ENT, and I believe gynecology. Yeah. So, I guess, what sorts of procedures is that, then, for anyone listening? Yeah. So, from my point of view, again, as an orthopedic surgeon, that would involve operations like hip replacements, knee replacements. My own specialty is conditions affecting the upper limb, in other words, the shoulder, so operations involved in the shoulder. So, basically, mainly, and what affects probably most people, would be the joint replacements, but also, small procedures, things like bunnions, lumps, bumps, all the bits and pieces that we do on a daily basis, really, but mainly, as I say, I think the thing that probably will have the main impact would be the major joint replacements, yeah. And that's what we're concerned about. And so, in response to this news coming to light, our medical society has issued this open letter, really, well, it was addressed in the Manx Care Board, but you've made it public. So, within that, you say that these cuts will have, quote, "a severe and far-reaching consequences for patient care and the overall health of our community." Can you give me a little bit of insight into why that is? I think from, again, speaking from sort of my point of view, if you reduce the number of operations or the frequency of our operations by 25%, which is the proposed cut, then what will happen is that patients will be waiting, inevitably, they will be waiting longer for the surgery. And, of course, the longer they're waiting, the more complicated their conditions get, so what might have been a relatively straightforward operation at the beginning, could turn into be quite a complex operation. And also, I mean, we are our patients' advocate. We want to treat our patients, and a lot of these patients that will be affected by these cutbacks are elderly patients. They're in pain, and that is going to be prolonged, really, because of these cutbacks. And some of the, on the other side of the spectrum, we've got young patients who may not be able to work, and they will be affected by this economically astute patients who will need this. And that's why these cuts are so important to us to object to or to bring to light to the general public. And you say as well that this is short-sighted and fails to consider those long-term implications. What sort of long-term implications could you see in patients if they're left waiting longer? Well, again, as I was saying, the longer you wait, the more complicated these operations become. And also in older patients, if they're not mobile, say if they've got arthritis in their knee or arthritis in their hip, and they can't get around, then other conditions that they might have, such as heart problems, chest problems, will inevitably get warrants. And so the operation that might have been relatively straightforward becomes very complicated. The rate of complications become more frequent and so on. So that's why we think that this is short-sighted. And that's why we are saying in our letter that it will, and if they do go ahead, they will inevitably lead to complications. We're convinced of that from our long experience, both from myself and Prakash. And yes, apart from the conditions themselves getting worse, most of what we call co-morbidities, which make the surgery and the anesthesia a lot risk here with time invariably progress. And all these conditions, cardiovascular respiratory conditions, if you're immobile, it's going to get a lot worse than if you could get on your feet. Even conditions like type 2 diabetes, obesity, if you have joints that basically need replacement, how are you going to reduce your weight or embrace a healthy lifestyle if you're not able to walk? And we, both primary care and ourselves, believe, and we've actually seen this before when there were mass cancellations of so-called elective surgeries around COVID time, the demand on pain clinic, for example, the GP surgeries really skyrocketed. And that's already a big waiting time for GP appointments, et cetera. That's only going to get a lot worse. And at some stage or other, you still have to operate on them. And our worry is, it's not only going to become more risky, more complicated. It can well become a lot more expensive also. And we wonder if the long-term plan, if there is one, is to import a for-profit company and pay way over the odds, like we did last year. Well, that's what I was going to say, in the letter as well, and what you touched on there, you say this move may form justification for further outsourcing to so-called for-profit companies such as Synaptic. That was part of the restoration and recovery program they've run in two phases recently. Do you think that this is kind of a signifier of the privatization of our healthcare system in any way, or just more of that outsourcing? Well, it is a worry. It's not necessarily a direction towards privatization because the government still pays for it. But whether it gets best value, that is a big question and a big concern for us. Looking at the Synaptic, what they call phase one, because they're confident they're going to come back, cost is a total of about 28 million pounds. We did a back of an envelope calculation of all the surgeries they had done, looking at the costs that would be incurred if the patients always sent to the most expensive private hospital in London. And we added air tickets and five nights stay in four-star hotels around London. It still only came up to about 12 million. Right, okay. And that's not to say as well that patients like to be operated on, to be treated by people they know. And that's what we've found as well, is that patients, we build up a relationship with patients over the years sometimes, I've known grannies, mothers and children, and I've treated them all. And they like to be treated by people they know. And people they know will be around to treat any difficulties, any problems that might arise afterwards as well. So it's things like that that we have a concern about. It's not only the cost, but obviously the cost is a major issue on it. But should complications arise, I think that people want to be assured that they will have those treated by somebody local, somebody on the island and somebody that they know as well. As far as you are both aware or the Al-Man medical site is aware, who was consulted before this decision was made in terms of the medical field. We tried to find that out and just yesterday had a conversation with the clinical lead for theatres and the clinical director for anesthesia. And they assured me they had no idea who made this decision and they had no input in this. And I haven't been able to identify any consultant or who made the decision. I suspect it probably was made at the executive director level. Whether they took appropriate input, we don't know. We did raise this because this was actually not even made known to us that this was on the cards. And week before last, it was presented as a fait accompli to my consultant surgical colleagues and they obviously came to us. And so we raised it in the joint consultative and negotiating committee meeting on the 20th of September in the afternoon and we were told that this was on the cards, but they hadn't finalized the plans. And the next thing we actually found out from Manx Radio website actually, that it's going ahead. Sorry. That was helpful. Yeah. We go to source of information. Well, thank you. I mean, we don't like being the bearer of bad news, but yeah. But the bearer of important information, you provide a very good service and that respect. Thank you very much. I'll take that. I'll leave that in the interview. So you basically are saying that you think this decision was made on that almost managerial executive level, not necessarily with any clinical staff contributing, you think, as far as you are. I suppose we are aware of this. What do you think then? I mean, this all comes down to the talking about savings to do with, they say they've paid 84,000 pounds per month in the first four months of the year, mostly on bank staff, local staff. And I think that's the key saving that they're trying to make here. But what do you think then is the incentive for medical professionals to take a permanent role on the Isle of Man if they're getting paid that much more as bank staff? I mean, how do you tackle that as the medical society? The medical staff on permanent contracts haven't had a pay raise in 18 months. And we're actually probably for the first time falling behind UK by quite a considerable margin, about 12% behind England, NHS England, and about 20% behind Jersey, and about 15% behind Northern Ireland. And this is making the basic contracts very unattractive. So what we are doing is attracting people who, almost like nomadic, doing mostly lukem agency type of work, who have no commitment. They don't put roots down on the island, they fly in, fly out. And in many cases, I believe we pay for their flights and accommodation while they're here as well. And there is a huge variation, like you pointed out, in what they pay permanent staff versus what they pay agency staff. If, for example, we took the approach of Jersey, have the best pay scales for basic salary in the British Isles, but have a maximum of 48 hours that you can work, then you have a much flatter pay structure. And you have much less of potential for cronies, favoritism, et cetera. And I think to answer your question as well, we need, and we've been trying as a society to get the management to implement our retention, our recruitment, and retention strategy. And as Prakash was saying, it must be attractive to work here, not only from the point view, of course it is from the lifestyle point of view, but also from the basic payments, the progression, and so on, in payments. And I think that if a proper recruitment and retention strategy was implemented, there wouldn't be the need to spend so much money on locals, and certainly that would have a lot of advantages in the sense that, number one, it would be cheaper. But more importantly, you would have, as Prakash was saying, you wouldn't have people coming just coming for the money, so to speak, and disappearing off again, but you would have people who had committed to the island, committed to our health service, like we have done, and that can only benefit everyone. There's nothing not to like about it, so to speak. Yeah. And I mean, you mentioned as well, like, amongst people, and many people like to be treated by people they know, and that history as well. I was going to come to this in a minute about some of the alternative cost-saving measures that, and we will get to that in a second, but you mentioned recruitment and retention. Is there then a particular strategy you would like to see them implement then? Is there like a headline, a strategy you'd like to see them go more towards? Okay. I would say we have to split it into short-term, medium, long, and long-term. For the short-term, I think the best option is to make the basic salary very attractive, and also assist with mentorship, assist with helping them finding a place to live. And like, for example, Jersey does, they give interest-free loans that can only be used towards paying deposit on a house in Jersey. So you know, the money is going to stay here, not go out on the ferry every day. And medium-term, I think you need to work with education, identify children in even sort of GCSE levels or A-levels who want to do medicine or nursing or physiotherapy. Identify named mentors, support them, help them with getting a seat in the university, and form a relationship. And I would say we need to pay their fees as well. Again, rather than giving grants, I would recommend something like interest-free loans, which can be written off, say, after five years of service to Manc's government after they come back. So I think we need a short, medium, and long-term plan. Absolutely. I mean, you mentioned that, I mean, I think there's wider issues isn't there about getting people to move here. We were saying in the newsroom, we've seen some posts on social media in the recent days of people saying that they are interested in maybe moving to the Isle of Man. One, I saw the other night, said that they were a nurse, but a lot of the comments underneath were like, you know, we'll good with housing or good luck with this and that and the other. And, you know, good luck trying to find a place where you can bring your kids and your dog, you know, some of this sort of thing. So yeah, you think there needs to be that wider look out into the longer term as well. And I think you agree, absolutely, and the government has a strategy for attracting people to the island, but if you attract people to the island, you also have to attract people who will provide the service, provide health care, provide teaching, and so on. And you've got to make it attractive, as Picard was saying, give them some incentives because, you know, if you're going to have an increased population and we have an increase in the elderly population who do need to avail of her health care services, but you also want to attract young people as well. And they, as Picard was saying, they need schooling, they need to be assured that there are enough teachers that class sizes are of a decent size as well. So those are the things, and we have, on numerous occasions, brought us to the attention of the D-Mankscare Board. I mean, I think the big question that the public have in reaction to this news is that basically earlier this year, the Department of Health and Social Care saw its budget increase. We saw income tax go up with that money ring fenced for the health and social care services. I guess for the Alabama Medical Society then, as far as your work, can you see that money being spent? Right. I don't know if you've seen this, but the Manks Radio actually covered this at that time. The Alabama Medical Society actually put out a very detailed rescue and reform plan for Mankscare, D-H-S-C. It's probably this piece of paper I've printed off here, so yeah. No, you're welcome. You've done your research. I've done my research but go on. We had almost like a seven-point plan or seven broad themes. Obviously, we actually thought we'd be welcomed with open arms so that we can actually work out the implementation plans. These are just broad themes like headlines. Somewhat to our disappointment, a handful of M-HKs have been very interested and have been engaging and seeking our advice. But Mankscare themselves for some reason saw that as a threat. I don't know why. We really want to help. Nobody benefits if a health care system fails or runs out of money or bankrupt services. So, we really want to work with them and we still remain very, very willing. But to cut a long story short, I think it needs a fundamental rethink of the whole management structure and invest in the front line. Yeah. I mean, I think that's one thing we'll be speaking to Theresa Coke tomorrow and that's one thing I plan on asking her. I think, again, a lot of the public's comments on this is you see comments flooding in of why is the management not being looked at. You've got these really highly paid board wise front line services taking the hit. And like you're saying, in your plan here, redesign the board, overhaul the current top heavy management structure, allocate funds efficiently. So, essentially, would you like to see Mankscare be a bit more receptive to some of these suggestions and maybe have a bit more of a voice at the table as representing our medical professionals plan? Absolutely. In fact, on our website, we've actually put a plan for a professional executive committee actually running the whole health system and it will be a lot more efficient. And these people, we expect the professional executive committee members to come from practicing clinicians, so not separate jobs. And that's such a system work successfully in many other jurisdictions. Like there's much published data mostly from Australia and USA that hospitals and health care systems led and run by physicians, doctors are more safer for patients and a lot more cost effective. And we are all taught to practice evidence-based medicine. I think we should practice evidence-based management also. To touch on something while you're here, one of the things in the plan is a top point here about enhanced political and managerial accountability, a point in MHK nominated by Coleman as the chair of the Mankscare board, ensuring a Manks resident majority. That's pretty similar to something we've been discussing this week with Chris Thomas and Andrew Smith, MHKs. Chris Thomas has an October motion in Timworld, essentially to kind of do this or try and put it out there and have it debated. He's worded it as a have a Timworld member nominated. Would you like to see then that, well, clearly you'd probably like to see it be welcomed then by the Timworld members. I guess how would that look for you if that was implemented? The Mankscare board, with due respect, I think they're all good people, but amongst the non-executive directors, only one is resident in the Isle of Man. Whilst making decisions that affects the population, they're a lot easier to make. If you don't have a stake, if you know what I mean, if you're not in the island, you're not dependent upon the health care system, we can make decisions just based on numbers. If you're based on the island, tomorrow you need to answer questions from a member of public and say, "I can't go to Tesco's without saying at least three or four parents of children I've looked after, and I know that I have to do my best for them." But if you're not based here, there isn't that obligation. There is a disconnection from what the population needs, and previously some people used to complain that there was too much political interference. That is also not appropriate, but this disconnect is much worse than perhaps too much political intervention. Oversight, that's the word I'm looking for. Yeah, I think that's one thing that would be a critique, I suppose, of this, is when Monksker became Monksker a couple of years off the John and Michael's report, the idea that it's an arms-length organization away from political interference, but you disagree that this wouldn't be backtracking, this would be maybe a different look. No, he didn't at the same time say that all the non-executive directors should live in England, did he? I don't know. Which is what we've done. I suppose with that role, I'm just trying to understand it, I think, from how it would look, from your point of view, what you'd like. Would it be sort of, at the minute, obviously, the health minister gets up and sort of feeds back Monksker related things to Timwald, you know, and is that kind of voice of accountability within Timwald? Do you think this would sideline that minister in any way, or do you think it would give another member an opportunity to kind of explain decisions instead of it always being the health minister, is that kind of the way it would be set up? In the long run, we have to question whether we need both the DHSC and Monksker. In other jurisdictions, you have the ministry that commissions services and the equivalent of Monksker that would provide the services. And here, Monksker commissions and provides the services. And some of us want to know what does the DHSC do? It regulates health care, but then what does CQC do? Right. I see what you're saying. And talking of outsourcing, we are outsourcing the wrong things, don't outsource the clinical procedures, outsource these other functions. For example, CQC could easily do this function. This is just my view, not necessarily the whole society's view. Small sub-office of cabinet office or treasury can perform that function very well. And if the DHSC has to continue, perhaps the minister can be part of the board, even a non-voting member, because at present, the minister is fed information from Monksker board that may not always be accurate. I'll give you one example from his answer to Ms. Edge's question. He didn't say he gave the impression that only general surgery, ENT, and gynecology was affected. But I'm sure Mr. Creighton can watch for the fact that orthopedics is affected as well in a big way. And for a current minister to not know that is worrying. So this, I suppose, jumping back to this weightless thing, then this could impact kind of every specialty you think within the hospital, then, if these were... I mean, it affects all of the surgical specialities. And by default, then, I mean, I'm talking as an orthopedic surgeon, so I've got sort of first-hand experience of that. But our general surgical colleagues are affected, our ENT colleagues, our ophthalmologists. And all of them have been affected or may well be affected by this idea of cancellating or cancellations of elective surgery. So, yeah, it's a much broader sweep than, as Prakash was saying, even the minister, I think, had knowledge of. So he was maybe being fed erroneous or less limited information, maybe the best way to describe a child. And then I guess one other question I maybe should have asked at the very beginning when we were explaining elective surgery, realistically, what does that look like for you then? Is it just less theatre-less, less time within the theatre? Like, how is this actually working practical terms? The current plan is to cancel whole theatre sessions, so however many patients were booked would have all been affected. It would probably mean sort of in realistic terms, maybe my aunt not being able to walk for a year longer than she should have been. Again, coming to orthopedics because that mobility is so important to human beings. On a practical point of view, I think, yeah, to answer your question, Ashwin, is that the intention is to, for us, as orthopedic surgeons, and I think the intention is probably very similar for my colleagues, is to cancel one entire day list per month for each of the orthopedic surgeons, there are four surgeons, and I have one full day list per week. And what the idea is that once a month, my list will be cancelled on that day, and on that day, I would do outpatient clinics, and by doing outpatient clinics, of course, I'm going to add patients to the waiting list. So it seems counterintuitive almost to say that it's just a cancellation of a list. So it works, if you like, as a 25% cancellation of the entire orthopedic, and so presumably general surgery, ENT, eyes, and all my other colleagues' lists, if that makes sense to you. Yeah, absolutely. And then, but then let you say, we've just, when we touch on earlier, we've just spent a lot of money reducing waiting lists, and it being a big deal made of, we've reduced waiting lists, but what you're saying is, if there's going to be outpatient sessions happening in those time periods, we're just going to potentially add back to those waiting lists. Absolutely. And the answer was said that this wouldn't impact that, because we've pulled the waiting lists down, this won't take them back up, but from your perspectives as surgeons, you're saying, no, this will add to waiting lists in the long run. Yeah, it will add to it from two prongs. It'll add to it because we're doing a lot of surgery, so people will be waiting longer and it'll add to it because the idea is that during the period when we would normally be operating, we will be doing outpatient clinics, and of course that's going to add because if I see someone coming in who needs a hip replacement or a knee replacement or a shoulder operation or a foot operation, I'm going to add them to the list. But because my list has been canceled, then they're going to invariably or inevitably wait longer. That's right. Absolutely. And I could keep you here all night talking about this, but I guess two part question for each of you. One, what would you like to see the solution here? I think we've kind of covered it, but what would you like to see the outcome of this conversation be? And two, I guess, from your perspective, what's your worry that we could see cut next for cost cutting? What do you think is your fear, maybe that your members are avoiding to you? Well, I mean, as I said at the very beginning of this interview, we are our patients advocate and ideally we don't want to see the lists being cut with, you know, I spent 14 years training to be an orthopedic consultant and I spent 29 years here operating. It's such a waste of a very specialized personnel, so to speak. So ideally, I don't want to see, I want Mank's care to reconsider this, to look elsewhere, to come to and talk to us about other means of saving money, maybe rather than cutting frontline services, because it will add to the waiting list. It may well result in outside for profit organizations coming back again. And that is not a solution, that we need a more permanent solution to the problem than having people come back at intervals, so to speak, to do that, and Prakash, I think you probably have ideas about alternatives to that, you know? Outside organizations coming in to do procedures have very long lasting effects, because the way we did it was, we actually very significantly cut down our own operations to allow them the space to operate, like one of our colleagues who's very good with numbers did the sums. Throughout the period that synaptic were here doing joints, they did 666 surgeries. And during the same time, if they hadn't come in, our local surgeons would have done around 500, so they only did 166 extra, but obviously they counted as a total of 666, plus it helps these kill our doctors, not necessarily the very senior ones, but the more juniors, trainees, and if we are going to train and expect the doctors to be fully trained and come back here, how are they going to come back here if we tell them to be signing prescriptions all day in clinic rather than actually learning from assisting Mr. Craig and one of his colleagues, so that is definitely not a good solution. Obviously, I'm not an experienced hospital manager or director, but we are at the moment recruiting for five jobs, the medical director, director of nursing, director of people, director of quality and safety, four jobs, I thought there were five, four jobs all paying over 150,000 a year, why not freeze that recruitment until the financial year is over, then you will save twice as much as the 220,000 that we are going to save, so do interventions that do not impact on the patients, they are the sole reason we are here. Thank you for making it to the end of the Manx Radio newscast, you are obviously someone with exquisite taste, may I politely suggest you might want to subscribe to this and a wide range of Manx Radio podcasts at your favourite podcast provider, so our best bits will magically appear on your smartphone, thank you. [Music] [BLANK_AUDIO]
