Health Committee Inquiry into Independent Sector Treatment Centres


Submission by the British Medical Association
February 2006 Executive Summary
The BMA does not oppose treatment centres run by the independent sector outright but, in our evidence, we highlight a number of risks that an expansion of this policy could engender if not properly planned and monitored.
  • The BMA wishes to see much stronger measures established to ensure that ISTCs, working alongside conventional NHS organisations, are properly integrated with existing structures to avoid the fragmentation of services and the loss of continuity of care for patients. To achieve this, local NHS clinicians must be fully engaged in the planning for, and the introduction of, ISTCs in local health economies. We are particularly concerned that, due to the current lack of robust audit data on outcomes the public and the NHS are unable to assess properly the quality of services or ensure new providers offer value for money.
  • The BMA has therefore identified a number of recommendations that the Government must address:
  • A level playing field should be established for all providers in respect of the financial cost of providing a high quality National Health Service and maintaining a skilled medical workforce.
  • Patients must be provided with a high quality, safe and seamless service, whether they receive treatment in the NHS or in the independent sector.
  • There must be a clarification of what function ISTCs will be expected to provide when access targets have been achieved and waiting lists have reached an acceptable level, and what strategies are in place to deal with failing NHS departments/hospitals if patients favour the independent sector as providers of their treatment.
  • To ensure patient safety, the care provided in treatment centres should be the subject of robust, peer-reviewed clinical audit that is transparent and not hindered by the issue of commercial confidentiality.
  • The training of doctors must not be compromised.

Consequently, criteria that we would strongly wish to see used in evaluating bids for the second wave of the ISTC programme, or any independent sector provision of NHS care, include:
  • Ability to deliver clinical care to high standards ensuring quality
  • Adherence to clinical governance frameworks
  • Ability to deliver undergraduate and postgraduate medical training and integrate research
  • Demonstrable value for money
  • Ability to augment capacity without negative impact on existing NHS services.
  • Commitment to fostering clinical leadership
  • Participation in national workforce planning
  • Transparency in operation

1.What is the main function of ISTCs?
1.1 From its inception, the ISTC procurement programme’s stated function was to establish additional clinical capacity in specialties that had traditionally suffered from long waiting times, such as orthopaedics and ophthalmology, and support the NHS in meeting government targets. The key benefit of ISTCs is their capacity to achieve a managed separation of elective and non-elective care and thus provide an environment in which scheduled operations are much less likely to be cancelled due to non-clinical reasons. Whilst the BMA supports this model of working in principle, we do not believe that the ISTC programme is the only viable means of putting the model into practice. NHS treatment centres, day surgery units and five-day wards all represent well proven, alternative means.

1.2. The BMA is increasingly concerned that the ISTC programme has developed well beyond the original undertaking to provide additional capacity and instead will see large volumes of activity transferred from conventional NHS organisations to the independent sector. This is particularly evident in the proposals for the second phase of the procurement, Along with this transfer of activity, the government expects the second phase to introduce much greater competition into the healthcare sector and be the main driver in having the NHS confront the realities of market forces. ISTCs are commercial ventures and will be operated with the intention of making a profit for the companies involved.

1.3. We are concerned that the long-term impact of these new functions on the stability of the NHS has not been sufficiently modelled and lacks underpinning evidence of beneficial effect. The BMA questions what function ISTCs will provide when access targets have been achieved and waiting lists have reached an acceptable level. It is not at all clear what role ISTCs would be expected to play if, or when, spare capacity routinely begins to develop in the NHS. In considering this issue, one must reflect on the evidence now emerging that some NHS organisations, despite having sufficient capacity, do not have adequate financial resources to fund the use of this capacity. As a consequence, clinicians are being ordered to stop operating. If capacity continues to expand, then funding issues such as this are likely to be exacerbated.

2. What role have ISTCs played in increasing capacity and choice, and stimulating innovation?
2.1. According to a recent BMA study (go ro reference 1 here) there is evidence to suggest that some patients have benefited from improved access and a reduction in waiting times as a consequence of the capacity made available to the NHS through treatment centres. However, we would be concerned if these benefits of increased capacity are being experienced at the expense of the standard of care being received. Of particular concern is the possibility of patient pathways becoming fragmented. The BMA study suggests that patients are often being directed to treatment centres without reference to their consultant in the local hospital trust and that patients are not being fully involved in the referral process.

2.2. Furthermore, we wish to highlight the fact that simply establishing increased capacity through the development of ISTCs does not in itself demonstrate increased effectiveness or efficiency. The BMA study provides evidence that patients are significantly more likely to be rejected for treatment by ISTCs (43%), compared with NHS treatment centres (13%) and the patients most likely to be rejected by the treatment centres are those with the most complex cases. Consequently, though ISTCs offer the prospect of additional capacity they remain reliant on capacity in conventional NHS settings for those patients who require a higher level of care.

2.3. In the long-term, the expected trend of transferring large volumes of NHS work to ISTCs appears to further undermine the intention to use these facilities for additional activity as a means of increasing overall capacity in the health service. This transfer of work represents a shifting of activity and therefore does not constitute a meaningful growth in capacity. Rather, money and NHS resources are being redistributed to the independent sector often to the detriment of existing NHS services elsewhere. We would contend therefore, that the independent sector’s ability to deliver additional capacity is limited. The transfer of activity demonstrates that much of the growth in NHS independent sector provision will be realised by drawing on existing public sector capacity.

2.4. ISTCs are clearly intended to support the patient choice agenda by extending the range of options available to patients with regard to when and where they can be treated. Whilst we welcome greater convenience and access, we believe strongly that patients must be provided with an understanding of the reality of finite resources, where increasing choice and access may mean less continuity and personal care. It is somewhat paradoxical that the opportunity for patients to exercise choice may in fact diminish as a result of local centres being downsized or closed in the face of competition from, and loss of activity to, ISTCs.

2.5. The development of the ISTC programme may encourage and stimulate innovative models of service delivery, both in ISTCs themselves and in conventional NHS providers, though to date evidence of this is lacking. Of course, much innovation already goes on within the NHS. In order to improve productivity and raise the quality of patient care it will always be necessary to take into account best practice and incorporate new processes and technologies. However, we would contend that the participation in research, teaching, and peer-reviewed activity that is vital for innovation in healthcare are not ideally suited to the working environments found within most, if not all, ISTCs. The employment of overseas clinical teams often on short-term, rotating contracts in ISTCs is one example of such a possible shortcoming.

2.6. We would wish to have noted that the early development of NHS treatment centres in England was successfully undertaken by NHS clinicians and managers wherein the innovations and learning processes were integrated into the local health economies and best practice was routinely shared between health communities. We are concerned that as a result of both the increased competition now being experienced in the UK healthcare market and the apparent lack of integration between ISTCs and their local NHS organisations this kind of cooperation will be less likely, to the detriment of patient care and clinical innovation.


3. What contribution have ISTCs made to the reduction of waiting times and waiting lists?
3.1. In assessing the contribution of ISTCs to the reduction of waiting times and waiting lists their productivity must be placed within the context of the wider current efforts to improve access for patients. Whilst the introduction of ISTCs has made a contribution to the reduction of waiting lists, their small number at present suggests this has been limited. Traditional NHS organisations, in response to government targets and by developing new ways of working, have made a far bigger impact in this respect.

3.2 For example, evidence suggests that the recent and marked improvements in waiting times for cataract surgery in England have been wrongly attributed to the mobile ophthalmic ISTC scheme. Waiting times for cataract surgery in England began to fall significantly some time before those ISTCs contracted for ophthalmic procedures became operational (go to reference 2 here). It also worthy of note that evidence from a BMA study (go to reference 3 here) suggests that whilst the benefits to patients from ISTCs centres have included shorter waiting times and improved access, according to the study, patients are more likely to benefit from shorter waiting times where an NHS treatment centre, rather than an ISTC, is in operation.

3.3. A confounding factor in attempting to assess the contribution of ISTCs to the reduction of waiting times is the limited number of these centres that are currently operational. The relatively small volume of procedures that have been undertaken in ISTCs to date is dwarfed by the General Supplementary (GSup) contracts and NHS Trust internal initiatives that were established to improve the management of waiting lists. It is therefore difficult to establish the true extent of the ISTCs’ contribution. However, it is our view that despite the likely impact of ISTCs on waiting times, a similar, if not better, reduction would have been, and could be, attained if the same level of investment (both finance and infrastructure) was channelled into existing NHS facilities and organisations.

4. Are ISTCs providing value for money?
4.1 Due to the commercial confidentiality considerations that apply to ISTC contracts there is a paucity of data in reference to the exact costing of these arrangements. This precludes a useful analysis of the value for money (VfM) of ISTCs established by new providers to provide NHS care. We believe that at present there is little robust evidence to suggest that VfM is being achieved and while the requisite data remains unavailable the true cost of ISTCs to the taxpayer will remain opaque. This lack of data is a real concern.

4.2. What little evidence does exist demonstrates that the NHS and the taxpayer is often paying a premium for independent sector involvement. Certainly, the Government has stated that in 2003-04 the “procedures purchased under the ISTC programme cost on average 9% more than the NHS equivalent cost” (Hansard, Official Report, 16 March; vol.432, c.273w). Moreover, the contract agreements pertaining to the first phase of the ISTC programme gave rise to a number of instances of ISTC block contracts being paid in full despite the ISTCs failing to deliver the number of clinical procedures stipulated in those contracts. We do not believe that ISTCs, fully staffed and fully resourced, that are operating well below their capacity can represent VfM.

5. Does the operation of ISTCs have an adverse effect on NHS services in their areas?
5.1. Evidence from the BMA study of Clinical Directors shows that where a treatment centre is in operation, most respondents report some impact on either their Trust as a whole (69%) or specifically on their clinical directorate (80%). More than half of these respondents report a negative overall impact of a local treatment centre on the facilities and services provided by their NHS Trust with more than two-thirds reporting a negative impact from an ISTC.

5.2. Most typically, reported concerns highlight the tendency of ISTCs to distort the case-mix experienced by local NHS services. This distortion results from treatment centres ‘cherry picking’ cases, focusing on simpler, more straightforward elective procedures that do not involve patients with co-morbidities. Whilst this practice reduces complexity and risk for the ISTC it leaves local services with the much more difficult task of taking on the burden of difficult cases and accommodating longer in-patient stays. This has a number of adverse consequences.

5.2 Due to the manner in which the Payment by Results system currently operates the local NHS services do not receive any premium for dealing with the more complex and therefore more costly case-mix. Whilst NHS services are faced with this increased cost pressure, ISTCs benefit from the high volume of simple case-mix, guaranteed referrals and the improved tariffs available to them as well as remaining able to rely on support services in the local NHS organisations if post-operative difficulties arise which again results in a shifting of financial burden. The inequities described here underpin the BMA’s recommendation that the second phase of ISTC procurement must proceed on a ‘level playing field’ where incentives and processes that favoured the independent sector in the first phase are not replicated.

5.3 However, current policy will see those conventional NHS centres reliant on routine work to cross subsidise large fixed overheads become increasingly vulnerable as activity is transferred to ISTCs. Consequently, we can expect severe financial pressures to be experienced that will extend beyond the services directly affected by ‘competition’ from ISTCs but also to the additional services such as non-elective, small specialty or support services, that the conventional NHS is responsible for and that ISTCs do not provide. The adverse effect of ISTCs on the training of medical staff will be dealt with below.

6. What arrangements are made for patient follow-up and the management of complications?
6.1. The Department of Health has given assurances that arrangements for follow-up care and the management of complications are included in the ISTCs contract. However, undertakings (Service Level Agreements) that local NHS services should provide for these arrangements often appear to have been agreed without engagement or agreement of local NHS clinical staff.

6.2. A lack of robust communication channels between ISTC clinicians in treatment centres and those in local NHS services also appears to be a significant problem, where almost three-quarters of respondents in the BMA study report that they are never able to discuss patient cases with staff in ISTCs, compared with a fifth of respondents with an NHS treatment centre. Concerns have similarly been expressed with regard to difficulties in obtaining patient notes and records.

6.3. Two thirds of respondents report that they are aware of patients who had developed complications following treatment in treatment centres and have required readmission to their hospital Trust. This is more likely to be the case for patients who have undergone treatment in an ISTC than in an NHS treatment centre. While post-operative complications do occur in clinical practice, in conventional NHS trusts they are usually dealt with ‘in-house’ by the medical team who performed the original procedure. However, in the case of complications arising from procedures undertaken in ISTCs, patients are being sent back to the local NHS trust for follow-up treatment because it is only there that the appropriate facilities and staffing are available. In the case of the mobile ISTCs they may have moved away. This both fragments the care pathway and increases the workload of the local NHS medical team.

6.4. We are concerned that despite the reassurances from the Department of Health there do appear to be deficits in the clinical governance arrangements in ISTCs. To ensure patient safety and high standards of patient care it is imperative that robust clinical governance systems are in place and that these are integrated with local services. Each ISTC should make a transparent declaration of the formal arrangements it establishes which should include the routine use of clinical advisory groups, regular audit meetings, critical incident reporting systems and clinical governance committees. We wish to highlight the fact that the National Patient Safety Agency (NPSA) is not made aware of patient safety incidents in ISTCs as its remit is currently restricted to NHS providers.

7. What role have ISTCs played and should they play in training medical staff?
7.1 We have serious concerns in respect of the potential threat to established training programmes for junior doctors as procedures most suited to training purposes are transferred to ISTCs. Most respondents to the BMA survey agree that the education and training of medical staff, particularly junior doctors has already or will be affected in the future. The impact of ISTCs ‘cherry-picking’ patients with straightforward pathology, means that these cases are no longer routinely available and this progressively reduces the extent and quality of training received by junior doctors and nursing staff in the NHS.

7.2. Phase one of the ISTC procurement programme initially excluded providers from training responsibilities completely, though a number of pilots will begin in 2006. However, there remains ongoing uncertainty with regard to the detail of proposals for both the pilots and the provision of training in the second phase of ISTCs. The Department of Health recently announced that:

“The Department is committed to provide training for NHS healthcare professionals from independent sector facilities. All Wave 2 surgical ISTC contracts will require providers to undertake training for NHS junior doctors.” (DoH press release, dated 14th December 2005).

Nevertheless, despite seeking clarification of how education and training will be incorporated into ISTCs contracts, in particular the details of funding arrangements, the BMA has yet to receive a satisfactory response. We are concerned that, without a full and open discussion with regard to the proposed mechanisms for protecting the standards of training, the quality of the future medical workforce will suffer.

7.3. This situation arises at a time when training time is already at a premium, with many specialties stating that the combination of Modernising Medical Careers and the European Working Time Directive means that training opportunities are being severely reduced and exposure to relevant cases is already insufficient. There is already evidence that Southampton’s NHS orthopaedic centre is at risk of losing training recognition due to the loss of capacity to the ISTC in Salisbury where no training is carried out.

7.4. If ISTCs continue to be exploited for current purposes and their case-mix remains as at present, then it will be vital that doctors in training have the opportunity to train in these centres to further their development. ISTCs have the potential to offer a favourable environment, though of limited scope, to a number of trainees in some specialties. However, ISTCs wishing to provide training will need to be under the scrutiny of the Deaneries and relevant Medical Royal Colleges. In the same way that NHS training posts are reviewed and quality assured, training posts in ISTCs would need oversight under the same standards (as set out by the Postgraduate Medical and Education Board) and the same Terms and Conditions of Service. Only posts that have this oversight, and are administered by fully accredited trainers, would be approved and recognised for training towards a certificate of completion of training (CCT). Moreover, it is not only inexperienced doctors in training that require routine cases to acquire skills. Clinicians of more mature years require routine cases to acquire new skills and adapt to advancing technologies. There is no point in a doctor’s career where learning is “complete”.

8. Are the accreditation and appointment procedures for ISTC medical staff appropriate?
8.1. We welcome the fact that senior medical staff in ISTCs are now required to be on the Specialist Register and have registration with the General Medical Council. However, such medical staff in the NHS are subject to additional procedures which ensure the suitability of clinicians to their post. For example, consultants are appointed through an Advisory Appointments Committee, founded on a Statutory Instrument, which requires input from the Medical Royal Colleges and peer review. No such equivalent exists in respect of ISTCs. Furthermore, the regular appraisal and job planning systems that are well established in the NHS, as well as regular formal and informal peer review, help to maintain quality and standards for NHS staff.

Short term appointments without this long term continuity fail to deliver similar quality assurances. Historically, questions have been raised over the nature and transparency of the appointment processes for ISTC medical staff in Wave One. A failure by providers to fully assess the accreditation and ability of medical staff to perform appropriate procedures clearly threatens patient safety and the quality of healthcare delivered.

9. Are ISTCs providing care of the same or higher standard as that provided by the NHS?
9.1. Concerns regarding the general quality of care provided by ISTCs were raised in the BMA study. Concerns centre on the quality of specialist care provided by the treatment centres, the loss of continuity in medical provision and the lack of long term patient care. Many respondents also comment on the high turnover of consultants working in ISTCs and the impact that this has on co-ordinated working. Many respondents argue that although the quantity of patients being treated may have increased, they have real concerns regarding the quality of patient care.

9.1. High quality clinical care depends heavily on collaboration and joint working between staff – through the formation of clinical networks, which have, for example, played a critical role in improving the quality of cancer services. There is a danger that the growth in ISTCs, by increasing service fragmentation and introducing competition, could put such models of collaborative working and clinical leadership networks at risk and undermine continuity of patient care.

9.2. Due to the resources available to ISTCs and the low-risk nature of their case-mix we would expect a high standard of care to be provided as the services matured. The preliminary report of four ISTC schemes published by the National Centre for Health Outcomes Development (NCHOD) in November 2005 used 26 Key Performance Indicators (KPIs) to monitor a range of factors including clinical quality. However, we believe the report’s findings cannot be considered a reliable audit due to the lack of peer review and the incomplete nature of particular elements which prevent the development of valid comparators. Indeed, the authors of the report themselves clearly identify the current deficiencies in this attempted audit. As a result of the ISTC programme’s infancy, the BMA would welcome further detailed and peer-reviewed audits of clinical outcomes from ISTCs before commenting further.

10. What implications does commercial confidentiality have for access to information and public accountability regarding ISTCs?
10.1 The NHS has always been subject to close scrutiny and this has been magnified by the Freedom of Information Act. A similar level of accountability, at the least as regards public scrutiny, does not apply to ISTCs, largely due to commercial confidentiality considerations. Consequently, there is a paucity of data which, as outlined above, impacts on opportunities to openly assess ISTCs’ value for money and clinical quality. The commercial status of the companies involved in the ISTC schemes further limits review of their processes and contracting. The process of judicial review, currently the final step in public body commissioning is not available to patients dealt with by private companies. The BMA would be particularly concerned if commercial confidentiality considerations hindered the work of bodies such as the Healthcare Commission or National Audit Office in inspecting ISTCs.

11. What changes should the Government make to its policy towards ISTCs in the light of experience to date?
11.1 Research carried out by the BMA indicates that NHS treatment centres, which are more integrated with the traditional NHS, have better outcomes for patients, can have positive impacts on the services provided by surrounding NHS trusts and have fewer negative impacts than ISTCs on local health economies. The evidence available therefore indicates that the continued development of the ISTC programme should be curtailed and proposed investment be diverted toward further funding of NHS treatment centres.

11.2. In lieu of this, the Government must address the long-term impact of transferring large volumes of routine elective activity into the independent sector on the future viability of integrated health economies and upon the provision of postgraduate medical training. If the traditional NHS is expected to take on the burden of more complex cases it must be adequately rewarded to enable the continued provision of necessary services, both core and support. Without such guarantees, existing high-quality NHS services will be damaged irreparably.

11.3. The BMA therefore recommends that a level playing field is established for all providers in respect of the financial cost of providing a high quality national health service and maintaining a skilled workforce. We wish to see stronger measures established to ensure that current ISTC provision complements traditional NHS institutions and promotes the development of high quality care pathways rather than compromising them. There must be a much greater engagement with, and involvement of, clinicians already working in the NHS in the development of the ISTC schemes.


12. What criteria should be used in evaluating the bids for the Second Wave of ISTCs?
12.1. As noted above there has been a lack of engagement with the profession during the development of the ISTC procurement. Little detail has been shared in respect of the criteria that have been used to evaluate Wave One or presently being employed with regard to the current procurement for Phase Two. It is imperative that any evaluation of bids for the second wave takes into account the lessons of poor contracting learned from the first wave, for example, follow-up arrangements, clinical exceptions and value for money.

12.2. Criteria that we would strongly wish to see used in evaluating bids for the second wave, or any independent sector provision of NHS care, once the clinical/service need has been rigorously established would include:
  • Ability to deliver clinical care to high standards ensuring quality
  • Adherence to clinical governance frameworks
  • Ability to deliver undergraduate and postgraduate medical training and integrate research
  • Value for money
  • Ability to augment capacity without negative impact on existing NHS services.
  • Commitment to fostering clinical leadership
  • Participation in national workforce planning
  • Transparency in operation

13. What factors have been and should be taken into account when deciding the location of ISTCs?
13.1. Similar to above, little detail has been made available in respect of the criteria that have been used to decide the location of ISTCs. Clearly, the service requirements and clinical needs of local health economies must be carefully determined in order to assess whether it is necessary to establish an ISTC in the locality, or if additional investment in existing services would prove more effective. We are concerned that in pushing forward the plurality agenda there has been a repeated failure to examine existing NHS capacity and sufficiently integrate ISTCs with local services.

13.2. We would wish to question the logic behind a scheme which requires patients to travel from Durham to Middlesborough for an MRI scan provided by the independent sector while an MRI scanner in Durham is idle. Similarly, should it be the case that patients in Southampton are expected to travel to an orthopaedics ISTC provider in Salisbury while Southampton’s own conventional orthopaedics centre has excess capacity and is now in fact having to close capacity due to the loss of work to the ISTC?

14. How many ISTCs should there be?
14.1 Whilst we welcome the Government’s commitment to reducing waiting lists and increasing access to healthcare, the development of the ISTC as a means to this end raises a number of concerns that we have outlined above. The BMA believes that the considerable investment earmarked for the ISTC programme would be better spent improving existing NHS services and encouraging innovation within the traditional NHS in order to achieve an integrated, world-class health service for the 21st century.

February 2006

References:

1. Health Policy and Economic Research Unit (2005) Impact of Treatment Centres on the Local Economy BMA: London.

2. Kelly SP. 'Recurring policy errors: blind spots over cataracts' The Lancet, 2005. 366:9498, 12 November, Page 1691.

3. Health Policy and Economic Research Unit (2005) Impact of Treatment Centres on the Local Health Economy BMA: London.


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