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ISTCs deliver better outcomes, RCS study shows

NHS patients undergoing elective operations in dedicated independent sector treatment centres report better outcomes than those seen by NHS hospitals treating emergency and elective patients, claims a study.

The research, by the Royal College of Surgeons and London School of Hygiene & Tropical Medicine, finds that these differences are the result of ISTCs treating younger patients, from more affluent areas and who are in better health before their treatment than those seen in the NHS.

In 2002, the Department of Health started the procurement of ISTCs in England with the aim of reducing waiting times, give patients more choice, and encourage innovative models for the provision of non-emergency services. ISTCs, however, were heavily criticised by many surgeons for being ‘subsidised’, poorly integrated, cherry picking patients and delivering questionable quality.

A health minister of the time, Lord Warner, now a strategic advisor to PA Consulting Group, suggested surgeons were trying to resist ISTCs because they wanted to maintain waiting lists in order to swell their private practices.

The Patient Outcome in Surgery Audit (POiS) is the first large scale study to compare patient reported outcome measures from operations conducted in NHS and ISTCs, and was set up due to the Health Select Committee expressing concern that there was a lack of data from private providers.

POiS looked at four common procedures – hip replacements, knee replacements, varicose vein treatment and inguinal hernia repair – and included responses from 25,000 patients treated at 16 ISTCs and 53 NHS providers across the country in 2008/2009.

NHS hospital patients had a 40% higher risk of reporting a poor hernia operation after adjustment for case-mix than at independent providers. And patients undergoing varicose vein surgery at NHS hospitals were three times more likely to need a further operation than at independent providers.

POiS finds, however, that for hip and knee replacement, NHS hospitals dealt with almost double the proportion of sicker patients. NHS hospitals took a higher proportion of patients with two or more co-morbidities for all four procedures – almost double for inguinal hernia.

Furthermore, NHS hospital patients were more likely to live in the poorest areas across all four operations.

The RCS believe that completely separate emergency and elective operating rotas would ensure both types of patient get care optimised rather than mixed operating lists.

Jan van der Meulen, professor of clinical epidemiology at London School of Hygiene & Tropical Medicine, and lead author on the research, commented: “Independent sector treatment centres treat only non-emergency cases. The separation of elective surgical care from emergency services is likely to have a positive impact on the quality of care, irrespective of whether the elective surgery is carried out by a private company or the NHS.”

The study contradicts research conducted in 2009 which suggested revision rates on hip replacements at one ISTC were much higher than the average in the NHS.

Professor Norman Williams, president of the Royal College of Surgeons, said: “This study suggests that patients treated at units dedicated to elective surgery experience improved outcomes. However, it also showed that independent sector providers have taken younger, fitter patients and we need to guard against any drift that could destabilise hospitals. Sicker patients have needs that only a comprehensive hospital can provide.”

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6 Responses to “ISTCs deliver better outcomes, RCS study shows”

  1. Andrea says:

    There are all sorts of things that should be looked at–for instance were trainees operating in both types of hospital? I suspect there is a significant difference in this as well as huge differences in co-morbidities.

  2. Doctor Death says:

    Surgical research is to research what military music is to music

  3. rob says:

    I wholeheartedly agree with Andrea. I suspect the fact that trainees do not operate unsupervised by specialists/consultants at the ISTCs has a positive effect on outcome, as does the cherrypicking of healthier patients. In addition, by only doing elective work, they are not subject to the organisational chaos and bed pressure produced by an unpredictable stream of emergency admissions. I think this model is the way to go.

  4. Gazdoc999 says:

    This is not the picture I recognise locally, where we had to revise several carpal tunnel releases because the ISTC surgeon, er, missed the tunnel. ALso the figures do not include the patients who will need knee replacements 5 years earlier because the ISTC surgeons gouged into the articular cartilage when they arthroscoped the knee, resolutely missing the (hard to access) posterior horn tear on the medial meniscus.

    Only specialists can tell you whether the treatment is good or not. Commissioners have no hope here and will just have to use the propaganda put out by the ISTCs. Let’s look again in 10 years’ time.

  5. Dr A R Markos FRCOG FRCP says:

    1) The private sector is going to have lower overheads, due to indirect sponsorship from the public sector workers TRAINING, ACCREDITATION, APPRAISALS and REVALIDATION. All time and resource consuming. It will boost results due to tunelled ONE CAESE nursing after-care.
    2) There is rhoetric on TEM WORK; but overlooking the dissociated post operative care; due to case mix on wards, which is not likely in treatment centers
    3)Waiting lists are entirely managed by managers; no lomger the claimed monopoly of surgeons. Is it likely that treatment centers are better MANAGED!!!!!!!!!!!!!!!!!

  6. Supersub says:

    In response to Andrea & Rob, this had nothing to do with unsupervised trainees – the explanation is clear in the article above: The NHS hospital looked after much sicker patients with more co-morbidities and with worse socio-economic indicators. Our 2 local ISTC’s won’t touch anyone who looks vaguely ill.

    This study was presumably submitted to The Journal Of The Bleeding Obvious.

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