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“Let’s make the most of the independent sector”

By Mike Broad - 26th April 2010 2:34 pm

The government’s preferred provider policy should be abandoned and NHS services should face periodic competitive challenge from the independent sector, a body has claimed.

The NHS Partners Network, which represents independent sector healthcare companies, also calls on the next government to create a level playing field in tendering in a new briefing document, which is being seen as a blueprint for a Conservative government.

The body lists a series of policy changes to enable the independent sector play a greater role in NHS service delivery. It claims independent providers are uniquely place to drive productivity and raise quality during a tough funding period.

NHSPN says the provider market is still underdeveloped and a level playing field needs to be created for healthcare providers. “Commissioners need to be more aware that the surest way of demonstrating they have secured best value is by using open, non-discriminatory tendering processes wherever practical,” the document says.

It claims that independent economic analysis shows that the independent sector currently has to operate with a 14% cost disadvantage to public sector providers.

The NHS pension scheme is blamed. NHSPN says a substantial part of the pension costs are carried by central government not by NHS provider organisations themselves, which puts the public sector at a competitive advantage.

“To deal with this it will be necessary to ensure that public sector bidders are assessed on the basis of their full cost to the taxpayer,” it says.

“This might be done either by increasing the percentage of their pension costs which they have to bear directly or by applying a ‘shadow’ weighting factor which forces commissioners into making a truer comparison when assessing bids.

“Unless this aspect of the playing field is levelled it is likely that over time the pitch will become unplayable for the independent sector.”

The NHSPN also calls for the publication of comparative quality data to support choice, and says the independent sector is already committed to publishing its own data relating to clinical outcomes from the summer.

It says the NHS competition regime and the Cooperation and Competition Panel (CCP) have to be put onto a statutory basis; full cost allocation and accounting in public sector providers has to be enforced and even-handed regulation developed.

Last month the Department of Health pulled the plug on an investigation into the preferred provider policy by the CCP.

Commenting on the document, Dr Mark Porter, chairman of the BMA’s consultants’ committee, said: “Many of the companies now arguing for a level playing field were quite happy to accept preferential contracts when the NHS was being opened up to competition. Private providers continue to enjoy competitive advantages that the NHS does not - the ability to cherry-pick, to set exclusion criteria, and to not have to deal with the consequences when problems arise.

“The preferred provider policy, while it does not fully address the fragmentation and waste caused by market reforms, goes some way to recognising the benefits of NHS care being delivered by NHS providers.”

NHSPN claims that private sector productivity has outstripped that of the public sector in healthcare delivery. Between 1997 and 2007, NHS productivity declined by 4% whereas that in the private sector increased by 23%.

Despite this, in 2007/2008, PCTs spent less than 5% of a £71.2bn commissioning budget on independent sector care.

On value for money, however, Dr Porter said that every eight cases diverted to an Independent Sector Treatment Centre costs the taxpayer the equivalent of almost ten cases dealt with by the NHS.

The BMA is currently running a campaign against further marketisation of the NHS.

Read the full NHSPN briefing document.

Tags: ISTCs, Preferred provider, Privatisation
Posted in Hospital Dr News | 1 Comment »

What has been the impact of the market in the NHS?

By Mike Broad - 9th March 2010 10:04 am

A new study, by think tank Civitas, has questioned the achievements of NHS reforms in introducing competition and driving performance.

NHS ‘internal’ or ‘quasi’ market policies in England have aimed to promote competition among providers in the hope of replicating the benefits markets have been known to bring about in the private sector: decreases in cost, and increases in efficiency, quality, innovation, and provider responsiveness.

In 2002, the government introduced a new round of market-based reform within the NHS, which was initially focused on increasing choice for patients, decreasing waiting times, and improving quality of care.

Demand-side changes saw the creation of the primary care trust to perform a purchasing role similar to that of health authorities; and practice-based commissioning, a re-incarnation of GP fundholding but focused on community-based and specialty services rather than elective care. Patients were also given a choice of elective care provider (including non-NHS providers) at the time of referral.

Supply-side changes included the introduction of quasi-autonomous foundation trusts, and the encouragement of provider plurality. Market-based changes to the secondary care payment system took the form of payment by results (PBR).

The study, called The impact of the NHS market, involved a large-scale literature search on the effectiveness of these policies.

So how have the reforms worked? A summary

Patient choice studies show the percentage of patients who recall being offered a choice of hospital for their first outpatient appointment was 47% in March 2009, up from 46% in December 2008 and 30% in June 2006.

Eighty nine percent of patients offered a choice are able to go to the hospital they choose. Choice has contributed to decrease waiting times for elective surgery. There is disagreement among researchers on whether choice has had a positive or negative effect on equity. Fear of the impact of patient choice (rather than actual impacts of patient choice) has led some NHS providers to advertise services to both patients and GPs. In practice, the uptake of choice policy is not yet widely realised, and degree of implementation varies geographically.

The Choose and Book system may not be enabling as much choice as expected regarding appointment date and time and number of providers offered; GPs may use the system as an online tool to make referrals as usual. Patients and GPs desire more information on provider quality.

Neither strong theoretical nor empirical support exists on the benefits of secondary care provider competition; studies exist citing both improved and harmful outcomes.

Contestability, or the threat of competition, may be driving up efficiency but at the expense of inter-professional and inter-organisational collaboration. Competition is fostering development of more business-like cultures in NHS hospitals. Various impacts of competition policy have been seen on health economies, such as attraction of top quality nursing staff to private providers, confusion of PCTs and NHS providers over the nature of their relationships, and resentment among medical professionals toward local ISTCs regarding lack of patient treatment data.

ISTCs provide equal if not better outcomes than NHS providers, and receive higher levels of patient satisfaction; however, they treat a healthier case-mix of patients than NHS providers (as was intended by their contracts). ISTCs may have negative effects on NHS surgical training.

Increased autonomy over certain governance and finance decisions may not currently be a strong enough incentive to encourage further applications for foundation trust status. Many lay governors and directors of foundation trusts are finding their roles ambiguous and difficult to define. Many perceive that they have made little impact on the decisions of the trusts to date.

However, evidence does show gradual increased involvement of both governors and the public in their activities. Foundation trusts have generally performed well financially and have generated surpluses; and they have been high performers in routine NHS financial and quality measures when compared to NHS trusts.

Surpluses have, however, been modest in relation to total revenue; and many were among the highest performing NHS trusts even before status conversion. Little robust evidence exists to suggest foundation trusts are using their new status to innovate in a significant way.

Payment by Results has been fully embedded across the NHS since 2008. Unit costs fell quicker in hospitals once PbR was implemented, although administration costs increased. Hospital activity increased as PbR was implemented. No association has been found between PbR and quality of care. Where increases in efficiency were found post 2002 (for example, the increase in number of elective surgery patients treated as day cases, decrease in the length of inpatient stays, and reductions in avoidable admissions), authors note other policies and trends have also encouraged such results.

Many hospitals have improved financial management and have a better understanding of patient costs since PbR implementation, yet a substantial agenda of cost improvement remains for the NHS. Mixed evidence exists on prevalence of hospitals ‘upcoding’ procedures in order to get paid more.

The fact that the PbR tariff for a procedure is set at average cost encourages hospitals to become ‘average’ rather than aiming to operate at the level of the most efficient hospitals. Being paid per case through PbR produces adverse incentives for hospitals to increase activity beyond affordable levels and possibly induce demand inappropriately.

Practice-based commissioning implementation is slowly advancing. It is being led by a few enthusiastic practices working with supportive PCTs. Variation exists in the quality of local relationships and levels of PCT support; with resources and experience often limited at both PBC and PCT level. Incentives and infrastructure used to support PBC are not sufficient to engage most GPs in commissioning. And many PBC consortia are more interested in self-provision than commissioning new services.

PCTs lack the necessary skills to purchase effectively; poor local management of resources was noted. PCTs do not always take full advantage of their potential power in the purchaser/provider relationship. Only weak incentives exist for PCT managers to break historical patterns of purchasing. The World Class Commissioning programme is too new for its impact to be determined.

In conclusion

Many researchers found difficulty in attributing improvements specifically to market-based reform. Improvements in NHS care, such as major reductions in waiting times, have more often been attributed to ‘targets and terror’ together with increased spending, than to competition. Lack of a stable policy environment de-motivates staff. As yet, there is a lack of patient and public understanding and support for market-based reform. And many desired outcomes have not yet been achieved, such as innovative models of patient care.

Although there are presently very few studies that evaluate the cumulative effects of market reform, there is an abundance of research on the effect of individual policies. While evidence on the impact on quality of care is mixed, research has found attributable impacts in the form of reduced waiting times, improved access for patients, and increased provider efficiency.

However, potential confounding factors (such as simultaneous increases in funding and pressure from enforced targets), along with weak monitoring strategies, make attribution to market policies alone questionable.

The market reforms of the past 20 years have had unmistakable effects on the culture of the NHS. In particular, the introduction of competition has developed a system-wide awareness of costs, efficiency and accountability. However, the reforms have not been proven to bring about the beneficial outcomes that classical economic theory predicts of markets, including provider responsiveness to patients and purchasers; large-scale cost reduction; and innovation in service provision.

Many researchers have attributed this to the failure to create a true, functioning market, as well as a lack of a stable policy environment to inspire staff commitment and enthusiasm. The available research indicates that the NHS may have found itself in a lose-lose situation - having taken on the extra costs of competition without experiencing the benefits.

Tags: Commissioning, ISTCs, Patient choice, Privatisation
Posted in Features | 1 Comment »

BMA seeks public support for its campaign

By Mike Broad - 14th February 2010 1:55 pm

The BMA is urging the public to support its Look After our NHS campaign against the role of commercial companies providing NHS care in England.

Successive government policies have created a market in healthcare and allowed commercially run firms to compete against existing NHS trusts and GP practices to provide NHS care. The BMA is concerned that this is having an adverse impact on many parts of the NHS in England.

The BMA’s Look After our NHS campaign website has been revamped so that members of the public can show their support for an NHS which is publicly funded and publicly provided.

Next week the BMA is sending campaign packs to each of its members in England - over 100,000 doctors and medical students. The packs contain posters picturing businessmen taking money out of the NHS, and call on the public to “help us put patients before profits”.

Leaflets for patients, warning them that “your local GP practice, hospital or community health service could be run by a commercial, profit-driven company in the future”, will also be distributed via GP practices and BMA representatives in hospitals.

The campaign packs for doctors contain a brochure warning of the impact market-based reforms are having on the NHS. It states that the creation of a market in the NHS has meant an increase in bureaucracy; the number of senior managers in the NHS rose by 91% between 1995 and 2008 - more than double the increase in numbers of doctors and nurses.

It also says many private NHS providers have received millions in guaranteed payments for contracts, despite treating fewer patients than planned; on average, the first wave of Independent Sector Treatment Centres delivered just 85% of activity paid for - suggesting a shortfall of £220 million on the £1.47 billion contracts.

Dr Hamish Meldrum, chairman of BMA council, said: “We want an NHS with patients, not profits, at its heart. The public values the NHS as a publicly provided, publicly funded service. Like doctors, they do not want vital funding to be diverted to shareholders.

“Doctors have already backed the campaign. Now members of the public can show politicians the extent of opposition to commercialisation of their NHS.”

The NHS Confederation, which represents managers and employers, has however come out in opposition to the campaign. Nigel Edwards, NHS Confederation director of policy, said: “With the £20bn of savings in the NHS required over the next five years, the focus must continue on reducing costs while also driving up quality. Given the scale of this challenge, to rule out any use of the independent or third sector would remove a very important source of innovation and change that can help to deliver improvements.”

Read the leaflet being distributed in surgeries and hospitals.

Tags: ISTCs, Privatisation
Posted in Hospital Dr News | 1 Comment »

Doctors fear private sector’s role in the NHS

By Mike Broad - 23rd December 2009 10:20 am

Eight out of ten doctors are concerned about private companies profiting from the NHS, a poll shows.

Doctors were asked whether they agreed with the BMA’s concerns that large multinational companies are making profits out of running local clinical services on behalf of the NHS.

Eighty percent of the 697 respondents said they either strongly agreed (51%) or agreed (29%) with the statement. Just 7% either disagreed (4%) or strongly disagreed (3%).

One respondent, a consultant urologist, said: “The NHS no longer exists. There are a number of health services in England, Wales, Northern Ireland and Scotland, all different, no longer national in a UK sense. We are at a time when foundation trusts have become businesses, motivated by profit and loss.”

A BMA report, listing the amounts of public money being wasted as a result of market-driven reforms, estimates that £1.54bn might have been overpaid to Independent Sector Treatment Centres in England. It suggests the NHS in England spent around £350m on management consultants in the last financial year.

Dr Hamish Meldrum, chairman of BMA council, said: “This is more evidence of the medical profession’s concerns about commercial values being imposed on the NHS. There are countless examples of taxpayers’ money being wasted because of the drive for services to be provided by profit-making companies rather than traditional NHS providers.

“When politicians talk about cutting waste they should consider the fact that the bureaucratic costs of a market are hitting the taxpayer hard. We’d like to see the NHS in England restored to a publicly provided, publicly funded service, driven by the needs of patients, not shareholders.”

ISTCs are “cherry picking less complicated patients”

The Times - 11th November 2009 2:00 pm

Treatment centres run by the private sector are profiting from NHS funding by taking on less risky patients while being paid the same rate as publicly funded hospitals, a study suggests.

Patients treated in centres that carry out thousands of planned procedures, such as hip and knee replacements, to relieve pressure on the NHS are less likely to come from deprived areas, have fewer diagnoses and undergo fewer procedures than those treated in NHS hospitals, according to analysis of more than 3.3 million patient records funded by the Department of Health.

The national system for funding hospitals for treatment - known as Payment by Results - pays hospitals and treatment centres the same average cost for carrying out particular types of operation.

The average cost of a hip operation, for example, is about £6,000. But the actual cost to a hospital can be much higher, meaning that ISTCs could be profiting by taking on only less complicated, less expensive cases.

The study, by the University of York and others, published in the journal Health Policy, found “evidence that hospitals are treating patients of greater complexity than treatment centres”. The authors add: “If these observed differences between hospitals and treatment centres drive costs, then payments should be refined to ensure fair reimbursement.”

The authors say: “If treatment centres routinely treat patients with less complex needs within a healthcare resource group, they may profit at the expense of NHS hospitals. If so, this would suggest that the prospective payment system is unfair.”

Keith Brent, deputy chairman of the BMA’s consultants’ committee, said that, unlike NHS hospitals, ISTCs could “cherry pick” patients who were less likely to need expensive treatment. He echoed the call for any centre with a selection policy to be paid a lower tariff.

Rules on market testing “unclear and misguided”

By Francesca Robinson - 21st October 2009 11:26 pm

The Government has been accused of insulting doctors and other staff working for private providers of NHS care by introducing new rules on market testing.

The jibe follows new guidance to commissioners that NHS organisations must in future be designated the ‘preferred providers’ of care. The new policy was announced by health secretary Andy Burnham last month.

In a letter to PCTs and SHAs, NHS chief executive David Nicholson says existing providers must be given an opportunity to improve before others are given a chance to tender. It will be the job of the commissioner to test whether these services provide “best value and real quality”.

“This will ensure everyone knows where they stand and services will stand or fall on the quality of the services they provide,” says Nicholson.

Previous Department of Health policy has been that “any willing provider” should be considered when commissioning services.

David Worskett, director of the NHS Partners Network, the organisation that represents private providers working within the NHS, described the policy as a retrograde step.

He said: “It is worrying and insulting for staff working for private providers of NHS care - many of whom are on secondment from the NHS, who achieve productivity up to 30% higher and higher patient satisfaction - to be told they are not the preferred provider. I think that is actually a rather shabby way to treat these people.”

But he said staff should not fear for their jobs because the policy would fall foul of the principles of competition. “These rules make it absolutely clear that PCTs should not take a decision which restricts choice. If a contract were to be re-let to somebody else on grounds other than quality and cost then it would be an unjustified restriction of choice and could be referred the the Competition and Cooperation Panel and overturned.”

Worskett said the announcement had been more about politics and appeasing the unions than about healthcare. “The guidance is so vague and unclear and the concept so misguided that in reality PCTs will carry on making the right decision in terms of who the provider should be,” he declared.

Shadow health secretary Andrew Lansley accused Andy Burnham of putting party politics above the best interests of patients.

Conservative Party policy is to open up the provider side of the NHS to a “proper” tendering process between NHS, the independent and charity sectors. “We think competition is the way to incentivise organisations to up their game,” said a spokesperson.

The BMA said the new guidance reinforcing the status of the NHS as preferred provider was a “positive sign” that the government was listening to their concerns about the increasing commercial involvement in the NHS.

But Dr Hamish Meldrum, BMA council chairman, warned: “There’s still a long way to go before we turn round the market philosophy that for so long now has been part of day-to-day working life in the NHS.”

Meanwhile, the only Scottish ISTC, which provides elective surgery to patients from three health boards in Angus, is being brought back under full NHS control.

Tags: Commissioning, ISTCs, Privatisation
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ISTC programme at a cross roads over damning evidence

By Mike Broad - 29th September 2009 4:09 pm

There’s nothing new in the quality of care at Independent Sector Treatment Centres being questioned. It has been going on for years. But, significantly, it’s increasingly based on evidence rather than rumour and anecdote.

In the past, consultants have been accused of sour grapes. There probably are a few surgeons whose resistance to ISTCs stems from wanting to protect their private practices. There are certainly a fair few consultants who have a moral issue with the private sector being introduced to deliver NHS services, regardless of their performance.

But, the overwhelming majority of doctors are concerned because they fear the ISTC programme is compromising patient care, damaging existing units and wasting valuable resources.

The medical profession is not alone with its concerns. Back in 2006, the House of Commons health select committee raised questions over the role of ISTCs.

“We are not, however, convinced that ISTCs provide better value for money than other options, such as more NHS Treatment Centres, greater use of NHS facilities out-of-hours or partnership arrangements. All these options would more readily secure integration and may be cheaper,” it said.

But they’ve had to wait a relatively long time for the real evidence to emerge. The September issue of the Journal of Bone and Joint Surgery published a paper called Short-term results of total hip replacements performed by visiting surgeons at an NHS treatment centre. It’s incendiary stuff.

It examines the results of total hip replacements (THRs) performed on patients referred from the Cardiff and Vale NHS Trust waiting list to Weston-Super-Mare ISTC. The need for revision surgery has been identified in 20 of 113 THRs (18%) at a mean of 23 months’ follow-up. The authors state poor technique, particularly with respect to cementing the acetabular component, to be the main cause of revision surgery.

Figures previously published for cemented hip replacement show the NHS-wide revision rate to be 0.9% at three years.

There’s no doubt that ISTCs were the product of a fairly noble aim - to increase the capacity of the NHS in elective surgery beyond that which the Department of Health could afford. Commissioners would purchase services from the independent sector that could then focus on the procedure in question without the ‘normal’ distractions. It has led to 25 fixed site ISTCs having been set up since inception in 2002.

But, in practice, there have been many challenges. There’s not only been the human cost already hinted at, but a significant economic one as well.

The supporting editorial in the Journal of Bone and Joint Surgery suggests that if the follow on costs associated with hip and knee replacements at Weston-Super-Mare ISTC were replicated in other ISTCs the finances behind the whole programme would become untenable.

Initial contracts were awarded at an average premium of 11.2% above the NHS equivalent price. A tenfold increase in the revision rate for total knee replacements, together with an 18-fold increase in that for hips, would “place a huge financial burden on the NHS as a whole, which would not be reflected by ISTC financial performance indicators”.

These figures come on top of the guaranteed payments scandal with the tax payer funding lots of unused operations by ISTCs. Edinburgh University academics Allyson Pollock and Graham Kirkwood recently estimated that up to £927m could have been wasted on unused operations in ISTCs nationally. Pollock estimates the whole ISTC programme has cost somewhere in the order of £5bn.

Their research concluded: “Contracts should not be renewed [for ISTCs] and new contracts should not be signed until a proper independent evaluation has been published assessing referrals, actual treatments carried out, and payments made for work done along with value for money analysis. Full contract details and costs must be placed in the public domain for this assessment to take place.”

It’s this apparent secrecy surrounding the ISTC programme that creates much of the suspicion. There isn’t even an open national register of how many ISTCs exist and where they are located.

Measuring ISTC performance is also problematic. Of the 28 key performance indicators that ISTCs are monitored for, only eight measure clinical performance. And, indeed, the first review of the data was carried out by the National Centre for Health Outcomes Development in 2005, stated that the data were of such poor quality that “any attempt at commenting on trends and comparisons between schemes and with any external benchmarks was rendered futile”.

As the editorial in The Journal of Bone and Joint Surgery states: “The lack of data from ISTCs regarding the quality of the care they provide makes it difficult to refute the evidence provided by these studies.”

The government machinery behind the ISTCs disagrees. David Worskett, director of NHS partners network at the NHS Confederation, wrote recently to The Times saying: “It should be remembered that this is one centre, run locally by the Weston Area Health NHS Trust. The suggestion by some surgeons that this research holds lessons for the whole independent sector in the NHS is one we disagree with in the strongest possible terms.

“Independent sector facilities achieve some of the best clinical outcomes in the NHS. Although fully comparable national data about surgical revision rates is not yet available, an independent study carried out for the lead NHS commissioner in the North West shows that ISTC revision rates are significantly lower than the regional NHS and international rates. Carrying out these procedures in treatment centres also significantly reduces the incidence of hospital-acquired infections.”

There have been issues with other ISTCs however. A review had to be conducted into 1,828 colonoscopies performed on patients at Shepton Mallet’s NHS Treatment Centre between 2005 and 2008. The inquiry was prompted by the death of a cancer patient after his condition was missed.

While the joint service investigation report concluded earlier this year that there was no evidence to support suggestions of misdiagnosis, it did identify a number of areas for improvement including “recruitment procedures, the pathway for direct referral colonoscopies, supervision in colonoscopy and effective reporting and monitoring of serious untoward incidents”.

The review was led by NHS Somerset and the treatment centre itself, but was subject to an independent clinical review by leading specialists accredited by the Joint Advisory Group on GI Endoscopy.

So, with many of the ISTC contracts due to come up for renewal, what could be done to improve the ISTC programme?

Good clinical governance lies at the heart of the problem, whether the surgeons already work within the NHS or are recruited from abroad. The Journal of Bone and Joint Surgery believes standardised outcome measures are needed and thorough patient follow-up.

It says: “The unease with which the orthopaedic community has viewed the drafting in of overseas surgeons to carry out procedures appears to be justified. The dissociation between the surgeon and the community he or she serves can only drive standards down, as follow-up becomes impossible and accountability is separated from surgical responsibility.”

The Royal College of Surgeons says that the same standards of clinical and financial audit in the rest of the NHS should apply to ISTCs. It wants greater transparency and sharing of data.

Mr John Black, president of the college, said: “These centres are not integrated properly with the rest of the NHS, particularly in the way the surgeons who work in them, who very often come from outside the UK, are appointed.

“They work on the principle of reducing operations to a factory production line in the misguided belief that this makes care more efficient. However, there is no such thing as a routine operation and every patient is different. The government was right to try to increase capacity to reduce waiting times, but it is now obvious that more would have been achieved if that capacity had been increased within the mainstream NHS.”

The whole programme is clearly at a cross roads. Should they be improved or scrapped?

The government appears a little undecided itself. Earlier this year Health minister Mike O’Brien announced that each contract will be reviewed on a case-by-case basis. In future, new ISTC services will be commissioned by the local PCT and the contracts will be paid under the same pricing arrangements as other NHS providers. Services will also be delivered under the terms and conditions of the standard NHS national contract for acute hospital services.

It was not before time for the BMA. Speaking at the time, Dr Hamish Meldrum, chairman of BMA council, commented: “It’s a shame it’s taken so long to get an acknowledgement that skewing the playing field in favour of private companies has been unfair and wasteful. Independent sector treatment centres have been able to cherry-pick easier cases, potentially destabilising existing services.

“Especially in the current climate, the NHS cannot afford poor value contracts, unnecessary competition, and duplication of services. We need much more of a whole-systems approach to the provision of healthcare, and we need the NHS to be run on the basis of co-operation collaboration, not competition.”

Maybe it will take the zeal of a new Tory government to breathe some life into the programme. But, if I were sat dispassionately on the Clapham Omnibus, the question on my lips would be: if ISTCs are providing treatment at higher costs than the mainstream NHS, with poorer outcomes, why are we sending our patients to them?

Read an alternative view of ISTCs.

Tags: ISTCs, Privatisation
Posted in Features | No Comments »

ISTCs cannot hide their performance anymore

By Mike Broad - 23rd September 2009 10:35 pm

I used to edit a magazine that printed something pointed about an independent sector treatment centre.

The ISTC promptly hired a fancy lawyer and threatened to take us to court for libel.

To cut a long story short, surgeons at the ISTC had made a series of rather obvious clinical mistakes. When they happened, they promptly packed the patients off to the local DGH to be sorted out.

The surgeon who wrote the article for us worked in the aforementioned DGH and knew the guys who were cleaning up the ISTC’s mess.

Based on this, he expressed some pretty strong opinions on the competency of the ISTC. The copy editor - me - knew the opinion was based on fact so we ran with it. It was a good piece.

Soon we were embroiled in a legal row. Lawyers were exchanging letters and the meter was running. The mistake I’d made was that while I knew we were right, proving it wasn’t going to be that easy. We should have taken our time, gathered more evidence and sought legal advice at the outset.

As it stood, we might have won in court but it would have been a long, protracted and costly business. But, more significantly, my employer wasn’t interested in toughing it out.

Instead I apologised in print and paid their legal fees. Ouch! I made sure the apology was as small as I could get away with and hid it deep within the magazine. A petty move I admit, but it made me feel better.

It was an object lesson in how ‘good’ lawyers can bully journalists and publishers through the threat of an expensive libel case, even when a story is true. You need the evidence up front so you can squash the legal challenge immediately.

Anyway, ISTC rumours continued generally. Poor integration, low quality, unused resource, etc. Evidence did emerge on what a waste of money ISTCs have proved to be, largely due to the diligent work of academic Allyson Pollock.

Even now, when the government is saying that ISTC operators will in future have to compete on the same terms as other health providers, there are heavy costs to pay. The government, for example, is committed to buying the facilities in which the ISTCs work for £200m.

There was less evidence, however, about the quality of the care at ISTCs. This is surprising considering the current health secretary’s obsession with the issue. When quizzed, the Department of Health just point to positive satisfaction surveys.

That was until this week, when The Times reported that a group of Cardiff surgeons have examined the hip operations performed by their local ISTC - Weston-Super-Mare NHS Treatment Centre.

Of 113 hip operations on patients sent from their trust to the treatment centre between 2004 and 2006, two thirds showed clear evidence of poor surgical technique, such as poor cementing of the hip.

In the three years since the operation, 18% of patients had undergone revision or were awaiting an operation - 20 times the 0.9% NHS-wide revision rate at three years.

This isn’t a case of sour grapes on my behalf. My ‘libel’ experience was with a different ISTC. I just doubt that this ISTC is alone, as it’s unlikely that Stafford Hospital is the only one of its kind. Proper audit is needed. It seems that whenever we try to increase volume and reduce cost, particularly through the private sector, we run the risk of compromising quality.

Imagine what our existing NHS orthopaedic and ophthalmic units would look like had we invested the £5bn spent on ISTCs in them instead.

The whole programme needs either overhaul or closure, regardless of what their fancy lawyers say.

Read opposing views on ISTC performance.

Tags: Audit, ISTCs, Privatisation
Posted in Dr Blogs | 7 Comments »

ISTCs to operate on “fairer basis”, says DoH

By Mike Broad - 6th August 2009 11:20 am

The government is trying to revive its ailing independent sector treatment centre programme by ensuring that future contracts will be on the same terms as other NHS providers.

Health minister Mike O’Brien announced that, with many ISTC contracts coming to an end next year, each will be reviewed on a case-by-case basis.

In future, new ISTC services will be commissioned by the local PCT and the contracts will be paid under the same pricing arrangements as other NHS providers. Services will also be delivered under the terms and conditions of the standard NHS national contract for acute hospital services.

ISTCs started operating in October 2003 with the intention of increasing competition and thus standards in the NHS. But they were quickly criticised for being poorly integrated with local NHS services, under utilised and for benefiting from guaranteed funding.

Edinburgh University academics Allyson Pollock and Graham Kirkwood recently estimated that up to £927m could have been wasted on unused operations in ISTCs nationally. There are currently 25 fixed site ISTCs.

Health minister Mike O’Brien said: “In the past the independent sector has sometimes been guaranteed payments. In the future it is intended that contracts will operate at NHS tariff prices using the standard NHS contract for hospital services.

“Where independent sector providers offer value for money, innovation and high quality patient care, they have a role to play within the NHS. Independent Sector Treatment Centres have helped patients by increasing choice and capacity, and reducing waiting times.

“Greater local control and day-to-day management will ensure these services are better integrated in to the local health system and reflect local needs.”

The government claims that more than 1.7 million operations, diagnostic assessments and primary care consultations have been provided at ISTCs, and 96% of patients said their care was ‘excellent’ or ‘very good’.

Dr Hamish Meldrum, chairman of BMA council, commented: “It’s a shame it’s taken so long to get an acknowledgement that skewing the playing field in favour of private companies has been unfair and wasteful. Independent sector treatment centres have been able to cherry-pick easier cases, potentially destabilising existing services.

Tags: ISTCs, Privatisation
Posted in Hospital Dr News | No Comments »

£200m for NHS to become ISTCs landlord

HSJ - 31st July 2009 9:25 am

The buildings and facilities of up to 16 independent sector treatment centres will need to be bought by the NHS over the next two years at a capital cost estimated at £200m, the Department of Health has confirmed.

The £200m cost relates to the so-called “residual value guarantees” that were built into the first wave of the ISTC programme contracts in order to minimise the risk to the private sector of taking on five year contracts to treat and diagnose elective patients.

The guarantees - which were made in addition to guarantees around the volume of work the centres would receive - require the NHS to buy back the remaining capital assets of the centres at their capital value at the point at which the contracts expire. The latest estimate given by the DoH is £200m.