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ISTC programme at a cross roads over damning evidence

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.

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