House of Commons - Health - Appendices to the Minutes of Evidence

Select Committee on Health Appendices to the Minutes of Evidence

Annex I

ACUTE INDEPENDENT SECTOR SERVICE PROVISION

It should be noted that in 2000 the independent sector has 211 hospitals providing acute care in the form of approximately one million surgical procedures each year.

The five largest acute hospital groups are General Healthcare Group, BUPA, Nuffield Hospitals, Community Hospitals Group and HCA International. The remainder of the acute sector consists of smaller groups and independent hospitals.

Exhibit 1: Independent hospital providers (by bed numbers)


Provider	Units	Beds	% total bed

General Healthcare Group (BMI Hospitals)	40	2273	22%
BUPA Hospitals	36	1883	18%
Nuffield Hospitals	38	1580	16%
CHG	21	859	8%
HCA International	7	785	8%
Other groups and single hospitals	79	3169	30%
Total	211	10549	100%

The following statistics are sourced from work produced by Professor Brian Williams, Professor of Public Health at the University of Nottingham. The work was commissioned by the IHA as background information to the capability of the acute independent sector in 1997 and 1998.

There were 828,422 admissions to independent hospitals in England and Wales in 1997-98, a rise of 22 per cent since 1992-93. There were 406,843 in-patients (down by five per cent) and 421,580 day cases (up 69 per cent). There were 17,200 overseas patients (down 17 per cent).

The respective analyses reported cover the following groupings of patients:


	Inpatient	Day Case	Total

All Hospitals
All patients	406,843	421,580	828,422
Residents of England and Wales	390,586	414,431	805,017
Residents of England and Wales but excluding termination of pregnancy (TOP) procedures	375,385	340,725	716,110
Excluding TOP Hospitals
All cases	384,345	347,378	731,724

Excluding the 89,000 abortion patients, 541,000 residents in England and Wales were funded through Private Medical Insurance (PMI) (up 13 per cent) and 119,000 were self-funded (up 69 per cent), a ratio of 9 to 2.

Excluding abortions, numbers of cases increased in every age group except children, 0-14 years (down 17 per cent). The number of elderly patients (65 plus) rose fastest (up 68 per cent) to 177,000. Females outnumbered males in all age groups except the youngest.

Regionally, the proportion of privately funded, non-abortion patients who paid through PMI varied from 75 per cent to 85 per cent. There was no discernible geographic gradient.

Self-funding was most common among the elderly—18 per cent of those aged 65-74, and 29 per cent of those aged 75 plus. Women aged 15-44 self-funded in 25 per cent of cases (excluding abortions), reflecting an increase in the use of cosmetic surgery.

The latest figures from independent healthcare providers show that self-pay has reached unprecedented levels. It has been reported that between 1997 and 1999 BUPA hospitals saw self-pay increase by 30 per cent, compared with 17 per cent in the two years preceding, and in 1999 it handled 25,000 self-pay admissions. It has been reported that Nuffield Hospitals experienced a similar trend, with self-pay now accounting for a quarter of its revenue. Furthermore, General Healthcare Group treated 35,000 patients. Across the board it is estimated that 160,000 self-pay operations took place in the independent sector in 1999, an increase of 40 per cent on the previous year.

Seventeen per cent of resident England and Wales patients were treated for non-surgical conditions. Excluding abortions (11 per cent), the commonest surgical procedure was endoscopy of the gut (11 per cent) or a joint (6 per cent), removal of a cataract (6 per cent), hernia repair (4 per cent), removal of skin lesions (4 per cent) and cosmetic operations (4 per cent). (Note—it is known that cosmetic surgery has increased.)

Self-funding was highest for treatment which relieved pain (eg total hip replacement) or restricted activities (eg cataract removal)—conditions commonest in the elderly.

The 39 hospitals within the M25 Motorway (London) treated 24 per cent of all non-abortion cases, including most of the patients from overseas. Relatively more heart surgery was performed in London. Otherwise the operation group profiles of London and provincial hospitals was similar.

Private funding purchased 14.5 per cent of all elective hospital spells (wherever provided), one tenth of which was spent in NHS hospitals. Private finance paid for one in four hip joint replacements, one in five operations on coronary arteries and two out of every five cosmetic operations.

Table I. Acute beds available per 100,000 population in England and Wales, 1997.


NHS Region	NHS acute Specialities	Independent Hospitals (a)	NHS pay bed Units (b)	Private sector (a) plus (b)

England and Wales	224.0	20.0	2.7	22.7
Northern & Yorkshire	240.8	10.2	0.7	10.9
Trent	228.3	10.6	1.5	12.1
Anglia & Oxford	189.5	20.4	2.7	23.1
North Thames	215.4	38.3	7.7	46.0
South Thames	188.8	32.4	4.2	36.6
South & West	220.0	17.8	1.6	19.4
West Midlands	213.9	13.6	1.2	14.8
North West	257.5	16.6	1.7	18.3
Wales	297.1	8.2	0.5	8.7
Actual number of beds	116,486*	10,381*	1,414*	11,795*

*NHS bed numbers are under estimate.

Table II. Comparison of patients admitted to independent hospitals in England and Wales, 1992-93 and 1997-98.


	1992-93	1997-98	% change

Total cases	678,703	828,422	22.1
In-patients	429,172	406,843	-5.2
Day cases	249,531	421,580	68.9
Origin of patients
England & Wales	651,673	805,017	23.5
Other UK	2,556	3,443	34.7
Overseas	20,782	17,199	-17.2
not known	3,691	2,764	-25.1
Source of funding (%)
i. Residents E&W n=	651,673 %	805,017 %	23.5
NHS	31,982 (4.9)	84,561 (10.5)	164.4
Private, insured	480,257 (73.7)	541,111 (67.2)	12.7
Private, self pay	133,567 (20.5)	165,054 (20.5)	23.6
Other*	37 (0.1)	9,228 (1.1)	(-)
Not known	5,492 (0.8)	5,062 (0.6)	-7.8
ii. Residents E&W excluding Top cases n=	569,927	716,110	25.6
NHS	14,288 (2.5)	41,942 (5.9)	193.5
Private, insured	478,575 (84.0)	540,966 (75.5)	13.0
Private, self pay	70,675 (12.4)	119,101 (16.6)	68.5
Other*	950 (0.2)	9,228 (1.3)	(-)
Not known	5,448 (1.0)	4,872 (0.7)	-10.6

*Patients who were sponsored by labour unions, embassies or charities.

Table III. Percentage of estimated number of cases treated in independent hospitals (1997-98), and in NHS hospitals (elective admissions 1996-97) according to method of funding. Residents of England and Wales, excluding termination of pregnancy cases.

Treated in:	Independent hospitals				NHS hospitals
Funding:	Private	NHS	Total*	% privately provided however funded	Private	NHS	Total	% privately funded wherever provided
EYES & ENT
Other eye operations	8,572	270	8,899	5.9	2,652	138,295	140,947	7.5
Lens operations	29,159	3,921	33,218	16.1	4,817	168,282	173,099	16.5
Tonsillectomy and adenoidectomy	11,223	1,730	13,037	13.1	604	86,098	86,702	11.9
Drainage of middle ear	10,413	425	10,872	17.0	390	52,649	53,039	16.9
Other ear, nose and throat	23,540	1,964	25,700	12.0	2,500	186,857	189,357	12.1
Dental operations	20,185	733	21,187	12.1	753	153,380	154,133	11.9
HEART/BLOOD VESSELS
Ops on coronary arteries	4,369	445	4,843	17.8	1,113	21,205	22,318	20.2
All other heart operations	10,540	583	11,162	11.8	2,805	80,673	83,478	14.1
Ligation/stripping varicose veins	12,781	1,888	15,057	23.6	505	48,340	48,845	20.8
GUT OPERATIONS
Cholecystectomy	6,022	336	6,390	17.2	441	30,316	30,757	17.4
Other major intra- abdominal operations	6,651	33	6,684	10.9	1,359	53,389	54,748	13.0
Diagnostic or therapeutic endoscopy of G-I tract	62,655	3,079	65,995	11.0	6,693	524,993	531,686	11.6
Abdominal hernia repair	20,424	1,398	21,973	21.2	1,104	80,633	81,737	20.8
Haemorrhoidectomy and other anal ops	8,945	634	9,647	15.4	654	52,414	53,068	15.3
MALE OPERATIONS
Prostatectomy	6,079	430	6,544	14.0	571	39,524	40,095	14.3
Vasectomy	2,384	1,874	4,310	10.4	190	36,913	37,103	6.2
Circumcision	3,250	90	3,374	12.0	281	24,372	24,653	12.6
GYNAECOLOGICAL OPS
Dilation and curettage	3,838	100	3,938	8.1	332	44,213	44,545	8.6
All hysterectomy	10,320	562	11,018	15.5	631	59,223	59,854	15.5
Division, ligation, occlusion of oviducts	469	449	918	1.9	195	47,432	47,627	1.4
Repair of prolapse of vagina or uterus	5,198	107	5,305	19.1	262	22,219	22,481	19.7
Other gynaecological	42,052	917	43,177	17.8	2,443	197,356	199,799	18.3
BREAST OPERATIONS
Total excision of breast	2,051	96	2,147	13.9	126	13,164	13,290	14.1
Partial excision of breast	7,116	456	7,572	17.6	466	34,983	35,449	17.6
ORTHOPAEDIC OPS
Total replacement of hip joint	9,571	1,655	11,299	23.7	1,136	35,239	36,375	22.5
Total replacement of knee joint	5,041	924	5,965	18.4	419	25,960	26,379	16.9
Other orthopaedic ops	36,362	2,146	38,833	16.2	3,330	197,058	200,388	16.6
Diagnostic or therapeutic endoscopy of joint	32,027	2,774	35,288	30.6	1,229	78,827	80,056	28.8
MISCELLANEOUS
Cosmetic ops	23,165	219	23,663	38.3	683	37,414	38,097	38.6
Sexual transformation	104	0	104	66.7	6	46	52	70.5
Removal of lesion of skin	19,406	1,349	21,122	11.0	1,139	169,764	170,903	10.7
ALL OTHER OPERATIONS	93,003	5,624	99,429	8.9	13,285	1,003,960	1,017,245	9.5
OPERATION TYPE NOT KNOWN	1,001	93	1,094	2.9	724	36,543	37,267	4.5
TOTAL OPERATIONS	537,917	37,304	579,762	13.1	53,838	3,781,734	3,835,572	13.4
NO. OPERATION	131,381	4,638	136,350	20.1	16,674	526,046	542,720	21.8
TOTAL	669,298	41,942	716,114	14.1	70,512	4,307,780	4,378,292	14.5
* Total includes method of funding not known.

A. Independent Sector Capacity for Critical Care

The independent sector has 151 appropriately staffed intensive care beds and 649 appropriately staffed high dependency beds.

The sector assisted with the provision of intensive care work for the NHS during the 1999-2000 winter crisis. The sector is intending to redefine its capabilities using the proposed levels of care in the critical care framework document entitled "Comprehensive Critical Care—A Review of Adult Critical Care Services" in preparation to participating where appropriate in the network development.

B. Independent Sector Capacity for Cardiac Surgery

In 1999 more than 5,000 of coronary artery bypass procedures were performed in independent sector hospitals—around 20,000 heart operations in all were carried out. Independent sector hospitals have both the capacity and capability to contribute to the targets set in the Cardiac National Service Framework. They have the facilities, the equipment and the intensive care nursing arrangements to help the NHS make real inroads into waiting list figures for heart surgery.

Table IV. Coronary Artery operations performed in independent hospitals in 1992-93 and 1997-98

	Total number of operations on coronary arteries	Operations on residents of England and Wales
1992-93	6,463	3,809
1997-98	5,803	4,843

C. Future Provision of More Specialist Diagnosis and Treatment

The following are examples of how the sector can assist in the future healthcare of the UK:

— IHA member organisations suggest further developments in cardiology and cardiac surgery that follow the national advances and improved cardiac rehabilitation in order to prevent further illness by altering lifestyle trends.

— Comprehensive oncology centres (to include radiotherapy and chemotherapy). The independent sector has proven ability to run such centres.

— Partnership arrangements with the independent sector should include increased high dependency and intensive care provision to support growth in complex work.

— Interventional radiography with X-ray reporting links to NHS hospitals and voice activated/instant reporting on films from the independent sector and vice versa.

— Provision of acute stroke units with a built review in approximately six months as regards using arrhythmia's agents which is now defined as evidence-based treatment.

— The use of full-field digital mammography units and digital fibroscopy room, to complement facilities provided within NHS Trusts.

— The sharing of CT scanners and Nuclio Anomaly scanning.

— The provision of Osteoporosis clinics.

— Continence promotion and laser treatments for gynaecological treatments are all areas that the independent sector can assist in the future provision of more specialist diagnosis and treatment.

— MRI and other imaging installations will include capability of tele-medicine links via the internet for reporting or additional highly specialised advice.

— The provision of evidence-based data set collection capabilities to comply with clinical audit/governance objectives in order to benchmark best practice initiatives so as to facilitate future provision of more specialist diagnosis and treatment.

D. General Projections of Future Activity in the Independent Sector

IHA members have invested a considerable amount in additional capacity in the independent sector in terms of in-patients, day case units, operating theatres, out-patient consulting rooms, diagnostic and therapeutic support areas.

For example:

— Major increases in diagnostic radiology/CT/MRI/cardiac catheterisation laboratory.

— Upgrading of MRI and CT services.

— New radio nuclide unit and new endoscopy unit.

— New programmes for Chronic Fatigue Syndrome.

— New programmes for Fibromyelgia (in-patient).

— New pain programme (in-patient).

— Women's Health (gynaecology and breast care).

— Expansion of well man health service.

— Expansion of fertility services to include IVF programmes.

— Out-patient hysterocopies.

— Development of comprehensive oncology centres.