Conclusions and recommendations
1. ISTCs
have not made a major direct contribution to increasing capacity,
as the Department of Health has admitted. It is far from obvious
that the capacity provided by the ISTCs was needed in all the
areas where Phase 1 ISTCs have been built, despite claims by the
Department that capacity needs were assessed locally. (Paragraph
35)
2. We are concerned
that the Department has attempted to misrepresent the situation
by presenting the BUPA Redwood figures as procedures performed
by the mainstream ISTC programme. (Paragraph 36)
3. ISTCs have had
a significant effect on the spot purchase price in the private
sector and on charges in the private sector more generally. (Paragraph
38)
4. ISTCs have for
the present increased choice, offering more locations and earlier
treatments. However, without information relating to clinical
quality, patients are not offered an informed choice. (Paragraph
41)
5. ISTCs have embodied
good practice and introduced innovative techniques, but good practice
and innovation can also be found in NHS Treatment Centres and
other parts of the NHS. ISTCs are not necessarily more efficient
than NHS Treatment Centres such as Dartford. (Paragraph 49)
6. The Department
claims that ISTCs drive the adoption of good practice and innovation
in the NHS, but we received no convincing evidence which proved
that NHS facilities were adopting in any systematic way techniques
pioneered in ISTCs. (Paragraph 51)
7. The threat of competition
from the ISTCs may have had a significant effect on the NHS. This
factor may be the most important contribution made by the ISTC
programme. However, the evidence is largely anecdotal. Waiting
lists have declined since the introduction of ISTCs, but it is
unclear how far this has happened because the NHS has changed
in response to the ISTCs or because of additional NHS spending
and the intense focus placed on waiting list targets over this
period. We are surprised that the Department has made no attempt
systematically to assess and quantify the effect of competition
from ISTCs on the NHS. Given its importance, the Department should
have ensured that this was done from the beginning of the ISTC
programme in 2003. (Paragraph 56)
8. There are examples
of poor care in ISTCs, as there are in the NHS. However, in the
absence of the necessary comparable data from both NHS Treatment
Centres and ISTCs, there is not the statistical evidence to suggest
that standards are different. The Department should have ensured
that such data were collected from both providers and published
in order accurately to assess quality of care, complication rates
and other quality measures. We are concerned that currently only
eight of the 26 KPIs are clinical indicators. We welcome the Healthcare
Commission's review of the quality of care in ISTCs which the
Chief Medical Officer has requested. (Paragraph 72)
9. Given the difficulty
in making comparisons, we are dismayed at the strident and alarmist
tone of some criticisms of clinical standards in ISTCs on the
basis of anecdotal evidence, highlighted by the BOA's questionable
claim that there are revision rates of 2.3% in ISTCs (Paragraph
73)
10. As a result of
the European legislation, the regulation of foreign-trained EEA
clinicians, who make up the majority of doctors in ISTCs, is not
as rigorous as it should be. The GMC made it clear to us that
it had reservations about the robustness of the current regulatory
system for doctors who qualified outside the UK. The fact that
language tests cannot be imposed on doctors from the EEA (although
they can be on international medical graduates) and that the GMC
has no discretion in accepting clinicians from the EEA who are
registered as specialists in their home country are causes of
concern. As a result, scrutiny of a foreign-trained doctor's fitness
to practise in a given set of circumstances is effectively passed
on to the employers. In view of the limited role of the GMC in
the accreditation of EU doctors, the appointment procedures used
by ISTCs must be carefully monitored. It is essential that the
Department stresses to those who employ EEA qualified doctors
the responsibility they have to ensure that these doctors are
proficient. As a safeguard we recommend that ISTCs use the same
appointment procedures as the NHS. In addition, ISTC clinical
appointments for overseas doctors should incorporate a standardised,
independent assessment system based on competency. (Paragraph
76)
11. The Department
admits that some ISTCs are poorly integrated into the NHS. In
our view, too many fall into this category. We were informed of
notable exceptions such as the Shepton Mallet Treatment Centre,
which show that with the right approach it is possible to engage
NHS doctors and other staff in the work of ISTCs. (Paragraph 82)
12. Even though Phase
1 ISTCs perform a relatively small number of procedures, there
can be a significant local effect on the training of junior doctors.
(Paragraph 84)
13. The ISTC programme
is intended eventually to provide about half a million procedures
per year at a cost of over £5 billion in total. This is close
to 10% of the total elective workload of the NHS and would clearly
affect the viability of many existing NHS providers over the next
five years and possibly beyond. Moreover as the quantity of ISTC
activity is not evenly balanced across the country, the impact
on the budgets of different local health economies is likely to
vary. (Paragraph 96)
14. The Phase 1 contracts,
including the 'take or pay' elements, give ISTCs a significant
advantage over NHS Treatment Centres and other NHS facilities.
This is one of the reasons that several NHS Treatment Centres
have spare capacity. (Paragraph 98)
15. In the longer
term, there are good reasons for thinking that ISTCs could have
a more significant effect on the finances of NHS hospitals. We
do not know how big that effect might be or how great the dangers
might be. The Department of Health has carried out analysis of
the possible effects of the ISTC programme on NHS facilities,
but it has refused to disclose the analysis to us. Phase 2 ISTCs
may lead to unpopular hospital closures under 'reconfiguration'
schemes. (Paragraph 99)
16. The cost of Phase
1 includes a premium over the NHS Equivalent Cost which was paid
to the ISTC providers, but without access to the detailed figures
we do not know how big this premium was. There were other costs
of Phase 1, for example the effect on NHS finances. It is hard
to see that this could have been justified in terms of the need
for additional capacity alone. The other major potential benefit,
the galvanising effect of competition on the NHS, was not and
probably could not be quantified when the decision to go ahead
with Phase 1 of the ISTC programme was made. It is claimed that
this decision was a leap in the dark in the hope that the 'challenge'
of ISTCs would improve efficiency in the NHS. We agree. (Paragraph
106)
17. Moreover, since
we do not know the details of the contracts, what figure was used
for the NHS Equivalent Cost or how it was arrived at, and since
the benefits of ISTCs have not been quantified, it is also impossible
to assess whether ISTC schemes have in practice proved good value
for money. (Paragraph 107)
18. In view of the
high degree of uncertainty about the wider benefits and costs
of the ISTC programme, we recommend that the NAO investigate them,
in particular the extent to which the challenge of ISTCs has led
to higher productivity in the NHS. (Paragraph 108)
19. The Department
has proposed a number of changes to ensure that Phase 2 ISTCs
are better integrated into the NHS than those in Phase 1. We welcome
the proposals to ensure better clinical engagement in all ISTCs.
In addition, we recommend that Phase 2 ISTC facilities be sited
in or near NHS hospitals. (Paragraph 120)
20. The Department
has recognised that the additionality principle has hindered integration
and proposes to restrict its application. It proposes to allow
NHS consultants to work non-contracted hours in ISTCs. We welcome
this and recommend that, in addition, the Department should ensure
that Phase 2 contracts encourage NHS staff to be seconded to treatment
centres. We also recommend that consultants be allowed to hold
sessions of NHS planned activities in ISTCs where this would be
thought appropriate for local service needs and to aid integration.
Consultants working non-contracted hours in ISTCs should do so
at NHS contract rates. (Paragraph 121)
21. If ISTCs are to
be fully integrated into the NHS, the Department will need to
address concerns about pay and conditions. Lower salaries and
poorer pension provision in ISTCs are unlikely to assist integration.
(Paragraph 122)
22. We support the
Department's decision to include the provision of training as
a contractual obligation for Phase 2 of the ISTC programme. This
will greatly help to break down barriers between ISTCs and the
NHS. The standard of training in ISTCs should be of the same standard
as in the NHS. (Paragraph 126)
23. It is difficult
at present, therefore, to assess the current state of Phase 2
of the ISTC programme, or the rationale behind it. The Department
of Health and the Secretary of State have, over the course of
our inquiry, given answers which have shifted in both fact and
emphasis as time has gone by, and the statement of the current
position by the Secretary of State leaves several important questions
unanswered. The decision to maintain the commitment to spend £550
million per year despite changing circumstances has not been explained,
and seems to sit uncomfortably with the Secretary of State's admission
that "in other [areas] it has become clear that the level
of capacity required by the local NHS does not justify new ISTC
schemes". It is not clear whether this represents simply
a failure coherently to articulate the situation or a more profound
incoherence in terms of policy as opposed to presentation. (Paragraph
139)
24. There are real
concerns that the expansion of the ISTC programme will destabilise
local NHS trusts, especially those with financial deficits. ISTCs
should only be built where there is a local need and after consultation
with the local health community. (Paragraph 140)
25. There are major
benefits from separating elective and emergency care in treatment
centres. Such centres should continue to be built where there
is a need and where the decision to build the centre has been
agreed with the local health community following Section 11 consultation.
We are not 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
such as those at Redwood. All these options would more readily
secure integration and may be cheaper. (Paragraph 145)
| 
