Select Committee on Health Written Evidence


Supplementary memorandum submitted by the Department of Health (ISTC 1C)

FOLLOW-UP QUESTIONS FROM 9 MARCH EVIDENCE SESSION

Question 1:  How may NHS treatment centres are open?

  1.1  44 NHS treatment centres are open and a further two are expected to open later this year.

Question 2:  What is the proportion of overseas doctors practicing in ISTCs compared to home-grown doctors

  2.1  In operational Wave 1 ISTCs, 96% of additonality compliant doctors are sourced from overseas and 4% are "home-grown" (4.5 WTE are home-grown from a total of 114.5 WTE). This figure excludes the contracts for the provision of MRI and the supplementary procurements for activity from existing incumbent independent sector providers.

  2.2  Home-grown refers to those individuals who have been recruited from within the UK who are additionality compliant as they have not been involved in the delivery of NHS services in the last six months. Overseas is interpreted as those countries outside of the UK.

DOCTORS CURRENTLY WORKING IN ISTCs


Total number of doctors currently working in ISTCs
126.6
(100%)
Of which—number currently seconded from the NHS
12.1
(9.5%)
Balance who are additionality compliant
114.5
(90.5%)


BREAKDOWN OF OVERSEAS DOCTORS BY COUNTRY OF ORIGIN (WTE)


European Union
91.0
Rest of World:
Lebanon
South Africa
Total:
2.0
17.0
19.0
Total
110.0


Question 3:  What is the total number of complaints in the ISTC Programme?

  3.1  In Wave 1 ISTCS, there have been 407 reported complaints out of 120,080 patients referred for treatment (this numbers includes both outpatient treatment and day-case/inpatient procedures to the end of January 2006 rather than just the number of discharged procedures). This represents a complaints rate of 0.34%. This figure excludes the contracts for the provision of MRI and the first year of supplementary procurement for activity from existing incumbent independent sector providers as these schemes are not covered by the same KPI reporting requirements.

  3.2  ISTCs, like NHS facilities, are required to have complaints processes in place in compliance with the Healthcare Commission's National Standards for Better Health.

  3.3  The patient complaint process for the independent sector is identical to that of the NHS. Patients are required to first report a complaint to the provider, after which, if they are dissatisfied, they may submit their complaint to the Healthcare Commission (HC). The HC processes these complaints in the same way they do those received against NHS providers.

  3.4  ISTC complaint frequency and resolution is reported to the Department's Central Contract Management Unit (CCMU); complaints against NHS providers are not recorded centrally. The reported KPIs are:

    —  rate of patient complaints; and

    —  percent of complaints handled outside the acceptable time frame.

  3.5  In wave 1, the patient complaints process differs slightly from how the NHS tracks patient complaints, and requires more frequent and comprehensive reporting. Given the low levels of complaints in wave 1 and the desire for NHS-comparable data, for the next phase of procurements the metrics have been modified to replicate NHS tracking.


Metric
ISTC Wave 1
NHS

Rate of patient complaintsReport monthly the number of "logged" complaints received as a percent of patients referred for (1) outpatient treatment (2) inpatients and (3) day cases. A "logged" patient complaint is defined as a written complaint or an oral complaint that requires follow-up by the provider. (KPI 19) Report quarterly the numbers of written complaints received. Oral complaints not reported.
Percent of complaints handled outside the appropriate time frame Report monthly the number of patient complaints not handled within the acceptable time frame as defined in the contract (KPI 20). NHS trusts report to the Healthcare Commission the number of written complaints received which were not locally resolved within 20 working days.


Question 4:  What is the definition of a "serious untoward incident"?

  4.1  For the purposes of reporting incidents into the CCMU and Department of Health, the following definition will be used: a reportable event includes an accident or incident when a patient, staff or a member of the public suffers serious injury, major permanent harm or unexpected death while on hospital or other healthcare premises or in other premises where care is provided. It may also include incidents where the actions of healthcare staff or the provider are likely to cause significant public concern.

  4.2  The providers consider incidents under a number of categories; near misses, minor, moderate and serious. Only serious incidents and more minor incidents which may be forming a trend are reported through to CCMU.

  4.3  The ISTC programme has contractual obligations for addressing adverse incidents and serious untoward incidents. This procedure has been written to:

    —  promote and maintain patient safety by avoiding risks and learning lessons from the past;

    —  outline expectations for the timely transmission of information and communications for providers, the CCMU and the Department of Health;

    —  provide guidance to providers, the CCMU and the Department of Health on the management of untoward incidents; and

    —  promote consistency in the way incidents are managed across all stakeholders.

Contract References

  4.4  An adverse patient incident is defined in the contract as "any event or circumstances that could have or did lead to unintended injury (physical or psychological), disease, suffering, disability, death, loss or damage to a patient."

  4.5  According to the contract, a serious untoward incident is "an accident or incident when a patient, member of staff (employed or engaged either by the provider or the authority or another Health Service body) or a member of the public suffers serious injury, major permanent harm or unexpected death in the facilities and where the actions of staff involved (whether employed or engaged by the provider or the authority or another Health Service body) are likely to cause significant public concern."

Examples of Reportable Serious Untoward Incidents

  4.6  This list is not exhaustive, but gives direction as to the types of incidents that must be reported to CCMU:

    —  all patient deaths whether in the provider facility or in another healthcare facility;

    —  wrong site surgery/wrong patient/wrong treatment;

    —  serious drug error involving patient harm requiring further treatment;

    —  admission/transfer to an NHS or other facility where the patient requires extensive supportive care, urgent revision surgery or critical care and where the admission is directly or indirectly linked to the procedure undertaken in the ISTC;

    —  multiple incidents indicating a possible trend where there is an adverse surgical outcome involving the same member of the surgical tea million, procedure and/or equipment. Examples may include multiple infections or similar complications;

    —  suicide or homicide committed by a person with mental health problems;

    —  major health risk, outbreak of infection or radiation incidents;

    —  suspension of a health professional because of concerns about professional practice;

    —  any incident where the reputation of the provider and/or the ISTC programme is likely to be adversely affected or that has already attracted media attention;

    —  serious damage to ISTC property, eg through fire, flood or criminal activity that may affect the ability to care for patients;

    —  large scale theft, fraud or litigation valued at more than £50,000; and

    —  serious injury or unexpected death involving a member of staff, visitor, contractor or another person to whom the organisation owes a duty of care.

  4.7  In the event that the provider is unsure whether to instigate the escalation procedure, advice should be sought from the Head of CCMU and the CCMU Clinical Risk Advisor.

  4.8  As of January 2006, there have been 254 SUIs reported across the whole of the IS programme: including ISTCs, the supplementary contracts for additional capacity in the incumbent sector and the MRI contract. Of this number, 94 have been reported from Wave 1 ISTCs (out of a total of nearly 49,000 procedures and over 13,000 diagnostics); 4 relating to the MRI contract (out of a total of over 100,000 scans), and 156 relate to the supplementary procurements (out of a total of nearly 37,000 procedures).

Question 5:  Please check the 97% patient satisfaction claim

  5.1  The reported patient satisfaction level in January 2006 was 97%. This figure is an average of the satisfaction ratings as reported in KPI 19 from each of the schemes and includes all Wave 1 ISTCs, the supplementary contracts for additional capacity in the incumbent sector and the MRI contract.

Question 6:  Do the NHS collect complication data?

  6.1  There is no single measure of complication rate in either ISTCs or the NHS. Complications will be picked up through a variety of different measures but there is no aggregate figure. Further information is provided under question 7.

Question 7:  How are complications managed and what provisions are there for the management of post-operative care?

  7.1  ISTCs, like NHS facilities, are required to comply with NPSA reporting requirements, NICE procedural guidelines and the complaints processes outlined by the Healthcare Commission.

  7.2  To supplement this with additional oversight, CCMU monitors ISTC complication management through four key metrics. These are:

    —  return to theatre (KPI 4);

    —  unforeseen inpatient admissions (KPI 7);

    —  unplanned transfers (KPI 8); and

    —  emergency readmissions (KPI 9).

  A full list of all the KPIs is annexed.

  7.3  For post-operative care, the specifics of the ISTC role in delivering post-operative patient care is clearly laid out in each contract in accordance with requirements of local NHS commissioners. This enables the requirements to:

    —  be appropriately tailored to the specific types of care delivered by the ISTC; and,

    —  align with local procedures and availability of the required after care.


Metric
ISTC Wave 1
NHS

Admission of day casesFor day cases, inpatient admission to the facility or to other providers' facilities (including NHS providers) which was unforeseen at the time of admission. For the purposes of the performance, threshold is measured as a percentage of all day cases in the facility. The NHS does not report this metric.

The NHS captures admission data for every patient in the Hospital Episode Statistics (HES) database. HES could potentially track this but coding quality may be questionable.
Return to theatrePatient returning to operating theatre for procedure which was unforeseen at the time the patient's previous procedure was completed as a percentage of all patients admitted in the facility. NHS does not report return to theatre data.
Emergency readmissionsEmergency admissions/readmissions of patients who have received inpatient treatment and have been discharged within 28 days of such discharge where such admission or readmission is related to or arising from the relevant inpatient treatment, for the purposes of the performance threshold measured by HRG as a percentage of all patients discharged.

The ISTC report on any known readmissions (this could include readmission of a patient to another hospital). Also, readmissions are only reported if they are related the original treatment. Not all readmissions in the NHS are reported to the ISTC Provider.
Percentage of all admitted patients who returned to the same hospital as an emergency case, regardless of specialty, within 28 days of initial discharge.

Similar measures but a direct comparison is not possible. The NHS report on all readmissions to the same hospital regardless of whether they relate to the original treatment. They also only report on the total number of patients readmitted (not by HRG as in the ISTCs).
Unplanned transfersTransfers of any patient for treatment which was not in the management plan for that patient upon admission to the facility. For the purposes of the performance, threshold is a percentage of all inpatients in the facility by HRG. The NHS measure this for all patients (daycase and inpatient) and do not break it down by HRG. As such a direct comparison is not possible without further analysis by HES.
Surgical site infectionsSurgical site infections through the SUI process. This will be a specific indicator in Phase 2. Trusts submit forms to HPA. HPA run a SSI surveillance service
MRSA/MSSA bacteraemiaReported through SUI process. Acute trusts are required to report levels of Staphylococcus aureus bacteraemias (including MRSA) to Health Protection Agency (HPA) on a monthly basis
MortalityReported to a number of bodies (Coroner, NCEPOD and SUI Process). Reported to a number of bodies (HCC, Coroner, through SUI process and NCEPOD)


Question 8:  What are the readmission rates in ISTCs and how do these compare to NHS?

  8.1  The definition for Emergency Readmissions in wave 1 of the ISTC Programme is:

  "Emergency admissions/readmissions of patients who have received inpatient treatment and have been discharged within 28 days of such discharge where such admission or readmission is related to or arising from the relevant inpatient treatment. The performance threshold is measured by HRG as a percentage of all patients discharged."

  8.2  To be included in this KPI, the readmission must be related to or arising from the relevant inpatient treatment. This is measured by the original HRG. This data is captured for all patients treated by ISTCs, regardless of age. The information is reported on a monthly basis.

  8.3  The Emergency Readmission rate for the ISTC Programme (excluding GSup) up to the end of January 2006 is 0.4%. The NHS Definition for Percentage Readmissions (source: Performance Investigator User Guide version 1.1 September 2005) is:

    "Percentage of all admitted patients who returned to the same hospital as an emergency case, regardless of specialty, within 28 days of initial discharge."

  8.4  This information is reported via HES on a quarterly basis. The HES reports are usually published a number of months after the last data has been submitted (for example, for 2005 Quarter 3 results (Oct-Dec), data was collected until February 2006 with a report likely to be published in April 2006).

  8.5  The measures between the NHS and ISTCs are similar. However a direct comparison is not possible for the following reasons:

    —  the NHS report on all (day case and inpatient) readmissions to the same hospital. They also only report on the total number of patients readmitted (not by HRG as in the ISTCs);

    —  the ISTCs report on any known inpatient readmissions (this could include readmission of a patient to another hospital). Also, readmissions are only reported if they are related the original treatment (the NHS could pick up other readmissions not related to the original treatment); and

    —  HES can carry out an extraction/analysis (by specific request) to show the number of patients treated more than once within 28 days in all facilities (including ISTCs). This comparison would have to be by HRG and is not picked up in standard NHS reporting.

Department of Health

March 2006



 
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