Evidence submitted by Partnership Health
Group (ISTC 52A)
INDEPENDENT SECTOR
TREATMENT CENTRES
PHG is a joint venture company between Care
UK Plc and Life Healthcare of South Africa. PHG currently operates
two ISTCs, in Barlborough Links and Plymouth, and has two further
ISTCs in construction in Maidstone and North East London.
QUALITY OF
CARE
Patient safety is paramount in PHG and standards
mirror or exceed those of the NHS. Attached are our clinical outcomes
data and a study comparing results of the Barlborough Treatment
Centre with that of the Nottingham City Hospital. The Nottingham
study shows that with the exception of dislocation rates for hips
post operatively, all outcomes significantly exceed that of the
traditional NHS facility (see appendix 1). In addition out of
7,618 cases done to date (as at the end of January 2006) at PHGs
facilities there has not been a single MRSA case.
Whilst we seek to improve further on these outcomes,
we believe that this is a creditable performance for a newly commissioned
service. The contributors to this performance are multifaceted
and include the following factors:
— Specialist clinicians are all on
the appropriate specialist register of the GMC and nearly a quarter
have had their specialist clinical training in the NHS.
— All surgeons are full time appointments
(typically on five year contracts) and there are no "visiting"
surgeons (although the NHS makes widespread use of visiting locums).
— The use of overseas' clinical staff
is limited to highly experienced doctors whose references are
carefully and independently checked and whose experience is matched
to the job that they are required to perform up to "super"
specialist level (eg orthopaedic surgeons are not only required
to be experienced in their speciality, but also in even narrower
aspects of that speciality such as shoulder surgery or knee replacement).
— Candidates are observed operating
in theatre and their clinical outcomes are reviewed before being
appointed. A further period of two weeks direct observation follows
appointment.
— An NHS trained and experienced surgeon
is appointed as a lead clinician at each site and is responsible
for clinical governance and mentoring.
— Monthly morbidity and mortality meetings,
chaired by the clinical lead with x-ray reviews, as well as pathology
(lab), nursing (infection control and theatre technique) and therapist
(rehabilitation) involvement, take place with an emphasis on learning
and continuous improvement. Anecdotally, the atmosphere in these
meetings has more integrity and is more robust than equivalent
meetings in many NHS settings.
— ISTC contracts require that they
collect and report on a wide range of Key Performance Indicators.
These are scrutinised monthly and published annually. If a centre
falls below targeted levels of performance a "Joint Performance
Review" is initiated to address the problem. Where shortcomings
have been identified these have been dealt with quickly and resolved,
with the resolution being carefully monitored. Disciplinary procedures
have been carried out where necessary, including dismissal.
— ISTC providers are contractually
obliged to deliver clinically safe, high quality care along agreed
patient care pathways. We currently work to Healthcare Commission
(HCC) standards that are audited independently and exceed those
required in NHS hospitals.
INNOVATION
Innovations range from the physical layout of
facilities to elements of administration and clinical practice.
Examples include:
— construction of new facilities designed
around more efficient and safer flow of patients;
— a hand held patient feedback system
allowing daily feedback from patients that is viewed "real
time" by centre managers who can immediately address any
problem areas that may have arisen;
— one stop multi disciplinary pre-admission
visits involving specialist consultation, MRI/CT scanning, x-ray,
blood tests, anaesthetic assessment, physiotherapy assessment
and nursing social assessment so that surgery is not delayed and
can commence within 10 weeks of being seen by a GP and within
six weeks of the pre-admission visit (in the absence of medical
complications requiring longer treatment). This avoids the inconvenience
to patients of multiple visits and reduces the likelihood of delays
arising from changes in patients' condition whilst awaiting treatment;
— keeping smaller ranges of prostheses
so that staff become more proficient and productive in their use;
— administering regional anaesthesia
instead of general anaesthesia for primary joint replacements
reduces the anaesthetic risk;
— modern pain management techniques
allow post-operative physiotherapy to commence earlier and so
reduces the length of stay. Length of stay in our facilities is
on average 10-20% shorter than in comparable NHS facilities. The
benefit of this for the patient is less exposure to potential
infection and better long-term outcomes;
— PHG has introduced innovative blood
conservation processes that also improve patient outcomes. These
are autologous cell saving systems, which soak up the patient's
own blood during and after surgery, separate out oxygen carrying
red blood cells, put them in a closed sterile environment and
then re-transfuse them in to the same patient. The system boosts
haemoglobin levels, which helps patients to recover from surgery
more quickly and effectively and assists with wound management.
It also reduces the possibility of a patient reacting to donor
blood and eliminates the risk of infection from donor blood;
— the post-operative team provides
advice and support to patients, where appropriate, following discharge.
This includes arranging for the loan of equipment, such as walking
frames, and conducting a home visit to provide advice on daily
activities. At Barlborough Links, PHG is responsible for post-operative
physiotherapy and care in patients' own homes providing better
continuity of care than where this is normally provided by district
nurses and social services; and
— the introduction of new "image
guided surgery" techniques for joint replacement, using state
of the art computer based 3-D images for aligning the new artificial
joint to the skeleton, reduces average deviation from 4-7% to
1-2%. PHG's ISTC's will be amongst the first centres in the country
to use this new technology.
REVIEW AND
EVALUATION
— Providers are required to report
data on 26 Key Performance Indicators on a monthly basis. This
enables the Department of Health to closely monitor performance
and ensure that problems can be identified quickly, minimising
risks to patients. This information is also independently assessed
annually by the National Centre for Health Outcomes Development
(NCHOD) who publish their findings. Ultimately, when sufficient
levels of activity are taking place this will help patients to
review comparisons both between the ISTCs and NHS and between
ISTCs.
— A recent report from the ISTC Performance
Management Analysis Service (PMAS)/National Centre for Health
Outcomes Development (NCHOD) stated that:
"There is a robust quality assurance
system in place, more ambitious and demanding than that for National
Health Service (NHS) organisations. The KPI data to be collected
and provided by the ISTCs extends beyond that used by the NHS."
— The Health Care Commission visits
and assesses each ISTC in order to ensure the quality of care.
All ISTCs are required to survey at least 10% of their patients.
Satisfaction rates across PHG consistently run at over 95% on
a sample of nearly 50% of patients.
CHOICE AND
COMPETITION
— Both PHG centres increase patient
choice for elective treatment that improves the patient experience
by encouraging both PHG and the traditional NHS providers to be
more responsive and patient-centred.
— We have found that local NHS Trusts
have responded to the opening of PHG's ISTCs by seeking to reduce
their own waiting times. A number of patients who had been on
lengthy waiting lists with NHS Trusts have been offered earlier
dates for admission by their respective trusts once they had been
offered a place at our ISTC.
— Once "patient choice" is
established and is operating in an open and consistent market,
PHG will be prepared to create and provide services without volume
guarantees and would consider the transfer of existing NHS personnel
and infrastructure.
ISTCS ARE
COST EFFECTIVE
— The overriding benefit of procuring
ISTCs is that there is a direct and contractual commitment to
provide a given number of operations as opposed to the less certain
impact of adding further funding to the established NHS.
— PHG works closely with PCTs to ensure
that the targeted case volume is attained. This includes active
communication with GPs and flexibility with case mix substitution
and phasing of case throughput. PHG's ISTCs are achieving 99%
of the planned case volume.
— PHG was asked to establish an interim
service within existing NHS facilities whilst the Barlborough
Links facility was in construction and initially this service
did have a shortfall against the planned activity. PCTs actively
communicated the availability of this new service but were initially
hampered by negative campaigning against the service by local
Consultants. The allegation that it was an unsafe facility because
it lacked a critical care unit was, at best, disingenuous in that
the planned case mix did not require such a unit and in that those
same Consultants carried out their own private practise in similar
units. However, the interim service did become popular as a result
of positive patient feedback to referring GPs and the targeted
activity level was attained during the latter stage of the interim
contract. For information, PHG actually incurred a net financial
loss from the interim contract as costs of operating within existing
NHS facilities proved to be more onerous than anticipated.
— A complaint against ISTCs is that
they "cherry pick" operations. This is an emotive misrepresentation.
To date, ISTCs have been focussed on providing routine operations
for otherwise well patients as part of a sensible streaming of
activity. This enables better treatment for both routine and complex
cases and provides for a better patient experience. The Independent
Sector would be quite prepared to deal with the total case mix
requirement (but would still stream the activity) or with complex
cases only. Indeed, PHG is now receiving complex cases, including
hip and knee replacement revisions where the initial operation
has been undertaken in an NHS Trust hospital.
— The tendency is for the cost of ISTCs
to be compared to NHS reference costs. Whilst this offers a useful
benchmark, care must be taken to allow for material differences
in circumstance. For example, the Independent Sector carries the
full cost of VAT, employee pensions and financing costs. These
items alone would account for a cost differential of well in excess
of 20%. ISTCs also have the cost of setting up new contracts and
facilities, along with the cost of international recruitment.
On the other hand, NHS Trusts carry the cost of clinical training.
— As has been widely reported, the
NHS has traditionally paid incumbent Independent Sector providers
a premium of 40% to 100% over reference costs. By bringing in
new providers and by establishing long-term commitments, the ISTC
programme has brought competition to the private market too, meaning
lower costs are sustainable.
— There is a strong lobby for the "additionality"
requirement of ISTCs to be relaxed and for there to be greater
integration with existing UK clinical staff. Whilst PHG supports
selective relaxation of additionality, evidence suggests that
the level of competitiveness in the market is not yet sufficiently
established. In developing solutions for wave 2 ISTCs, PHG has
sought proposals from incumbent UK Consultants and has been surprised
by the expected level of earnings, annualising at around £500,000
per Consultant—around four times higher than internationally
sourced alternatives.
TRAINING
In the wave 2, ISTCs will be expected to provide
training. In addition, a number of ISTCs in the first wave will
also offer training, including those in Nottingham, Maidstone,
and North-East London. Training committees have been established
or are about to be established with a view to developing training
contracts. When fully established the contracts will include provision
for junior doctor, nurse or allied health professional training.
They will cover operative techniques appropriate to the case-mix,
general nursing care of the surgical patient and clinical techniques
for allied health professionals according to the case mix.
Many surgical, anaesthetic and other activities
that will be provided in ISTCs are part of the core training requirements
of NHS staff. Through the provision of modern facilities and delivery
of new ways of working, ISTCs can provide NHS staff with the opportunity
to access new and innovative work practices in these areas. ISTCs
will also provide the opportunity for training and transfer of
knowledge in the following areas:
— innovative clinical techniques and
new ways of working;
— management of patient flows and processes
leading to greater clinical productivity;
— management of clinical services,
including outcome measurement;
— administratively, ISTCs offer an
ideal training environment over more traditional NHS settings
since they are based around regular work flow, uninterrupted by
priority cases and high volume activity. These factors offer trainees
a predictable training environment in which they can concentrate
on appropriate cases in a time-efficient manner; and
— the training of NHS staff in ISTCs
is particularly important in instances where clinical activity
is transferred from traditional NHS settings to ISTCs. In such
circumstances the training attached to the transferred activity
should be provided in the ISTC setting.
Partnership Health Group
15 March 2006
|
