Evidence submitted by NHS Elect (ISTC
58)
1. BACKGROUND
INFORMATION ON
NHS ELECT
1.1 NHS Elect is a network of NHS elective care
providers, working to support these providers in piloting innovation
and delivering better care, partly though joint working between
sites. The programme was originally established in 2002 by a group
of NHS CEOs and clinicians to support the development of NHS Treatment
Centres (TCs) on their sites and now works to support 18 elective
care providers within the NHS. More information on NHS Elect can
be found on our website (www.nhselect.nhs.uk).
1.2 In relation to the terms of reference set
out for the Health Committee's enquiry into ISTCs, NHS Elect is
only able to comment in any detail on the impact of the development
of ISTCs on NHS elective care provision and, in particular, on
NHS TCs. It should be noted that the views expressed in this memorandum
are the views of the NHS Elect central team and may not reflect
the views of our member Trusts.
2. BACKGROUND
INFORMATION ON
THE NATIONAL
TC PROGRAMME
2.1 The NHS Treatment Centre programme was launched
by the Department of Health in 2002. The programme had two key
aims: firstly and straightforwardly to provide additional elective
capacity to enable the NHS to deliver NHS Plan waiting time targets
and secondly to pioneer new ways of working to improve the delivery
of elective care.
2.2 There were 46 treatment centres approved
within the original NHS TC programme. Most are now open, with
a final handful due to open in the next few months. Many of the
larger TCs were commissioned to support delivery of NHS Plan targets
and were therefore designed with spare capacity, with business
cases predicated on securing additional work outside of their
host Trust. NHS TCs still, however, receive funding through mainstream
allocations only, dependent on the number of patients seen. For
NHS TCs, it is therefore imperative that activity meets business
case predictions to avoid budget deficits in these facilities.
Patient care within the NHS TCs is excellent, with TCs known to
NHS Elect routinely scoring in excess of 95% satisfaction in patient
surveys. Furthermore, NHS TCs have embraced the opportunity to
change and improve patterns of elective care, with many using
pathways pioneered in US treatment centres that optimise efficiency
and improve the clinical care and patient experience.
2.3 The ISTC programme was launched separately
and one year after the NHS TC programme, creating further additional
elective capacity through the use of independent sector providers.
These providers have, to date, been commissioned to undertake
two sets of activity. Firstly, the Department of Health (DH) has
commissioned a further set of TCs to be built and run by the independent
sector, with independent sector TCs commissioned from companies
in two "waves". Wave 1 was launched in 2003 and Wave
2 is currently being commissioned. Secondly, in 2004 and 2005,
the Department also commissioned "supplementary activity"
from the independent sector, providing PCTs with additional elective
work funded outside of the mainstream allocations. For the ISTCs,
funding arrangements differ from the NHS TCs as the DH guarantees
to provide a large percentage of the agreed contract value, irrespective
of the number of patients seen and ISTCs have been permitted to
price work at above the national tariff.
3. ISSUES FOR
NHS PROVIDERSSPARE
CAPACITY
3.1 The programmes described above have delivered
a tremendous amount of additional elective capacity in the UK.
However, there is now, despite the excellent care offered by NHS
TCs, a significant problem in the under-utilisation of commissioned
NHS elective care facilities in many parts of the country and
for the last two years many NHS TCs have found themselves unable
to secure funding to treat additional patients, with resultant
under-utilisation of NHS TC capacity. Clearly, this is an issue
that has many causes but has been exacerbated by the creation
of additional capacity in ISTCs.
3.2 It is difficult to quantify the actual spare
capacity within the NHS TCs, as the spare capacity locally identified
often differs from that "offered" to the national TC
programme and, over the last 3 years, inevitably some NHS Trusts
have decided to close or reduce the size of their TC or change
the function of the facility. We know from discussions with colleagues
that spare capacity exists in many centres. Although we cannot
provide a full picture of spare capacity, we can, however, provide
details of the spare capacity known to NHS Elect at this time,
as follows:
|
Treatment Centre | Capacity currently
utilised pa (FCEs)
| Additional capacity
available pa (FCEs)
|
|
Ravenscourt Park Hospital | 6,000
| 6,000 |
ACAD (Central Middlesex) | 8,000
| 3,000 |
Kidderminster | 12,000*
| 8,000* |
Crewe | 8,400
| 6,000 |
Birmingham City* | 7,200
| 1,500 |
|
* Includes endoscopy
The figures given are all approximate but do give some indication
of the size of the issue, particularly as few of the "spare
capacity" figures include weekend or evening working. The
problem can only be exacerbated by the opening of further TCs
in the future.
3.3 When looking at the financial implications of this under-utilisation,
it is difficult to quantify the true cost of this spare capacity
to the NHS. A number of the NHS Elect TCs have, in the past, carried
out a financial analysis of the impact of their own spare capacity,
which does provide an indication of the cost to the NHS of this
under-utilisation. To give one particularly extreme example hereat
Ravenscourt Park Orthopaedic Hospital in West London, clinicians
currently carry out approximately 6,000 operations per year. The
TC needs to carry out 10,000 operations to cover its fixed costs
and its business case was approved on this basis. The facility
therefore faces a recurrent deficit of around £9 million
per year.
3.4 Clearly, the fixed costs of all NHS TCs will need to
be met by the NHS, irrespective of the amount of capacity provided
on each site. Any under-utilisation of NHS TCs will therefore
increase the unit cost of the services provided in these facilities
and represents a "fixed overhead" cost to the NHS. This
is particularly pertinent to note in relation to the procurement
of IS activity, as, using the case of Ravenscourt Park again to
provide an example, the IS would need to offer a saving of in
excess of £2,200 per case before offering real savings compared
to using existing spare capacity within the NHS. While this is
clearly an extreme case, it does serve to demonstrate the financial
implications of the under-utilisation of NHS TCs.
4. ISSUES FOR
NHS PROVIDERSOPPORTUNITIES
FOR COLLABORATION
4.1 One of the stated aims of the ISTC programme was to stimulate
innovation in elective care delivery. In response to this, a number
of NHS and IS providers have, over the last three years, developed
proposals to work collaboratively, attempting to transfer learning
between the IS and the NHS and improve models of care across
both sectors. As part of this, NHS and IS providers have prepared
proposals to undertake DH funded work together, often using existing
NHS facilities, thus making best use of existing and paid for
physical capacity. For example, a number of NHS TCs collaborated
with colleagues in the IS to submit bids to undertake additional
activity as part of the "Year 1 supplementary activity"
and a number of NHS Trusts had declared an intention to work with
interested IS partners in the so-called Wave 2 of the ISTC programme.
4.2 These proposed collaborative ventures have not been widely
supported by the DH, with only one NHS TC known to NHS Elect hosting
a joint programme with an IS partner as part of the national procurement.
This would appear to be a lost opportunity for sharing of innovation
and for the creative use of existing facilities.
4.3 In addition, the separate nature of the IS programme
has led to some operational difficulties in managing care for
patients. For example, lack of communication has meant that the
arrangements made for follow-up and the management of complications
are problematic in some areas, with IS providers providing only
part of the pathway for certain patients and NHS providers unwilling
to follow-up patients operated on in an IS facility. Furthermore,
IS providers in some areas have very tight criteria for accepting
patients, requiring more complex patients with co-morbidities
to be treated by the NHS. While there are some good examples of
successful integration, the separate nature of many ISTCs can
cause difficulties (operational, clinical and financial) for the
NHS provider, particularly in delivering care for a more complex
set of patients.
5. CONCLUDING REMARKS
We hope this memorandum is helpful in setting out the issues
facing NHS providers in relation to the ISTC programme. We would
stress that NHS providers are keen to work in collaboration with
IS partners and that the overall policy of pluarity is one that
is strongly supported by NHS Elect. Indeed, one of our key aims
as an organisation is to encourage NHS elective care providers
to embrace innovative models of care from all sectors and health
systems and we routinely organise study tours to IS providers
to learn from their models of care and their ways of delivering
improved customer service that is more responsive to patient needs.
Furthermore, we know that many of our own members and other NHS
providers are keen to develop joint ventures with IS colleagues
and that many IS companies would welcome opportunities to work
with the NHS. In recent months, the DH has indicated that it is
now prepared to consider seriously sensible proposals for collaboration
and partnership bewteen the NHS and IS in the delivery of elective
care and we are very encouraged that this represents a new phase
in the plurality programme. We hope that there will now be an
opportunity to move towards more sophisticated models of plurality
and return to a system where additional capacity is only created
in response to the genuine need for further provision to meet
national targets and that models that build on joint working between
the NHS and the IS are embraced by policy makers.
NHS Elect
13 April 2006
|