Evidence submitted by the Association
of Anaesthetists of Great Britain and Ireland (ISTC 40)
SUMMARY
The AAGBI is the senior body representing anaesthetists
with 10,000 members including most of the anaesthetists in the
UK, the largest group in the hospital medical workforce (16%).
What role have ISTCs played in stimulating innovation?
ISTCs have a different balance for stimulating
"innovations" but patient safety, must come first. Their
role should concentrated on the more efficient and speedy implementation
of existing, acknowledged safe practices as they do not have (and
may be would not want) the research development and audit overheads
now necessary.
Are ISTCs providing value for money?
By selecting only fit patients (ASA I and II)
ISTCs can benefit from the current system whilst superficially
seeming to work to the same tariff and on an even playing field
with ordinary NHS Trusts. This may not be value for money. This
also explains the value of patients being adequately preoperatively
assessed and any comorbidities being optimised prior to surgery
and anaesthesia to reduce the high risk 10% group to say 5%, with
benefits to all, particularly the patients.
What arrangements are made for patient follow-up
and the management of complications?
In the immediate and early postoperative period
it is important for the anaesthetist to be easily available to
manage complications. The ISTC managements seem to have been reluctant
to take account of this clinical governance issue despite it being
drawn to their attention.
What role have ISTCs played and should they play
in training medical staff?
We are not aware of any medical staff receiving
training in ISTCs at present. NHS consultants will only wish to
carry out the training in ISTCs on the basis of equal pay for
work of equal value.
Are the accreditation and appointment procedures
for ISTC medical staff appropriate?
We do not think so. The Expert Group on Cosmetic
Surgery (28 January 2005) recommendations may be applicable.
Are ISTCs providing care of the same or higher
standard as that provided by the NHS?
The NHSLA provides ISTCs medical indemnity cover
based on CNST standards and any reduction would breach that arrangement.
Shepton Mallett ITC planned to work below this standard by not
employing dedicated qualified assistance for anaesthetists. Is
the mechanism for monitoring this robust enough and sufficiently
informed?
What changes should the Government make to its
policy towards ISTCs in the light of experience to date?
The DH funding the NHS contracts with ISTCs
wish to maintain an arms length relationship with ISTCs on the
Parity issue. The Government should change this policy.
What criteria should be used in evaluating the
bids for the Second Wave of ISTCs?
The Independent Providers operating ISTCs, Capio,
Nuffield, BMI and BUPA have not been following the NHS principle
of equal pay for all consultants, including anaesthetists and
surgeons. This new departure from Government and NHS policy results
in an unfair discrimination on grounds of gender, since there
is a far higher proportion of women amongst consultant anaesthetists
(34%) than there is amongst consultant surgeons (7%).
Compliance with the principle of equal pay for
work of equal value should a criterion for evaluating the bids
for the Second Wave ISTCs and other NHS work. Non compliance should
result in exclusion.
1. The AAGBI is the senior body representing
anaesthetists in the country with nearly 10,000 members including
the majority of UK anaesthetists, who make up the largest group
of the hospital medical workforce (16%).
2. It was founded in 1932 with the objective
of "developing anaesthesia" and it has successfully
instigated all the major developments in the speciality since.
In 1935 the first examination for anaesthetists, the Diploma in
Anaesthetics (DA), in 1948 The Faculty of Anaesthetists of the
Royal College of Surgeons (FFARCS) and in 1988 The College of
Anaesthetists which later (1992) became the Royal College of Anaesthetists
(RCA) . Along the way the AAGBI inaugurated the first UK Safety
Committee in 1976 before safety was talked about, set up the "Sick
Doctor Scheme" in 1978 and pioneered mortality audit when
it was controversial starting the Confidential Enquiry into Perioperative
Deaths (now NCEPOD) in 1987. The AAGBI has published over 50 guidelines
and standards documents including "Standards of Monitoring"
1986 and "Consent for Anaesthesia" 2006 and is the largest
provider of Continuing Medical Education (CME) for anaesthetists
through our educational meetings and journal "Anaesthesia".
We are also the largest provider of anaesthetic research grants
and support trainee anaesthetists through our Group of Anaesthetists
in Training (GAT)
3. Anaesthetists in the UK are involved
in the care of two thirds of all hospital patients (Audit Commission
Report). Their expertise extends beyond the main operating theatre
to acute and chronic pain management, leading resuscitation teams,
managing Intensive Care Units, working in maternity units, accident
and emergency departments, radiology, the care of some dental
patients and the transfer of critically ill patients.
PREAMBLE: PATIENT
CARE STANDARDS
AND PARITY
4. The AAGBI welcomes this inquiry into
ISTCs and is pleased to summit written evidence towards it. Our
consistent stance has been to uphold and progress standards of
patient care wherever it takes place and share this aim with many
other organisations contributing to this inquiry.
5. Appreciating the Health Committee's workload
and as an Anaesthesia specialty organisation we will concentrate
on particular evidence in relation to our speciality. Apart from
Standards of patient care one particular ISTC issue which concerns
us greatly is a general principle, affecting our speciality most
at the moment, and that is "Parity" the founding principle
of the NHS providing equal rates of pay for consultants (and other
grades irrespective of speciality). I would emphasise that this
"Parity" is not about actual amounts of pay but a much
more fundamental principle which if it continues to be ignored
by ISTCs will have far wider long term repercussions ultimately
reflecting back on patient care. As we are the currently affected
speciality the committee may not receive much evidence about this
from other contributors so we feel it important to include it
in some detail.
What role have ISTCs played in increasing capacity
and choice, and stimulating innovation?
6. "Innovation" and "Anaesthesia"
are synonymous. From chloroform masks to conscious craniotomy
the whole culture and development of the speciality has been based
on innovation, new devices, technology, intensive care, drugs
and patient pathways. For example the development of Acute Pain
Services and Acute Pain Nurses as a result the 1991 report, which
must be one of the top practice changing documents of British
Medicine. Anaesthesia embraced this and following a somewhat uphill
struggle surveys demonstrate that NHS implementation was always
in advance of Europe has now even overtaken the USA in this regard.
7. The possibility to do many procedures
as day cases is largely as a result of improvements in anaesthesia,
applying techniques that permit faster recovery, return to street
fitness and more effective post operative pain relief. Nationally
and locally anaesthetists have driven this innovation.
8. Behind every headline of new surgical
innovations by our surgical colleagues is a parallel and often
crucial anaesthetic innovation that without which the heralded
surgical development would not be possible. For example, "Awake
Cardiac Surgery" was the same operation for the surgeon but
a totally new epidural technique for the anaesthetist.[9]
9. There are many more examples but suffice
it to say they will continue to take place wherever anaesthetists
work. Most potential innovations have actually been theoretically
considered before but only when the circumstances, technology.
pharmacology, materials permit do they take place. The factor
driving these innovations for anaesthesia however has always been
improving patient care, and although doctors are not remote from
economic considerations some innovations have cost more (eg pain
nurses, although may have saved length of stay) and some have
cost less (eg day case developments). ISTCs, most with shareholders,
do alter the cost benefit balance of stimulating "innovations"
but the raison d'etre of the whole exercise, the patients
and their safety, must come first. Our experience of an ISTC not
wishing to provide qualified assistants outlined below (para 23-24)
is probably an example of this.
10. Should the ISTCs role be to use their
expertise on the more efficient and speedy implementation of existing,
acknowledged safe practices as they do not have (and may be would
not want) the research development and audit department overheads
now necessary.
11. Others are probably better qualified
to consider capacity and choice questions.
Are ISTCs providing value for money?
12. This is complicated but it may be useful
for the Health Committee to reflect on the following:
Consider 100 patients with NHS tariff of £1/patient
and total cost of group care £100
It is generally accepted that within any group
of patients having a particular procedure, hip replacement, cardiac
surgery, hernia repair, because of other co existing illnesses
eg diabetes, respiratory disease when considering the cost of
the group as a whole 10% of the patients will use up 50% of the
resources.
So 10 patients (10%) operations cost £50
(£5 each) and the other 90 patients (90%) cost £50 (£0.55
each).
If we can reduce the expensive first group
by 1%
Nine operations cost £45 so the remaining
£55 can now fund 99 operations (£0.55 each). So a total
of 108 patients now cost £100 an increase of 8% for no extra
cost.
If we can halve the expensive group to 5%
Five operations cost £25 so the remaining
£75 can now fund 135 operations (£0.55p each) so 140
patients now cost £100 an increase of 40% for no extra cost.
If we can completely remove the expensive
group (eg possibly through expensive patients being excluded at
the outset by ISTC contracts)
180 operations cost £100 (so at NHS tariff
price of £1/patient 80% surplus possible).
13. Therefore by selecting only fit patients,
ASA I and II, (see below) hospitals such as ISTCs can benefit
from the current tariff system whilst superficially seeming to
work to the same tariff and on an even playing field with ordinary
NHS Trusts. This may not be value for money.
14. The NHS Trust which has to treat the
20 expensive cases associated with such a group (10% selected
out of 200 leaves 180) needs £100 (20 x £5) to fund
the care for which under tariff they will receive £11 (20
x £0.55p)
15. These considerations also explain the
value of patients being adequately pre-operatively assessed and
any comorbidities being optimised prior to surgery and anaesthesia
to reduce the 10% to say 5%, with benefits to all, particularly
the patients.
16. ASA Physical Status Classification System.
Classification system adopted by the American
Society of Anesthesiologists (ASA) for assessing preoperative
physical status:
I. A normal healthy patient.
II. A patient with mild systemic disease.
III. A patient with severe systemic disease.
IV. A patient with severe systemic disease
that is a constant threat to life.
V. A moribund patient who is not expected
to survive without the operation.
VI. A declared brain-dead patient whose organs
are being removed for donor purposes.
The addition of an "E" indicates emergency
surgery.
What arrangements are made for patient follow-up
and the management of complications?
17. In the immediate and early postoperative
period it is important for the anaesthetist to be easily available
to manage complications. In smaller more isolated units such as
ISTC's it is less likely that there would be other colleagues
on site to cover and so an anaesthetist or surgeon who travels/resides
further away will not be in a position to quickly return unless
they have made alternative arrangements (The NHS has regulations
on residence distance) This could be a reduction in the standard
to that normally available. For example anaesthetists have been
travelling daily from Birmingham to do ISTC/GSup work in the BUPA
Hospital Leicester and from Leeds and Hull to the Nuffield Hospital
in York with no local post operative cover arrangements in place.
This is because local consultants are not volunteering to do the
NHS work for the unequal pay being offered by BUPA Hospitals and
Nuffield Hospitals. The ISTC managements seem to have been reluctant
to take account of this clinical governance issue despite it being
drawn to their attention.
What role have ISTCs played and should they play
in training medical staff?
18. We are not aware of any anaesthetic
trainees having received training in ISTCs and believe that ISTCs
have played no role in training any other medical staff to date.
If the numbers of cases suitable for training (eg ASA I and II)
treated at ISTC's significantly deplete the numbers of these patients
being treated at NHS Trusts this will reduce the current anaesthetic
and surgical training opportunities available. These Trusts are
where the existing Schools of Anaesthesia are well established,
set up and resourced for training anaesthetists and our Royal
College of Anaesthetists who oversee and accredit this training
would be best placed to advise.
19. Training and trainer ISTC contracts
for all specialities would be a new departure and probably complicated.
NHS consultants familiar with UK training and examinations would
meet the job specification and be ideally placed to be involved
but consultants carrying out the training in the NHS Trusts are
employed on the basis of equal pay for work of equal value and
it has already been demonstrated that they would be unlikely to
wish to be involved on any other basis.
Are the accreditation and appointment procedures
for ISTC medical staff appropriate?
20. We do not think so. As medical staff
will often be practicing independently current standards for that
ie NHS Consultant appointment should be replicated. Appraisal
and revalidation of NHS consultants is already established in
local trusts. The current Medical Advisory Committee (MAC) structure
in Independent Sector Hospitals is in its infancy as regards approving
visiting rights for consultants de novo. In the past it
has usually only been asked to further approve local consultants
mostly already known to them who have also previously undergone
the rigorous NHS consultants appointment committee process with
external representatives including impartial Royal College advisors
etc.
21. A number of ISTC MAC Chairmen refused
to, or declared themselves not in a position to, grant visiting
rights to short term overseas specialists so the ISTC companies
then bypassed the process. Nuffield hospitals set up a "virtual"
or National MAC to rubber stamp such applications, some of which
proved disastrous for patients (eg Nuffield Hospital Cambridge).[10]
22. The Expert Group on Cosmetic Surgery
(28 January 2005, DH Gateway Reference number: 2005/0032) looked
at this issue in some detail and recommended that all cosmetic
surgeons and nurses provide to potential and actual patients details
of their qualifications, registration, membership of professional
organisations, and other medical training and education. Harry
Cayton, Director for Patients and Public, said: "I believe
that the recommendations in our report will help ensure that people
can make informed choices before undergoing cosmetic surgery,
and that they can be confident that cosmetic surgery and procedures
are well regulated." We agree and if this is good enough
for patients having cosmetic "lifestyle operations"
how much more important for say hip replacement and gall bladder
surgery etc?
Are ISTCs providing care of the same or higher
standard as that provided by the NHS?
23. The AAGBI has been involved in successfully
developing standards of perioperative care over many years and
has unrivalled experience of the issues and pitfalls in not maintaining
them in anaesthesia and hospital care.[11]
11 We would be most concerned if the same standards as in the
NHS were not maintained by ISTCs and as the NHS Litigation Authority
is providing medical indemnity cover on the basis of the Clinical
Negligence Scheme for Trusts (CNST) standards applying this would
also be a breach of that arrangement. One area that is of particular
concern for anaesthetists included in these standards (and our
own AAGBI recommendations—Anaesthesia team 2nd Edition 2005)
is the provision dedicated qualified assistance for anaesthetists
wherever anaesthesia is administered (eg Operating Department
Practitioners, ODPs) etc. This is for example just as important
as the surgeon always having a scrub nurse present when operating.
24. This is a real concern as we are
already aware of an attempt by one ISTC, the Shepton Mallett Independent
Treatment Centre (SMITC) to work below this standard in April
2005. This was drawn to our attention and following correspondence
and a meeting with representatives of the Mendip PCT and the ISTC
the Chairman of our Safety Committee Dr John Carter was reassured
by Kate Glass, Project Director, Mendip Primary Care Trust that
the standard would be upheld. (Annex 1 and Annex 2).
25. In this regard it seems that the
contracting PCT and NHS representative for the ISTC may be the
initial point of monitoring for these standards, is this mechanism
robust enough and sufficiently informed?
What implications does commercial confidentiality
have for access to information and public accountability with
regard to ISTCs?
26. We would be concerned that all remuneration
to medical staff is transparent in connection with our issues
of Parity (see para 28-51) Some ISCTs claiming to pay parity have
then made further additional payments on tenuous grounds, eg paying
surgeons the same amount again as the operating fee for an outpatient
visit. Unnecessary commercial confidentiality is used as cover
for this.
What changes should the Government make to its
policy towards ISTCs in the light of experience to date?
27. The DH who are funding and laying down
many other standards in these NHS contracts with the ISTCs say
for some reason wish to maintain an arms length relationship with
ISTCs on the Parity issue and will not act. (see para 28-51) The
Government should change this policy.
What criteria should be used in evaluating the
bids for the Second Wave of ISTCs?
28. Compliance with the principle of
Parity should be one of the criteria used for evaluating the
bids for the Second Wave ISTCs and other NHS work. Non-compliance
should result in exclusion.
29. The Independent Sector Providers operating
ISTCs, Capio, Nuffield, BMI and BUPA Hospitals have not been following
the principle of equal pay for all consultants, including anaesthetists
and surgeons. This principle was established at the foundation
of the NHS and is the basis for remuneration of 4 million NHS
procedures every year. Quite apart from the departure from Government
and NHS policy of equal pay for work of equal value, this oversight
results in an unfair discrimination on grounds of gender, since
there is a far higher proportion of women amongst consultant anaesthetists
(34%) than there is amongst consultant surgeons (7%).
30. As they are contractually bound by the
employment legislation framework any ISTC Provider that has not
complied with this condition in previous NHS contracts (eg BUPA,
Nuffield, Capio, BMI) they should not be considered for further
work unless a binding agreement is made to implement it immediately.
The Government should rigidly apply this criterion.
BACKGROUND TO
THE PARITY
ISSUE
31. We attach our letter to Surinder Sharma
the NHS Equality Czar (Annex 3) which summarises the background
and led to discussions with Mr Bob Ricketts last autumn and a
copy of an AAGBI press release (Annex 4) following an agreed statement
approved by Sir Nigel Crisp, Mr Andrew Foster and Mr Ken Anderson
(DH Commercial Directorate). 12
32. Anaesthetists and the AAGBI are particularly
concerned about the arrangements for remuneration for medical
staff in the ISTC's and regret anaesthetist were never involved
in the original discussions about them. It has taken over 18 months
to meet with the DH to discuss it. This is even more surprising
following the publication of the DH Guide "Promoting Equality
and Human Rights in the NHS".
33. Ever since 1948 consultant anaesthetists
and consultant surgeons and have been paid the same, equal pay
for work of equal value. This principle of "parity"
has served the NHS and its patients well for 57 years. We know
of no medical organisation that does not support the principle
and several have made statements about it.
34. BMA Guidance on Parity for NHS work:
"The BMA believes that in relation to
NHS work there should not be a differential in fee between specialists
for the same procedure where the same amount of work is undertaken."
[12]
35. Hospital Consultants and Specialists
Association (HCSA) Guidance on Parity for NHS work:
"Parity of pay has been a fundamental
principle of the NHS since 1948 and the HCSA fully supports its
maintenance and implementation in connection with NHS work in
the Independent Sector". Dr P A Ritchie President, HCSA
18 October 2005
36. Medical Women's Federation:
"The MWF fully support the stance you are
taking to maintain parity as a point of principle."
Dr Selena Gray President 28 February 2005
37. Association of Anaesthetists' position
statement on Parity of Pay:
Association of Anaesthetists continues to
fully support the NHS principle, established in 1948, of parity
of pay for all Consultants employed to care for NHS patients.
This principle is consistent with modern employment
law and has served the NHS and its patients' well for over 55
years in maintaining high standards of patient care and safety
throughout the service.
The new development of NHS patients being
cared for in Treatment Centres does not change this principle.
AAGBI Council December 2004 NHS PAY
PHILOSOPHY
38. Equal pay and status for consultants
of all specialties was an important issue at the start of the
NHS including public concern about equal geographical access to
professional skills. Two levels of consultant had been suggested,
surgeons and physicians in one and pathologists radiologists and
anaesthetists etc in the other. Eventually it was the President
of the Royal College of Surgeons, Sir (Lord) Alfred Webb-Johnson,
who convinced everyone of the importance of equality of pay and
esteem to the success and development of safer anaesthesia for
surgical patients and the NHS. The British Medical Association
(BMA) also supported the principle and history has proved its
justification in that mortality from anaesthesia has fallen from
around one per 1,000 anaesthetics in 1948, to one in 240,000 today.
Anaesthesia is also recognised as a driving force for the improvement
of safety, clinical and management standards throughout the NHS
and the National Audit Commission identified its crucial role
in the care of over 60% of NHS Hospital patients. With the NHS
now recognising the value of being "an organisation with
a memory", the lesson of parity must not be ignored.
39. All NHS Consultants remuneration is
based on exactly the same pay scale, now published annually by
the Doctors and Dentists Review Body, providing equal pay for
equal professional time spent caring for patients. This principle
was all reconfirmed in the new 2003 Consultant Contract.
40 Because this NHS work was taking place
in ISTC operating theatres the Independent Hospital managers unthinkingly
did what is normally done for Private patients and offered the
surgeons fees per case 250% greater than those paid to the anaesthetists
eg £100 for the surgeon £40 for the anaesthetist. This
large differential in Private Fees is historical in Great Britain
largely influenced by the different Surgical and Anaesthetic Benefit
schedules of the leading insurer BUPA who have 40% of the market.
The justification for this differential is that surgeons have
to cover greater expenses than anaesthetists, requiring more secretarial
help and sometimes spend more time seeing the patients postoperatively
etc.
41. None of this however applies for this
ISTC work as the NHS patients have already been seen and assessed
in the traditional NHS and a large number are day cases or short
stay. All medical indemnity costs also continue to be covered
by the NHS Litigation Authority scheme. For all these reasons
anaesthetists believe that one the NHS founding principles of
equal rates of pay ("parity") for all consultants should
be maintained for this NHS work.
NHS WORK
42. Some Independent Providers notably Mr
Keith Cunningham, manager BUPA Hospital Leicester (a BUPA ISTC
Lead) tried to convince local consultants that these were Private
Patients to justify his refusal to comply with Parity. He consistently
queried the NHS aspect of this work at the outset we believe it
is clearly NHS work for the following reasons:
— their care is an NHS responsibility;
— this is part of the NHS Plan;
— the NHS and its Trusts are arranging
the contracts specifying NHS standards of care and performance;
— the NHS is providing indemnity cover
to CNST standards; and
— it is all officially NHS funded and
the NHS will have to care for the late post-op and further treatment
episodes after the contract period.
43. No one in authority has ever suggested
that this is not NHS work and that is why anaesthetists do not
feel able to volunteer for it for non parity pay rates. Indeed
the NHS contracts prescribe a lot of the detail, Sir Nigel Crisp
has recommended that all providers to use the NHS logo and even
BUPA Insurance does not insist on its logo being used by the BMI
or HCA hospitals.
UNLAWFUL DISCRIMINATION
44. Rt Hon Patricia Hewitt's statement in
her first speech as Health Minister on 13 May 2005 spoke of "embedding
the principle of equal pay for work of equal value" in NHS
work. She had also previously been approached by the AAGBI when
Minister for Women as unequal pay in these circumstances would
represent indirect sex discrimination against women: women currently
constitute 34% of consultant anaesthetists but only 7% of consultant
surgeons. A similar submission was made to the "Women and
Work Commission" chaired by Baroness Prosser which to date
has not reported. For the Service to permit a departure from the
principle of equality of pay for those of its staff seconded to
work in the Independent Sector on NHS patients at the time when
this disparity has become apparent would expose the Service as
well as those providers in default to allegations of indirect
discrimination on grounds of gender.
45. On 21 July 2005 the DH published a new
Guide to Promoting Equality in the NHS. (DH Reference number:
2005/0264), saying the NHS is at the forefront of promoting equality
within both national and local economies. Health Minister, Rosie
Winterton said: "If the NHS is to maintain and develop its
position as a world-class service, it must be a service that treats
its patients and staff with fairness, dignity and respect."
47. On 6 October 2005 the DH instructed
the Independent Sector Providers supplying catering, portering
and cleaning services to the NHS to pay equal pay for work of
equal value rates.[13]
THE CURRENT
POSITION
48. When all this has been pointed out to
the DH who are funding and laying down many other standards in
these NHS contracts they say for some reason wish to maintain
an arms length relationship with ISTCs on this issues and will
not act. The DH officials privately say they agree with parity,
would not expect anaesthetists to do the work for anything else
and do not think anaesthetists are being unreasonable asking for
it and not volunteering to work without it. For NHS consultants
the DH describe this work as "NHS work in non-contracted
hours" For 40 hours of the week our normal contracted NHS
work is paid on the basis of parity what is so different about
further NHS work in a few additional non contracted hours?
49. At present we are waiting for the meeting
the DH said they would ask the Independent Health Care Forum (IHF)
to facilitate between the AAGBI, the BMA and the IHF to discuss
these issues. The IHF Chief Executive Tim Elsigood has resigned,
the organisation in disarray and we now believe Mathew Kay of
the DH Commercial Directorate is now organising the meeting directly.
There is no guarantee that Parity arrangements in ISTCs will be
the outcome of this meeting.
50. Anaesthesia, as in 1948, is at a crossroads
here again and anaesthetists feel that parity of pay is a fundamental
NHS standard indirectly affecting the care of patients. This matter
has the support of the BMA, HCSA, MWF and other practitioner organisations
and as the NHS is proposing to further develop ISTC work and require
the services of anaesthetists it is important that this standard
is maintained and clearly specified in any such ISTC contracts.
51. We would ask the Health Committee to
support these staff through the ways suggested above in the interests
of NHS patients.
Dr David Whitaker
Association of Anaesthetists of Great Britain and
Ireland
14 February 2006
9 http://news.bbc.co.uk/1/hi/health/3146837.stm Back
10
http://news.bbc.co.uk/1/hi/england/cambridgeshire/4133158.stm Back
11
http://www.aagbi.org/guidelines.html Back
12
Not printed here. Available from www.aagbi.org Back
13
(Agenda for Change, BBC News site) http://news.bbc.co.uk/1/hi/health/4316602.stm Back
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