Evidence submitted by the British Orthopaedic
Association (ISTC 25)
SUMMARY
5. Does the operation of ISTCs have an adverse
effect on NHS services in their areas?
Answer—Yes:
(a) Contracting for all cases but choosing
the simple and allowing the remainder to go back to the NHS.
(b) Reducing elective workload at NHS hospital,
wasting valuable resources. Capacity in the NHS is underused.
(c) NHS hospitals left taking trauma cases
only.
(d) NHS hospitals undertaking the complications
arising from ISTCs.
(e) Strategic Planning is not possible owing
to uncertainties.
6. What arrangements are made for patient
follow-up and the management of complications?
Answer—Inadequate:
(a) Patients with complications are left
to see their GP who refers them to the NHS hospital, probably
where they were first seen.
(b) NHS hospitals have to pick up the problems,
usually without adequate information.
(c) There is near-total loss of continuity
of care.
(d) Patients are ill informed as to the process,
many believing their consultant has authorised the transfer of
care and that they will still be under that consultant's care.
7. What role have ISTCs played and should
they play in training staff?
Answer—(a) none and (b) training opportunities
should be provided under nationally-recognised criteria
(a) Training is expensive.
(b) The ISTCs take away training opportunities
from the NHS training centre, depleting the competence of the
next generation.
(c) Training can only take place in an ISTC
if the surgeon employed there is recognised as being a trainer
by the Competent Authority.
8. Are the accreditation and appointment
procedures for ISTC medical staff appropriate?
Answer—currently, the procedures appear
not to be equivalent to the appointment process in the NHS.
(a) The quality assurance of the surgeons
is not robust and allows the opportunity for surgeons to take
on operative procedures for which they are not trained.
(b) Entry on the GMC Specialist Register
should be in the appropriate specialty and the holding of CCST(or
CCT) from any European Country does not indicate that the surgeon
is of equal ability as a surgeon trained in the NHS.
9. Are ISTCs providing care of the same or
higher standard as that provided by the NHS?
Answer—There are too many reports of bad
results in orthopaedic surgery coming from the Independent sector.
(a) The Orthopaedic surgeons in the NHS,
especially in major joint replacement centres, are seeing above
average revision rates and re-admission rates from ISTCs and GSupp
work.
(b) All cases undertaken in ISTCs must be
rigorously audited and results assessed at least up to five years
and probably longer. A higher complication rate means an increased
expenditure on health care. NHS hospitals would welcome similar
funded audit.
(c) Proof must be sought that the ISTCs are
submitting their data to the National Joint Registry, as stated
in their contract.
10. What implications does commercial confidentiality
have for access to information and public accountability with
regard to ISTCs?
Answer—the true rate of complications
is obscure as figures are not made available. It is not possible
to obtain the names and NHS numbers so that a proper audit can
be conducted.
11. What changes should the Government make
to its policy towards ISTCs in the light of experience to date?
(a) Contracts with ISTCs should include the
care of complications arising during the first five years.
(b) Medical appointment procedures must be
as robust as that in the NHS.
(c) ISTCs should fund Audit of their clinical
outcomes, especially of joint replacements.
(d) ISTCs must accept all cases referred
to them or fund another hospital to undertake the complex work.
Cherry picking should not be allowed.
(e) NHS hospitals should be competing on
a level playing field.
INDEPENDENT SECTOR TREATMENT CENTRES—THE
BOA VIEW
INTRODUCTION
The British Orthopaedic Association (BOA) is
the professional association of orthopaedic surgeons in the United
Kingdom. It is a charity whose objects are: "the advancement
for the public benefit of the Science, Art and Practice of Orthopaedic
Surgery with the aim of bringing relief to patients of all ages
suffering from the effects of injury or disorders of the musculoskeletal
system."
The BOA has always stated that the long waiting
lists in orthopaedic surgery result in inadequate clinical care
and has consistently stated, following its Manpower Report in
1994, that a significant increase in consultant numbers was necessary
to address the enormous workload and bring waiting lists down.
Twelve years later there is still an insufficient number of orthopaedic
Surgeons in this country to address the needs of an increasingly
aging population. The current ratio of orthopaedic surgeons to
population is 1:37,000. Our stated aim is for 1:25,000 and this
will require a further 511 to be appointed in England, 620 in
the United Kingdom as a whole. The waiting lists have not been
created by surgeons, as is often said; they are a result of inadequate
investment by all governments in a field of surgery which predictably
expanded rapidly, as did patient demand for its services.
The BOA has very serious concerns about a new
health system that does not build on the strengths of the well-established
and enviable health service in this country. The BOA regrets the
missed opportunity of being in the position of providing early
advice to the Department of Health in the planning of the development
of ISTCs. Many of the problems now facing too many patients could
have been alleviated substantially had we been able to proffer
our professional experience at an earlier stage. Unfortunately,
it was necessary for the BOA to approach the Department when it
learned of the plans for ISTCs but by this point the first contracts
had already been signed. The BOA remains available and would be
pleased to assist governments in providing a high standard of
orthopaedic and trauma care.
This memorandum addresses the relevant issues
as stated in the Terms of Reference.
5. Does the operation of ISTCs have an adverse
effect on NHS services in their areas?
(a) The "cherry picking" of simple
cases and the rejection of patients with co-morbidities (eg diabetes,
heart problems etc) leaves the local NHS Trust with the complex,
higher risk and more expensive cases. A complex hip replacement
may take a half day list at a cost of £25,000, compared with
a straightforward one in which three cases could be done in the
same time, each being reimbursed at nearly the same rate per case.
(b) The tariff paid to the NHS does not reflect
this complexity. The ISTC gets paid a higher tariff for the same
case and even gets paid if it does not do the operation.
(c) The NHS is picking up the early revision
surgery of cases done in the Independent Sector. This and (a)
above distort the waiting list of the NHS Trust which is then
penalised for not reaching targets.
(d) Capacity in the NHS is underused. Some
NHS Orthopaedic Units are now doing fewer joint replacements than
two years ago because PCTs send patients to an ISTC to meet agreed
referral targets.
(e) Units are told they cannot expand because
targets are not reached and the unit is uneconomic. (vide supra)
Example: The Portsmouth ISTC has removed £5 million from
the NHS hospital which has to recoup the loss by savage cuts in
all surgical services. The ISTC carries on with a guaranteed 5-year
contract and we have been told it gets paid whether the work is
done or not.
(f) Strategic planning for local health care
providers is not possible due to total uncertainty as to their
role in the future. Example: Chapel Allerton Orthopaedic Service
(CHOS) near Leeds has just been completed and local targets are
being met. The PCTs will not renew their contracts as they are
investing in ISTCs in Bradford, Goole and York. The consequence
is the closing of beds and theatres and loss of staff.
(g) The introduction of ISTCs has made national
workforce planning extremely difficult, if not impossible.
(h) Orthopaedic surgeons provide the trauma
care in the UK. ISTCs do not take trauma. Example: In Banbury,
all the elective orthopaedic surgery has been given to an ISTC
(Capio). This leaves the orthopaedic surgeons to deal with the
emergency work (often in unsocial hours) at the NHS hospital.
Surgeons will leave. There will be no surgeons left to take care
of the trauma. This is also occurring in other hospitals, the
most important so far being Southampton General where all elective
surgery has been contracted out to Independent providers, leaving
only trauma.
(i) The BOA believe that public money would
have been more efficiently spent in the improvement of the infrastructure
in current NHS hospitals and the training of more orthopaedic
surgeons so that the workforce reached the recommended BOA level.
The UK is still undersupplied with orthopaedic surgeons compared
with the rest of the developed world and languishes close to the
bottom of the table by comparison with its European neighbours.
(j) It is alleged that the PCTs are `forced'
to contract with the ISTC and not with the NHS.
6. What arrangements are made for patient
follow-up and the management of complications?
(a) It has not been possible for the BOA
to find out what is in the various contracts in this area of clinical
care.
(b) The BOA receives a large number of reports
of patients being discharged after surgery, or after one follow-up
visit to the ISTC, and turning up at their original NHS hospital
not knowing where to turn for advice. There is a lack of ownership
of patients by the ISTCs.
(c) Patients are seriously misunderstanding
the system, sometimes to their detriment. Many patients, when
contacted by the clerical staff and offered a place at an ISTC,
believe that they have to accept or go to the bottom of the waiting
list. Furthermore, they believe they will remain under the care
of the consultant whom they saw in the NHS clinic.
(d) NHS surgeons pick up the pieces. If surgery
does not give the expected result, the patients first of all complain
to their GP who does not have the facility to send them back to
the ISTC. There is no other alternative than to send them back
to the original NHS clinic, where the surgeon is required to explain
what went wrong, usually without any operative note or communication
from the ISTC.
(e) The standard of writing of operative
detail is generally poor or non-existent, according to our members.
Evidence can be provided if the Committee require.
(f) Continuity of patient care has been lost.
It is good surgical practice prior to any procedure to meet and
understand the needs of the patient, discuss the alternative treatments
and provide informed consent. Based on a confidence (or not, as
the case may be) the patient decides to entrust their treatment
to the team they have just met. The patient now meets another
surgeon, usually from abroad. This surgeon decides if she/he will
perform the operation initially planned, do a different one or
even not do it at all if it is considered too difficult.
(g) Some ISTCs employ surgeons from abroad
on a rotating basis. This means that the surgeon whom a patient
initially sees at the pre-operative visit may have returned home
by the time the operation is due. The patient is then faced with
a surgeon they do not know at the operating table and when it
comes to follow-up they may be faced by yet another surgeon they
have not seen before. There is no attempt at longitudinal treatment.
(h) The experience of our members is that
there are NO arrangements to look after complications. We have
been led to understand that this is not in the contract and no
funds are available to deal with the complications. Therefore
the GP sends the patient to the nearest NHS hospital. Some complications
require emergency admission. However, ISTCs do not take emergency
admissions and may not have even have the facilities to deal with
them. A dislocation of the hip joint, for example, requires emergency
treatment.
7. What role have ISTCs played and should
they play in training medical staff?
(a) To our knowledge they have played no
part in providing the training of the future generation of orthopaedic
surgeons.
(b) The ISTCs have cherry picked the easy
cases, thus leaving the training centres void of any "simple"
cases on which to be trained. A surgeon needs to start on the
easy and progress to the difficult, as in any profession.
(c) The electronic logbook for trainees developed
by the BOA is now able to factually support evidence of the dwindling
number of cases being undertaken by trainees. There is one example
given of a trainee on a knee surgery unit not doing one total
knee replacement in a six-month attachment.
(d) The shortening of training time resulting
from `Modernising Medical Careers' and the introduction of the
European Working Time Directive have reduced and will further
reduce the exposure of a trainee to operative surgery. The reduction
of exposure by the presence of an ISTC aggravates this problem.
(e) The Southampton General Hospital, one
of the major teaching units in the country, may well lose its
training recognition because of the loss of elective work to ISTCs.
(f) ISTCs could train as long as the surgeons
employed by ISTCs are qualified to train. At present, most are
trained overseas and their ability to train is not known.
8. Are the accreditation and appointment
procedures for ISTC medical staff appropriate?
(a) The appointment procedures in ISTCs do
not match those required of the appointment of an NHS consultant
where there is a Statutory Appointment Committee which includes
a representative of a Royal College of Surgeons whose role is
to assess the training of the surgeon and judge if it is appropriate
for the position. This is a time-proven excellent method.
(b) There have been numerous examples of
surgeons being appointed who are not trained for the job. The
Verita inquiry into the early revision of hip prostheses at Portsmouth
is a clear example of this.
(c) The BOA has received reports of the consequences
of poor appointment procedures into the Nuffield G Supp work in
Cambridge, Cheltenham and Leeds.
(d) When surgeons are appointed to ISTCs,
the BOA believe the standards should be the same as for an NHS
hospital. This would give the quality assurance that patients
deserve.
9. Are ISTCs providing care of the same or
higher standard as that provided by the NHS?
(a) The evidence available to the BOA is
that they are not in Orthopaedic Surgery.
(b) The results of joint implants cannot
be judged on the results of a questionnaire about hospital comforts.
It is judged on acute complications and the need for early revision
of the implant. It is expected that 80% of implants should last
10 years. A revision at 2-3 years is a failure and is probably
due to a faulty prosthesis or deficient surgeon. Early dislocations
occur in NHS hospitals and there is an expected number. It is
an incidence falling outside the norm which should turn on a red
light. It is thus important to compare the results of an ISTC
with an NHS hospital, based on matched patients. The BOA, in a
meeting with the then Deputy Chief Medical Officer, Professor
Halligan, recommended this approach but to our knowledge this
was never carried out. Correspondence has taken place since then
but we are not aware of any such audit.
(c) NHS orthopaedic surgeons continue to
have grave concerns about the standard of surgery. There are many
anecdotal stories of overseas surgeons inserting unfamiliar prostheses,
not cementing those designed to be cemented etc. There are about
200 different femoral prostheses on the world market, each having
its own peculiarities. Surgeons from abroad most probably use
different hip and knee prostheses from those in common use in
the UK. ISTCs generally contract for a limited range of prostheses,
which is cost-driven. There is a learning curve for each surgeon
with each brand of prosthesis.
(d) The National Joint Registry is in its
infancy but should eventually have the tools to compare the short
term results of prostheses, hospitals and surgeons provided everyone
feeds the information into it. We are told by Sir Nigel Crisp
that all contracts with ISTCs make this reporting compulsory.
However we are told that there is no way of checking that this
is happening.
(e) It is not possible to get information
from the ISTCs. The number done is kept confidential and there
is no obvious way of tracking the patients operated on there.
They go to their local NHS hospitals with their complications
and are admitted under the consultant there. Even if they were
admitted to the ISTC, the surgeon who did their operation may
have gone home by this time.
(f) Eventually this information will become
apparent but it would be better if patients were not subject to
these complications in the first place.
(g) All work undertaken in the Independent
NHS-funded institutions needs to be carefully audited. All NHS
orthopaedic surgeons would welcome a commitment by the Department
of Health to fund audit of their work as well.
(h) The BOA has submitted to the DH two dossiers
containing lists of problems encountered in Independent-funded
NHS patients. These have been investigated by the DH but the response
has not done anything to prevent further problems. It is very
difficult for surgeons to report cases due to patient confidentiality
problems, reluctance of some Trusts to allow their surgeons to
report the complications they see coming from ISTCs, and the time
involved to gather all the information. Most surgeons just get
on and sort the problem, feeling sorry for the way the patient
has been treated.
(i) The BOA is not stating that all surgery
done in an ISTC is bad, nor is it stating that all surgery done
in an NHS hospital is perfect. It is only through proper audit
that the beliefs of the surgeons can be proven. The problems should
surface eventually.
(j) Stand-alone Orthopaedic hospitals were
shut down during the 1990s because they did not have the medical
and ITU backup. ISTCs have flourished in an environment previously
thought unsafe.
11. What changes should the Government make to
its policy towards ISTCs in the light of experience to date?
(a) Implement a rigorous medical staff appointment
mechanism.
(b) ISTCs should fund rigorous audit as part
of their contract. Audit should be scrutinised by a national surgical
professional body.
(c) ISTCs should contract to take care of
all adverse consequences arising from the surgery for a period
of 5 years in Orthopaedics.
(d) ISTCs should not be contracted to cherry
pick. If they feel it is unsafe to do the surgery, they should
pay the NHS hospital the appropriate rate to deal with the complication.
This should be formalised and enforced.
Prior to submission of this document, we did
a last-minute survey of our members with specific reference to
question 5, relating to adverse effects of ISTCs. In three days
we received over 120 comments, many lengthy, expressing discontent.
Fewer than 5 responders reported no evidence of adverse effects.
Ian J Leslie FRCS
President
British Orthopaedic Association
13 February 2006
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