Select Committee on Health Written Evidence


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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Prepared 9 March 2006