Evidence submitted by BUPA Hospitals (ISTC
23)
SUMMARY
1. BUPA opened the first independent sector
Diagnostic and Treatment Centre (BUPA Redwood Hospital) in 2003.
This centre was the prototype for the subsequent Independent Sector
Treatment Centre programme. The NHS funds all the operations at
the Centre, which has completed over 35,000 cases for the local
NHS. As a result, the Centre has provided better access and more
capacity to the NHS and waiting times have fallen dramatically.
Patient satisfaction is very high and clinical outcomes are good.
BUPA recommends that the Government extends its use of independent
sector treatment centres to increase capacity, choice and quality
for NHS patients.
ABOUT BUPA HOSPITALS
2. BUPA Hospitals (BHL), which forms part
of the BUPA Group, operates 26 independent hospitals in the UK,
providing services to privately-insured and self-pay patients
and to the NHS. In 2005, BHL treated 200,000 in-patients and day
cases, of which 29,000 (14%) were NHS-funded patients, and 640,000
out-patients of whom 26,000 (4%) were NHS patients. These patients
provide data for a range of patient-related outcome measures,
as outlined later in this submission (see paragraph 25).
BACKGROUND
3. In this submission, BHL provides evidence
based on our experience with BUPA Redwood Hospital, which was
the first Treatment Centre to provide care in an independent sector
unit exclusively for NHS-funded patients. In December 2002, with
the agreement of the Department of Health, BUPA entered into a
five-year contract with the Surrey and Sussex Healthcare NHS Trust
(SASH) to provide both inpatient and day case care in orthopaedics,
gynaecology, general surgery and diagnostic endoscopy at Redwood.
The Centre is exclusively used for NHS patients and has made a
significant contribution to reducing waiting times locally which
are now at their lowest recorded level. [19]
4. Redwood provides a dedicated elective
care facilitythis means that planned treatment is not disrupted
by the unpredictable needs of emergency and complex acute patients.
As a result, the number of cancellations of routine operations
has been dramatically reduced from 149 a quarter to 67. [20]Consultant
medical staff at Redwood continue to be employed by SASH but use
the Centre for the majority of their routine elective patients.
This regime enables the consultants to access the best of both
facilities and so each consultant has been able to treat more
patients in the course of a year. Consultant satisfaction with
Redwood is extremely good with 72% rating the service as "very
good" or "excellent".
5. Non-medical staffing for Redwood is shared
between BUPA and SASH. BUPA provides the management, including
a general manager, matron and marketing team. The majority of
the nursing and support staff are employed by BUPA, but from the
outset around 25 staff transferred from the NHS under a structured
secondment agreement. BUPA and NHS staff now work alongside one
another, wearing the same uniforms and under the same management.
As with consultant satisfaction, staff satisfaction survey at
Redwood is also very high.
6. Since 2002 the range of services offered
at BUPA Redwood has increased so that the NHS and BUPA ensure
maximum patient benefit. Redwood recently treated its 35,000th
NHS patient. Redwood is also providing a service for 40 breast
care patients a month, including those with breast cancer. By
taking on more work, Redwood is helping to dramatically lower
NHS waiting times, with particular success in helping the Trust
to achieve a two week maximum waiting list in endoscopy for patients
suspected of having cancer.
RESPONSES TO
HEALTH SELECT
COMMITTEE QUESTIONS
1. What is the main function of ISTCs?
7. The aims of an ISTC are twofold: to add
capacity to the NHS and to provide high-quality, innovative services.
By adding this capacity ISTCs are able to fulfil their main function,
which is to help reduce waiting times for NHS patients. By enabling
the NHS to shorten waiting lists, ISTCs are helping NHS Trusts
to provide services when they are needed. By treating NHS patients,
paid for through contracts with the NHS rather than through private
means, ISTCs are helping the NHS to achieve its objective of making
comprehensive health services available to all, when they are
needed, free at the point of use.
8. Independent sector companies can also
add capacity to a local health economy rapidly by building new
ISTC facilities or by refurbishing existing premises. Timescales
for bringing independent facilities into use are typically faster
than for equivalent NHS schemes.
9. ISTCs provide examples of best practice
in customer service and operational efficiency. Patient satisfaction
at Redwood is very high: 87% of patients in a recent survey rated
their care as either "excellent" or "very good".
The quality of care has also been improved by implementing generic
care pathways working in collaboration with the health professionals.
These pathways clearly define the course of a patient's treatment
and allow audit so we can reduce variations in care. For example,
at Redwood, the length of stay for a routine hip replacement could
be up to five days but now some patients are discharged as early
as day two and given additional rehabilitation from a care team.
The Centre also innovates by using patient diaries to check that
their treatment follows the approved care pathway.
2. What role have ISTCs played in increasing
capacity and choice, and stimulating innovation?
10. BUPA Redwood has treated 35,000 NHS
patients in Surrey and Sussex, so adding to the capacity of the
local health economy. It also provides another choice for patients
who need treatment for one of the conditions that the NHS has
commissioned under the contract. The management of the Centre
has stimulated innovation by working with health professionals
to streamline the process of care and so improve patient satisfaction.
The Centre originally treated about 7,000 patients a year, but
has increased its throughput to around 12,000 patients a year
and is now planning to increase this to 14,000 in 2006. The Centre
has also improved theatre utilisation, while meeting high clinical
governance standards.
11. A 2005 London School of Economics study
examined the utilisation of operating theatres and using the example
of BUPA Redwood [21]
found starkly different levels of utilisation between Redwood
and the NHS average. Measuring three types of utilisation figures
and then calculating an overall score, the study compared the
targets set by the Audit Commission in 2003, [22]the
average NHS results as detailed in the Healthcare Commission Review
in 2005 and results from BUPA Redwood. [23]The
overall target for theatre utilisation was 77%. The NHS overall
result was only 56.9%. BUPA Redwood, which scored higher than
the NHS in every section, had an overall score of 81%, above even
the Audit Commission's optimistic target.
3. What contribution have ISTCs made to the
reduction of waiting times and waiting lists?
12. The experience of BUPA Redwood shows
that its use has helped to drastically lower waiting lists in
the Surrey and Sussex Healthcare NHS Trust. This has been particularly
successful in helping the Trust to achieve a two week maximum
waiting list in endoscopy for patients suspected of having cancer.
As noted above, the Trust's overall waiting lists have also gone
down by over a third and in orthopaedics by over 40%. All of these
patients are now treated within six months of being put on the
list. This significantly reduces the potential pain and the worsening
of their condition that patients experience while they are on
waiting lists.
13. More broadly, ISTCs contribute to a
more modern and appropriate balance between emergency and elective
care. As Hensher and Edwards [24]
put it: "the implicit assumption that elective cases are
less urgent than emergency cases (and hence can wait) can produce
perverse outcomes, whereby patients with urgent surgical needs
are forced to wait for care while people with health emergencies
are admitted to hospital when they could have been cared for elsewhere."
The ISTC programme is helping to reduce these perverse outcomes.
Another aspect of waiting is the time taken to travel to an acute
centre. As Healy and McKee said: ". . . ambulatory care centres
can be more dispersed than acute hospitals and thus improve population
access to care". [25]
4. Are ISTCs providing value for money?
14. BUPA has no data on this for other Centres
but in the case of Redwood we are providing services at prices
broadly equivalent to the local NHS tariff. The tariff at Redwood
is competitive with the local NHS tariff, although exact comparisons
are difficult as some of the services (such as medical staff)
are shared. As the quality of the service we provide is enhanced
by lower waiting times and increased patient satisfaction, we
suggest that the Centre increases value for money for taxpayers.
15. While there has been no comprehensive
or independent evaluation of Treatment Centresmany of which
have not been operating long enough to collect sufficient datawe
can demonstrate lower waiting times, good clinical outcomes and
enhanced patient satisfaction at Redwood because it has been operating
for three years. As the Committee has previously noted, this period
of time is the minimum that an organisation would need to gain
and be able to display the benefits of a reorganisation.
5. Does the operation of ISTCs have an adverse
effect on NHS services in their areas?
16. The operation of ISTCs has a beneficial
effect on NHS services in the area because it provides an additional
channel through which to send patients for routine operations,
so freeing up resources in local NHS hospitals for emergency patients.
This helps to prevent the pressure of emergency admissions leading
to cancelled operations and so pushing waiting times up. This
policy of "streaming" has been advocated by, among others,
NHS Scotland's Elective Care Action Team, who found that: "streaming
of scheduled care will undoubtedly provide significant improvement
in a range of key outcome indicators, for example, a predictable
and increased workflow, reduction in cancellations, value for
money, improved recruitment and retention, and importantly, reduced
waiting times for patients." [26]They
also found that 89% of elective care by volume requires a critical
care stay in less than 1% of cases. In other words, the vast majority
of operations do not usually need the back-up of a critical care
unit.
17. This separation of planned from emergency
surgery is in line with international best practice. [27]As
the London NHS Modernisation Board put it: "with its work
insulated from emergency pressures, the DTC can serve as a reliable
and dedicated high volume service which can safely, quickly and
conveniently provide routine diagnosis and elective surgery, and
the patient can be guaranteed that they will be treated."
[28]It
means that the less-complex cases are treated rapidly using appropriate
facilities in Treatment Centres and so the more complex cases
and emergencies can be treated using the full range of facilities
available in a General Hospital. As Prof Sir Ara Darzi, National
Advisor on surgery said in April 2002: "Diagnostic treatment
centres will make a difference. They . . . are one of the exciting,
novel solutions that will contribute to taking the NHS forward."
This has proved to be the case in the subsequent few years. The
Audit Commission also said in 2002 that the number of day surgery
cases could be increased by around 120,000 a year and that 85%
of operations could be undertaken as day cases. ISTCs are helping
to meet this objective.
18. Treatment Centres typically undertake
a relatively narrow range of elective surgery procedures using
a small dedicated team of staff. This enables the clinical and
operational processes to be optimised to deliver high levels of
utilisation and strong clinical outcomes. When this is also combined
with a customer centric approach, financial targets can be met.
These results can be transferable to other areas of the NHS. For
example, BUPA Hospitals has recently been asked to lend its management
expertise to another unit in Surrey so as to help achieve the
same productivity and patient satisfaction improvements as at
Redwood.
6. What arrangements are made for patient
follow-up and the management of complications?
19. BUPA Redwood is fully integrated in
to the local NHS system. Patients are booked for follow-up in
the local NHS Trust and contract arrangements stipulate how any
complications are to be managed. In practice, the level of complications
and unexpected transfers back to NHS facilities is very low. This
reflects the appropriate selection of lower risk patients to undergo
treatment at the Centre. A survey across a large sample of the
independent sector (not just Treatment Centres) showed that in
2004 only 0.2% of discharges were transfers out to the NHS29[29].
20. Part of the service re-design is to
provide more concentrated care and to focus on preventing complications.
For example, intensive weekend physiotherapy is available which
means that patients recover more quickly and are able to go home
sooner. BUPA uses its experience to evaluate outcomes continuously
and to make improvements. For example, we are introducing new
technology to reduce the risk of deep-vein thrombosis in knee
and hip surgery.
7. What role have ISTCs played and should
they play in training medical staff?
21. ISTCs should be involved in the provision
of medical staff training, and funding should be made available
to facilitate this as it is for NHS Trusts. Redwood provides a
progressive environment for training and developing medical, nursing
and other health professional staff. Junior doctors employed by
the NHS work in the Centre in an approved training environment.
Training standards for other staff are high, as noted in the recent
Healthcare Commission inspection report on Redwood which says,
"Any staff with specialist roles receive relevant training
in their specialist area . . . Arrangements for the training and
assessment of adaptation students are robust." [30]
22. ISTCs can also provide an environment
for training nurses and other health professionals in innovative
techniques. For example, they can be used to train nurses to carry
out endoscopies, so economising on the skills of surgeons and
providing more capacity to treat patients. Nurse-led gastrointestinal
endoscopy is said to be a priority clinical area in the UK and
there is evidence that nurses can be trained to provide it. [31]
8. Are the accreditation and appointment
procedures for ISTC medical staff appropriate?
23. BUPA believes that they are. NHS consultants
who work at Redwood have undergone the NHS appointment procedures.
In addition, NHS staff have to undergo further checks on their
suitability when they work in independent sector facilities as
these are registered and inspected by the Healthcare Commission
under the Care Standards Act 2000. For example, the Commission
requires medical staff to pass a Criminal Records Bureau check
before they can work in an independent hospital.
9. Are ISTCs providing care of the same or
higher standard as that provided by the NHS?
24. At present, there is no objective way
of comparing the performance of ISTCs with similar NHS units.
All ISTCs have to submit regular data on a range of Key Performance
Indicators to the Department. If the same regime applied to NHS
providers then a more meaningful comparison would become possible.
25. In addition to collecting data on the
range of indicators which the Department requires ISTCs to collect,
such as re-admissions to hospital and infection rates, we also
collect patient reported outcome measures (PROMs) and feed them
back to the specialties working at the hospital. This, together
with our clinical governance processes, encourages continuous
quality improvement. The use of agreed clinical pathways enables
audit of care and there is careful scrutiny of clinical data through
Medical Advisory Committees in all BUPA hospitals. The BUPA Board
also has an independent Medical Advisory Panel to which the group
medical director and BUPA Hospitals director of clinical services
are professionally accountable.
26. The facilities of independent hospitals,
including Treatment Centres, are subject to stricter registration
and inspection requirements than the NHS. The Healthcare Commission
has a duty under the Care Standards Act to register premises and
so a Treatment Centre cannot open until it is approved by the
Commission. The Act also requires the Commission to inspect the
Centre at least annually against National Minimum Standards. Reports
on the hospital's achievement of standards are posted on the Commission's
website. [32]The
Commission can issue an Improvement Notice if any Standard is
not met and has powers to close an independent hospital, and to
impose penalties including fining or imprisoning its management.
None of these provisions apply to NHS hospitals, which can operate
without passing registration tests and do not have to meet legally
enforceable minimum standards. They cannot be closed down by the
Commission.
27. All these provisions help to ensure
that ISTCs provide a high quality of service. In terms of patient
satisfaction, the evidence of a range of surveys is that independent
providers of NHS-funded care score very highly. As noted, Redwood's
latest patient satisfaction scores show 87% of patients rating
their care as excellent or very good.
10. What implications does commercial confidentiality
have for access to information and public accountability with
regard to ISTCs?
28. Due to the competitive nature of NHS
procurement of ISTCs and other independent hospital services,
a small range of issues are subject to commercial confidentiality.
Unless this confidentiality is maintained, the benefits of competitive
tender will not continue to be available to the taxpayer. Under
the contracts, independent hospitals and Treatment Centres are
however fully accountable to the NHS and the Department of Health.
With respect to Redwood, the contract was subject to a rigorous
affordability scrutiny involving external review by the Department
of Health's advisors.
11. What changes should the Government make
to its policy towards ISTCs in the light of experience to date?
29. As noted above, the inspection regime
for independent hospitals is more onerous and so the Government
should align quality standards for the NHS with the tighter legal
requirements it has placed on the independent sector. This would
create a `level playing-field' of standards and would help to
assure quality. This in turn would help to provide the level of
access to care in a plural market of providers which patients
enjoy in other countries. It would also allow for the results
of inspections to be compared fairly so that patients would be
able to make an informed choice of provider.
30. We believe the Redwood model is a successful
one and so the Government should use it as the basis of expanding
the ISTC programme to bring the benefits to a wider pool of NHS
patients.
12. What criteria should be used in evaluating
the bids for the Second Wave of ISTCs?
31. These criteria are for the Department
of Health and the NHS to decide but we would suggest that they
include:
providing increased access;
facilitating patient choice;
shortening waiting times for patients;
providing value for money;
evidence of achieving partnership
working with the NHS;
improved patient satisfaction; and
high-quality clinical outcomes.
13. What factors have been and should be
taken into account when deciding the location of ISTCs?
32. This is a matter for national, regional
and local planning in the NHS. BUPA has consistently argued for
national capacity planning so that investors can have an outline
idea of how much work the NHS will procure over, say, the next
five years. At regional (SHA) level, independent providers should
be fully included in discussions on capacity planning. Locally,
the future is for independent providers to integrate themselves
seamlessly into the pattern of local health services.
14. How many ISTCs should there be?
33. As with question 13 this is a matter
for NHS planning to meet need within available resources and so
there is no simple answer. However, the use of additional capacity
from the private sector has been found to have the advantages
of speed and of providing competition for public providers in
a number of countries including Spain, Denmark, Australia, Sweden,
Ireland and New Zealand. [33]This
suggests that the Government should continue to consider the merits
of using independent sector capacity to meet demand.
RECOMMENDATIONS
34. BUPA recommends that the Government
considers the following actions:
Involving independent sector providers
fully in national, regional and local capacity planning, so that
the sector can play its full part in helping achieve NHS objectives.
Aligning the regulation of healthcare
quality inspection so that all providerswhether statutory
or independent adhere to the same standards.
Requiring NHS providers to submit
an agreed minimum data set to the Department of Health to enable
appropriate comparisons to be made between ISTC and NHS performance.
Adopting the "Redwood model"
for treatment centres more widely by replicating the model of
working in close collaboration with the NHS and using a combination
of both NHS and BUPA staff in more locations.
CONCLUSION
35. BUPA has invited members of the Committee
to visit BUPA Redwood, as we feel that is the best form of evidence
we can present. Alternatively, we are willing to give oral evidence
to a hearing of the Committee, if that would be helpful. We are
particularly keen to demonstrate the value of treatment in independent
centres on the basis of our experience as we feel this is highly
relevant to a fair appraisal of the formal ISTC programme.
Clare Hollingsworth
Managing Director, BUPA Hospitals Ltd
13 February 2006
19 On 31 December 2005, there were 4,501 patients on
the Surrey and Sussex NHS Trust's inpatient waiting list, none
of whom had waited more than six months. This compares with 7,309
patients at the end of 2002, just before the Centre opened, of
whom 2,000 had waited over six months. See also http://www.performance.doh.gov.uk/waitingtimes/2002/q3/kh07-u-rtp.html Back
20
http://www.performance.doh.gov.uk/hospitalactivity/data-requests/download/cancelled-operations/Q2webtables.xls Back
21
Anastasiou, A. Examining Utilization of Operating Theatres;
the example of Redwood Diagnostic and Treatment Centre A dissertation
for the MSc Health Policy Degree, London School of Economics (November
2005) (Passed with merit). Back
22
Audit Commission Reports: Operating Theatres (June 2003)
(http://www.audit-commission.gov.uk/reports/NATIONAL-REPORT.asp?CategoryID=&ProdID=6CDDBB00-9FEF-11d7-B304-0060085F8572) Back
23
Acute Hospital Portfolio Review: Day surgery Healthcare
Commission (July 2005). Back
24
Hensher, M. and Edwards, N. The Hospital and the external environment:
experience in the United Kingdom in Hospitals in a changing Europe. Back
25
Healy, J. and McKee, M. The role and function of hospitals,
in Hospitals in a changing Europe. Back
26
The National Framework for Service Change in NHS Scotland: Elective
Care Action Team Final Report 2004. Back
27
Treatment centres in the NHS: RCS Bulletin quoting Ann R Coll
Surg Engl (Suppl) 2004;86:154-155 Back
28
www.london.nhs.uk/modernising/dtc.htm Back
29
Independent Health Forum 2004. Back
30
see http://www.healthcarecommission.org.uk/assetRoot/04/02/22/79/04022279.pdf Back
31
Kneebone, R L, Nestel, D, Moorthy, K, Taylor, P, Bann, S, Munz,
Y & Darzi, A (2003) Learning the skills of flexible sigmoidoscopy-the
wider perspective. Medical Education 37 (s1), 50-58.doi: 10.1046/j.1365-2923.37.s1.2.x Back
32
see footnote 26 above. Back
33
Hurst, J. and Siciliani, L. OECD (2003)6: Tackling excessive waiting
times for elective surgery: a comparison of policies in twelve
OECD countries. Back
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