House of Commons - Health - Written Evidence

Select Committee on Health Written Evidence

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 facility—this 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 Centres—many of which have not been operating long enough to collect sufficient data—we 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 providers—whether 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