Select Committee on Health Written Evidence


Evidence submitted by Capio Healthcare UK (ISTC 35)

1.  INTRODUCTION

  1.1  The UK is behind most western countries in its debate on the value of the independent sector in the provision of publicly funded healthcare services. The vast majority have already accepted that the independent sector can provide a high quality of service and good value for money. The two main political parties now agree that the independent sector can drive NHS reform. The challenge is not whether we should do it, but how we should do it in a way that accelerates the advantages to patients while causing the least disruption to staff and managers in the NHS. Much of this, as always, is about leadership and communication and we believe that by working together with local NHS teams, we can help to introduce the additional services in a more acceptable way.

  1.2  The ISTC programme was introduced to create immediate capacity to reduce waiting times. In the longer term, the Government also constructed it to create sufficient capacity to enable choice and competition between providers. This, together with other reforms in financial flows and patient empowerment, has enabled a change in the dynamics of the NHS towards the welfare of patients rather than the hospital buildings and the organisations that run them.

  1.3  Much of the resistance to the independent sector is based on misunderstandings and fears of job security. Not on the evidence of consequences for patients. Some who oppose the ISTC agenda claim that the independent sector (IS) cannot put patients or clinical quality first. However a system of robust accountability, based on time-limited contracts with tough clinical Key Performance Indicators (KPIs) (tougher than those applied to the rest of the NHS) will focus the mind on clinical quality and patient care. We recommend that the indicators used for the IS should be rolled out across the NHS. This will inform patients when both sets are published.

  1.4  ISTCs are important partners of the NHS. Capio already facilitates the trains NHS nurses and physiotherapists and will shortly start to facilitate the training of NHS doctors. ISTCs do not cherry-pick patients—the types of procedures the ISTCs are contracted to perform are decided by the local PCT(s). ISTCs provide high-quality and high-efficiency operating units for patients who would otherwise experience damaging delays. This in turn allows NHS hospitals to concentrate on more difficult cases.

  1.5  ISTCs are stopping suffering and improving quality of life for thousands of NHS patients every year. Patients give consistently high approval ratings for the care they receive.

  1.6  Capio would be happy to arrange for the members of the Health Select Committee to visit any of its ISTCs.

2.  CAPIO HEALTHCARE UK

  2.1  Capio is a progressive company with a commitment to fair employment and has five board members who are trade union representatives. We provide healthcare in Sweden, Norway, Denmark, France, Finland, Spain and the UK. Across Europe, 90% of the patients Capio treats are publicly funded. Capio Healthcare UK is the fourth largest provider of independent healthcare services. Before the ISTC programme, Capio had 21 acute units throughout England, plus six mental health units (providing adult, child and adolescent services), two neurological units and a dedicated eye clinic. All continue to treat NHS patients under national and local arrangements.

  2.2  Capio shares the values of the NHS, and wants a long term partnership. The company believes its contribution to treating NHS patients is helping to grow a publicly funded health service, not undermine it.

  2.3  Capio has a contract with the NHS to establish ten ISTCs across England, from Cornwall to Northumberland. Six of the centres are newly constructed—two are on existing NHS estates and four are new builds in innovative locations, chosen to fit with the requirements of the local Healthcare Community and to improve patient access as pragmatically as possible. Of the remaining Capio ISTCs; two are facilities within existing NHS hospitals, and two are within existing Capio hospitals. Approximately 95,000 NHS patients will be cared for at our centres over the five year contract (until 31 March 2010). The value of the contract is £300 million. A previous Capio contract (G Supp) to treat 13,600 patients (worth £23.9 million) has been successfully completed.

3.  PURPOSE OF ISTCS

Capacity

  3.1  ISTCs increase capacity and drive down waiting times. Since April 2004, Capio has treated 5,084 people who were languishing on local Trusts' waiting lists. ISTCs are designed to undertake a high through-put of routine elective surgery. Traditionally waiting times have been highest for these types of procedures because they are often cancelled and delayed in larger acute hospitals due to the priority given to other conditions. Separating elective and emergency work in this way creates greater efficiency and reduces delays and cancellations which may cause the patient's condition to deteriorate to a degree which makes eventual surgery more difficult. The economic advantages of this extend to the community as well as to the individual as they are able to return to normal life quicker and require less additional care.

Choice

  3.2  The least well-off are nearly one-third more likely to need a hip replacement than the best-off—but they are one-fifth less likely actually to get it [34] ISTCs have provided all patients, independent of wealth or background, with additional choices on where and when they are treated.

Competition

  3.3  Many of Capio's ISTCs have developed strong partnerships with local NHS organisations. Two of Capio's ISTCs are actually within existing NHS facilities. However, the Government has also made clear that the ISTC programme is only one of a number of tools to improve efficiency and choice in the NHS and to create a truly patient focused health service.

Improving services and Innovation

  3.4  The efficiencies provided through the ISTC model reduce waiting lists and improve taxpayer value for money. They also allow new practices to be embedded in NHS practice. Capio ISTCs are undertaking operations on a day case basis which many parts of the NHS still provide as in-patient care. This helps to deliver the Audit Commission recommendation of increasing NHS day case and ambulatory care.

  3.5  Capio has adopted an innovative design for its newly built ISTCs. These are built in a horseshoe shape, with the patients moving through the building in one direction. The continuous flow avoids any need for patients to retrace their steps and helps to reduce the spread of infection. Design features include separate entrances and exits not only for patients but for equipment and materials going in and out of theatre. Capio ISTCs currently have extremely low rates of hospital acquired infection.

  3.6  Capio ISTCs have developed many innovative new methods of care. These innovations are of course more likely to transfer to the NHS where we are allowed to work with NHS doctors on secondment. The Boston NHS Treatment Centre has pioneered "See and Treat". The ISTC is based in a rural community, so asking patients to visit for an outpatient appointment and then making them return later for an operation (as is usual in the NHS) was inconvenient. Patients coming for minor surgery are now referred for a 45 minute appointment in which they are seen and assessed by their clinician and then receive treatment, if necessary, during the same visit.

4.  IMPACT OF ISTCS

Adverse effects

  4.1  ISTCs are part of the NHS family, holding contracts with local NHS organisations on the basis of local delivery plans to tackle capacity gaps in local service provision. The arrival of an ISTC may require some change to local service provision, but Capio's aim is always to complement and add to the sum of local NHS services rather than undermine it. Capio has worked hard to develop strong local partnerships and to integrate as part of the local health economy. Where there has been stronger local leadership, the introduction of ISTCs has produced a better result for patients and NHS trusts alike. Where the local leadership has shown resistance to national policy, there are sometimes unnecessary obstacles to close and effective working.

Value for money

  4.2  ISTCs provide good value for money. Capio's ISTC contract is at a slightly higher tariff than the NHS but includes costs for building a number of ISTCs and recruiting clinical staff from overseas. This price is still lower than many NHS providers who operate significantly at above NHS tariff without the requirement to build new facilities or recruit new staff from overseas. The tariff will also taper off over the period of the contract.

  4.3  There is concern that NHS hospitals are losing out financially for taking on more difficult cases. This should not happen as tariffs should be higher for more resource intensive cases.

  4.4  Capio is accredited to provide NHS care at tariff price in a number of its existing independent hospitals through Choose and Book.

Waiting times

  4.5  The current average waiting times from referral to a Capio ISTC is 29 days. This means patients are, for example, walking and seeing more quickly than they otherwise would. The Capio ISTCs have already seen 5,084 inpatients and 10,344 outpatients, and once all the centres have opened across the country Capio will be treating 19,000 NHS patients per year in its ISTCs. This means 95,000 less patients waiting in pain and disability for a routine operation.

Post-operative follow-up care

  4.6  Capio always prefers to provide all post operative care. However, the post operative follow-up actually given reflects what the local PCT(s) requested, as specified in each ISTC contract. In some cases Capio provides full follow-up services and in others the patients transfer back into the hands of NHS providers.

  4.7  All patients receive a follow-up call from the ISTC 72 hours after discharge.

  4.8  Capio has an extremely low rate of complication and hospital re-admission—0.08%. However, where complications occur, Capio is contracted to take full responsibility of these cases. Every Capio ISTC operates a helpline service which all patients are invited to call after discharge if they experience any problems. This service is manned by an experienced nurse, supported by an anaesthetist and surgeon for advice. If triaged as a non urgent problem, the patient is requested to come back to the ISTC as soon as possible.

  4.9  Any necessary treatment is given by the ISTC. If it is considered that the required treatment is not appropriate at that ISTC, then arrangements are made to admit the patient to an appropriate facility. All ISTCs have a formal arrangement with their local NHS trusts and have clinician to clinician dialogue to support this so as to minimize risk and inconvenience to patients. Where a patient requires care for a complication in an NHS trust, the cost is covered by Capio.

Standards

  4.10  Capio aims for the highest standards, whether this relates to clinical outcomes, cleanliness or customer service, and strives to be the best healthcare provider in this country. Capio ISTCs are modern sites designed explicitly to provide the right environment for fast through-put, cost effective care with low infection rates. Our patients appreciate the simple advantages of using our ISTCs such as free car parking and, where overnight stay is required, private or double inpatient rooms. Capio is proud of its performance and standards, but is not complacent. It measures and monitors its performance, allowing it to strive continuously for improvement.

  4.11  As part of the ISTC contract, Capio is required to report to the Department of Health on a number of KPIs, including clinical. There is no comparable requirement in the NHS. A report published by the National Centre for Health Outcomes Development (NCHOD) in November 2005 assessed the outcomes of these KPIs and found that the volume and quality of data collected by ISTCs is innovative, challenging and vigorous.

  4.12  The NCHOD found that Capio had performed within expectations for all relevant KPIs and demonstrated high performance. For example, cancellations for non-clinical reasons were extremely rare (only 3 out of nearly 13,000 admissions). There were also no incidents for the following KPIs: complaints handled outside agreed timescale, reportable incidents, NHS staff recruited in breach of Clause 9, security breaches, confidentiality breaches and failure to meet treat-by date. [35]

  4.13  Our high standards of cleanliness [36] help to give us a very low rate of infection and help to keep our patients healthy and safe.

  4.14  Capio has commissioned an independent organisation to manage a patient satisfaction survey at each of the ISTCs. Feedback has been extremely positive—with our ISTCs scoring an average of 9.5 out of 10.

Training

  4.15  Capio understands that removing volumes of elective surgery from teaching hospitals to ISTCs may restrict the procedures available for the training of junior doctors in those teaching hospitals. This does not mean that the ISTCs inhibit training, but rather that training needs to catch up with the new locations of surgery. Capio already facilitates the training of NHS nurses and physiotherapists in some of its hospitals. It is also very close to signing a contract to facilitate the training of junior doctors in one of its ISTCs, and hopes that similar arrangements can be made in others. Training doctors inevitably results in a lower through-put of cases in a facility, and therefore raises cost per case. ISTCs, like the NHS, will need to be reimbursed for the additional expense of training.

Recruitment

  4.16  Doctors working for Capio must be fully registered with the GMC and also be on the appropriate specialist register. Capio's ISTC recruitment procedure uses Department of Health requirements for the contracts as a base line. Our own recruitment process for medical staff from abroad includes language tests, police checks, qualification and reference verification, health assessment and, if applicable, work permit confirmation. The Capio interview panel ensures the physician's experience and technical capability is of the highest standard. In addition, new recruits are monitored to ensure they are performing to the standards required.

  4.17  Capio recognizes that currently the registration requirements are necessarily more demanding for ISTC doctors, than their NHS equivalents. Capio expects an early leveling of the playing field as the public and medical profession recognise the high quality of clinical care, and in particular surgery, carried out in an ISTC.

  4.18  As the ISTC programme grows it will become even more important for the statutory national regulatory bodies to manage the significantly increasing demand for clinical registration. At present, not only is the delay in achieving clinical registration for overseas clinicians unreasonably long (and some regulatory bodies are worse than others), mainly because the regulatory bodies have not adjusted their processes to address the changing market place, but the process is frustratingly opaque. The regulatory bodies would do well to work cooperatively with the IS on this issue, as all stakeholders have a real and enduring interest in the provision of safe clinical services.

5.  THE CONTRACT

Commercial confidentiality

  5.1  Capio has published the financial value of its ISTC contract, the volumes and procedures to be provided. In addition, transparency of clinical performance is a vital part of the ISTC programme, and if patients are to make informed choices, it is vital that all providers of NHS services are transparent. As part of the ISTC contract, Capio is required to report to the Department of Health on a number of key performance indicators (KPIs). These KPIs, published in the NCHOD report, are more demanding than any data the Government requires NHS hospitals to collect and publish.

Potential ways to improve the contracts

  5.2  The additionality rules contained in the first wave of ISTCs have been successful in bringing additional doctors to work in the NHS. We believe that these rules should now be relaxed to allow free movement of staff between providers, as is allowed in any other area of work. There are very few consultants who work purely in the IS, and the rules have forced Capio to deny employment to a number of UK clinicians who have wanted to treat NHS patients in this way.

  5.3  Rigid separation of the NHS and ISTC workforces makes it more difficult to share and spread best practice and innovation. Patients will benefit from the movement of staff between the NHS and ISTCs. In particular the ability of ISTCs to deliver safe, high volume elective surgery—more a patient and clinician management process than narrow surgical skills—could transform the clinical productivity currently achieved in the NHS.

  5.4  Utilisation of the excellent clinical facilities in ISTCs to facilitate the training of junior doctors, in particular, would also improve the quality of the skills acquired, and expose young doctors and nurses to innovative clinical and patient management processes. Again the benefits to the NHS and patient care would be very significant.

  5.5  Capio would also recommend that the Government seeks earlier local involvement in contract discussions between ISTC bidders and PCTs or other NHS partners. Originally these delays were instituted to avoid putting the procurement process at risk but we believe that the Department of Health has recognised this and intends to act upon it.

  5.6  Finally we feel that in some parts of the NHS, greater support and commercial training should be given to local teams negotiating and implementing the ISTC contracts. These contracts are legally binding and differ from the "NHS contracts" which most of the NHS is used to working with, which are not legally enforceable.

Second Wave ISTCs

  5.7  Capio believes that the criteria for evaluation should include:

    —  Clinical quality.

    —  Value for money.

    —  Speed of access.

    —  A record of successful delivery for the NHS.

    —  Customer service.

    —  Flexibility and reliability.

    —  Adherence to NHS values and public sector partnership.

Location and Quantity of ISTCs

  5.8  It is impossible to answer this point without collecting together the NHS capacity planning data. However, there is a clear role for ISTCs where additional capacity is needed, either to reduce waiting lists or to provide choice where this is lacking.

  5.9  ISTCs should be easily accessible and convenient for patients. Partnerships should explore co-location with other services such as pharmacy, social care, primary care and other acute facilities. However, there are also other important considerations affecting location such as:

    —  Availability and cost of sites.

    —  Local Government consent and guidelines (eg building on brownfield and greenfield sites).

    —  Closeness to NHS sites.

    —  Transport links.

  5.10  It may be of interest to the Committee that the programme is developing life and momentum of its own, away from the nationally driven exercises. Capio has been approached by PCTs and Trusts for information on the value of IS providers to NHS patients.

Capio Healthcare UK

13 February 2006







34   Patricia Hewitt speech to London School of Economics (13/12/05). Back

35   Preliminary Overview Report For Schemes GSUP1C, OC123, LP4 and LP5, National Centre for Health Outcomes Development (NCHOD), November 2005. Back

36   A Snapshot of hospital cleanliness in England, Healthcare Commission (21/12/05). Four Capio hospitals were inspected scoring an average of 92.3 out of 100. Back


 
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Prepared 9 March 2006