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:
— A record of successful delivery for
the NHS.
— 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.
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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