Select Committee on Health Written Evidence

Evidence submitted by Nations Healthcare (ISTC 24)


  Nations Healthcare welcomes the opportunity to submit evidence to the Health Select Committee's inquiry into Independent Sector Treatment Centres (ISTCs). The company would also like to extend an invitation to the Committee to view Nations' Treatment Centres at a time convenient to members.

  Although we are still an early stage company our experience to date indicates that Nations' success within the ISTC programme has been and will continue to be predicated on:

    —  clearly demonstrating benefits to patients;

    —  being invited and welcomed into local health communities;

    —  working as an integral and enduring part of those local health economies;

    —  working in close partnership with the NHS and evidencing this to clinicians, patients and the public;

    —  providing value for money for the taxpayer; and

    —  bringing additional examples of innovation and best practice to the NHS.

  As one of the forerunners in the ISTC programme, Nations Healthcare has worked with the NHS through the often challenging period of bringing the early stages of policy introduction to fruition. We recommend to the Committee:

    —  the importance of generating the learning from the programme to date and using the learning to sharpen up and speed the processes of ISTC development from ITN to financial close and beyond;

    —  evaluating, and more proactively making clear to patients, the public and the NHS the benefits of the choice of dedicated ambulatory care; and

    —  clarifying the nature of partnership between the NHS and the independent sector; in particular more overtly recognising the realities of the pressures and imperatives informing both party's stances. This is especially critical in developing a shared view of risk, both commercial and financial.


  1.  Nations Healthcare is a UK based company, founded in 2002, with its origins in the US. The company is dedicated to creating the best inpatient and ambulatory care centres and developing clinical practice and a clinical environment where an increasing range of procedures can be treated safely and effectively through day treatment.

  2.  The Nations Healthcare model is developed in line with international best practice standards giving an innovative and proven effective approach to its service delivery. In the UK this model is being incrementally introduced to ensure innovation is fully supported by clinical teams with the training and ownership of change to maximise the benefits to patients.

  3.  Nations Healthcare has recruited over 100 staff in its three Treatment Centres in Bradford, Burton on Trent and Nottingham and its London Headquarters. 65 of these are front-line operational clinicians and support staff. This figure will rise to 450 by 2007.

  4.  The Bradford scheme was opened to treat patients in June 2005 with 45 NHS consultants seconded in from Bradford Foundation Trust as part of a groundbreaking structured agreement. The Burton on Trent scheme is scheduled to open in July 2006 and the Nottingham scheme, which is the largest co-located, single site ISTC in the country, will be opened in December 2007.

  5.  Nations Healthcare has a consortium of distinguished international companies supporting its operations in the UK including:

    —  Johns Hopkins University Health System International in Baltimore—clinical strategic partner and voted number one hospital in the United States for the 14th consecutive year;

    —  Harvard School of Public Health—academic partner analysing the public health impact of ISTCs;

    —  Alliance Imaging (Nations Imaging in the UK)—diagnostic partner and the largest provider of diagnostic services in the US;

    —  America Healthways—long term care partner and the biggest specialists in chronic disease management in the US; and

    —  Vision Group—ophthalmology partner and the leading ophthalmology group in Australia.

  6.  Nomura, the Japanese Investment Bank, is a major investor in the company and a further consortium member.

  7.  In the first wave of ISTC procurement:

    —  180+ international companies applied for pre-qualification for the programme. Nations Healthcare was one of only 15 companies pre-qualified.

    —  Nations Healthcare was short-listed on more projects than any other company.

    —  Nations Healthcare had more wave one "wins"" than any other company.

    —  Nations Healthcare closed three contracts including the contract for the first comprehensive ISTC scheme (Bradford).

What is the main function of ISTCs?

  8.  Nations Healthcare was pleased to respond to the Government's invitation to bid as part of the procurement programme for ISTCs and we endorse the Government's aims for the programme.

  9.  Through our participation in the programme we aim to support the NHS in achieving:

    —  more capacity to deliver faster care for NHS patients;

    —  services designed around the patient to improve their overall experience of healthcare and offer them greater choice; and

    —  the development of innovative services in partnership with the NHS, building on the best of what the NHS already does.

  The company's approach to the above must in addition enable Nations' viability and sustainability in delivering healthcare, innovation and value for money in the UK.

What role have ISTCs played in increasing capacity and choice and stimulating innovation?

  10.  Capacity in each of the three local health communities where Nations Healthcare is working in partnership with the NHS will be increased as follows:

    —  Bradford: contracted year one to provide 18,000 multi-specialty diagnostic tests and 6000 day surgery operations.

    —  Burton on Trent: contracted year one to provide 17,000 ophthalmology outpatients and 13,000 day surgery operations. In addition the PCTs have asked for a further 4,000 outpatients in year one over and above contract.

    —  Nottingham: contracted year one to provide 150,000 multi-specialty outpatients (this includes diagnostic tests) and 24,000 day cases comprising a mixture of day surgery and other same day procedures.

  11.  Choice for patients only exists when GP referrers, patients and the public are aware of their local ISTC and what it provides, and have confidence in the facility, its clinicians and management. In the three areas of Nations' Treatment Centres, we have been working in close association with the Primary Care Trusts developing strategies to support GPs in understanding their referral choices.

  12.  The strategy in Bradford is clinician-led and includes GP visits to the centre, information for GPs, consultant surgeons' presentations to, and engagement with, GP groups. We are also progressing other options including the establishment of a dedicated website for GPs.

  13.  In addition we continue to actively raise the profile of the Treatment Centres with patients and the public through open days, press releases and feedback from patients. These strategies will be rolled out in Burton and Nottingham.

  14.  In Bradford the first patient satisfaction survey required by the Healthcare Commission revealed a score of 93.5% on the satisfaction index with a statistical reliability of plus or minus 1.6%.

  15.  Stimulating Innovation has been achieved by Nations Healthcare in a number of ways:

    —  Through the contribution of Johns Hopkins' clinicians working with our consultant surgeons and anaesthetists in the areas of case selection, care pathway development and treatment centre development. Johns Hopkins has been a leader in both innovation and provision of ambulatory care for almost 20 years.

    —  In our Bradford Treatment Centre through the introduction of the "Green Light Laser", a technique to improve the treatment of prostate cancer and the numbers of men treated. The procedure, which is locally only available in the Treatment Centre, and nationally carried out in a small number of acute trusts, has been spearheaded by a seconded senior NHS urologist.

    —  The expansion of the "basket" of procedures undertaken by day treatment within the local health communities served.

    —  The design of our centres and clinical processes both of which are engineered to provide the best and most efficient patient experience. For example North Bradford Primary Care Trust, which commissioned Nations Healthcare to construct and run the Eccleshill NHS Treatment Centre, has recently won the award for "Service Re-design" in the NHS Alliance Acorn Awards.

  16.  Nations Healthcare is exploring opportunities to further introduce innovation in all of its centres and particularly in Nottingham in conjunction with the Queens Medical Centre.

What contribution have ISTCs made to the reduction of waiting times and waiting lists?

  17.  Nations Healthcare in its Bradford Treatment Centre treats patients from both Bradford and Leeds. Patients coming to the centre have a maximum two-week waiting time for diagnostic tests and a maximum four-week waiting time for day surgery.

  18.  We do feel our treatment centres have the potential to make a meaningful contribution to reducing waiting lists and waiting times. However it is our opinion that the host Primary Care Trusts (PCTs) are best placed to offer a balanced view on the contribution of the work undertaken.

Are ISTCs providing value for money?

  19.  One of the clear areas of learning for the ISTC programme is the challenge to shift the referral patterns of GPs and both Nations and the Primary Care Trusts alike probably underestimated the achievement of this. In Bradford the number of referrals to the centre from Bradford and Leeds has not yet reached the figure covered in the contract between Nations and the PCTs. In the first six months of operating the centre treated 2,091 patients a figure which is 27% lower than that anticipated by the PCTs.

  20.  Reasons for this include:

    —  established referral patterns and loyalties;

    —  a high level of inappropriate referrals which cannot be accepted by the centre;

    —  a lack of awareness by referrers of what the Treatment Centre can and cannot do; and

    —  limited use by referrers of the electronic referral methods forming part of Nations contract with the PCTs.

  21.  Nations has taken four key steps to tackle these issues:

    —  the company has not imposed the financial minimum take upon the PCTs in Leeds and Bradford and has given them a year to catch up with referrals;

    —  we have brought in additional resources to train PCT personnel in understanding and using electronic referrals incorporating the patient's history and diagnosis;

    —  a clinician-led referrals strategy is being implemented to `market' the Treatment Centre to GPs and build their awareness and understanding of procedures suitable for referral; and

    —  nations senior managers are meeting regularly with PCT managers and clinicians to monitor referrals and consider additional ways to increase numbers.

  22.  Alongside this local agenda Nations has proposed to the CCMU a "ramp-up" period built into future schemes to recognise the challenges in achieving a shift in referral patterns.

  23.  Nations is taking this learning to Burton and Nottingham to start the process of engaging GPs from the earliest possible time.

Does the operation of ISTCs have an adverse effect on NHS Services in their areas?

  24.  In Bradford the number of patients treated is small compared with those treated by the whole health economies in Bradford and Leeds. Whilst patients would formerly have been treated in the acute trusts they are still treated by NHS consultants, within the policy of additionality, under contract to Nations to provide sessions at the centre. The advantage lies in the centre being a dedicated elective facility and not therefore subject to the pressures of emergencies and associated late cancellations. We do know the consultants welcome this advantage and it is clearly beneficial to patients.

  25.  Nations does not feel able to comment effectively on the impact of the centre on local services, adverse or otherwise, at this juncture and believes this evidence would be better provided by either the PCTs or the acute trusts or both.

  26.  In a reference for Nations Healthcare provided by the North Bradford PCT ISTC Project Director, the Director states "The PCT is very happy with the service being provided—primary care has never had such good access to radiological diagnostics or day surgery. This is a model of provision which should be rolled out across the country". This reference can be made available to the Committee if required.

What arrangements are made for patient follow up and the management of complications?

  27.  Patient Follow-up—most patients undergoing day surgery in Nations' Centres do not require follow up and their treatment is completed on the day. Where there is a need for a follow up outpatient appointment this is undertaken within the Centres.

  28.  Physiotherapy or other follow up treatment needed to support a patient in achieving the best outcomes from surgery is carried out in primary care. This arrangement was agreed as the most effective by the PCTs and it forms part of contracts with Nations Healthcare.

  29.  Management of Complications—experience from Johns Hopkins in the US indicates that the incidence of complications in patients receiving day surgery is extremely small. In Nations' Centres, arrangements have been made for the speedy transfer of patients to local acute facilities should any complication arise that cannot, or should not, be managed within the centres. This arrangement again forms part of our contracts with the PCTs and the acute trusts.

  30.  To date there have been no clinical emergencies associated with procedures carried out in Bradford that require a patient's transfer to the acute hospital. There have been occasions when diagnostic tests undertaken within the centre have revealed more serious conditions necessitating transfer (not immediate) to Bradford Foundation Trust. For example Nations Healthcare and the senior colorectal consultant/general surgeon in the Trust have developed a co-operative approach to diagnosis and this has earned a Yorkshire Cancer Network nomination for exemplar practice.

What role have ISTCs played and should they play in training medical staff?

  31.  Nations Healthcare is fully committed to playing its part in the education and training of the next generation of healthcare professions particularly (but not solely) medical staff.

  32.  We recognise the potential impact that not being involved in the training of medical staff would have on the viability of training in teaching trusts and this would not be in the interests of either the trusts or Nations Healthcare. Furthermore we are clear that the opportunities for junior doctors, rotating through Nations Treatment Centres, are to gain highly focussed experiences in surgery with surgeons whose lists are not subject to change and emergencies. This latter valuable experience can be achieved within the acute trusts.

  33.  Nations Healthcare has signed the first major training, education and research contract in the country at the Queens Medical Centre and is also contractually committed to a pilot project for training in Burton.

  34.  Furthermore, our Medical Advisory Board is leading the development of a clinical leadership programme with a bespoke curriculum designed to foster best practice and change. This programme is accredited in the US by Johns Hopkins and the Harvard School of Public Health.

Are the accreditation and appointment procedures for ISTC medical staff appropriate?

  35.  Although to date Nations Healthcare's consultants have been drawn from the NHS, through secondments or contracted sessions in accordance with the additionality policy, and the staff have therefore already been through NHS appointment procedures, nevertheless it is Nations' policy to check the registration and qualifications of every doctor and nurse.

  36.  In the event of Nations employing doctors who have not previously worked within the NHS—for example overseas doctors—we have policies in place to ensure the integrity of the procedures and the fitness for purpose of recruited doctors.

  37.  Lord Turnberg, a past president of the Royal College of Physicians, is the chair of Nations' Medical Advisory Board.

Are ISTCs providing care of the same or higher standard as that provided by the NHS?

  38.  All ISTCs are inspected and regulated by the Healthcare Commission and are obliged to meet the standards laid down by the Healthcare Commission.

  39.  Nations Healthcare believes that NHS standards of treatment are as good as any in the world and our partner Johns Hopkins has endorsed this belief. Where Nations is able to add value is in the innovation the company can introduce to its Treatment Centres, faster access for patients and the experience patients have before and after treatment.

What implications does commerical confidentiality have for access to information and public accountability with regard to ISTCs?

  40.  Nations Healthcare has held firmly to the view that in all of its work alongside the NHS we would meet all reasonable requests for information to demonstrate public accountability.

What changes should the Government make to its policy towards ISTCs in the light of experience to date?

  41.  Nations Healthcare takes the view that it is in the interests of the Government, the NHS and the company to share learning from our experience of the ISTC programme to support achieving greater effectiveness in the partnership between the NHS and Nations in the future.

  42.  Our main comments cover six important areas:

    —  Patients and the public—feedback from patients treated in North Bradford demonstrates the value they place on fast access to the diagnostics and surgery they need and the patient satisfaction survey showed a high level of satisfaction with the patient experience from start to finish. If patients and the public across the country are to have confidence in ISTCs as a treatment choice such good news stories must be communicated.

    —  Positioning—from the outset Nations has gone the extra mile to build positive partnerships with local health communities and can evidence ways in which this has been achieved. For example:

      —  We have actively arranged for groups of clinicians and managers from Burton and Nottingham to visit the centre in Bradford to increase their understanding, offer an educational experience and grow their confidence in the capacity of Treatment Centres. These visits have proved extremely successful.

      —  Clinicians and managers from local health communities in the areas of all three schemes have spent time with Nations' clinical and academic partners in the US as an educational opportunity and a chance to judge the efficacy of the clinical practice proposed by Nations in its centres.

      —  In all three areas, joint arrangements are being developed for crucial organisational processes such as communications, patient involvement and referrer engagement.

    We believe this is one of the most critical areas of learning and strong partnership working lays much stronger foundations for positioning our treatment centres as an integral and enduing part of the NHS.

    —  Engaging referrers—as already mentioned Nations and the PCTs in Bradford made some assumptions about referrals following the needs defined by the PCTs. This has not been the case to the degree anticipated. In Nottingham we have engaged GPs as part of our "Partnership Board" and in our "Partnership in Practice" development programme. It is further our intention to engage with contracted numbers from the opening of the Centre.

    —  Clinician-led—much of the credibility Nations has gained in the areas of its three Centres results from its philosophy to build a clinician-led organisation. We are not yet in a position to say this has been fully achieved, but where we have made strides the outcomes in building understanding and co-operation between the NHS and Nations and the impact on patient care has been extremely positive. For example, all three of our Treatment Centre General Managers are clinicians.

    —  Intrinsic understanding of the NHS, its ethos and capabiliites—Nations Healthcare has always been clear that melding the best in the UK with the best in the US is a key company aim. For this reason we recruited respected ex-NHS managers to bring an intrinsic understanding of the NHS, its ethos and its capabilities. This strategy has paid dividends in the areas of strengthening partnership, taking commonsense, informed approaches to dovetailing systems and processes, and building a culture putting the patient at the centre through the integration of NHS values with those prevailing in healthcare in the US.

    —  Speed of development—Treatment Centres are comparatively small NHS facilities, yet the speed of contract negotiations has meant the advantages to patients have taken a long time to be achieved. For example in Nottingham, from the time of the first meeting with QMC to the time of the first patient treated is likely to be in excess of four years. Although this incorporates approximately two years construction time we believe the contract stage of development could be accelerated. Nations Healthcare would be happy to work with the NHS to support achieving this.

What criteria should be used in evaluting the bids for the second wave of ISTCs?

  43.  Nations Healthcare believes the criteria used to evaluate bids should take account of the learning noted above, build on what has worked to date and avoid the pitfalls that have slowed progress and created tensions.

  44.  We suggest the following:

    —  the ability to provide a proven good patient experience;

    —  the ability to staff treatment centres with "fit for purpose" healthcare professionals working in teams shaped to provide the best patient experience;

    —  the ability to design, build and run a treatment centre that offers the best patient experience;

    —  the flexibility to accommodate sponsoring PCTs' defined needs for the community served and in the future to respond to Practice-Based Commissioning;

    —  established systems and processes to enable the construction of strong working partnerships with the NHS;

    —  the capability to bring innovation to NHS patients;

    —  the commitment to supporting training, education and research;

    —  a strong financial and commercial base with demonstrated good governance arrangements; and

    —  the ability to articulate the added value to NHS patients of the company's Treatment Centres.

What factors have been, and should be, taken into account when deciding the location of ISTCs?

  45.  In the first wave of the ISTC programme, Nations Healthcare bid for a number of schemes to establish its base in the UK. As an established company, we are now able to make more informed judgements about where we would wish to develop treatment centres.

  46.  The factors to consider in making these judgements include:

    —  Is the local health community in agreement with the need for a treatment centre?

    —  Is the location one where there is evidenced under-capacity in the NHS?

    —  To what extent are referrers currently prepared to refer to a treatment centre?

    —  Are the innovations Nations offers ones that are not available to NHS patients through other local NHS trusts?

    —  Can patients relatively easily access the proposed treatment centre?

    —  Is Nations already part of nearby health communities and therefore connected to local NHS networks?

    —  Is the treatment centre located sufficiently close to an acute trust to ensure patient safety in any emergency?

How many ISTCs should there be?

  47.  Nations Healthcare believes that the decision about how many ISTCs are needed to complement NHS provision is not one that can or should be taken by the independent sector.

Nations Healthcare

13 February 2006

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