Evidence submitted by the NHS Alliance
(ISTC 41)
1. INTRODUCTION
1.1 The NHS Alliance is recognised as the
principal independent representative organisation for primary
care. Its membership includes primary care organisations in the
UK and GP practices, while individual membership is fully multi-professional,
including NHS chief executives and other managers, doctors, nurses,
allied health professionals, pharmacists and other primary care
professionals together with PCT board chairs and non-executives.
In particular it reflects the critical partnership between lay
people, managers and clinicians in planning, securing and evaluating
efforts to improve the health of local populations. It is in regular
and close contact with Ministers and the Department of Health.
1.2 Its 12 professional networks have a
growing role in sharing good practice and informing strategy and
policy at a national level. In addition, the NHS Alliance is unique
in bringing together practices and primary care trusts in planning,
securing and evaluating local health services. 55
1.3 The NHS Alliance is committed to values
of fairness, equity and collaborative working within a structure
that is mutually supportive and accountable. Both national and
local organisations have an important role to play in delivering
those values.
1.4 This Memorandum of Evidence is provided
on behalf of NHS Alliance members.
2. THE CURRENT
EXPERIENCE OF
INDEPENDENT SECTOR
TREATMENT CENTRES
2.1 NHS Alliance members are more than willing
to work in co-operation with the private sector. We have identified
none who object to the principle of private sector involvement
with the NHS. However primary care trust PEC chairs (clinical
chairs) and senior managers report mixed experiences of Independent
Sector Treatment Centres (ISTCs). Some have seen improved access,
reduced waiting times and good quality services while others have
experienced few benefits. Those areas where there was good engagement
with local GPs and acute trust consultants at the planning stage
are more likely to report positive outcomes.
2.2 ISTCs' access times for patients are
generally good and this is very welcome. However a relatively
small proportion of patients benefit. The services provided by
ISTCs are limited to specific surgical procedures within a given
speciality (as defined by the ISTC's local clinical criteria)
and only those patients who fall within this definition are treated.
There is not a general benefit to all patients.
2.3 The ISTC first wave contracts were negotiated
on a national basis. PCTs have been committed to these block contracts
that provide guaranteed payments to the ISTC—via their Strategic
Health Authority's share of the national contract—regardless
of work done (the "Minimum Take") and at a higher price
than the national NHS tariff. At least some of these contracts
are due to run for five or seven years. PCTs are required to "find"
patients to take up their share of the activity within the ISTCs.
For a variety of reasons, in some cases that has proved impossible,
resulting in a financial loss to the PCT. Understandably, those
PCTs that are managing deficits are particularly anxious about
the consequent impact on patient care in clinical areas not served
by an ISTC. Examples are described in the annex to this document.
2.4 Even where decisions were imposed by
SHAs, many ISTCs are working well. Often this has depended on
the active involvement of primary care trust PEC chairs. For example,
in Somerset the system is working close to capacity and is popular
with patients while North Bradford has cut waiting times for day
surgery to four weeks. Elsewhere the experience is less happy
and patients as well as professionals have rejected ISTC services.
2.5 The lack of widespread clinical engagement
with local GPs and NHS hospital consultants has been a significant
failure of the first wave of ISTC procurement. In some areas,
the Department of Health's national implementation team did visit
local communities where an ISTC was being developed, staying in
the local area and talking to local health professionals. This
type of good practice is helpful. However, it would appear not
to have been the standard in every area. As a result, local clinicians
in both primary and secondary care have felt disengaged and angered
by the lack of meaningful dialogue regarding local clinical issues
and their interest, commitment or willingness to work with the
ISTCs.
2.6 There is a perception that the first
wave contracts were politically driven regardless of whether the
impact on patient care would be positive or negative, and at any
cost. Some members have expressed concerns about clinical quality
or that contracts are too inflexible to meet local needs. In one
case—Barnet—that has resulted in the curious problem
that a PCT that wishes to use local independent sector providers
is prevented from doing so.
3. THE FUTURE:
CHANGES GOVERNMENT
SHOULD MAKE
IN ITS
POLICY TOWARDS
ISTCS
3.1 There are significant conflicts between
current ISTC policies and both Payment by Results and Practice
Based Commissioning. If PCTs are locked into national contracts,
what ability will practice commissioners have to commission services
they select—or to redesign to deliver more cost effective
services in primary care? How can practice based commissioners
achieve savings where their PCT is locked into a long term block
contract? How can Payment by Results operate fairly and effectively
where there are first wave ISTCs that have advantageous financial
arrangements? These conflicts must be resolved if NHS reforms
are to deliver real improvements.
3.2 The NHS Alliance believes that the IS
Procurement Programme should be undertaken on a "call off"
basis, with PCTs able to access activity as and when required,
paying only for activity that is actually used. Whilst the principle
of paying only for activity when utilised has now been recognised
within the current 2nd Wave Programme, presently out to tender—and
this is to be welcomed—the NHS is still paying for under-utilised
IS contracts because they have been unattractive to local patients
for a host of reasons.
3.3 That implies that existing contracts
with 1st Wave ISTCs should be re-negotiated.
3.4 It also implies that future procurement
should depend upon the decision by each primary care trust, agreed
with its practice based commissioners, that there is local requirement
for the service. It is clear that Value for Money is dependent
upon procuring and paying for only those services that are needed,
that practice based commissioners are content to commission, and
that patients are willing to use.
3.5 Genuine clinical engagement within both
primary and secondary care is critical within any IS programme.
Effective local clinical pathways, suiting the needs of local
patients, are essential if clinicians and the public care to have
confidence in the health system. There has been some recognition
of this within the 2nd Wave Programme, but it needs to be a fundamental
requirement of any negotiated IS contract.
4. ADDITIONAL
INFORMATION
4.1 Further information is provided in the
attached annex to this document by NHS Alliance members with direct
frontline experience of ISTCs.
NHS Alliance
15 February 2006
See www.nhsalliance.org
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