Evidence submitted by the Royal College
of Anaesthetists (ISTC 8)
The Royal College of Anaesthetists is the official
professional organisation representing all anaesthetists in the
United Kingdom and has responsibility for anaesthesia, critical
car and pain management. We have more than 13,000 Fellows, Members
and Trainees.
We welcome the additional surgical capacity
provided by Treatment Centres, be they independent or in the NHS.
We believe their full benefit will be achieved when a partnership
with local NHS providers is better formed.
Many of the perceived problems of ISTCs are
caused by a veil of secrecy governing their workings, and by a
failure to provide and publish systematic audit and assessment
of outcome. The public therefore rely on press reports and unreferenced
anecdotes; we too are constrained by this lack of evidence in
our submission to the committee. We think that the public interest
should prevail over "commercial confidentiality". We
also think the committee should satisfy itself that probity has
not been breached by the relationships of those who were employed
or retained to advise the DoH and the owners of ISTCs who on at
least one occasion subsequently employed an adviser.
We ask if the speed of the placement of contracts
took first place over the understanding of the full implications
of what the delivery of services actually involved.
The overall shortage of consultants and the
original arrangements that prevailed, barring recent NHS staff
from working in ISTCs meant that overseas doctors were recruited
by ISTCs, sometimes on short-term contracts. For these doctors,
being listed on the UK Specialist Register is in itself not a
guarantee of competency. In the interests of public safety, those
providing NHS services should be subject to the more robust selection
processes that apply in NHS hospitals.
To the extent that patients are treated in ISTCs,
training of medical and other staff is at risk. This problem,
which should be capable of solution, already affects orthopaedic
surgery and is beginning to threaten our own service specialty.
ISTCs should apply to the Postgraduate Medical Training and Education
Board for recognition of suitability of their premises, and their
specialist staff to the relevant Royal College for assessment
of their ability to train. With these in place Postgraduate Deans
would be enabled to place training contracts with ISTCs.
1. What is the main function of ISTCs?
The main function is to provide increased elective
capacity to relatively fit patients on a site distinct from enough
from a NHS DGH to prevent admission of patients with urgent medical
conditions. This will become more important as the ageing population
with less support from families makes increasing demands on acute
hospitals.
2. What roles have ISTCs played in increasing
capacity and choice, and stimulating innovation?
Capacity
Capacity has been increased, although it may
in part be an alternative to "waiting list initiatives"
by re-allocating funding. To an extent for orthopaedic surgery,
ISTCs might be regarded as a return to the specialist hospitals
of earlier decades, except that unless staffed by local consultants
those operating may not have been trained to the standard of a
NHS consultant. Some ISTCs operate below their capacity.
Choice
Patients want to be treated near their homes
and articulate ones want to be guided to the best available consultant,
normally by a well-informed general practitioner (GP). Increased
choice of hospital is not increased choice of competent surgeon.
We know little and can guarantee even less about the competence
of doctors working in an ISTC.
If services have been removed from a local hospital
to an ISTC there is no net increase of choice. If established
Trusts lose too much elective work to ISTCs, under Payment by
Results (PbR), their deficits may force some to declare bankruptcy,
and technically could be forced to shut. This would reduce choice.
Innovation
Apart not allowing the patient to use a GP's
guidance to select a surgeon, ISTCs are difficult to distinguish
from private hospitals.
If innovation can be measured by a degree of
panic, in the established Trusts about how to implement PbR, Choose
and Book and the increasing competition from ISTCs local to them
it has happened. In ISTCs only operating on a day-care basis a
drive to do more challenging operations may escalate use of alternative
techniques to ensure patients can go home the same day. However,
if innovation is taken to indicate research into new techniques,
funding will need to be identified as it seems unlikely that this
will occur because of the time taken to frame questions and obtain
consent and make whatever recordings would be required.
3. What contribution have ISTCs made to the
reduction of waiting times and waiting lists?
We understand that waiting times have fallen,
but cannot tell to what extent they were already doing so before
ISTCs were developed; an example is the widely publicised fall
for cataract surgery which may have been in part a consequence
of an ophthalmology initiative. We presume that most of the monies
from this have now gone to the ISTCs. However, it is clear from
data from the Royal College of Ophthalmologists that despite all
that is claimed more than 90% of all cataract operations still
take place within the NHS and that this is where much of the credit
should go for the reduction in waiting lists.
Readmission rates, and the rates of "re-do"
operations would possibly not show up on the waiting list figures,
as these patients would have been "discharged from care"
and have "completed consultant episodes" appended to
their files.
4. Are ISTCs providing value for money?
We have no evidence to answer this and do not
know the details of the financial arrangements that pump primed
ISTCS, nor to discuss the allegations that they are paid for operations
they do not perform.
Where new buildings are commissioned ISTCs are
likely to start from a basis of cleanliness. This will compare
favourably with NHS hospitals that have to finance the management
of infected patients (including those that may have had their
operation in an ISTC).
5. Does the operation of ISTCs have an adverse
effect on NHS services in their areas?
We do not know if viability of local NHS services
was part of the strategic and tactical planning of the locations
and the issuance of ISTCs' contracts.
We have already dealt with some of this (see
Question 2—Choice). The reason for impact on the ability
of the local trust to continue to provide health care for the
area is obvious. Put simply, by ISTCs being able to "cherry
pick", the loss of "easy surgical cases" that under
PbR will be the ones that bring in money to the Trust and what
the health care professions need for training of their beginner
trainees are serious issues. In at least one location, we understand
there is excess capacity for the fitter patients when the ISTC,
the private and the DGH are considered together, but it will still
be the NHS hospital in which there is pressure to operate on the
iller patients. This in turn puts pressure on the availability
of Intensive Care beds.
There will be increased average real cost for
those patients rejected by an ISTC who will need to seek care
from their NHS hospital. The financial stream identified for these
schemes (£500 million) would ensure many NHS trusts could
comfortably deliver the demanded increase in provision, although
we concede it would not encourage their becoming more efficient.
A further, but important issue is emerging with
the relaxation of the "rules" governing the secondment
of NHS consultant staff to work in ISTC's, particularly when transferred
activity, rather than additionality is involved. While the consultant
anaesthetic staff are sent to the remote ISTC to anaesthetise
fit patients, their juniors are left at the base hospital to look
after the sicker patients remaining within the NHS. Put another
way, the supervising consultant has to leave the trainees relatively
unsupervised by others. This has resulted in serious issues over
continued training approval in at least one Trust.
6. What arrangements are made for patient
follow-up and the management of complications?
We only know of anecdotes and press reports
of complications being handled by local NHS hospitals after the
operating surgeon has left the country. These are widespread,
and there seems to be no organised audit of this. Arrangements
cannot be expected to be robust if the operating surgeon was an
overseas doctors who worked as a "holiday locum" in
an ISTC.
Follow up must mean long term assessment of
results, not just the short term objective of whether or not "an
operation" was performed within some defined time frame.
We refer the Committee to the Royal College
of Ophthalmolgy (website: www.rcophth.ac.uk) for its President's
letter to Lord Warner.
7. What role have ISTCs played and should
they play in training medical staff?
If substantial amounts of elective surgery are
transferred to ISTCs, it will be essential for elective anaesthesia
for these procedures to be taught in the ISTCs. This has already
happened in the case of transfer of orthopaedic work from the
Royal Sussex County Hospital (Brighton) to a TC. It seems that
nobody planned in advance how to continue to offer training to
orthopaedic surgeons. The same might apply if the South West London
Orthopaedic Centre is sold to a private concern; this would affect
anaesthetic trainees because this centre provides orthopaedic
services for five surrounding trusts; were it just one it might
be possible to gain the training elsewhere in the NHS. Training
in anaesthesia is competency-based and involves core requirements
of every trainee. Although these are being met currently there
is no guarantee that the future workforce will be suitably trained
in anaesthesia for operations largely carried out in ISTCs.
The replenishment of clinical and nursing staff
depends on well-organised training schemes working within accredited
processes. This is embedded in the NHS, including Foundation Trusts,
but is a costly add-on for ISTCs. If funding is provided for one
but not the other this may have a profound influence on the way
hard-pressed Trusts view training (of all staff).
Training slows throughput and costs money. We
see no reason why Private Health Care Companies should take any
"hit" on throughput. Therefore there is no reason to
expect them as "for-profit" suppliers to want trainees,
unless out-of-hours cover was provided by them. If they (or any
other NHS staff members are seconded to the treatment centres
"following the patients"') clearly forward planning
over money is urgently needed.
With proper forethought and organisation ISTCs
could provide valuable training but standards for training must
be in accordance with those expected by the Postgraduate Medical
Education and Training Board, the competent body and delivered
by the Postgraduate Dean in accordance with the curricula set
by the Royal Colleges. This includes assurance that trainers are
capable of delivering the relevant curriculum [55]
and taking part in assessment processes.
8. Are the accreditation and appointment
procedures for ISTC medical staff appropriate?
The issue is one of patient safety
It is the often misunderstood difference between
being on the Specialist Register and being safe and competent
to do the job, that NHS hospitals are keen to not fall foul of,
in the interests of long term safety of patients. It is quite
possible for overseas doctors used to working in more sheltered
environments than an ISTC to gain access to the Specialist Register.
Were appointments subject to the current DoH Guidance to Advisory
Appointment Committees an additional layer of discernment would
exist. Our evidence is that even Foundation Trusts, although not
obliged to follow this guidance are almost always doing so. Overall
many NHS hospitals will leave a post unfilled, rather than make
an unsuitable appointment.
For ISTCs the procedures appear to be variable,
and therefore unsafe.
9. Are ISTCs providing care of the same or
higher standard as that provided by the NHS?
We know of no audit evidence that supports this;
audit seems sparse, but we suppose it might exist. We have learnt
of a deal struck by one provider with the manufacturers of one
particular prosthesis leading to local NHS surgeons if not overseas
ones declining to operate on patients in whose interest they do
not think it is to use such a prosthesis. On the other hand, we
ask if audit might reveal what we guess might be the case—a
reduction in infective complications as a result of segregation
of elective surgical patients from other acutely ill patients.
Back-up facilities (on-call teams, ICU/HDU,
proximity of laboratory services) are needed for the safety of
an ISTC. We do not think these are uniformly provided.
Properly managed, many of these problems should
be easily resolved. It may be that after the contracts with ISTCs
were struck the necessary details were only later thought of.
10. What implication does commercial confidentiality
have for access to information and public accountability with
regard to ISTCs?
The current financial cloud of secrecy under
the guise of commercial confidentiality is in our view unacceptable
when dealing with public funds. We question the probity of a system
which immediately after being set up employs the initiating staff
within the providers.
Unless a proper external audit of ISTCs is performed,
without constraint and limitations on the data provided, it will
be impossible to properly assess the standards of care provided
and also be impossible to identify any "problem" surgeons
or anaesthetists, (some of whom will have returned to their country
of origin at the end of their contracts).
Commercial confidentiality should not take priority
over public accountability, especially when the public purse is
being used to pay for the services provided.
11. What changes should the Government make
its policy towards ISTCs in the light of experience to date?
We suggest lifting the veil of secrecy, arranging
robust audit of performance, employment procedures that ensure
competence of staff, placing of training contracts by the Postgraduate
Deans and arrangement of financial matters that do not penalise
NHS trusts.
12. What criteria should be used in evaluating
the bids for the Second Wave of ISTCs?
We suggest:
— Locale and staffing issues need to
be better controlled.
— Access to ISTCs accredited by PMETB
as adequate for training of junior doctors and with College recognised
trainers be used by Postgraduate Deans.
— While micromanagement by the government
should be avoided in "centres for profit" there should
also be agreed rules about who can staff run the centres.
— Appropriate appointment and accreditation
standards.
— Openness of the management structure
and access to management.
— Collection of data from the centres
in an open manner with public debate. And with data made available
to the press.
— A willingness of the health care
company to work with the local trust and medical staff, not just
with PCTs.
— Track record and performance figures
of the companies being considered.
— Mutual waiting lists if not with
equity of case mix then with financial penalty for those not willing
or able to accept "difficult" surgery.
— Public scrutiny of contracts for
all staff not just clinicians.
— External review of performance by
the healthcare commission.
— Local lay and professional membership
of the ISTC boards.
13. What factors have been and should be
taken into account when deciding the location of ISTCs?
We do not know what has been taken into account
and are told of siting of ISTCS that appear to be haphazard. We
suggest:
— Waiting lists, and medical overload
of surgical beds.
— The proximity of the local DGH.
— Ability and ease of access to proper
backup in the event of a critical incident/medical catastrophe.
— How well the local Tertiary care
Trust is performing and whether or not it is meeting its targets.
14. How many ISTCs should there be?
We accept the drive to privatise care for elective
surgery and degenerative medical conditions is an imperative for
this (and probably a future) government. The number depends on
their size, the overall need of surgical facilities and the density
of the local populations that should be served.
Dr Peter Simpson
Royal College of Anaesthetists
12 January 2006
55 We have prepared our own document for recognition
of suitably qualified trainers. Back
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