Evidence from the Royal College of Obstetricians
and Gynaecologists (ISTC 5)
INTRODUCTION
1. The Royal College of Obstetricians and
Gynaecologists (RCOG) received its Royal Charter in 1947. Its
role is to encourage the study and the advancement of the science
and practice of obstetrics and gynaecology. The RCOG, to this
end, oversees standards of clinical practice and training in all
aspects of obstetrics and gynaecology.
2. The RCOG Supports improvement and modernisation
of service delivery within the NHS. It is keen to see new models
of clinical care, which lead to improved, efficient and quality
services.
3. So far the RCOG is unaware of any significant
impact of ISTCs on gynaecological practice, however, we share
many of the concerns that have been expressed in the past, particularly
those relating to staffing, clinical governance, training and
payment tariffs.
MEDICAL STAFFING
4. It is essential that the quality and
expertise of staff employed in ISTCs is of the highest calibre.
There is not a surplus of doctors and the staffing of ISTCs will
either come from overseas, competition from Trusts, or by sharing
staff with Trusts. To date we believe that employment has been
on short-term contract and the majority of the staff have come
from overseas. The ability to quality assure clinical staff has
not been proven and there is concern that doctors employed by
ISTCs on short term contracts may not have the appropriate skills
and abilities.
CLINICAL GOVERNANCE
5. It is essential that the work of ISTCs
has encompassing methods of audit and governance. The quality
of care delivered in ISTCs must be monitored very carefully. Although
it may be difficult to compare complication rates with Trusts,
particularly as the more simple cases will be selected by ISTCs,
one would expect better outcomes and lower complication rates.
6. The RCOG is particularly concerned that
its close liaison with departments of obstetrics and gynaecology
in Trust hospitals will not exist with ISTCs. The RCOG issues
guidelines and recommendations which its Members and Fellows implement
and audit in clinical practice in Trust hospitals.
CASE SELECTION
7. It is not clear who will select cases
for ISTCs. It is important to identify means and mechanisms of
referral. Pros and cons of direct primary care and/or involvement
of NHS Trust clinicians should be considered. It is imperative
that the correct specialist is identified so as to give most appropriate
treatment for the patient's condition. It is not clear how primary
care will achieve this particularly when choice means that the
selection options are even greater.
8. It is essential that continuity of patient
care is maintained at ISTCs, as they have the potential to interfere
with continuity and lead to fragmentation. Should complications
of treatment in an ISTC arise, then it is essential that these
are dealt with promptly. If medical problems occur on site in
an ISTC, there must be clear mechanisms as to how these emergencies
can be resolved.
CONTINUITY OF
CARE
9. The complexities of arranging confidential
patient clinical notes to be available for the clinician at the
right time in the right place are considerable. Will clinical
notes travel with the patient or be sent in advance? What happens
when there is a complication and how will the notes be available
to the doctor who may be dealing with the complication in another
hospital? Maintaining confidentiality through this process will
be very difficult.
TRAINING
10. It is essential that training opportunities
are available throughout NHS clinical practice. In particular
the more simple and straightforward surgical operations that are
planned to be performed in ISTCs are ideal training opportunities.
Those clinicians working in ISTCs must be trained to deliver training
as part of their role. Such training must meet the standards set
by the Postgraduate Medical Education and Training Board (PMETB)
and the Royal Colleges.
IMPACT ON
TRUSTS
11. The selection of simple cases for ISTCs
lead to an imbalance in case-mix. Difficult cases, often with
the same payment tariff, will remain in NHS Trust hospitals.
12. It will be difficult to develop new
techniques and innovations when efficiency and costs are so paramount.
Many new procedures are initially expensive and take surgeons
longer to perform before the full benefits to the NHS and patients
are realised.
13. We are concerned that with shortages
across all the medical professions, ISTCs will compete for valuable
human resources. With less acute work and more structured hours
of employment, ISTCs may well attract staff from hard-pressed
Trusts!
14. It is unlikely that the simple tariff
rates will be able to discern between the simple cases selected
for ISTCs and those that are left at the Trust.
CONCLUSION
15. The RCOG welcomes service improvements,
which lead to higher standards of care and improved access and
efficiency. We endorse processes that lead to modernisation and
productivity. However, we have major concerns that there are conflicts
between ISTCs and healthcare delivery in Trusts. Consideration
must be given to all these issues if ISTCs are to lead an overall
enhancement of NHS Service.
Richard Warren
Honorary Secretary
Royal College of Obstetricians and Gynaecologists
7 February 2006
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