Evidence submitted by the Royal College
of Surgeons of England (ISTC 39)
INTRODUCTION
1. The Royal College of Surgeons of England
(RCSEng) welcomed the announcement of the inquiry into ISTCs on
12 January 2006. It wishes to thank the Health Committee for the
opportunity of submitting this memorandum of evidence. The College
would value the opportunity to present additional oral evidence
should the Committee feel that this would be of assistance.
2. For ease of reference, the College's
responses to the specific questions posed in the Committee's terms
of reference are set out immediately below but these should be
read in the context of the subsequent sections that provide a
background from the College's point of view.
RESPONSES TO
QUESTIONS RAISED
UNDER THE
TERMS OF
REFERENCE
3. What is the main function of ISTCs?
The stated aim in Growing Capacity: a New
Role for External Healthcare Providers in England[56]
was to develop plurality and diversity in the delivery of health
services designed to meet the ambitious targets for reducing waiting
times for treatment set out in Delivering the NHS Plan.
[57]This
included the use of clinical teams in existing NHS provider organisations
both to support existing services and to help staff new NHS-managed
developments as well as the development of an international establishment
of providers to set up and run healthcare units in this country.
The NHS units have a strong track record which is achieved largely
by the separation of elective surgery from the competing demands
of emergency care provision.
4. What role have ISTCs played in increasing
capacity and choice, and stimulating innovation?
Capacity
There is developing a progressive increase in
capacity but sadly, although initially designed to provide this
in areas with the greatest target gap, imbalances are occurring
with destabilisation of existing NHS facilities.
Choice
Although patient choice is extended, the reality
is that in the majority of cases they prefer to opt for existing
NHS facilities. In addition, general practitioners who have traditionally
referred patients to local NHS consultants are, with transfer
to ISTCs, losing direct contact with a known and trusted service.
Stimulation of Innovation
So far there has been no evidence of innovative
technical advance in the ISTCs established in the First Wave programme.
In addition, both the profession and wider public await solid
evidence that the projected more efficient ways of working are
providing sustained safe and quality surgical care for patients.
5. What contribution have ISTCs made to the
reduction of waiting times and waiting lists?
Although there is the evidence that in certain
areas waiting times for certain procedures have diminished, it
is unclear whether, in the light of experience, this will be sustained
and whether the provision of care in a balanced manner across
the health economy can be ensured.
6. Are ISTCs providing value for money?
Unfortunately, there is clear evidence that
this is not the case and that a number of Primary Care Trusts
(PCTs) have expended significant sums of public money in the advance
purchase of surgical procedures which have not been taken up.
It is difficult to assess the benefits objectively
as there are no outcome data available to evaluate procedures
performed.
7. Does the operation of ISTCs have an adverse
effect on NHS services in their areas?
There is clear evidence from a number of areas
that triaging arrangements have diverted patients into ISTCs leaving
existing NHS facilities under-utilised with a concurrent deleterious
effect on fragile NHS Trust financial balances. There is also
evidence to show that training of surgeons in adjacent NHS hospitals
has suffered. (Personal Communication—SAC Report Southampton)
8. What arrangements are made for patient follow-up
and the management of complications?
Unfortunately, there is increasing evidence
of a relatively high level of complications for example in patients
undergoing major orthopaedic surgery where the ISTC has been unable
to manage these with consequent transfer to existing NHS facilities
and on occasions to the consultant to whom the patient was initially
referred. Documented examples have been made available to the
National Clinical Governance Support Unit.
9. What role have ISTCs played and should
they play in training medical staff?
So far there has been no surgical training provided
in the First Wave of ISTCs and the College has recently been working
with the Conference of Postgraduate Medical Deans (COPMeD), the
Central Clinical Procurement Unit, the Central Clinical Management
Team and educational colleagues in the Department of Health in
an endeavour to resolve this. There is concern that lack of central
guidance is impeding the work of Local Training Steering Groups.
The College is anxious to assist in any way that it is able on
this issue.
10. Are the accreditation and appointment
procedures for ISTC medical staff appropriate?
The College has from the outset been concerned
that this is not the case and at an early stage set down a set
of guidelines which have been disseminated to surgical colleagues
at the local level and made available to the Department of Health.
[58]
11. Are ISTCs providing care of the same
or higher standard as that provided by the NHS?
Although patient satisfaction surveys reported
by the Department of Health show 80% satisfaction rates, reports
received by the College and specialist surgical societies have
suggested that care provided by ISTCs is often of an inferior
standard to that provided by NHS staff in NHS facilities. It is
recognised however that there may well be examples of good practice
and that these have not been highlighted. The outcome of detailed
patient satisfaction surveys is awaited with interest.
It is unfortunate that College lead representatives
have encountered difficulty in identifying those involved at the
local level with the Joint Service Review (JSR) process.
In this context the College welcomes the establishment
of a Clinical Reference Group.
12. What implications does commercial confidentiality
have for access to information and public accountability with
regard to ISTCs?
Clearly, the work of the College in assisting
the establishment of quality standards for patient care, surgical
training and continuing professional development of surgeons employed
in ISTCs has been impeded by commercial confidentiality in the
procurement process of both First Wave and Second Wave programmes.
13. What changes should the Government make
to its policy towards ISTCs in the light of experience to date?
Effect on Service in the NHS
It can be seen that First Wave of ISTCs has
had a great impact on the NHS dependent on the geographical location
of the ISTCs.
There is a significant body of evidence of ISTCs
"cherry picking" the more straightforward cases. Furthermore,
as previously stated there is increasing evidence of a relatively
high level of complications and there is no real evidence of the
ISTCs being able to provide all the necessary post operative care.
In these cases patients are referred back to the existing NHS
services.
The existing ISTCs are adversely affecting training
and skewing the case mix. Furthermore, because in the First Wave
activities were considered to be additional, no provision was
made for transfer of activity. Problems have been highlighted
in Bradford, Portsmouth and Maidenhead. There is evidence that
the movement of healthy patients with few anaesthetic complications
eg ASA grade I has had an adverse impact, increasing the number
of high risk patients with co-morbidity in the adjacent NHS hospital.
For orthopaedic patients, the number of ASA I patients has fallen
from 33% to 8% while the number of ASA III patients has risen
from 15% to 25%.
Training in ISTCs
In the first instance, the issue of training
in ISTCs had not been considered by central government as the
priority was service development/"productivity" and
the philosophy of "additionality" was a further complicating
factor.
The Department of Health had originally indicated
that training in ISTCs should be cost neutral with no impact on
the training provider. In fact it has been very difficult to manipulate
this to remain cost neutral and to identify alternative funding
streams.
Further information about the effects that ISTCs
have had on training in individual cases is available from the
College and from the Joint Committee on Higher Surgical Training.
In particular, there have been reports of the effect that ISTCs
are having in trauma and orthopaedics.
It is now implicit in discussions that training
will be taking place in the Second Wave of ISTCs. Phase 2 of the
invitation to negotiate (ITN) has been completed although there
is still debate about whether the training schedule would be applied
to all at this stage. The expectation is that training will now
take place as a result of transferred activity rather than additionality.
Mechanisms for the Set Up of ISTCs
The College has major concerns about the mechanisms
for the set up of ISTCs. The National Implementation Team no longer
exists and has been replaced by the Central Clinical Procurement
Programme (CCPP) and the Central Contract Management Unit (CCMU).
The main concern is that there is a disconnection between the
Department of Health Dept of Education and the CCPP/CCMU (ie the
implementation arm).
Furthermore, most of the work involved with
training in ISTCs has been devolved to Local Training Steering
Groups (LTSGs). The concerns here are that no one knows about
the composition and experience of these groups and there does
not seem to be any uniform structure for them. Undoubtedly there
is significant willingness locally but not always the experience
and understanding of training and education, particularly in view
of the changing environment and the introduction of Modernising
Medical Careers.
14. What criteria should be used in evaluating
the bids for the Second Wave of ISTCs?
The original guidance set down by the College
remains valid. [59]The
College is supportive of any initiative designed to improve the
access for patients to high quality surgical care and has provided
guidance for Fellows involved in assessing bids, selecting preferred
providers and determining contracts for surgical services in ISTCs.
It is anxious to ensure that careful monitoring of the skills
and capabilities of the surgical teams takes place before the
contracts begin and that arrangements are put in place to ensure
a high level of clinical governance. The College is also keen
to ensure that opportunities for training are introduced. Modular
training will be required to allow trainees to spend time in the
treatment centres working with consultants who are recognised
by the College as trainers.
However, there is increasing anxiety that the
geographical location of some facilities within the Second Wave
may have increasing deleterious effects as a result of inaccurate
or unbalanced projections. NHS Treatment Centres benefit from
being able to separate the elective from the emergency work thus
avoiding the cancellation of routine elective work.
15. What factors have been and should be
taken into account when deciding the location of ISTCs?
Unfortunately commercial confidentiality has
clouded information shared with the Royal Colleges and their representatives
on this issue.
Reference to this was made in the provision
of evidence by the College to the recent Gateway Review of ISTCs.
Second Wave ISTCs are best located in private hospitals which
are readily accessible to consultants in neighbouring NHS hospitals.
16. How many ISTCs should there be?
The College has consistently stated that the
underlying concept of ISTCs lacks long term consistency and that
it favoured a progressive advance in the development of NHS facilities
underpinned by high quality as initially set out at the commencement
of the current government administration during 1997 in The
New NHS: Modern Dependable. [60]An
enhanced NHS Treatment Centre programme would in the view of the
College have rendered the ISTC project redundant. Consideration
should be given to expanding the number of NHS Treatment Centres.
BACKGROUND
17. The RCSEng welcomes any initiative to
enhance the quality, safety and additional provision of surgical
care for patients in line with the stated aims for the National
Health Service in the introductions by the Prime Minister in The
New NHS: Modern Dependable and The NHS Plan: a plan for
investment, a plan for reform [61]
and by a former Secretary of State for Health in A First Class
Service: Quality in the new NHS. [62]Indeed
the clearly stated intentions to "replace the former internal
market with integrated care" and to provide "fair, prompt
access to modern and dependable treatment delivered with courtesy
and a real understanding of patients fears and worries" were
laudable.
18. Clearly the stated intentions for the
provision of additional staff and facilities and for the reduction
within a limited timeframe of waiting times for treatment as extra
staff were recruited were ambitious and it was evident that the
targets were unlikely to be met. It was therefore with this background
that further initiatives were introduced including:
— Extending Choice [63]
in which patients were able be treated in a wider range of NHS
facilities, private facilities or abroad.
— An International recruitment campaign
with a programme of International Fellowships and recruitment
from targeted nations including Spain and Germany.
— Overseas Clinical Teams [64]
a scheme in which clinical teams from France, Germany, Belgium,
South Africa, Spain and Scandinavia were introduced into NHS hospitals
in England.
— Growing Capacity; a new role for
external healthcare providers in England [65]
which set the foundation for the establishment of Independent
Diagnosis and Treatment Centres.
19. The College had been aware of the introduction
sometimes covertly of overseas surgical teams into NHS hospitals
and had concerns that basic standards of clinical governance,
Good Medical Practice [66]
and Good Surgical Practice [67]
were being transgressed. Indeed, following an emergency meeting
convened by the President with officials of the Department of
Health, an agreed set of guidance [68]
was published. This was subsequently reiterated in the RCSEng
response to a consultation exercise Overseas Clinical Teams:
Code of Practice and Guidance. [69]
20. The responsibilities of the College
are to:
— set and help to maintain the highest
standards of surgical practice and patient care;
— develop the potential of the profession
by education, training and research;
— provide strong leadership and support
in all matters relating to practise throughout a practitioner's
career; and
— ensure that patient needs are at
the centre of all activities.
21. Set against this background, the College
from the earliest stages has consistently stated that, while it
welcomes additional investment in the NHS generally, it does not
support the employment of an overseas workforce of this type,
preferring investment to be made in the infrastructure for surgical
resources required for the sustained benefit of NHS patients.
[70]
22. With the continued introduction of a
programme of Independent Sector Treatment Centres (ISTCs), formerly
Independent Sector Diagnosis and Treatment Centres, the College
set down recommendations for the training, qualifications and
experience of surgeons to be employed as well as for their standards
of practice. [71]
23. In addition, from the outset the RCSEng
has repeatedly raised concerns about the consequential effects
of the introduction of ISTCs, for example:
— The loss of training for the next
generation of surgeons as patients are transferred out of NHS
units.
— The effects of "cherry picking"
of patients with low co-morbidity (ASA I).
— The balance between elective and
emergency care provided by NHS hospitals in the locality—any
shift of elective work increases the percentage of emergency work
done. General surgery and trauma and orthopaedics, emergencies
make up 50% of the total work done. Increasing the percentage
of emergency is likely to place more stress on the staff in these
hospitals.
— Arrangements for the management of
complications and the provision of secure follow-up and continuity
for patients.
— The risk of destabilisation of local
NHS healthcare provision with the introduction of Payment by
Results. [72]
24. It is clear that the initial concerns
raised had significant foundation and that the realities have
come to light in that the political pressure to advance the ISTCs
programme is having an adverse effect on existing NHS services
and on surgical training as well as on planned developments, even
though they have so far treated a relatively low number of patients
(we understand around 16,000) in contrast we believe to over 106,000
by the generally well integrated NHS Treatment Centres. It was
indeed unfortunate that in Treatment Centres: Delivering Faster,
Quality Care and Choice for NHS Patients [73]
a statement by the former Secretary of State for Health inferred
that ISTCs operate far more efficiently than units in NHS hospitals.
25. Although it has been agreed that surgical
training will be encouraged in the ISTCs, there are still a number
of hurdles to be overcome and there is, to the knowledge of the
College, only a single example of a pilot scheme for surgical
training so far with further programmes unlikely to be implemented
before 2007. However, the College was heartened to note the announcement
of five NHS centres as leaders in the field of innovation and
training in short stay elective care with funding of £1.5
million per year for the next three years. [74]It
is anticipated that they will act as models of good practice in
day surgery and short stay elective care and we welcome this.
26. Although the initial stated intention
was that ISTCs would be sited in areas where the gap between waiting
times and targets was greatest, it is understood that an orthopaedic
unit in a major university teaching hospital with a track record
of well controlled waiting lists has lost at least 50% (2,000
patients) of its elective work with resulting closure of a ward.
In addition, ophthalmological surgeons have reported patients
transferred to ISTCs with the consequence that finance has been
identified for only one-third of 30 planned new consultant appointments.
27. The College is also aware that at least
two ISTC orthopaedic programmes have not attracted the predicted
number of patients under the Choice [75]
initiative and that PCTs are concerned that the planned surgical
procedures for which they have paid £2 million in advance
are not being carried out. General practitioners have also confirmed
that patients are being selectively transferred ("cherry-picked")
although the company operating one of the centres has pointed
out that it was contracted to undertake elective cases on a fast-track
basis.
28. The College has also been very concerned
to hear reports of complications in patients treated in a number
of ISTCs with poor arrangements for their management. Although
stringent clinical governance measures must be put in place by
the contracted providers, we remain anxious that the monitoring
of these currently leaves much to be desired as does compliance
with clinical audit. Furthermore interim arrangements with two
independent providers under the G Supp 1 contracts are
even less well controlled as they largely fall outside the control
and principles set down by the National Implementation Team (Central
Contract Purchasing Unit and Central Contract Management Unit).
Clearly therefore there is much to do to try to ensure that the
quality of care and safety of patients as well as the training
of tomorrow's surgeons is preserved.
The Royal College of Surgeons of England: A
way forward:
— The College would like to see central
guidance provided to the Local Training Steering Groups and would
welcome the opportunity to assist in this process.
— The College wishes to see a central
position on education and training in the IS which should come
from the Department of Health. Common principles should be devised
at a national level. Again the College would like to contribute.
— The College calls for greater awareness
at the NIT/CCPU of issues surrounding training in particular the
impact of training on service delivery.
— The College would like to see a link
between the Department of Health Dept of Education and the NIT/CCPU.
— The College welcomes the establishment
of a Clinical Reference Group in view of the difficulties that
the College has found in identifying those involved at the local
level with the Joint Service Review (JSR) process.
— While the College understands that
the NHS does not currently see NHS DTCs as a way forward, the
College would like still to commend the model offered by the NHS
DTCs. This model provides an effective means for the separation
of elective from emergency work on the same site.
Bernard Ribeiro CBE
President
The Royal College of Surgeons of England
14 February 2006
56 Growing Capacity: a New Role for External Healthcare
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on reform. Department of Health. April 2002. Back
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Independent Sector Diagnostic and Treatment Centres. New Provider
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and Treatment Centres, Royal College of Surgeons of England.
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61
The NHS Plan: A plan for investment A plan for reform.
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63
Extending Choice. Department of Health: London; 2001. Back
64
Overseas Clinical Teams. Department of Health. 2002. Back
65
Growing Capacity: a New Role for External Healthcare Providers
in England. Department of Health: London; June 2002. Back
66
Good Medical Practice. General Medical Council. 2001. Back
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in England. Department of Health: London; June 2002. Back
69
Overseas visiting surgical teams, Royal College of Surgeons
of England July 2002. Back
70
Ibid, and Overseas Clinical Teams: Code of Practice
and Guidance: Consultation Exercise. Response by the Royal
College of Surgeons of England. May 2004. Back
71
Independent Sector Diagnostic and Treatment Centres. New Provider
Surgical Services: ISDTCs. A Royal College of Surgeons of
England Position Paper, June 2003, Independent Sector Diagnosis
and Treatment Centres, Royal College of Surgeons of England.
July 2003. Back
72
Implementing Payment by Results: Technical Guidance 2006-07.
Department of Health. January 2006. Back
73
Treatment Centres: Delivering Faster, Quality Care and Choice
for NHS Patients. Department of Health. January 2005. Back
74
Flagship NHS surgical centres lead the way in innovation and
excellence. Department of Health. December 2004. Back
75
Choice, Responsiveness and Equity. Response by the Royal
College of Surgeons of England Patient Liaison Group. March 2004. Back
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