House of Commons - Health - Written Evidence

Select Committee on Health Written Evidence

Evidence submitted by UNISON (ISTC 42)

1 INTRODUCTION

1.1 UNISON is the largest trade union in the UK, with 1.3 million members. We have 450,000 members working within the health service and across the whole range of healthcare provision. We have been instrumental in helping to develop health policy and are pleased to have the opportunity of submitting evidence to the select committee on Independent Sector Treatment Centres (ISTCs).

1.2 As the largest trade union and the voice of the healthcare team, we are instrumental in influencing policy at regional, national and international level. We work with Government and other international unions to shape healthcare. UNISON has a long history of working with a range of stakeholders and members to develop education pathways and frameworks, which meet the career aspirations of all health workers, we hope that some of our expertise will aid the Committee's deliberations.

1.3 We have sought to work in partnership with a number of other organisations in sharing views and concerns relating to the current provision of ISTC's. We work closely and effectively with a number of trade unions and professional associations including the British Medical Association. Since the introduction of ISTC's we have sought to work in partnership with the Department of Health on a range of issues but paying particular attention to the human resources agenda.

1.4 We hope that the Committee will take into account the weight of UNISON's views and evidence as a major stakeholder. We would also wish to put on record our appreciation for the extension to the submission; this enabled us to take a strategic analysis of our evidence. We are grateful for the Committee's support in this.

1.5 The Committee in gathering its evidence has posed a series of questions, whilst we have tried to cover all of them, UNISON has particular expertise in a number of areas and we have sought to cover these in as much detail as possible.

2 EXECUTIVE SUMMARY

2.1 UNISON has serious concerns regarding the continued use of the private sector in the development of ISTCs, the NHS has additional capacity which could be and is being used reduce the waiting lists. What they lack is the funding, as this is currently being handed over to the private sector.

2.2 Looking at Government documents, almost £5 billion will be handed over to the private sector over the next five years. In wave one we have seen Primary Care Trusts financially compromised, as ISTCs have had to be paid in full irrespective of contract delivery.

2.3 UNISON firmly believes that the financial pressures that the ISTCs will place on the NHS, will inevitably lead to local services being cut or closed. Particularly in light of the current primary care re-configuration it will be difficult to bring back services once they are lost to the NHS and thus furthering the fragmentation of the service and widening the marketisation agenda.

2.4 Whilst UNISON understands that there may be issues of commercial sensitivity, we believe that these are being applied too vigorously and seriously impacting on local accountability and public scrutiny.

2.5 The innovation and expertise in training and development of staff that the NHS provides will be lost as currently, despite the claims, ISTCs are not held to the same standards as the NHS. The weakening of the additionality clause in effect means that we will be relying on the "goodwill" of the private sector not to poach NHS staff whole scale. It has long been recognised that the NHS's most valuable commodity is its staff, what future it might have if they are lost or enticed from it.

3 BACKGROUND

3.1 UNISON has not opposed the separating of elective and complex surgery by using specialists treatment centres in the attempts to reduce waiting times, but did express concerns over the impact of these centres on the existing NHS resources. [76]Indeed it became common practice since the introduction of waiting list targets for NHS organisations to be provided with additional funding in the final quarter of the financial year to clear the 48 month and 18 month patient waiting times. This coupled with other measures had already started to make a significant impact on the surgical waiting lists. However, the plurality of provision in this untested manner is alarming, the government did not consult on the establishment of independent ISTCs and a there has been no research to assess whether this should be the direction of travel. [77]

3.2 UNISON has not been ideologically opposed to Treatment Centres—our opposition has been in the provision, with large amounts of work being handed over to the private sector without assessing the true long term impact on the NHS, its patients, staff and the viability of future service. UNISON is particularly concerned that, due to the lack of evidence based on vigorous audit it is impossible to properly assess the quality of service or ensure new providers offer value for money. No comparison has ever been drawn from the 36 NHS Treatment Centres.

3.3 UNISON represents health workers who currently work within ISTCs, we have been actively involved at a local level in the contractual negotiations in a number of the wave one sites. We have recruited new members within ISTC's by working with them to resolve issues. We have national and local recognition agreements with a number of organisations and have actively sought to assist in the process. We have been working very closely with a number of members working for one ISTC provider after they expressed concern about patient safety and questioned a range of employment practices. We are currently seeking a ministerial meeting with Lord Warner and have drawn these concerns to the attention of the regulators. [78]

4. What is the main function of ISTCs?

4.1 ISTCs were originally announced by the Prime Minister on the 30 July 2003 and were introduced to provide additional capacity for the NHS [79] to reduce the existing waiting times. However, many NHS organisations had already made significant progress on this issue by looking at the patient journey and planning more effectively manageable surgical lists. Previously the Government had sought to use the private sector to reduce the waiting lists, but while this proved popular with the sector, the irony was that many patients were operated on by the same team including NHS staff, the location simply becoming geographic. If the argument of additional capacity was a key driver, it is surprising that a full assessment was never made to assess the true requirement of the NHS to clearly identify what they could provide and where. This would have given an emerging picture, to enable additional capacity to be sought, where necessary.

4.2 In the recent adjournment debate in the Houses of Parliament Kevan Jones, MP for North Durham, [80]cited a letter that he had received from the Chief Executive of University Hospital North Durham in which he stated "The MRI scanner at University Hospital North Durham is considerably under employed and had been for some time, and it is the case that had the "Alliance Medical" money been direct to us, at the University Hospital North Durham we would have been able to put on a large number of scanning clinics, which would have almost eliminated in total our waiting times and waiting number". He went on to say, "It was a disappointment for us when the Department of Health said that providing individual hospitals with additional resources was not an option, the additional resources had to be made available to the private sector." Considering this example it is difficult to see how, in this case, the system provided value for money for the health service, or reflected the needs and capacity of the local NHS trusts.

4.3 Elective surgery is easier to manage as there are predicable levels and the ability to assess and choose cases. However, this also increases the burden on the NHS, who undertake the more complex procedures or care for patients with other underlying medical conditions. [81]In addition ISTCs do not have to compete with increasing demands and unpredictable admissions, for example it is highly possible that the admission of a complex road traffic accident needing surgical intervention, could impact in a number of ways. They could, for example, need lengthy theatre time, more than one surgical team could be involved or perhaps they may need an ITU bed. The NHS is used to dealing with these competing demands and prioritise accordingly, hence we have seen the increased use of day surgical units, five day surgical wards, a dedicated emergency theatre available 24/7 and innovation in home care.

4.4 UNISON would seriously question the introduction of phase two sites as there is no analysis to demonstrate that wave one has been any more effective than the NHS. Indeed we would strongly argue that they do not provide value for money. In the future patient choice will become an old catch phrase, the reality is that patients would, we firmly believe, choose to have the surgical procedure performed at their local hospital. UNISON contends that the future of ISTCs is about a sustainable market for the private sector and not what is in the best interests of patients or the public purse. The NHS will achieve an 18 week waiting time if it were not for a Governmental push requiring PCTs to contract from ISTCs. What future would ISTCs and their shareholders have when waiting lists become a historical fact?

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

5.1 UNISON has seen little evidence to clearly demonstrate that ISTCs have effectively contributed to the reduction in NHS waiting lists. Indeed a number of wave one sites are still not operational. While they have been heralded by the Department of Health, many have questioned the statistical examples given in Ophthalmology services. In a letter to Hospital Doctor magazine Mr Simon Kelly consultant ophthalmic surgeon, stated, "it is the efforts of NHS ophthalmology teams who perform over 300,000 cataract operations annually in England that have brought down cataract waiting times". [82]

5.2 It has been stated that ISTCs are discharging hip replacements earlier than the NHS as a result of their innovative practice. Most NHS organisations, including NHS treatment centres have moved to or are moving towards a four-five day discharge approach. Within the NHS this has been developed for a variety of procedures using a patient care pathway approach (PCP). The NHS has developed a multidisciplinary approach to their design, which commences with the surgical assessment. At this stage patients are referred to a community team who can assess the patient at home and identify what additional care or resources they may need. This coupled with improved communications, often means that on the day a patient is discharged their equipment is either already there or being delivered. A single document used by all members of the team caring for the patient ensures a consistent and seamless approach to care.

5.3 We have received complaints from staff in one ISTC provider who stated that medical instructions not to discharge a patient have been overridden by others; 78; this was cited in the case of a post-operative patient following a hip replacement whose wound was oozing. A patient presenting with this would be at risk of infection and we would argue that in the NHS this particular patient would not have been discharged.

5.4 A number of the current ISTC providers are replacing NHS provision, but we cannot assume that this is improving overall capacity in the NHS. Indeed a number of PCTs have come under increasing pressure to commission services from an ISTC irrespective of their local circumstances. A PCT in Oxford had very early misgivings when first made aware of the planned initiatives in January 2003 and the lack of transparent information surrounding ISTCs. The board members expressed concern and consistently opposed the contract as they did not believe it was in the interests of the local population. They argued that waiting lists were being met by the local NHS and that they had been awarded Beacon status for excellence and also had additional capacity in the NHS. [83]

5.5 Innovation has been best developed where it is complimented by research and teaching and has often evolved through service development. However we could not identify any specific innovative practice which had been developed as a direct result of ISTCs.

5.6 UNISON acknowledged early on the role that diagnostic treatment centres and subsequently NHS ISTCs could have in service delivery within elective work. However we strongly argue that there is little long term justification for the extension of this within the private sector.

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

6.1 Only a small number of the wave one ISTCs are currently operational, so we believe it is difficult to assess what impact they have made on the reduction of waiting lists. The situation is even more complex as there are no mechanisms to identify lists which have altered as a result of the numerous other NHS initiatives to tackle this challenging issue. However, we believe that improvements in the way the NHS manages surgical cases, the establishment of waiting list targets, role re-design and the modernisation agenda have contributed more effectively to delivering the current reduction than the ISTCs.

6.2 The question must also be seen in the context of patient safety and standards of care, 70 NHS patients had to be returned to theatre after having orthopaedic surgery at treatment centres run by Partnership Health. In 15 months 70 patients had to go back into theatre—more than 2% of the 3,253 patients treated, compared with the five other providers measured who reported between 0-0.4% of patients returning. [84]

6.3 Staff working in outpatients for Partnership Healthcare report being expected to care for 50 patients while undertaking the preadmission procedures. While UNISON has fully supported the modernisation agenda we are deeply concerned that some staff have been observed with stop watches. A significant number of patients presenting for elective orthopaedic replacements are elderly. It is impossible to say that every patient will only take 10-15 minutes to complete their assessment. Every patient should be treated equally and to ensure that this can be done, each must have their own needs taken into account and have sufficient time for their questions and fears to be addressed.

6.4 Elsewhere in the evidence we have presented examples of where capacity has not been additional but has utilised the spare capacity that the NHS already has. At Middlesbrough, Kidderminster, Tyne and Wear, and Oxford the patient numbers that the ISTCs have treated would have been manageable within the NHS and without the huge sums of money that are paid to the private provider.

7. Are ISTCs providing value for money?

7.1 Along with the additional capacity that the ISTC programme was supposed to provide to the NHS the added claims that they would provide value for money was another attraction highlighted by supporters. However, among the initial concerns expressed one of the main areas of contention was the cost of private sector involvement and the effects on the NHS having to pick up the bill. The contract signed by 28 PCTs in Trent and South Yorkshire for the services of Partnership Health Group Limited (PHG) at both its interim sites at Bassetlaw and Ilkeston and then its purpose-built £7.5 million site at Barlborough felt a huge financial burden in its first year of contract. The value of which for 2004-05 was £13.4 million with the actual uptake being worth £10.1 million. This shows a loss of £3.3 million for operations that PHG never performed. Nottingham City PCT was one of the biggest losers to the tune of £800,000. Additional documents obtained by a local newspaper revealed the government made £5 million available to local health authorities to offset losses and encourage more use of the centre and GPs were being asked to "cold call" patients on waiting lists. [85]

7.2 At a meeting of the Maidstone & Tunbridge Wells NHS Trust Board, their Chief Executive, commenting on their ISTC project, said "The ISTC has been reviewed. The project is now costing at 125% of National Tariff|This means that £3.1 million is likely to be released to the Trust this financial year. Locally there will still be affordability issues for the project that will have to be addressed". [86] Exactly what impact this would have on other NHS services in the area is not clearly documented.

7.3 Papers from a presentation given to Central Manchester PCT highlight the financial risk that they were facing. The paper states that "Latest figures from the contract management team suggest that the ISTC contract overall is being under utilised and if this continues then the PCT would be liable to pay under the risk sharing agreement. This is a matter of some concern to the PCT|the maximum risks that the PCT will be exposed to is £500k and the working assumption is a £250K overspend". [87] With 14 contracting PCTs signed up to the ISTC based at Trafford this figure could well be replicated as they all suffer due to poor uptake of planned activity. The private provider profits whether or not they complete scheduled numbers of operations.

7.4 As mentioned elsewhere in this evidence, Oxfordshire and the contract with Netcare has provided numerous examples of concern. A six month review [88] of the contract highlighted the financial impact on the local health economy. Netcare were contracted to provide 800 cataracts a year in North and South Oxfordshire from April 2005 for four years, South Oxfordshire was contracted to take on average 456 cataracts operations and 593 pre-operative assessments per year. The review showed that in the first six months of the contract despite only £40k of work being carried out, Netcare were paid £255k and the contract honoured irrespective of the volume of completed activity. The review concluded that the population commonly requiring cataract surgery is elderly and Oxford Radcliffe Hospitals had such a strong reputation and short waiting lists that local people preferred the NHS to the new ISTC. This merely echoed previous concerns expressed by local PCTs when assessing the accountability to local people and the cost of the scheme that the NHS would have to bear.

7.5 The Cobalt ISTC on North Tyneside, run by Capio Healthcare UK, has a contract value that is worth £6.5 million to provide 2,000 day-case procedures a year for five years, including minor skin procedures, endoscopies and surgery for hernias and varicose veins. Yet over the first three months of the contract most referrals were made for minor skin procedures such as epidermal cysts. Tyne and Wear GP Dr Sam Misherki was quoted as saying "The whole thing is a farce. They gave a five-year contract that wasn't even needed. Certainly for minor surgery we would not refer. Almost every GP is capable of doing that. It is ironic that, at some stage, there were thoughts of training non-medical staff to carry out less complex surgical procedures to cut the costs, and here we find taxpayers' money is being spent to pay a private clinic that employs a consultant surgeon to do epidermal cysts". [89]

7.6 When assessing the contract values of other schemes and comparing them with examples already given, it is clear that there is alarming potential for contracting PCTs, particularly those already in debt, to face financial meltdown and be forced to utilise ISTCs at the expense of the NHS. Worrying figures of contract values that could present problems include the following: Burton-upon-Trent—Nations Healthcare Limited—contract value £77 million, North West—Interhealth Canada—contract value £146 million, Halton—Nuffield—contract value £120 million, Kidderminster—Interhealth Canada—contract value £26 million.

8. Does the operation of ISTCs have an adverse effect on NHS services in their area?

8.1 The NHS Treatment Centre at Kidderminster in Worcestershire offers a broad range of services for short stay and day cases in areas such as ophthalmology, general surgery, orthopaedics and radiology. A £14 million purpose built site that saw early success in reducing waiting lists could perform 15,000 procedures a year. Yet despite operating well below capacity (3,000 procedures in its first year) a new ISTC run by Interhealth Canada was set up within the existing NHS site to provide additional capacity that bizarrely already existed. General Manager David Evans at the time stated, "The whole issue in losing out to the private sector is that it is hard to compete on a level playing field with the independent sector". [90] Other fears that orthopaedic activity undertaken at neighbouring Evesham Hospital would be transferred to the ISTC in Kidderminster were strongly expressed, particularly as funding had already been committed for a pre-determined level of service. The effects on the local NHS services could be disastrous as activity is lost and costs increase. Also the fear of loss of services force patients to travel long distances for treatment, becomes a real factor.

8.2 It is frightening to consider what could be the long-term impact of ISTCs on the NHS. We could end up with a fragmented service, with funding being ring fenced and directed to the private sector. Department of Health figures show that wave one and phase two will cost the NHS almost five billion. It's not hard to imagine how the NHS could have utilised that funding to clear the waiting lists and how many nurses, healthcare assistants, theatre staff, surgeons and anaesthetists could be employed. There is evidence that the NHS has the capacity to deliver the agenda, what they appear to lack is the funding.

8.3 The weakening of the additionality statement will enable the private sector to actively recruit from the NHS. While some posts will be protected, large numbers will not. The ISTCs are exempt from implementing the new pay system Agenda for Change, so in effect there will be a two tier system within the health economy and also within the site itself. The additionality clause in wave one prevented ISTCs from recruiting anyone who had worked for the NHS in the last year. The statement will now only protect specific staff. Some staff may be seconded over to the ISTC, on their NHS terms and conditions, while others will be directly employed by the ISTC on varying terms and conditions and no NHS pension rights. This level of inequity will, we believe, lead to instability within the local health economy.

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

9.1 The importance of post operative care cannot be under estimated. The need for re-admission following hip replacements is a real possibility given that patients are at a higher risk of dislocation within the first 12 weeks of surgery. In the NHS multi-disciplinary discussions take place within and between teams and there is close liaison with community services for home care, often starting months before surgery with a home assessment.

9.2 Re-admissions following surgery are often an emergency, so patients would normally be taken to their nearest A&E department. The only data that we have been able to source on the subject of re-admission was published by the National Centre for Health Outcomes Development on 11 November 2005. The report appeared to identify a higher rate of re-admission for patients who had been operated on within PHG. [91]

9.3 As a result of commercial sensitivity we cannot ascertain the number of complications or critical incidents which have occurred within ISTCs as they are not required to report incidents to the National Patient Agency (NPA) While they are expected to have governance arrangements in place we have not been able to examine them. So we cannot assess whether they are sufficiently robust to protect patient safety, nor can we compare their management to that of the NHS. The NHS uses a multi-disciplinary process to locally assess all adverse clinical incidents and are required to document and investigate where appropriate to ensure that all possible lessons are learnt to prevent, where possible, the same thing happening again.

9.4 ISTCs will have the indemnity protection of the NHS under the clinical negligence systems so are expected to comply with appropriate risk management. They are not however, required to share any information about their systems.

9.5 The loss of critical skills as a result of the elective/complex split could mean that staff will become deskilled. We have yet to see evidence that training systems are in place at a vigorous standard in order to avoid this. We have seen cases within the private sector of patients being transferred back to the NHS as they were too ill to be cared for within that sector.

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

10.1 The importance of training and development that the ISTCs should be required to provide in the ways the NHS does is highlighted by the orthopaedic case mix at Southampton University Hospitals NHS Trust (SUHNT). This is too skewed to meet training needs because the healthiest patients are going to an ISTC. This leaves future doctors' training and service in turmoil, unless contracts between PCTs and private providers are renegotiated. In fact the Chief Executive of SUHNT, Mark Hackett, asked the specialist advisory committee (SAC) in orthopaedics to visit Southampton because he was so concerned at the situation. Since the ISTC run by Capio opened, the trust has treated 25% fewer healthy patients (ASA grade 1) and 10% more complex (ASA grade 3) patients. The SAC report ordered the contract be "reworked" and that failure to do so "would lead to the SAC advising the competent authority of the need to withdraw training".[92] Matt Freudmann, British Orthopaedic Trainees' Association Chair, said that "the rising age of the UK population is causing ever-increasing demands for orthopaedic surgery. It is vital the surgeons who will perform these operations are properly trained".

10.2 Evidence that UNISON has gathered over several months' extensive research at the ISTC in Barlborough, run by Partnership Health Group Limited (PHG) provides alarming examples of the lack of training being offered, including basic health and safety training as well as clinical training. Only a handful of staff have received training on what action to take in the event of a fire or a patient having a cardiac arrest. In the NHS this would be considered mandatory and every member of staff is expected to have annual training on this. One member of staff who was also a fire bleep holder described an event where the alarm had gone off but noone, including them, knew what to do. Another member of staff received an electric shock from trailing cables which highlights a level of neglect from the private provider. Staff have had little or no training in the use of equipment, some staff have been expected to work as anaesthetic assistants, where their roles included checking the anaesthetic machine, preparing anaesthetic agents, assisting in intubation of patients for their procedures and positioning the patient appropriately without having received any specific training. In the UK this is recommended as a highly specialised role. The recommended standard, which is supported by the Royal College of Anaesthetists, is that staff should have either a post basic anaesthetic qualification or have studied for a course in surgery and anaesthesia such as Operating Department Practice.

10.3 Lack of fundamental training in health and safety, fire and resuscitation has resulted in incidents unacceptable in the NHS. In conjunction with this there is poor access to courses and no set pattern for developmental reviews. More worryingly is where staff have been asked to work within anaesthetics and were doing so without either proper training or supervision.

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

11.1 The standard of care that the ISTCs offer is meant to be measured by the high clinical standards that the NHS is governed by. UNISON has, during the course of research into experiences from wave 1 sites, uncovered specific examples where the level of care offered by certain ISTC providers has been significantly lower than their contracts. One reason highlighted early on was the fact that there was no requirement for a private provider to be registered with the regulatory watchdogs of the NHS. A private clinic that carried out thousands of cataract operations for the NHS was one such provider not registered with the Healthcare Commission. Levent Clinics, which performed around 4,000 cataract operations in Nottingham and Derbyshire in 2003-04, was in fact never registered and openly admitted that they were not required to do so. A Trent Strategic Health Authority (SHA) spokesperson talked of "extensive advice" taken from the Department of Health and assurance given that they could operate without having to be registered. This must surely be a minimum requirement in ensuring that the private sector meets the same standards as the NHS. Local opthalmologists highlighted concern with both the Commission and the Royal College of Opthalmologists over patients with co-morbidity whose cataracts were treated by Levent. Patients with problems such as glaucoma were allegedly released following operations without onward referral for treatment and the NHS was left with the more costly follow up treatment.

11.2 The issues that we have presented from evidence at Barlborough, run by Partnership Health Group Limited (PHG), have covered virtually the whole range of concerns that UNISON has with the ISTC programme. We have sought on several occasions to raise these issues with PHG, but sadly they have declined at every stage. We also raised the issue of trade union recognition, as a means of using our expertise to resolve some of the clinical issues that staff were concerned about in partnership, every positive step we sought to take has been resisted. Our concerns included examples of swab count policies (routine for the NHS) not being included in existing clinical policies and procedures and thus not followed. We believe that this has resulted in serious breaches of the clinical governance. One case in particular was where a pin was left in place following an operation and this was missed at the swab and post operative assessment meaning either no x-ray was taken, or if it was, it was incorrectly cleared. This was only diagnosed when the patient presented to their GP in pain and the pin was felt upon examination. [93]In the NHS three swab counts are taken, (close of cavity, muscle and skin) all equipment, pins, needles and swabs used are counted by two persons and the accuracy of the count would be reported to the surgeon. Following all joint replacements xrays are taken post operatively to check the position of the prosthesis and to assess the surgery, this is checked and assessed by a competent person.

12. What implications does commercial confidentiality have for access to Information and public accountability with regard to ISTCs?

12.1 Public accountability and access to information is vital to encourage local scrutiny in any area of the public and private sector. Many of the private providers claim high rates of patient satisfaction and operational success rates yet this information has proved impossible to obtain. A recent Freedom of Information (FOI) request to Nottingham City PCT revealed that the commercial interests of the private provider are placed before the public interest. When asked to provide a list of the number of recorded complaints at the local ISTC and audit figures to show how patient satisfaction rates were constructed and measured, both were refused on the grounds that, "This information is withheld as likely to prejudice the commercial interests of the provider under Section 43 (2) of the Act|In assessing the balance of public interest, it is important to be able to compare these to audit figures for other units of a similar nature. As these are not available it is not considered in the public interest to release them".[94] Therefore, the private provider can publicise approval rates of 97%, as Partnership Health Group Limited have done, and yet not have to justify this in the interests of commercial sensitivity.

12.2 The government and the previous Secretary of State, John Reid MP, consistently provided assurances that the final decision over the acceptance of an ISTC contract lay with the PCTs and their respective boards. [95]As the case in Oxfordshire concerning the Netcare contract highlights, this method of accountability and scrutiny was completely bypassed. Decisions made at local level by South West Oxfordshire PCT and Cherwell Vale PCT in opposition to the contract was based on the belief that it was not deemed beneficial for the local population. The local NHS trust, Oxford Radcliffe Hospitals, was already meeting its waiting list targets and the proposed ISTC seriously risked undermining the quality of training and therefore in the long term, the standard of clinical expertise. The fragmentation of local services and the financial pressures on the PCTs were also cited. The decision to approve the contract came after months of constant pressure at SHA and government level with members of the respective PCT boards even being removed from office to secure a positive vote. Accountability to the local people was taken out of the hands of the PCTs and despite the opaque business case that was put before them the five year contract was approved.

12.3 The ability to scrutinise the role of the private sector and in particular the private providers, from contract details to patient satisfaction rates, is not only a real worry but grounded in fact when looking at another area of the government's modernisation agenda. Foundation Trusts in their autonomy have frequently declined to provide information, hiding behind their new-found independence from the rest of the NHS. This lack of accountability will prevail with the ISTCs for as long their business interests are protected.

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

13.1 We believe that information is too limited at the moment to asses any impact that ISTCs may have had on NHS waiting lists. However, we would contend that Phase two of the ISTC programme should be halted until such time as a full assessment has been undertaken, the scope of which should include governance, patient safety and whether they are delivering value for money.

13.2 We recognise that patients want a faster and more responsive service, we also believe that they do not wish to travel 40 miles to receive this treatment if they can access it locally. The NHS has already done so much to improve services; health workers have always, and will continue to deliver, high standards of care. Unless we make a true measure of need we cannot assess capacity or demand effectively, we are rather playing with figures and, in our opinion, wasting public money by handing millions over to the private sector.

13.3 We believe that the current ISTC programmes will undermine the future of the NHS and this, coupled with the current financial situation within the service, makes a worrying picture. There is a real risk to the NHS and local services; an example of this exists in the Brighton ISTC. Our members there have reported fears from staff regarding the future of the Princess Alice site at Haywards Heath. At this ISTC Mercury have been commissioned in Wave one to provide elective orthopaedic surgery, complex cases will be undertaken at Brighton University Hospital. However, questions now appear to have emerged regarding whether they need to retain an ITU at the Princes Alice site. If ITU goes in the future, the site will not be able to receive certain cases as they would not have the capacity to care for them. The staff remain concerned that as a result of the ISTC centre being on the site, coupled with the £18 million overspend their future could be bleak. The cost of this ISTC could wipe out the Trust's current deficit.

13.4 No real assessment has been made of the possible long term risks of ISTCs on the remaining health economy. What we can be sure of is that, without the long term commitment that the government is giving to the private sector, we would not have ISTCs. Where else would we find an organisation that was paid irrespective of what work it undertook? What incentive does this give any organisation to deliver on targets? We can hardly argue a level playing field when NHS trusts who fail to meet government targets are labelled as poorly performing and those ISTCs who do not meet the case numbers are still paid and heralded as reducing NHS patient waits.

13.5 The use of commercial sensitivity affects all parties' ability to assess the full picture and scope of ISTCs and undermines the level of accountability that we should all be held to. [96]How are we to make informed decisions if we cannot effectively question organisations and systems? While we recognise that there may be issues with commercial sensitivity, it appears to currently cover even the most bizarre elements, such as how many cases an organisation is contracted to perform and how many they have done. If the objective of ISTCs was to reduce the waiting lists, surely this information should be transparent to ensure it delivers on its objective.

14. What criteria should be used in evaluating the bids for the second wave of ISTCs?

14.1 There is a need for a real debate on the use of ISTCs. A clear criteria from the outset was capacity, however we can find little evidence that the schemes we have looked at have added capacity. In the main they are taking over existing areas of work and not increasing capacity at all. This will impact on the future of the local economy.

14.2 Currently the government requires work to be commissioned from ISTCs up to a maximum of 15%, however this does not appear to be monitored, so how will they prevent more than 15% being commissioned? As there is no partnership involved in the selection process we believe that there is also no transparency. While the trade unions have been involved in some of the human resource discussions, we have been denied access to commercially sensitive information in the same manner as everyone else.

14.3 The Department of Health has, in a number of documents, stressed the need to ensure effective governance and training. The NHS treatment centres appear to be integrated into the local health economy and work effectively in partnership. The orthopaedic centre in South West London has been highlighted by staff as having excellent nurse/clinical leadership. However, despite contributing to the waiting list work, it is threatened with being handed over to the private sector.

14.4 We believe that the evaluation of bids must start at a much earlier stage with local consultation and discussion on their appropriateness. This would allow the local area to assess, in a much more informed manner, what is required and whether they have the capacity to deliver it. We would wish to see NHS centres considered first and we can clearly see the merit in exploring different ways of delivering healthcare. However, we would argue that these ways should be seamless, local, affordable and deliver high standards of care.

14.5 A number of other factors should also be taken in to account and the local service should be able to judge each and ever bid in a consistent transparent manner. We would wish to see trade unions and professional organisations involved at all levels, as they are with other contracts. Governance must be more vigorously tested, it is not good enough for an organisation to state that they will have systems in place, they must demonstrate that they are and must be consistent with the NHS system. Organisation must be able to stand up to scrutiny.

14.6 We would also wish to see the following included in any evaluation:

— closer working relations as part of the local healthcare unit;

— commitment to Agenda for Change;

— value for money;

— delivering additional capacity not replacing existing services;

— training, in a consistent manner;

— regulation;

— local and national workforce planning;

— compliance with clinical governance frameworks;

— transparency at all levels of the process;

— accountability;

— future partnership working with trade unions;

— trade union recognition.

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

15.1 There has been a cloud of secrecy surrounding the selection of wave one sites and this continues with the process for phase two. We do not know who the short listed bidders are, we cannot therefore judge their ability to work effectively within the NHS nor their ability to deliver the contract on time. There will continue to be little or no accountability to stakeholders as they are not required to publish statistics in the same manner as the NHS and will, we believe, continue to use commercial sensitivity and their independence as a means to keep information private.

15.2 We have found it alarming that no review or comparison of NHS centres has been undertaken to assess what additional capacity they may have or whether they can provide more services. Without this information we cannot assess what, if any, involvement the private sector may need to provide.

15.3 There is no logic in a patient having to travel 50 miles for a scan when the local hospital, the University of Durham, has one available but not funded. We have already seen NHS hospitals closing wards because of transferred activity to the ISTCs and this is only from the few ISTCs currently operational in wave one. If this pattern were to continue, the impact of phase two could be catastrophic.

16. How many ISTCs should there be?

16.1 UNISON believes that the money which is currently being handed over to the private sector could be better spent enabling the NHS to increase its capacity. UNISON is not opposed to the role that treatment centres could play, however if they are to be truly effective and deliver not just on waiting lists, but on the modernisation agenda, they must be retained by the local NHS services. The local NHS should have greater control over what is required within the local health economy.

17. CONCLUSIONS

17.1 The ISTC programme was originally designed to provide additional capacity to the NHS and drive down waiting lists while offering patient choice. However, the creation of the market within the NHS has had the opposite effect.

17.2 Patients are treated as consumers and in cases highlighted earlier, the ISTC becomes a conveyor belt treating these consumers. Patient care, particularly around complications, takes second place to maximising profit. The market itself requires competition and as the Department of Health's own independently commissioned Sustainability Analysis stated, three or four big companies are needed to create and control the market to allow the private sector to survive in the public sector domain. It also states that the market has to be big enough and robust enough to maintain this market which will no doubt raise questions over Lord Warner's assertion that ". . .I guarantee that by 2008 the independent sector will not account for more than 10% of NHS work. . ." [97]

Due to the nature of this market no one organisation will develop an overview of understanding of what the local community needs.

17.3 UNISON believes that ISTCs ultimately fail because:

— the private sector failing to deliver the required standards;

— abuse of monopoly power;

— unequal distribution of information;

— resorting to maximising profits first;

— they do not stand up to public scrutiny;

— we do not believe that they deliver value for money, any NHS organisation with empty theatres and scanners cannot be justified;

— we have seen little evidence of training and development in the ISTC s wave one sites;

— ISTCs are cherry picking the cases, this leaves the NHS with the more complicated cases but without receiving any additional funding to cover this patient mix.

17.4 The evidence in wave 1 is still being assessed and evaluated. The relaxation of the "Additionality Clause" that previously prevented anyone who had worked in the NHS within the last six months from working in an ISTC presents further problems and risks adding to the fragmentation of the NHS.

17.5 The research so far has shown that ISTCs do not provide value for money, but instead place further strain on already demanding PCT budgets. Local decision making and accountability is threatened with PCTs being forced to sign up to potentially damaging contracts that are under utilised and sometimes in places where the NHS has spare capacity itself.

17.6 Workforce issues (including lack of training and development of staff) and patient care are being threatened by autocratic management who refuse to work closely with other stakeholders, including trade unions, and wilfully protest about "partnership working". The government mantra of patient choice and value for money are overridden by serious doubts about any choice at all, particularly where GPs are incentivised to send patients to the ISTC. As for cost, there is a real risk of the ISTC programme becoming the white elephant of the NHS.

UNISON

13 February 2006

76 UNISON Bargaining Support paper-June 2005. Back

77 Operating for Profits An examination of the UK government's policy of promoting "Independent Sector Treatment Centres" Dr John Lister September 2005. Back

78 UNISON letter to Lord Warner 13 February 2006. Back

79 In the Interests of Patients? Examining the impact of the creation of a competitive commercial market in the provision of NHS care-UNISON September 2005. Back

80 HC Deb, 19 October 2005, Col 270WH. Back

81 Private outcomes data "misleading" Hospital Doctor 6 October 2005. Back

82 Letter to Hospital Doctor 6 October 2005 Mr Simon Kelly. Back

83 Health Committee, Second Report of Session 2005-06, Changes to Primary Care Trusts, HC 646, Ev 167. Back

84 National Centre for Health Outcomes Development (NCHOD) 11 November 2005. Back

85 Chris Locke, Chief Executive of Notts Local Medical Committee. Back