Evidence submitted by Mr Z (ISTC 44)
My points are as follows:
1. The introduction of ISTCs was too hasty
and did not accurately take account of the expanding capacity
of the existing NHS.
2. A great deal of unnecessary anxiety and
bad blood has been caused by the Department of Health's requirement
that up to 15% of a Trust's patients should be treated privately.
PCTs and Trusts all too often have no say in the matter.
3. In the case of Southampton, the orthopaedic
ward is virtually empty, the PCT having required patients to go
to the local ISTC. Consultants who demur are threatened with disciplinary
action according to the magazine "Hospital Doctor".
4. Where patients are required to go to
ISTCs, they are always the easiest patients, thus leaving behind
in the Trust the more difficult ones, whose care costs more. The
resulting average costs of the parent Trust are therefore higher.
At a time of tariff and PBR, the Trust will therefore be doubly
penalised and may have to make further patient savings elsewhere,
not on account of anything which the Trust has done, but on account
of DOH pressure. The impression of inefficiency is forced onto
them by the presence of the ISTCs. (All this is false anyway,
for the NHS has no idea at all of its own costs, nor how to apportion
common costs across services. Tariff is purely notional.)
5. The ISTC will be here today and gone
tomorrow. In the meantime, the service will have been fragmented.
6. There is considerable concern about the
quality of the Doctors who come from abroad. The medical director
of Netcare resigned following the publication of adverse orthopaedic
results.
7. I suggest that you watch the Channel
4 News programme on Netcare which was broadcast at 1900 hours
on 7 December 2005. This shows you what can go wrong if the emphasis
is always on throughput rather than all-round quality. (Although
this may not be strictly relevant to your enquiry, you may also
wish to look at another by-product of the target culture; at Kingston
Hospital the appointment of a foot surgeon was so very popular
with the public that there were instantly long waiting lists.
The only way for Kingston to escape from the DOH constant criticism
about failure to meet the waiting list targets was to cancel the
service. The foot surgeon now works wholly privately.)
8. All too often, ISTCs have been paid for
work which they have not done. In its rush to entice additional
provision to the UK, the first round of Contracts involved payment
not according that whihc was actually done, but that which was
contractually stated. While this has changed with the second wave,
there are still first wave ISTCs which receive money, I believe
for work not actually done.
9. Sheffield is a case in point. Patients
were required to go to the ISTC in Derby. Many refused to do so.
The ISTC was paid, nevertheless, for the agreed volumes and the
PCT at Sheffield had either to put the poor patient on the bottom
of the list—because he had "refused" treatment—or
had to pay for it a second time. The amount of money received
by ISTCs in the area for treatment not given is in the region
of £4.5 million.
10. The South West London Elective Orthopaedic
Centre (SWLEOC) in Epsom started life as a NHS ISTC. It is to
become an ISTC, with ownership very probably passing to the Hospital
for Special Surgery in New York. The HSS is reported to be getting
cold feet as the NHS TC was not able to cover its costs. The Queen
opened the NHS TC; history does not relate what she thinks about
it being sold off to the HSS!
11. There are no doctors on the wards at
SWLEOC, as these cannot be spared from the surrounding Trusts.
Instead there is an arrangement whereby Consultant Intensivists
are paid £2,000 per night to stay over night. This is not
popular with the Trusts as they are depleted of intensivists.
12. Where things go wrong, patients tend
to be shipped back from the ISTC to the Trust. This is not a good
service for patients.
13. Arrangements are made directly between
an ISTC provider and the Department for Health. The DOH then requires,
with no consultation with the PCTs or the Trust, that a given
number of patients should be sent straight from the waiting list
to the ISTC; this causes many problems for the Trust and the PCT,
both budgetary and operational.
14. In some cases, it is not possible to
find a local consultant or trained doctor to perform the procedure.
Colonoscopy lists have been performed by doctors who have been
brought out of retirement or have been imported from Germany.
As the caecum has not always been reached—the Clinical governance
point—a second procedure sometimes has to be performed on
return to the parent Trust. This is bad for the patient and wasteful
of resources.
15. The ground rules keep changing. In order
to justify the importing of overseas doctors, there has been a
prohibition on UK doctors who have worked in the NHS working in
the ISTCs. The principle of "additionality" however,
is increasingly being jettisoned, not officially, but by default.
There appear to be no longer any "rules", as the Government
changes tack incessantly.
16. Undergraduate medical education is suffering;
with the emphasis on throughput, ISTCs have little time to devote
to education. Nor, as far, as I can gather, is the government
insistent, in every case, that the new provider takes students.
Where they do, the education is of course only for the simplest
of procedures. This involves another shift in resources—this
time for training—away from the permanent Trust to the ephemeral
ISTC.
17. A similar lack of clarity surrounds
ISTCs from the regulation point of view. They should be regulated
under the Care Standards Act and should be subject to regular
inspection by the Health Care Commission. I do not believe that
this is always the case, by any means.
18. I hope this is of some use. By all means
use this material, but I should be grateful if it is used anonymously.
10 February 2006
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