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10 May 2007 : Column 151WH—continued
“90 per cent. of patients happy to recommend the centre in our last patient survey.”
That sounds good on the face of it, but it also sounds a little like manager’s spin. I am not particularly interested in the results of the latest survey; I am interested in the overall assessment by patients over an extended period. I hope that Capio will make that information available directly to the public in York and, through the Department of Health, to the public more generally, so that we get a real analysis of the benefits and costs of the independent centres, as against treatment provided by NHS trusts.
Mr. Barron: Has Capio given any percentages for the number of local clinicians and doctors who are prepared to recommend the York centre to patients?
Hugh Bayley: I have not asked Capio that question, and it has not volunteered the answer, but my right hon. Friend makes an important point. I remember, 12 or 14 years ago, when I was a member of the Select Committee on Health, picking up in the United States a publication called the Washington health Checkbook—which is a pun in American, because they do not know how to spell the type of cheque that one writes to one’s bank. It compared performance, hospital by hospital and consultant by consultant, of hospitals in Washington DC, northern Virginia and Maryland. It included interesting information about post-operative infection rates and re-admissions—or perhaps it was mortality—30 and 90 days after discharge. It also included information about which consultants and hospitals were chosen by health professionals seeking treatment. That may be an important indicator of informed opinion about the quality of the care likely to be received from a hospital or consultant. I should welcome publication of such information in the UK.
The Capio centre in York has attracted mixed reactions locally. One constituent came to my surgery to complain that he was offered treatment there—at a private centre rather than an NHS trust. Concern has been expressed to me by the local medical committee and by consultants at York hospital that the centre is failing to treat as many patients as it is contracted to treat. The point was reinforced by a letter that a constituent who is a retired nurse sent to me recently. She said:
“I have recently been fortunate enough to have a hip replacement operation at the new NHS Treatment Centre at Clifton Park where I received excellent care.”
Later in the letter, however, she says:
“I was an in-patient for four days and was one of only three patients being treated, leaving 22 empty beds”.
Such concerns prompted me to table some written questions to the Department of Health. To establish the context, perhaps I should say that North Yorkshire and
York primary care trust has one of the worst, if not the worst, deficit of any PCT in the country, at about £30 million. The York Hospitals NHS Foundation Trust has been commissioned in the current year, 2007-08, to treat fewer patients than it did in 2006-07, as part of the PCT’s effort to reduce the deficit. As a consequence of that reduced level of commissioning, the hospital is reducing staff by not filling vacant posts, and it is closing beds. Some of those beds are being closed because of a substantial increase in the capacity of the day surgery unit at York hospital, but I suspect that some are also being closed because 25 additional beds have been provided for elective surgery at the Clifton Capio centre. The question that comes to my mind is whether the provision of the Capio centre is a good use of resources by the local PCT. That is what prompted my questions.
I tabled three questions on 11 January, and they were answered a couple of weeks later on 25 January. I asked, first,
“how many procedures for NHS patients will be (a) paid for and (b) provided by the York Capio Centre in 2006-07”.
“what the (a) national reference cost, (b) average cost per case at the York Capio Centre and (c) average cost per case at York NHS Trust was for each procedure provided for NHS patients at the York Capio Centre in the most recent year for which figures are available”
“what the total NHS expenditure on the York Capio Centre will be in 2006-07.”
I quote part of Minister of State’s answer, the rest of which describes the nature of the centre. He said:
“It is not possible to provide the data in the format requested. Reference costs data are collected from NHS trusts and primary care trusts. Reference cost data will cover procedures that are carried out by the trust and those that are contracted out, which will include to an independent sector treatment centre. However, information on the payments for services and operational costs of Capio UK is commercially sensitive.”—[Official Report, 25 January 2007; Vol. 455, c. 2052-3W.]
If the Government have entered into contracts with those independent treatment centres on a basis that, for commercial reasons, will not allow information to be made available about the treatment of NHS patients in privately-run NHS units, but allows information about NHS hospitals to be made available to Members of Parliament and the public, there is a serious problem with the accountability of the national health service to Parliament and the public. I thought about that for some time and on 2 March I wrote to Sir John Bourn, the Comptroller and Auditor General, to explain that I was dissatisfied with the Department’s failure to answer my questions about NHS treatment paid for with NHS cash for NHS patients in my constituency. Among other things I said:
“One of my responsibilities as a Member of Parliament is to scrutinise the Executive to find out whether its services provide good value for taxpayers’ money. It severely undermines my ability to do so when a Minister declines to provide information about the volume of NHS activity and costs of providing this at an NHS treatment centre in my constituency.”
I went to see my hon. Friend the Minister, to express my concern. He thought about the issue and said that he would re-examine it, and encouraged me to put
down a pursuant question, which I did on 12 March. I heard nothing for a little while, and on 17 April Sir John Bourn wrote a holding reply. He said:
“We are investigating this matter with the Department of Health and the North Yorkshire PCT and will write to you with a substantive reply as soon as possible.”
A few days later I received an answer from the Minister, who said:
“The Clifton National Health Service Treatment Centre is expected to deliver approximately 10,000 procedures over the five year contract period. At the end of January 1,817 procedures had been delivered for NHS patients.”—[Official Report, 24 April 2007; Vol. 459, c. 1055W.]
I still did not have enough information to make an informed judgment about whether the Capio centre carries out as many treatments as it was commissioned to carry out and is being paid to carry out by the local PCT—which is, of course, in deficit. Nor did the reply allow me to make any assessment of whether the cost of providing those treatments in the independent treatment centre is more or less, per case, than the cost of treating patients in the local NHS hospital. When a local primary care trust is deeply in deficit and cutting services to patients because of a shortage of money, it matters enormously to me, as the Member of Parliament, and to people locally, to know that their money is being well spent. That is why comparative information is so important. I tabled further questions to my hon. Friend quite recently to ask for that comparative information. He has not yet replied, and I hope that before he does so he will feed in his reflections on the debate and be able to provide me and Parliament with the information that we need to make comparisons.
I congratulate the Select Committee on the report that it has produced. It examined wide policy issues and raised important questions, and I wish briefly to reflect on how some of its points affect the situation in York. The Committee raised the issue of capacity, stating that it is not clear whether the independent treatment centres have actually increased capacity. What has happened in York adds doubt and underlines the importance of drilling down to find out whether we are increasing capacity by encouraging the private sector to build new units.
Yes, we have 25 additional beds for elective surgery at the independent treatment centre, but we are losing beds at York hospital. I do not know whether we are increasing capacity overall, but we do know that the most important determinant of capacity for elective surgery in York is the financial standing of the North Yorkshire and York PCT. Providing extra beds does not increase the amount of money available to pay for treatment. I hope that the Select Committee will consider the issue further.
The Committee makes the point that we do not really know anything about clinical quality in the independent treatment centres compared with that in NHS hospitals. I do not wish to prejudge the issue; the information that I have had about the quality of care at the Capio centre in York is extremely good, but I should like an evidence-based, rather than anecdotal, assessment of the relative quality of care.
Finally, the Government response to the Committee points out that the utilisation rates of independent units is high, at 84 per cent. That suggests that my constituent’s experience that 21 out of 24 beds were vacant is very much the exception rather than the rule, and I am pleased to hear that. I am not sure whether 84 per cent. is a high utilisation rate compared with the use of beds in NHS hospitals in the areas in which the private treatment units are competing, but again I hope that the Select Committee will examine that.
I have detained the House far too long. I am grateful for its indulgence—I have an independent unit in my constituency and it has posed important questions. I see the Capio centre as part of the solution to provide more treatment to more patients more quickly in York, but plenty of questions need to be answered. They are primarily about the quality of care; the relative cost-effectiveness of the independent centre and the service provided by the same doctors at the York Hospitals NHS Foundation Trust, and whether the creation of the independent centre has increased capacity and therefore the number of patients being treated in York.
3.33 pm
Dr. Richard Taylor (Wyre Forest) (Ind): It is a pleasure to follow the hon. Member for City of York (Hugh Bayley), who put his finger on several problems. I shall refer to several of them in the course of my contribution.
I begin by disagreeing with the hon. Member for Southend, West (Mr. Amess), because I wish to congratulate the Minister on the Government’s response. It is easy to understand, because for once they have answered the report’s points in the order in which they appear. I remember not long ago, having a nightmare wading through another response, in which none of the Government’s responses were numbered. They were in a higgledy-piggledy order and lumped together. I congratulate the Minister—it is reasonable and reasonably full. I wish to follow up a lot of things in it, and as it is from six months ago, I think the Minister will be able to update us on progress.
I wish first to mention the quality of care and outcomes, which are crucial. I am a little confused about the taskforce and Healthcare Commission examinations, which are supposed to have reported, one in the spring and one in March. I would be grateful for an accurate update on when we can expect them to do so. I am slightly worried about the remit of the Healthcare Commission review. Paragraph 28 of the Government’s response lists as part of that remit
“the extent to which the quality of care in ISTCs can be compared with the NHS”.
That does not imply to me that there will actually be a comparison, which is what we want. It will just be about the extent to which the two can be compared, but we want an absolute comparison. Another bullet point is
“patients’ assessment of quality of clinical care and their overall experience of care provided by ISTCs”.
As many hon. Members have said, we desperately need a factual, evidence-based survey of the outcomes of the NHS and ISTCs.
Since our inquiry, some more little bits of isolated information have come to hand. I have had a note to tell me that long before ISTCs, Cardiff and Vale NHS
Trust was worried about its waiting lists and commissioned Weston Area NHS Trust to carry out a number of its routine orthopaedic procedures. It discovered that nine out of 147 knee replacements carried out by Weston required revision in the first year. That was absolutely appalling and about six times the expected revision rate. The criticism was not that it was an ISTC—it was an NHS centre—but that it was distant from the originators of the referrals. There was no communication between the centres, and different surgeons carried out the pre-operative assessment, the operation and the follow-up. Those problems seem to have led to much less accountability and problems with a distant service provided in the NHS.
Then I came across an earlier report in the “Annals of the Royal College of Surgeons” of 2005. It reviewed a relatively small number of patients who had been sent from the NHS in Exeter to the NHS in London for hip replacements. It found that over a period much longer than a year, the rate requiring revision was 12 out of 27 hip replacements, 44 per cent., compared with about 4.9 per cent. of those done in Exeter at the same time. As in the Cardiff example, the differences in outcome were because of patient selection, implant selection, the absence of follow-up and the absence of audit and accountability. The report implied that whenever an operation is done distantly from the originating hospital and consultant, there are specific problems to consider. The success or lack of it thus appears to relate to the distance from the originating unit.
That brings me straight on to the problems of integration and additionality. If there is integration between the referral point and the point where the operation will be carried out, whether NHS or independent, there will be communication, and the same doctors will do the pre-op, the post-op and the operation. One could hope that things would be much more satisfactory altogether. On integration, the Government’s response states in paragraph 19:
“Integration between ISTCs and the NHS has not yet reached the level we should hope for. This has limited the flow of innovation and best practice from the independent sector to the NHS and vice versa.”
“Our aim is for the independent sector to work in partnership with local healthcare economies to provide solutions which reflect and cater to local requirements.”
That brings us to additionality. Paragraph 37 states:
“As recognised above, integration between ISTCs and the NHS has not yet reached the level we should hope for but changes to phase 2 should encourage greater integration.”
Crucially, the paragraph continues:
“For example, local SHAs must demonstrate how ISTCs will be integrated within the local health economy”.
I am confused by additionality. Paragraph 39 states:
“The relaxation of the additionality rules for the phase 2 ISTCs will bring about greater professional integration”.
That is confusing, because we have been told elsewhere that shortage specialties will not be allowed, and that additionality will still apply. I believe that that applies to orthopaedic surgeons, yet many ISTCs are doing a lot of orthopaedics, which is the very place where we want additionality and integration.
It is implied that NHS consultants who work in ISTCs should do so during non-contracted hours. I do not think that there should be such a limitation. I am quite sure that what is happening in some ISTCs—it is probably happening in the ISTC in the constituency of the hon. Member for City of York—is that NHS consultants are doing the work as part of their job plan. If it is written into their job plan and paid for at the same rate as ordinary NHS work, the combination could work.
Dr. Stoate: Surely, if the work is part of the job plan and is therefore part of the NHS work load, how can capacity be increased and NHS waiting times and lists reduced? My understanding is that those were the main rationales for ISTCs in the first place.
Dr. Taylor: Capacity could be increased because there are occasions when theatre lists are not used completely because of a shortage of beds in NHS hospitals. I am absolutely in favour of separating emergency and elective services so that that does not happen, but, if they are not separated, and if orthopaedic surgeons are kicking their heels, this would be a useful place for them to fill in.
Training, quality, audit and follow-up would all be improved with closer integration. There is criticism of cherry-picking, but minor cases will be seen in treatment centres in any case. Provided that NHS surgeons are dealing with them, they will get some of the easier work—the work that is better for training.
It is absolutely inexplicable, if we go back a bit, that NHS Elect was set up to do just what the ISTCs are doing but within the NHS. It was set up, but I believe that within eight months there was the first wave of ISTCs, some of which stabbed NHS Elect centres in the back. I believe that the NHS centre at Ravenscourt Park hospital found itself in great difficulties because of competition from the independent sector.
We have a weird set-up in Kidderminster, in that part of our treatment centre is NHS and part is independent. Sadly, because of a total lack of integration, there is competition between the local NHS orthopaedic consultants and the ones working in the independent sector, so there are barriers to referral to the ISTC. That would not happen if there were integration and if ISTCs were part of the whole system.
I want to move on to phase 2 treatment centres, which I find quite worrying. Apparently there is no sign of the Government increasing the number of NHS treatment centres, yet the Department is negotiating contracts for some 20 new ISTCs. I was interested in the Select Committee Chairman’s comments that there will be none in Yorkshire, and I wonder whether there is a geographical split. Perhaps in some areas doctors and trust managers are less resistant, and the Government are finding it easier to put ISTCs in place.
The ISTCs will have quite an effect—1.4 million operations in five years at a cost of £3.75 billion—and I cannot believe that they will not have some effect on NHS provision. I wonder if tariffs will take into account the greater severity and complexity of the work that will be done in the NHS.
I was slightly encouraged by one of the points in the Government’s response. They say that strategic health authorities can decide whether they want ISTCs. I hope that they really will be allowed to decide whether they need one.
I would like to ask the Minister whether the Government have faced up to the consequences of a further push towards ISTCs. I refer him to a recent paper by Professor Chris Ham of the Health Services Management Centre in Birmingham. It is entitled, “When politics and markets collide”, and it makes interesting reading. Professor Ham is a well-respected health service design consultant. Under the sub-heading, “The Next Stage of Health Reform”, he states:
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