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10 May 2007 : Column 162WH—continued
It is easy to say that the NHS could by itself have put those problems right. There is nothing to say that we needed independent sector treatment centres to improve
any of the things that I have mentioned. Surgeons could have been trained in the latest techniques; hospitals could have chosen to buy the latest equipment; operating theatres could have been upgraded in line with best practice; and capacity issues could have been addressed by individual hospitals and trusts as and when they chose. However, that was not happening.
For all the problems with independent treatment centres, they have acted as an enormous spur or at least as a driver to try to bring all centres up to the best standard. We have heard from colleagues this afternoon that many NHS centres have achieved that. The question is: would they have achieved it if we had not been having a debate over the past 10 years on whether we increase capacity by using the independent sector? My view is that, although the overall effect of independent treatment centres has been quite small in terms of numbers, they have raised the debate to a level to which it was not previously raised, which in itself has been a driver for best practice improvements in other parts of the sector. Therefore, the programme should be welcomed at least as an extremely useful debating point and a very useful springboard for improving practice.
There is no question but that the establishment of ISTCs was driven by a wish to reduce surgical waiting lists and to improve cost-efficiency in the NHS, which in itself should be laudable. The centres have indeed offered more patient choice. Where they exist, patients and doctors have an extra choice over and above the existing system. Many ISTCs have been able to introduce best practice and have been successful in introducing a range of innovative working practices. They have, therefore, been able to improve patient care.
I have done some research on the issue and had a look around the country to see what has been achieved in various centres. I shall mention just a few examples. In some areas, mobile solutions have been provided whereby the provider supplies clinical services from mobile units set up on agreed sites, particularly to improve access in remote areas. There has been the construction of new facilities designed around the clinical flow of patients and thus improving productivity. That is a brand new concept for designing services.
There has been improved process design, to improve the patient’s experience by increasing throughput without compromising patient safety or clinical quality. Mobile ophthalmology units, for example, are capable of dealing with 20 to 23 cases a day due to streamlined processes facilitating efficient use of theatre space and resources. Extraneous administrative processes have often been put online, so that surgery is not delayed and can commence at the start of the working day. Some centres have stocked a smaller range of prostheses, allowing theatre staff to become more proficient and more productive in the use of a more limited range of prosthetic devices.
Some centres have used local anaesthetics instead of general anaesthetics for primary joint replacements, thereby reducing the anaesthetic risk and the average length of stay to five days from the eight days previously experienced in the NHS. Some centres have introduced blood conservancy and recycling measures that reduce the need for transfusions. That is an important issue as well. However, none of those issues
is exclusive to those centres. All those things could have been achieved elsewhere, but the fact is that in too many cases they have not been.
That said, it is important not to over-emphasise the impact that ISTCs have had. The British Medical Association, for example, contends that
“the participation in research, teaching, and peer-reviewed activity that is vital for innovation in healthcare is not ideally suited to the working environments found within most, if not all, ISTCs. The employment of overseas clinical teams often on short-term, rotating contracts in ISTCs is one example of such a possible shortcoming.”
It is also clear to me that ISTCs are not necessarily more efficient than NHS treatment centres. I was very proud that the Health Committee chose to visit my local unit in Dartford—the Woodland centre—which has been extremely efficient. Indeed, many colleagues have referred to its very good practice and the very streamlined approach that it has taken, integrating the NHS treatment centre into the mainstream hospital, thereby getting many of the benefits and very few of the disadvantages of the system. In fact, that centre has achieved a theatre utilisation rate of 90 per cent., which by any standard can be considered very high.
Similarly, the Nuffield orthopaedic centre in Oxford, where care pathways were written with primary care involvement, has been successful in achieving a reduction in the length of stay from 12 days to just five days. In Goole, the average length of stay in orthopaedics has been reduced from 12 to about six days, thanks to improved pre-operative assessment techniques.
It seems that innovation in most ISTCs is largely a matter of better processes and clinical management, rather than revolutionary surgical techniques. It is probable that it has been driven by the regular and consistent case mix, and stems from the elective surgery only status of all treatment centres, rather than the independent sector’s involvement in the treatment centre programme.
A number of written submissions to the inquiry also made the point that some specialties and operations may be more suited to the ISTC system than others. Cataract surgery, for example, is a relatively simple patient pathway and is well suited to the system. A general practitioner or an optician can make the diagnosis and the patient is then referred to an ophthalmologist. A relatively straightforward operation is performed and the patient can often be discharged with no follow-up at all, apart from perhaps a visit to their local GP.
However, many other surgical procedures are not so straightforward. A patient with rheumatoid arthritis, for example, who requires joint replacement surgery may have poor bone density, other medical conditions, a complicated drug regime and mobility problems, and therefore probably is not a suitable case for the type of procedure that I have described. They may need far more follow-up and rehabilitation.
While ISTCs might be ideal models for simple, one-stop surgery, they do not work so well with complex conditions that require continuing care. Many NHS hospitals and departments have developed multi-disciplinary teams to manage the rehabilitation of post-operative and other patients, who may be seen for several weeks after their discharge. As ISTCs do not provide multi-disciplinary teams, they cannot and do not provide such a complete care package, and therefore do not have to bear the
financial consequences of aftercare, which the NHS often has to pick up. Concerns have also been raised about the tendency of some ISTCs to cherry-pick patients, and to leave the more difficult cases that require significant amounts of post-operative care to the NHS.
There is also an issue with training, which has been mentioned. In giving ISTCs that are run by non-NHS staff responsibility for carrying out a large number of procedures in key specialties, we might be making it more difficult for junior doctors to gain the requisite amount of experience in those areas. I know that the Government have looked into that, and I am keen to hear what the Minister has to say on it. The fact remains that, if we are to train the next generation of surgeons to the very high standards that we require so that they are able to provide a good service, they must gain a lot of experience with routine patients as well as more complex cases. Many of my colleagues who work in general surgery are worried that if all the routine, relatively straightforward cases are sent to the independent sectors, leaving only the complex and rare cases behind, that does not leave a good training base to provide all-round, well-trained surgeons.
Some of those problems are not only expensive, but can slow down patient care, and are inconsistent with the Government’s stated aim of moving more care from specialist secondary services and into primary care services. People have raised with me their concerns that many of the procedures that are carried out in ISTCs could be performed by trained GPs in their surgeries, such as the removal of certain cysts, minor skin procedures, endoscopies, colposcopies and so on. Indeed, many such procedures are already being provided by specialist, trained GPs. If we steer many of those patients to ISTCs, we will maintain high costs and will risk flying in the face of Government policy to transfer much more of that kind of care back into the primary care sector.
In conclusion, I think that there is a role for ISTCs in the NHS as additional providers of services, but they need to be carefully managed. We should use best practice in those services to direct and drive care and modernisation within the NHS, to act as a focus for improved efficiency and to show hospitals across the NHS what can be achieved. They can be a useful pilot to show how they can be a genuinely useful addition to NHS capacity that improves the patient experience at a cost that really is affordable. However, we need to recognise the lack of transparency in some of these issues—many hon. Members have mentioned that. Provided that ISTCs do not undermine the NHS’s existing work, they can and should be seen as a useful addition to what we currently offer.
4.22 pm
Dr. Andrew Murrison (Westbury) (Con): I congratulate the Chairman and members of the Health Committee on producing the report, which is excellent and very fair. It is a pity that it has taken so long for this issue to be debated, as it now lacks an element of currency, but the debate is quite timely given the impending decisions that Ministers have to make about phase 2 ISTCs. I hope that the Minister is going to say something about those.
It is a mark of the times in which we live that the campaign group “Keep Our NHS Public” has accused Ministers of acting ideologically because of their apparent preference for supporting the independent sector in health care. I certainly would not accuse Ministers of being ideological in that respect, but I shall ask the Minister to account for many of the elements of ISTCs that were highlighted by the Select Committee. What matters for us is what works. Like Ministers, I hope, we have no particular ideological hang-ups about public, private and not-for-profit. Surely what matters—I hope that we can all agree on this—is what delivers outcomes for patients.
The report focused very well on issues such as choice, quality, cost-effectiveness and innovation. We, too, need to focus on them, as well as on supplementary areas such as training, about which we have rightly heard today. We need to focus on the impact that ISTCs might have on those areas, and on the extent to which those issues might have been overlooked by Ministers in their pursuit of ISTCs. There is clearly a case to answer, because some of those elements have been recognised and addressed as part of phase 2.
I know that this matter is of great interest to the Labour party and has caused quite a lot of unhappiness. It divided the party conference and caused some problems for the Health Secretary at that time. Helpful as ever, my hon. Friend the Member for South Cambridgeshire (Mr. Lansley) offered some words to the Health Secretary back in September. He said that she
“would not have this problem if she had listened to our advice and created genuine competition, not preferential competition, which means that independent treatment centres currently carry out 73 per cent. of work, but are paid for 100 per cent. This is why hospitals are closing down wards.”
The Department of Health has analysed the possible effects of independent sector treatment centres on district general hospitals, but has refused to be entirely candid about the results of that analysis. That is a great pity. We have heard about our ability to hold the Government to account, which we do largely through Select Committees. If the Department of Health feels unable to share that kind of information, that degrades our ability, as parliamentarians, to call the Government to account and is a serious matter.
We need to know why the Committee and the House have been denied that information. That is particularly important at this point, because district general hospitals are facing something of a pincer movement. They are facing threats from ISTCs and from the move towards tertiary centres. We have had the Boyle and Alberti reports recently, and the idea that trauma should be centralised and that some accident and emergency departments should, perhaps, be downsized. Those factors have serious implications for the concept of district general hospitals.
Ministers are right to say that nothing should stand still and that a model that was created in the 1960s needs to be updated. However, we need to celebrate what is best in our health service and we must also remember that district general hospitals provide a whole range of things in addition to direct patient outputs. We have talked about training and I hope that the Minister will talk about it a little more.
Tomorrow, I am going to visit the Gloucestershire Royal hospital, where I worked briefly before I was elected. No doubt, the hospital will want to discuss what phase 2 will mean for it. There seems to be some confusion out there in the provider arm of the national health service about what independent sector treatment centres there are going to be and when contracts are going to be signed off.
It is also important to recognise that it is not only large district general hospitals that are affected by ISTCs. The hon. Member for Dartford (Dr. Stoate) mentioned primary care, and rightly so. Community hospitals will also be affected. I know, to my cost, that a very valuable cataract service at Westbury community hospital has ceased to exist; of course, those sorts of services are threatened when ISTCs appear.
One of the selling points of ISTCs was the idea of innovation: that ISTCs were going to innovate and bring new things to health services. There is nothing particularly new about stand-alone centres of these sorts. I recall a hospital called Black Notley near Braintree, which closed down in 1998. It had provided services for local communities, particularly cold orthopaedic surgeries, since 1904. We can sign up to the concept that cold and non-acute cases might usefully be separated from emergency cases if cold cases are consistently being delayed or de-prioritised. We must also recognise that there need not necessarily be an ISTC model delivering services. Other hon. Members have discussed how that problem, which affects the cold, elective part of the health care service when it is faced with the priority of emergencies—of course, priorities come with emergencies—can be addressed.
I am also less than convinced, as I believe the Committee was, by the idea that ISTCs brought innovations to the health service. Interestingly, Professor Karol Sikora was talking about cancer treatment on this morning’s “Today” programme, and parallels do exist because his concern is not that the NHS is not good at innovation and research, but simply that it is not terribly good at rolling out its results. I have seen no evidence——neither, clearly, has the Committee——for suggesting that ISTCs, rather than the wider service, have been the crucible for innovation. The problem has been that the wider service has perhaps not rolled out innovations in quite the way that we might have hoped; in a sense, they have been reinvented in a number of ISTCs.
One or two hon. Members mentioned the avoidance of cancellations. I support measures that will avoid the awful situation where people are phoned on the morning of their operation and told, “Don’t come in, because we are full. We have emergencies and we simply cannot accommodate you.” Such situations are not always due to emergency surgery; they can occur for a range of other reasons. Recently, wards have unfortunately had to be closed because of infections. I do not discern any difference in the pace of that cancellation rate. The rate remains, and these situations are deeply distressing, particularly for patients who have worked themselves up for operations. I am thinking of elderly patients and those requiring hip replacement surgery. Often such people have starved themselves overnight only to be told not to come in, sometimes on a serial basis. I commend Ministers to examine measures that might avoid that happening. This issue is important and cancellations are still occurring.
The case mix on pages 12 and 13 of the report shows that ISTCs are not necessarily doing the sort of stuff that is likely to be subject to cancellation. Orthopaedics are clearly in the frame, because where an emergency requires theatre time, cold cases—orthopaedic cases and elective cases—will be cancelled, but ISTCs are doing a range of other things: ophthalmology; dermatology; ear, nose and throat—ENT; rheumatology; and endoscopies. Such things require different practitioners from those who might be involved in emergency cases, different facilities and different operating theatres. It is unlikely that ISTCs, certainly as currently configured, will make a big impact on avoiding hospital operation cancellations. I wish that they would, but I simply do not see it happening, given the case mix displayed.
Training is vital and topical. Ministers have to deal with the debacle of modernising medical careers and the medical training application system—MTAS. There is a real problem in the training of junior doctors. Phase 1 ISTCs did not do training in any meaningful and systematic way. To be fair, the Government response appears to have recognised that and at least says that they will ensure that training is a part of phase 2, but the Minister needs to give us more detail. What does he mean by training? Who will be trained? To what standard will they be trained? Will those doing the training be competent? Will they be in a position to train juniors in the kind of competency-based way that we expect these days?
It is bizarre that additionality means that NHS juniors will not be trained because we are effectively importing overseas doctors under the additionality rule. That is odd indeed. I hope that as part of phase 2 and the contracts which we believe are up for signing shortly, Ministers will ensure that additional training capacity is created. We were told recently in the House that it would be, in order to sort out some of the shortfall that we expect shortly and the medical unemployment that seems likely. This seems to be an opportunity, and I should be interested to hear from the Minister what he has done with independent sector providers to ensure that capacity for training within ISTCs has been upgraded to fulfil the Health Secretary’s promise that additional places will be created.
There appears to be an element of job loss within the service. I recently received a note from a consultant at the Royal United hospital in Bath on the impact of ISTCs on his institution. It starts extremely well, saying:
“First, I just wanted to say how much I appreciate your strong and high-profile campaigning on the NHS nationally.”
Naturally enough, I warmed to this correspondent immediately. He went on to say:
“Regarding the imminent cutbacks and job-losses at the RUH...I just wanted to make a point which I feel is not really being highlighted and yet I feel is very relevant. It is no surprise that job-losses are felt necessary by our trust’s management. One contributing factor is the so-called Treatment Centre...nearby in Shepton Mallet...which is treating straightforward patients for routine ops at an inflated tariff and leaving the more complex cases as well as sorting out their errors, to the local NHS.”
That is a pervading worry of ours. Because we have not got the data to refute it, there will always be a suspicion that ISTCs are in some way poaching staff and providing a service that is not as effective as that in the
mainstream NHS. The fault lies with data collection: if we do not have the data, we cannot refute the allegation.
The hon. Member for Wyre Forest (Dr. Taylor) talked about consultants “kicking around”—I believe that those were his words. I think that he meant that they had some spare capacity. The British Orthopaedic Association, which is vilified directly and indirectly in the report and the Government response, says that at least 30 trained surgeons with certificates of completion of training are unable to get jobs and cannot work in ISTCs because of the rules on additionality. The Minister says that phase 2 will involve a relaxation of the additionality rule, which must be welcome. Apparently, there is a list of shortage professions whose members will not be admitted to work in ISTCs but everybody else, by implication, will be. But of course, shortages mean many things and one cannot simply identify a shortage profession. Is that list speciality-sensitive? Is it geographically defined? Is it grade-specific?
Much has been said about the quality of output from ISTCs. In January, a Department of Health document was leaked. It pointed out that national data on the clinical quality of ISTCs are
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