Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Not just costly
- Andrew Roberts (11 May 2009)
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Independent sector treatment centres: learning from a Scottish case study
- Gerry Marr (11 June 2009)
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Response to Gerry Marr, Chief Operating Officer, NHS Tayside
- Allyson M Pollock, Edinburgh EH8 9AG (13 June 2009)
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Andrew Roberts, Orthopaedic surgeon Robert jones & Agnes Hunt Orthopaedic Hospital , Oswestry, Shropshire SY10 7AG
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Pollock and Kirkwood(1) shed light on a costly exercise that might have been implemented to act as a spur to greater NHS productivity. Unfortunately the excessive cost of an ISTC may well offset any productivity gain in the NHS. A reticence to reveal the true cost, whilst politically understandable, would seem unethical owing to the diversion of funding from patient care into company profits. A culture of non disclosure will also have unhealthy effects on the ability of an ISTC to correct care quality problems early. A report on total knee replacement outcomes from Kempshall et al(2) appears to highlight just such a problem. As Dreghorn and Hamblen(3) state "We caution against short term economies, which may well produce considerable clinical and financial burdens in the long term." 1. BMJ 2009;338:b1421 2. J Bone Joint Surg [Br]2009;91-B:229-33. 3. BMJ Mar 1989; 298: 648 - 649 Competing interests: None declared |
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Gerry Marr, Chief Operating Officer NHS Tayside Delivery Unit, Ninewells Hospital and Medical School, Dundee, DD1 9SY
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Dear Professor Pollock ARTICLE REFERENCE: BMJ 2009;338:b1421 Analysis Independent sector treatment centres: learning from a Scottish case study Allyson M Pollock, professor and director, Graham Kirkwood, research fellow, Centre for International Public Health Policy, University of Edinburgh, Edinburgh EH8 9AG Your article published in the British Medical Journal on 30 April, 2009, demonstrates a fundamental misunderstanding of the terms of the contractual Services Agreement for the Scottish Regional Treatment Centre (SRTC) based at Stracathro Hospital, in Angus, Tayside. The analysis and subsequent assumptions relating to the value for money aspect of this contract are, therefore, both inaccurate and misleading. It is extremely disappointing that no attempt was made to validate or verify the data with NHS Tayside prior to publication, with conclusions being drawn that essentially are fundamentally flawed. In particular, your assumption that Netcare may have been paid up to £3m for patients who did not receive treatment, warrants particular comment. Whilst no clear derivation and substantiation of the £3m is evident within the article, the following points illustrate the misleading nature of the facts presented:- 1. No attempt has been made to understand the activity profile of work undertaken and how this would translate into nationally reported records. NHS Tayside’s internal records identify that 1,526 patients were treated over the period 1 December, 2006, to 31 December, 2007, of which almost one third are not classified for national reporting purposes as an In-patient or Day Case and, therefore, no SMR01 record is required to be provided. 2. No attempt has been made to recognise the ramp up of activity over the first year of the contract, culminating in the acceptance of Major Joint referrals in August 2007. As the Pricewaterhouse Coopers 10 Month Contract Review makes clear, the delay in the commencement of major joint activity resulted in no payments for this aspect of the service being made and the funds retained in the NHS. 3. At any point in time there are patients who will be on their treatment pathway. No assessment has been made of the value of this activity. 4. Inevitably not all patients referred for treatment at the SRTC will be suitable. Any referrals rejected require to be replaced with alternative patients to ensure that contracted volumes are met. No consideration has been given to the level of referrals that ultimately will translate into actual treatments undertaken and therefore measurable against the contract. There are sound mechanisms in place to monitor this aspect of the contract. There are robust management processes in place within Tayside and the other referring NHS Boards to ensure that this contract delivers the benefits to patients that it was set out to provide. In this regard a full report will be provided to a future NHS Tayside Audit Committee demonstrating the performance of the contract to date. Yours sincerely Gerry Marr
Competing interests: None declared |
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Allyson M Pollock, Director Centre for International Public Health Policy, University of Edinburgh, Edinburgh EH8 9AG
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Dear Mr Marr In response to the points made in your letter dated 19th May 2009 Our paper and analysis is based on the only audited publicly available data in Scotland that held by Information Services Division NHS Scotland (ISD). As you will be aware NHS Tayside is one of the poorer performing health boards in Scotland in terms of its data returns to ISD with respect to both data completeness and quality. ISD estimates show data completeness of 93% for NHS Tayside for the last quarter of 2007, in other words the discrepancy between NHS Tayside locally reported data and national data reported by ISD can not be properly explained on this basis. 1. Activity profile of work undertaken and how it translates into national records. According to your letter around a third of data are not returned to ISD as SMR01 records i.e. day case and inpatient activity. If patients are seen as outpatients the data should none the less be returned as SMR00 records to ISD. ISD SMR00 returns show that there were no new attendances and 322 follow up appointments as outpatients at the Scottish Regional Treatment Centre (SRTC) to December 2007. In other words no new treatments appear to have been delivered to outpatients to the end of December 2007. It is our understanding that data from all treatments specified in the contract as Healthcare Resource Groups should be returned to ISD. 2. Ramping up of activity. You suggest that we have failed to recognise ‘ramping up’ of activity. The Price Waterhouse Coopers (PWC) report provides no account of payments made for joint replacement procedures or what funds were retained by the NHS with respect to joint replacement procedures. Tayside health board has not published these data. Our analysis was extended to Dec 07, well beyond the ‘ramping up period’ on which basis one would have excepted to have seen a significant increase in activity, however as of 13 months only six percent of the annual contract volume for joint replacements had been carried out. 3. Patients on treatment pathways. You suggest that our analysis will exclude or lose patients referred but not treated or waiting for treatment. Our analysis covered the first ten months and first thirteen months of operation and the low completion of treatments cannot be accounted for by numbers of patients waiting for treatment. 4. Other patients were substituted for patients deemed unsuitable. The contract payment mechanisms are on the basis of referrals and not treatments as was the analysis of the PWC report. We have been unable to ascertain the proportion of referrals which were actually seen at the SRTC and, of those, the proportion which resulted in completed treatments because the data are not available. We note that you have still not provided any data on the total number of referrals, the proportion of referrals seen by the SRTC and not treated, proportion of referrals referred back to the NHS and substitute referrals. We note that a full report will be presented to the NHS Tayside Audit Committee outlining performance and hope that this will be made publicly available. We expect you will wish to publish • The number of patients referred and receiving treatments where no data are returned to ISD and the reason for not returning data • Numbers of patients referred by health board and seen in the SRTC and of those patients the numbers which resulted in treatment and treatment category • The total contract value of referrals and treatments • Payments in relation to referrals and payments in relation to treatments • Money retained by the NHS and returned to health boards through failure to provide treatment • Money paid to Netcare for "non default events" and an account of non default events • Money paid to Netcare through the 90% ‘take or pay’ mechanism for patients not treated • Net payments made to Netcare for treatments and for all activity • Data on complications, revisions and readmissions Yours sincerely Professor Allyson Pollock
Competing interests: None declared |
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