Reviews Personal views

Independent sector treatment centres: how the NHS is left to pick up the pieces

BMJ 2006; 332 doi: (Published 09 March 2006) Cite this as: BMJ 2006;332:614
  1. W Angus Wallace, professor of orthopaedic and accident surgery (Angus.Wallace{at}
  1. University of Nottingham

    There is no doubt that the expansion of orthopaedic services, provided by the Department of Health through private hospitals and independent sector treatment centres (ISTCs), has been a much needed development, but it has occurred at a price. Admittedly there are many patients who have benefited from the development of ISTCs and are now leading pain free lives as a result of surgery carried out much earlier than would have been possible in the early 1990s, when our health service was grossly underfunded. However, the number of patients we are seeing with problems resulting from poor surgery—incorrectly inserted prostheses, technical errors, and infected joint replacements—is too great.

    The number of patients we are seeing with problems resulting from poor surgery is too great

    Perhaps we should look at the mechanisms through which this whole ISTC exercise has been carried out. Surgeons from overseas have been flown into the United Kingdom to increase the numbers available to provide elective orthopaedic services. They have come from many countries, usually European, and their training and clinical practice at home are quite different from those to which they are exposed in an ISTC.

    In Germany, Hungary, and Croatia, for example—countries I know about because I have visited surgical centres in all of them—the junior specialist usually attends rounds first thing in the morning, during which the planned operations for the day are presented and discussed with the senior consultant. The senior consultant then instructs the junior specialist about which operation is to be carried out and how, and the junior specialist then goes off and performs the surgery. The x ray result of this surgery is presented at subsequent rounds. Clearly there is careful supervision of the relatively inexperienced specialist.

    What has happened in ISTCs is that these junior specialists have been imported and asked to provide total surgical care without help and supervision from a more senior colleague—a situation that is alien to many of them. They do not have a senior colleague to turn to for help with difficult cases, nor if things go wrong—hence the reason why the failures find their way to the NHS hospitals.

    This situation has arisen because of a political philosophy called “additionality.” When former health secretary Alan Milburn set up ISTCs there was clearly concern that their development might result in NHS hospitals losing some of their own surgical staff. To ensure that this could not happen a six-month rule was imposed—an NHS surgeon could not work in an ISTC until he or she had stopped working for the NHS for six months. While this ensured that the NHS hospitals were protected from losing their own staff, it also meant that the ISTCs did not have access to many, or any, senior surgeons who could act as senior consultants and help their colleagues when they ran into trouble. Now we are seeing the consequences of this philosophy—poor operations, inadequate supervision of surgeons, and a poor mechanism for remedying any problems that occur.

    The NHS has, in the past decade, emphasised the importance of clinical governance. I am aware, as a result of discussions with industry representatives and theatre staff who have moved to ISTCs, that there are many clinical governance issues that the new systems appear not to have addressed. For example, many overseas orthopaedic surgeons have been asked to carry out joint replacement operations that they have never seen or done before.

    Because of the single supplier contracts that many of the ISTCs now have, only one joint replacement type is available to the surgeon and that is the joint that he or she is asked to put in. It is clear that this has occurred with inadequate training of both the surgeons and the operating theatre staff and as a consequence there have been several serious errors—joint replacements put in without bone cement when bone cement was essential for that joint replacement, the use of the incorrect size heads (ball) for a hip joint replacement, etc.

    We are frustrated by the artificially created divide between the ISTC and the NHS hospital

    There is also a difference in the rules that apply to staff. NHS consultants have to attend regular hospital audit meetings, their clinical director oversees them in their NHS work, and they have an obligatory annual appraisal system. It is not clear how these procedures are being addressed in ISTCs and this creates a suspicion by NHS staff that corners have been cut in achieving the goals of high productivity and throughput.

    Perhaps the issue that should be of most concern, however, is that of training the country's up and coming surgeons. The “straightforward” cases, now dealt with by the ISTCs, had been the cases on which young surgeons learnt their craft, firstly by observing the consultant, and then by performing parts of the operation under the consultant's supervision; when fully competent, they would conduct the operation themselves with the consultant present or available in the hospital. This time honoured and soundly proved method of training has now, sadly, been denied. Even if training were to be allowed in ISTCs, the supervising surgeons may not be fully competent themselves, as previously mentioned, let alone competent as trainers. Consequently the competence of our next generation of surgeons is in jeopardy.

    Embedded Image

    Cutting corners: how do ISTCs hit their targets?

    Credit: PHOTOS.COM

    We, as NHS staff, need to help, and many of us wish to, but we are frustrated by the artificially created divide between the ISTC and the NHS hospital.

    Why has the problem with ISTCs, which have now been running for three years, not been aired and addressed before now? Firstly, Alan Milburn and prime minister Tony Blair wanted them to succeed despite any shortcomings. Subsequent health secretaries have taken similar views. Secondly, during the past 10 years NHS consultants have become increasingly fearful that if they publicly criticise the government or the Department of Health, by speaking up about their patients' problems and complications, then this will harm their own career and their future. This is a sad reflection on our opportunity to work with our government and our employers in addressing the problems arising within the modern NHS.

    The government has created a two-level health service that is creating many problems. I believe that we should now integrate the ISTCs with the NHS instead of running them as a private healthcare system paid for by the state.

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