Independent sector treatment centres: evidence so far
BMJ 2008; 336 doi: https://doi.org/10.1136/bmj.39470.505556.80 (Published 21 February 2008) Cite this as: BMJ 2008;336:421
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This article explains how the government is creating a health care market using taxpayers money but without ever having obtained the consent of citizens or Parliament. Further details of this policy are examined in more depth than is possible in a BMJ article in 'Confuse and Conceal' by Stewart Player and Colin Leys published by Merlin Press on 7th Feb. (www.merlinpress.co.uk). Despite the failure of the DH to set up proper monitoring of the outcomes the policy of using the private sector to stimulate the NHS to be more efficient continues to be pursued with vigour and is now becoming evident in the GP sector as described by Chris Salisbury on p400-401 of this issue. It is time for the BMA to fight these government policies which threaten the integrity of the NHS-the rhetoric of 'patient choice' and 'patient led NHS' conceals their true purpose which appears to be to emulate the US despite thier poor health outcomers, large number of uninsured (47million)and the highest cost per capita in the OECD.
W Savage Chair of Keep Our NHS Public steering group.www.keepournhspublic.com
Competing interests: None declared
Competing interests: No competing interests
Dear Editor,
Pollock and Godden’s analysis is well written and made me laugh despite the depressing content. Their argument is built almost entirely on government documents, indicating the government has been aware for some time that public funding is being wasted on an experiment that is already going off the rails.
The Freedom of Information Act (FOI) came into force in 2005, but members of parliament have put themselves outside it’s reach, and the same seems to be true for requests to scrutinise financial proficiency in the NHS. I have been trying to obtain an answer to a simple request about the cost of a primary care practice since June 2006.
The shroud of secrecy over the deals with the independent sector providers is worrying, it seems unlikely that financial details are being kept from us because so much money is being saved.
I note the comments of Professor Black regarding satisfaction ratings, but no study has ever been able to link satisfaction ratings to health outcomes and satisfaction ratings cannot be taken as a measure of high quality clinical care. If the ratings are the only advantage of private sector involvement, the question remains how much of the public purse should be spent on the smell of fresh paint.
Competing interests: None declared
Competing interests: No competing interests
The Scottish Regional Treatment Centre in Stracathro Hospital, Angus, is the first ISTC in Scotland. The contract was awarded to Netcare UK. The SRTC opened in January 2007 and was only fully operational in August 2007.
Funding for private healthcare providers was announced to the Scottish Parliament on 15 December 2004. Prior to that there were no specific debates in the Scottish Parliament on ISTCs or private healthcare providers in the NHS in Scotland.
The SRTC Pilot Project was announced in a Scottish Executive press release in May 2005.
There was no mention of ISTCs in the NHS in Scotland by the Scottish Labour Party, or their coalition partners, in the manifestos for the 2003 Scottish Parliament elections, and it can be argued that the Scottish Executive did not have a mandate for the introduction of private healthcare providers, with long-term contracts, into the NHS in Scotland.
There was a lack of public debate within Tayside about this ISTC and a request for a public consultation, based on the NHS Reform (Scotland) Act 2004, was refused by Tayside Health Board. The public watchdog, the Scottish Health Council, said it would not investigate the lack of public consultation due to the direct involvement of the Minister for Health and Community Care.
After the contract between Tayside NHS Board and Netcare UK was signed, in November 2006, the contract was published on the internet, but without any financial data. Without that financial data the public, and researchers, are not able to make an assessment of value for money or productivity.
The contract is a 'take or pay' contract and NHS Tayside must send a minimum of 90% of the patients promised to Netcare UK or pay for unfilled contracts.
In October 2007, a formal Freedom of Information request for the costs of the contract was denied by NHS Tayside on the grounds that such disclosure would be likely to prejudice substantially Netcare UK's commercial interests. The Scottish Information Commissioner has allowed an appeal of the case and the decision will follow in due course.
In November 2007, Nicola Sturgeon, Deputy Prime Minister and Cabinet Secretary for Health and Wellbeing, said a comprehensive evaluation of the SRTC project will take place prior to the end of the three-year contract. It is the Secretary's view that this will need to examine value for money, the benefits to patients and whether these benefits could have been, or could possibly in the future be, realised in different ways.
The concern is that more contracts will follow before there is time for evaluation, as despite its pledge not to go down the market route, the Scottish government has recently stated that it will use private providers to meet waiting time targets.
Please also see “The Scottish Regional Treatment Centre (SRTC) Pilot Project at Stracathro Hospital by Brechin, Angus. The first Independent Sector Treatment Centre (ISTC) in Scotland - and perhaps the last”, a report by Ronald N Macdonald and John R Evans published at http://www.keepournhspublic.com/pdf/SRTCfinallong.pdf.
Competing interests: None declared
Competing interests: No competing interests
While sharing Pollock and Godden's concerns about the value for money of the first wave independent sector treatment centre (ISTC) contracts, I do not agree that "Data to support government claims that ISTCs offer...high quality health care..are lacking".
The Healthcare Commission review, which they cite (reference 6), collected data on patients' experience of the humanity of their care and compared the findings with that from NHS providers. They reported:
"While patients in both ISTCs and the NHS tend to rate experiences positively, the Commission’s survey found patients in ISTCs are generally even more positive about their care than those in the NHS. Ninety-six percent of the patients surveyed rated their overall care as ‘excellent’ or ‘very good’. Of the 33 issues explored in the patient survey, patients assessed ISTCs consistently better than the NHS on 28 of them. Looking at the areas with the most difference: 98% of those surveyed said the toilets and bathrooms were “very clean” or “fairly clean” in ISTCs, compared to 92% in the NHS; 65% of those surveyed said they were given a choice of admission date in ISTCs compared to 27% in the NHS; 96% of those surveyed said they were told who to contact if they were worried about their treatment in ISTCs compared to 76% in the NHS; 98% of those surveyed said that there were enough nurses on the wards in ISTCs compared to 92% in the NHS. Overall the views of the experienced NHS consultants who accompanied the review team on visits to the 12 ISTC providers were positive. Most were impressed with the facilities they visited and reported that procedures in the centres broadly matched that of the NHS. Observations during surgery indicated that clinical practice was of a good quality."
These findings don't necessarily justify the ISTC policy but they do need to be considered when reviewing the overall evidence available.
Competing interests: Member of Steering Group of Healthcare Commission Review of ISTCs
Competing interests: No competing interests
Further still than ISTCs
I think that the message about medical unhappiness with ISTCs has got through. A proposal to develop an ICATS (Independent Clinical Assessment and Treatment Service) network for musculoskeletal services in Lancashire/Cumbria has been abandoned not least because it became apparent that the negative and destabilising effects on existing services were eventually understood. There have been examples not just of fixed contract payments regardless of workload but also of over-commissioning. Thus in one area an independent osteoporosis screening service was requested to do 3000 scans per year when the existing hospital department had a minimal waiting list but was only doing 2000. Similarly it is alleged that a private wing in a newly built PFI hospital is being paid on a block contract basis despite being partly occupied by overflow emergencies from the acute hospital - which is also paying for these. If ISTCs and ICATS have to generate a profit for their owners it is difficult to see how they can make financial sense to a cash-strapped commissioning sector, and politicians are getting this message.
However there are other ways that PCTs may be able to change services but make a profit from so doing. In outpatients it is possible, as both dermatologists and rheumatologists have found, for PCTs to set up services within general practice run by specialists but costing far les that Payment by Results (PbR) tariffs. Secondary care specialists cannot do this without undercutting their own employers; the PCTs can, nevertheless, pay their specialists well over the odds yet still find it cheaper to do this.
As an example, in rheumatology a clinic of 8 new patients would attract a tariff payment of £1840 while a standalone consultant could expect to receive about £600 per session - approximately twice the current NHS sessional rate but still one-third the cost under PbR. Thus it is entirely possible for an existing service to lose a substantial number of referrals, even to the point of becoming financially non-viable; furthermore the ISTC issue of "cherry-picking" easy cases is mirrored.
A primary care service is not currently subject to the Choice agenda. Whether such set-ups are in breach of competition law is yet to be determined; what is clear, however, is that the clinical governance implications, the effects on training and research and the effects on existing services have been ignored.
All of these perverse incentives threaten the pattern of specialist care and the establishment and maintenance of multidisciplinary working. They also help to encourage unnecessary activity, particularly in diagnostics, where it becomes reasonable to send all back pain patients for MRI scans (because patients want them) despite both the expense and lack of clinical utility.
So there is more to all of this than simply a lack of evidence of clinical benefit from independent services; some may be more expensive, and some less, but all of them will threaten the existence of current provision without any overall proof that the exercies are financially prudent. We must ensure that if today's services are to be destroyed, what replaces them will be better. Otherwise what is the point?
Competing interests: None declared
Competing interests: No competing interests