Too independent for patients’ own good?BMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b4077 (Published 07 October 2009) Cite this as: BMJ 2009;339:b4077
All rapid responses
Some of the facts in Nick Clarke's Review of the Week about
Panorama's recent programme on ISTCs cannot go unchallenged (BMJ
He refers to a recently published study in the Journal of Bone and
Joint Surgery about poor clinical results of joint replacement operations
on Welsh patients at the Weston NHS Treatment Centre in Somerset. Hip and
knee replacement patients from that centre had a significantly higher
early re-operation rate than would be anticipated. He fails to mention
that the Weston NHS Treatment Centre was not an ISTC unit. It was set up
before the ISTC programme had started. It was an NHS initiative, run by
the NHS. The only non NHS aspect was that NHS managers decided to use
visiting surgeons from abroad. Mr Clarke, like the British Orthopaedic
Association, fails to make the important distinction between the ISTC
program and this NHS unit in Weston.
Mr Clarke blames ISTCs for reducing training opportunities for junior
staff. The ISTCs perform 5% of joint replacements in England and Wales
but traditional private hospitals perform 30%. It is therefore
predominantly the latter which is taking the cases from the NHS.
Mr Clarke tells us that ISTCs do not have to submit data to the
National Joint Register. The facts are that 100% of the ISTCs undertaking
joint replacements submitted their data in 2008 compared with only 90% of
This information is all in the National Joint Registry 2009 report.
Other data shows about a 2% revision rate for hip replacement in England
and Wales after three years and about a 2.5% rate for knee replacement
over the same period. When analysed according to where the operations
were done the revision rate of ISTC cases was the same as for the wider
For the last two years a detailed study looking at joint replacement
clinical outcomes from ISTCs, NHS treatment centres and NHS district
hospitals has been undertaken by the Royal College of Surgeons (the POIS
study). Data on many thousands of hip and knee replacements is being
collected and the results should be available by the middle of 2010. The
answers to the questions about ISTC quality will have to await that study.
Meanwhile the reality is that all surgeons have complications and all
types of hospital will have some early failures after joint replacement.
The units which do best, NHS or ISTC, will have well established clinical
pathways, high joint replacement volumes, experienced surgeons and, most
importantly, robust clinical governance processes.
Paul Evans FRCS MSc
Consultant Orthopaedic Surgeon, Peninsula NHS Treatment Centre, Plymouth
Medical Director of a Wave 1 ISTC
Competing interests: No competing interests