---

Independent Sector Treatment Centres

It is a pleasure to follow the hon. Member for City of York (Hugh Bayley), who put his finger on several problems. I shall refer to several of them in the course of my contribution. I begin by disagreeing with the hon. Member for Southend, West (Mr. Amess), because I wish to congratulate the Minister on the Government’s response. It is easy to understand, because for once they have answered the report’s points in the order in which they appear. I remember not long ago having a nightmare wading through another response, in which none of the Government’s responses were numbered. They were in a higgledy-piggledy order and lumped together. I congratulate the Minister—it is reasonable and reasonably full. I wish to follow up a lot of things in it, and as it is from six months ago I think the Minister will be able to update us on progress. I wish first to mention the quality of care and outcomes, which are crucial. I am a little confused about the taskforce and Healthcare Commission examinations, which are supposed to have reported, one in the spring and one in March. I would be grateful for an accurate update on when we can expect them to do so. I am slightly worried about the remit of the Healthcare Commission review. Paragraph 28 of the Government’s response lists as part of that remit"““the extent to which the quality of care in ISTCs can be compared with the NHS””." That does not imply to me that there will actually be a comparison, which is what we want. It will just be about the extent to which the two can be compared, but we want an absolute comparison. Another bullet point is"““patients’ assessment of quality of clinical care and their overall experience of care provided by ISTCs””." As many hon. Members have said, we desperately need a factual, evidence-based survey of the outcomes of the NHS and ISTCs. Since our inquiry, some more little bits of isolated information have come to hand. I have had a note to tell me that long before ISTCs, Cardiff and Vale NHS Trust was worried about its waiting lists and commissioned Weston Area NHS Trust to carry out a number of its routine orthopaedic procedures. It discovered that nine out of 147 knee replacements carried out by Weston required revision in the first year. That was absolutely appalling and about six times the expected revision rate. The criticism was not that it was an ISTC—it was an NHS centre—but that it was distant from the originators of the referrals. There was no communication between the centres, and different surgeons carried out the pre-operative assessment, the operation and the follow-up. Those problems seem to have led to much less accountability and problems with a distant service provided in the NHS. Then I came across an earlier report in the ““Annals of the Royal College of Surgeons”” of 2005. It reviewed a relatively small number of patients who had been sent from the NHS in Exeter to the NHS in London for hip replacements. It found that over a period much longer than a year, the rate requiring revision was 12 out of 27 hip replacements, 44 per cent., compared with about 4.9 per cent. of those done in Exeter at the same time. As in the Cardiff example, the differences in outcome were because of patient selection, implant selection, the absence of follow-up and the absence of audit and accountability. The report implied that whenever an operation is done distantly from the originating hospital and consultant, there are specific problems to consider. The success or lack of it thus appears to relate to the distance from the originating unit. That brings me straight on to the problems of integration and additionality. If there is integration between the referral point and the point where the operation will be carried out, whether NHS or independent, there will be communication, and the same doctors will do the pre-op, the post-op and the operation. One could hope that things would be much more satisfactory altogether. On integration, the Government’s response states in paragraph 19:"““Integration between ISTCs and the NHS has not yet reached the level we should hope for. This has limited the flow of innovation and best practice from the independent sector to the NHS and vice versa.””" Paragraph 36 states:"““Our aim is for the independent sector to work in partnership with local healthcare economies to provide solutions which reflect and cater to local requirements.””" That brings us to additionality. Paragraph 37 states:"““As recognised above, integration between ISTCs and the NHS has not yet reached the level we should hope for but changes to phase 2 should encourage greater integration.””" Crucially, the paragraph continues:"““For example, local SHAs must demonstrate how ISTCs will be integrated within the local health economy””." I am confused by additionality. Paragraph 39 states:"““The relaxation of the additionality rules for the phase 2 ISTCs will bring about greater professional integration””." That is confusing, because we have been told elsewhere that shortage specialties will not be allowed, and that additionality will still apply. I believe that that applies to orthopaedic surgeons, yet many ISTCs are doing a lot of orthopaedics, which is the very place where we want additionality and integration. It is implied that NHS consultants who work in ISTCs should do so during non-contracted hours. I do not think that there should be such a limitation. I am quite sure that what is happening in some ISTCs—it is probably happening in the ISTC in the constituency of the hon. Member for City of York—is that NHS consultants are doing the work as part of their job plan. If it is written into their job plan and paid for at the same rate as ordinary NHS work, the combination could work.