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Independent Sector Treatment Centres

I congratulate my right hon. Friend the Member for Rother Valley (Mr. Barron), the Chair of the Health Committee, on securing the debate, which has proven to be extremely informative. Hon. Members have raised extraordinarily interesting points, which I hope my hon. Friend the Minister will deal with in due course. My right hon. Friend has set out the terms of reference under which independent sector treatment centres were set up, and we have listened to hon. Members mentioning some of the pros and cons of those issues. I would like to keep things even simpler than that. In my view, the mark of whether the ISTC programme is a success or not is, first, does it improve patient care and, secondly, does it do so at a reasonable cost? To answer that question, I would like to go back a few years. I have been in the health service for many years and I can think back to many times when waiting lists were far worse than they are now. Not too long ago, it was not unusual to wait two to three years for a hip replacement. The wait for someone with a hernia was not much different. Similarly, for many orthopaedic procedures, there were very long waiting waits and very poor provision. The NHS at that time was simply not modernising as it needed to do. Outmoded treatments were still being offered by some centres. Not every centre was offering the most up-to-date surgical techniques. There were reasons for that. One reason was that some surgeons simply were not trained to the high level that we would expect. In other areas, they did not have access to the equipment that they needed for more modern surgical techniques, because the hospital simply did not see those as a major issue. Often, there was underutilisation of capacity: there were empty beds and surgeons were sitting around unable to operate because theatre capacity was not sufficient. Poor capacity in intensive care units meant that operations had to be postponed because there was not the staff, the equipment or the facilities to ensure safe operations. We have heard this afternoon that it was very common at one time for operations to be cancelled at the very last minute—sometimes when the patient had already been sedated—because an emergency had come in. At other times, people received a phone call the previous day to say, ““I’m sorry. Your bed’s been taken by an emergency. Come back next week and we might be able to help you then.”” That was all too often, and all too depressingly, the case. People would have put a lot of time and effort into planning for their operation. They would have talked to their family; they would have talked to their children. Their husbands or partners would have taken time off work. They would have made arrangements for their children to be cared for. They would do all that only to find the day before that the operation was cancelled. I have always been an advocate of complete separation of acute treatment and elective treatment and having them in completely different sectors. I am very pleased that the Government have responded to the many calls made by me and others for separation of acute and elective surgery in particular, so that those operations simply would not be cancelled any more, because the elective centre would have in effect ring-fenced staff, ring-fenced facilities and ring-fenced theatres. That is extremely good news. It is easy to say that the NHS could by itself have put those problems right. There is nothing to say that we needed independent sector treatment centres to improve any of the things that I have mentioned. Surgeons could have been trained in the latest techniques; hospitals could have chosen to buy the latest equipment; operating theatres could have been upgraded in line with best practice; and capacity issues could have been addressed by individual hospitals and trusts as and when they chose. However, that was not happening. For all the problems with independent treatment centres, they have acted as an enormous spur or at least as a driver to try to bring all centres up to the best standard. We have heard from colleagues this afternoon that many NHS centres have achieved that. The question is: would they have achieved it if we had not been having a debate over the past 10 years on whether we increase capacity by using the independent sector. My view is that, although the overall effect of independent treatment centres has been quite small in terms of numbers, they have raised the debate to a level to which it was not previously being raised, which in itself has been a driver for best practice improvements in other parts of the sector. Therefore, the programme should be welcomed at least as an extremely useful debating point and a very useful springboard for improving practice. There is no question but that the establishment of ISTCs was driven by a wish to reduce surgical waiting lists and to improve cost-efficiency in the NHS, which in itself should be laudable. The centres have indeed offered more patient choice. Where they exist, patients and doctors have an extra choice over and above the existing system. Many ISTCs have been able to introduce best practice and have been successful in introducing a range of innovative working practices. They have, therefore, been able to improve patient care. I have done some research on the issue and had a look around the country to see what has been achieved in various centres. I shall mention just a few examples. In some areas, mobile solutions have been provided whereby the provider supplies clinical services from mobile units set up on agreed sites, particularly to improve access in remote areas. There has been the construction of new facilities designed around the clinical flow of patients and thus improving productivity. That is a brand new concept for designing services. There has been improved process design, to improve the patient’s experience by increasing throughput without compromising patient safety or clinical quality. Mobile ophthalmology units, for example, are capable of dealing with 20 to 23 cases a day due to streamlined processes facilitating efficient use of theatre space and resources. Extraneous administrative processes have often been put online, so that surgery is not delayed and can commence at the start of the working day. Some centres have stocked a smaller range of prostheses, allowing theatre staff to become more proficient and more productive in the use of a more limited range of prosthetic devices. Some centres have used local anaesthetics instead of general anaesthetics for primary joint replacements, thereby reducing the anaesthetic risk and the average length of stay to five days from the eight days previously experienced in the NHS. Some centres have introduced blood conservancy and recycling measures that reduce the need for transfusions. That is an important issue as well. However, none of those issues is exclusive to those centres. All those things could have been achieved elsewhere, but the fact is that in too many cases they have not been. That said, it is important not to over-emphasise the impact that ISTCs have had. The British Medical Association, for example, contends that"““the participation in research, teaching, and peer-reviewed activity that is vital for innovation in healthcare is not ideally suited to the working environments found within most, if not all, ISTCs. The employment of overseas clinical teams often on short-term, rotating contracts in ISTCs is one example of such a possible shortcoming.””" It is also clear to me that ISTCs are not necessarily more efficient than NHS treatment centres. I was very proud that the Health Committee chose to visit my local unit in Dartford—the Woodland centre—which has been extremely efficient. Indeed, many colleagues have referred to its very good practice and the very streamlined approach that it has taken, integrating the NHS treatment centre into the mainstream hospital, thereby getting many of the benefits and very few of the disadvantages of the system. In fact, that centre has achieved a theatre utilisation rate of 90 per cent., which by any standard can be considered very high. Similarly, the Nuffield orthopaedic centre in Oxford, where care pathways were written with primary care involvement, has been successful in achieving a reduction in the length of stay from 12 days to just five days. In Goole, the average length of stay in orthopaedics has been reduced from 12 to about six days, thanks to improved pre-operative assessment techniques. It seems that innovation in most ISTCs is largely a matter of better processes and clinical management, rather than revolutionary surgical techniques. It is probable that it has been driven by the regular and consistent case mix, and stems from the elective surgery only status of all treatment centres, rather than the independent sector’s involvement in the treatment centre programme. A number of written submissions to the inquiry also made the point that some specialties and operations may be more suited to the ISTC system than others. Cataract surgery, for example, is a relatively simple patient pathway and is well suited to the system. A general practitioner or an optician can make the diagnosis and the patient is then referred to an ophthalmologist. A relatively straightforward operation is performed and the patient can often be discharged with no follow-up at all, apart from perhaps a visit to their local GP. However, many other surgical procedures are not so straightforward. A patient with rheumatoid arthritis, for example, who requires joint replacement surgery may have poor bone density, other medical conditions, a complicated drug regime and mobility problems, and therefore probably is not a suitable case for the type of procedure that I have described. They may need far more follow-up and rehabilitation. Whilst ISTCs might be ideal models for simple, one-stop surgery, they do not work so well with complex conditions that require continuing care. Many NHS hospitals and departments have developed multi-disciplinary teams to manage the rehabilitation of post-operative and other patients, who may be seen for several weeks after their discharge. As ISTCs do not provide multi-disciplinary teams, they cannot and do not provide such a complete care package, and therefore do not have to bear the financial consequences of aftercare, which the NHS often has to pick up. Concerns have also been raised about the tendency of some ISTCs to cherry-pick patients, and to leave the more difficult cases that require significant amounts of post-operative care to the NHS. There is also an issue with training, which has been mentioned. In giving ISTCs that are run by non-NHS staff responsibility for carrying out a large number of procedures in key specialties, we might be making it more difficult for junior doctors to gain the requisite amount of experience in those areas. I know that the Government have looked into that, and I am keen to hear what the Minister has to say on it. The fact remains that if we are to train the next generation of surgeons to the very high standards that we require so that they are able to provide a good service, they must gain a lot of experience with routine patients as well as more complex cases. Many of my colleagues who work in general surgery are worried that if all the routine, relatively straightforward cases are sent to the independent sectors, leaving only the complex and rare cases behind, that does not leave a good training base to provide all-round, well-trained surgeons. Some of those problems are not only expensive, but can slow down patient care, and are inconsistent with the Government’s stated aim of moving more care out specialist secondary services and into primary care services. People have raised with me their concerns that many of the procedures that are carried out in ISTCs could be performed by trained GPs in their surgeries, such as the removal of certain cysts, minor skin procedures, endoscopies, colposcopies and so on. Indeed, many such procedures are already being provided by specialist, trained GPs. If we steer many of those patients to ISTCs, we will maintain high costs and will risk flying in the face of Government policy to transfer much more of that kind of care back into the primary care sector. In conclusion, I think that there is a role for ISTCs in the NHS as additional providers of services, but they need to be carefully managed. We should use best practice in those services to direct and drive care and modernisation within the NHS, to act as a focus for improved efficiency and to show hospitals across the NHS what can be achieved. They can be a useful pilot to show how they can be a genuinely useful addition to NHS capacity that improves the patient experience at a cost that really is affordable. However, we need to recognise the lack of transparency in some of these issues—many hon. Members have mentioned that. Provided that ISTCs do not undermine the NHS’s existing work, they can and should be seen as a useful addition to what we currently offer.