The Impact of Treatment Centres
Some comments and questions stemming from the FIPO DTC Meeting
The Treatment Centre (TC) concept has been broadly welcomed and there is recognition that there is a need for increased capacity. There are, however, suspicions, irritations and provisos. The overriding question is whether these new ISTCs are an efficient use of resources and whether competition in the healthcare market will be ultimately beneficial for the patients. Will TCs break the mould or bust the system and what impact will other factors have such as the European Working Time Directive?
• Impact on Patients
The reaction of the patients and their wants needs to be addressed. It is not clear if all patients will react favourably to being bounced between teams or to travel far and wide for surgery. There remains the issue of patient “loyalty” and the consultant/patient relationship. Patient choice is much vaunted but there are no easy ways for the patient to judge the merits of different units. There is some anxiety about the possible downgrading of the General Practitioner’s role as the gatekeeper and referrer to secondary care.
• Impact on the Quality of Care
The goal of TCs and ISTCs is higher quality and more responsive services. Current day care units in the NHS are rigid and relatively unresponsive to change. New companies running ISTCs promise a flexible and patient orientated approach. Staffing from abroad is said to be of the highest calibre, with full health checks and indemnity. A proportion of staffing within ISTCs will come from UK staff but the question of poaching from the NHS is denied.
• Impact on Price structure
The UK Independent Hospital groups were not successful in their bids for new ISTCs. Whether this was due to a political decision to exclude them or because they were non-competitive is unclear. The downward pressure will challenge the new providers, and may not be sustainable. Primary care (PCTs), as the lead commissioner, will be the driver, entry point and determinant of TC success. The impact of HRGs (healthcare resource groups) as fixed national tariffs, with purchasing by PCTs at these rates for each procedure performed, is hard to assess but will certainly put pressure on providers. At what cost this will be to service and quality remains unclear. However, a standard tariff will help PCTs who have no competence to negotiate rates.
• Impact on NHS hospitals
NHS hospitals will lose revenue and this will result in higher unit costs. Staff losses may ensue which will be demoralising and destabilising. Hospitals will be left with increased co-morbidity with a greater proportion of complex, challenging and costly cases. This impact is potentially huge.
• Impact of Increased Market Capacity on the NHS and Independent Sector
There could be overcapacity in the market with too little recognition of the acute competition that will take place for support staff. As waiting lists fall certain NHS units could be threatened. This could impact on the independent sector as reduced waiting lists and reduced demand for private healthcare may ensue. This would drive up private hospital costs and thus the cost of private insurance.
• Impact of Regulation on Clinical Quality
The accountability of the new providers will be through CHAI. There are concerns about managing a multiplicity of providers. What the standards and quality of clinical work will be is uncertain. The follow up of patients and the management of complications by itinerant surgeons could result in a second-class service.
• Impact on Consultants and Trainees
It seems likely that there will be diminished training opportunities for specialist registrars in ISTCs. Formal teaching in these centres is achievable but may be difficult, incomplete and costly. Consultants will face a more open market which may challenge and quickly erode today’s barriers and defined hierarchies. There will thus be a profound impact for the medical workforce shifting skills, grades and boundaries that could result in a competence-based not consultant-based system. The impact on the financial rewards of practice could be affected.
The formation of consultant groupings in “Chambers” is one way in which UK consultants may contract with ISTCs but this is as yet untested territory.