Report from the FIPO Conference on DTCs, 7th October 2003
The Chairman of FIPO, Mr Geoffrey Glazer, in welcoming the audience of 150 people, introduced Mr James Johnson, Chairman of the Council of the British Medical Association, and asked him to open the Conference with a general overview of DTCs (now called TCs or ISTCs - Independent Sector Treatment Centres).
Several of the presentations are available to review online, follow the links associated with each presenter's name.
OPENING COMMENTS
Mr James Johnson
Chairman of Council, British Medical Association
Mr Johnson welcomed the prospect of additional capacity and a richer tapestry of providers. There was a long overdue need to ring-fence surgical beds in the NHS. However, whilst not opposing private practice in any way, it seemed as though the new overseas companies who will manage the ISTCs could compete with the NHS on staffing.
The responsibilities and liabilities of ISTCs will vary but the contracts will be explicit.
He felt that destabilisation of NHS Trusts is inevitable as funding will flow from Trusts and difficult (and more costly) cases will remain in the NHS. This will increase pressure on staff although there will be downward pressure on costs through the fixed price mechanism.
Mr Johnson was concerned about the training of junior staff and stated that this will be a cost that PCTs may not be able to pick up. The increasing impact of the European Working Time Directive (EWTD) will challenge round-the-clock working and could make NHS Trusts and possibly Treatment Centres unviable in many cases.
SESSION ONE
Chairman, Matthew Young
Special Projects Director of the Adam Smith Institute
Diagnostic & Treatment Centres
The Model (NHS and Private)
Questions posed: DTCs; what and where are they? Who will run them? How are they funded? How will the NHS and independent DTCs interact?
Dr
Tom Mann
Director, National Implementation Team
Dr Mann noted that in the UK there remains a capacity gap and that’s the challenge. The government’s position is to recognise that the outpatient (day surgery) model works. There is an indifference to where the work is done, provided it is done properly. All proposals were welcomed.
Dr Mann admitted that training issues had not yet been dealt with. He doubted that poaching of NHS staff would be a problem.
The targets for ISTCs will be more challenging than for the NHS centres and results will be published. Governance will be under CHAI and there would be no compromise on standards.
Sadly it appeared that some small bidders for ISTCs failed the test of financial robustness.
Professor
Sir Ara Darzi
Professor of Surgery Imperial College & Chair, London Modernisation
Board
Sir Ara Darzi said that the NHS will account for 80% of TC capacity. The looked-for goal is improvement in patient experience, process, integrated care and waiting list reductions.
Improved efficiency can deliver part of the extra capacity and this was illustrated by his experience of running a pilot scheme at the Central Middlesex Hospital. The biggest obstacle to change was reluctance of consultants (pooled waiting lists and travel to a new hospital site) and bureaucratic inertia.
In the Central Middlesex TC it was found that 10-15% of patients on the waiting list were removed after review by a senior surgeon. Rosters had to be constructed to ensure that the surgeon is capable of performing the procedure.
Sir Ara Darzi commented about the fact that BUPA Insurance rates were some of the highest paid to consultants and that sessional rates for surgeons (or fee for service) in his unit were much lower but were an inducement for consultants (anaesthetists in particular) to cooperate.
He admitted that quality and audit remains a challenge and that the private sector already has the best data.
Charles
Auld
Chief Executive, GHG Ltd
Mr Charles Auld, BMI Healthcare, the biggest group in the independent sector with 45 private hospitals, commented that ISTCs will prove to be a milestone and a fundamental shift in philosophy from a Labour Government. The government wants excess capacity and the pressure will be on to perform or fail. He predicted even greater flexibility in provision in the future.
However, existing private hospitals could meet the challenge of 200,000 waiting list cases a year. This would be cost effective and entirely from current resources (without taking anything from the NHS) and could work across the country. This had been proved by the cardiac model where patients had been transferred and treated with a resulting drop in the waiting lists and spare capacity in some NHS units such as the NHS Heart Hospital in London.
Mr Auld then offered to clear the NHS orthopaedic waiting list from within his own hospital group within a year under the Concordat arrangements.
SESSION TWO
Chair –John Randle
Management Consultant
Diagnostic & Treatment Centres
A third healthcare market?
Questions posed: Who will work in DTCs and under what terms? Can ‘Chambers’ contract for work and will this force more consultants into ‘Chambers’ groupings? Will foreign teams be involved? Can the UK Private Providers work in an NHS framework? Will a ‘Third Market’ open up? What will be the impact on independent hospitals and consultant private practice? Should DTCs employ or contract with doctors? Will private medical insurance be forced to change?
Professor
Nick Bosanquet
Professor of Health Policy, Imperial College
Professor Bosanquet of Imperial College, London, and a PCT Board member spoke on the issues for Primary Care Trusts (PCTs) of the introduction of DTCs. He emphasised that despite the substantial increase in NHS funding, most of it would go into the existing cost base of health provision relating to staff salaries, general inflation and the higher rates of medical inflation common throughout the world. He saw no likelihood of additional workload for DTCs beyond the requirement to meet government target levels and that therefore waiting list problems were likely to persist for many years. Additionally the shortening of waiting lists could lead to a shift from the private sector of over 50,000 patients who currently are funding their own care but would utilise NHS services if they were more readily available. Additional provision also was likely to lead to an increase in referral rates and if any real progress was to be made it would be essential to increase the performance of NHS hospitals to ‘best international practice’ on the volume of delivery.
Professor Bosanquet also stressed the difficulties arising from lack of professional staff in Britain and considered that the introduction of foreign teams would not solve the problem and ran the risk of being seen as a battering ram on existing consultants.
The planned provision of DTCs in the NHS and ISTCs run by the private sector ran the risk of over-provision of elective surgery capacity if the whole volume of NHS, existing private sector and the new services were taken into account. Considerably more work and research was needed to establish what true demands would be if productivity could be increased by other means.
Caroline
Southwood
Director of Corporate Affairs, Standard Life Healthcare
Caroline Southwood spoke on the potential impact of DTCs on private medical insurance companies. In the view of Standard Life, DTCs would be likely to enhance the overall provision of healthcare and that the new overseas entrance to the markets plus the presence of foreign doctors would open up the ‘third market’ and enhance choice for private practice. PMI companies needed to be alert to the changes in healthcare funding and delivery and to modify their products accordingly. Standard Life did not feel that corporate PMI would be affected because it was seen by companies as a major employment benefit and there would always be a small section of society who would only use the private sector. Although there could be some effect on individual subscribers the ability of the NHS, even with increased provision, to meet ever-growing demand seemed unlikely. Additionally, Standard Life saw the development of new techniques in medicine as likely to bring costs down because of the tendency towards day-care and shorter lengths of stay with a net effect of reducing costs and therefore making private medicine and insurance more affordable for the general public.
Overall, Standard Life saw DTCs to be a potential major benefit for the future and to lead progress on expanding the market and reducing costs, particularly with the introduction of national tariffs by government.
Derek Fawcett
Consultant Urologist, Reading Urology Group
The third speaker in the morning session was Derek Fawcett FRCS, a consultant urologist who is the lead clinician in the Harold Hopkins Department of Urology in Reading. Mr Fawcett is one of the pioneers of a partnership structure for provision of consultant services through the Reading Urology Partnership which was formed in 2001 in conjunction with one of the major private hospital groups who assisted in the setting up and funding of the facilities.
Mr Fawcett was careful to draw distinctions between individuals practising in barrister-type ‘chambers’ with no legal entity as opposed to the formal partnership structures which he saw as more likely to be the way forward for those consultants wishing to act collectively. Advantages for partnership working were driven by a number of factors including the ability to enhance clinical governance, the development of sub-specialties within a broader specialty consulting grouping, the sharing of costs and the ability to negotiate collectively both with the private sector and the NHS. He placed considerable emphasis on the need for consultants considering partnerships to be able to work together amicably in the long-term and also to address the ‘quality of life’ issues which came about by being able to share responsibilities and ensure adequate clinical cover.
Although Mr Fawcett did not see chambers or partnerships as being an imminent alternative development to NHS employment, he drew attention to the growing interest in such an arrangement across the country. He warned that setting up a partnership arrangement is time-consuming, complex in terms of legal and accounting systems, requires recognition of employment, the Care Standards Act and health and safety issues – as well as needing to be sure that the Competition Act was being observed. He foresaw the likelihood of groups of doctors getting together to negotiate with both the NHS and the private sector and that in the longer-term growth was inevitable.
SESSION THREE
Chair –Geoffrey Glazer
Consultant Surgeon & Chairman of FIPO
Diagnostic & Treatment Centres
Professional Aspects
Questions posed: What can be done in DTCs? How will the profession fit into this and with what the impact on current NHS Trusts and work patterns? What are the clinical and governance issues? What are the implications for junior doctor training, and long term manpower planning? What are the liability issues?
David
Ralphs
Consultant Surgeon & President of the British Day Care Association
Mr Ralphs stated that currently in the NHS some 58% of patients were treated as day cases. A target figure of 75% was achievable although the classification of certain cases (colposcopy or endoscopy) might be considered as inflating some figures. It seemed apparent that there is wide variation in practice which is both surgeon dependent and also due to hospital variations. There was a need to challenge a degree of clinical inertia and many units lack a clear operational policy.
Interestingly Mr Ralph’s patient surveys had shown that the subsidiary issues that affect patients are often predominately related to travel or parking arrangements rather than the quality of care.
He noted that there were issues relating to continuity of care and the fact that 2-3% of patients require admission gave rise to some concerns in the audience in terms of functioning of new DTCs. Overall the picture was one of no national standardisation and wide variations on the type and volume of work in NHS day units. It is conceivable that new TC’s would stimulate change.
Charles Collins
Consultant Surgeon & Council Member of the Royal College
of Surgeons
Mr Collins is the Royal College of Surgeons spokesman on TC’s. Mr Collins presented the college’s view on the competence and experience of surgeons who might have been trained abroad and insisted that all foreign surgeons should follow GMC and college guidelines on good surgical practice.
He addressed the question of surgical complications and the financial and professional issues that might flow from these. He was also concerned about the loss of surgical and anaesthetic training opportunities and the need for approved trainers to maintain continuity with their trainees.
The college was also concerned about destabilisation of Trusts and individual units where case flow might be diverted to local TC’s which would impact not lonely on financial stability but also on the balance of surgical practice and training. The methods of funding were also unclear.
Additionality (ISTCs not being able to “poach” NHS staff) was an issue as were patient’s rights in terms of their choice of surgeon and the role of the GP as the gatekeeper of secondary care.
Ian
McDermott
President of the British Orthopaedic Trainees Association (BOTA)
Mr McDermott is a specialist Orthopaedic registrar in his 6th year also spoke on behalf of ASiT (Association of Surgeons in Training). He thus represented the views of all surgical trainees in all specialties in the UK.
The trainees were overall concerned about the length and quality of their training. The length has not altered dramatically since the introduction of the Calman reforms but experience has now been dramatically affected by the European Working Time Directive. This was illustrated by various estimates of the reduction in man hours that registrars were working, although there was some evidence that operative experience had not altered dramatically.
The impact of ISTC’s would obviously have an affect on the operative experience to be gained by junior doctors. Secondment to NHS TCs was perfectly plausible but there would have to be some consideration given to training both in the independent TCs and possibly even the private sector.
The junior doctors were also affected by the changing ethos of the service and the low morale which affects all levels of staff.
Dr
Gerard Panting
Communications & Policy Director of Medical Protection Society
Dr Panting reviewed the legal liabilities of the medical profession and hospital providers. He discussed the various legal jurisdictions that could be faced by the profession and reminded the audience that consultants were owed a duty of care to their patients and that any breach of duty and resultant damage could result in legal action.
He saw no particular concerns with the introduction of ISTCs as it was assumed that they would carry normal insurance and all consultants or other doctors working therein would be fully insured (indeed were required to be).
Dr Panting foresaw some possible areas of concern if operative consent for fast track patients was not adequate and also if the follow up arrangements for this new group of patients was sketchy. There could be some potential legal and insurance confusion in a mixed economy with patients moving from one sector to another and some doctors working with and some without NHS contracts but overall these were matters that could be resolved major difficulties.