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The Royal College of Ophthalmologists

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									                           The Royal College of Ophthalmologists
                       RESPONSE TO HEALTH SELECT COMMITTEE
                 New Inquiry - Independent Sector Treatment Centres (IS-TCs)



Executive Summary

The Royal College of Ophthalmologists (the College) wishes to thank the Select Committee for

this opportunity to contribute to the Committee’s Inquiry into IS-TCs. The College welcomes

extra investment in healthcare by Government but we favour investment in local integrated NHS

ophthalmic services, including in NHS Treatment Centres, rather than in IS-TCs. We believe

such investment will reap long term gains which are presently being undermined by the current

focus on IS-TCs in England at the expense of local NHS departments.



In summary the College has concerns about:

   •   Adverse clinical or patient safety incidents in the IS-TCs;

   •   Adverse impact of IS-TCs on the finances or services at local NHS eye units;

   •   Adverse impact of IS-TCs on local NHS clinical staff morale;

   •   Adverse impact of IS-TCs on local NHS clinical training;

   •   Destabilisation of clinical manpower planning by IS-TCs.



The College’s response to the questions follows in the order the questions were posed.




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1. What is the main function of IS-TCs?

   To increase capacity, often for a single procedure, such as cataract surgery. The
   separation of planned elective care (often called cold surgery, e.g. cataract extraction) in
   ring-fenced beds or treatment areas away from the pressures of providing emergency
   care is of considerable merit in healthcare. It makes good operational management and
   safe clinical sense. In National Health Service (NHS) hospitals this is provided in
   dedicated day treatment or day care areas on the site of existing acute hospital services.
   Ophthalmologists in English NHS care have long been leaders in this field. The College
   has encouraged such innovations along with NHS managers, nursing and paramedical
   colleagues for some years.



2. What role have IS-TCs played in increasing capacity and choice, and stimulating
   innovation?

   2.1 CAPACITY. IS-TCs have resulted in a small increase of capacity of around 7%. To
      increase capacity, the College favoured expansion and upgrading of local NHS
      hospital eye service (HES) units. Excellent progress has been made with the
      commissioning of dedicated day-care cataract facilities within the Action on Cataracts
      scheme (2000)1, an initiative undertaken long before the introduction of IS-TCs. Over
      300,000 cataract operations were performed by the NHS in England in 2005, an
      increase from 175,000 in 2000. Only 20,000 cataract operations have been performed
      in IS-TCs cumulatively to date.2

   2.2 CHOICE. While having more providers inevitably gives more choice, in reality, in
      ophthalmology, patients have chosen their established NHS eye service. In many
      areas it has been necessary for PCTs to direct patients to ISTCs and, despite this and
      local advertising campaigns, capacity at the IS-TCs has not been utilised.

   2.3 INNOVATION. We are unaware of any innovation relevant to ophthalmology from
      either the mobile or static IS-TCs to date. We do have evidence of some outdated
      practices with adverse incidents to patients.3 IS-TC procedures by overseas visiting
      teams have had to be raised to UK standards. Participation in research, clinical audit
      and peer-reviewed presentations are vital for quality assurance and innovation in
      healthcare but are not compatible with the short term nature of rotating (overseas)
      teams in IS-TCs. There is also a complete lack of training in any ophthalmic IS-TC.




                                         Page 2 of 8
3. What contribution have IS-TCs made to the reduction of waiting times and waiting
   lists?

   Very little as waiting times for cataract surgery in England came down before the cataract
   IS-TCs became operational.2



4. Are IS-TCs providing value for money?

   We do not know. The evidence suggests that IS-TCs select the more straightforward
   cases and exclude those with co-morbidity (for example poor mobility) but receive the
   same funding or tariff per case while NHS hospitals accommodate all patients including a
   significant proportion with severe or multiple co-morbidities such as dementia without any
   supplement. IS-TCs do not provide holistic care. We understand IS-TCs received
   additional start-up funding at the outset. Furthermore the ISTCs are paid for block
   contracts of work regardless if this work is ever undertaken or not.



5. Does the operation of IS-TCs have an adverse effect on NHS services in their
   areas?

   Yes. The diversion of funds away from NHS hospital eye services to IS-TCs is
  threatening the provision of comprehensive ophthalmic care for whole communities –
  emergency care for injuries or retinal detachments, the management of chronic blinding
  conditions such as diabetic retinopathy, glaucoma, macular degeneration, children’s eye
  problems etc. Some NHS eye units are contracting (not replacing ophthalmologists who
  retire) and may become unviable, requiring patients, mainly children, the elderly and
  visually impaired people, to travel further for care. The local hospital is also
  accommodating patients who suffer adverse incidents at the IS-TCs often requiring
  months of ongoing care and sometimes further surgery to prevent blindness.



6. What arrangements are made for patient follow-up and the management of
   complications?

  6.1 Patient safety in the IS-TCs is a concern in ophthalmology 3 and in other specialities 4,5
  College guidance on prudent steps to take in advance of commissioning cataract surgery
  6
      was largely ignored by sponsors.

  6.2 Several examples of poor care arrangements have been made known to the College
  in correspondence from patients and ophthalmologists. This correspondence has been
  shared by the College with the Healthcare Commission. Patients following surgery at
  mobile units have been told by the ISTC ‘Help Line’ service to travel considerable


                                         Page 3 of 8
   distances for urgent follow up.     The used of brief standardised letters by ISTCs to
   general practitioners has lead to a breakdown in communications and a total lack of
   information accompanying the patient with complications who arrives at their local NHS
   unit. Service Level Agreements said to have been made by IS-TCs with Trusts have not
   been communicated to NHS clinicians who actually deliver the back up care.

   6.3 The College is concerned that the National Patient Safety Agency (NPSA) will not be
   made aware of patient safety incidents in IS-TCs as their remit is currently restricted to
   NHS providers. We are not aware of any risk assessment being made in advance of the
   mobile IS-TC deployment.



7. What role have IS-TCs played and should they play in training medical staff?

   No training has been provided to ophthalmic medical, nursing or paramedical staff in the
   IS-TCs that we are aware of. In order to offer high volume surgery, IS-TCs are not a
   suitable location for training as trainees in all clinical professions require time and are
   encouraged to practice holistic care, not usually provided in single-procedure settings.
   However the ‘cherry-picking’ of the straightforward surgical procedures to IS-TCs has
   implications for surgical training, as NHS units are left with more complex cases, which
   are less suitable for the training of junior surgeons7. There is an ethos of training among
   all clinicians in NHS units which is not found in IS-TCs.



8. Are the accreditation and appointment procedures for IS-TC medical staff
   appropriate?

   8.1 There are concerns about the uncertain appointments of IS-TC specialists compared
      with the robust NHS Advisory Appointment Committees for consultants in the NHS.
      Staff employed by the NHS in any clinical capacity within the previous 6 months have
      been specifically excluded from working in Wave 1 IS-TCs. This ‘additionality’ rule
      had the effect of favouring overseas bidders for IS-TC work, employing overseas
      doctors working in their vacations. Although registered as specialists with the GMC,
      overseas doctors have not been subject to NHS appraisal and clinical governance
      systems long familiar to UK clinicians.

   8.2 We are aware of concerns from both the Healthcare Commission and from the
      Department of Health with regard to inconsistencies in appointments to IS-TCs. The
      inconsistencies that have been listed by Marney Prouse, (Clinical Governance Lead
      for the ISTC programme at Central Contract Management Unit (CCMU) in 2005) to
      Royal Colleges at the Royal College Leads/National Implementation Team meeting
      include variations in:


                                        Page 4 of 8
                  Recruitment agency practices
                  English language assessment
                         -   Testing mechanisms
                         -   Communicating under stress
                  Medical education in country of origin
                  Working practices in country of origin
                  Availability of suitably qualified personnel
                  Interviews and practice privileges awards
                  Short term contracts
                  Assessment techniques by providers
                  Induction for new staff
                   Use of Alert Letters



9. Are IS-TCs providing care of the same or higher standard as that provided by the
   NHS?

   9.1 We find no evidence that IS-TCs provide cataract surgery of higher standards than
      that provided by NHS units. There is evidence that co-existent problems such as
      diabetic retinopathy or glaucoma in the patient’s same eye are ignored. Treating
      patients as individuals with an integrated multidisciplinary holistic care approach for
      both acute and chronic eye conditions locally is preferred. The current IS-TCs can
      only receive the most straightforward patients for surgery and exclude wheel chair
      patients, deaf patients, patients requiring general anaesthesia, children etc from the
      mobile cataract units. (Netcare Principals Document, Netcare UK).

   9.2 There is also no coordination with services for blind and partially sighted individuals
      and the patient groups and charities that represent them.          There is a risk of
      fragmentation of existing comprehensive NHS ophthalmic services.

   9.3 We share the reservations of the National Centre for Health Outcomes Development
      concerning the monitoring of quality, especially clinical outcomes, from the ISTC
      schemes.8     A recent survey of PCTs revealing little or no robust monitoring of the
      quality of cataract care commissioned by most Primary Care Trusts is important and a
      further worry. 9



10. What implications does commercial confidentiality have for access to information
   and public accountability with regard to IS-TCs?

   The true costs of IS-TC care are unknown and are protected by ‘commercial
   confidentiality considerations’ from scrutiny. NHS units are readily accessible for



                                          Page 5 of 8
  accountability and are subject to the Freedom of Information Act. As overseas providers
  are based in other countries, their activities are remote from UK investigation including
  the Audit Commission.



11. What changes should the Government make to its policy towards IS-TCs in the
   light of experience to date?

  While we welcome the additional investment by Government in healthcare we believe it
  should be directed to expanding local NHS hospitals. Treatment centres should be run in
  co-ordination with established units (as NHS Treatments centres are) to ensure quality
  and equality of patient care, integrated services available to all patients and training
  opportunities for our future healthcare professionals. Medical staff would be subject to
  more robust regulation procedures and clinical governance issues would be open to
  scrutiny.



12. What criteria should be used in evaluating the bids for the Second Wave of IS-
   TCs?

  12.1    Little or no clinical or local NHS management or informed public engagement
      occurred in ave 1 commissioning. We see the same errors repeating in Wave 2 bids.
      The lack of discussion and engagement with local clinicians is allegedly for reasons of
      commercial sensitivities.

  12.2    The College has written to Dr Bruce Websdale, Clinical Director, detailing which
      specialist ophthalmic operations should NOT be commissioned/purchased from IS-
      TCs as they are invariably part of a long term treatment plan for the patient and
      require multidisciplinary team care for optimal results.

  12.3    Some ophthalmic treatments may be suitable for treatment centres, such as (i.e.
      low clinical risk) high volume day care cataract care, minor eyelid surgery while other
      more complex cases, which are part of a continuum of care, are not.



13. What factors have been and should be taken into account when deciding the
   location of IS-TCs?

   Where there is a documented need for an increase in routine surgery expansion should
   be considered. Any such expansion should be fully integrated into the existing NHS
   services, as occurs with NHS Treatment Centres, even if geographically distinct, to
   ensure continuity of care for the patients and good communications with other clinicians
   and support services involved. This would have the added benefit of accommodating the


                                        Page 6 of 8
       training of new healthcare professionals at all levels and ensure innovation and research
       is continued in a controlled environment.

       With the piecemeal roll out of IS-TCs without local clinical and managerial engagement
       we risk destabilising existing world-class NHS hospital eye services. This will be at the
       peril of future generations’ eyecare.


  14. How many IS-TCs should there be?
       We favour NHS Treatment Centres, rather than IS-TCs, integrated into existing local
       NHS services, possibly in a hub and spoke model. Examples exist and function very
       effectively with the operational benefits of single procedure surgical lists but with the
       guaranteed quality and patient safety associated with an established, well-governed NHS
       eye unit.




REFERENCES

   1         Department of Health. ‘Action on Cataracts – Good Practice Guidance’. NHS
             Executive. Feb 2000. http://www.dh.gov.uk/assetRoot/04/01/45/14/04014514.pdf
   2         Kelly SP. ‘Recurring policy errors: blind spots over cataracts’
             The Lancet, 2005. 366:9498, Page 1691
   3         Kelly SP. Cataract care is mobile; is direction correct?
             British J Ophthalmol. 2006 90: (1) 7- 9
   4         British Medical Association. ‘Impact of Treatment Centres on the Local Health
             Economy in England.’ Report. December 2005. London. British Medical
             Association.
   5         Lowry J. ‘Cause for concern: extending choice, growing capacity and the
             independent sector treatment centres’ Bulletin of The Royal College of Surgeons of
             England.2005 87, (3) 92-93
   6         Royal College of Ophthalmologists. ‘Commissioning Cataract Surgery-An outline of
             good practice’. London. May 2005
             http://www.rcophth.ac.uk/docs/profstands/ophthalmic-
             services/CommissioningCataractSurgery2005.pdf
   7         Catherine Guly, Richard Sidebottom, Kim Hakin, Keith Bates ‘Challenges of private
             provision in the NHS: Treatment centres and their effect on surgical training’. BMJ
             2005;331:1338.
   8         National Centre for Health Outcomes Development. ‘An overview of performance
             under the Independent Sector Treatment Centre programme’ Dec 2005. London.
             National Centre for Health Outcomes Development.



                                               Page 7 of 8
9   Paul R Brogden, Ian G Simmons. ‘Good quality monitoring is crucial for informed
    choice.’ BMJ 2006;332:118.




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