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Patient procedures, private providers and politicians
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The article in this Orthopaedics Today issue that reports concerns over the poor quality of surgery in some Independent Sector Treatment Centers highlights the tensions developing between government politicians and surgeons working in the National Health Service in Great Britain [Click here for story].
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![David L. Hamblen, PhD, FRCS [photo]](/~/media/images/shared-images/david-l-hamblen-phd-frcs.jpg)
Beginning in 2002, there was a massive increase in government funding for the National Health Service (NHS), but this failed to generate the extra capacity required to deal with the long waiting lists for elective surgical procedures, particularly in ophthalmology and orthopaedic surgery. Politicians became frustrated by their inability to deliver their much-publicized target of a six-month maximum wait for inpatient treatment by December 2005. The federal government’s solution was to purchase extra capacity through the provision of Independent Sector Treatment Centers (ISTCs), partly in the NHS and partly through contracts with the private sector.
These centers were designed to provide safe, fast, prebooked day- and short-stay surgery and diagnostic procedures through contracts with the local NHS providers. Their major advantage over traditional NHS general hospitals was the separation of elective (ie, planned) care from emergency surgery and unplanned admissions.
Good and bad points
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The concept worked well in the majority of centers developed alongside and integrated with NHS facilities. They were particularly successful in dealing with large numbers of patients awaiting cataract surgery, reducing the waiting time to less than three months.
The problems have largely centered on the smaller number of centers run by the independent private sector, particularly where these have extended their concept of orthopaedic short-stay procedures to include hip and knee joint replacements. The ISTCs were not allowed to recruit staff working in the NHS and were forced to import staff from other European Union countries, often on a very temporary or part-time basis.
Many of the surgeons employed, though classed as specialists under the training regulations of their own country, lacked the wider experience and seniority of the British-trained consultant. This inexperience, combined with an apparent lack of expertise or facilities to deal with more serious complications, has thrown an additional burden on the NHS hospitals. These surgeons, in turn, feel disadvantaged financially due to an adverse contract system that pays the ISTC at a rate up to 20% in excess of the equivalent procedure in the NHS.
The final criticism — that surgeons in training are not able to benefit from the operative experience offered by the large number of standard procedures performed in these centers — has been recognized by the federal government as valid. They have agreed to allow trainees to work in the second-phase centers now being developed, but have not decided how this training will be supervised and monitored.
What have we learned?
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What lessons can be learned from these problems, which seem to have resulted from a clash of political and professional cultures? The basic concept of increasing and protecting elective capacity is a good one and has already yielded major benefits for NHS patients, who previously faced unacceptable delays for routine surgery.
What politicians failed to realize, or were not told by their advisers, was the impact this policy would have on NHS services at a local level in destabilizing financial support for other vital clinical services. They also failed to understand the professional relationships between surgeons and their patients in terms of continued clinical responsibility and accountability.
Solutions to the current situation demand better understanding and communication between the government, as purchasers of health care, and the providers, both managers and clinicians. Where the independent private sector is to be used, it must be subject to the same financial contracts, staffing standards and clinical audit procedures as the NHS. These must include prospective peer-reviewed audits of clinical outcome data and not just measures of management performance, such as length of stay and initial patient satisfaction.
It should also put in place clear and defined links with existing local NHS services and training programs to ensure that patients receive the most appropriate and best supervised treatment at all times.
David L. Hamblen, PhD, FRCS
Consulting Editor