Surgeons cite inferior outcomes at independent sector facilities

The British Department of Health counters it sees no difference in surgical quality or patient satisfaction for independent vs. NHS hospitals.

Independent Sector Treatment Centers throughout the United Kingdom may cut wait times and relieve National Health Service caseloads, but some British orthopaedic surgeons claim that the centers also provide substandard results.

“A large number of patients who are treated in the centers are getting satisfactory results, but the proportion of poor results is unacceptably high,” W. Angus Wallace, FRCS, an orthopaedic professor at the University of Nottingham, told Orthopaedics Today. “We now know from three U.K. studies — and these studies are not perfect — that the complication rate from Independent Sector Treatment Center (ISTC) treatment has been recorded as between three-and 10- times higher than in National Health Service (NHS) hospitals.”

“A large number of patients who are treated in the [independent] centers are getting satisfactory results, but the proportion of poor results is unacceptably high.” — W. Angus Wallace, FRCS

Critics of ISTCs cite predominately foreign-trained staffs and the “principal of additionality” — or the requirement that NHS surgeons must take a six-month leave before working at independent centers — for causing a purported increase in surgical problems. These centers cull surgeons from Germany, Czech Republic or Croatia, which offer different — and in some cases shorter — training programs, Wallace said.

“[Some countries] do not have a formal assessment or examination at the end of their training, and the standards that are laid down … may be lower than they are in the United Kingdom,” he said.

Many ISTC surgeons are junior specialists who are supervised in their native countries, but fail to receive mentorship in independent centers.

“The companies that have [these junior specialists] set up are not altruistic,” Wallace added. “They are business people wanting to make money. As a result, their emphasis is on ensuring that there is the delivery of a service, but at a cost that will not be too great. Therefore, employing additional surgeons who might act as supervisors or overseers is something that they have not considered.”

Additionality

Regulations regarding “additionality” compound the lack of surgical supervision and highly trained specialists in these facilities, he said. Additionality principals state that NHS surgeons must take a six-month leave before working at independent centers. “Surgeons in the United Kingdom would not necessarily wish to leave the National Health Service for six months because it is the main employer in the United Kingdom,” Wallace said.

The bottom line, according to critics, is that unsuspecting patients may be receiving suboptimal treatment.

“If you actually sit back and ask why have these surgeons come to the United Kingdom, it’s probably because they have not been able to progress their career in their own country in the way that they wanted,” Wallace said. “Therefore, you may be getting the less knowledgeable [and] the less skillful surgeons coming to the United Kingdom because their career path is not as good as they would want.”

Difficulties may result even when centers employ expert surgeons.

“On a couple of occasions, surgeons who may be well-qualified but are completely unfamiliar with the particular implants they’re expected to use and who have very poor language skills are being thrown into operating theaters and are not doing terribly well,” Malcolm S. Glasgow, FRCS, an orthopaedist in Norfolk, England, told Orthopaedics Today.

Anecdotal evidence

The situation has led to anecdotal reports from NHS surgeons who claim to perform revisions on an increasing number of ISTC-treated patients. Glasgow said he revised three hip and knee replacements following ISTC care.

“I wouldn’t go as far as to say that there was overt negligent insertion, but we’re talking about problems with infection, problems with recurrent pain after arthroscopic surgery [and] problems with stiffness after arthroplasty,” said Glasgow, who is a member of the Orthopaedics Today editorial board. “But again, you have to be very careful. This is anecdotal, and surgery can go wrong even in the most skillful hands.”

Nevertheless, the reports have grabbed the attention of the British Orthopaedic Association (BOA). The organization’s president, Ian J. Leslie, FRCS, said surgeon-members have also noticed a slightly higher incidence of prosthetic malalignment and early hip dislocations among patients treated at ISTCs.

“There was an example of a patient being sent home in three days after a hip replacement in Cornwall with bleeding from the wound, and the patient had to find [his or her] own transport home some distance away,” Leslie told Orthopaedics Today. The patient then had to be “readmitted urgently to an NHS hospital. So, one of the problems, it seems, is that some of these patients are having high earlier complication rates than we would expect.”

Glasgow added that two ISTC surgeons in his region have had cancelled contracts due to poor procedures. “One had a 50% major complication rate after joint replacement, and he was eventually stopped from operating,” he said.

Comparable quality?

Despite the criticism, the Department of Health says that these claims fail to match the audited data.

“The patient feedback shows that they are 97% satisfied with the service they get,” a Department of Health spokesperson who declined to be named told Orthopaedics Today. “We have found no evidence to show that [these outside surgeons] are not providing the standard of care that we would expect from any NHS provider.”

The department receives monthly reports, which measure the quality of ISTCs on 26 key performance indicators. The audits are then published and made available to the public. The next report will be released in the fall.

“Orthopaedic work is put on the national joint registry as well, so that there are a range of ways [to determine performance],” the department spokesperson said. “So far, there has been no proof that there is any significant difference” between NHS surgeons and those hired at ISTCs.

He also said that had no knowledge of ISTC surgeons with cancelled contracts due to service.

Challenging the audits

The BOA has questioned the validity of the auditing process and issued statements to the government almost two years ago, Leslie said.

“We have just been informed by the government that the audit has been suspended,” he said. “So what audit that’s going on is anyone’s guess. We don’t believe that one is going on.”

In correspondence with the Department of Health, the BOA pointed to a lack of postop follow-up and called for comparisons between NHS and ISTC complication rates.

“We have found no evidence to show that [these outside surgeons] are not providing the standard of care that we would expect from any NHS provider.” — Department of Health spokesperson

“We’re concerned about the audit of the work being done,” Leslie said. “We feel that if [you are] introducing something new into a system like this, you should have a very careful audit of it, not just what the patient thinks of the hospital and not what the immediate complication rate is, but what are the orthopaedic complications in the longer term?”

The group also challenges the specificity of the performance indicators.

“These key indicators don’t address orthopaedic problems such as dislocations three weeks later [or] wound infections recurring after [patients] have left hospitals,” Leslie said. “So, I think the permanent health group need to be asked, what is the audit, what are they measuring and when are they measuring it?”

The BOA also raised concerns about the qualifications of ISTC surgeons. In a recent report, the Department of Health’s commercial director, Ken Anderson, wrote, “All surgeons working in treatment centers must first be registered on the appropriate Specialist Register of the General Medical Council’s Specialist Register before they can perform surgery.”

Leslie added that a European specialist can obtain a certificate for completing training in orthopaedics and, therefore, belong to the registry; however, this surgeon may not have received trauma training.

Helping or hurting?

The Department of Health holds that independent centers aid NHS hospitals and patients by decreasing wait lists and providing more choices. Anderson noted that more than 250,000 patients have received ISTC services at 21 ISTCs so far, and 11 more centers are expected to open in the next 18 months. “In 2006, ISTCs are expected to treat [an additional] 145,000 NHS patients,” he wrote in the report.

But some surgeons say that the centers cause more problems than they alleviate. Leslie pointed to gaps in the continuity of care for ISTC patients. The centers maintain a rotating staff, which often return to their native countries and are replaced by other overseas surgeons.

“The follow-up arrangements are such that, if they do have a complication, what happens to them is often just left to the poor patient and for the local general practitioner to sort out,” he said. Patients also seek NHS treatment because many ISTCs lack emergency rooms, he added.

What’s more, some surgeons say that independent centers siphon easy cases, leaving NHS hospitals with more obese and comorbid patients.

“For example, pressures on the intensive care and high-dependency units are greater today because a far larger proportion of our patients that we operate on now require those facilities, [since] the fit, healthy, slim ones have been taken away,” Glasgow said. The situation also creates a deficit of easy training cases for junior NHS surgeons.

“I think that inevitably, there is going to be some antithesis on behalf of surgeons practicing in this country with NHS appointments, because these cases are perceived as being taken away from them,” Glasgow said.

The future

The Department of Health estimates that the centers will eventually require less than 1% of NHS funds and perform 10% of all elective treatment. “It is important, therefore, to note that ISTCs exist to challenge the system and supply some additional capacity, but they do not represent an end to the NHS as we know it,” Anderson wrote.

Yet, Leslie said that the NHS hospitals feel the ripple effects of less money and fewer patients.

“[ISTCs] do contract for work, but often they are paid for work they don’t even do because, if they find it is too complicated, they send them back to the NHS,” he said. “That tends to destabilize the local NHS hospital [surgeons], who don’t know … whether they are going to have work next year to do.”

Call for change

While ISTCs proponents cite comparable quality, some NHS-affiliated surgeons continue to call for reform. Wallace said that additionality should be eliminated, while Glasgow recommends changes in funding allocation.

“I think the government is beginning to realize that they’ve made some mistakes, and I think that they are likely to change the rules so that people can move to the treatment centers even though they work in the health service,” Wallace said.

Glasgow added: “I think that the disappointment of the whole thing is that enormous amounts of money have been spent on this process merely to window-dress and to try to bring the waiting lists down without any thought to putting in an infrastructure that will allow these patients to be [treated] in a reasonable time by surgeons who are [approved in the U.K. manner].”

For more information:

• Wallace WA. Personal views-Independent sector treatment centres: how the NHS is left to pick up the pieces. BMJ. 2006:332; 614 www.dh.gov.uk/PublicationsAndStatistics