Evaluation of contract in ISTCs

Abstract

Nick Black questions whether our paper on Scotland's only Independent Sector Treatment Centre (ISTC), in which cataract surgery, knee and hip replacement, and other treatments are delivered to NHS patients by for-profit companies in mainly private facilities is the first independent evaluation.1 Our study is the first and only independent evaluation of public money paid for an ISTC contract in the UK; it showed that in Scotland's only ISTC, the company Netcare may have been paid up to £3 million for treatment that had not been provided to patients in the first year of the contract worth £6 million a year. In contrast, Black's study,2 to which we refer, was a questionnaire survey of patient-reported outcomes of 1895 patients treated in NHS hospitals and 769 patients treated in six ISTCs. This week the Scottish health minister responded to our academic evaluation by deciding not to renew the contract with Netcare and to return the services to the NHS. This is in sharp contrast to England where the £5 billion ISTC programme is still unevaluated, on account of the contracts remaining commercial in confidence. Academic scrutiny of value for money claims cannot be undertaken. Furthermore, unlike Scotland any evaluation of the ISTC programme in England is further hampered by lack of data, and incomplete and poor quality data returns. Although all ISTCs are required to submit hospital episode statistics on all NHS patients treated, the Healthcare Commission (HCC) found that during 2005–2006 fewer than half of them returned any data.3 Of the data returned, 43.4% were missing primary procedure codes and 7.6% had invalid primary procedure codes.4 For 2006–2007, 18.8% of episodes were missing primary procedure codes and 1.3% were invalid.4 Patients attending such centres are healthier and better off than those attending the NHS. Black et al. have shown that patients attending ISTCs are routine and straightforward elective cases – that is, with fewer complications and co-morbidities than other NHS patients – the HCC has shown that ISTCs also treat a lower proportion of patients in the lowest socioeconomic group than the rest of the NHS.3 The contribution of ISTCs to reducing waiting times and improving access cannot be evaluated without complete data on all patients. While patient-reported outcomes are an important aspect of healthcare evaluations they provide a partial picture of access and quality of care. It is unfortunate that the government in England has thus far failed to place the contract data in the pubic domain or to ensure the completeness and quality of routine data on all NHS patients. Unlike Scotland, the lack of data means that policy of using private for-profit companies in the NHS is not subject to proper informed public and parliamentary scrutiny. It's time that England took a leaf from the Scottish health minister's book.