Independent Sector Treatment Centres Research Articles

Private sector expansion and the widening NHS treatment gap between rich and poor in England: Admissions for NHS-funded elective primary hip and knee replacements between 1997/98 and 2018/19

Parliament has imposed duties on the government and NHS in England aimed at reducing health inequalities. Aimto understand the effect on inequalities of government policies, which require the NHS in England to outsource elective surgery to the private sector.We analysed the numbers of admissions for hip and knee replacement surgery from the least and most deprived population quintiles in three time periods: before the introduction of the policies (1997/98–2002/03); following the implementation of the independent sector treatment centre programme (2003/04–2006/07); and after the extension of 'choice at referral’ (2007/08–2018/19). Resultsdespite admission rates doubling and trebling for hip and knee replacements, respectively, between 1997/98 and 2018/19, inequality grew to the detriment of the most deprived. Inequality grew at the fastest rate during period 3; admission rates to the NHS fell while admissions to the private sector continued to rise. By 2018/19 almost a third of NHS funded procedures were provided privately.In 1997/98, for every 10 patients admitted for hip and knee surgery from the most deprived quintile, 13 and 9, respectively were admitted from the least deprived, by 2018/19 the gap had widened to 19 and 15, respectively.Socio-economic inequalities for hip and knee replacement have widened as outsourcing of NHS treatment to the private sector has increased. The NHS must rebuild in-house capacity and provision instead of outsourcing care.

Royal College of Ophthalmologists' National Ophthalmology Database study of cataract surgery: report 11, techniques and complications of local anesthesia for cataract surgery in the United Kingdom.

To describe variation in local anesthesia techniques and complications over a 10-year period for cataract surgery in the United Kingdom. Reporting centers to the Royal College of Ophthalmologists (RCOphth) National Ophthalmology Database (NOD). Retrospective cross-sectional register-based study. Data from the RCOphth NOD were used. Eligible for analysis were 1 195 882 cataract operations performed using local anesthesia between April 1, 2010, and March 31, 2020, in 80 centers. Overall, topical anesthesia alone was used in 152 321 operations (12.7%), combined topical and intracameral in 522 849 (43.7%), sub-Tenon in 461 175 (38.6%), and peribulbar/retrobulbar in 59 537 (5.0%). In National Health Service (NHS) institutions, 48.3% of operations were topical with/without intracameral vs 88.7% in independent sector treatment centers (ISTCs). 45.9% were sub-Tenon in NHS vs 9.6% in ISTCs. 5.8% were peribulbar/retrobulbar in NHS vs 1.7% in ISTCs. Anesthetic complication rates decreased from 2.7% in the 2010 NHS year to 1.5% in the 2019 NHS year (overall, 2.1% for NHS; 0.2% for ISTCs). Overall anesthetic complication rates were 0.3%, 0.3%, 3.5%, and 3.1% for topical alone, combined topical/intracameral, sub-Tenon, and peribulbar/retrobulbar, respectively. Complication rates were higher for sharp-needle anesthesia (peribulbar/retrobulbar) in patients taking warfarin rather than direct oral anticoagulants (4.8% vs 3.1%; P = .024). Considerable variation was observed between centers on anesthetic choices and anesthetic complication rates. Combined topical and intracameral is the most common choice of anesthesia for cataract surgery in the United Kingdom and is associated with lower anesthetic-related complication rates than sub-Tenon and peribulbar/retrobulbar anesthesia. Variation in the anesthetic choice exists between centers and between NHS and ISTC sectors.

Royal College of Ophthalmologists’ National Ophthalmology Database study of cataract surgery: report 8, cohort analysis of the relationship between intraoperative complications of cataract surgery and axial length

ObjectivesTo describe the relationships between axial length and intraoperative complications in patients undergoing cataract surgery.DesignCohort analysis of the Royal College of Ophthalmologists’ National Ophthalmology Database (RCOphth NOD).Setting110 National Health Service...

Does competition from private surgical centres improve public hospitals' performance? Evidence from the English National Health Service

This paper examines the impact of a government programme which facilitated the entry of for-profit surgical centres to compete against incumbent National Health Service hospitals in England. We examine the impact of competition from these surgical centres on the efficiency – measured by pre-surgery length of stay for hip and knee replacement patients – and case mix of incumbent public hospitals. We exploit the fact that the government chose the broad locations where these surgical centres (Independent Sector Treatment Centres or ISTCs) would be built based on local patient waiting times – not length of stay or clinical quality – to construct treatment and control groups that are comparable with respect to key outcome variables of interest. Using a difference-in-difference estimation strategy, we find that the government-facilitated entry of surgical centres led to shorter pre-surgery length of stay at nearby public hospitals. However, these new entrants took on healthier patients and left incumbent hospitals treating patients who were sicker. This paper highlights a potential trade-off that policymakers face when they promote competition from private, for-profit firms in markets for the provision of public services.

Elective hospital admissions: secondary data analysis and modelling with an emphasis on policies to moderate growth

BackgroundThe English NHS faces financial pressures that may render the growth rates of elective admissions seen between 2001/2 and 2011/12 unsustainable. A better understanding of admissions growth, and the influence of policy, are needed to minimise the impact on health gain for patients.ObjectivesThis project had several objectives: (1) to better understand the determinants of elective activity and policy to moderate growth at minimum health loss for patients; (2) to build a rich data set integrating health, practice and local area data to study general practitioner (GP) referrals and resulting admissions; (3) to predict patients whose treatment is unlikely to be cost-effective using patient-reported outcomes and to examine variation in provider performance; and (4) to study how policies that aim to reduce elective admissions may change demand for emergency care. The main drivers of elective admissions growth have increased either supply of or demand for care, and could include, for example, technical innovations or increased awareness of treatment benefits. Of the factors studied, neither system reform nor population ageing appears to be a key driver. The introduction of the prospective payment tariff ‘Payment by Results’ appears to have led to primary care trusts (PCTs) having increasingly similar lengths of stay. In deprived areas, increasing GP supply appears to moderate elective admissions. Reducing the incidence of single-handed practices tends to reduce referrals and admissions. Policies to reduce referrals are likely to reduce admissions but treatments may be particularly reduced in the lowest referring practices, in which resulting health loss may be greatest. In this model, per full-time equivalent, female and highly experienced GPs identify more patients admitted by specialists.ResultsIt appears from our studies that some patient characteristics are associated with not achieving sufficient patient gain to warrant cost-effective treatment. The introduction of independent sector treatment centres is estimated to have caused an increase in emergency activity rates at local PCTs. The explanations offered for increasing elective admissions indicate that they are manageable by health policy.ConclusionsFurther work is required to understand some of the results identified, such as whether or not high-volume Clinical Commissioning Groups are fulfilling unmet need; why some practices refer at low rates relative to admissions; why the period effect, which results from factors that equally affect all in the study at a point in time, dominates in the age–period–cohort analysis; and exactly how the emergency and elective sections of hospital treatment interact. This project relies on the analysis of secondary data. This type of research does not easily facilitate the important input of clinical experts or service users. It would be beneficial if other methods, including surveys and consultation with key stakeholders, could be incorporated into future research now that we have uncovered important questions.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

From evidence cart to smart phone.

Where do you stand on Brexit? You might find this a hard question since facts are difficult to establish. Sober analysis is lost amid the feverish passions of protagonists. The effects on health and science may not be top priorities for politicians, but they should be important considerations. In an attempt to cut through the red rage of emotion, clinicians and scientists from Imperial College explain why a vote for Brexit is a mistake.1 I expect many readers will disagree with our editorialists, and even if they do agree with them their vote will be won or lost for other reasons. Whatever the outcome of the referendum on 23 June, the challenges to UK’s health services remain stark. In the dash for health service reform, new care models, and the promised land of innovation, the value of evidence needs to be reinforced. Like other innovations, those designed to improve evidence-informed practice are difficult to implement and evaluate. The world famous ‘evidence cart’ pioneered at Oxford’s John Radcliffe Hospital in the 1990s was an attempt to bring the library to the bedside. While the cart helped improve decision-making based on searches of evidence resources, its bulk and reliance on power cables made it an impractical companion on wards rounds and emergency departments. Smart phones have made these issues irrelevant, but the challenge remains of integrating relevant evidence with clinical data to promote optimal patient care.2 Marshall et al.3 argue that the ‘know-do’ gap in health services research may be greater than in clinical research. Many service changes are implemented, they say, unguided by research evidence. Walk-in centres, integrated care programmes and independent sector treatment centres are just three examples of service changes ‘that have gone badly awry’. In an age where Barnsley Football Club has a poet in residence and the All England Tennis Club employs an artist in residence, a researcher in residence on a clinical team might be the catalyst to achieving participatory research that brings about successful service transformation? Whether in or out of Europe, you might want to consider the main finding of this month’s research paper, which finds no support for low, aspirational, BMIs among adult patients on hospital discharge.4 Whether you prefer your evidence best delivered by cart, smart phone or researcher in residence, research evidence has the power to surprise and challenge received wisdom.

Cataract surgery outcomes at a UK independent sector treatment centre

Background/AimsThe goal of this study was to review cataract surgery outcomes at three independent surgery treatment centres established by the UK Specialist Hospitals (UKSH) and to compare these outcomes with...

McDonaldization or Commercial Re-stratification: Corporatization and the multimodal organisation of English doctors

This paper investigates transitions in the social organisation of medicine found in the extended opportunities for private corporations to own, manage and deliver public healthcare services in the English National Health Service. It follows recent calls to explain the reconstruction of medical work without reducing analysis to either the structures of organisational control or the strategic resistance of doctors. Accordingly, the paper considers how doctors interact, mediate and co-create new organisational environments. Central to our analysis are the variable sources of power that influence whether doctors acquiesce, resist or re-create change. Drawing on ethnographic research carried out between 2006 and 2010 in two Independent Sector Treatment Centres – private providers of public healthcare - the paper shows how doctors' responses to bureaucratic and commercial structures reflect their own structured forms of power, which have variable value within this new commercial environment. These include clinical experience and specialist knowledge, but also social and economic influence. Building on established sociological debates, these divergent sources of power explain how for some doctors the expansion of private healthcare might involve more extreme forms of McDonaldization, while for others it might involve opportunities for Commercial Re-stratification.

The Impact of an Independent Sector Treatment Centre on Basic Surgical Training

The reorganisation of postgraduate medical training in the UK as a result of Calman reforms, the New Deal and the implementation of the European workingTime regulations (EwTr) has led to a substantial reduction in working hours and a fall in operative experience for surgical trainees. The move of large volumes of minor and intermediate NHS surgical caseload into independently run hospitals and specialist centres (of which the Southampton NHS Treatment Centre, an independent sector treatment centre (ISTC) is a well-established example) has also radically altered the basic surgical training environment. The Southampton ISTC is run on contract by Care UK and is medically staffed by a mix of full-time Care UK employees from the UK and abroad as well as by visiting consultants from University Hospital Southampton NHS foundationTrust (UHSFT).

ENT training and the independent sector

An increase in training numbers and a general reduction in training opportunity have been well documented in the recent literature. Over the last few years the involvement of the independent sector in providing NHS-funded healthcare has steadily increased. Since 2000, the government has implemented the independent sector treatment centre (ISTC) programme, on which £2.7 billion of NHS money has been spent. Current plans in healthcare policy will further increase the role of the independent sector in providing NHS-funded healthcare. To date, the NHS-funded independent sector has been dominated by the ISTCs that were commissioned by the last government. These were commissioned directly from the department of Health, primarily to provide service provision. As a part of the commissioning process, a commitment to training by the ISTCs was also expected.

Outcomes of elective surgery undertaken in independent sector treatment centres and NHS providers in England: audit of patient outcomes in surgery

Objective To compare characteristics of patients and outcomes after elective surgery in independent sector treatment centres (ISTCs) and NHS providers.Design Follow-up study with outcomes reported by patients three to six...

Going private: Clinicians’ experience of working in UK Independent Sector Treatment Centres

ObjectivesWith increased possibility that public healthcare services in the UK will be out-sourced to the private sector, this study investigates how clinicians working in Independent Sector Treatment Centres perceive the differences between public and private sectors. MethodsQualitative interviews with 35 clinicians recruited from two ISTCs. All participants were transferred to the independent sector from the public National Health Service. Interview data were analysed to identify shared experience about the variable organisation and delivery of services. ResultsClinicians perceived differences between public and independent sectors in the areas of ‘environment and facilities’, ‘management’, ‘work organisation and care delivery’, and ‘patient experience’. The independent sector was described as offering a positive alternative to public services in regard to service environment and patient experience, but there were concerns about management priorities and the reconfiguration of work. ConclusionsClinicians’ experience of moving between sectors reveals mixed experiences. Although some improvements might legitimise the growing role of the independent sector, there remain doubts about the commercialisation of services, the motives of managers and the impact of clinical roles and capabilities. With policies looking to expand the mixed economy of public healthcare services, the study suggests clinicians will not automatically embrace a move between sectors.

Innovation and the English National Health Service: A qualitative study of the independent sector treatment centre programme

Over the past two decades, an international trend of exposing public health services to different forms of economic organisation has emerged. In the English National Health Service (NHS), care is currently provided through a quasi-market including ‘diverse’ providers from the private and third sector. The predominant scheme through which private sector companies have been awarded NHS contracts is the Independent Sector Treatment Centre (ISTC) programme. ISTCs were designed to produce innovative models of service delivery for elective care and stimulate innovation among incumbent NHS providers. This paper investigates these claims using qualitative data on the impact of an ISTC upon a local health economy (LHE) composed of NHS organisations in England. Using the case of elective orthopaedic surgery, we conducted semi-structured interviews with senior managers from incumbent NHS providers and an ISTC in 2009. We show that ISTCs exhibit a different relationship with frontline clinicians because they counteract the power of professional communities associated with the NHS. This has positive and negative consequences for innovation. ISTCs have introduced new routines unencumbered by the extant norms of professional communities, but they appear to represent weaker learning environments and do not reproduce cooperation across organisational boundaries to the same extent as incumbent NHS providers.

Inconsistency in health care professional work

The purpose of this paper is to investigate the impact of recent outsourcing and public-private partnership (PPPs) arrangements on the consistency of professional employment in health care. A case study methodology is applied. The paper finds that multiple arrangements for employment within the ISTC creates numerous sources for inconsistency in employment: across the workplace, within professional groups and with national frameworks for health care employment. These are identified as having implications for organisational outcomes, threatening the stability of current partnerships, and partially stymieing intended behavioural change. The study is a single case study of an independent sector treatment centre. Future research is required to investigate wider trends of employment in heterogeneous outsourcing and PPP arrangements. The paper informs both managers and clinical professionals of the unanticipated complexities and practical challenges that can arise in partnerships and outsourcing arrangements. The paper presents a unique in-depth investigation of employment within recently established ISTCs, and highlights important employment changes for the core health care workforce and high-status professionals in the evolving health care organisational landscape.

Healthcare identities at the crossroads of service modernisation: the transfer of NHS clinicians to the independent sector?

Health policies increasingly support private businesses to take an active role in the organisation and delivery of public healthcare services. For the English NHS, this is exemplified by the introduction of Independent Sector Treatment Centres. A number of these facilities involve the wholesale secondment of NHS clinicians to the private sector which, we suggest, raises important questions about the identities of healthcare professionals accustomed to working in the public sector. Our paper investigates this transition highlighting three prominent discontinuities in clinical work: the ethos of private sector ownership, new lines of authority and fragmented relationships. Drawing on Giddens, we examine how clinicians experience and interpret these changes and how they keep their biographical 'narrative going'. The 'pioneers' interpreted the independent sector as an opportunity to re-invigorate their practice through new roles, relationships and higher quality care; the 'guardians' as an opportunity to replicate and protect the customs and standards of the NHS in the private sector; whilst the 'marooned' longed to return to the NHS. Our study illustrates how the sectoral context can shape healthcare identities, and how contemporary reforms aimed at promoting partnerships across public and private sectors can have profound implications for clinicians.

The Impact of ISTCS – A Clinician's Perspective (Questionnaire Study)

Independent sector treatment centres and their effect on the NHS remain a controversial aspect of healthcare delivery. This postal questionnaire study aims to identify the general attitude among surgical consultants about their effects, specifically on NHS workload, departmental/trust finances, training opportunities and case mix. NHS hospitals within five miles of an ISTC offering day case/inpatient services were targeted.

Confuse and Conceal - The NHS and Independent Sector Treatment Centres Player Stewart Leys Colin Confuse and Conceal - The NHS and Independent Sector Treatment Centres 128pp Merlin Press 9780850366099 0850366097 [Formula: see text

The main thrust of this book is that independent sector treatment centres (ISTCs) were set up as a covert way of introducing private providers into the NHS, rather than offering patients more choice of where to receive surgical care.

Evaluation of contract in ISTCs

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.

Pride and prejudice

Pride and prejudice

Quality of care in ISTCs

I was puzzled by Pollock and Kirkwood's1 claim to have conducted ‘the first independent evaluation’ of Independent Sector Treatment Centres (ISTCs) when they were clearly aware of our earlier study as they cite it.2 Far from showing, as they state, ‘how case-mix in ISTCs differs from the NHS making comparisons of costs and quality difficult’, we demonstrated that when we allowed for case-mix differences, there was little difference in patient reported outcomes between those treated in NHS providers and those treated in ISTCs. If anything, outcomes were slightly better in ISTCs though we speculated that this may reflect the Healthcare Commission's finding that patients in ISTCs reported a better experience of the humanity of care than those in NHS providers.