NHS Cleaning Up After Private Medicine

Sam Lister writes:

People having hip replacements at private treatment centres brought in to cut waiting times are up to 20 times more likely to need painful and expensive repair work. Many operations are having to be redone in NHS hospitals, at great cost and with serious staffing implications for the health service.

A study by orthopaedic surgeons in Cardiff found that of 113 hip operations on patients sent from their NHS trust to Weston-super-Mare NHS Treatment Centre between 2004 and 2006, two thirds showed clear evidence of poor surgical technique, such as poor cementing of the hip.

In the three years since the operation, 18 per cent had undergone revision or were awaiting an operation — 20 times the 0.9 per cent NHS-wide revision rate at three years. A study on knee operations at the unit, conducted earlier this year, recorded a tenfold increase in revision rates.

Since the Independent Sector Treatment Centre (ISTC) programme was introduced in 2003, dozens of centres have been set up, mainly conducting orthopaedic surgery, cataracts and diagnostic screening. A total of 44 are described as NHS centres — though they are often staffed by independent sector contracts — and 23 are provided by private companies.

Leading surgeons said that this new data underlined the need for a significent overhaul of the multimillion-pound programme, which was introduced with great fanfare by the Government to reduce waiting times and increase patient choice.

They said a total lack of supervision of the sector and its clinical outcomes was a dereliction of duty by the Government, which had put a premium on reducing numbers rather than patient care. Early concerns about poorly vetted overseas doctors carrying out the work had not been addressed, they said.

The Cardiff study, published in the Journal of Bone and Joint Surgery, offers the most compelling evidence to date of problems with care in the sector, and the lack of proper auditing.Surgeons told The Times that the data backed anecdotal reports from elsewhere in the country, although it was likely to be at the high end. They said that NHS trusts were being left to manage the extra workload created.

While a hip replacement costs £6,000, the more complex repair operations, with more expensive implants, bone grafts and longer hospital stays, cost between £10,000 and £15,000. In an accompanying editorial in the journal, Fares Haddad, a consultant orthopaedic surgeon based at University College Hospital, London, says that the whole programme is in jeopardy because of the lack proper audit and follow-up. He adds that were such performance data available — and even if revision rates were lower — it would still “make the economic argument for ISTCs untenable”.

Mr Haddad told The Times that the disruption caused by the errors had an acute impact on hospitals, budgets and patients. He said that a revision rate of 3 per cent would still be unacceptable as it was “200 per cent greater than the NHS norm”, and even more so given that most treatment centres were sent the easier orthopaedic cases.

“We all want to cut waiting lists and give excellent care to patients,” he said. “But this was introduced without data to show that it worked. We are now seeing the studies to show that.

“We have all had work increased by this, and the cost implications are huge too. Revision work costs two or three times the cost of a primary replacement. What is more, the failure of a joint replacement is often worse than the arthritis that led to the original operation. Mr Haddad added that if it were compulsory to register every operation on the National Joint Registry, trends would quickly emerge. “We would start picking up on those that were failing,” he said.

Tony Hui, chairman of the British Orthopaedic Directors Society, which represents heads of NHS orthopaedic departments, said that care in his area of South Teesside had also been affected. “We are seeing patients that have been treated elsewhere and they have problems and end up back at the NHS. The work has been suboptimal, and we have to do the revision which is time consuming, risky and expensive. With each case that comes along it’s another half day of operating — which could be two other patients.”

Steve Cannon, a surgeon at the Royal National Orthopaedic Hospital, Stanmore, northwest London, said the scheme had been about “speed of getting through the numbers” and was an “iniquitous waste of money”.

David Worskett, director of NHS Partners Network, which represents independent providers, said that the sector was being unfairly portrayed by surgeons and many were offering care of an excellent standard. He said that he could not comment on the case of Weston-super-Mare because, although private provision of care was involved, it was organised by the NHS.

A Department of Health spokesperson said: "Patient safety is top priority with all contracts with the independent sector.

"The Department of Health requires all Independent Sector Treatment Centres to have robust policies and procedures in place. All ISTCs operate under standards monitored by the Care Quality Commission, the independent health watchdog.

"The CQC... have not raised concerns with the Department about the safety of ISTCs."