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Friday, March 10, 2006 

The result of more "choice".

Government ministers, especially those in charge of the public services, have had only one thing on their mind of late: choice. Whether the idea started off in focus groups, came from industry or was dreamt up in-house isn't known; what is known that it isn't going at all smoothly.

Take today's report in the British Medical Journal - Angus Wallace, a professor of orthopaedic and accident surgery at Nottingham University writes that the NHS is having to correct dodgy work done by independent sector treatment centres (ISTCs):

"the number of patients we are seeing with problems resulting from poor surgery - incorrectly inserted prostheses, technical errors and infected joint replacements - is too great."

Many overseas surgeons, he says, "have been asked to carry out joint replacement operations that they have never seen or done before". Many of the centres have contracts to buy just one type of artificial joint - but sometimes it is one that the surgeon has no experience in using.

"It is quite clear that this has occurred with inadequate training of both the surgeons and the operating theatre staff and as a consequence there have been several serious errors - joint replacements put in without bone cement when bone cement was essential for that joint replacement, the use of the incorrect size heads (ball) for a hip joint replacement, etc," he writes.

It is hard to know how many operations are going wrong, Prof Wallace told the Guardian, but it is clear there are problems that ought to be investigated.

"We expect failures of hip replacements at approximately 1% a year and knees at about 1.5% a year. But we have got some of the ISTCs that are looking at 20% failure rates," he said.

The British Orthopaedic Association has submitted two dossiers of cases to the Department of Health, its president, Ian Leslie, told the Guardian. The first went to then deputy chief medical officer Aidan Halligan about 16 months ago and the second was submitted nine months ago.

"Although they investigated, it hasn't made much difference to our concerns," he said. "The difficulty is getting hold of the information from the ISTCs. We don't know how many patients are being done in the treatment centres."

But in two centres where the figures have been examined the failure rate was significantly higher than in NHS hospitals - at a diagnostic and treatment centre in Weston-super-Mare it was three times the NHS rate and in Cheltenham it was something like 10 times the rate, he said.

At an inquiry by the Commons health select committee yesterday, Royal College of Surgeons president Bernard Ribeiro said the government policy in establishing the treatment centres was "to win elections and to get waiting lists down".

Extra theatre time for hip and knee replacements had indeed been needed, he said. "The government gave us capacity through ISTC but somewhere down the line it lost the plot. In developing ISTC it is challenging the NHS."

These "independent" centres (jargon for private) were set-up with the idea that they could help take some of the workload off the NHS. While in some cases they have done that, the contracts that were drawn up had a specific number of operations that they were to perform. Since some patients have been suspicious (rightly, it seems) of these centres, not all of the operation numbers have been actually carried out. Despite this, the NHS has still paid the centres for the number originally agreed. So not only are these centres getting money for work they haven't done, but some of the work is having to be carried out again because it's been done badly the first time. This is without going into the realisation that doctors are still being poached from overseas to work at these centres - often from the developing world which is in dire need of its college graduates staying on.

The choice agenda so far hasn't had the effect the government thought it would have on the general public - they imagined it would be embraced, and as a result of patients going to other hospitals than their local, drive up standards. Instead patients are opting to stay local, which is what the unions said from when the plans were first mooted. People don't seem to want to travel even longer distances to receive essential treatment; they want it nearby. What the choice agenda may instead achieve is actually the closure of hospitals that don't manage to improve. The trusts which are slipping into debt, thanks to both overspending and PFI deals are likely to get hit even harder as a result of the government's reform plans.

The sacking this week of the chief executive Nigel Crisp, who was subsequently rewarded with a life peerage courtesy of Mr Blair, most likely to shut him up, was because of the failure both by himself and ministers to stem the huge shortfalls. The debts haven't stopped Patricia Hewitt's plans to keep introducing her reform plans at breakneck speed, despite indications that they are also part of the problem and are demoralising staff. She has already said that there will be no new cash to bail out the failing trusts, which are now planning to make deep cuts in order to balance the books. While only a quarter are in debt and those are mostly in the wealthier south, the real terror is if it starts happening in the North, in Labour's heartlands.

The whole current running of the NHS, and contracting out of operations to the private sector, as well as the PFI initiative in building new hospitals needs urgently to be rethought to stop that from happening.

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