Evidence submitted by Nations Healthcare
Nations Healthcare welcomes the opportunity
to submit evidence to the Health Select Committee's inquiry into
Independent Sector Treatment Centres (ISTCs). The company would
also like to extend an invitation to the Committee to view Nations'
Treatment Centres at a time convenient to members.
Although we are still an early stage company
our experience to date indicates that Nations' success within
the ISTC programme has been and will continue to be predicated
clearly demonstrating benefits to
being invited and welcomed into local
working as an integral and enduring
part of those local health economies;
working in close partnership with
the NHS and evidencing this to clinicians, patients and the public;
providing value for money for the
bringing additional examples of innovation
and best practice to the NHS.
As one of the forerunners in the ISTC programme,
Nations Healthcare has worked with the NHS through the often challenging
period of bringing the early stages of policy introduction to
fruition. We recommend to the Committee:
the importance of generating the
learning from the programme to date and using the learning to
sharpen up and speed the processes of ISTC development from ITN
to financial close and beyond;
evaluating, and more proactively
making clear to patients, the public and the NHS the benefits
of the choice of dedicated ambulatory care; and
clarifying the nature of partnership
between the NHS and the independent sector; in particular more
overtly recognising the realities of the pressures and imperatives
informing both party's stances. This is especially critical in
developing a shared view of risk, both commercial and financial.
1. Nations Healthcare is a UK based company,
founded in 2002, with its origins in the US. The company is dedicated
to creating the best inpatient and ambulatory care centres and
developing clinical practice and a clinical environment where
an increasing range of procedures can be treated safely and effectively
through day treatment.
2. The Nations Healthcare model is developed
in line with international best practice standards giving an innovative
and proven effective approach to its service delivery. In the
UK this model is being incrementally introduced to ensure innovation
is fully supported by clinical teams with the training and ownership
of change to maximise the benefits to patients.
3. Nations Healthcare has recruited over
100 staff in its three Treatment Centres in Bradford, Burton on
Trent and Nottingham and its London Headquarters. 65 of these
are front-line operational clinicians and support staff. This
figure will rise to 450 by 2007.
4. The Bradford scheme was opened to treat
patients in June 2005 with 45 NHS consultants seconded in from
Bradford Foundation Trust as part of a groundbreaking structured
agreement. The Burton on Trent scheme is scheduled to open in
July 2006 and the Nottingham scheme, which is the largest co-located,
single site ISTC in the country, will be opened in December 2007.
5. Nations Healthcare has a consortium of
distinguished international companies supporting its operations
in the UK including:
Johns Hopkins University Health System
International in Baltimoreclinical strategic partner and
voted number one hospital in the United States for the 14th consecutive
Harvard School of Public Healthacademic
partner analysing the public health impact of ISTCs;
Alliance Imaging (Nations Imaging
in the UK)diagnostic partner and the largest provider of
diagnostic services in the US;
America Healthwayslong term
care partner and the biggest specialists in chronic disease management
in the US; and
partner and the leading ophthalmology group in Australia.
6. Nomura, the Japanese Investment Bank,
is a major investor in the company and a further consortium member.
7. In the first wave of ISTC procurement:
180+ international companies applied
for pre-qualification for the programme. Nations Healthcare was
one of only 15 companies pre-qualified.
Nations Healthcare was short-listed
on more projects than any other company.
Nations Healthcare had more wave
one "wins"" than any other company.
Nations Healthcare closed three contracts
including the contract for the first comprehensive ISTC scheme
What is the main function of ISTCs?
8. Nations Healthcare was pleased to respond
to the Government's invitation to bid as part of the procurement
programme for ISTCs and we endorse the Government's aims for the
9. Through our participation in the programme
we aim to support the NHS in achieving:
more capacity to deliver faster care
for NHS patients;
services designed around the patient
to improve their overall experience of healthcare and offer them
greater choice; and
the development of innovative services
in partnership with the NHS, building on the best of what the
NHS already does.
The company's approach to the above must in
addition enable Nations' viability and sustainability in delivering
healthcare, innovation and value for money in the UK.
What role have ISTCs played in increasing capacity
and choice and stimulating innovation?
10. Capacity in each of the three local
health communities where Nations Healthcare is working in partnership
with the NHS will be increased as follows:
Bradford: contracted year one to
provide 18,000 multi-specialty diagnostic tests and 6000 day surgery
Burton on Trent: contracted year
one to provide 17,000 ophthalmology outpatients and 13,000 day
surgery operations. In addition the PCTs have asked for a further
4,000 outpatients in year one over and above contract.
Nottingham: contracted year one to
provide 150,000 multi-specialty outpatients (this includes diagnostic
tests) and 24,000 day cases comprising a mixture of day surgery
and other same day procedures.
11. Choice for patients only exists when
GP referrers, patients and the public are aware of their local
ISTC and what it provides, and have confidence in the facility,
its clinicians and management. In the three areas of Nations'
Treatment Centres, we have been working in close association with
the Primary Care Trusts developing strategies to support GPs in
understanding their referral choices.
12. The strategy in Bradford is clinician-led
and includes GP visits to the centre, information for GPs, consultant
surgeons' presentations to, and engagement with, GP groups. We
are also progressing other options including the establishment
of a dedicated website for GPs.
13. In addition we continue to actively
raise the profile of the Treatment Centres with patients and the
public through open days, press releases and feedback from patients.
These strategies will be rolled out in Burton and Nottingham.
14. In Bradford the first patient satisfaction
survey required by the Healthcare Commission revealed a score
of 93.5% on the satisfaction index with a statistical reliability
of plus or minus 1.6%.
15. Stimulating Innovation has been achieved
by Nations Healthcare in a number of ways:
Through the contribution of Johns
Hopkins' clinicians working with our consultant surgeons and anaesthetists
in the areas of case selection, care pathway development and treatment
centre development. Johns Hopkins has been a leader in both innovation
and provision of ambulatory care for almost 20 years.
In our Bradford Treatment Centre
through the introduction of the "Green Light Laser",
a technique to improve the treatment of prostate cancer and the
numbers of men treated. The procedure, which is locally only available
in the Treatment Centre, and nationally carried out in a small
number of acute trusts, has been spearheaded by a seconded senior
The expansion of the "basket"
of procedures undertaken by day treatment within the local health
The design of our centres and clinical
processes both of which are engineered to provide the best and
most efficient patient experience. For example North Bradford
Primary Care Trust, which commissioned Nations Healthcare to construct
and run the Eccleshill NHS Treatment Centre, has recently won
the award for "Service Re-design" in the NHS Alliance
16. Nations Healthcare is exploring opportunities
to further introduce innovation in all of its centres and particularly
in Nottingham in conjunction with the Queens Medical Centre.
What contribution have ISTCs made to the reduction
of waiting times and waiting lists?
17. Nations Healthcare in its Bradford Treatment
Centre treats patients from both Bradford and Leeds. Patients
coming to the centre have a maximum two-week waiting time for
diagnostic tests and a maximum four-week waiting time for day
18. We do feel our treatment centres have
the potential to make a meaningful contribution to reducing waiting
lists and waiting times. However it is our opinion that the host
Primary Care Trusts (PCTs) are best placed to offer a balanced
view on the contribution of the work undertaken.
Are ISTCs providing value for money?
19. One of the clear areas of learning for
the ISTC programme is the challenge to shift the referral patterns
of GPs and both Nations and the Primary Care Trusts alike probably
underestimated the achievement of this. In Bradford the number
of referrals to the centre from Bradford and Leeds has not yet
reached the figure covered in the contract between Nations and
the PCTs. In the first six months of operating the centre treated
2,091 patients a figure which is 27% lower than that anticipated
by the PCTs.
20. Reasons for this include:
established referral patterns and
a high level of inappropriate referrals
which cannot be accepted by the centre;
a lack of awareness by referrers
of what the Treatment Centre can and cannot do; and
limited use by referrers of the electronic
referral methods forming part of Nations contract with the PCTs.
21. Nations has taken four key steps to
tackle these issues:
the company has not imposed the financial
minimum take upon the PCTs in Leeds and Bradford and has given
them a year to catch up with referrals;
we have brought in additional resources
to train PCT personnel in understanding and using electronic referrals
incorporating the patient's history and diagnosis;
a clinician-led referrals strategy
is being implemented to `market' the Treatment Centre to GPs and
build their awareness and understanding of procedures suitable
for referral; and
nations senior managers are meeting
regularly with PCT managers and clinicians to monitor referrals
and consider additional ways to increase numbers.
22. Alongside this local agenda Nations
has proposed to the CCMU a "ramp-up" period built into
future schemes to recognise the challenges in achieving a shift
in referral patterns.
23. Nations is taking this learning to Burton
and Nottingham to start the process of engaging GPs from the earliest
Does the operation of ISTCs have an adverse effect
on NHS Services in their areas?
24. In Bradford the number of patients treated
is small compared with those treated by the whole health economies
in Bradford and Leeds. Whilst patients would formerly have been
treated in the acute trusts they are still treated by NHS consultants,
within the policy of additionality, under contract to Nations
to provide sessions at the centre. The advantage lies in the centre
being a dedicated elective facility and not therefore subject
to the pressures of emergencies and associated late cancellations.
We do know the consultants welcome this advantage and it is clearly
beneficial to patients.
25. Nations does not feel able to comment
effectively on the impact of the centre on local services, adverse
or otherwise, at this juncture and believes this evidence would
be better provided by either the PCTs or the acute trusts or both.
26. In a reference for Nations Healthcare
provided by the North Bradford PCT ISTC Project Director, the
Director states "The PCT is very happy with the service being
providedprimary care has never had such good access to
radiological diagnostics or day surgery. This is a model of provision
which should be rolled out across the country". This reference
can be made available to the Committee if required.
What arrangements are made for patient follow
up and the management of complications?
27. Patient Follow-upmost patients
undergoing day surgery in Nations' Centres do not require follow
up and their treatment is completed on the day. Where there is
a need for a follow up outpatient appointment this is undertaken
within the Centres.
28. Physiotherapy or other follow up treatment
needed to support a patient in achieving the best outcomes from
surgery is carried out in primary care. This arrangement was agreed
as the most effective by the PCTs and it forms part of contracts
with Nations Healthcare.
29. Management of Complicationsexperience
from Johns Hopkins in the US indicates that the incidence of complications
in patients receiving day surgery is extremely small. In Nations'
Centres, arrangements have been made for the speedy transfer of
patients to local acute facilities should any complication arise
that cannot, or should not, be managed within the centres. This
arrangement again forms part of our contracts with the PCTs and
the acute trusts.
30. To date there have been no clinical
emergencies associated with procedures carried out in Bradford
that require a patient's transfer to the acute hospital. There
have been occasions when diagnostic tests undertaken within the
centre have revealed more serious conditions necessitating transfer
(not immediate) to Bradford Foundation Trust. For example Nations
Healthcare and the senior colorectal consultant/general surgeon
in the Trust have developed a co-operative approach to diagnosis
and this has earned a Yorkshire Cancer Network nomination for
What role have ISTCs played and should they play
in training medical staff?
31. Nations Healthcare is fully committed
to playing its part in the education and training of the next
generation of healthcare professions particularly (but not solely)
32. We recognise the potential impact that
not being involved in the training of medical staff would have
on the viability of training in teaching trusts and this would
not be in the interests of either the trusts or Nations Healthcare.
Furthermore we are clear that the opportunities for junior doctors,
rotating through Nations Treatment Centres, are to gain highly
focussed experiences in surgery with surgeons whose lists are
not subject to change and emergencies. This latter valuable experience
can be achieved within the acute trusts.
33. Nations Healthcare has signed the first
major training, education and research contract in the country
at the Queens Medical Centre and is also contractually committed
to a pilot project for training in Burton.
34. Furthermore, our Medical Advisory Board
is leading the development of a clinical leadership programme
with a bespoke curriculum designed to foster best practice and
change. This programme is accredited in the US by Johns Hopkins
and the Harvard School of Public Health.
Are the accreditation and appointment procedures
for ISTC medical staff appropriate?
35. Although to date Nations Healthcare's
consultants have been drawn from the NHS, through secondments
or contracted sessions in accordance with the additionality policy,
and the staff have therefore already been through NHS appointment
procedures, nevertheless it is Nations' policy to check the registration
and qualifications of every doctor and nurse.
36. In the event of Nations employing doctors
who have not previously worked within the NHSfor example
overseas doctorswe have policies in place to ensure the
integrity of the procedures and the fitness for purpose of recruited
37. Lord Turnberg, a past president of the
Royal College of Physicians, is the chair of Nations' Medical
Are ISTCs providing care of the same or higher
standard as that provided by the NHS?
38. All ISTCs are inspected and regulated
by the Healthcare Commission and are obliged to meet the standards
laid down by the Healthcare Commission.
39. Nations Healthcare believes that NHS
standards of treatment are as good as any in the world and our
partner Johns Hopkins has endorsed this belief. Where Nations
is able to add value is in the innovation the company can introduce
to its Treatment Centres, faster access for patients and the experience
patients have before and after treatment.
What implications does commerical confidentiality
have for access to information and public accountability with
regard to ISTCs?
40. Nations Healthcare has held firmly to
the view that in all of its work alongside the NHS we would meet
all reasonable requests for information to demonstrate public
What changes should the Government make to its
policy towards ISTCs in the light of experience to date?
41. Nations Healthcare takes the view that
it is in the interests of the Government, the NHS and the company
to share learning from our experience of the ISTC programme to
support achieving greater effectiveness in the partnership between
the NHS and Nations in the future.
42. Our main comments cover six important
Patients and the publicfeedback
from patients treated in North Bradford demonstrates the value
they place on fast access to the diagnostics and surgery they
need and the patient satisfaction survey showed a high level of
satisfaction with the patient experience from start to finish.
If patients and the public across the country are to have confidence
in ISTCs as a treatment choice such good news stories must be
Positioningfrom the outset
Nations has gone the extra mile to build positive partnerships
with local health communities and can evidence ways in which this
has been achieved. For example:
We have actively arranged for
groups of clinicians and managers from Burton and Nottingham to
visit the centre in Bradford to increase their understanding,
offer an educational experience and grow their confidence in the
capacity of Treatment Centres. These visits have proved extremely
Clinicians and managers from
local health communities in the areas of all three schemes have
spent time with Nations' clinical and academic partners in the
US as an educational opportunity and a chance to judge the efficacy
of the clinical practice proposed by Nations in its centres.
In all three areas, joint arrangements
are being developed for crucial organisational processes such
as communications, patient involvement and referrer engagement.
We believe this is one of the most critical areas
of learning and strong partnership working lays much stronger
foundations for positioning our treatment centres as an integral
and enduing part of the NHS.
Engaging referrersas already
mentioned Nations and the PCTs in Bradford made some assumptions
about referrals following the needs defined by the PCTs. This
has not been the case to the degree anticipated. In Nottingham
we have engaged GPs as part of our "Partnership Board"
and in our "Partnership in Practice" development programme.
It is further our intention to engage with contracted numbers
from the opening of the Centre.
Clinician-ledmuch of the credibility
Nations has gained in the areas of its three Centres results from
its philosophy to build a clinician-led organisation. We are not
yet in a position to say this has been fully achieved, but where
we have made strides the outcomes in building understanding and
co-operation between the NHS and Nations and the impact on patient
care has been extremely positive. For example, all three of our
Treatment Centre General Managers are clinicians.
Intrinsic understanding of the NHS,
its ethos and capabiliitesNations Healthcare has always
been clear that melding the best in the UK with the best in the
US is a key company aim. For this reason we recruited respected
ex-NHS managers to bring an intrinsic understanding of the NHS,
its ethos and its capabilities. This strategy has paid dividends
in the areas of strengthening partnership, taking commonsense,
informed approaches to dovetailing systems and processes, and
building a culture putting the patient at the centre through the
integration of NHS values with those prevailing in healthcare
in the US.
Speed of developmentTreatment
Centres are comparatively small NHS facilities, yet the speed
of contract negotiations has meant the advantages to patients
have taken a long time to be achieved. For example in Nottingham,
from the time of the first meeting with QMC to the time of the
first patient treated is likely to be in excess of four years.
Although this incorporates approximately two years construction
time we believe the contract stage of development could be accelerated.
Nations Healthcare would be happy to work with the NHS to support
What criteria should be used in evaluting the
bids for the second wave of ISTCs?
43. Nations Healthcare believes the criteria
used to evaluate bids should take account of the learning noted
above, build on what has worked to date and avoid the pitfalls
that have slowed progress and created tensions.
44. We suggest the following:
the ability to provide a proven good
the ability to staff treatment centres
with "fit for purpose" healthcare professionals working
in teams shaped to provide the best patient experience;
the ability to design, build and
run a treatment centre that offers the best patient experience;
the flexibility to accommodate sponsoring
PCTs' defined needs for the community served and in the future
to respond to Practice-Based Commissioning;
established systems and processes
to enable the construction of strong working partnerships with
the capability to bring innovation
to NHS patients;
the commitment to supporting training,
education and research;
a strong financial and commercial
base with demonstrated good governance arrangements; and
the ability to articulate the added
value to NHS patients of the company's Treatment Centres.
What factors have been, and should be, taken into
account when deciding the location of ISTCs?
45. In the first wave of the ISTC programme,
Nations Healthcare bid for a number of schemes to establish its
base in the UK. As an established company, we are now able to
make more informed judgements about where we would wish to develop
46. The factors to consider in making these
Is the local health community in
agreement with the need for a treatment centre?
Is the location one where there is
evidenced under-capacity in the NHS?
To what extent are referrers currently
prepared to refer to a treatment centre?
Are the innovations Nations offers
ones that are not available to NHS patients through other local
Can patients relatively easily access
the proposed treatment centre?
Is Nations already part of nearby
health communities and therefore connected to local NHS networks?
Is the treatment centre located sufficiently
close to an acute trust to ensure patient safety in any emergency?
How many ISTCs should there be?
47. Nations Healthcare believes that the
decision about how many ISTCs are needed to complement NHS provision
is not one that can or should be taken by the independent sector.
13 February 2006