The NHS Consultants' Association

CCSC statement on CATS and ICATS

January 2007

Primary Care Trusts in Cumbria and Lancashire have issued a consultation seeking the public’s views on the establishment of a Clinical Assessment, Treatment and Support (CATS) service in Cumbria and Lancashire.

Plans to roll out a similar scheme in Greater Manchester are also underway. This is called Integrated Care Assessment and Treatment services (ICATS) and it will also be provided by the independent sector.

These services are a radical development whereby the independent sector will provide triage, assessment, diagnostic and some treatment services in a number of specialties, outside local acute trusts, on referral from GPs. The specialties are: -

ENT

General surgery

Gynaecology

Orthopaedics

Rheumatology

Urology

The preferred bidder in Cumbria is Netcare UK, an independent sector provider which already operates a number of treatment centres and primary care walk-in centres in England.

This scheme’s stated aim is to help reduce waiting times, so that the area can achieve the 18 week waiting time target by 2008. It is also intended to push forward the “care closer to home agenda” – the Government’s intention to move more care traditionally provided by hospitals into community and primary care settings – and to simplify the patient journey.

These types of referral management scheme present considerable challenges to the secondary sector. They introduce a new tier between primary and secondary care and ultimately threaten to remove large parts of local acute Trusts’ work, particularly pre-assessment and diagnostics, and shift it to different settings altogether. Ultimately this may have serious implications for medical services in those trusts.

Naturally, the BMA’s Central Consultants and Specialists Committee has serious concerns about CATS and ICATS. It is encouraging medical staff and patients in these areas to participate in the CATS consultation which can be found at www.cumbriaandlancashirecats.nhs.uk, to be participate in planned public meetings and to raise the issues in their Trusts

The BMA believes this consultation to be totally inadequate, as it is largely about the logistics and location of the scheme, rather than about whether it needs to be provided by the independent sector, or indeed whether an additional tier in the local NHS is a good use of public money at all. Those decisions are not presented as up for public debate, either locally or nationally.

Some of the questions which need to be asked of CATS and ICATS are: -

• Is the work being moved all additional to core NHS activity?

• Why can't the work be done by existing staff?

• Where will staff working in CATS/ICATS be recruited from? How many will be required and at what grades?

• Who will train, monitor and assess the staff in the CATS/ICATS?

• Who will draft and agree the protocols under which they will work?

• Will GPs/Patients have a choice not to go via CATS/ICATS?

• What assessment has been made of the impact of the diversion of such a large number of cases on the training of NHS staff?

• What evidence is there that CATS/ICATS will improve accessibility? In relation to ICATS, for example, how many people in Greater Manchester are more than 30 minutes away from one of the 10 acute hospitals?

• How will local patients know that the service has improved? Will the quality of the treatment received in CATS/ICATS be recorded and assessed and be compared with that previously received in the local NHS hospitals?

• Has an assessment been made of the impact of CATS/ICATS on the local health economy and, in particular, local NHS hospitals?

• How can they be sure this will be value for money when that of Independent Sector Treatment Centres (ISTCs) has been questioned by the House of Commons Health Select Committee.

• How will they ensure that the quality of work is maintained when existing audit has been severely criticised by the Healthcare Commission?

We are raising all these questions and concerns at national level. For that we need reliable information from the local level. It would therefore be very helpful for any consultants affected by these plans to e-mail us information at info.ccsc@bma.org.uk or to contact their local BMA Industrial Relations Officer (via ask BMA) if concerned about the implications for them.

CCSC
19 January 2007

Coming to an SHA near you – CATS, ICATS, ISCATS…how long till the NHS disappears in your region?

Prof Janet Wilson, Consultant ENT surgeon in Newcastle upon Tyne, contemplates the reconfiguration from NHS to NHI – national Health Insurers

Enjoy the freedom to read this missive, comrades – such commentary from NHS employees could soon be a thing of the past. Not, of course, that free speech is under threat, merely the NHS. It does remain rather mysterious to me, (q Edinburgh, 1979) that so much privatisation has been achieved by the good comrades, with so little protest. I should have been warned, however, that the death of the NHS would not elicit calls of protest – far less a state funeral. I should have better understood the lack of interest – far less protest - when comrade Reid advised that the poor should be allowed to smoke, having so little else. I should have registered when comrade Hewitt sanctioned the totally private management of the Lymington New Forest Hospital by the Partnership Health Group. I should have read more carefully the KONP booklet – ‘The Patchwork Privatisation of our Health Service: a Users’ Guide’.

But I did not comrade, I did not. Last autumn, we asked is it too late to save the NHS? Now, there remains only one question: Do we still have a National Health Service? Sadly, thanks to the tireless efforts of the DoH comrades, in some areas the answer must be no. But if you are reading in an area of healthcare provision not yet effectively ‘reconfigured’ – it may not be too late. Especially if your Party representative is one of those cabinet comrades who object to reconfiguration of their local compound. We salute woman comrade Blears whose protest is an altruistic act of faith on behalf of her constituents (quite unrelated to her job security). Women are indeed useful in this regard, as we are in general higher users of healthcare services, live longer and have more need of elderly care. We are also, conveniently, less politically active, allowing the leading Department of Health citizens to focus on targets for the more able male voter. The rapid disuse atrophy of voting and the imminent demise of democracy itself will allow the Party full, unopposed privatisation as chief citizen Cameron wants to ditch NHS provision just as much as President Blair.

Thus while ‘depoliticisation’ was once the great hope of NHS workers, now, too late, we realise that beyond Party headquarters lies not Narnia, but that weary tundra of Netcare landscape. Is the gift of the NHS cash cow to the South African Netcare a public act of reparation by President Blair for the wholesale poaching of a continent’s nurses?

What does it all mean for UK healthcare?

Financial

The sums passed into private hands are stratospheric to mere directorate budget holders. The desperation to shrug off the NHS as a service provider and metamorphose into mere service purchaser is so great that tens of billions of pounds have been spent on PFI initiatives, inducements, choose and book, IT, all well documented in the recent KONP publication. The impact of competitor services is not just direct revenue loss, but also mammoth bleeding of resources into these underpinning developments. David Nunn, consultant orthopaedic surgeon at Guy’s and St Thomas’s has broken cover on the hopelessness surrounding the NHS tariffs, which so undercut operational costs as to represent the most obvious destructive weapon as the DoH guns down the NHS. Doubly demoralised, NHS workers are left not just short of equipment, beds, drugs and operating slots, but ridiculed by Party members for taking oodles more money for far less activity. Of course, the Party is not going to all this trouble just to humiliate us. Why on earth would it bother? Rather, it has proved vital to create this cash crisis, which can act as a systems amplifier, and justify calls by lead privatiser Nicholson, for managers not to ‘shy away from major service changes that address financial difficulties.’ [While secretary Hewitt stands on the sidelines, like the mother of the recently celebrated 14 stone eight year old, quoted ‘Well, I must love him, mustn’t I, because I am giving him all this food…’]

Service provision

The North West model of ICATS covers Carlisle, Barrow, Lancaster, Blackpool, Birmingham and Burnley. Manchester’s central teaching hospitals are very likely to survive, but for much of the population we seem to be moving back to a system uneasily close to the GP tonsillectomists of yore. The general public has not been slow to assimilate some of the implications of gifting the NHS cash cow to Netcare. Secretary Hewitt was challenged recently by the decision to set up an ISTC in Bristol, and the lack of consultation. The patient, Rebecca Fudge, who made the challenge is obviously an ‘old democrat’ Party member and does not yet understand the new labour regime, where consultation after a contract has already been sponsored and agreed by the DoH is the norm. Also, any such consultation , as in the North west of England must be completed in days, if at all possible, not weeks. After all, since many - if not most – of the public have abandoned the habit of voting, democracy too can be reconfigured to meet the goals of the minority. Ms Fudge must await judgement on 27^th March as to whether this case will proceed – let us hope that citizen Goldsmith, does not destroy his minimal residual credibility by directing the judge to find against her.

Is all lost for the provider NHS? Ironically the Party is a victim of its own targets at this critical time, when all is said and done. As the new private consortia come on line, they are exposed by the prior meeting of said targets by existing NHS providers. It is a great credit to the application and persistence of the NHS that it could manage, against the swells of bureaucracy, to beat an ISTC. Red stars to the University Hospital of North Staffordshire NHS Trust. Pity poor Graham Urwin, whose Stoke PCT is thirled to Nations Healthcare for another three years. For the same University hospital is now so impoverished that its plastic and reconstructive surgery patients must wait for 20 weeks, despite idle theatres and surgeons. Colleagues elsewhere report MRI machines at a standstill, while the radiology waiting room throngs with patients using the department as a passageway to the Alliance portacabin out in the back

For most trusts, therefore, the loss of business to CATS, ICATS and ISTCs, coupled with spiralling bureaucracy has led to under-funding of front line services. Sadly, so complete has been the indoctrination that even those expressing horror at the speed of privatisation, like the chair of Cumbria’s Health Scrutiny committee, see it as a ‘quick-fix solution’. But to what problem precisely, did Lancashire GP, David Wrigley see privatisation as the answer? His comment - it ‘hasn’t been a level playing field’ hardly does justice to the process.

Training

While the NHS engaged a flexible culture of interdisciplinary working, the replenishment of service providers, be they physicians, surgeons, surgeons assistants, nurse endoscopists or physiological measurement technicians, is critically dependent on a strong and progressive national training network. The loss of high volume activity from the remaining few major hospitals leaves a residue of complex cases totally unsuitable for training all but the most superspecialised minority. How dire is the Party record on the organisation of health education!

As part of the modernisation agency – now disbanded, in 2003, it launched the NHS University –with an annual budget of tens of millions (£38m from DoH; £37m parliamentary funding). The next year, more than £150 million later, the NHSU was axed. Many even in the NHS had never even heard of it. Little wonder ‘extra money’ has achieved less than hoped for in service delivery!!

Undaunted? unheeding? uncaring? - the Party plans, nonetheless, to train at the barefoot doctor level – i.e. capable of implementing Party protocols, and has set up a model institute in South West England. Strangely, while the public seem more extended about the influence of Tesco on the High Street, and Parliament about the privatisation of the probation service.

However, the Party does not concern itself much with training as it is a longer term exercise than the length of any one parliament. A very expensive exercise, better outsourced to the EEC. If the trainee numbers should swamp the limited training options offered by CATS / ICATS – the push of a single button will delete the whole lot from MTAS and no-one will be any the wiser. Meanwhile the trainees themselves will undertake an old Labour-style historical protest pageant on 17^th March from the RCSEng

An estimated 3200 accredited medical specialists will have no consultant post by 2008-11. Already in ENT, a small speciality with fewer than 500 consultants, over 20 accredited surgeons are without a consultant post. The intention is to force down employment conditions, drive out staff to the private companies, and take the pressure off the NHS pensions bill. Many of this highly intelligent young cohort may opt for fully independent practice in chambers. Not one of David Nunn’s orthopaedic Guy’s and Thomas’s CCT holders has a consultant post – and no doubt they will survive very well in the private sector, serving those well enough off to afford to pay private healthcare insurance as well as their NI contributions.

Should the public accept this double billing? Or will they soon realise once the NHS has fully mutated into NHI – National Health Insurance, once all that is left of is a consortium of entrepreneurs, purchasers, and no providers, they would be better off ditching the middle men and going for a fully private system? That would be good news for the Party, good news for the orthopaedic SpRs, and good news for those leasing chambers in Harley Street. Not quite so good for Netcare, admittedly – but no doubt they will reconfigure marvellously from their privileged position. No losers then………….

And the dissenters? Well, they should have thought about that when they forgot to vote, shouldn’t they? The passing of the NHS could only have followed the death of democracy itself. Mourn not for Barbara Castle – she is long gone, , and Diane Abbott sits cosy on the couch, touching arms with Michael Portillo.

But let’s not dramatise. Most folk will be all right. Well - the poor, the chronically sick, those whose illness needs major research developments, the elderly. They might be losers. Yes, it could be any of us one day. Yes, we did all come in to the NHS to help them. But the NHS – well, that no longer exists.

2007 - President Blair’s final tableau from a life dedicated to the Law of Unintended Consequences – NHS RIP. Long live NHI.

JANET WILSON

Consultant ENT Surgeon

NHS A&E

The NHS Institute for Innovation and Improvement (III) has produced a draft Directory of Ambulatory Emergency Care. In this they recommend that most emergency patients admitted to hospital with certain conditions should be treated in the community. They claim that 90% of current hospital admissions pulmonary embolism, transient ischaemic attacks and deep vein thrombosis, and up to 60% of ectopic pregnancy and patients with chest pain could be treated outside hospital.

The Institute of Public Policy Research (IPPR), quoting a medical paper, state that 500 additional lives per year could be saved by having specialist techniques, such as angioplasty, available for treating heart attacks. It also quotes the British Orthopaedic Association and the Royal College of Surgeons who say that 770 extra lives would be saved if all trauma patients were treated at specialist centres. The IPPR state that universal access can only be provided at a smaller number of specialist hospitals.

Both points are probably correct, as basic statements, but both will be used as reasons for closing down smaller hospital A&E departments, such as at Ayr and at Monklands, though in both locations the primary driving force is finance not patient care.

However there are major problems with both positions. The III case will require management by the GPs. However it requires the skill and experience of a specialist gynaecologist to decide which patients with ectopic pregnancy could be managed at home. It is impossible for GPs to have or acquire that level of expertise. Also the accepted view is that for people to be an expert in a particular field they need to have exposure to that type of case or operation many times every year. Again it is most unlikely that GPs would have that level of exposure to all these conditions suggested. And for a person with chest pain which may be an MI the diagnostic tests for confirmation and severity are not available in General Practice.

The IPPR statement is clashing with that of the III. If it is important to treat heart attacks with angioplasty, stents or other specialised measures, the decision is not one which can be left for a GP to make in isolation. The other point not considered by IPPR, because not specifically mentioned in their reference articles, is the risk of increased travelling time. The American army in Korea started out with the same view as quoted by IPPR. Though the evacuations were by helicopter with on board paramedics, the death rates were unacceptable and the American army had to invent their MASH units much nearer the source of casualties. There the minor problems were treated, major ones which could wait were sent on and others had their conditions stabilised before being sent onto the major unit. If this was found to be the best management when helicopter transport times could be virtually guaranteed, how much more important is it for land based travel in an ambulance. For example the Lanarkshire Health Board state that the ambulance transit time between Monklands and Wishaw is only 20 minutes but ambulance drivers themselves state that this is the best possible time, and that in rush hours it could be twice or three times as long. The position is much the same in the case of an MI and on purely medical grounds it would surely be better to maintain Monklands A&E since it is placed right in the middle of an area which has one of the highest incidences of MI in the world. It is obviously unfair on ambulance paramedics and unsafe for severely ill patients whether trauma or medical, for the medical responsibility for a case during long transport times to be left to a paramedic.

The articles quoted by IPPR are correct but they need to be supported by a network of A&E units which can perform the role of the MASH units. The academic pundits in IPPR and III seem to be ignorant of the lessons from Korea. It would of course be essential that the “MASH” A&E units had good contacts and relations with the superspecialist centres and did not try to hold on to patients who would benefit from specialist services unavailable in their own hospital.

EVAN LLOYD

Consultant Anaesthetist. Edinburgh