The Disgraceful History of ISTCs in England

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“ISTCs (Independent Sector Treatment Centres) matter not because they are a breach of the non-commercial principle but because they are one modest brick in the wall of commercialism which is currently transforming the National Health Service .” (Ruane, S., 2008, page 4) British Labour Governments after 1997 were committed to “the reintroduction of the profit motive and more individualised and consumerist notions of health care (a “commodity privately bought and sold”)   ( Ruane, Sally,2008) “)

This  reversed one of the  central principles of the NHS founded by Aneurin Bevan “the transfer of a ‘whole segment’ of activity from private enterprise and individualism to collective goodwill, public enterprise and public administration.”

Bevan wrote  that

“A free Health Service is a triumphant example of the superiority of collective action and public initiative applied to a segment of  society where commercial principles are seen at their worst.” (Bevan (1952) p109)  [1]


“Abuse occurs where an attempt is made to marry the incompatible principles of private acquisitiveness with a public service. 1952, p108)

Since the early 1990s, clinicians in the NHS had been advocating the separation of elective from emergency surgical procedures in order to improve productivity and relieve pressure on the acute sector.This would not necessarily have  involved private sector management: indeed the first treatment centres were run by the NHS and some turned out to be very successful. (Plumridge, 2008. )

In 1999, the first treatment centre in England dedicated to elective procedures was opened. At this time, the then Labour  Government was caused considerable embarrassment by waiting lists of more than a year and frequent cancellations of such procedures. (Plumridge, 2008). In 2002, the Department of Health announced that it was creating a programme of similar NHS Treatment Centres as a systematic approach to the issue.

However, at the end of that year, the Government decided to commission a number of Independent Sector Treatment Centres (ISTCs) to treat NHS patients who required relatively straightforward elective or diagnostic procedures. Most ISTC’s were to concentrate on providing orthopaedic procedures, especially hip and knee replacements and also cataract surgery. ISTCs were introduced ostensibly to expand capacity and drive down waiting times. They are commercially owned and operated surgical treatment centres offering fairly routine fast-track elective surgery and some diagnostic procedures exclusively for NHS patients. Wave 1 of the ISTC programme, which saw the first centre open in October 2003 and the scale of  focused principally on routine orthopaedic, ophthalmic and general surgery. All of the companies contracted in wave 1 are based overseas and bring many of their staff from overseas.(Ruane,2008) [2]

The ISTC programme’s objectives  included

  • Increasing elective capacity available to the NHS in order to reduce waiting lists and times;
  • Increasing patient choice within the NHS;
  • Encouraging best practice and innovation;
  • Stimulating reform within the NHS through competition.[3] ( House of Commons 2006, Volume I, page 3)

The original business model for a ‘diagnostic and treatment centre “was the health service equivalent of the supermarket: ‘pile it high and sell it cheap’. It was based in the approach oriuginally used for eye surgery in the Soviet Union.It was  assumed  that ‘straightforward pre-planned operations’ could be separated from the general workload of NHS hospitals where they were competing for operating theatre time with emergencies, to be “managed slickly  and efficiently in dedicated specialist units”.

Early in 2005, the Health Minister John Reid made a radio broadcast in which he said “ the monopoly of the NHS has meant waiting lists for years”  In May 2005, his successor as Health Secretary boasted that more than 20,000 cataract operations were being carried out by the independent sector and that no elderly patient had to wait for more than three months for cataract treatment. Indeed some of the new ISTCs were extremely productive (Plumridge, 2008. )

The programme went through two phases. Phase 2, announced in March 2005, broadened the scope of procedures and expanded the diagnostic element significantly . Phase 2 was expected to deliver ‘up to’ 250,000 elective procedures per year with a further 150,000 procedures offered through an Extended choice Network at a cost of around £3 billion,  and two million diagnostic procedures annually at a cost of around £1 billion (Department of Health, 2006a). (Ruane)  the second phase tended to consist of smaller facilities often located on existing NHS sites. This gave readier access to general emergency facilities such a blood transfusion which would not have been so readily or quickly available on isoklated ISTC sites  But the problems experienced in the first two phases. prompted the Health Secretary Alan Johnson to scrap plans for a third wave of ISTCs  in 2007. Nevertheless, the Department of  Health approved plans for the development of three more ISTCs in 2008 at an estimated total cost of  £50 million. This despite  the fact that there were strong indications that NHS Hospitals in England had  all the capacity they needed, having almost completely achieved the target of a maximum 18-week wait for diagnosis to treatment.[4] (Plumridge 2008)

The first phase of the programme was reviewed by a House of Commons Committee during 2005/6. The Committee pointed out that the Department of Health had admitted that the number of procedures performed by ISTCs represented a tiny fraction of the NHS’s total capacity.(page 4) Waiting lists had declined since the introduction of ISTCs, but it was not clear the extent to  this has happened because the NHS has changed in response to the ISTCs or because of additional NHS spending and the intense focus placed on waiting list targets over this period. MPs  criticised the contracts for phase one of the scheme, which gave private providers a premium on top of the NHS tariff rate for routine procedures such as hip operations. Some of the early ISTCs were indeed very productive, but this was achieved by setting very generous terms to attract large multinational providers into the new NHS market.

Some of the early entrants in the market were paid substantially  more than the prices paid to internal NHS providers. This was partly justified by high set-up costs involved in setting up state of the art facilities ISTCs were  also guaranteed payment even if the contracted levels of activity were not achieved. (Plumridge, 2008. ) However, a Minister announced in August 2009 that new contracts with private firm would no longer offer them a premium price over NHS rates. But the NHS would still be liable for “huge sums” under clauses in contracts to phase one suppliers in the case of failure to renew contracts on the original terms [5] Moreover, in the autumn of 2009, The Opposition’s shadow health minister Mike Penning pointed out  that the contracts set up by  the Department of Health included a  a clause that if the Department failed to renew the contracts or changed their terms the taxpayer would be liable for the residual value of the buildings’. He pointed out that.the contracts  also guaranteed payment for a set volume of operations, regardless of how many were actually carried out. In reply to a question he asked in the House of Commons, the Health Minister Ben Bradshaw admitted that up to £176 million would have to be paid to private health firms if the contracts for the first phase of the ISTC programme were not renewed, The ‘take or pay’ clauses  of the contracts guaranteed  ISTCs their income for five years regardless of whether they performed the contracted number of procedures or not.

Up to £927m could have been wasted on unused operations in ISTCs nationally.

“Contracts should not be renewed [for ISTCs] and new contracts should not be signed until a proper independent evaluation has been published assessing referrals, actual treatments carried out, and payments made for work done along with value for money analysis.” (Pollock and Kirkwood, 2009.)

PCT commissioners were convinced that  patients should be referred  to the new centres regardless of any consequential harm to local NHS providers. In a  survey published in 2005    61 per cent of PCT  chief executives said that the approach to the implementation of the ISTC progranmne was prescriptive and 37 per cent said that it as being enforced by bullying. PCTs – which had been required to divert their commissioning away from traditional NHS providers and towards the new ISTCs – were forced  to find ways to shepherd patients towards the private treatment centres. (Ruanbe, 2008)

Accordingly, in some areas, NHS trust finance was hit as patients were diverted to ISTCs to use the  capacity that had to be paid for whether it was used or not.

The House of Commons Health Select  Committee received evidence that most ISTCs were still performing well below the contracted number of operations, with the volume as low as 9% of the paid-for level in one case  The House of Commons committee  had criticized  the Department of Health for failing to make any systematic attempt to assess and quantify the effect of competition from ISTCs on the NHS. They suggested that the Department should have ensured that this was done from the beginning of the ISTC programme in 2003. The concerns of professional medical bodies and others, that ISTCs were poorly integrated into the NHS and that they were not training doctor were well-founded.ISTC’s  reliance on overseas staff, prompted by concerns that ISTCs should not “poach” staff from the NHS, had raised concerns about clinical quality and continuity of care in ISTCs. However, the Committee concluded that, as a consequence of deficiencies  in the quality of data collection by both NHS and IS (Independent Sector)  providers there was no hard, quantifiable evidence to prove that standards in ISTCs differed from those in the NHS. Later it was reported that while hip replacement failures normally ran at about 1 per cent and knee replacement  failures at 1.5 per cent, some ISTCs experienced  20 per cent failure rates, attributed to mistakes made by inexperienced, poorly supervised foreign surgeons. ( Shifrin, 2009 ,Plumridge, 2008. )

The ISTC programme was intended eventually to provide about half a million procedures per year at a cost of over £5 billion in total. This could clearly have  affected the viability of many existing NHS providers for several years. Moreover, as the quantity of ISTC activity is not evenly spread across the country, the impact on the budgets of different local health economies is likely to vary. The Phase 1 contracts gave ISTCs a significant advantage over NHS Treatment Centres and other NHS facilities. In the longer term, there are good reasons for thinking that ISTCs could have significant effects on the finances of NHS hospitals. We do not know how big that effect might be or how great the dangers might be. The Department of Health had analysed  the possible effects of the ISTC programme on NHS facilities, but refused to disclose the analysis to the Committee, which was worried that . Phase 2 ISTCs could  lead to unpopular hospital closures (p5).

There was also considerable scepticism about whether the ISTC programme represented value for money. The House of Commons Committee could not  make an assessment since the Department would not provide  detailed figures on the grounds of commercial confidentiality. Ruane 2008 suggests that this flouts “ the principles of democratic accountability …the withholding of contractual information from the public (and academics)”  renders “  public and … independent academic assessment of value for money impossible The House of Commons Committtee.  found it hard to see that the decision to commission Phase 1 could have been justified in terms of the need for additional capacity alone. Indeed it has been suggested that ISTCs have resulted in a reduction in capacity. There are several contributory factors in this : the transfer of NHS activity to ISTCs and the diversion of NHS funds away from NHS providers, (including new NHS owned treatment centres at least some of which have been made unviable by the transfer of patient activity to ISTCs); the higher cost of procedures in ISTCs : a given amount of expenditure secures fewer procedures than would have been the case had they been commissioned from NHS providers, combined with the underperformance of ISTCs relative to contractual expectations. In addition, ISTCs undermine the capacity of NHS hospitals through the loss of activity and staff skills. (Ruane, 2008)

In March 2005 the Department announced that it would commission a second wave (“Phase2”) of ISTCs. The Department acknowledged some of the anxieties which Phase 1 had created and promised to address them in Phase 2.

Phase 2 was to  consist of an elective element (£2.75 billion)  and a diagnostic element, (£1 billion)  The involvement of NHS staff in ISTCs would be increased to  improve integration; and all ISTCs would be obliged to offer training provision for NHS staff if required by local needs.  Indeed by 2009, it was anticipated that medical students would start  training in ISTC hospital facilities. (Bowcott 2009) . The Department also proposed to allow NHS consultants to work in ISTCs. The committee  welcome this and recommended that, in addition, the Department should ensure that Phase 2 contracts should encourage NHS staff to be seconded to treatment centres.

Nevertheless, the House of Commons  Committee found it difficult to assess the current state of Phase 2 of the ISTC programme, or the rationale behind it. The Department of Health and the Secretary of State had  given answers to the Committee  which had shifted as time went  by, and the statement of the current position by the Secretary of State left several important questions unanswered. The decision to maintain the commitment to spend £550 million per year despite changing circumstances has not been explained, and seems to sit uncomfortably with the Secretary of State’s admission that “in other[areas] it had become clear that the level of capacity required by the local NHS does not justify new ISTC schemes”. It was  unclear “whether this represented simply a failure coherently to articulate the situation or a more profound incoherence in terms of policy as opposed to presentation.” There were  also real concerns that the expansion of the ISTC programme would destabilise local NHS trusts, especially those with financial deficits.

The committee was concerned that Phase 2 ISTCs were  not only to be built where local plans show the capacity was  needed but they are also to be used as part of ‘reconfiguration’ plans. This could mean that major hospitals would be closed and the elective services they provide be undertaken by ISTCs. They were told that ISTCs would only go ahead where local health communities considered them appropriate, but were concerned  about the pressure put on such communities by the Department. There are major benefits from separating elective and emergency care in treatment centres. Such centres should continue to be built where there is a need and where the decision to build the centre has been agreed with the local health community following consultation.

The committee were not  convinced that ISTCs provide better value for money than other options such as more NHS Treatment Centres, greater use of NHS facilities out–of–hours or partnership arrangements which might more readily secure integration and could  be cheaper.

In the three years after the House of Commons committee reported, the  muddled and  confused state of policy revealed by the Committee persisted and perhaps even worsened.  Ruane (2008)  commented “On a number of occasions, information has been put into the public domain by the Department of Health which, it subsequently transpires, is inaccurate and/or misleading.

By 2009, the vast majority of  hospitals were still owned and run by the National Health Service (NHS), but some are owned and run by private companies as Independent Sector Treatment Sectors (ISTCs). ISTCs only treat NHS patients who do not pay for their treatment: no private patients are treated at ISTCs.  Senior consultants at an  ISTC may have part-time contracts  to work at NHS hospitals and at ISTCs. Other staffs such as nurses may be employed full time at either NHS hospitals or ISTCs. Some staffs  normally work at NHS hospitals other staff are on loan from the NHS to ISTC hospitals . No private patients are treated at ISTC hospitals

Ast the time of writing (end 2009) Mike Parish was chief executive of Care UK, probably the largest supplier of  ISTC hospital services. He said that he was proud of the firm’s very high patient satisfaction rates and its clinical record in the NHS of no cases of MRSA infections. He estimated that 6% of all NHS work was being carried out by private firms. But by that time, even  Labour Government Ministers  seem to be ambivalent about the advantages and disadvantages of ISTCs.

Supporters claimed  that ISTCs  had created internal competition within the NHS which was resulting in progress towards improved standards. In Autumn 2009. both a  Department of Health minister Andy Burnham, and his department, the Department of Health  seemed equivocal. The Minister  was quoted as suggesting :”With quality at its core … the NHS can finally move beyond the polarising debates of the last decade over private or public sector provision but he went on to say: “Where I stand in this debate … is that the NHS is our preferred provider”.But the meaning of  “preferred provider” was unclear. The Department of Health attempted  to explain by stating  that: “Where existing NHS services are delivering a good standard of care for patients, there is no need to look to the market.” But the Department of Health’s subsequent comments failed to clarify the Government’s views: “Where [NHS] primary care trusts are commissioning new services, then we expect them to engage with a range of potential providers before deciding whether to issue an open tender. These decisions will be made locally, and we will not choose to exclude either NHS or private providers on grounds of ideology – quality and what is best for patients must always come first. This could well mean more private provision, not less.” The Minister’s  promise that the NHS should be the “preferred provider” was interpreted by the private sector as a snub, and by health unions as a signal of  Gordon Brown’s [6]  support for traditional Labour values.

Mike Parish, the Care UK chief executive, became increasingly anxious about the situation. He suggested that “Across primary care trusts there are people who are enthusiasts in terms of reform (i.e. keen on private sector involvement) and others who are uncomfortable with any concept of plurality. (The Minister’s statement)  could take things in a direction that was never intended. There’s a risk of a runaway horse. We are already seeing tenders being issued for the redesign of services with the invitation going exclusively to NHS providers only. It not only constrains the options for Primary Care Trusts (PCTs)[7] and patients, it’s also certainly anti-competitive. I don’t know if it’s even permissible.” His  company is considering bidding for what would be the first privately run NHS district general hospital. Parish was reported as fearing that  the “preferred provider” publicity would  blight his chances.[8]  ( Bowcott, 2009)

This paper seeks to develop a hypothesis that the most effective way of improving a nation’s health is likely to be via an integrated national health service system in which a range of health services are delivered to individuals free at the point of use; and in which all the facilities delivering these services are publicly owned. Of course, the level, type and nature of the public health services a country needs and can afford is dependent on a large number of factors such as the wealth and income of the country, its climate and geographical location.

Evidence for this  is provided by the experience of the author during periods of a few days in two hospitals within the English National Health Service (NHS) in 2009. Hospital A is a privately owned and operated specialist orthopaedic hospital  which specialises in operations and procedures such as hip or knee replacement. It derives its revenues from the NHS and pays the direct costs of all its inputs, medical and nursing costs, buildings, operating theatres etc. If the revenues it receives form the NHS exceed the costs it is responsible for paying, the company owning the hospital retains the difference as profits. Similarly, if the revenues received from the NHS were to be insufficient to pay the costs incurred by the hospital, this difference would represent a loss to the company owning the hospital.

Hospital B  is a general hospital offering a wide range of medical services, and is owned by the NHS itself. Hospital B  pays all of its costs out of public funds provided by the NHS itself.

In the case of neither hospital do patients make any contribution to the costs of the treatments they receive.

The attempt is made to show that, as a consequence of the fundamental nature of the practice of medicine, there can be no logic in the attempt to attribute specific costs and benefits to the private hospital (A)  on the basis of which it draws up a balance sheet and achieves a certain level of profit or loss. If the attempt to do this is successful, it would indicate that all the facilities within a national heaslth service should be publicly owned, and that there is no logic to having specific parts of a national health service in private ownership.

The deep but extremely narrow basis of the empirical evidence presented in this paper is such that no reliable conclusions can be drawn from it. All that is claimed for this paper is that it generates a rich hypothesis that should form the basis for further research.

I do not attempt to express any views on whether or not there should be a role within a national health service for hospitals offering specialist services. I seek to show by considering the fundamental nature of medical practice that it is fundamentally illogical to have units within a publicly national health service which are privately owned and derive profits or losses from selling their services to the national health service.


Abstract. This case study demonstrates that any process of attributing costs and benefits and deriving profits and losses for independent private hospital providing operations must be  fundamentally flawed.

On Thursday 10th September 2009 I attended hospital A for preliminary tests –blood tests, blood pressure tests etc. These having presumably been proved satisfactory, the following Monday, September 14th. 2009, I reported to reception at the hospital at 7.30 am in order to have a full hip replacement operation. I met the surgeon who was to conduct the operation, was required to answer medical and other questions, and asked to sign a form consenting to the operation which I did. I was informed that hip replacement patients are normally ready to be discharged from the hospital 3 to 5 days after the operation , which in my case would have been between Thursday 17 September and Saturday 20 September.

At about 8 am on Monday September 14th,  I received an epidural  anaesthetic and other medication, and the hip replacement operation was carried out. After the operation, I spent some time in a Recovery Room on a trolley, and was then moved to a four bedded ward in the hospital where I was to remain until my discharge from this hospital on Thursday 17 September. During the period of the operation and my time in the recovery room, I experienced very little pain. Indeed, when I woke up after the effects of the anaesthetic had begun to wear off, I had access to a button which, if I had pressed it, would have delivered predetermined doses doses of morphine to me in up to a prescribed limit to alleviate the pain. I experienced no need to press the button at all.

I was later to find out that the medication I received included Diclofenac Sodium which was administered during the four days during which I was in hospital , and which I was also expected to continue to  take for about ten days  after I was discharged from Hospital A. In the event, I continued to take Diclofenac Sodium tablets only until the afternoon of Tuesday  22  September, 8 days after the hip operation, for reasons which will become apparent shortly.

Hospital A’s  policy is to get patients out of bed as soon as possible after the operation, and to get them active as soon as possible so as to accelerate the process of recovery from the operation; and to develop the skills, muscles etc.  necessary to use the replacement hip effectively as soon as possible. This seems a very sensible and effective policy.

Accordingly , on Tuesday 15, September, the first day after the operation, I was assisted to get out of bed, to walk first with the aid of a zimmer frame and then to abandon the zimmer frame and walk with the aid of crutches. One of the other three patients on the ward made faster progress than me. I had slept badly on the Monday night, partly because of a lot of noise in the ward that night, and fell asleep on the Tuesday afternoon. The physiotherapist in charge of my case managed to wake me eventually, but my sleep cut short the time available for me to begin physiotherapy.

On the morning of Wednesday 16 September, I awoke refreshed and my physiotherapy –exercises, learning to walk properly, to climb up and down stairs with the aid of crutches etc., progressed rapidly. The patient  who had made faster progress than me was discharged from the hospital at about  1  pm. About an hour after that, my physiotherapist asked me whether I should like to go home later the same afternoon, and I replied that I should like that very much. So I phoned my wife and asked her if she could come to collect me  that afternoon and she said that she could. She arrived at about 3.30 pm to take me home. However, at about 3 pm, a nurse had come up to me and said that it had been decided that I should not go home until 11 am the next day, Thursday 17 Septemebr.  While this was a little disappointing, in view of the fact that I had not been expecting to be discharged from hospital until at least 3 days after the operation, we did not regard this as a major setback.I was discharged from Hospital A  at  11 am on the following day, Thursday 17th September.

On Wednesday, when my wife arrived, I informed her of the changed decision. I was not to go home that day Wedneday but the following day  Thursday when I would be discharged at 11 am. On her way out of the hospital , seeking confirmation, my wife asked a nurse when I would be discharged . She said that she or a colleague would  phone my wife when I was ready to be discharged.

Accordingly, on Thursday morning, nurses and other staff made all the preparations thought necessary for my discharge. The mainly blood pressure reducing drugs which I had brought with me to the hospital wer returned to me, together with a three week supply of (the injection) and about ten days supply of Diclofenac Sodium. I was given no warning about the possible  serious side effects of  taking Diclofenac Sodium which were to prove so serious a few days later.  I was told that the dressing on the wound  would have to be changed and that my wife  would have to do that, even though at no time was she given any instructions about how to carry out that task.

At 11 am , I sat in the reception area  of the hospital waiting for my wife to arrive to take me home. By 11.30 am , I was beginning to worry about what had happened to her, so I asked the receptionist to let me use the phone to call her. I did so. She was sitting at home waiting to hear  for the nurse who had said that she would phone her when I was going to be ready for discharge. At about 12.30   my wife arrived to take me home.

This episode makes it clear that the hospital had failed to install a simple but rigorous procedure for deciding when patients should be discharged; and for communication about discharge of patients to the patients themselves or to the friends, relatives, taxi drivers etc. who have agreed to collect patients acfter their discharge.

What seemed to happen normally was that physiotherapists s assessed when the patients whom they were ready for discharge and then communicated that information to the patients themselves.

In my case, it became obvious that this fundamentally sloppy procedure was not the policy of the hospital, but that a more rational policy weas in operation but not properly implemented.  Clearly, the decision when to discharge patients should be a multi-disciplinary procedure in which all aspects of the patient’s condition are reviewed and the decision when to dfischarge made on that basis.

In my case, the physiotherapist  decided that I was ready for discharge on the afternoon of Wednesday 16th September and told me that this decision had been made. It seems that in doing this, she was not following the procedure which the hospital had in place. Clearly, as her decision was countermanded within an hour or so of her communicating it to me, some sort of multi-disciplinary consjultation had taken place, and that process led to her decision being countermanded.  When I was informed of the changed decision, I was given a totally incomprehensible account of the reasons.

In relation to communication of discharge decisions to patients, there was a similar  pattern of  either sloppy procedures or perhaps  sound procedures  which were  not being followed.

It would be logical, for example, to have an established procedure in which the patient and ther patient alone is given the information about when s/he is to be discharged. When the deciasion not to discharge me  on Wednesday was made, I was told that I was to be discharged at 11 am on Thursday. On the Wednesday afternoon, when my wife asdked a nurse when I was to be discharged, the nurse said that someone would phone my wife to inform her. If the policy  was for patients alone to be given information on discharge dates and times, the nurse was failing to follow the correct procedure. The nurse’s correct reply to my wife should have been “Please ask your husband when he is to be discharged. We give patients ths information”

This general sloppiness of the development of proper policies and procedures and their proper implementation  can have serious consequences for patient welfare , as it did in my case. A multi-disciplinary review to decide on patient discharge day/time is essential, and it is essential to communicate the results of this review to patients by a pre-determined route. Hospital A failed completely in this respect.  At the very least, that review should have decided to warn me of the possible side effects of continuing to take Diclofenac Sodium tablets.

Improvement in my health, my mobility etc.  appeared to be progressing well for four days until the afternoon of Tuesday 22 September. IO began to feel a little unwell and went upstairs fro a short rest on my bed. At about 1 pm, my sister and brother in law arrived to vist me and I, they and my wife went into the garden to have lunch and enjoy the lovely sunshine. Suddenly, while sitting on a chair, I fell  unconscious and would have fallen off the chair had I not been rescued by my close relations. I remained unconscious for about ten minutesx before regainin g consciousness. My wife phoned NHS Direct to ask for advice. They asked her questions which were clearly intended to exclude the possibility that I had had a heart attack or stroke. Nevertheless, they recommended that I should be taken to Accident and Emergency at Hospital B.

I seemed to recover very quickly. So my wife telephoned our local GP practice and managed (with some difficulty) to get an appointment for me to be seen by a doctor there the following morning 23rd September  at 10 am. Reading the leaflets enclosed with all the drugs I  was taking, I reached the conclusion that the drug which was causing the problem might well be Diclofenac Sodium –and this was subsequently confirmed

Diclofenac is a non-steroidal anti-inflammatory agent (NSAID) which is used to relieve pain and inflammation[9].


After asking what had happened, a GP on duty took my blood pressure. Her assessment of the situation was that I should go to the Accident and Emergency Department of Hospital B immediately. It took about 20 minutes for my wife to drive me there. After a wait of about ten minutes, I was put on a trolley by a hospital technician who took my blood pressure and took blood samples for testing. After a further test by a doctor, and after about another hour, I was taken to the endoscopy department and an endoscopy procedure was undertaken. The endoscopy procedure involved inserting  a tube with cameras on it down my gullet into my stomach and ontestines. The endoscopy revealed that there were two large ulcers in my stomach and upper intestines, plus anumber “in double figures” of smaller ulcers. The endoscopy process was also used to insert a covering of material which was capable of reducing the bleeding from the ulcers. Tests also revealed that I had lost a significant amount of blood through the bleeding ulcers.

After a couple of hours, I was taken up to a digestive system ward where I was to be treated.

The treatment consisted mainly of a drip which contained substances designed to cover the ulcers in my digestive system so as to stop the bleeding. The drip had to proceed over the 72 hours from the evening of 23rd September  until my discharge from hospital B at about 7.30 pm on Saturday 26th September.


 Hospital A carried out a hip operation which seems to have been very successful. However, during the course of the operation and afterwards, I was treated with Diclofenac Sodium, and after being so treated for four days was given further tablets to take for about a fortnight after being discharged from  hospital A. However, five days after being discharged from Hospital A, I stopped taking Diclofenac sodium because I guessed –correctly as it turned out –  that I was suffering seriously from their side-effects.

I spent the following  four days in hospital B being treated for the side effects of a drug which was administered to me in the course of and subsequent to treatment in hospital A. It is not necessary to attribute any blame to hospital A  in order to point out that the costs incurred in hospital B were the direct if unintended consequence of the activities carried out in Hospital A.

But hospital A is a privately owned hospital whose profits or losses are determined by the differences between the costs it incurs, in terms of wages and salaries for doctors, nurses, administrators etc., and the fees it receives from the NHS for carrying out the orthopaedic operations and procedures in which it specialises.


It is suggested that this case study demonstrates that the holistic nature of medical services is such that any process of attributing costs and benefits and deriving profits and losses for operations provided by independent private hospitals must be  fundamentally flawed.

This constitutes a tiny case study of phenomena which are due to become endemic throughout the NHS when the Coalition Government ’s current plans for the reform of the NHS are implemented

[1] Bevan, A., (1952) In place of fear, Heinemann

[2] Ruane , Sally, (2008) ‘One modest brick? Independent Sector Treatment Centres and the Re-Commercialisation of the NHS’, Radical Statistics Issue 96

downloaded 4 Oct 2009

[3] ( House of Commons

Health Committee, 25 July 2006,Independent SectorTreatment Centres

Fourth Report of Session 2005, HC 934-I,  House of Commons

London: The Stationery Office Limited Volume I, page 3,

[4] Noel Plumridge, 2008, Running out of Steam? , Public Finance May 2008/..

[5] Minister puts paid to private provider premium, Public Finance, August 2009.

[6] The then Prime Minister

[7] Primary Care Trusts (PCTs)

[8] Owen Bowcott,2009,  Private provision of NHS services under threat.  The Guardian, Wednesday 2 December

[9] Source: Leaflet enclosed in carton containing Diclofenac Sodium 50mg tablets.

Allyson, M. Pollock and Kirkwood, Graham, 2009, Independent sector treament centres:Learning from a Scottish case study, BMJ, 30 April

One thought on “The Disgraceful History of ISTCs in England”

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