I founded the All Party Specialist Orthopaedics Group several years ago in response to the financial challenges facing the Nuffield Orthopaedic Centre in my constituency. I was appalled to realise that, while providing some of the best orthopaedic treatment in the world, and some of the lowest infection rates, I might add, this organisation was in financial peril because the Payments by Results system was simply massively underpaying for specialist work.
In addition to wanting to protect this precious service for my constituents, I also couldn’t really understand why this was happening – for surely innovation is a way to raise standards. I also believe that, if used properly, innovations and treatments that may initially seem expensive in fact save money in the longer term by allowing children to go to school, and adults to remain independent and in employment. These are often lifelong savings.
So what was going wrong? Well it was, and is, one of those situations when a system simply cannot suit everyone it is trying to manage. Payment by Results is a good system for generalists – it just fails single speciality organisations, and this is a pattern repeated where similar systems are used throughout the world.
But it is of course difficult, and often very slow, to persuade large government organisations to make changes to their system – and that is where the All Party Group has been trying to encourage the adoption of specialist-friendly procedures and methods. We have aired the subject in Westminster Hall Debates (at one of which Andy Burnham during his last stint at the Department Health made a commitment to get Payment by Results right for orthopaedic specialists), Parliamentary Questions and during debates.
I and my colleagues on the committee are committed to ensuring that these specialist centres are able to continue treating the rarest cases, caring for patients with the highest risks, providing vital second opinions, receiving tertiary referrals, and picking up the pieces when things go very wrong in terms of infection. All this is before you mention their vital roles in world class teaching and research.
Indeed, since they were first conceived during the Great War, specialist orthopaedic hospitals have pioneered the way ahead with many of the now mainstream orthopaedic treatments that improve thousands of people’s lives every year – for example making hip and knee replacements possible for even the most complex and fragile patients - and developing methods that ensure the very best outcomes.
Many reasons have been used to argue against the existence of specialist orthopaedic hospitals over the years, including an obsession that 'big is always better' in terms of establishment size, and a belief in a number of long disproved myths – for example, that smaller specialist hospitals are somehow inherently unsafe; that specialist orthopaedic hospitals are somehow unnecessarily expensive to run; and that all orthopaedics procedures are essentially the same. But these really are myths - the truth is that it is very hard to match specialist orthopaedic hospitals in terms of undertaking their core work and also in terms of their exceptionally high patient satisfaction ratings – something that should not be ignored in the age of patient choice.
The truth is that, although the Government has sought to remedy problems with Payment by Results through the provision of transitional relief (now ended), adjustments to the tariff, and the provision of top-ups, Payment by Results has not yet arrived at a satisfactory system that seems able to sufficiently recognise complexity and pay for it fairly. The current scenario of potentially making a profit on an amputation and an enormous loss on limb salvage is clearly unsatisfactory.
Surely the system needs to work for all types of organisations not just large generalists. Although we are all waiting with bated breath to see the reality of the 2010/11 tariff, it will need to be a fairly momentous shift in approach if specialist orthopaedics is going to find itself equitably funded.
In my view, the only way forward is to ensure that specialised commissioning fully embraces all highly specialised orthopaedic procedures. This way forward will not only help ensure fair payment for hospitals but will ensure that rare conditions are only treated by experts with the right skills – this will ensure the very best outcomes.