Netcare Orthopaedic Surgery

Michelmores’ reaction to the SHA Report on behalf of its clients

Michelmores’ clients believe that the report fails to probe far enough into the issues surrounding Netcare’s provision of outsourced surgical procedures. The Department of Health has an understandable desire to “drive down waiting lists”. However, there is concern that private providers of surgical procedures, under pressure to drive down costs, may be tempted to cut too many corners.

It is our concern, and our clients’ concern, that patient-care may suffer as a result of the weak recruitment procedures for doctors and the lack of regulation described in the report. Since it concludes that the Netcare contract at Haslar was “successful” in spite of contrary evidence we feel it is necessary to comment further.

First, in spite of the report’s own terms of reference, it focuses its review on a ten-day period. In the context of a six- month project for a full range of orthopaedic procedures, we consider that such a narrow approach cannot represent a thorough analysis of the events that led to our clients’ injuries.

In addition, it appears from our cases that Netcare may have been operating beyond March 2004, so we feel that this window provides a mere snapshot of the real picture.

This narrow remit also centres upon the clinical performance of ‘Dr Y’, ignoring the performance of the other Netcare surgeons. Given the independent view that at least five out of his six hip replacements will fail in the future it may be justifiable to single him out for specific criticism. However he was the surgeon in only two of Michelmores’ Netcare cases.

The report considers that a surgeon with Dr Y’s clinical experience should have been able to perform these operations in spite of his lack of familiarity with the prostheses. When considered with the comment that references were “not always seen”, we feel that broader questions about the clinical performance of the Netcare team are evident and should have been investigated.

Against this background, the fact that the review team appear to have received the medical notes of only six of Dr Y’s patients, if correct, can hardly be regarded as a robust analysis even of this narrow field, quite apart from the 1000 other Netcare patients.

The terms of reference promised a thorough look at hip replacement procedures within the ten-day window. In reality the report combines a description of the working environment with repeated analysis of Dr Y’s individual performance rather than a wider review of the other Netcare surgeons.

We question the focus on hip replacements in the context of an outsourced contract for 1000 orthopaedic procedures. The report explains there were only 194 hip operations, yet identifies significant weakness in the general recruitment and vetting of Netcare professionals. Unfortunately it does not then question the wider impact of these failings. It refuses to consider the clinical performance of other Netcare surgeons. From our clients’ experience of other failed procedures, we believe this to be a real shortcoming.

The report praises Netcare’s post-operative audit, but criticises the lack of longer-term audit. Without this we cannot be certain of the clinical performance of the Netcare surgeons. It may well be that most procedures were a success, but the nature of orthopaedic surgery is such that sometimes problems arise only in the longer term. Until the five out of six hips that Dr Y operated on, predicted to fail, do in fact fail we simply do not know whether procedures were successful. In fact two of those six hip replacements had already failed by the time the report was published.

In spite of these observations the report invites us to conclude with Professor Tinston that the contract was “on the whole…successful”. We are not convinced by this analysis.

The report does not address the cost issues surrounding the Haslar project. With an overall contract value of £2,553,000 this represents an average of £2,553 for each surgical procedure. These figures concern us. We query whether Netcare was under pressure to deliver a range of orthopaedic procedures with varying complexity and risk factors too cheaply. It is not clear that the ‘true’ cost of these operations has been investigated. Was patient-care potentially compromised by the insistence of the Department of Health on cutting cut waiting lists and costs by outsourcing?

The report also mentions hostility between Netcare professionals and NHS staff and the issues surrounding a different working culture and attitude. However, the report makes no mention of what steps should be taken to resolve these issues or of any consultation with local NHS specialists with whom the Netcare professionals were expected to liaise.

At no point does this review mention the reports in the press that the Netcare consultants were not registered on the GMC’s specialist register. It transpires that they were merely registered as ‘medical practitioners’. It has been reported that Netcare believed its surgeons to be working as “honorary consultants” and thus did not require specialist registration. It is our belief that unless this has been addressed it demonstrates at best a lack of transparency on the part of OCTs such as Netcare. At worst it has the potential to confuse patients as to the qualifications of the surgeons operating on them.

We also note that there have been concerns over outsourcing to OCTs both in the press and by professional associations, such as the British Orthopaedic Association who predict a “10% complication rate in the long term” and consider that the ISTC project “transgresses basic principles of good patient care”. A group of 43 consultant orthopaedic surgeons in the South West wrote to the Daily Telegraph on 13th May 2004 to express their concerns, concluding: “[t]he whole ISTC initiative appears to be driven…to reduce waiting lists, without regard to the quality of surgery and the cost to patients.” We are therefore surprised that the report makes no recommendations as to how their fears should be allayed.

The report makes no specific recommendations as to how overseas surgeons under these private initiatives should be vetted. This is despite its conclusion that the vetting process in this instance was weak.

Continued on page four: Conclusion

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