The problem with ISTCs

“Perfidious financial idiocy” was how a previous editor of this journal described the private finance initiative (PFI), a way of securing private funding for public projects, notably hospital building (BMJ 1999;319:2-3, www.bmj.com/cgi/content/full/319/7201/2). Richard Smith based his assessment largely on the work of Allyson Pollock, who, Cassandra-like, found her message ridiculed when it wasn’t ignored. But that was then. The current unravelling of PFI, with the government bailing out projects in trouble, makes her analysis look prescient. So we should at least take notice of what Professor Pollock has since turned her attention to.

Her latest target is independent sector treatment centres (ISTCs), the beneficiaries of the British government’s policy of contracting out clinical services to commercial companies. Last year, she castigated the Department of Health for failing to collect and provide data to allow evaluation of this policy, quoting a member of the Commons Health Committee who said that the whole area seemed to be “an evidence-free policy zone^” (doi:10.1136/bmj.39470.505556.80).

While researching a series of articles on the NHS last year I was surprised to discover one of the reasons why: commercial sensitivity. In trying to analyse the effects of the NHS’s reform programme, the Audit Commission and the Healthcare Commission found themselves prevented from working out whether ISTCs were value for money because relevant data, deemed to be commercially sensitive, were denied them. Recall for a moment that the Audit Commission is meant to promote value for money for taxpayers, auditing the £200bn ($302bn, €268) spent by 11 000 local public bodies. Even more worryingly, the Healthcare Commission could not report on the quality of care at ISTCs because the centres failed to comply with the data requirements of the Hospital Episode Statistics. Seeking to bring this weird state of affairs to wider attention, I accompanied my article with a quote from the commissions’ report (doi:10.1136/bmj.a524).

They do things differently in Scotland and, after a public interest appeal to the Scottish information commissioner, NHS Tayside placed the only Scottish ISTC contract in the public domain. In this week’s article Allyson Pollock and Graham Kirkwood pore over its content, alongside an assessment by management consultants PricewaterhouseCoopers and the contemporaneous Scottish Morbidity Record (doi:10.1136/bmj.b1421). It might be that the treatment centre’s owners got a much better deal than the taxpayer, being paid up to £3m for patients who did not receive treatment. But without access to the full data we’ll never know. Pollock and Kirkwood’s surely uncontroversial bottom line is that a proper assessment of ISTCs requires the full contract details and costs to be in the public domain.

Jane Cassidy discusses the use of the Freedom of Information act to uncover this sort of information, but reports that England’s Department of Health needs to up its game (doi:10.1136/bmj.b1798). The department has been ticked off twice by the information commissioner in the past year and has been ruled to have acted wrongly in 14 of 16 decisions that have gone to appeal since 2005.

With doctors having to endure endless lectures on the virtues of “quality” and “leadership” emanating from the Department of Health, could they request a spot of “transparency” in return? Who knows—it might shed some interesting light on both the quality of care provided by ISTCs and the leadership abilities of those entrusted to spend taxpayers’ money wisely and well.