Led largely by Irish management, a private hospital group is challenging the dominance of Britain’s NHS by doing things differently

FIONA CALNAN was a banker in an earlier life before deciding to run hospitals. In her first weeks in 2005 with the newly-created UK Specialist Hospitals, she was faced with a plan, few staff and a field near Glastonbury.

Nine months later, the Shepton Mallet hospital was built and opened, equipment and IT systems had been bought and installed, while 150 staff, including surgeons, had been hired, mostly from overseas, including Ireland.

Today, UK Specialist Hospitals, a company created to benefit from reforms driven by Tony Blair to introduce some competition into the National Health Service, has five facilities in the southwest of England.

Most importantly, it has gained a reputation after it was listed by the Dr Foster Hospital Guide– the league table bible for UK hospitals – as the best in which to have hip operations on the NHS and the third best for knee surgery.

Unlike the situation that exists for most private hospitals in the UK and Ireland, UKSH does not treat private patients, since everyone who passes through its doors are NHS patients, without private health insurance.

“Tony Blair did not want to introduce wholesale competition. He was selecting areas where the waiting lists were particularly long to try and change some of the approaches and to see what would happen. I don’t think that they knew what the outcomes would be,” says Calnan.

In the beginning, patients came to Shepton Mallet with faith, and in pain. “People were waiting more than a year for some procedures. In orthopaedics, people were waiting anything from a year up to three years to get a hip done,” she says.

Somerset NHS patients were given a choice between the old and the new. “They were told that they could choose the new centre, where they do things slightly differently, but they are not proven. Then, nobody knew whether we would be any good. There was a lot of scepticism,” says Calnan.

Equally, the Labour government wanted not only to cut waiting times, but also to reduce the amount of time that a patient spent in hospital – and the costs of care that inevitably comes with it.

“It was very fraught. We started into a very political arena, unexpectedly, and there was a lot of negativity towards what we were doing – from the press, the NHS, the British Medical Association,” she goes on.

In the beginning, it could not hire staff from NHS hospitals. “They felt that it needed more staff, not less. They also did not want the complaint that we were stealing their staff to do our services and that was why the NHS figures might have got worse.”

Seven years ago, Calnan says, the average length of stay for a hip or knee operation was “seven to eight days, maybe longer”. UKSH started off with a four- to five-day stay and has now cut that figure nearly in half.

The key, according to UKSH’s medical director Dr Cath Finn, who trained in University College, Galway, is “a relentless attention to detail” and a determination that the patient will move as quickly as possible after surgery.

Preparations for an early departure begin before the patient arrives in theatre, since all are given pre-operation exercises to ensure that muscles are well-toned. “That bit that goes before, the physiotherapy and the education, is crucial to early mobilisation.”

In a bid to encourage patients to prepare properly before they arrive, UKSH has produced the Pocket Physio app as a free download. Now it is encouraging other hospitals to use it to help their patients.

So far, patients and GPs have made approving noises about the app. Devon patient Adrian Rockey used it during recent treatment in Bristol. “I’ve only just started texting, so I’m in no way computer literate.

However, I found easy to use.

It’s easier than the usual booklet of physiotherapy exercises,” he says.

Dr Sue Frankland, a GP who advises UKSH, says: “Patients in the past have often struggled to understand exactly how to carry out their exercises and sometimes have given up as a result. helps them understand precisely how to carry them out and why.”

In seven years, staff numbers at UKSH have risen to 600, drawn from 33 nationalities: the Irish contingent is small, numbering just eight, but it is influential. Besides Calnan and Finn, Calnan’s deputy is Mayo-born Lorcan O’Murchu.

The company is paid the same rate for operations as NHS hospitals, though it does not take patients with serious underlying medical conditions who might require intensive care subsequently. “But that doesn’t mean that we don’t take a difficult hip, knee or cataract,” says Finn.

The Dr Foster study and one in the British Medical Journaltook into account the different patient mix, both Calnan and Finn insist. "The outcomes are still better. I would argue that they should be because that is what we do every day of the week," says Finn.

“In our new facility in Bristol, we have noticed that the health of our patients seems to be very different from Somerset. Perhaps, because we are in a city, we will get a lot of different mixes of poor health, so we have learned to adapt to that.

“We are taking a different cohort of patients and we have learned that we can handle an awful lot of these situations, and I am very keen that we do, to be frank. We have put a lot of infrastructure in support, so there is a lot that we can do,” she goes on.

Transparency, both argue, is the key to quality. “In our case, outcomes are given by doctor, so you can see how many doctors have had a patient readmitted into hospital. You can see their trends over every month, every quarter.

“You can see if they did a hip replacement and the hip replacement didn’t go well and had to be revised. We monitor everything,” said Calnan, adding that every operation is recorded on video for inspection later, if necessary. “I would say that we are unique in that.”

New staff of all ranks serve out a probationary period, unlike in the NHS, and are constantly assessed throughout. Problems, if found, are addressed, with the assistance of an external board of medical advisers.

“If one of our doctors isn’t fit for our purpose in delivering the techniques that we want, then we would do a bit of mentoring and support through the clinical adviser with that individual. Clearly, if there isn’t an improvement . . . ” says Finn.

A small number have been sacked.

“Medics, mainly. Most of them will go themselves first. They will see the pattern, they will understand that they are not suiting the organisation, or that the organisation doesn’t suit them and they will leave.

“It doesn’t necessarily mean that they are bad doctors. They are fit to practice, they just need to do a different kind of case-mix, or whatever,” she continues, adding that other hospitals will be told that a surgeon was stopped from carrying out certain operations.

However, she believes constant inspection and ranking is a motivating factor. “You can see the lights coming on in people’s eyes. Some people love that.

Surgeons thrive on being competitive, to be frank. That is the nature of our being,” says

Finn, a Co Galway-born consultant gynaecologist who joined UKSH in 2009 after 19 years with the NHS.

Everything must be measured, argues Calnan, who comes from Kilmoganny, Co Kilkenny. “We take in people up to 90 years old, so we are not cherry-picking young, healthy individuals. The key to everything is a relentless attention to detail, outcome-driven data. That needs to happen everywhere, Ireland included.

“Do people have to go back into hospital within a year of having their surgery? Did they have complications? Did they have post-operative infections? How many patients with infections have you had in the last year.

“How many times do you have ruptures in the eye during cataract surgeries? Do you have post-op issues there? One of the things I discovered is how common blood-clots are. How many patients did you have?” she goes on.

Patients are offered private or shared rooms. The young prefer the privacy, while older patients, Calnan says, prefer company. TV, which now costs £5 a day in NHS hospitals, good food and free telephones are included. “The telephones have never been abused,” she says.

However, the priority is to get the patient home as quickly as possible, “needing nothing more than a packet of Panadol”, says Finn.

“The evidence is that when people are at home, they are much more inclined to move around and potter around. They’ll walk up and down more if they are home.

“In hospitals, patients are very fixed to their environment and to their bed,” she says, creating the risk – no matter how well run the hospital – of infection and clots.

Calnan agrees: “It does cost money if people stay in hospital longer, but our advice is the shorter the stay in hospital, the better for the patient, because the longer you are in a hospital, then the more chance that you have of picking up an infection.

“So we would recommend to anybody to find out if the procedure that you are having can be done as a day surgery. If it can be done as day surgery – even if it can be done overnight – you should try and get out during the day. That is my advice,” she says.

Advances in drug treatments have assisted, with UKSH avoiding general anaesthetics in favour of “a little cocktail of painkillers in around the joint. That combined with a spinal block means that they can mobilise that afternoon,” says Calnan.

“The physio comes around. Patients can sit at the end of the bed and mobilise that afternoon and it is all about getting them moving straight away. If you do that, you don’t get stiffness and fixity, those kind of things.”

Ten years ago, a hip operation “would have kept you in hospital for 10 to 12 days and months of pain subsequently”, says Finn. “They wouldn’t be back playing golf for three to six months, that’s for sure.

“Nowadays, some of ours will be back playing in about six weeks to three months. It is about refining the technique. The implants have been refined dramatically. And we have learned a lot,” she says.

The involvement of private firms in the NHS still bitterly divides opinion, with opponents charging that they have been allowed to make profits on the back of guaranteed contracts paid at a higher rate.

However, patients are making their own choices. Last year, UKSH almost doubled its turnover from £32.9 million to £62.7 million, and reported a pre-tax profit of £5.6 million, compared with a £1.2 million loss the year before.

Today, the company’s ambition is to have patients discharged happily in two days. “To be honest, when they said to me four years ago that that is the direction we will be moving to, I thought that I would never see it, having seen how ill the patients are.

“But the advances in anaesthesia and the overall approach to medicine now are remarkable. I saw a 76-year-old woman recently charging up and down the corridor, and it was day two after her surgery.

“There was another man sitting there with his knee already bent and that is very rare on the second day after an operation. I said, ‘Have you any pain?’ He said, ‘No, the pain in my head is worse than the pain in my knee’.”