An unanticipated but welcome benefit of opening up the NHS market has been to highlight the failings of the independent sector. Many of these failings are outlined in the CHPI’s report, Patient Safety in Private Hospitals: the known and the unknown risks. However, one can only analyse what is recorded, and some aspects of this need further exploration.
The open NHS market has provided new opportunities for doctors: for example, many have set up group practices to tender for and provide healthcare in the independent sector. However, the potential for conflicts of interest is vast. For instance the CHPI report refers to conflicts of interest in relation to the Medical Advisory Committees which are responsible for clinical governance in private hospitals but whose members have an interest in the hospitals’ financial success. This issue is now even more significant given the expansion of the NHS market and the wider business interests of some MAC representatives. Independent healthcare providers must adopt the principle of including lay/patient representation on each hospital’s MAC.
Furthermore, from a patient’s perspective, NHS patients have increasingly tended to lose control as to who provides their care. For example, a patient requiring major elective surgery may be referred on by a NHS Trust to a third party provider because the Trust has sub-contracted the work. In theory patients should give informed consent to this, but it is not clear that it is consistently sought. This is ironic, given that ‘patient choice’ is one of the principles on which the open market is based. In such cases patients need to have the implications explained to them.
There is also the issue of the hours worked by consultant surgeons and anaesthetists who practise in private hospitals. Who Operates When?, the 2003 report of the National Confidential Enquiry into Perioperative Deaths, concentrated in particular on who was operating outside normal working hours in NHS hospitals. With the evolution of care provision, whereby growing numbers of NHS patients are being treated in private hospitals, I feel we now need to consider improved ways to examine an individual doctor’s whole practice. I often make comparison with the aviation industry. For example, a pilot cannot fly a transatlantic flight and then immediately go on to fly again for another airline. There are mechanisms in place to protect against this. But in healthcare a surgeon or anaesthetist can operate for many hours in one hospital and then go on to operate in another, and private hospitals don’t consistently monitor their whole practice throughout a working day. I myself would not consent to have elective treatment if, for example, the practitioner in question had already completed many hours of work that same day.
Of course, many will point to the fact that the cornerstone of the revalidation of doctors is the annual appraisal. The appraisal is a mandatory review of all aspects of each clinician’s work. However an NHS appraiser may not fully appreciate such issues relating to independent practice. Consultants and independent hospital directors need to be sensitive to this, irrespective of commercial demands.
I feel that the organisation of my own specialty in the independent sector, anaesthetics, needs particular scrutiny. The Royal College of Anaesthetists has introduced an accreditation process whereby a hospital can have its anaesthetic service reviewed and accredited as appropriate. In principle, this is a robust governance process. However, to date none of the Independent Healthcare Providers has embraced the concept. To my mind this is because they don’t have to. In other words, the independent sector does what it needs to in order to meet current requirements, but no more. The IHPs tend to report surgical outcomes as a reflection of the ‘quality of their surgeons’ without applying the same standards of governance to the service specialties as are applied in NHS hospitals. This is, in part, because the surgeon is the cornerstone of their marketing approach.
As a result, little attention is paid to the organisation of anaesthesia. For example, there still exists in many private hospitals what is to my mind the outdated practice in which a surgeon organises his/her own anaesthetic cover. Of course I agree with the idea that a surgeon should be able to work regularly with the same anaesthetist. That in itself is good practice. However, the anaesthetist should be accountable to the same governance processes as in the NHS and should not work as a sole practitioner. Organisation of anaesthetic services in the independent sector was raised in the case of David Sellu (a surgeon who was held responsible for the neglect of a patient who died in a private hospital) as the coroner felt the lack of structure (including a last-minute difficulty in finding an anaesthetist) contributed to the failings in the care of the patient concerned.
These are just a few of the issues which I feel could be explored further. NHS commissioners approve tenders for services and rely on regulators such as the Care Quality Commission to measure standards. However, does what they measure reflect the full picture and is it in the best interests of all patients cared for outside the mainstream NHS?