Feature

Look behind the mask

Under Labour’s public-private ‘concordat’ increasing numbers of NHS patients will be cared for in the private sector. But will the safety and clinical standards of commercial hospitals be up to scratch? Richard Ennals has doubts

What counts is what works – ministers’ oft-used chant to justify sending thousands of NHS patients for treatment in private hospitals – will ring hollow with the many victims of substandard care in the private sector. Profit-motivated corner-cutting, especially in the form of inadequate, unsafe staffing, coupled with weak legislation, has resulted in a sizable annual crop of often horrific injuries and deaths in private hospitals.

The Commons Health Select Committee, in the report of its 1999 inquiry into private healthcare, listed many of these hospitals’ specific deficiencies:

• the continuing risks of treating patients in single rooms;
• the lack of specialist wards and resident specialist nurses and doctors;
• the hours of consultants being largely unmonitored, with the risk of misjudgements due to fatigue;
• the lack of proper resuscitation and back-up facilities;
• inexperienced resident medical officers; and
• the absence of even informal peer review as clinicians in private hospitals do not work in NHS-type teams.

The Committee noted that, even with improvements, the small size of the average private hospital and the need for it to operate commercially could continue to jeopardise patient safety.

Despite the private sector’s repeated claims that there has now been a major sea change in its delivery of care, and media reports of the health committee’s findings as a crackdown on private healthcare, there has been no such thing and certainly nobody has been brought to account.

The patients’ group Action for the Proper Regulation of Private Hospitals (APROP) continues to receive many calls from injured patients or bereaved relatives. Shoddy surgery, poor theatre staffing and undiagnosed complications continue to be frequent complaints, resulting in death, or people left with long-term pain, brain damage or severe disability. (Advertising claims that private hospitals offer care ‘of the highest quality’ are hard to sustain).

The most common complaint and the cause of much further distress is the manner in which private hospital managers continue to respond to complaints, which is almost invariably dissembling, obfuscatory and cavalier, escalating in some cases even to legal threats (and Britain sadly has no shortage of lawyers quite happy, for a fee, to intimidate even the bereaved). Such is the private sector ‘expertise’ now being ‘harnessed’.

APROP’s view is that before the government entered into any concordats with private sector it should have undertaken a thorough Bristol-type inquiry into private hospitals, to expose and deal with bad practices and cavalier managers.

The suggestion that Labour’s former opposition to NHS use of private hospitals was purely ideological is quite untrue. Both Robin Cook and David Blunkett, as shadow health secretaries, expressed concern at standards of clinical care, and health ministers refused an offer of beds during the winter of 1997-98 because they feared emergency care was not up to NHS standards.

APROP is concerned that NHS patients being treated in private hospitals under the public-private concordat before the supposedly more stringent controls of the Care Standards Act come into effect could be exposed to the same risks as private patients.

Although The NHS Plan stipulates that high standards of care have to underpin any arrangements, it is unlikely that NHS patients will in all cases be supported by adequate healthcare teams, specialist postoperative care staff and 24-hour anaesthetist emergency cover to genuinely ensure high standards.

The draft standards and regulations of the act, which seem to promise a number of improvements in patient protection, are currently out for consultation (and improvement would not be difficult, given the flimsiness of the Registered Homes Act). For example, they state that ‘the management of specific conditions will take account of evaluations by NICE [National Institute for Clinical Excellence] and specific clinical guidelines from the relevant Royal Colleges’ (draft Core Standard 3).

Hopefully, such guidelines would recommend against major surgery being carried out single-handed by surgeons in private hospitals, with only an anaesthetist and a scrub nurse for support, a sadly not uncommon occurrence that has contributed to a number of incidents.

The government would also be wise to take on board the Guidance for Purchasers published by the Royal College of Anaesthetists in 1995. This holds that hospitals carrying out surgery should have 24-hour resident anaesthetist cover in order to fully guarantee patient safety in emergency situations.

For the first time, a clear legal definition for the necessary ‘fitness’ of the private hospital manager is proposed, stating that the person must be ‘of integrity and good character’ (draft Regulation 11). Managers who routinely cover up in the wake of an untoward incident may now finally be held to account. Integrity implies a duty of candour. Complainants who have received unsatisfactory responses in the past will also be able to raise their concerns with the Care Standards Commission.

Advertising will have to comply with the Advertising Standards Authority’s principles (Core Standard 2). This would include having to be ‘legal, decent, honest and truthful’. It is doubtful whether a hospital that offers night-time cover of just a junior doctor and a handful of agency nurses to its patients could continue to describe its care as ‘of the highest quality’.

A number of major weaknesses, however, have not been properly addressed. There is no clear provision for the proper NHS-type healthcare teams that campaigners are seeking with, at the minimum, for example, a resident doctor of registrar level and specialist nurses.

The draft act’s vague wording – that the hospital must ensure only that there is an ‘appropriate’ number of staff – echoes the 1984 Registered Homes Act’s requirement only for an ‘adequate’ number of staff. Such wording has enabled private hospitals to get away with dangerous and sometimes fatal understaffing over the years.

Standards or regulations should also more clearly set out that a hospital must take responsibility for errors or bad practice on the part of its admitting consultants, as happens in an NHS hospital. The role of the hospital’s and consultants’ insurers must also be addressed, with a view to curtailing their scope for obstructing investigations.

There are also proposals for a ‘lighter touch’ of regulation, whereby a hospital will be accredited by a ‘quality assurance’ scheme. APROP’s experience is that some of the most horrific incidents and worst instances of subsequent dissembling have occurred in hospitals that have received high ratings in such schemes. These are primarily organisational and not clinical audits, and the public can be easily misled.

Worryingly, it is proposed that inspections will be reduced from two to one a year, while inspectors will be recruited from among former health authority registration and inspection officers. APROP members who sought health authority investigations of their complaints – for which there are comprehensive NHS Confederation guidelines – consistently found a considerable reluctance to investigate, even in instances of severe injury and death. The commission’s training projects will hopefully lead to the development of a more proactive and patient-centred approach among its inspectors.

As regards complaints, hospitals will only be required to have a procedure in place. Although the private sector has had a code of practice for complaints for over 10 years, most complainants have not been told of its existence. APROP’s view is that an independent procedure should be set up, with the early involvement of the commission to oversee the course of the complaint at all stages. There is no provision for an NHS-type commissioner.

Fitness as regards operators covers only their provision of facilities. Questions concerning integrity and good character will not apply. Healthcare multinationals with dubious histories will therefore be able to continue their expansion in Britain unopposed (perhaps further facilitated by GATS).

Other legislation might improve the private patient’s lot. The Human Rights Act’s right to life, right to a fair trial and freedom of expression might help prevent unsafe clinical practices resulting in untoward death, tampering with medical records (sadly this happens often) and the use of libel laws to frighten off complainants. It seems that the government’s proposed corporate manslaughter bill will also extend to private hospital managers and consultants.

Unless the Care Standards Act in its final form can be shown to genuinely protect patients, APROP will continue to advise private patients to give private hospitals a wide berth and, instead, to use the private wings of NHS hospitals, where they will find better staffing, skill-mix, facilities and emergency back-up. Those insured through a company scheme (60 per cent of health insurance holders) should insist that their employers switch to a corporate trust scheme.

Action for the Proper Regulation of Private Hospitals, PO Box 418, Weybridge, Surrey KT13 0FJ. Tel: 01932 849403.