Informal oversight of clinicians compromising patient safety, says CQC

The Independent Doctors Federation (IDF) has called for ‘zero tolerance’ of poor safety standards in independent hospitals after a report published today by the CQC found informal governance arrangements and lack of clinical oversight for consultants were compromising patient safety in some facilities.

The regulator said longstanding relationships based on familiarity with consultants were being used in place of formal governance processes at some independent hospitals, posing a ‘real danger’ that poor practice could be overlooked. In addition, it said consultants were sometimes treated as ‘customers’ bringing business to the hospital, making providers reluctant to challenge them.

‘There is a tension in the fact that clinicians are not employed by the provider, but work under practising privileges – and as such can be viewed as ‘customers’ of the provider,’ said the report. ‘We saw examples of Medical Advisory Committees not effectively managing the practising privileges of consultants, for example not ensuring that a consultant was only undertaking procedures they were experienced to do or not undertaking new or innovative procedures without effective risk assessment, informed consent and monitoring.’

IDF president Dr Brian O’Connor said that although it was unrealistic to expect all hospitals to be problem-free all of the time, patients have the right to the highest standards of care and safety and ‘there should be zero tolerance of anything less’.

‘As doctors we want to see the same high standards across the whole of the healthcare sector, private and NHS and while we support the continuing efforts of the CQC to help make this a reality, we call on all providers to ensure enough resource is available to ensure the highest standards of clinical governance,’ he said.

The report comes in the wake of the independent inquiry into the practises of disgraced breast surgeon Ian Paterson, which is due to report next summer. The CQC warned that safety in the independent sector was ‘too often’ viewed as the responsibility of individual clinicians rather than a corporate responsibility – something which it said the Paterson case had brought into sharp focus.

‘It is essential that providers demonstrate that they are proactively auditing and monitoring consultants’ work, and have real oversight of services in order to protect patients and ensure they are being treated safely and effectively. In many cases they could not,’ said the report.

This is the CQC’s first comprehensive report on the state of care in the sector since it began rating independent hospitals under its new inspection regime in 2015. As of 2 January this year, 30% of the 206 independent hospitals inspected were rated ‘requires improvement’.

Although the regulator identified many examples of ‘good and outstanding care’, with independent hospitals scoring highly in key questions on the provision of effective, responsive and caring services, it said ‘substantial improvements’ were needed regarding governance, risk management, clinical audit and safety culture. On the question of safety, 41% of hospitals were rated ‘requires improvement’ and 1% as ‘inadequate’. In addition, 30% of hospitals were rated as ‘requires improvement’ and 3% as ‘inadequate’ on the question of being ‘well-led’.

As well as a lack of formalised governance procedures, inspectors found that safety procedures were not always fully embedded; clinical outcomes were not always monitored effectively and some hospitals were not fully prepared for the possibility of deterioration in a patient’s condition.

‘The competitive nature of the sector creates an incentive for less transparency about clinical outcomes and benchmarking of patient data, and sharing of information in the interests of encouraging improvement across all services,’ said the report.

However, it added that providers in the sector had been quick to respond to its concerns and were ‘proactively addressing areas where further work is needed to improve patient care’. Over half the 13 locations that have been re-inspected have improved: two from an initial rating of ‘inadequate’ to ‘good’; two from ‘inadequate’ to ‘requires improvement’; two from ‘requires improvement’ to ‘good’; and one from ‘good’ to ‘outstanding’. The other six locations maintained their rating.

As a group, BMI Healthcare had the most facilities with a ‘requires improvement’ rating – 26 out of the 49 hospitals inspected. Ten of the 31 Spire Healthcare sites inspected were rated as ‘requires improvement’ as were nine of the 28 Ramsay facilities.

Health insurer Bupa said it was concerned that quality of care at BMI’s facilities could be further impacted by its South African parent company’s decision to exit the business in the wake of ‘unaffordable’ rents.

CEO of Bupa Insurance Alex Perry said that combined with sustained underinvestment in BMI’s facilities, Netcare’s decision to dispose of its interest in the UK business could hinder BMI’s ability to develop its services.

‘For the sake of our customers, we will be closely monitoring this to ensure the necessary improvements are made,’ he added.

However, it is not just national groups that need to improve their CQC ratings. Some of central London’s most well-known and prestigious sites also ‘require improvement’, say CQC inspectors, including Bupa’s own Cromwell Hospital, which was one of the 3% of sites rated ‘inadequate’ on the question of being ‘well-led’. Marylebone’s King Edward VII hospital and HCA’s Princess Grace Hospital also received ‘requires improvement’ ratings.

The CQC’s chief inspector of hospitals Professor Ted Baker said: ‘Much of the care and treatment we have seen at independent acute hospitals is good – and we found that effective leadership at a local level, good staff engagement and a close oversight of the services being provided played a key role in ensuring high quality care… Encouragingly, we have seen clear evidence that our regulation is having an impact, with providers taking rapid action in response to our concerns. We want to see this continue and more providers learning from those services that are getting it right.’

Commenting on the report, NHS Partners Network clinical director Dr Howard Freeman said: ‘Where the CQC has identified areas for further improvement in independent hospitals it is encouraging that it has found that ‘providers have been quick to respond to inspection findings’, with over half of the independent acute hospitals re-inspected improving their rating.

‘We look forward to working closely with the CQC and other bodies to ensure independent hospitals continue to focus on safe, high-quality and responsive care and the best possible patient experience.’