Reforming private hospitals in England after the Ian Paterson scandal
Executive summary
- This report sets out a series of recommendations to reform the private hospital sector in England following the Ian Paterson scandal which left over 500 hundred women who underwent unnecessary breast surgery in two private hospitals maimed and injured.
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As we have shown in two previous reports, there are a number of systemic patient safety risks which are specific to the private hospital sector. The reaction by both the regulator the Care Quality Commission and the private hospital sector to the Ian Paterson scandal highlights the extent to which those risks remain and will continue to do so unless extensive reforms are introduced.
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Based on an extensive review of the CQC inspection reports of 177 private hospitals in England this report provides evidence which identifies the
characteristics of the private hospital business model which make it susceptible to exploitation by ill-meaning or incompetent surgeons. -
The report shows that these systemic risks stem from one central flaw. Unlike any other type of hospital the vast majority of private hospitals seek to transfer the risk and the liability for something going wrong to the NHS or other companies.
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The refusal by private hospital companies to accept full responsibility for what happens in their facilities means that patients will always be at risk. Or put another way there can be no guarantee of patient safety in private hospitals without full liability.
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Further, the regulatory regime which covers private hospitals does nothing to address this central weakness and has in most cases ignored or overlooked the extent to which patients have been put at risk.
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The report makes the following 5 recommendations to reform the private hospital model in order to make them truly safe for patients and to avoid a repetition of the Ian Paterson case.
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First, private hospital companies should directly employ the surgeons and anaesthetists who work at their hospital facilities and should take on responsibility for monitoring their activities and appraising their performance. The failure by the private hospitals to accept the liability for the actions of Ian Paterson was not an isolated case, but is central to how the private hospital business model operates. Allowing hundreds of NHS trained and employed surgeons to carry out operations in small private hospitals, but without having a direct contract of employment with them, prevents the private hospital from being able to effectively monitor their performance.
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Further, if private hospitals are not liable for the activities of the surgeons operating in them, they have no incentive to monitor their performance and activities.
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In addition, this report shows that in hundreds of cases the failure by private hospital businesses to directly employ surgeons means that it is entirely possible that a surgeon will not have performed an operation in a given private hospital for over a year but would be allowed to do so tomorrow. This poses direct risks to patients as the surgeon is unlikely to be familiar with the hospitals procedures, facilities and staff.
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This report also shows that those hospitals with the highest number of surgeons who are granted the right to practise within a hospital tend to have above average rates of adverse incidents for patients. It also shows that some private hospital businesses allow surgeons to be 45 minutes away from the hospital after they have carried out an operation and so are not on site to deal with any post-operative complications. This has been found to be a key factor in the avoidable deaths of patients at private hospitals and is contrary to the Royal College of Surgeons Standards on Unscheduled Surgical Care, which require consultants to be no more than 30
minutes away. Despite this risk the regulator of the private hospital sector permits this practice to occur. -
Second, private hospitals will not be truly safe unless they have adequate facilities to deal with those situations where a patient’s life becomes endangered following an operation and where the hazardous transfer of patients to NHS hospitals ceases. Currently, the great majority of private hospitals transfer patients to the NHS when complications post-surgery arise. We estimate in this report that this reliance on NHS hospitals could have cost as much as around £250m over the course of the last three years, with no evidence that private hospital businesses have paid anything to cover these costs. Whilst the safety net for private hospitals provided by
the NHS saves lives, its existence is an impediment to a true patient safety culture in private hospitals. If the private hospital business does not have to deal with the consequences of post operative complications it has no incentive to prevent things from going wrong in the first place. -
Third, private hospital businesses must end their reliance on a single junior doctor (a Resident Medical Officer), working extreme shift patterns, to provide post-operative care for patients. This report shows that most private hospitals have only one junior doctor in charge, irrespective of the number of patients in the hospital, with some being responsible for up to 96 beds. In addition, the current working patterns of these junior doctors are incompatible with the European Working Time Directive with many doctors working shifts of 24 hours a day (168 hours per week) for one or two weeks at a time.
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Instead of relying on an outside agency to employ these doctors – which again allows the private hospital business to seek to avoid liability if they are not properly trained or vetted – the hospitals should employ them directly. There is no good clinical reason why the current Resident Medical Officer model should continue to be used to provide post-operative care to patients in private hospitals.
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Fourth, as we have stated before, private hospitals should be required to adhere to the same reporting requirements as NHS hospitals in order to enhance the possibility that the risk of harm to patients can be more easily detected. This report shows again that the notification of adverse patient safety incidents (such as unplanned patient transfers or readmission rates) to the CQC is haphazard, and the quality of the data is unreliable – currently only 63% of private hospitals registered provide regular returns to the CQC as they are not mandated to do so by law.
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What data is available shows that there is a huge variability in the occurrence of patient safety incidents across private hospitals but that despite this the CQC does not have the ability to determine where potentially dangerous practices are occurring. Instead where patient transfer rates are 4 or 5 times the national average the CQC has deemed these to be of no concern and has often rated these hospitals as ‘good’ or ‘outstanding.’
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The private hospital companies have argued that the data which they have been required by the Competition and Markets Authority to provide to the Private Hospital Information Network (PHIN) address the concerns about data transparency. However, despite the misconception that this data contains patient safety information it is of limited value. It is also information which has yet to be fully collected and published by private hospitals, despite this now being a legal requirement. The organisation which has been set up to publish and validate this data is funded by and governed by representatives from the private hospital businesses.
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Fifth – The legislation governing private hospitals should be amended to make clear that all those who are registered with the CQC should be fully liable for all the services which are provided within it, including the actions of surgeons and other healthcare professionals. The Health and Social Care Act 2008 sets out requirements for private hospitals to ensure that they employ properly trained and competent surgeons and other healthcare professionals. However, the difficulties that the victims of Ian Paterson have had in gaining compensation and redress for the harm caused to them shows that this legislation is either unclear or inadequate.
The fact that the requirements of the existing legislation have not been properly enforced by the CQC raises the question whether the Paterson scandal could have been prevented had the regulator intervened at the time. A simple amendment to the Health Service Safety Investigations Bill currently before Parliament could easily rectify this issue. -
Finally this is an issue for the NHS as much as for private funded patients. The risks posed by the current private hospital model do not only affect patients who are funding their treatment themselves or through private insurance. The analysis set out in this report shows that almost half of all inpatients treated in private hospitals are funded by the NHS, as are a third of outpatients. There are now 82 private hospitals in England where the majority of patients are funded by the NHS. This puts the NHS and the Department of Health in a very strong position to require changes to the private hospital business model in order to ensure the safety of NHS patients.
Key facts about private hospitals in England
- 500 + – the number of women on whom Ian Paterson carried out unnecessary breast surgery in two private hospitals.
- £250m – the estimated cost to the NHS of treating patients who have been transferred from private hospitals.
- 45% – the percentage of inpatients in private hospitals who are funded directly by the NHS.
- 32% – the percentage of outpatients in private hospitals who are funded directly by the NHS.
- 82 – the number of private hospitals where more than 50% of patients are funded directly the NHS.
- 104 – the number of patients who died following a transfer from a private hospital to an NHS hospital.
- 168 hours – the typical weekly shift of a junior doctor a Resident Medical Officer in a private hospital.
- 32 – the average number of beds for which a single Resident Medical Officer is responsible in a private hospital.
- 868 – the number of consultants who have the right to practise at the Harley Street Clinic, a hospital with 100 beds.
- 45 minutes – The duration, in travelling time, which a consultant is allowed to be away from a number of registered private hospitals in the event of their patient becoming unwell.
Read the full report at the CHPI website