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clinmed/2000090012v1 (October 24, 2000)
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Private Healthcare under the Care Standards Act
The article by Doyle and Bull of PPP Healthcare (BMJ Volume 321, 2nd September 2000) and the commentary by Keen of the King’s Fund which followed, both speculated on how the public and private healthcare sectors might best work together in future; the so-called Concordat.
The following comments refer only to private acute hospitals, the sector that it is proposed to use more extensively for elective surgery in order to ease the waiting-list problem in the NHS. The question of patient welfare will also be covered, a subject ignored in both articles.
Only Keen referred to the Care Standards Bill, now an Act having received Royal Assent in July 2000. The Care Standards Act (CSA) will introduce much needed changes in the regulation, inspection and management of the private sector, largely to improve patient safety and improve standards of care.
BMJ readers will know that since 1984 private acute hospitals have been registered and regulated as nursing homes even though, as Doyle and Bull point out, they now carry out the most sophisticated of medical and surgical procedures. These "hospitals" are inspected twice a year, but in most cases the inspectors are not medically qualified. It would matter little if they were, as they have no right to inspect medical records. Amazingly, the management accepts no responsibility for the clinical care of its patients. This rests with the admitting consultant who is unsupervised and responsible to no one. If in the event of a clinical accident no suitable explanation and apology is given, (as is most often the case), the patient is left with little option but to go to law and/or the GMC. The Medical Advisory Committees are ineffectual in monitoring the clinical performance of fellow admitting consultants, who are usually colleagues in an NHS hospital.
The complaints procedures in these hospitals are useless, most patients being ignorant of their existence. A new Code of Practice has been introduced recently as an interim measure until the DoH pronounces on the matter, but the body to which it was submitted for approval did not approve it before it was circulated to private hospitals for implementation. APROP hopes that a statutory complaints procedure will be imposed upon the industry.
All this would matter less if the consultants, as in the NHS, worked in teams alongside senior and junior medical and nursing staff experienced in their particular fields. In a private hospital no such team exists, the sole medical presence being a comparatively inexperienced resident medical officer (RMO). This unfortunate young doctor is expected to deal with any emergency in any field of medicine in the absence of a consultant. Consultants are absent, of course, for most of the day and all of the night. To compound the precarious position of a patient in trouble is the absence in most private hospitals of emergency facilities such as crash teams and intensive care units, staffed and equipped to NHS standards. No wonder an increasing number of private patients are opting for treatment in private wings of public hospitals.
The above describes the present situation in private acute hospitals. How the CSA will improve patient care and safety in the private sector will not be known until the associated Statutory Instruments (Rules and Regulations) are published and the mechanisms of control and enforcement are known. Until that time the DoH is unlikely to significantly increase the number of patients referred to the private sector. Even though such patients carry with them their NHS rights under the so-called "Patients’ Charter" it is not much consolation to know their rights if they have suffered a grievous or even mortal injury. When pressed by journalists on this subject of patient referrals, the Secretary of State was careful to state that NHS Trusts could refer patients to the private sector provided that funds were available and that the hospital was suitable, i.e. properly equipped and staffed.
Many other questions remain to be answered such as where do the extra surgeons come from? It takes nine or ten years to train one and they cannot operate in two theatres at once. Other matters of concern include the domination of the London market by a US company; the propriety of medical insurance companies having financial interests in private hospitals that are classified as "Preferred" in their lists; the influence of medical insurance companies on where their clients are treated (in preferred hospitals) and interference by insurance companies on clinical decisions (should an insurance company decide on whether or not a client has a hysterectomy?) These are only some of the deficiencies in the private sector which have to be rectified. Unfortunately, the DoH does not have the power to act on them all.
Arising from the CSA is the creation of a powerful new body, The National Care Standards Commission, whose remit includes regulating private healthcare in accordance with new national standards.
"It will carry out regular inspections of services and will have strong powers of enforcement to ensure that providers meet the required standards. The aim is to drive up the quality of services and improve the level of protection of vulnerable people. The Commission will also have an important role in investigating complaints and providing people with information about services."
The Commission will be legally established in April 2001 and will take on its regulatory responsibilities in April 2002. It would therefore seem that widespread use of private sector facilities, especially surgical, is unlikely to happen until 2002.
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