Private healthcare: does something need to change?

If you have been following recent news reports about safety concerns in private hospitals, you could be forgiven for wondering why anyone uses private healthcare, let alone why the NHS subcontracts a fair amount of its routine surgery to the private sector. What is really going on behind the headlines, though? Is change genuinely needed and if so, what?

A series of unfortunate events?

The private healthcare sector is currently the subject of a public inquiry following the jailing of breast surgeon Ian Paterson, who carried out a large number of completely unnecessary operations on women over several years. That could be put down to ‘one bad apple’, and astute commentators will also note that Paterson worked in the NHS, where his activities similarly went unnoticed for some time. But there is more.

Back in April this year, the Care Quality Commission (CQC), the healthcare regulator, published a report into private hospitals that found that two fifths were failing to meet expected safety standards. The Commission raised particular concerns about the lack of adequate supervision of consultants working in private hospitals. The issue is that consultants are not employees of private hospitals. Instead, they are effectively ‘customers’ of the hospitals, who bring in patients. Hospitals may therefore have an incentive not to look too closely at the quality of care provided. Clinical governance is entrusted to a committees of doctors who work at the hospital, but it is difficult to challenge peers without very good evidence, and few doctors have time to spend watching each other at work.

A coroner in the North West has also raised concerns about private sector practice in a letter to Jeremy Hunt, the Secretary of State for Health, following the death of a patient in Manchester. This patient had undergone routine hip surgery, but his deteriorating condition was not spotted quickly enough, and he died despite transfer to the local NHS hospital. This case highlighted an important aspect of private hospitals: they do not, in general, have critical care beds or emergency facilities. Patients needing this type of care have to be transferred to NHS facilities.

Identifying real concerns

There is no question, therefore, that there have been real concerns about how private hospitals operate, both in terms of their business model, and how they manage patient safety. But is it just a matter of improving current practice, or is fundamental change needed?

Just over 40% of private hospitals inspected needed to improve patient safety measures, and 1% were actively unsafe. This is a significant proportion of private hospitals. It would be possible to argue that large numbers of NHS hospitals also need to improve, but there is a clear improvement regime for them, and action is already being taken.

The same cannot be said for the private sector, as Health Secretary Jeremy Hunt noted in a letter to private hospital chief executives on 8 May 2018. He has therefore demanded increased transparency, to match the NHS commitment to publishing information about avoidable deaths and surgical outcomes by clinician. Hunt also highlighted the importance of having procedures to manage cases where patients’ condition deteriorates, and to improve supervision of consultants in the private sector. He noted that he had asked the Department of Health to look at ways to claw back some of the costs arising for the NHS of treating patients where private hospitals have been negligent. His letter closed by asking for a response within 2 weeks, a level of urgency which suggests that he is taking this very seriously indeed.

A partnership for care

Jeremy Hunt was not responsible for the initiation of the policy that has seen much routine NHS work transferred into the private sector as a result of patient choice. He has, however, been a reasonably active supporter of this policy. His letter included the view that the private sector currently makes a useful contribution to increasing the capacity of the healthcare system in the UK, and we agree that it certainly has a place and a part to play for patients who choose this route, or unfortunately may not be able to get their needs met in a shrinking NHS.

Hunt’s letter also makes clear though, that he is not prepared to continue to support the use of the private sector to supplement the NHS on ideological grounds alone. Instead, he wants to see real commitment to improving patient safety, increasing transparency, and driving up quality in the private healthcare sector. These changes can only be good for patients, and also for clinicians who want to provide high quality care to their patients. There may be cost implications, but profit does not, and should not, triumph over good care.

‘A problem shared is a problem halved’

And change is coming – albeit patchy and often driven by clinicians themselves wanting to improve care and consistency. Some private health specialists are championing the multidisciplinary team oversight of patient care common in the NHS, to provide scrutiny and shared decision making within private hospital settings. They are setting up regular multidisciplinary meetings in-house which allow for case discussion and a variety of expert opinions on diagnosis and treatment options. The aim is to ensure that the chances of another Ian Paterson working for years with little scrutiny or challenge are reduced, and the devastating consequences to patients minimised.

Of course this is not without challenge in a setting where clinics and hospitals are incentivised to keep their clinicians happy. Add to this the fact that health specialists have sporadic working patterns juggled with NHS commitments, may be dependent upon one another for referrals and are often operating in direct competition with colleagues in the same specialty for patients.  But transparency, rigour and both peer and independent oversight of individual specialists can only protect both patients and clinicians from harm, and private providers from reputational damage.

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