Select Committee on Health Appendices to the Minutes of Evidence


Memorandum by Hospital Consultants and Specialists Association (PM 91)

  "A scandal of the proportions of the Bristol baby hearts saga is waiting in the wings to happen in the private hospital sector."

  This prophecy was made by Mr Winston Peters, President of the Hospital Consultants and Specialists Association (HCSA) to its Executive Committee meeting on 24 February which has put the need for clinical governance measures in private practice at the top of its agenda for the last four months.

  Mr Peters also put the same point to representatives of BUPA in talks held on the same day (24 February).

  The HCSA's conclusion is that two courses of action have to be taken simultaneously to improve quality control in private hospitals and prevent the rare "rogue doctor" working in a sector which has fewer safeguards than the NHS.

  Firstly, the stringencies of the Government's plans for clinical governance in the NHS must be adopted by the private sector to allow poor performance in private hospitals to be picked up and dealt with.

  Secondly, there must be closer correlation between the two sectors, so that disciplinary measures taken against a doctor in one sector is matched by similar action, or at least investigation by the other sector. For the two sectors are thoroughly intertwined and cannot be separated from each other.

  Therefore, the HCSA also supports the BMA's contention, put to your Committee on 31 January 1999, that private doctors, hospitals and insurers should be subject to common sets of monitoring systems and complaints procedures.

  The media has been awash with stories about doctors who have been suspended or dismissed from the NHS, either through their professional or personal behaviour, who continue to practise in private facilities.

  The cases of Kent gynaecologist Mr Rodney Ledward, who was struck off the register by the GMC last September for gross incompetence, and Northallerton gynaecologist Mr Richard Neale, who was the subject of a BBC TV Panorama exposé on 1 March, are well documented.

  But the situation must be put into context. It should be stressed that the very reason for these doctors' high media profile is their rarity which determines their high "news value". The number of "rogue doctors" uncovered in the last few years barely makes it into double figures—a tiny fraction of the 25,000 senior hospital doctors in the UK.

  However, the HCSA is no apologist for the incompetence and bad behaviour of a tiny minority of rotten apples, and our Association prides itself on its founding principles to improve the quality of service offered by medical specialists.

  It is through our Association's desire to improve the image of consultants that it is campaigning to improve the safeguards for patients in the private sector and close the loopholes which appear to exist.

  Yet the only private group which appears to have grasped the nettle so far is BUPA Hospitals. BUPA rules state that, if a consultant is suspended by his NHS employer, BUPA will temporarily suspend that consultant's visiting rights to BUPA hospitals.

  BUPA has also recently amended its rule book to stipulate that the chairman of each hospital's Medical Advisory Committee (MAC) is to be held responsible for monitoring the quality of doctors to whom his committee grants visiting rights.

  The HCSA's view is that, while this is at least a positive step to deal with the problem, it places a huge burden on the MAC chairman, who does not have the power to institute proper audit or monitoring systems and who is sometimes not even medically qualified.

  HCSA members have also pointed out that, while the medical director of an NHS hospital knows his consultant workforce well, the part-time chairman of a private hospital's MAC cannot possibly know the abilities of the scores of doctors performing the occasional procedure there.

  This Association has held exploratory talks with BUPA representatives on the subject of quality control in private practice. It was agreed a joint working group of the two organisations should be established to discuss the topic in greater detail.

  There are only rare cases reported of a consultant banned from working in a private hospital who has subsequently been suspended by his NHS hospital as a direct consequence. But talks held between HCSA officers and the chairman of the Nuffield in January, revealed the Nuffield's view that if a consultant was suspended by a private hospital, it should not necessarily affect his NHS employment.

  While the HCSA supports the principle that suspension from working in the NHS should lead to suspension from working in the private sector, and vice versa, it has several caveats to stress.

  The first is that automatic suspension from working in the private sector following suspension by the NHS should only be in cases of professional misconduct and cases of personal misconduct where the police are involved or where there is an immediate danger posed to the public.

  The second caveat relates to the flaws in the existing system for dealing with suspension, the principal manifestation of which is the inordinate length of time consultants' careers remain on hold while their employers engage in "fishing expeditions" to find the evidence to incriminate the clinician.

  The HCSA believes that eradicating the faults in the system of suspending doctors must go hand in hand with any plans to improve regulation of the private sector. For our Association is determined that doctors falsely accused must not have their private practice damaged by the NHS's poor handling of and rash recourse to the suspensions system.

  This system's faults are lucidly described in a report published in January by the Working Group of the Society of Clinical Psychiatrists entitled "A Blot on the NHS Landscape: 2",written by Dr Harry Jacobs and Dr Peter Tomlin.

  HCSA President Mr Winston Peters attended a conference of interested parties chaired by Baroness Knight of Collingtree at the House of Lords on 10 March, from which a consensus statement on how best to reform the suspensions system will be published.

  The HCSA view is that there are too many instances where doctors have been wrongfully suspended from the NHS or have been left suspended for too long without their case being dealt with.

  So any action initiated to improve quality control in the private medical sector must also tackle the shortcomings of the NHS suspensions procedure.

  1.  One recommendation Mr Peters took to the Lords' meeting is that an outside body should be brought in as soon as a doctor has been suspended for one week. This group should have the power to reinstate the doctor if it finds the accusations frivolous or motivated by personal rivalry. It could, of course, agree to continue the suspension and indicate when it will come back to revisit the problem after more evidence has been gathered.

  The HCSA view is that this outside group to arbitrate and monitor should be modelled on the exemplary procedures devised by Poole Hospitals NHS Trust. These procedures stipulate that the outside panel be led by a legally-qualified chairman from the Lord Chancellor's office and include a member of the Joint Consultants Committee, as well as representatives from management and a representative chosen by the suspended doctor.

  2.  Another recommendation Mr Peters called for is the introduction of a new right for a suspended doctor to take his case to a court if nothing has been resolved at the end of six months.

  This would force the authorities to either sack or reinstate the doctor. If left suspended for longer, the doctor would find it well-nigh impossible to pick up his private practice, let alone keep up with medical practice.

  3.  Mr Peters also urged the Lords' conference to lobby for a compensation system for doctors reinstated after wrongful suspension. This would not only act as a deterrent against malicious or frivolous accusations against doctors, it would also reimburse them for lost private practice earnings.

  For although doctors are suspended on full pay from the NHS, they would be prevented from working in private practice if the HCSA's policy of linking NHS suspension to private sector suspension is made law.

  4.  Another improvement to the suspensions' procedure Mr Peters demanded is a strict definition of who can suspend and on what evidence. Too often doctors have been suspended on weak, manipulated and contrived data.

  The HCSA view is that the decision to suspend should be made by the medical director and must follow consultation with one of the panel of "Three Wise Men"—experienced consultants already established under current NHS disciplinary procedures.

  Obviously, in the absence of the medical director or in cases involving the medical director himself, the chief executive must follow the procedure outlined in the previous paragraph.

  With the advent of clinical governance, the chief executive must be made responsible for suspension at all times, since the rules of clinical governance lay the duty for overseeing quality issues at the door of the chief executive.

  But the HCSA view is that suspensions must still be made by the medical director using powers invested in him by the chief executive.

  5.  It must also be stressed clearly from the outset what the charge is, whether professional or personal misconduct, and Trusts must not switch between charges simply to get one to stick.

  It is the HCSA's view that most of the cases involving suspended doctors relate to doctors' behaviour, rather than competence. As one member of our Executive Committee, who is a medical director of an NHS trust put it: "These cases usually involve dysfunctional people in dysfunctional departments".

  Many cases of suspension could be resolved if the doctor was retrained in some area of his or her expertise. But no-one has yet tackled the question of who holds responsibility for retraining the doctor, who pays for it and who signs off the doctor as being successfully retrained.

  Even in the Bristol baby heart death scandal—whose public inquiry findings the HCSA does not wish to pre-empt—the issue was not just of competence. There were also faults in the system which allowed them to introduce a new procedure in paediatric cardiothoracic surgery without receiving outside expert tuition.

  But the public inquiry into this sad episode could well lead to improvements in the way consultants' fears of their colleagues' clinical shortcomings are reported, logged and investigated.

  A properly-constituted system of this kind, where faults could be reported and examined under controlled circumstances, without prejudice, to eradicate petty jealousies, will be a big step to eradicating future tragedies in both the public and private sectors.

  The General Medical Council last month voted to adopt the principle of having a doctor's registration linked to successful completion of five-yearly checks—a move supported by the HCSA's Executive Committee. (Although it should be stressed that the details of how this should best be achieved will not be debated by the HCSA's Council until its meeting on 18 March).

  It is the HCSA's view that such a system of revalidation will help root out clinicians failing to keep up with good practice.

  In summary, with the arrival of the Bristol heart deaths inquiry, clinical governance and GMC revalidation—the last two of which will introduce annual appraisals of consultants—health managers will soon have at their disposal a raft of effective measures for dealing with and perhaps pre-empting failing doctors.

  The prospect of a new contract for consultants—negotiations on which are about to commence between the Government and representatives of the profession—could well add another safeguard. For the new contract presents an opportunity for the guardians of good medical practice—the Royal Colleges—to stipulate what is a safe workload for consultants to undertake.

  All these factors paint an optimistic picture for quality control in health care. If adopted in the private sector as well as just the NHS, these measures would preclude the need for the Government to establish a draconian outside inspectorate, akin to the Police Complaints Authority or the Civil Aviation Authority, as some commentators have mooted for the health service.

  There is a danger of overkill in all these moves. Commentators may be right in suggesting that plans for revalidation is a knee-jerk reaction to the events of the Bristol saga, which could have been prevented by checks and balances outside the range of GMC revalidation. Many doctors seem to think so, as evinced by the letters page in Hospital Doctor 25 February (page 24) which has the headline "Revalidation is panic reaction to Bristol affair".

  It has been said that clinical governance and revalidation are examples of double jeopardy. This is borne out by the fact that the BMA's Central Consultants and Specialists Committee is split over revalidation. For a substantial majority of that committee believes revalidation can be achieved simply through the mechanisms of clinical governance, which will expose the poor performers who can then be referred to the GMC's new performance review committee set up last year to deal with lazy, rude and incompetent doctors.

  Establishing an independent inspectorate of hospitals would simply constitute triple jeopardy for doctors, whose rotten apples should already be dealt with under the systems for clinical governance and revalidation yet to take effect.

  The feature in last week's Hospital Doctor headlined "How to help doctors who underperform" (enclosed)[22] also shows that the mechanisms for dealing with poor workmanship already exist in the NHS. It is merely a question of requiring the private sector to adopt the same methods.

  From national newspaper reports today (18 March 1999) on Government plans for an inspectorate of private hospitals, it appears the Government is contemplating the worst of all worlds. For the Government wants a hotchpotch of regional commissions to inspect private residential nursing homes (already outlined in a white paper earlier this year), a new inspectorate for private hospitals, and to keep the private sector outside the remit of the National Institute for Clinical Excellence and the Commission for Health Improvement.

  This policy appears to separate the private sector from the NHS, each having separate monitoring mechanisms. Perhaps this is intentional for political reasons. But surely the best way forward is to make the same quality safeguards on stream for the NHS applicable to the private sector?

  Another trend in private practice which concerns the HCSA is the private sector's adopting of the "Managed Care" philosophy prevalent in the USA, where insurers attempt to control costs by strictly defining lengths of stay and treatment protocols for every condition for consultants to follow.

  The HCSA is anxious that Managed Care should not produce "underperformance" in terms of clinical results as a consequence of consultants being pressurised into premature discharges; for example, inadequate physiotherapy following joint replacement.

  Furthermore, there is a need to regulate the standards of Resident Medical Officers in private hospitals, as many private hospitals have RMOs with greater or lesser degree of permanence. Their standards do influence clinical outcomes and their performance can be of concern to consultants living at a distance from the private hospital.

March 1999

22   Not printed. Back

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