APPENDIX 40
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
| 
