Memorandum by Federation of Independent
Practitioner Organisations (PS35)
EXECUTIVE SUMMARY
I. The Federation of Independent Practitioner
Organisations (FIPO) welcomes the inquiry into the relationship
between the NHS and the independent medical sector. FIPO represents
the majority of the medical profession's organisations in Britain
which have private practice committees. It was formed in 2000
to provide a unified voice for the profession in similar fashion
to the way in which the Independent Healthcare Association represents
hospitals and the Association of British Insurers represents the
private medical insurance industry.
II. FIPO is neutral on the extent of future
partnership between the public and private sectors but is definitive
on the requirement that patient treatment should be available
at the time of need without fear of the financial consequences.
We believe that the provision of healthcare should not be confused
with its funding.
III. FIPO recognises the benefits of using
spare capacity in the acute independent sector for the benefit
of NHS patients but we consider that arrangements need to be made
on a local basis to reflect local needs.
IV. Concordat arrangements must take account
of the availability and suitability of independent hospital facilities,
the availability of medical and other professional staff and the
potential financial benefits which may accrue from using spare
capacity. We do not believe that central direction on contracting
will lead to viable solutions.
V. We have concerns on the possible administrative
complexities of dealing with small contracts and on the potential
for inconsistency in the types of contractual arrangements, which
could lead to confusion and conflict. It will be essential for
clear standards to be established on quality controls and clinical
governance.
VI. Arrangements for the remuneration of
medical and professional staff will need to be clearly defined,
including the effect upon extant employment contract arrangements.
VII. Defined protocols for patient selection,
assessment, treatment and subsequent follow-up and audit will
need to be closely defined in order to ensure that the highest
standards of care overall can be delivered.
1. BACKGROUND
TO THE
FEDERATION OF
INDEPENDENT PRACTITIONER
ORGANISATIONS
1.1 The Federation of Independent Practitioner
Organisations (FIPO) is a federation of all the specialist and
general organisations with independent (private) practice committees.
The supporting organisations are listed at the end of this document,
together with a list of the directors of FIPO. In addition FIPO
has the support of numerous Medical Advisory Committee (MAC) Chairmen
from independent hospitals in the UK.
1.2 There is a triangular structure in the
acute private healthcare market, with the hospital providers represented
by the IHA (Independent Healthcare Association) and the insurers
by the ABI (Association of British Insurers). FIPO speaks for
organisations representing the medical profession. In outlining
this structure it is vital not to forget the most important component,
namely the patient.
2. REMIT AND
PHILOSOPHY OF
FIPO
2.1 The remit of FIPO is appended and it
can be seen that this organisation is primarily concerned with
standards and quality within the independent sector. As such we
accept all the national guidelines on best practice, for example
the GMC's Guidance on "Good Medical Practice", and we
welcome the new Care Standards Act and improved regulation within
the independent sector.
2.2 The involvement of the independent sector
in the treatment of NHS patients is a government initiative. We
will not comment on this except to say that the attitudes of the
NHS staff at all levels has been varied in the degree of enthusiasm
with which they have embraced previous partnership agreements.
2.3 All of the Board of FIPO are also NHS
consultants, with one General Practitioner representative, and
without exception are strong supporters of the principles behind
the NHS and of the need to improve the quality of care extended
to NHS patients. In particular we support treatment according
to clinical need and by the best possible evidence based methods.
We support the principle of treatment without payment at the point
of delivery although alternative methods of financing may be developed.
We cannot comment on these except to say that the provision of
healthcare should not be confused with the funding of healthcare.
3. FIPO'S VIEWS
ON THE
NHS/PRIVATE CONCORDAT
3.1 In this submission we will reserve our
comments to the first of the three bullet points in the Select
Committees Press notice ie "The NHS Concordat with the Private
and Voluntary Sectors".
3.2 Within the acute sector of healthcare
(and excluding here psychiatric services and intermediate and
long term care) there is potential for relieving waiting lists
and accelerating treatment by utilising independent hospitals.
We do not consider small private specialised clinics in our submission
and only refer to the recognised independent hospitals.
3.3 There is a fundamental question over
local autonomy in arranging potential contracts as against centralised
directives. These issues over the Concordat can be considered
as either strengths or weaknesses and are as follows.
4. STRENGTHS
OF THE
CONCORDAT CONCEPT
— flexibility to utilise variable local
independent resources;
— potential for local innovation unhindered
by central controls;
— local design of manpower and support
service solutions; and
— autonomy to local contractual parties
to agree financial solutions.
4.1 Flexibility to utilise variable local
private resources
(i) Workloads within the independent sector
vary on a weekly and seasonal basis. Bed availability is however
fairly easily predictable as there is less emergency workload.
Provided that there is adequate planning it should be perfectly
possible to organise for NHS treatments on a regular basis and
without the risk of last minute cancellations, which are common
in the NHS.
(ii) There are geographical variations in
hospital availability. In London, for example, very few of the
independent hospitals could guarantee to perform routine surgical
work on a regular basis. However, there are more specialised facilities
in London and there is the possibility of more major contracts,
eg for cardiac surgery.
(iii) On a national basis it is difficult
to estimate the number of NHS surgical procedures that could be
performed annually although some have given this figure as up
to 100,000. (Professor Bosanquet.)
4.2 Potential for local innovation unhindered
by central controls
(i) FIPO believes that there is potential
for local solutions to the Concordat. Given the variability of
NHS demand and of independent hospital availability, we believe
that central directives would be destined to failure and that
local flexibility in planning would be preferable.
4.3 Local design of manpower and support service
solutions
(i) As part of the flexibility in planning
we believe that there should be a local design of clinical and
service manpower issues. Possible solutions could be the local
NHS clinical staff working in the independent sector on contracted
NHS patients or other consultants being contracted for this work.
4.4 Autonomy for local contractual parties
to agree financial solutions
(i) As part of the flexibility and development
of Concordat contracts to the local managers we believe that there
should be local financial solutions. This might encourage a more
competitive atmosphere with obvious advantages.
5. WEAKNESSES
OF THE
CONCORDAT CONCEPT
— administrative effort expended for
small volumes of caseload;
— lack of consistency in administrative
and contractual processes;
— potential inequities in remuneration
of professional staff;
— pre-operative assessment/complications/follow
up/patient transfer issues;
— fulfilment of Regulatory requirements
of the Care Standards Act;
— arrangements for Governance and Audit
provision; and
— difficulties in involvement of trainee
and non-consultant grades in treatment/cover arrangement.
5.1 Administrative effort expended for small
volumes of caseload
(i) The administrative workload involvedin
setting up these agreements could be considerable and would not
be cost effective for irregular, unpredictable and small volumes
of work.
5.2 Lack of consistency in administrative
and contractual processes
(i) There is a lack of consistency in the
administrative process of negotiating and implementing contracts.
This could lead to inefficiencies and possible clinical errors.
(ii) There are a variety of contractual
relationships possible, which could add further confusion. Some
contracts might be within the main NHS hospitals with private
wings for which simpler contracts would apply.
(iii) Part of the contractual process would
need to deal with the questions of quality, complaints and legal
liability for contracted work.
5.3 Potential inequities in remuneration of
professional staff
(i) Evidence to date on professional staff
remuneration for NHS contracted work is anecdotal but seems to
indicate some variations. There is clearly a potential for inequities
and much would depend on the type, timing and extent of the contracted
work.
(ii) Consultant services may be obtained
from the referring NHS hospital, if the private facilities are
situated locally, or by other recognised consultants. Freedom
for local negotiation would be one approach, which FIPO would
accept. Our only concern would be that clinical services are not
equated with other hospital services such as hotel, portering
or catering facilities where contracts are awarded largely on
the basis of price competition. It is imperative to maintain standards
in clinical practice based on a "fair and reasonable"
staff remuneration.
5.4 Pre-operative assessment/complications/follow
up/patient transfer issues
(i) FIPO is concerned that there could be
clinical problems arising from the types of patients referred
for treatment from the NHS. The variability of the clinical needs,
the associated potential complicating conditions, the need for
up to date clinical records and assessments are all practical
matters that could affect the quality of care.
(ii) There are no insuperable problems here
provided full information is obtained and careful assessments
are made. Thus, there would be a necessity for proper pre-operative
booking and assessment clinics.
(iii) Another issue would be the management
of any complications and the adequacy of clinical cover and facilities.
By and large such issues should be explored in the initial contracting
process, as should the financial implications of any complication.
(iv) Follow up and careful reviews of all
contracted work would be necessary. Inherent in the whole process
would be the methods of transfer of patients and the effect on
relatives. There may thus be geographical limitations on some
forms of treatment but in life saving or less threatening but
painful conditions this may be a low priority.
5.5 Fulfilment of Regulatory requirements
of the Care Standards Act
(i) FIPO has welcomed the initial draft
of the Care Standards Act. It would seem self-evident that any
independent facility must be fully registered and approved and
that any treatment of NHS patients would fall within the regulatory
standards of the Act when it comes in to force.
5.6 Arrangements for Governance and Audit
provision
(i) As part of the Care Standards Act and
in line with best practice FIPO would need assurance that Governance
and Audit of all contracted work should take place within both
the NHS and independent sector. In fact the computer facilities
of the independent sector are generally favourable to such data
collection but all such audits should be measured against other
similar work. Wherever possible there should be benchmarking against
national yardsticks for example in the provision of cardiac services.
5.7 Difficulties in involvement of trainee
and non-consultant career grades in treatment/cover arrangement
(i) Contracts for simple surgery may be
entirely consultant based and not require overnight stay. More
complex surgery requires the assistance of junior medical staff
or non-consultant career grades. This would have to be anticipated
in the contract. Many large independent hospitals provide suitable
resident medical officers (RMO) but there may be the need for
specialist junior staff. The actual size of this problem cannot
be estimated but cover arrangements need to be carefully considered.
(ii) How and when NHS junior staff are required
would be best resolved at local level. Several issues would need
resolution, including professional indemnity for juniors in the
independent sector, their hours of duty and the potential loss
of training opportunities. This latter issue would not be of major
import unless substantial contracts are awarded. Nevertheless,
there is concern from the Royal Colleges about training opportunities
in an era of reduced hours of duty and any loss could be deemed
a problem.
6. FIPO RECOMMENDATIONS
6.1 Whilst encouraging a large degree of
local autonomy there could be some place for certain national
agreements.
6.2 Given some of the issues raised there
could be a case made for restriction of professional employment
arrangements to a limited menu of formats. Contractual terms,
if not remunerative levels, might be agreed with the BMA, the
HCSA, FIPO and other national medical bodies.
6.3 Central guidance might need to be agreed
with the Professions on minimum standards to be achieved in patient
management including the basic arrangements for assessment, follow
up and audit.
6.4 Although not a direct matter for the
medical profession, consideration should be given to the creation
of an Internet/NHS-net based business to business (B2B) trading
arena. This could facilitate and more efficiently manage the matching
of NHS demand, available resources in the private sector and the
availability of the required professional expertise.
September 2001
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