By John Tingle
One thing that strikes the UK visitor to the USA is the vast array of large public and private hospitals that exist with many having trauma and emergency rooms. Private hospitals don’t exist on this scale in the UK. Our major hospitals are public, state run NHS (National Health Service) hospitals. Independent, private acute hospitals are generally small in size, have no emergency rooms and maintain a bespoke health care provision. The focus is on patients with a single condition and routine elective surgery. The myriad number of complex multiple conditions, dementia etc that the NHS regularly face as a norm are not covered in the independent sector here with such cases being screened out. This limited focus on the type of care provided does mean that staff within independent acute hospitals have a sheltered and more controlled work remit and environment. This is a significant patient safety issue.
The Independent Health and Social Care Regulator of England, the Care Quality Commission (CQC) have recently published their findings of independent acute hospital inspections. They inspected and rated 206 independent acute hospitals and the majority were assessed as providing high quality care. At 2nd January 2018, 62% were rated as good,16 (8%) as outstanding. The report contains some very positive findings on health care provision in these hospitals but also some major governance and patient safety failings were found which are very concerning.
The Independent Newspaper reported back in 2015 reported that private hospitals ‘lack facilities to deal with emergencies’, and quoted a study that found that between 2010 and 2014, 800 patients, including those referred by the NHS, died unexpectedly in private hospitals.
The CQC found a substantial variation in the quality and effectiveness of governance arrangements and a number of examples of poor practice. Independent acute hospital care providers need to demonstrate that they are proactively auditing and monitoring consultant’s work. The focus appears to be on the providers treating the consultants as customers bringing in essential business so they go unchallenged.
Examples were found of poor, inconsistent monitoring of risks. No underpinning systematic processes to learn from risks and then to raise these issues further with the provider. Providers could be quite generic in how they assessed operational risk management. Standardised templates lacked depth and did not proactively identify the risk for individual services.
The CQC found that some providers were not even collecting their own outcome data. Improvement is needed in how providers audit, report and benchmark outcomes.
Safety Culture Failings
The CQC report draws all the patient safety failings identified into a safety culture section towards the end of the report and it begins with a key and dramatic statement:
“We found that a key risk to the provision of safe care was a lack of a culture of learning from incidents and a weakness around incident reporting – where systems may have been in place but were not as robust as they needed to be. This included examples of where services were not always being open and transparent about patient safety mistakes in terms of their responsibilities under the duty of candour. “(p.29).
The informality in the operating theatre is noted along with a lack of preparedness for patients whose condition could deteriorate and in meeting the needs of dementia patients. Some theatre staff not observing the WHO patient safety checklist. The CQC also found several examples of poor practices around record keeping, including incomplete and missing records. Records failed to include information such as relevant safeguarding issues, records not stored correctly, not reviewed in a timely manner, illegible and incomplete.
Some hospitals were found to rely solely on the consultants to maintain patient records’. Inspections sometimes found hospitals failing to address infection control and prevention. They saw specific examples of poor cleanliness. Poor disposal of clinical waste within restricted and enclosed sluice rooms.
Examples were also found where consent to treatment had not always been achieved. The Mental Capacity Act 2005 was in some cases not followed when assessing the best interests of patients.
Whilst the CQC report contains a lot of positive findings on the quality of care in independent acute hospitals these are all overshadowed by negative patient safety and governance findings which do require urgent attention and improvement.