SCR0006

Written evidence from the Care Quality Commission

27 September 2018

Dear Sarah

When we met in May, you asked about our views on the current quality of care delivered by IH providers, including any concerns we had about particular risks in the sector, so that the HSC can hold a session to discuss them in the autumn. We have inspected a number of different sectors in independent healthcare and have focussed here on three - independent acute hospitals, independent ambulance services and independent substance misuse services.

The Care Quality Commission has inspected all independent acute and mental health hospitals, community health and independent ambulance services, and stand- alone termination of pregnancy, dialysis, refractive eye surgery, and substance misuse services. We used our comprehensive inspection methodology which asks five key questions about every service we inspect: is it safe, is it effective, is it caring, is it responsive and is it well-led? Detailed inspection reports on each individual provider have been published. We have also published a summary report of our findings about the independent acute hospitals sector.

Inspections are underway, or are planned, to complete the remaining independent healthcare sectors we regulate, including diagnostic imaging services and independent doctors. We will use our comprehensive inspection methodology as described above and report in the same way.

CQC inspection findings – independent acute hospitals

We published a report1 in April 2018 outlining our overall findings in the sector following a programme of comprehensive inspections. We regulate independent hospitals in the same way as their NHS counterparts, and expect them to meet the same standards. We do not currently assess performance at a corporate level, unlike NHS Trusts – each independent hospital location is awarded a rating.

1 https://www.cqc.org.uk/publications/major-report/state-care-independent-acute-hospitals

As at 2 January 2018, we had inspected and rated 206 hospitals. Of these, 128 (62%) were rated good and 16 (8%) were rated outstanding, which compares favourably to similar services in the NHS. 62 (30%) were rated require improvement, and none were rated inadequate. Initially, we had rated four hospitals as inadequate – all had improved this rating on re-inspection.”

We have seen much good and outstanding care, in particular around:

• Responsiveness – patients have prompt access to treatment and procedures and short referral to treatment times with few cancellations or delayed admissions.
• Staff interaction with patients – patients received good continuity of care, individualised, one-to-one attention and their privacy and dignity were very well respected
• Effective treatment – highly skilled staff, supported by pre-selected admissions, were effective in carrying out routine elective procedures.
• Leadership and engagement with staff and patients – in a number of providers there was strong, visible, local leadership, based on a clear understanding of the service, good staff engagement and a focus on being patient centred.

There were also a number of areas where services need to make substantial improvements:

• Governance – there was a wide variation in the quality and effectiveness of governance arrangements and a number of examples of poor practice. Some providers did not have formalised governance processes in place, but instead tended to rely on informal arrangements based on long-standing relationships. There was a lack of oversight of practising privileges (the granting of admission rights for consultants to be able to practice in a particular hospital). This meant that some providers could be reluctant to challenge consultants. Regulations set out that consultants working under practising privileges are considered in the same way as directly employed staff, and the provider has the same regulatory accountability for both. This was compounded in some cases by the ineffectiveness and informality of some Medical Advisory Committees. We saw examples of committees not effectively managing the practising privileges of consultants, for example not ensuring that a consultant was only undertaking procedures they were experienced to do or not undertaking new or innovative procedures without effective risk assessment and monitoring.
• Clinical audit – there needs to be substantial improvement by a number of independent acute providers in terms of auditing, reporting and benchmarking

outcomes. We were particularly concerned that some providers were not collecting their own outcome data, partly caused by expectations among providers that consultants were monitoring their own outcomes.

• Safety culture – in some cases, systems for incident reporting and learning from them              were not as robust as they needed to be. There were risks in operating theatre safety due to informal practices and insufficient challenge to consultant behaviours. There was a lack of preparedness for patients whose condition could deteriorate.

The Secretary of State (SofS) subsequently wrote to the chief executives of the main independent acute hospital groups2. He asked the sector to take urgent action to address the patient safety concerns set out in our report. He specifically asked them to respond within two weeks of his letter, setting out what the sector intended to do, amongst other actions, to:

• improve governance systems and monitoring of consultants’ private practice;
• ensure clear and agreed arrangements were in place for the transfer of critically ill patients to NHS acute trusts; and
• comply with requirements for submitting comprehensive data sets to the Private Healthcare Information Network (PHIN).

The sector responded collectively through the NHS Partners Network (NHS PN), the representative body for most independent acute hospital providers. Individual providers also responded separately.

Having challenged the sector to provide “urgent assurances that you will get your house in order on safety”, the sector’s response3 to the SofS was disappointing. Rather than setting out what the sector would do themselves to address these issues, the emphasis of the response was more about how favourably the sector compared to the NHS, and how the wider healthcare system needed to work together better, with support for the IH sector to enable this to happen. For example, it suggested that the SofS support the sector to enable them to submit data to all national data sets, rather than specifically responding to his requirement for assurance about compliance with PHIN data submission.

CQC meets regularly with NHS PN. In discussions about their response to the SofS’s letter, we have urged the sector to collectively concentrate on those issues that are unique to them, for example, consultants working at multiple locations, the process for granting, reviewing and withdrawal of practicing privileges, and the

2 https://www.gov.uk/government/publications/patient-safety-letter-to-independent-healthcare- providers/patient-safety-and-acute-care-in-the-independent-sector

3 https://www.nhspn.org/news/nhspn-responds-to-secretary-of-state-letter-on-safety-in-independent- hospitals/

effectiveness of the Medical Advisory Committee. We have been clear that IH providers must be able to assure themselves that the basics for safety are in place, such as, how do they know if patients are giving truly informed consent, or if medicines/products are being used off-license? We continue to have constructive and regular meetings with NHS PN where areas for improvement are discussed.

The responses to the SofS’s letter from individual providers were more focussed on the specific actions they would be taking to address the findings in our report. We have been impressed how quickly most providers have responded to our findings and taken action to improve. We have also been encouraged to see locations being a lot more open with each other within their own provider organisations, and discussing how they can share learning across sites – taking the learning they receive from our inspections and learning from each other in response.

Key points from other independent healthcare providers

We have also been inspecting independent ambulance and substance misuse services, and you might be interested in our findings.

CQC inspection findings – independent ambulance services

There were a number of areas where services need to make substantial improvements:

• Governance and management of risk – we found poor or absent policies and procedures. Systems for reporting incidents or managing complaints needed significant improvement and there was little evidence of any learning from them being put into practice. We had concerns about the maintenance of ambulances and equipment, infection prevention and control and the safe storage of medicines.
• Staff management – we found poor recruitment practices, issues with safeguarding training, and the supervision and performance management of staff

CQC inspection findings - substance misuse service

There were a number of common areas of concern, with almost two-thirds of providers not meeting the requirement for providing safe care and treatment:

• Safety and management of risk – we found services were not assessing the risks to the safety of people prior to their admission, and were not following recognised national clinical guidance on treating people who are withdrawing from alcohol or drugs We also found inappropriate storing, dispensing and handling of medicines appropriately, including controlled drugs.
• Staff management – we found that services were not carrying out full employment checks or sufficiently training their staff

Independent Primary Care doctors and clinics

Finally, I thought you would be interested to know that CQC has recently agreed internally to commission a piece of work drawing together our findings from inspection of independent primary care doctors and clinics. We expect this work to report in the spring, towards the end of the financial year, and will ensure you are briefed on our findings.

I hope these reflections are helpful to you and your colleagues. Should you wish to discuss any of the points I have raised, please do not hesitate to let us know.

Yours sincerely

Professor Ted Baker

Chief Inspector of Hospitals