The debate over the regulation of private and independent healthcare has provoked an onslaught of opinion from all corners of the health industry. Frank Dobson’s establishment of the Health Select Committee was prompted by the white paper Modernising Social Services
And since then almost everyone is in agreement that the current system is out of date and there appears to be unanimous support from providers, insurers, consumers and healthcare campaign bodies to enforce and regularly monitor specific standards.
The strength of their argument lies partly in the numbers involved. According to figures supplied by the Independent Healthcare Association (IHA), the non-NHS sector is comprised of 443,000 health and social care beds and employs over 550,000 people making it the UK’s 10th largest employer. The sector is actually larger than the NHS, yet it is subject to significantly less statutory scrutiny. So it comes as no surprise that there is a strong advocacy for change. As Gillian Gibbons, press officer at Prime Health, stresses: “Because the current regulation system is so outdated, it is in everyone’s interest to change it.” Norwich Union echoes the encouragement: “Although we don’t run hospitals, as BUPA does, and so don’t have standards that must be met, any step to standardise would be welcome,” says press officer Louise Zucchi.
According to Zucchi, Norwich Union “agrees with the principle of a similar system to the NHS”. BUPA also has strong views. “We need more transparency between the sectors,” says Claire Cater, head of corporate communications. “And as consultants work across both sectors, we support the open sharing of data.”
It is not just the business side of the industry that is looking for change. The Royal College of Nursing (RCN) strongly suggests total regulation of the entire healthcare market. “Every patient should have the right to safe care with minimum quality standards, irrespective of the sector in which they are treated,” says Sally Taber, RCN independent sector adviser. *”In addition, many NHS patients are treated in the independent sector, including one fifth of mental health patients.” Currently, the only legislation applicable to the inspection of the private sector is the Registered Homes Act of 1984. Under this Act, private health establishments, which include nursing homes, are subject to two inspections per year. “Special attention is often paid to our fire procedures but not so much to our nursing standards,” says a Buckinghamshire nursing home manager.
Most agree that the 1984 Act is severely out of date. And by focusing predominantly on standards relevant to nursing homes, the Act fails to cater for general healthcare in terms of regulation. “From our perspective, we would recognise that the world has moved on considerably since the 1984 Act was passed,” Martin Stainforth, head of corporate affairs at the NHS executive, has told the committee. “It probably now does not provide an adequate legislative framework for regulation of the independent health care sector.”
A principle reason for applying the same regulation standards to both the private and public sectors is that there is a genuine cross-over in treatment. Frequently, State patients are treated in private sector establishments, especially since the current government has taken pains to reduce waiting lists. Furthermore, consumers can choose to be treated in private sections of NHS hospitals and NHS emergency departments have been known to claim costs after treating patients with PMI. And this blurring of parameters between private and State premises and staff indicates that an all-embracing standards body is required.
At the moment, it is not clear how a regulatory body would be funded. The RCN advocates that the independent sector should pay for its own regulation. According to a spokeswoman: “The RCN supports the principle that regulation should be self-financing through fee income paid by regulated providers.”
Of course this raises the questions surrounding the effect of self-funding on premiums. According to BUPA, “the private sector should fund itself,” but it is currently unable to specify where these funds would come from. Gibbons at Prime Health agrees that the “independent sector should fund its own regulation”. She explains: “It might be quite low cost and absorbed easily so that it doesn’t have an effect on premiums.”
The IHA has been campaigning for 10 years for the statutory regulation of the independent sector. Representing private and independent healthcare, Caroline Quest, executive director, says: “Specifically, IHA calls for the sector to be included under the government’s new regulatory mechanisms, the National Institute for Clinical Excellence (NICE) and the Commission for Health Improvement (CHI).” NICE is the government appointed body monitoring clinical standard and CHI regulates quality.
These two bodies have monitored the public sector since the beginning of April. Before that this duty fell to bodies such as health authorities which were also responsible for the twice yearly checks of the independent sector and the standards of care in the private sector. They have the power to decline registration, deregister and prevent the establishment from undertaking particular techniques.
This cut and dried approach has stimulated objections. Claire Perry is chief executive of Bromley Health Authority and gave evidence to the Health Select Committee on behalf of the NHS Confederation. She pointed out that the power to close an establishment “is actually quite a blunt instrument when you are trying to work towards improving quality for the residents”. She added: “And to threaten people with deregistration – the procedures to go down that route are not always the best ways to get a relationship between regulator and provider to enhance care.”
In February, NICE presented three suggestions to the Health Select Committee. The first was to establish a national appraisal system of new technologies. As Sir Michael Rawlins, chairman of NICE told the committee: “This form of appraisal will provide a robust assessment of the clinical and cost-effectiveness of new technologies and should advise on whether they should be in routine use or subject to further research.”
NICE has also proposed to devise and distribute a series of disease-oriented guidelines on treating clinical conditions, as well as introducing a clinical audit for the zones where the appraisal and guideline suggestions are employed.
NICE’s recommendations have been welcomed by the health insurance industry. “The private sector no longer focuses on minor conditions and procedures. Today it carries out a substantial amount of highly complex care such as neurosurgery, major heart surgery and joint replacements,” acknowledges Adrian Bull, medical director at PPP healthcare. “It should be regulated in the interests of the millions of people who use its services to ensure that it meets the highest standards of safety and competence.”
The introduction of a comprehensive complaints system is a repeated suggestion. Included in its submission to the Health Select Committee, PPP suggests: “The establishment of a new independent complaints procedure for patients so that complaints against private doctors can be properly considered and resolved – both at a local level and at a national level.”
The IHA has endorsed the recommendation to the Health Select Committee that the body employed to handle NHS complaints should also be used for the independent sector. “We are calling for the whole sector to be included in the NHS Ombudsman scheme to deal with complaints,” explains Quest.
Another motivation for the Select Committee is the occurrence of accusations aimed at the private sector for so-called “cowboy” practitioners practising unnecessary surgery and treatment. To confine the occurrence of scandals, many are suggesting that the private sector is subject to the clinical standards stipulated by NICE.
The General Medical Council (GMC) also recognises that “there is an issue”. According to Sir David Irvine, president of the GMC: “Patients want to be sure that their doctors are up-to-date, properly skilled and really capable of doing the job.” Consequently, the GMC recently endorsed and promoted a programme advocated by the Revalidation Steering Group. The GMC advocates continual registration every five years as the most effective means of regulating doctors and ensuring they maintain professional competence.
The prospect of new legislation is good news not only for the PMI sector, but also for long term care (LTC). PPP lifetime care, market leader in LTC, encourages a revitalised look at statutory frameworks. “We welcome the move to better standards for nursing standards in care homes and also of regulating domiciliary care. All organisations providing care at home should be regulated not only those who want to compete for local authority business,” says Paul Bennett, marketing manager of PPP lifetime. He adds: “Immediate regulation of individuals would be a mammoth job. The government has taken a practical approach and been sensible to make sure that care is regulated first.”