The inquest into the death of Laura Touche following a Caesarean section at the prestigious Portland hospital has sent shivers through the private healthcare sector. Touche had a brain haemorrhage after her blood pressure went unmonitored for two-and-a-half hours.
Not only did the nurse caring for her fail to carry out checks on blood pressure, temperature and pulse, she did nothing when Touche complained of a headache, a classic warning sign, but went for her break leaving the patient alone. When the registered medical officer (RMO) finally discovered dangerously high blood pressure, it took another hour to give the patient an anti-hypertension drug because a supply could not be found.
At the inquest the hospital was criticised for bad record keeping, caused partly by malfunction of a machine monitoring blood pressure during the operation.
The events in question took place in 1999, since when the Portland has introduced new protocols. There is now a two-hour recovery period for mothers, during which blood pressure is taken every 15 minutes as part of one-on-one intensive care. And drug ampoules are kept closer to where they may be needed.
Most people realise only the horror stories hit the headlines. At the same time they know there is a degree of risk attached to any surgical procedure, especially if it involves general anaesthetic. Western Provident director of communications David Ashdown notes that policyholders increasingly want to know more about the treatment they are to undergo.
He says: “They ask what is the success rate for procedures, who is the surgeon, is there an intensive care unit and what would happen if something goes wrong.”
Mishaps have occurred at private hospitals when patients have been transferred too quickly to a private room after undergoing a major operation such as a triple bypass. Private rooms are essentially hotel rooms, with no monitoring apparatus, oxygen or resuscitation equipment.
Another cause of injury and fatality is where the RMO has been absent for some reason and no doctor has been in the hospital. The private sector has been busy tightening up on these lapses. Protocols for the attendance of RMOs and other doctors have been introduced. The RMO must also be suitably trained and experienced for the caseload of the hospital.
Where children are treated, extra precautions apply. In Bupa hospitals the RMO has to have paediatric advanced life support accreditation. Furthermore, one-third of Bupa hospitals no longer carry out paediatric work because they are unable to offer the appropriate back-up.
Private hospitals have paid greater attention to the need to explain success rates and risk adequately, including the possibility of scarring. They also have stricter controls on record keeping, including operation notes and post-operative records.
The Independent Health Association (IHA) insists all member hospitals should either have or be working towards Health Quality Service (HQS) accreditation, the foremost independent auditing system for the private and public sectors. Nuffield Hospitals, for example, has been HQS accredited for nine years, with two recently acquired facilities undergoing assessment.
IHA spokeswoman Sally Taber says: “We’ve agreed collation of key performance indicators for hospitals and hope to implement this from 1 April, starting with acute hospitals. And we’ve done an extensive amount of work on implementing practice reviews in connection with the revalidation agenda.” Revalidation is an essential part of keeping the skills of all medical personnel up to date.
Private medical insurance providers are not responsible for the work of hospitals but they do have a duty of care. Bupa has a rigorous inspection system for the 600 hospitals it uses. A team led by head of partnership development and quality David Quick does 60 hospital visits a year on a rolling programme. His team includes a nurse and a radiographer and calls upon other specialists such as paediatricians as necessary.
New hospitals and ones that have changed significantly are visited as a matter of course, as are those that want to be one of Bupa’s preferred providers. If problems arise and Bupa receives complaints from doctors or patients, a visit is arranged at short notice. “We make sure it’s safe for our members to be treated there,” says Quick.
The government published league tables of NHS hospitals and other facilities last autumn, giving them a star rating of zero to three.
“Most of the hospitals we go to are of a very high standard,” maintains Quick. “Some of the best places I’ve seen are private facilities of NHS hospitals.” He mentions the facilities of St Richard’s hospital in Chichester as a particularly good example.
“But,” he adds, “sometimes we see quite shocking things. We’ve had to revisit three times in one or two instances, though we can count the number of hospitals we have had to derecognise on the fingers of one hand.”
As far as the Portland hospital is concerned, Quick says when he last took a team in he was very impressed. It had a low complication rate, ie few instances of readmittance, reoperating and suchlike. Indeed, since the tightening up after the Touche incident, the Portland is probably one of the safest hospitals in Britain.
Inspecting hospitals is one thing. Checking on the people who work there is another. The General Medical Council (GMC) is loath to strike off consultants except in the very worst cases of professional misconduct. Despite failing to spot breast cancer in numerous patients, two consultant radiologists in the West Country recently escaped being struck off, though they were banned from private work.
On the other hand, a doctor who falsified medical reports in connection with fraudulent insurance claims was struck off, despite having an unblemished clinical record and being highly respected.
With the large number of consultants, keeping track of them all is not easy. Bupa recognises 19,000, of whom 9,000 send in regular bills. “They’ve all been vetted, which means checking with the GMC,” says Quick. “In the case of GMC disciplinaries, you have to look at things individually. Was it a managerial issue? Have they a drink problem? We’re guided by the GMC.”
Hospitals grant so-called practice privileges to consultants. These give a licence to the practitioner to use the hospital’s facilities for private practice, and define the consultant’s responsibilities and the standards to which they must adhere. The IHA has been instrumental in developing a protocol on the renewal of privileges and how often they must be reviewed.
Similarly, there are procedures for vetting locums and agency nurses. The private sector faces some of the same problems as the NHS in contracting permanent staff, especially in London, which makes robust tendering processes for personnel suppliers essential.
Private healthcare providers generally agree there should be just one body responsible for regulating healthcare. The government previously would hear none of this.
It was insisting on two separate inspectorates, the existing Commission for Health Improvement (CHI) for the NHS and a Care Standards Commission for the private sector, to commence operation in April this year.
But it now seems the CHI will eventually absorb the Care Standards Commission, with a degree of integration with the Social Services inspectorate and the Audit Commission. In addition, the National Institute for Clinical Excellence will continue to set standards.
Furthermore, an Office for Information on Healthcare Improvement is to be set up, partly as a result of the Kennedy inquiry into the Bristol baby scandal. Death rates occurring within 20 days of an operation are to be published for every cardiac surgeon. By April 2004 the previous two years’ performance will be available and from April 2005 the three-year performance on a rolling basis for each surgeon and centre.
This has provoked mixed reactions. BCWA commercial manager Richard Esler says: “Tables only denote operative success. I think they should be measured on added value. If a procedure normally has a 70 per cent success rate and you achieve 80 per cent, you are performing well.”
The changes will mean a culture shock for some health professionals. In former days consultants would arrive in a chauffeur-driven car, wearing morning dress, and be presented with a buttonhole by a junior doctor before doing the rounds of a hospital. Now, they are more likely to wear a black polo neck.
But a vestige of the old arrogance and aloofness still survives in a few pockets. The medical profession is also known for closing ranks when anything goes wrong.
With the increasing plethora of rules, regulations and legislation, there is bound to be more openness in future. There should be few slip-ups in private hospitals, which are mainly performing routine elective rather than innovative surgery. Medical practitioners are only human and some mistakes will be made. But private patients are safer now than they have ever been.