Safety watchdog publishes major report on NHS-funded care in independent hospitals

Integrated Care Systems must take steps to ensure that effective processes have been implemented to identify local capability and capacity of their local independent acute hospitals, says the Healthcare Safety Investigation Branch.

This is HSIB’s first investigation into NHS-funded care in the independent sector and focuses on the surgical care of patients as the sector continues to provide care for NHS patients, including urgent NHS elective surgical care and delivery of cancer pathways in the wake of the Covid-19 pandemic. During the pandemic, a national agreement was put in place to secure extra support from the independent sector.

The national investigation was launched after a 58-year-old man with bowel cancer died following open surgery after being transferred to an independent hospital in response to the Covid-19 pandemic. The investigation’s aim was to gain insight into the patient safety issues associated with shared care across the NHS and independent sector.

While HSIB recognised that Covid-19 had placed ‘unprecedented demand’ on the NHS and independent sector, it recognised that there has been a history of collaboration between the NHS and independent hospitals when delivering care to patients, and the most effective care was delivered where there was a longstanding and direct relationship.

Key findings

• The capability and capacity of independent hospitals for the provision of surgical care was seen to vary across the country.
• National and local NHS organisations had limited understanding of independent hospitals’ capabilities. This resulted in variation in how independent hospitals were used during Covid-19. With a move to integrated care systems there have been limited efforts to understand the capabilities of independent hospitals. This may undermine future relationships and understanding of how best to use resources at times of high demand.
• Some independent hospitals saw patients with increasingly complex conditions and undertook more complex operations during Covid-19. The increasing complexity was well managed where capability of the independent hospitals had been evaluated and addressed prior to implementation of new services.
• Other factors that created risks in NHS-funded surgical pathways between NHS and independent hospitals included: unclear roles and responsibilities; limited integration of information and communication systems; and variation in what surgery was deemed suitable for an independent hospital.
• There was variation in how preoperative assessments were undertaken across NHS and independent hospitals. This included what tests were ordered and risk assessments undertaken.
• Preoperative nutrition screening was inconsistent across NHS and independent hospitals. Examples were identified where it was not undertaken, or undertaken too late to allow any preoperative optimisation – for example to make sure the patient was in the best possible nutritional state before their operation.
• Remote preoperative assessment became the norm during Covid-19, but created risks when staff were not able to see the patient. Lack of video call facilities and staff preference meant assessments were commonly done by telephone.

Safety recommendations – a total of six are made

NHS England/Improvement

• Ensures that effective processes have been implemented in integrated care systems to identify local capability and capacity of their independent acute hospitals.
• Reviews models of perioperative care for their value and impact. This should inform future work to support implementation of a standardised approach, based on evidence, across all healthcare providers that deliver surgical services.
• Establishes a process to ensure that findings of the National Institute for Health Research’s policy research programme into frailty in younger patient groups are reviewed and acted upon.

NHSX

• Expands its work programme addressing the challenges associated with interoperability of information systems used in healthcare to include transfer of information between the NHS and independent sector in support of safe care delivery.

Care Quality Commission

• Reviews and appropriately develops its methodology for regulatory assurance of arrangements between NHS and independent providers for the provision of care across care pathways. This is to include any screening and risk management processes used to ensure the safe transfer of care between providers.
• Incorporates regulatory assurance of surgical pathways between providers at a system level when developing its methodology for the regulation of integrated care systems.

Commenting on the report, David Hare, Chief Executive of the Independent Healthcare Providers Network, said:

“With independent healthcare providers continuing to play a key role in supporting the NHS to clear the elective care backlog, it is vital that the NHS and independent sector can continue to work seamlessly together to deliver the safest possible care for patients. We therefore welcome HSIB’s recommendation for new NHS Integrated Care Systems (ICSs) to fully understand local independent healthcare provision and ensure the sector is a key part of this new system working. This is something IHPN have long been calling for and which will ensure the NHS and independent sector can work together to improve patient access to high quality care in the months and years to come.”