Spire’s response to the Secretary of State’s letter to private healthcare providers

21 May 2018

Dear Secretary of State

Patient Safety and Acute care in the Independent Sector

I write in response to your letter to NHS Partners Network, dated May 8, on which I was copied as CEO of Spire Healthcare. It raised a number of important points and I wish to respond directly on behalf of Spire. In addition, Professor Dame Janet Husband, Non-Executive Director and Chair of our Board Clinical Governance and Safety Committee, has asked to be a co-signatory to demonstrate her support and the company’s commitment to the principles and actions stated, as well as to underline her personal engagement in Spire’s quality programme.

I welcome your focus on patient safety, which is at the heart of Spire’s activities and central to our programme of continuous improvement in the quality of care we provide. To reflect the paramount importance with which we take your concerns, I have shared your letter with all our Hospital Directors, Governance Leads and Chairs of Medical Advisory Committees. They will be in no doubt that Spire takes the matters you raise very seriously indeed and the points you raise will be reviewed and discussed at each of these local Spire bodies. It has also been shared with members of our Clinical Governance and Safety Committee.

This detailed response is intended to provide the assurances you seek, and to recommend actions that we believe would further support patient safety.

In particular:

• Spire has robust quality and safety governance at all our hospitals up to the plc Board, overseen by the Clinical Governance and Safety Committee. We are able to evidence scrutiny and good practice in all the areas you mention, and have an open learning culture to promote continuous improvement. Some details are provided below.
• Spire is already transparent with outcome and safety data and would welcome the opportunity for further information sharing. In particular, today Spire shares detailed data openly with the Care Quality Commission, the General Medical Council, PHIN, the Health Protection Agency (HPA) and the National Joint Register (NJR), with many sites having awards for the strength of their data submissions to the NJR. We also publish quality data in our Annual Report and Accounts. 
• Spire relies on active sharing of clinician scope of practice and appraisal outputs between the NHS and Independent Sector (and Spire has engaged extensively with NHS England in this regard). Many Trusts work closely with us, but there remains resistance to sharing this data which is key to consultant oversight. I would call on you to facilitate a national database of practising privileges and other critical consultant performance data for NHS and Independent Providers, and to encourage all Trusts to share consultant appraisals with all sites where they practice.
• The medical indemnity framework for consultants in its current format is not fit for purpose and is fundamentally flawed. It offers insufficient protection to patients, with discretion being used by indemnity providers to fail to give cover, including where a clinician’s acts are found to be criminal. I would ask you to initiate an immediate review of this framework, leading to insurance cover that is compulsory, comprehensive, affordable and FCA regulated for all consultants. I believe this must be urgently addressed.

Subsequent to this letter, I, along with Dame Janet,  would be very happy to meet and discuss matters further.

Spire Healthcare is the  largest independent hospital group in the United Kingdom by revenue and, as such, strives to apply the highest possible standards of care for all patients be they NHS, self-pay, or insured. I have publicly committed to the key strategic goal of making all our 39 hospitals, 11 clinics and one Specialist Cancer Care Centre meet the Care Quality Commission’s rating of “Good” or “Outstanding”. This commitment, and further information on all our plans, can be found in our recently published shareholder materials which we are happy to forward should you wish.

I was pleased by your letter’s acknowledgement that the independent sector has, and continues to play, an important role as a supportive partner of the NHS, while also relieving a considerable burden from publically funded services.

As a sector leader, Spire can provide planned capacity as well as extending patient choice. With that role comes a responsibility for both transparency and demonstrably high standards of care. You are therefore right to seek assurances and evidence that independent providers are meeting these responsibilities.

To this end, Spire supports the valuable work of the CQC as a regulator. Its recent sector report was a balanced overview highlighting the many positive aspects of independent hospital care, as well as areas where there is room for improvement.  

At Spire, 70% of our facilities are rated “Good’ or “Outstanding” by the CQC. We have no sites rated “Inadequate”. A principal strategic goal is to lift this figure to 100% by the end of 2022, or sooner if re-inspected by the CQC. Indeed, every hospital inspected within the Spire Healthcare network by the CQC since the end of 2016 has been rated “Good” or “Outstanding”.

To achieve our strategic goals, Spire has a strong and well-established programme for clinical assurance and a capable and well-resourced central clinical team led by our Group Medical Director, Dr JJ de Gorter, and Chief Nursing Officer, Alison Dickinson. This team supports a comprehensive clinical governance structure which is overseen by the Board, Chaired by Dame Janet, with rigorous intervention at every level. 

Furthermore, outstanding clinical practice is valued and recognised through a programme of awards to hospitals and individual members of staff. 

Turning to the specific points raised in your letter, I would like to take each in turn.

“Inadequate” CQC ratings

I agree that no hospital, independent or NHS, should be rated as “Inadequate”, and reiterate that Spire has no hospitals rated “Inadequate”. In the NHS this would trigger an improvement regime. I agree that if an independent sector hospital is rated “Inadequate”, it too should be subject to an intensive improvement regime. 

Transparency

I fully agree that total transparency is vital to driving up standards. Improving patient care, however, would be best served by considering transparency across the healthcare system as a single entity, regardless of provider - NHS or independent.

For example, all providers should be able to submit data to national registries and, in turn, receive information and insights which enable them to reinforce clinical governance and deliver better patient outcomes and standards of safety. Spire today is proud to supply comprehensive data to the Health Protection Agency (HPA) and National Joint Registry (NJR). Nine of our sites have quality awards for strong data contribution to the NJR.

Our Group Medical Director was instrumental in founding the organisation in 2009 that became the Private Health Information Network (PHIN) and we are fully compliant with its requirements including all Patient Reported Outcome Measures (PROMs) data. Spire’s average data contribution is rated at the higher end of all those who submit.

Spire reports any deaths within 31 days of surgery to the CQC and we share, and discuss, the root cause analysis and seek to learn from any findings. Alongside this information, we will also provide support to bereaved families and carers. If the patient has been cared for by two providers, we link together to share information. We meet the General Medical Council every quarter and notify it of ‘Never Events’ and the consultants involved. Spire also publishes quality data, including infection rates and mortality rates, in our Annual Report and Accounts.

More broadly, Spire strives to be an organisation that learns from experience. Our culture encourages staff to use  all sources of insight, including complaints, to improve services and quality of care, particularly for the most vulnerable. As part of the implementation of the CQC report “Learning, Candour and Accountability”, we have appropriate arrangements for ensuring we can learn everything possible from patient deaths.

However, we strongly believe there are important changes that the Government can introduce to further improve transparency:

• There are currently gaps in data sharing arrangements between NHS Trusts and independent sector providers. These gaps could put patients at risk. Spire would support the creation of a single national database of consultants with practising privileges to improve data sharing between the independent and NHS sectors and between independent providers themselves. This data would include, but not be limited to, indemnity cover, scope of practice and identity of Responsible Officers.  A central database of consultants would speed the identification of poor clinical standards. Spire would expect to engage in discussions over financial arrangements for such a data system.  
• Spire would also like to be allowed to submit data to every national clinical register. These registers typically allow only clinicians to enter and access data. However, access to this data by providers and their responsible officers is vital if we are to assess outcomes and drive up national standards further. Spire would also expect here to engage in discussions over financial arrangements for access to such data across healthcare.
• Elsewhere, we would like to see NHS HES (hospital episode statistics) data incorporated into PHIN to offer patients complete transparency of activity and outcomes. This is not currently possible through NHS Digital.
• We are especially keen to submit data to the National Reporting and Learning System (NRLS) and are in the process of revising our incident categories using Datix to automatically match the NRLS platform. Datix records all adverse events at Spire, however minor, and will we hope be a valuable contribution to national learning.
• The Health Care Safety Investigation branch (HSIB) became operational on 1st April, 2017. Its purpose is to improve safety through effective and independent investigations that do not apportion blame or liability. We share the results of their investigations but these are currently limited to NHS patients. We would welcome the ability to refer our incidents to HSIB for investigation to ensure all relevant data is available to the healthcare system as a whole, regardless of the funding source.
• Spire, and all independent sector providers, depend on the close co-operation of NHS Trusts in providing up to date appraisals on consultants, and sharing the outcomes of Multi-disciplinary Teams (MDT). Most work very collaboratively with us and we appreciate their candour and support. Some are slow to provide data and can even be unresponsive. We would ask Government immediately to require all healthcare organisations, NHS and independent, to actively co-operate in the sharing of appraisals, soft data and MDT outcomes in a timely manner.

NHS cost recovery

Your letter refers to the cost to the NHS as a result of any proven negligence. This is a complex but important area for all involved in any case of proven negligence in healthcare. We are at your disposal for further discussions as how to progress this topic. 

Transfer of patients

An inter-hospital transfer is a well-accepted and regulated practice across the NHS and as such is in the patient’s best interest. There are many reasons to transfer patients.  These include, but are not limited to, moving the patient to another care site more suited to their needs, like a hospice, or the patient requiring a specialist scan or higher level of care. We understand that when NHS providers transfer between facilities these are classed as “internal” movements, where the patient never leaves an NHS provider even though they change site.

Our primary responsibilities are to minimise the need for transfers in the first place, and to ensure that, should the need arise, a transfer happens effectively and safely.

The first responsibility is discharged by ensuring only patients appropriate for our hospitals, treatment mix and facilities are admitted. This is determined by a detailed pre-operative assessment. If in any doubt, hospital teams are expected not to admit a patient and conduct further tests or recommend a different pathway. Training for and auditing pre-assessment compliance is a key part of the Spire governance process.

Incidents requiring the sort of transfer that has caused you concern are extremely rare. For context, in 2017 Spire saw 750,000 patients and admitted 270,000 for treatment. We transferred out 0.16% of our total admissions and only 0.05% of treated patients were transferred out to NHS critical care facilities. 

When such a transfer does occur, the most responsible action is to transfer patients as quickly and safely as possible. All of our 39 hospitals have a transfer agreement (SLA) with a local NHS Trust. In addition, eight of our sites have high dependency units. This means none of Spire’s transfers should involve a 999 call but will be a pre-planned and well-tested process between sites with established protocols.

Our staff are well trained and practice the necessary protocols while anaesthetists are on call for all sites throughout the day and night should they be required. Spire provides dedicated transfer training days and maintains a focus on pre-operative assessments to identify potential issues in advance. Relevant training is delivered through a full six day, in-house Critical Care Training Programme which also has a shorter, two day refresher version.

We conduct a quarterly audit of compliance against the national early warning score (NEWs) – the system of alerting the early warning of the deterioration of patients. The latest audit score against compliance for the Group is 96% for 2017. The early warning regime is central to effectively assessing if a patient is deteriorating and communicating this to the attendant clinicians. Our Resident Medical Officers are also subject to rigorous training programmes to ensure compliance with regulations while all standards of their work, including working hours, are closely monitored.

We are, however, not complacent on this critical matter and are making further process improvements.

New elective admissions processes and admissions criteria will be launched shortly and mandatory pre-operative assessment training for nurses has already begun. More than 100 nurses will have completed a new three day competency-based training course by the end of this year. In addition, all NHS Choose and Book referrals are screened against elective criteria agreed with Clinical Commissioning Groups.

Paterson

Your letter also references the Paterson case, practising privileges and employee liability. Naturally this is a matter of heightened focus for our organisation as Paterson practiced within Spire theatres and those of the local NHS Trust.

Spire, as with all independent sector providers, is legally liable for the actions of its employees, including nurses and other members of employed clinical staff. As a responsible healthcare provider, we maintain significant and appropriate indemnity insurance in respect of our employed members of staff - and indeed have significantly increased the level of our insurance cover as a direct result of the Paterson affair. 

Consultants who are granted practising privileges to provide treatment in our hospitals are all independent practitioners and not employees of Spire, an arrangement which has been in place since 1948 when the NHS was established and which is standard across the independent sector. This structure allows consultants to practice across a range of private providers, not least to suit their patient’s location and preference. 

It is a condition of being granted practising privileges at a Spire hospital that a consultant must prove on an annual basis that they have professional indemnity insurance to cover any liability that may arise and a record of a current practice appraisal. I have commented above on the importance of NHS appraisal information and scope of practice to Spire’s continuous assessment of consultants, along with our rigorous oversight activities across the company.

We were the first private provider to impose minimum indemnity requirements (£10m minimum cover from a regulated insurance company or indemnity from one of the ‘big three’ medical indemnity organisations) on our consultants to ensure that cover is appropriate for the type of work they are undertaking. If a consultant is unable to provide proof of adequate indemnity arrangements, then practising privileges are suspended and they cannot treat patients in our hospitals. Practising privileges are also tracked monthly and reported to the Executive Safety, Quality and Risk Committee meeting, chaired by myself.

However, it is a matter of serious concern to us that, in the Paterson case, Mr Paterson’s medical defence organisation, the MDU, did not stand behind its member and instead used the discretionary nature of its cover to avoid paying compensation to patients. In contrast, Spire ensured that patients were compensated because we believed strongly it was the right thing to do.

We believe that consultant indemnity should work for the benefit of patients, not doctors, and would therefore welcome statutory reform and FCA oversight of the medical indemnity regime to ensure that patients are always protected, including in cases of criminal activity. Compulsory and affordable fully comprehensive insurance would be one practical solution.

As you have yourself championed, safety is also about culture. Spire has an open culture, which challenges bad practice, and allows individuals to call out safety concerns. We have a well-established and active whistle-blowing process. All whistle-blowing cases are rigorously investigated and reported to our Board-level Clinical Governance Committee. Spire’s annual staff survey showed that 91% of staff are aware of, and know how to use, this facility, and 82% feel comfortable raising any concerns about safety, bad practice or other serious risks with their manager. We have also introduced Freedom to Speak up Guardians across all our sites in line with the policy you have led. We believe we are the first independent sector provider to do this. We also recently hosted the NHS National Freedom to Speak Up Guardian representative, Dr Henrietta Hughes, who presented to all our hospital directors.

Apprenticeships

Spire is committed to developing our people in line with our key strategic objective of delivering clinical excellence, and we are working closely with training providers to ensure we have more apprentices within our organisation. Our initial focus has been on developing Level 2 and 3 Healthcare Assistants (HCAs). We have 180 HCAs on a recognised Apprenticeship Standard at Level 2 or 3 and are aiming for 200 by the summer. 

We have also launched a Medical Laboratory Assistant apprenticeship in January with an initial cohort of seven apprentices. We are developing our Ophthalmology capability using the Level 4 Healthcare Science Apprenticeship in partnership with the Association of Health Professions in Ophthalmology and are due shortly to commence a cohort of apprentices for Sterile Services and Radiology.

Elsewhere, a range of non-clinical apprenticeships commenced in the early part of this year and we currently have 20 people on programmes including Business Administration, Engineering, Accountancy and Human Resources

We are in discussion with the University of Derby to develop the Apprenticeship programme in Theatres and we will be one of the first in the country to take a cohort of HCAs through the three year ODP degree programme. In addition, plans are in place to pilot the newly developed Nurse Associate role in Spire once available in September 2018, with a wider roll out in 2019. Finally, we are also working closely with Buckingham and Sunderland Universities to develop the Nurse Degree apprenticeship with a view to welcoming a first cohort in September this year with a wider roll out also in 2019.

If you think Spire can further advance the cause of effective healthcare apprenticeships, we would be delighted to work with you on this. For your information, we have been invited by your colleagues Alok Sharma and Andrew Griffiths to take part in their efforts to improve employment amongst groups under-represented in the labour force and we have enthusiastically agreed to engage with them on this important initiative.

I hope this letter provides you with the assurances you are seeking, and practical suggestions to help meet your objectives. We are keen to be an open and collaborative partner with the Department of Health and Social Care and are at your disposal for further questions or discussion on any of the points raised in this letter.  

Yours sincerely

Justin Ash

Dame Janet Husband DBE,FMedSci,FRCP,FRCR