This is our first investigation into NHS-funded care in the independent sector and focuses on surgical care of patients. During the pandemic, a national agreement was put in place to secure extra support from the independent sector, including certain types of surgery. Our report emphasises that, while the agreement was in response to the urgent circumstances, NHS patients being cared for in independent health has been in place for many years and will likely continue.
To gain insight into the patient safety issues associated with shared care, we examined the case of Rodney, a 58-year old man, who died following bowel cancer surgery. His surgery was scheduled at an NHS hospital but due to Covid-19 changes was cancelled and rebooked at a nearby independent hospital. Eight days after his surgery, he deteriorated rapidly and had to be urgently transferred to the NHS hospital. A scan showed a leak in his bowel which led to sepsis and multiple organ failure. He died on same day as his scan and a post-mortem examination commented that Rodney had a frail physical state meaning that his ability to cope with the infection would have been poor.
Following analysis of Rodney’s case, the national investigation explored the safety risks that can occur when new surgical services are set up with joint responsibility for a patient’s care. We identified variation across the country in terms of the capability of independent hospitals to provide surgical care meaning some were asked to take on more complex surgery than they were used to during Covid-19. They also found examples of limited understanding of these capabilities by national and local NHS organisations. This compounds other risks in shared surgical pathways such as lack of clarity over roles and responsibilities and the limited integration of information and communication systems.
The investigation highlighted that safety risks could be reduced with successful collaboration between the NHS and the independent sector. HSIB found that collaboration was most effective when formed between closely located hospitals and where there had been pre-existing, direct relationships. The report also emphasises that planning and better understanding between the NHS and independent care providers will be important as the NHS moves to a more integrated models of care at a local level.
The investigation also identified safety risks associated with the assessment of patients prior to surgery. Across NHS and independent hospitals, they found limitations with assessments and that they did not always identify those patients at higher risk of complications from surgery or anaesthesia. Recent national guidance has also highlighted this and the report directs hospitals to review their assessment processes.
The report concludes with six safety recommendations, with the aim of improving the integration of surgical pathways between NHS and independent hospitals and improving the assessment of and care for patients going through surgery. The investigation also calls for more of a focus on frailty in younger adults. One safety action has been completed since the investigation started.
Kathryn Whitehill, Principal National Investigator at HSIB says “ NHS patients are being cared for in the independent health sector now more than ever before. The health service continues to deal with the repercussions of the pandemic and the services and pathways that have been implemented between the NHS and the independent sector are likely to continue in response to these ongoing pressures.
“The reference case we examined and the national investigation findings highlight that if there are any gaps in the surgical care pathway, the impact can be devastating on patients, families and healthcare staff. The report emphasises that successful care between the NHS and independent hospitals is underpinned by strong collaborative relationships where there is proactive resource planning and good transfer of information. Covid-19 demonstrated that the capability and capacity of independent hospitals could be used as part of an integrated system and we have designed our recommendations to support the safe delivery of NHS-funded care so that it could be used to respond to future challenges.”
- NHS England and NHS Improvement ensures that effective processes have been implemented in integrated care systems to identify local capability and capacity of their independent acute hospitals.
- 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.
- The 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.
- The Care Quality Commission incorporates regulatory assurance of surgical pathways between providers at a system level when developing its methodology for the regulation of integrated care systems.
- NHS England and NHS Improvement 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.
- NHS England and NHS Improvement 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.