Select Committee on Health Minutes of Evidence

Memorandum by Federation of Independent Practitioner Organisations (PS35)


  I.  The Federation of Independent Practitioner Organisations (FIPO) welcomes the inquiry into the relationship between the NHS and the independent medical sector. FIPO represents the majority of the medical profession's organisations in Britain which have private practice committees. It was formed in 2000 to provide a unified voice for the profession in similar fashion to the way in which the Independent Healthcare Association represents hospitals and the Association of British Insurers represents the private medical insurance industry.

  II.  FIPO is neutral on the extent of future partnership between the public and private sectors but is definitive on the requirement that patient treatment should be available at the time of need without fear of the financial consequences. We believe that the provision of healthcare should not be confused with its funding.

  III.  FIPO recognises the benefits of using spare capacity in the acute independent sector for the benefit of NHS patients but we consider that arrangements need to be made on a local basis to reflect local needs.

  IV.  Concordat arrangements must take account of the availability and suitability of independent hospital facilities, the availability of medical and other professional staff and the potential financial benefits which may accrue from using spare capacity. We do not believe that central direction on contracting will lead to viable solutions.

  V.  We have concerns on the possible administrative complexities of dealing with small contracts and on the potential for inconsistency in the types of contractual arrangements, which could lead to confusion and conflict. It will be essential for clear standards to be established on quality controls and clinical governance.

  VI.  Arrangements for the remuneration of medical and professional staff will need to be clearly defined, including the effect upon extant employment contract arrangements.

  VII.  Defined protocols for patient selection, assessment, treatment and subsequent follow-up and audit will need to be closely defined in order to ensure that the highest standards of care overall can be delivered.


  1.1  The Federation of Independent Practitioner Organisations (FIPO) is a federation of all the specialist and general organisations with independent (private) practice committees. The supporting organisations are listed at the end of this document, together with a list of the directors of FIPO. In addition FIPO has the support of numerous Medical Advisory Committee (MAC) Chairmen from independent hospitals in the UK.

  1.2  There is a triangular structure in the acute private healthcare market, with the hospital providers represented by the IHA (Independent Healthcare Association) and the insurers by the ABI (Association of British Insurers). FIPO speaks for organisations representing the medical profession. In outlining this structure it is vital not to forget the most important component, namely the patient.


  2.1  The remit of FIPO is appended and it can be seen that this organisation is primarily concerned with standards and quality within the independent sector. As such we accept all the national guidelines on best practice, for example the GMC's Guidance on "Good Medical Practice", and we welcome the new Care Standards Act and improved regulation within the independent sector.

  2.2  The involvement of the independent sector in the treatment of NHS patients is a government initiative. We will not comment on this except to say that the attitudes of the NHS staff at all levels has been varied in the degree of enthusiasm with which they have embraced previous partnership agreements.

  2.3  All of the Board of FIPO are also NHS consultants, with one General Practitioner representative, and without exception are strong supporters of the principles behind the NHS and of the need to improve the quality of care extended to NHS patients. In particular we support treatment according to clinical need and by the best possible evidence based methods. We support the principle of treatment without payment at the point of delivery although alternative methods of financing may be developed. We cannot comment on these except to say that the provision of healthcare should not be confused with the funding of healthcare.


  3.1  In this submission we will reserve our comments to the first of the three bullet points in the Select Committees Press notice ie "The NHS Concordat with the Private and Voluntary Sectors".

  3.2  Within the acute sector of healthcare (and excluding here psychiatric services and intermediate and long term care) there is potential for relieving waiting lists and accelerating treatment by utilising independent hospitals. We do not consider small private specialised clinics in our submission and only refer to the recognised independent hospitals.

  3.3  There is a fundamental question over local autonomy in arranging potential contracts as against centralised directives. These issues over the Concordat can be considered as either strengths or weaknesses and are as follows.


    —  flexibility to utilise variable local independent resources;

    —  potential for local innovation unhindered by central controls;

    —  local design of manpower and support service solutions; and

    —  autonomy to local contractual parties to agree financial solutions.

4.1  Flexibility to utilise variable local private resources

  (i)  Workloads within the independent sector vary on a weekly and seasonal basis. Bed availability is however fairly easily predictable as there is less emergency workload. Provided that there is adequate planning it should be perfectly possible to organise for NHS treatments on a regular basis and without the risk of last minute cancellations, which are common in the NHS.

  (ii)  There are geographical variations in hospital availability. In London, for example, very few of the independent hospitals could guarantee to perform routine surgical work on a regular basis. However, there are more specialised facilities in London and there is the possibility of more major contracts, eg for cardiac surgery.

  (iii)  On a national basis it is difficult to estimate the number of NHS surgical procedures that could be performed annually although some have given this figure as up to 100,000. (Professor Bosanquet.)

4.2  Potential for local innovation unhindered by central controls

  (i)  FIPO believes that there is potential for local solutions to the Concordat. Given the variability of NHS demand and of independent hospital availability, we believe that central directives would be destined to failure and that local flexibility in planning would be preferable.

4.3  Local design of manpower and support service solutions

  (i)  As part of the flexibility in planning we believe that there should be a local design of clinical and service manpower issues. Possible solutions could be the local NHS clinical staff working in the independent sector on contracted NHS patients or other consultants being contracted for this work.

4.4  Autonomy for local contractual parties to agree financial solutions

  (i)  As part of the flexibility and development of Concordat contracts to the local managers we believe that there should be local financial solutions. This might encourage a more competitive atmosphere with obvious advantages.


    —  administrative effort expended for small volumes of caseload;

    —  lack of consistency in administrative and contractual processes;

    —  potential inequities in remuneration of professional staff;

    —  pre-operative assessment/complications/follow up/patient transfer issues;

    —  fulfilment of Regulatory requirements of the Care Standards Act;

    —  arrangements for Governance and Audit provision; and

    —  difficulties in involvement of trainee and non-consultant grades in treatment/cover arrangement.

5.1  Administrative effort expended for small volumes of caseload

  (i)  The administrative workload involvedin setting up these agreements could be considerable and would not be cost effective for irregular, unpredictable and small volumes of work.

5.2  Lack of consistency in administrative and contractual processes

  (i)  There is a lack of consistency in the administrative process of negotiating and implementing contracts. This could lead to inefficiencies and possible clinical errors.

  (ii)  There are a variety of contractual relationships possible, which could add further confusion. Some contracts might be within the main NHS hospitals with private wings for which simpler contracts would apply.

  (iii)  Part of the contractual process would need to deal with the questions of quality, complaints and legal liability for contracted work.

5.3  Potential inequities in remuneration of professional staff

  (i)  Evidence to date on professional staff remuneration for NHS contracted work is anecdotal but seems to indicate some variations. There is clearly a potential for inequities and much would depend on the type, timing and extent of the contracted work.

  (ii)  Consultant services may be obtained from the referring NHS hospital, if the private facilities are situated locally, or by other recognised consultants. Freedom for local negotiation would be one approach, which FIPO would accept. Our only concern would be that clinical services are not equated with other hospital services such as hotel, portering or catering facilities where contracts are awarded largely on the basis of price competition. It is imperative to maintain standards in clinical practice based on a "fair and reasonable" staff remuneration.

5.4  Pre-operative assessment/complications/follow up/patient transfer issues

  (i)  FIPO is concerned that there could be clinical problems arising from the types of patients referred for treatment from the NHS. The variability of the clinical needs, the associated potential complicating conditions, the need for up to date clinical records and assessments are all practical matters that could affect the quality of care.

  (ii)  There are no insuperable problems here provided full information is obtained and careful assessments are made. Thus, there would be a necessity for proper pre-operative booking and assessment clinics.

  (iii)  Another issue would be the management of any complications and the adequacy of clinical cover and facilities. By and large such issues should be explored in the initial contracting process, as should the financial implications of any complication.

  (iv)  Follow up and careful reviews of all contracted work would be necessary. Inherent in the whole process would be the methods of transfer of patients and the effect on relatives. There may thus be geographical limitations on some forms of treatment but in life saving or less threatening but painful conditions this may be a low priority.

5.5  Fulfilment of Regulatory requirements of the Care Standards Act

  (i)  FIPO has welcomed the initial draft of the Care Standards Act. It would seem self-evident that any independent facility must be fully registered and approved and that any treatment of NHS patients would fall within the regulatory standards of the Act when it comes in to force.

5.6  Arrangements for Governance and Audit provision

  (i)  As part of the Care Standards Act and in line with best practice FIPO would need assurance that Governance and Audit of all contracted work should take place within both the NHS and independent sector. In fact the computer facilities of the independent sector are generally favourable to such data collection but all such audits should be measured against other similar work. Wherever possible there should be benchmarking against national yardsticks for example in the provision of cardiac services.

5.7  Difficulties in involvement of trainee and non-consultant career grades in treatment/cover arrangement

  (i)  Contracts for simple surgery may be entirely consultant based and not require overnight stay. More complex surgery requires the assistance of junior medical staff or non-consultant career grades. This would have to be anticipated in the contract. Many large independent hospitals provide suitable resident medical officers (RMO) but there may be the need for specialist junior staff. The actual size of this problem cannot be estimated but cover arrangements need to be carefully considered.

  (ii)  How and when NHS junior staff are required would be best resolved at local level. Several issues would need resolution, including professional indemnity for juniors in the independent sector, their hours of duty and the potential loss of training opportunities. This latter issue would not be of major import unless substantial contracts are awarded. Nevertheless, there is concern from the Royal Colleges about training opportunities in an era of reduced hours of duty and any loss could be deemed a problem.


  6.1  Whilst encouraging a large degree of local autonomy there could be some place for certain national agreements.

  6.2  Given some of the issues raised there could be a case made for restriction of professional employment arrangements to a limited menu of formats. Contractual terms, if not remunerative levels, might be agreed with the BMA, the HCSA, FIPO and other national medical bodies.

  6.3  Central guidance might need to be agreed with the Professions on minimum standards to be achieved in patient management including the basic arrangements for assessment, follow up and audit.

  6.4  Although not a direct matter for the medical profession, consideration should be given to the creation of an Internet/NHS-net based business to business (B2B) trading arena. This could facilitate and more efficiently manage the matching of NHS demand, available resources in the private sector and the availability of the required professional expertise.

September 2001

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