HSIB: Surgical care of NHS patients in independent hospitals (28 October 2021)

Summary

The purpose of this investigation by the Healthcare Safety Investigation Branch (HSIB) is to help improve patient safety in relation to the care of patients who have NHS-funded surgery in an independent hospital. This was initiated in the context of the COVID-19 pandemic, where because of increased pressure on the NHS, independent hospitals have been providing more care for NHS patients, including urgent elective surgical care and delivery of cancer pathways.

The HSIB investigation reviewed the experience of a patient with a diagnosis of bowel cancer, who was booked to undergo laparoscopic (keyhole) surgery to remove part of his bowel in in an independent hospital. Following surgery, the patient made slow progress and on day eight following surgery he started to deteriorate rapidly. He was transferred to the local NHS hospital for investigation and further surgery. He died later the same day as a result of sepsis following a complication of his recent surgery.

Content

The investigation explored:

• Safety issues associated with the establishment of surgical services in independent hospitals to support the NHS and in particular the specialist services that are in place to deliver patient care.
• The assessment of patients prior to surgery to identify their risk and suitability for an operation and where it was to be undertaken; this included identification of patients with frail physical states.

Key findings included:

• 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.
• 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.
• Where pathways between NHS and independent hospitals were effective, it was often found that relationships between the hospitals had been longstanding and direct.
• 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 – that is, 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

• HSIB recommends that 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.
• HSIB recommends that 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.
• HSIB recommends that 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.
• HSIB recommends that 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.
• HSIB recommends that 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.