Independent Practice Committee update January 2019
It was agreed that the medical directors of BUPA and AXA would be invited to meet with representatives from the Association to discuss recent issues involving anaesthetists.
A meeting is being organised to clarify the role of the Association and also the articles of association, before we rejoin FIPO.
Independent practice survey summary
Tthe independent practice survey summary has now been published on the Association's website and is available here.
The newly updated Independent Practice guideline, titled 'Anaesthetic practice in the independent sector' has been published and is available here. This will be a useful resource for those undertaking independent practice and especially for those considering doing so.
Independent Practice Committee update September 2018
After a brief lull in activity over August the Association and IPC are in full swing again. The Association of Anaesthetists' year begins in September bringing a change in council members, and 2018 sees a new President, Officers and Committee chairs. After four years as a council member, including two years as IPC chair, Guy Jackson has reached the end of his term and is standing down from the Association. He will be handing over the chair of the IPC to Mathew Patteril who will continue to work hard on behalf of members engaged in independent practice.
The newly updated Independent Practice guideline, titled 'Anaesthetic practice in the independent sector' is in the final stages of approval and will be published shortly. This will be a useful resource for those undertaking independent practice and especially for those considering doing so.
Publication of the IPC survey has now been approved. We plan to repeat the survey in 2019.
Federation of Independent Practitioner Organisations (FIPO)
The IPC is aware of a growing number of anaesthetists finding themselves in conflict with some private medical insurers (PMIs). This is mostly related to fee schedules, shortfalls and threats of derecognition unless certain terms and conditions of engagement are agreed. The Association has decided to move towards re-joining FIPO, in order to best represent the interests of our members engaged in independent practice. FIPO represents a significant number of medical organisations with an interest in practice in the independent sector. Adding our anaesthetic voice and knowledge will be an excellent way of representing our members nationally.
PHIN (Private Hospital Information Network)
PHIN continue to work towards full publication of outcome measures and fees for all clinicians engaged in independent practice, as directed to do so following the Competition Market Authority (CMA) ruling in 2014. Ensuring these outcome measures and fees are accurate and useful for patients is a big challenge for PHIN.
Independent Practice Committee update July 2018
The IPC met on 22 June 2018, here's an update on the discussions of issues affecting those working within the independent sector.
Handover to new Chair
After four years on the Association Council and two years as Chair of the IPC, Guy Jackson is now at the end of his term. Mathew Patteril will be taking over as Chair from September 2018. Guy offers his thanks to all involved for support and advice over the last few years.
Much has changed in the sector since our Independent Practice Guideline was written in 2008. We're in the final stages of updating the guideline and the period for member consultation has closed. We hope this will be a useful resource for members in independent practice, especially those new to it or looking to start.
In 2017 we conducted a survey of members within independent practice. 157 members replied, helping us form a picture of anaesthetic practice within the independent sector, as well as identifying some of the issues affecting members. We've now produced a report summarising the answers, which will soon be available on the IPC webpage. We plan to repeat the survey every two years to review trends over the coming years and inform the activity of the IPC.
Private Medical Insurers (PMIs) and 'fee assured' status of anaesthetists
We've received a number of member enquiries suggesting increasing activity of the PMIs looking to restrict anaesthetic fees. Both new and established consultants are being targeted by different PMIs looking to persuade clinicians to be 'fee assured'. We are working with other organisations including the Federation of Independent Practitioner Organisations (FIPO) and the British Medical Association to ensure the interests of consultants are defended. Further news in due course.
Some recent issues highlighted by our members include:
- Private Medical Insurers and 'fee assured' status of anaesthetists (as above)
- Pre-operative anaesthetic consultations
We are aware of significant variations in practice nationally for the remuneration of pre-operative consultations and management between PMIs. Practises around pre-operative management have changed significantly in both the NHS and independent sectors. The Association is supportive of members seeking appropriate remuneration for pre-operative management within the independent sector, and we are aware of the difficulties faced by some. We are in the process of writing guidance on this to help explain the importance of this aspect of patient care to PMIs, and the standards within NHS practice that should be transferable to the independent sector.
- Ramsey Hospital NHS Terms and Conditions
Member query regarding Ramsey Hospital NHS terms and conditions, specifically relating to the episodic fees set out in the Fee Scales. Concern that fee covers all of the following stated activities:
- Surgeon: pre-operative consenting appointment, surgery and any and all attendances during patient's in-patient stay as well as any returns to theatre, management of post-operative complications and any further work required where the patient is re-admitted for a reason relating to their original treatment
- Anaesthetist: anaesthetic review as appropriate, surgical episode and post-operative attendance and any returns to theatre, management of post-operative complications and any further work required where the patient is re-admitted for a reason relating to their original treatment
The Association, any anaesthetic group or individual may have an opinion as to the role of the anaesthetist in ongoing care of a patient, but that may differ substantially from the independent hospital they work in. There may also be differences in opinions as to rates of remuneration.
A hospital has the right to dictate their terms of engagement in the same way an anaesthetist can take or leave the work offered (they cannot be made to do the work).
We hope there is a process of negotiation to get to a point where both parties are happy with the working arrangements. Increasingly independent hospitals undertaking NHS work are dictating terms and fees that are not attractive to anaesthetists (or surgeons).
The Association has no influence over this and is not able to negotiate terms and remuneration nationally. The Association has written guidance from 2008 and we are in the process of rewriting this guidance. The draft statement about anaesthetist responsibilities is below. Clearly this is at odds to the Ramsey T+Cs that the member forwarded.
We would encourage anaesthetists to explain to Ramsey hospital what service you (as an individual or a group) provide for the fee proposed. There may be a need to talk and negotiate. Document clearly what you offer following those discussions. Ultimately if you are not willing to accept their terms and conditions we would advise not undertaking the work.
Draft wording for the Association's Independent Practice Guideline 2018:
The anaesthetist has an ongoing clinical responsibility to their patients that continues into the postoperative period. However, this responsibility has limits, and we suggest that the anaesthetist makes the limits clear to the surgeon, other healthcare professionals involved in the patient's care, and the independent hospital management. Such limits may be:
- Until postoperative high dependency or intensive care is no longer needed or is handed over to an intensivist or another anaesthetist
- For patients not requiring intensive or high dependency care, the limits of the anaesthetist's care may be when the patient is:
- Awake and discharged from the recovery room
- Physiologically stable and satisfactory
- Free from significant postoperative pain, nausea and vomiting
- Not receiving intravenous opioid treatment, e.g. patient-controlled analgesia
- Not receiving neuraxial or peripheral local anaesthetic infusions
- Free from the short-term effects of peripheral or neuraxial nerve blocks
Any care provided by an anaesthetist beyond these limits may be separately chargeable if the patient has been warned of this before treatment. It is reasonable to expect an anaesthetist to be available for a patient for the period during which the early and predictable complications of surgery may occur. However, we suggest that this period should not normally exceed 24–48 hours and should certainly cease at the discharge of the patient from hospital.
Independent Practice Committee update February 2018
The IPC has spent the last year consulting, meeting, and responding to members and external organisations. The following update looks at some of the issues we've been working on that affect those within the independent sector.
The IPC chaired a session at the 2018 Winter Scientific Meeting. We heard from Aaron Swinton, Chartered Accountant and Partner at Sandison Easson Ltd, and Dr VJ Joshi, Clinical Informatics Officer at PHIN. After the presentations a Q+A addressed many issues affecting members. We plan to hold a session at WSM 2019 so please do join us.
The current Independent Practice Guideline was written in 2008 and much has changed since then. We are now in the final stages of updating the guideline, which will be published later this year.
We conducted a survey of members with independent practice at the end of 2017. 157 members took part, helping us form a picture of anaesthetic practice within the independent sector as well as identifying some of the issues affecting members. We plan to summarise the survey for publication, and to repeat the exercise at regular intervals to help identify trends over the coming years.
We've been made aware that BUPA have undertaken a pilot trial of a new model of remuneration for anaesthetists in one London hospital. The Association and the IPC have not been involved in this trial, but we are trying to find out more information from BUPA. If any members can provide more information for the IPC then please contact us.
PHIN (Private Hospital Information Network)
We are aware of confusion amongs anaesthetists about the role of PHIN and individual responsibilities around the Competition Market Authority (CMA) order. We have written a summary of the CMA process and subsequent arrival of PHIN within the Independent Practice guideline (soon to be published).
In summary: The Competition Market Authority (CMA) investigation into private healthcare in 2014 identified a lack of transparency and quality of information within the sector.
CMA created legally enforceable remedies to:
- Improve data collection
- Publish safety and quality measures – see below
- Publish clinician fees (note the legally enforceable bit is the clinician, not hospital, fee) – known as Article 22
PHIN was appointed as the information organisation with a duty to:
- Collect data from all providers of privately funded care
- Publish performance measures to help patients make informed decisions
- Publish by hospital site and for individual consultants
Independent, not-for-profit, with patients as core focus
Funded by mandatory subscriptions
Represented by a Board of Directors – clinical, hospital, insurer, academic, and CMA representation
PHIN has two main products with the following stated aims:
1. Online portal for consultants and hospitals
- Displays data submitted by hospitals (and NHS data)
- Displays consultant performance measures as they'll appear online BEFORE publication
- Allows consultants to check the accuracy and completeness of data prior to publication online
- Performance measures adjusted for complexity and benchmarked
2. Public website for patients
- Shows only performance measures for hospitals and individual consultants
- Adjusted for complexity
- Contextual information to help patients interpret information
- Performance measures driven by data in portal
What will be published?
- All care in independent hospitals = about 15% of healthcare
- Performance measures published by hospital and individual consultants
- Activity volume/Length of stay/Infection rates/Readmission rates/Revision rates/Mortality rates/Unplanned transfers/Patient feedback+satisfaction/Clinical registries and audits/Improvement in health (PROMs)/Adverse events
- Where are PHIN now?
- PHIN are focusing on performance outcomes, letters of engagement with clear initial consultation and procedure fees (focusing on self pay clinician fees in the first instance).
Article 22 – consultant fees
The CMA found a lack of transparency on consultant fees, which were often separate from hospital fees. FIPO launched an appeal against this remedy, which was rejected by the Court of Appeal in July 2016.
Consultant letters to patients
- By 31 December consultants must send written information outlining initial consultations
- By 28 February consultants must send written information outlining treatment and intervention fees
- Hospital must maintain an audit
- Publication of fees on PHIN's website
- By 31 December 2018 fees for privately funded care submitted to PHIN
- 30 April 2019 PHIN will publish consultant fees
We have met with PHIN on several occasions highlighting the Association as the largest membership organisation for anaesthetists with activity in the independent sector. FIPO (Federation of Independent Practitioner Organisations) were appointed to PHIN as the only clinical representation and we have been clear that anaesthetists need separate representation.
The CMA remedies only ordered the publication of clinician fees (probably no more than 25% of total fees), not hospital fees. PHIN are working with independent hospitals on how to include an indication of hospital fees. It's difficult to see how publishing clinician fees without the hospital fees truly helps patients but CMA set out the legal ruling and this is what PHIN have to do.
The Association has made representation to PHIN as to how to publish anaesthetic fees. Initially plans were in place to include surgical fees, a proposal that anaesthetists would oppose. The Association are aware that the publication of fees is extremely complicated and may vary depending on local and national variables. Our aim is to help PHIN find the best way of doing this legally enforceable and unavoidable process.
What do you need to do?
Currently PHIN are focusing on self pay surgical consultant and hospital fees; anaesthetic consultant fees are deemed too complicated to address in the first wave, mainly due to the fact that patients rarely have the opportunity to choose their anaesthetist. This is still under significant discussion and the solution is not clear. PHIN will have to address anaesthetic fees as well as fees for patients with private medical insurance in order to comply with the CMA order.
You should engage with PHIN and your independent hospitals and provide any information requested of you. The Association will continue to lobby PHIN to defend the interests of anaesthetists and has further meetings with them to find a workable solution to this legally enforceable order.
We are happy to consult with members about any matter affecting their independent practice. We aim to provide advice and identify trends. Some recent issues include:
A number of independent hospitals are reportedly requesting disclosure and sharing of the full annual appraisal. Previously most doctors shared a summary and confirmation of appraisal. There's no national requirement to share the full appraisal, but it may form part of local requirements for continued practicing privileges. Do be mindful of patient confidentiality if sharing your full appraisal.
2. Pre-operative anaesthetic consultations
We are aware of significant variations in practice nationally for the remuneration of pre-operative consultations and management between private medical insurers (PMIs). Practises around pre-operative management have changed significantly over recent years both within the NHS and independent sectors. The Association are supportive of members seeking appropriate remuneration for pre-operative management within the independent sector and are aware of difficulties faced by some when seeking appropriate remuneration. We are looking to draft guidance on this subject to help explain the importance of this aspect of patient care to PMIs.
3. Threat of de-recognition by PMIs and threat of withdrawal of practicing privileges by independent hospitals
We are aware of members being threatened with withdrawal of PMI recognition or withdrawal of hospital practicing privileges. The circumstances are varied for the threat to be issued but the advice remains the same. Ensure you are familiar with the terms and conditions of engagement – both PMI and local hospital. Use national guidance to negotiate with the PMI and/or local hospital. Let the IPC know of your difficulties so that trends can be identified, and advice given where possible. If a member of the BMA then also inform the BMA Private Practice committee.