The Care Standards Act

The Care Standards Act sets stringent rules which govern the recognition and regulations of all independent hospitals and all other facilities. The role of the Medical Advisory Committee (MAC), which is a group of consultants appointed in each hospital to advise management on clinical issues, will be fundamental to this.

The responsibilities and duties of the MAC and its Chairman have already been very well defined by all independent hospital groups. As part of their responsibilities the MAC must ensure that only specialists with appropriate qualifications are given admission rights and that all clinical work is carefully monitored and audited. Clinical governance committees and lead clinicians in audit will be necessary.

The minimum data set of information as required by the Care Standards Act is listed below but many private hospitals go much further than this in their audit procedure.

FIPO strongly supports this and is planning to carry out national reviews from its member organisations to compare and contrast these audit results.

Acute Hospitals - Independent Health Care

Human Resources

Qualification of All Medical Practitioners

OUTCOME
Patients receive investigation and treatment from appropriately trained, qualified and insured medical practitioners.

STANDARD A3

A3.1 All medical practitioners (i.e. including medical practitioners undertaking independent private practice whether employed, contracted or self-employed providing health screening or resident medical officer services on behalf of and as part of the hospital) are registered with the General Medical Council as medical practitioners.
A3.2 All medical practitioners have annual appraisals and are revalidated and in line with GMC requirements.
A3.3 All medical practitioners are covered by appropriate professional indemnity insurance either as specifically identified employees of the hospital or as members of a medical defence organization approved by the hospital and its insurers.
A3.4

All medical practitioners provide the registered person with, and make available to the National Care Standards Commission, the following clinical and performance indicators about any patient they have treated:

  • any deaths at the hospital;
  • unplanned re-admissions to hospital;
  • unplanned returns to theatre;
  • unplanned transfers to other hospitals;
  • adverse clinical incidents;
  • incidence of post-operative deep vein thrombosis;
  • post-operative infection rates for the hospital.

Qualifications and Experience of Medical Practitioners Undertaking Independent Private Practice (i.e. without supervision, commonly known as "Consultants")

OUTCOME
Medical practitioners who work independently in private practice are competent in the procedures they undertake and the treatment and hospital services they provide.

STANDARD A4

A4.1

Medical practitioners who work independently in private practice:

  • Clearly demonstrates that they have the necessary qualifications, expertise and experience to undertake competently and safely the treatment and services they provide; and
  • Have arrangements in place for continuing medical education relevant to the treatment and services they provide.
A4.2

Medical practitioners who work independently in private practice (except GPs):

  • are on the specialist register of the General Medical Council; or
  • where they were undertaking cosmetic surgery in the independent health care sector before 1 April 2002 and are not on the specialist register, satisfy the following conditions:
  • have completed recognised basic surgical or medical training;
  • have undertaken specialist training in a specialty
  • maintain a record of patients to whom they hve provided treatment or services in the establishment, which is made available to the registered person and to the National Care Standards Commission;
  • undertake regular patient satisfaction surveys, a record of which is made available to the registered person and the National Care Standards Commission at least annually.
A4.3 Medical practitioners undertaking cosmetic surgery independently in private practice for the first time from 1 April 2002 are on the specialist register of the General Medical Council.

Practising Privileges and the Medical Advisory Committee

OUTCOME
Patients receive treatment from medical practitioners who have the appropriate expertise.

STANDARD 5

A5.1 Where medical practitioners are granted practising privileges there is a medical advisory committee for the hospital, which is responsible for representing the professional needs and views of medical practitioner to the registered manager of the hospital.
A5.2 The medical advisory committee meets quarterly as a minimum and formal minutes are kept of meetings.
A5.3

The medical advisory committee makes recommendations to the registered manager on:

  • eligibility criteria for practising privileges;
  • each application for practising privileges;
  • the review and possible suspension, restriction or withdrawal of practising privileges;
  • the introduction of new clinical techniques to the hospital, including the training requirements for medical practitioners to undertake the technique, the equipment required and the training/experience required by other clinical staff to support the technique(s).
A5.4

The medical advisory committee reviews twice per year as a minimum, information collated on the clinical work undertaken at the hospital by all practitioners with practising privileges by specialty, procedure and by clinical responsibility, to include as a minimum:

  • any deaths at the hospital;
  • unplanned readmissions to hospital;
  • unplanned returns to theatre;
  • unplanned transfers to other hospitals;
  • adverse clinical incidents;
  • incidence of post-operative deep vein thrombosis;
  • post-operative infection rates for hospitals.