The Federation of Independent Practitioner Organisations (FIPO)

Guidelines for Medical Advisory CommitteeChairmen and Members in the Independent Sector

This first edition of MAC Guidelines was issued in October 2005

THIS DOCUMENT IS THE PROPERTY OF FIPO.NO PARTS MAY BE COPIED OR REPRODUCED WITHOUT CONSENT.

Further information or copies of this document may be obtained from

FEDERATION OF INDEPENDENT PRACTITIONER ORGANISATIONS

14 Queen Anne’s GateLondon SW1H 9AA

Phone: 020 7222 0975 Fax: 020 7222 4424email: info@fipo.orgwebsite: www.fipo.org

Section Page

Glossary of Terms 3

Introduction 1 5Background to the FIPO MAC Guidelines 1. (A) 5Revision of the FIPO MAC Guidelines 1. (B) 5

The Federation of Independent Practitioner Organisation (FIPO) 2 5FIPO History and Remit 2. (A) 5

The Healthcare Commission 3 5The Healthcare Commission – Roles and Goals 3. (A) 5

The Care Standards Act (2000) 4 6The Care Standards Act 2000 and the National Minimum Standards 4. (A) 6Legal obligations of Medical Advisory Committee Members and Chairmen 4. (B) 6

The Contractual Relationship between Consultants and Patients 5 7FIPO Documentation and the Patient Consultant Contract 5. (A) 7

The Contractual Relationship between Consultants and Independent Hospitals 6 7Consultant Practising Privileges Contract 6. (A) 7

The Medical Advisory Committee Structure 7 7MAC Membership / Selection / Term of Office 7. (A) 7MAC Chairman and Deputy Chairman / Selection / Term of Office 7. (B) 7Administrative Functions of the MAC Chairman and Members 7. (C) 8Indemnification for MAC Chairmen and Members 7. (D) 8Reimbursement for MAC Chairmen, Members and Clinical Governance Consultant(s) 7. (E) 9Probity Issues Affecting the MAC, Consultant Staff and Hospital Management 7. (F) 9

Clinical Governance in the Independent Sector 8 10Governance Responsibilities in Acute Independent Hospitals 8. (A) 10The Role of the Clinical Governance Consultant (CGC) 8. (B) 10Hospital Clinical Governance Committee (HCGC) 8. (C) 11Functions of the Hospital Clinical Governance Committee (HCGC) 8. (D) 11

CONTENTS

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Section Page

The Medical Advisory Committee Functions 9 12Legal and Professional Functions of the MAC 9. (A) 12

Functions of the MAC relating to the Regulations and the National Minimum Standards 10 12Hospital and Consultant Data Sets and Statutory Reports 10. (A) 12Consultant Appraisal and Assessment of Competency 10. (B) 12GMC Revalidation Proposals 10. (C) 13Criteria for Consultant Practising Privilege 10. (D) 13Renewal of Consultant Practising Privileges 10. (E) 14Practising Privileges after the age of 70 years 10. (F) 14Suspension of Consultant Practising Privileges – 10. (G) 15• When a consultant loses his/her GMC licence to practise 10. (G) a 15• When a consultant loses his/her recognition by a private medical insurer 10. (G) b 15• When a consultant is reported to the GMC 10. (G) c 15• When a consultant is suspended in his/her NHS Trust or another private hospital 10. (G) d 16• When a consultant is in breech of his/her contractual relationship with the hospital 10. (G) e 16• When a consultant is found by the MAC to be behaving inappropriately 10. (G) f 16• When a consultant is found by the MAC to be acting incompetently 10. (G) g 16New Clinical Techniques 10. (H) 16Resident Medical Officers (RMO) 10. (I) 17Surgical or other Assistants 10. (J) 17Foreign and Non-Consultant Contracted Medical Staff Working Independently 10. (K) 17

Functions of the MAC Relating to Professional Issues 11 18The MAC and Management Interface 11. (A) 18The MAC and Insurance Interface 11. (B) 18Clinical Integrated Care Plans, National Guidelines, Audit and Monitoring Quality Assurance 11. (C) 19FIPO’s Role in Clinical Governance and Audit 11. (D) 20Investigation of Clinical Incidents 11. (E) 20Interpersonal Consultant Disputes 11. (F) 21

Appendix 1 FIPO Board and Supporting Organisations 22

Appendix 2 The Care Standards Act and the Role of the MAC and MAC Chairmen 23

Appendix 3 FIPO’s leaflet on “Patients Rights and Responsibilities” 24

Appendix 4 Consultant Data required for appraisal 25

Appendix 5 Template MAC Agenda 26

Appendix 6 Risk Grading System 27

CONTENTS

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CEO Chief Executive Officer

CGC Clinical Governance Consultant

CNO Chief Nursing Officer

CSA Care Standards Act

FIPO Federation of Independent Practitioner Organisations

FIPO CGAC Federation of Independent Practitioner Organisations Clinical Governance Advisory Committee

FIPO Nat-MAC Federation of Independent Practitioner Organisations National Medical Advisory Committee

GMC General Medical Council

GP General Practitioner

HCGC Hospital Clinical Governance Committee

HGC Hospital Governance Committee

HQS Health Quality Service

IHF Independent Healthcare Forum

ISTC Independent Sector Treatment Centre

MAC Medical Advisory Committee

NICE National Institute for Clinical Excellence

RMO Resident Medical Office

GLOSSARY OF TERMS

Guidelines for Medical Advisory Committee Chairmen and Members in the Independent Sector

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1. INTRODUCTION

1. (A) Background to the FIPOMAC Guidelines

1. Increasing regulation of acuteindependent healthcarefacilities and of consultants,coupled with an entirelyappropriate desire from allsides (including patients) forimproved quality of care hasplaced new responsibilities onthe members of the MedicalAdvisory Committee (MAC)and its Chairman inindependent hospitals.

2. Several official bodies anddocuments govern MAC andconsultant activities somelegal, some contractual andsome based on professionalguidelines. For example theHealthcare Commission whoimplement the CareStandards Act, the GMCguidelines (Good MedicalPractice), and theIndependent Hospital Forum(IHF) contracts forconsultants – some with localindependent hospitalmodifications – are allinterwoven. Others, such asThe Health Quality Service(HQS) are a voluntaryinspectorate to whichhospitals may subscribe andwhich has its own set ofstandards.

3. Although the Care StandardsAct is clear in itsrequirements many MACChairmen and MAC membersare confused about theirresponsibilities and legalstatus. They questionwhether they are part ofmanagement (similar to aMedical Director in a NHSTrust), a mouthpiece for theircolleagues, an advocate forthe patients or a combinationof all these. Some MACChairmen may take on moremanagerial roles than othersand in these cases theyshould be aware of theguidance issued by the GMCin “Management inHealthcare – The Role ofDoctors”.

4. This booklet providesguidance for consultants on aMAC and represents TheFederation of IndependentPractitioner Organisations(FIPO) interpretation of therole of the MAC and itsChairman and members. FIPOhas produced this with inputfrom the GMC, the MedicalDefence Union, The MedicalProtection Society, certainindependent hospitalproviders and otherprofessional bodies. TheHealthcare Commission hasbeen fully consulted at allstages of the preparation ofthis booklet and has advisedon a number of points but asa Regulator it is not in aposition to formally endorse aprofessional publication.

1. (B) Revision of the FIPO MACGuidelines

5. It has become evident duringthe production of theseguidelines that many areas ofclinical governance areevolving i.e. the rules overpractising privileges for thoseover 70 years of age, themethods by which StreamTwo complaints to the GMCwill be handled and the wholequestion of consultantrevalidation. For this reason itis likely that these guidelineswill need revision in the12–18 months.

2. THE FEDERATION OFINDEPENDENTPRACTITIONERORGANISATIONS(FIPO)

2. (A) FIPO History and Remit6. The Federation of

Independent PractitionerOrganisation (FIPO) wasfounded in 2000 and is anoverarching professionalorganisation for all privatepractice committees,independent physicianassociations, specialty groupsin the independent sector anddoctors working in groups(Chambers).

7. FIPO has also linkedindependent hospital MACsthroughout the UK into anetwork known as FIPO Nat-MAC (FIPO National MedicalAdvisory Committee).Periodic newsletters andmeetings organised by FIPOserve to inform MACChairmen and MAC membersof their developing role undernew legislation andhealthcare market changes

8. FIPO’s remit is to representthe profession on all aspectsof independent care withquality issues high on itspriorities. Futuredevelopments may involvemore co-ordination of thequality agenda. FIPO isworking with the HealthcareCommission and the majorindependent hospitalproviders to co-ordinate thestandards and outputs fromMAC’s and to provide aprofessional input to theseclinical issues.

9. The FIPO supportingorganisations and thecomposition of the FIPOBoard (as at 2005) is shownin Appendix 1. Further detailsabout FIPO and informationabout how to obtain copies ofprevious FIPO publicationscan be found at www.fipo.org.

3. THE HEALTHCARECOMMISSION

3. (A) The Healthcare Commission– Roles and Goals

10. The Healthcare Commission(an abbreviated title for theCommission for HealthcareAudit & Inspection) is thesuccessor to the NationalCare Standards Commissionand resulted from a mergerof that body with the NHSregulator, CHI (TheCommission for HealthcareImprovement) and with theValue for Money arm of theAudit Commission.

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11. The role of the independentsector division of theHealthcare Commission willbe to review compliance withthe regulations whichunderpin the Care StandardsAct via an ongoing system ofinspections. These include notjust the inspection of allhospital premises but also areview of the MAC structure,its functions, documentationincluding the files on eachconsultant. The independenthospital governance data, anyoutcome studies and auditswill be recorded and trendswill be analysed.

12. One of the goals of theHealthcare Commission isconvergence whereby thestandards in the NHS andacute independent healthcaresector will be integrated.Given the differences inservices, clinical staffing andmanagement styles offeredbetween the two sectorsthere could be somedifficulties and thus a numberof changes may beanticipated in the privatesector. Included under theindependent division of theHealthcare Commission willbe the ISTC’s whose clinicalgovernance and audit returnsare set contractually with theDepartment of Health.

13. The authority of theHealthcare Commissionremains unchanged and theregulator has the power toclose independent hospitalsfor failure of compliance. TheCommission must beinformed of any major eventsuch as the death of apatient, the suspension of aconsultant in any arena (NHSor private) or of anycomplaint about an individualconsultant to the GMC. Theoverall involvement of theHealthcare Commission in thecomplaints system ispresently undefined but mayincrease.

18. The Standards themselves donot have statutory force butthe regulations relating to theStandards, incorporated inthe same document, arelegally enforceable throughthe Healthcare Commissionvia their inspection teams.The regulations are known asthe Private and VoluntaryHealthcare (England)Regulations 2001, availableat the website.

19. All consultants working in theindependent sector – andparticularly those who sit asmembers of an MAC – areadvised to be familiar with theRegulations because theyimpact substantially onindividual clinical performance,the monitoring of consultantpractice and the maintenanceof admitting privileges.

20. For each hospital there isrequired to be a registeredprovider (i.e. the owner of thehospital) and also a 'registeredperson' who is the manager ofthe hospital and who isultimately legally responsiblefor what goes on within itincluding the granting andwithdrawal of practisingprivileges to medicalpractitioners. This normally isthe Chief Executive Officer(CEO) or equivalent.

21. Part III of the Regulationsrelates to ‘quality of serviceprovision’. Regulations 15-24have significant relevance forconsultant users andparticular responsibilities formembers of a MAC, includingclinical governance andmedical audit groups.

22. Within the main NationalMinimum Standards for acutehospitals, A3 and A4 cover thequalifications, experience andcompetence of consultantusers. Standard A5 isconcerned particularly withthe requirement for there tobe a Medical AdvisoryCommittee for the hospital“which is responsible forrepresenting the professionalneeds and views of medicalpractitioners to the registeredmanager of the hospital”.

4. THE CARE STANDARDSACT (2000)

4. (A) The Care Standards Act2000 and the NationalMinimum Standards

14. The Care Standards Act 2000introduced a number ofregulations and NationalMinimum Standards whichgovern all aspects of care andmanagement in theindependent healthcaresector. All healthcare facilities,ranging from hospitals tostand alone consulting rooms,are subject to regularinspections by the HealthcareCommission to ensure thatthey meet the requiredstandards and regulations.

15. The overriding concern forFIPO is the maintenance andimprovement of clinicalstandards. Central to thisobjective are the functionsand activities of the local MACand a number of NationalMinimum Standards refer tothe role and responsibilities ofthe MAC and its Chairman.

4. (B) Legal Obligations of MedicalAdvisory Committee Membersand Chairmen

16. An outline of the main pointsof the National MinimumStandards and Regulations asthey affect MACs is given inAppendix 2. The relevantdocuments are available onthe Healthcare Commissionwebsite atwww.healthcarecommission.org.uk.

17. The Care Standards Act 2000incorporates core standardsfor all healthcare providers,which are the NationalMinimum Standards set bythe Secretary of State forHealth. In addition, there areservice-specific standards foracute hospitals which areincorporated in Chapter 9(Standards A1 – A48) of the‘National Minimum Standards’DoH publication datedFebruary 2002 and can befound athttp://www.dh.gov.uk/assetRoot/04/07/83/67/04078367.pdf and alsoon the HealthcareCommission website.

5. THE CONTRACTUALRELATIONSHIPBETWEENCONSULTANTS ANDPATIENTS

5. (A) FIPO Documentation andthe Patient Consultant Contract

23. All doctors practice within awell-known professionalframework. Within the privatesector there is an addedfeature, namely the financialcontractual relationshipbetween the patient and thedoctor. In to this may comeother stakeholders such asthe payer, which may be aninsurance company, the NHSor some other party such asan employer or the patientsthemselves. It is essential thatthis financial contract doesnot affect the relationshipbetween patient and doctor.

24. As part of its variousfunctions FIPO has produceddocumentation to assistconsultants and also a leafletfor patients outlining theirRights and Responsibilitiesand their contractualrelationship with consultants(Appendix 3). It isrecommended that all MACChairmen use thesedocuments as a template andadvise local colleaguesaccordingly (for moreinformation see www.fipo.org).

6. THE CONTRACTUALRELATIONSHIPBETWEENCONSULTANTS ANDINDEPENDENTHOSPITALS

6. (A) Consultant PractisingPrivileges Contract

25. The great majority ofindependent hospitals in theUK signed up to threedocuments which weredrafted jointly by the formerIndependent HealthcareAssociation (part of whoserole has now been assumedby the IndependentHealthcare Forum – IHF) and

the BMA in consultation withthe GMC, FIPO, and themedical defence bodies. Thefollowing three templatedocuments have been agreed:I. a model policy on practising

privilegesII. a model letter for consultants’

practice privilegesIII. a paper on private practice data

for appraisal.

26. These documents have beenadopted by most hospitalsalthough some groups havemade certain changes. Theseset the terms and conditionsfor consultants and theirwork practices. It isimperative that the MAC befully aware of the localdocuments and should ensurethat the consultant body areaware of their implications.

7. THE MEDICALADVISORY COMMITTEESTRUCTURE

7. (A) MAC Membership /Selection / Term of Office

27. Rules governing MACstructure and functions havebeen produced by differenthospital groups and aresimilar in outline but varyslightly in detail. Thosehospitals wishing to undergoHQS assessment will needTerms of Reference for theirMAC. This should be based onthe following criteria.

28. It is generally agreed that theMAC comprises “elected”consultants and co-optedmanagement, nursing or otherconsultant members. The corevoting group of consultantsshould ideally number morethan six (plus a Chairman); themaximum size will depend onlocal factors (i.e. number ofspecialities needingrepresentation) and could beup to twelve or more. TheMAC should have the power toco-opt members as requiredand for variable periods. Someco-opted members will attendon a regular basis (CEO ordeputy, senior nurse manager)and others includingconsultants on a regular or

sporadic basis. The ClinicalGovernance Consultant andthe Consultant Chairman ofthe Hospital ClinicalGovernance Committee (if thislatter appointment has beenmade) should attend. Co-optedmembers should not havevoting rights. The MAC shouldhave the right to meet inprivate with only electedconsultant members shouldthe need arise to discussspecific issues.

29. It is helpful to have a GPmember on the MACCommittee from thesurrounding district.Consultant MAC membersshould broadly represent thespecialist interests of thehospital. MAC members shouldbe impartial and fair in theirdecisions and must carry theconfidence of their colleagues.Selection of MAC membershipshould either be by electionfrom specialist groups, byagreed rotation amongst thespecialist group, or byselection by the existing MAC(the least preferred route butone which may be essential incertain circumstances).Depending on the size of thehospital there may be a casefor a general election of MACmembers by the wholeconsultant body afternominations have been sought.

30. The term of office of eachmember of the MAC is notcritical but should be for 3years with the option of anextension, subject to theselection process.

7. (B) MAC Chairman and DeputyChairman / Selection / Term ofOffice

31. The core MAC membershipshould elect the Chairman ofthe MAC. He/she may or maynot already be a member ofthe MAC but some experienceof MAC functions would be aprerequisite for the post. Atrusted senior impartialconsultant with goodinterpersonal andadministrative skills would berequired.

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32. Primarily the Chairman’sposition is an MACappointment but clearly thehospital management willhave an interest and theremust be agreement over thismatter. The balance betweenthe MAC’s and hospitalmanagement’s input to theappointment of the Chairmanis delicate. However, if thereis an attempt to enforce anappointment of Chairman onthe MAC or if there is noconsensus of support fromthe MAC for a particularcandidate then this wouldresult in a seriousundermining of theChairman’s authority.

33. It is important to rememberthat the MAC has two majorroles – one to advise hospitalmanagement and the other torepresent professional (andthus patient) interests. Thereis therefore a potential foroccasional conflicts and theChairman needs to besensitive to the balance.

34. The MAC Chairman shouldhave defined term of office,probably 3 years being idealwith the option of anextension with no specificlimits but subject to review.Some hospitals requireannual renewal during thisperiod by a MAC proposedand seconded motion.Removal of a Chairman fromoffice would be only if therewere serious health issues orif there was a formal vote ofno confidence by the MAC.

35. A Deputy Chairman may beappointed and this is a matterfor local decision. The DeputyChairman may act in theabsence of the Chairman,carry out some of his/herresponsibilities and mayeventually succeed to theChairman’s post if this isagreed local policy. If theChairman and DeputyChairman are unable to attenda meeting the Committeeshould elect a Chairman forthat meeting only.

take part in specific enquiries.They will be called upon toreview in detail all applicationsfor practising privileges intheir own speciality.

7. (D) Indemnification for MACChairmen and Members

41. The Care Standards Act andthe model policy onpractising privileges definesthe roles of MAC and itsChairman including authorityof recommending thegranting, suspension orrenewal of practisingprivileges of consultants andgeneral practitioners (GPs).Thus, the MAC Chairman (ordesignate) is required toeither sign off and approve orotherwise reject allconsultants with privilegesjointly with the hospitalmanager who will only act onthe MAC Chairman'sprofessional advice in thisrenewal process.

42. This responsibility of the MACChairman and members could,in theory, lead to potentialchallenges by consultant orGP users. Although ultimatelyit is the hospital CEO ormanager who is responsiblefor all decisions this does notnecessarily absolve the MACChairman or other MACmembers from possibleaccusations of deprivingdoctors of their admissionrights inappropriately or ofdamaging their reputation. Aneven less likely scenario is if,in a negligence case against aconsultant user, the actioncould be construed in someway as resulting from aninappropriate granting orrenewal of practisingprivileges. For these reasonsthe MAC Chairman and allmembers who are makingrecommendations to thehospital CEO as the registeredperson, must have fullindemnity cover providedunder the hospital's indemnityinsurance.

43. The hospital providers maywithdraw indemnification inthe event that an MAC

7. (C) Administrative Functions ofthe MAC Chairman andMembers

36. The MAC Chairman shouldhave secretarial supportprovided by the hospital forhis/her official functions. Thisshould extend to thepreparation of Minutes,Agenda, meetingdocumentation (includingdetails of all applicants forpractising privileges), notekeeping at meetings and anyofficial or other MAC relatedcorrespondence.

37. The MAC Chairman should bepersonally responsible forwriting the Minutes and forthe content of the MACAgenda. There is merit inhaving a regular structure tothe Agenda with fixed itemssuch as presentations orreports from the Governanceteam, CEO, Chief NursingOfficer (CNO) and MACChairman. A template for aMAC Agenda is shown inAppendix 4 but this is notprescriptive.

38. All Minutes should beformally confirmed atsubsequent MAC meetings.MAC Chairmen and membersshould note that the MinuteBook may be subject toinspection by the HealthcareCommission.

39. The circulation of copies ofthe MAC Minutes to some orall of the consultant body orto other hospital managers ordepartments may beconsidered as a positive andtransparent approach. This isa matter for local decision.However, there could bematters of commercialsensitivity or details ofindividual consultant reviewscontained within the Minutesand so these should bewritten carefully. In general itis preferable to anonymiseany reviews about individualconsultant performance.

40. Apart from regular attendanceat MAC meetings, members ofthe MAC may be required toadvise on specific issues or to

Chairman, MAC member orother “appointed” consultant(i.e. a governance consultantor lead clinician) should act ina way that infringes hospitalpolicy or breachesconfidentiality. For this reasona formal agreement orcontract should be given toall consultants on the MAC.

7. (E) Reimbursement for the MACChairman, MAC Members andClinical GovernanceConsultant(s)

44. Membership of the MAC hasalways been a voluntaryobligation. It has beentraditional for the MACChairman not to receive anyreimbursement for fear that itwould compromise his/herposition as an impartialadvocate for colleagues.Reimbursement, it issuggested, could lead to theChairman becoming overidentified as part ofmanagement.

45. There is no clear guidanceabout reimbursement for theMAC Chairman. In view of theenlarging role of MACChairman and also because asmall number do receivefinancial reimbursementthere may be an argument infavour of a nationalagreement to pay all MACChairmen in the sector. Thismay evolve but until suchtime as a decision is madeChairmen are advised not toreceive payment or if they doso to make this transparentand preferably to utilise thefunds in some appropriatebut non personal fashion.

46. Reimbursement for MACmembers is not the normalthough they may obtaincertain indirect hospitalbenefits. Some, such as MACdinners or an away study andreview day on hospitalbusiness, are acceptable.Others, such as financiallybeneficial rates for consultingroom rental or secretarialassistance are unacceptable.

47. The position of the ClinicalGovernance Consultant (CGC)

or clinical Chairman of theHospital Clinical GovernanceCommittee (HCGC) (seebelow) is different as he/sheis appointed for a specificadministrative function,he/she reports to the MACChairman and CEO andspecific time must be given tothis task. Reimbursement isappropriate for this and maybe paid according toequivalent NHS sessionalrates. If the MAC Chairmanfulfils this Governance rolethen reimbursement may bepaid subject to MAC approval.

7. (F) Probity Issues Affecting theMAC, Consultant Staff andHospital Management

48. The MAC Chairman andmembers should act in anopen and impartial mannerand should declare at anystage if there is a conflict ofinterest in any MAC matter.For example, consultantapplications for privileges,renewal of privileges orsuspensions may directly ortangentially involve individualmembers of the MAC or itsChairman and in this casethey should not take part inthe decision making process.In the event of a complaint orcase review involving an MACmember then that personshould take no part in theprocess.

49. The MAC is not normallyinvolved in financialnegotiations or arrangementswith the hospital. Sucharrangements might involvenegotiated reimbursementwith radiologists, pathologistsor other groups or hospitalfinancial support for individualconsultants, secretaries orconsulting room rental rates.In some instances the hospitalmay provide reception orother administrative supportfor specific clinical units but ingeneral there should be anequitable situation with allconsultants receiving equaltreatment. Exceptions to thismay be an initial relief on aconsulting room rental for ashort period (3 – 6 months)

for newly appointedconsultants starting inpractice.

50. If the hospital shouldnegotiate contract work withthe NHS or anotherpurchaser then the MACshould ensure that allconsultants in the requiredspeciality have equal and fairaccess to this work.Emergency or other workreferred from the hospitalshould be shared out equally.Difficulties can arise ifconsultants, who are onlyoccasional and sporadic usersof the hospital, wish tobecome involved over andabove more regular users.

51. The development ofChambers may also lead toother tensions with thepossibility of preferentialtreatment to one group overanother or to individuals whocannot gain access to theChambers group. SomeChambers or even individualconsultants may seekpreferential hospital rates fortheir self pay patients,particularly if they are majorusers of the hospital. Whilstthere is a market force to beconsidered, this is generallynot thought to be a good ideaas it gives an unfairadvantage to certainconsultants over others.

52. The changing role of theinsurers may also impinge iftendering becomes morecommon and in many hospitalsthere will be different streamsof patients being treated fromdifferent “purchasers”. It isthe duty of the MAC to ensurethat the same high standardsapply to all patients.

53. It is self evident that probityand transparency are alsorequired in these and all othermatters from the hospitalmanagement. Although theMAC is not directly involvedwith financial issues it is aninitial court of appeal for localconsultants and the MACshould be concerned toensure that there is nopreferential treatment given

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to any individual or group. Inthe event that a consultant(s)appeals to the MAC as a resultof some dispute the Chairman(plus committee) may need tointercede according to thecircumstances.

54. Throughout this guidancedocument reference has beenmade to the obligations ofthe MAC and its Chairman inparticular. These increasingregulations may bring theMAC into conflict with theircolleagues who are in effecttheir constituency. The fineline between a managementmember and a consultantadvocate is a hard one totread.

55. The Chairman and the wholeMAC must act with fairnessand transparency (but retainconfidentiality).Documentation on eachconsultant should be keptconfidential and onlyreviewed if there is an issue.This consultant database andfiles should be open forinspection and challenge bythe consultant (if necessary)and should be available forhis/her appraisal.

8) CLINICALGOVERNANCE IN THE INDEPENDENTSECTOR

8 (A) Governance Responsibilitiesin Acute Independent Hospitals

56. Governance responsibilitiesmay be best consideredunder three main overlappingheadings as shown (above).

57. There may be confusionabout terminology andresponsibilities. It must bemade clear that the overallhospital governance is theresponsibility of theregistered manager (i.e. theCEO). However, clinical andprofessional governance canonly take place if managedand led by consultants.

58. Corporate (or Organisational)governance will involve thehospital’s response to its

facilities, personnel,complaints system, financialcontrols and all the othergeneral functions and riskmanagement of the hospital.This is the responsibility ofthe hospital management.

59. Professional governancerelates to the medical staffingand questions of practisingprivileges, renewal ofprivileges and suspensions.This is the directresponsibility of the MAC,which must advise the CEOaccordingly.

60. Clinical governance refers tothe range of ways in whichthe hospital clinicalperformance is monitored andhopefully improved. This willthus involve all clinicalrecords, audits, reviews,clinical incidents, deaths andcomplaints. This is theprofessional responsibility ofthe MAC, which may provide afiltering mechanism in theshape of a designatedconsultant who may functionalone or within the frameworkof a Hospital ClinicalGovernance Committee.

61. This manner in which eachhospital organises itself is amatter for local discussion.An overlap between thevarious aspects ofgovernance is obvious andthus, for example, systemsfailures are a major source of

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clinical incidents. Likewisebehavioural problems whichmay be consideredprofessional could lead toclinical incidents. There isthus some merit in setting upa specific Hospital CLINICALGovernance Committee toevaluate all sources ofpotential problems and asthis is a clinical committee itshould be clinically led.

8. (B) The Role of the ClinicalGovernance Consultant (CGC)

62. In order to facilitate anefficient and accuratecollection and interpretationof all the hospital governanceand audit data the MAC maywish to recommend theappointment of a ClinicalGovernance Consultant (CGC)to lead the governanceprogramme. In some cases,particularly if the hospital issmall, the CGC role will beassumed by the MACChairman.

63. The appointment of a CGCshould be made jointly by theMAC Chairman (taking advicefrom MAC members) and thehospital CEO. This consultantmay or may not already be amember of the MAC but if nothe/she should be invited to siton the MAC as an ex officiomember. Voting rights for thisindividual may or may not begranted at the discretion of

Corporate

Clinical Professional

the MAC. The period ofappointment of the CGCshould be determined andextended as required. Therewould be a need foradministrative support andreimbursement for thisconsultant.

64. The CGC is responsible to theChairman of the MAC and thusto the hospital CEO. Thefunctions of the CGC are toreview all the clinical data asrequired and to filter andrefine this crude informationin to a presentable andcomprehensive package forthe MAC. The CGC should bepart of the Hospital ClinicalGovernance Committee(HCGC) if this exists andideally should chair this group.In larger hospitals more thanone consultant may beinvolved with governanceissues and a division ofresponsibilities would benecessary with one consultantto chair the HCGC and one tobe the lead clinician in clinicalaudit. The CGC should takenote of the overall governanceof the hospital and not feelconfined to the purely clinicalaspects of his/her role.

8. (C) Hospital ClinicalGovernance Committee (HCGC)

65. The manner in which hospitalshandle their governanceissues will vary and dependson the hospital size and workpatterns. Normal riskmanagement will cover allaspects of the hospital andmay be handled and reviewedin a different forum to clinicalissues but there is an overlap.Many hospitals have a specificHospital Clinical GovernanceCommittee (HCGC) with awide remit covering allaspects of care systemswithin the hospital. Thus,membership wouldnecessarily involve all majordepartments (i.e. nursing,theatres, pharmacy,physiotherapy, infectioncontrol, risk management etc).Many of these may haveseparate subgroups to controlmanagerial functions.

69. Thus the overall clinicalthrust of the HCGC should bebased on the clinicalprotocols derived from NICEand other professionally ledguidelines and these shouldbe encouraged in amultidisciplinary teamapproach. These should beinterpreted locally andconstantly reviewed withregard to clinical and costeffectiveness and otheraspects of patient satisfactionand risk management.

70. The HCGC reports to the MACand should makerecommendations aboutservice improvements andtake appropriate follow upaction to checkimplementation. The datasets required by the NationalMinimum Standards shouldbe prepared and reviewed bythis committee or consultant.Specific clinical incidentsshould be filtered and gradedby severity; minor incidentsshould be recorded and dealtwith by the HCGC whilst themore severe ones should bepassed through to the MACfor consideration (see Section11(E)). Similarly all deathsshould be reviewed andclassified accordingly. Thecommittee should reviewcomplaints or issues relatingto misconduct by a specificmedical practitioner.

71. Hospital audit data may besuitable for merger either atgroup level or at a widernational level for presentationand promotion of standardsand of the independentsector as a whole. Some ofthis may be commerciallydriven and is theresponsibility of the hospitalproviders but some aspectsmay be requested by theHealthcare Commissionworking via FIPO and variousother bodies.

66. The HCGC brings thesetogether with a focus onclinical issues and thehospital management wouldnormally be represented onthis group as would the CGCor a MAC representative. Asstated previously it ispreferable that a consultantchairs this committee andthis may be the CGC or inlarger hospitals by anotherconsultant, which leaves theCGC to deal specifically withconsultant and audit issues.

8. (D) Functions of the HospitalClinical Governance Committee(HCGC)

67. The Hospital ClinicalGovernance Committee needsto consider all the relevantfunctions of the hospitalincluding clinical incidents,near misses and complaints.There needs to be anappropriate system ofrecording and reportingincidents and complaints. Asthese frequently involve bothservice aspects and directclinical problems it isessential to have consultantinput to their review and theCGC involvement should notbe restricted to clinicalincidents alone.

68. Although hospitals may varyin their approach to clinicalgovernance depending ontheir size and workloadpatterns the demand for aquality assured programmeand consultant involvement isoverwhelming. In the NHSthere has been a dislocationbetween managementaspirations (mainly to fulfilgovernment objectives) andthe clinicians desire toimprove the quality clinicalservices. The need to refocuson a clinically drivengovernance strategy is aconcept that may be moreeasily achieved in theindependent sector wherethere is a more restrictedrange of services and fewerpolitical objectives.

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9. THE MEDICALADVISORY COMMITTEEFUNCTIONS

9 (A) Legal and ProfessionalFunctions of the MAC

72. The National MinimumStandards sets out the legalfunctions of the MedicalAdvisory Committee for thehospital ‘which is alsoresponsible for representingthe professional needs andviews of medical practitionersto the registered manager ofthe hospital’.

73. The MAC is by definition anadvisory group and does nothave executive ormanagement functions withinthe hospital. However, it wouldbe most unwise for anyhospital Chief Executive ormanager to ignore theconsidered professionaladvice of the MAC as he/shewould then be in an untenableposition in the event of asubsequent incident.

74. The MAC and its Chairman inparticular have two broadfunctions of regulatorycompliance and professionalmatters which commonlyoverlap.I. Functions of the MAC relating to the

Regulations and the NationalMinimum Standards

II. Functions of the MAC relating toProfessional Issues

10. FUNCTIONS OF THEMAC RELATING TOTHE REGULATIONSAND THE NATIONALMINIMUM STANDARDS

75. The MAC functions relating tothe National MinimumStandards may be grouped asfollows;• Hospital and Consultant Data Sets and

Statutory Reports • Consultant Appraisal and Assessment

of Competency• GMC Revalidation Proposals• Criteria for Consultant Practising

Privilege• Renewal of Consultant Practising

Privileges• Practising Privileges after the age of

70 years• Suspension of Consultant Practising

Privileges• Resident Medical Officers

10. (A) Hospital and ConsultantData Sets and StatutoryReports

76. The MAC has severalfunctions as defined by theNational Minimum Standards.Each MAC is required to meetformally at least quarterly, tomaintain suitable records(Minutes) and to makerecommendations to theregistered manager onvarious issues. Whilst theMAC may receive briefingsfrom senior managers, nursesand others and may alsodiscuss other generalmatters, a core function ofthe MAC is to review theinformation required underthe National MinimumStandards, and to consider allClinical Governance and otherrelevant professional matters.

77. All data disclosed to membersof the MAC must beprocessed in compliance withthe Data Protection Act 1998and professional members ofthe MAC are also bound bythe GMC guidance on patientconfidentiality. The MACshould ensure that sucharrangements are in place intheir hospitals.

78. In terms of clinicalgovernance the MAC isrequired to review at leasttwice a year the clinical datasets for all practitionersworking in the hospital with aminimum requirement ofI. any deaths at the hospital;II. unplanned re-admissions to hospital;III. unplanned returns to theatre;IV. unplanned transfers to other

hospitals;V. adverse clinical incidents;VI. incidence of post-operative deep

vein thrombosis;VII. post-operative infection rates for the

hospital.

79. This data set for the wholehospital staff should beaggregated and presented ina suitable format for the MACby the CGC. MAC Chairmenmay wish to place summariesof these reports in the MACMinutes.

80. The confidential data forindividual consultants, whichmakes up this summary,

should be made available toeach consultant for thepurpose of appraisal(Appendix 4). The MACChairman may need to referto this data set when writinga consultant reference for anoutside enquiry.

81. In analysing these reports theMAC should be certain of theveracity of the informationpresented and must interpretthe crude data with caution.For example, deaths should benoted in terms of ‘anticipated’or ‘not anticipated’ andwhether or not there wereany adverse events leading upto the death; it is theresponsibility of the CGC tohave previously reviewed allthese deaths. Reasons forunplanned transfers to otherhospitals may be for nonclinical reasons such asinsurance restrictions. Theincidence of post-operativedeep vein thrombosis is hardto obtain even under trialcircumstances and post-operative infections may notbe manifest until long afterthe patient has beendischarged.

82. The review of adverse clinicalincidents is dealt with inSection 11 (E). These requirea balanced approach and anunderstanding of recognisedcomplications and thestatistical likelihood of a truetrend or an acceptable, ifregrettable, situation.

10. (B) Consultant Appraisal andAssessment of Competency

83. Appraisal and assessment are different. Appraisal ofconsultants is not a functionof the MAC or of the hospitalmanagement but assessmentis.

84. Appraisal is a confidentialprofessional issue betweenappraiser and appraisee. Thismay be whole practiceappraisal in the NHS and inthis case the consultant shouldbring to the attention of theNHS appraiser the details ofhis/her private work. Someconsultants only work in the

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independent sector or maychoose not to be appraised bytheir NHS colleague for theirprivate work. In these cases aprivate appraisal must bearranged through somemanaged environment whichcan guarantee that the processis thorough.

85. The CEO and managementshould make available to theconsultant his/her worksheet, complications, resultsof any audits, complaints andall positive reports and theseshould be used by theconsultant during appraisal.However, the appraiser is notrequired to judge the scope ofpractice of the appraisee butshould ensure that theconsultant is comfortablewith their work and to adviseif further training or help isrequired. Personal goals maybe set.

86. The consultant must returnproof of a complete appraisalto the CEO and MACChairman. It is not necessaryto return all the appraisalforms in the independentsector and these shouldremain confidential to theconsultant and his/herappraiser. The CEO and MACChairmen must however besure that the appraisalprocess has been completedin a proper fashion, preferablyin a managed environment.

87. Whilst this proof of appraisalis required it is a CEO andMAC responsibility to lookseparately at the consultant’sscope of practice and results.It should be noted thatappraisal is a professionalnon-judgmental process not alicensing process and theresults are just one of thefactors to be consideredwhen renewing practisingprivileges or a consultant’swork practices.

88. Appraisal is not the same as“assessment” which looks atthe actual results of theconsultant. Thus the MACChairman and the MAC areresponsible for theassessment of a consultant’s

93. For appraisal, localcertification would confirmfor each doctor that: I. appraisal has taken placeII. the appraisal process produced an

agreed Personal Development PlanIII. the appraisal process was carried

out and signed off by a trained andexperienced appraiser

IV. the appraisal process was informedby verifiable data about the doctorsactual practice

94. In terms of the doctor’s fitnessto practice, local certificationwould confirm that, locally:I. there are no concerns about the

doctors healthII. there are no known concerns about

the doctor’s probity.III. no disciplinary procedures are

currently in progressIV. there have been no relevant

disciplinary findings over thespecified period

V. clinical governance processes –including appraisal – are qualityassured

95. Employing authorities willneed to set in placeprocedures for producing localcertification. For independentor non-NHS consultants thereare alternative recognisedprofessional bodies preparedto offer appraisal by suitablytrained appraisers at a fee(see http://www.london-consultants.org/).

10. (D) Criteria for ConsultantPractising Privileges

96. The MAC must makerecommendations to theregistered manager onI. eligibility criteria for practising

privileges;II. each application for practising

privileges;III. the review and possible suspension,

restriction or withdrawal ofpractising privileges;

97. A vital governance function ofthe MAC is therecommendation of practisingprivileges to medicallyqualified applicants. Thecriteria for granting admissionrights are generally acceptedfor the applicant to be thepossession of a CCST and tohold a substantive NHSConsultant appointment or tohave previously held such anappointment. Difficulties mayarise over applicants holding alocum consultant appointmentwith each case being dealtwith on its merits.

performance rather thantheir appraisal, which alsolooks at many other aspectsof the consultant’sprofessional life andaspirations.

89. The principle plank of serviceand standards in theindependent sector is thequality and competence ofthe consultant staff. A majorfunction of the MAC will be toensure that the scope ofpractice of all consultants isappropriate to their skills andthis task will be facilitated bycareful reviews of practice.However caution is needed asa small workload may makethe statistical validity of anyaudit very hard to interpret.Other information about aconsultant may be obtainedfrom the medical defenceorganisations that havesystems for monitoring claimsand adverse incidentsaffecting their individualmembers.

10. (C) GMC Revalidation Proposals90. As at September 2005 the

GMC proposals forrevalidation in theindependent sector suggestthat this can be obtained fordoctors working within a“GMC approved environment”.These doctors will be able tosecure revalidation through“local certification” – wherelocal systems generate theevidence on which localcertification is based. Fordoctors who are not able tosecure local certification therewill be a more detailed reviewof their fitness to practice.

91. A GMC improved environmentmeans:I. has in place an effective system of

clinical governance or, if outside theNational Health Service, an effectivequality assurance system;

II. has in place an effective annualappraisal system which is based onthe principles in good MedicalPractice and

III. is regulated or quality assured by anindependent body or organisation.

92. Independent hospitals willneed to fulfil the abovecriteria in order to gainrecognition by the GMC.

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98. All applicants should beinterviewed by the CEO priorto consideration by the MAC.It is not generally appropriatefor the MAC or any individualMAC member or Chairman tointerview prospectiveapplicants, although they maybe asked to act as referees insome cases.

99. Each applicant should have acomplete set ofdocumentation which is I. Up to date CVII. Two referencesIII. Confirmation of Hepatitis B

immunisation statusIV. Copy of GMC Registration V. Copy of NHS appointment letter VI. Copy of Medical Defence certificate

(see below*)VII. Photocopy of current passport VIII.Criminal Record Bureau Enhanced

Certificate

100. *The Medical Defenceorganisations vary in theirapproach with the MDUproviding an insurance policyand others discretionaryindemnification. Thusconsultants should furnisheither a copy of their clinicalnegligence insurance policyor a certificate ofmembership of a medicaldefence organisation.

101. There may be morerequirements for certainspecialties such as cosmeticsurgery and paediatrics,which will depend onchanging regulations andlocal interpretation.

102. Particular attention should bemade to the scope of practiceof each applicant and ingeneral this should follow theapplicant’s normal NHSpractice. Partial or limitedprivileges may be grantedbased on an analysis of theconsultant’s practice profile.Newly appointed consultantsmay not have been throughthe process of an appraisal atthis level and so this shouldbe ignored at this stage andemphasis placed upon thereferences. Attention shouldbe paid to the geographicaldomicile of the applicant andtheir availability foremergency attendance. It canbe possible to accept an

arrangement for suitablecover from another colleaguefor aspects of theconsultant’s work but thisneeds careful monitoring.

103. Consultants wishing toperform paediatricprocedures will need to satisfyenhanced criminal recordclearance and to confirm theirattendance at paediatric lifesupport and other paediatriccourses. The hospital will needto provide appropriatepaediatric nursing and otherfacilities as required by theCare Standards Act.

104. The question of non-consultant applications forpractising privileges mayarise (i.e. podiatrists) andthese should be consideredwithin the hospital policy.Attitudes to this will vary.This trend of non-medicalpractitioners performingcertain procedures maydevelop in the NHS but iscontrary to the currentphilosophy and organisationof private practice. The MACmay have difficulty inaccepting non-medicalqualified staff that comeunder different “professional”regulations.

10 (E) Renewal of ConsultantPractising Privileges

105. Renewal of practisingprivileges on at least a twoyearly basis has to be madeon all consultants withpractising privileges. Thisexercise will require a reviewof the consultants’ basicdocumentation (listed above)together with evidence of aformal appraisal. In addition astatement from the managinggroup running the appraisalin the private sector and astatement from the NHSappraiser (or a MedicalDirector) that the appraisalhas been appropriate andinclusive of the consultant’sprivate work will be required.

106. As part of the renewalprocess the personal data setof each consultant (coveringworkload, complications,

complaints etc) should bereviewed. This data set shouldin any event have been madeavailable to the consultant forreview during their appraisal.Any specific complaints orincidents should be discussedbut care should be taken notto make inappropriatejudgements based on smallnumbers of cases which maynot achieve statistical validity.

107. Difficulties may occur if aconsultant has been removedfrom an insurance company’srecognition list. This hashappened on occasions andwill give rise to administrativedifficulties within the hospital.The MAC should considerthese issues carefully and inparticular the reasons why theconsultant has been de-listedby the insurance company.

108. The renewal of practisingprivileges will be confirmedand signed off by the CEOand Chairman of the MAC orhis designate. This exercisemay be onerous when thereare large numbers ofconsultants and thus may bedealt with outside the normalMAC meetings. However, theMAC should review the list ofall consultants who aregranted renewal of privilegesand should consider in detailall cases where there is aquestion of competence orany other matter which mayhave arisen.

109. A system of renewingprivileges for the MACmembers and Chairmanshould be instigated fromwithin the MAC and, in theunlikely event that a questionarises over a MAC consultant,then that consultant shouldabsent himself from any MACdiscussion.

10. (F) Practising Privileges afterthe age of 70 years

110. Previously most practisingprivileges policy documentsindicate that all practiceshould cease at thepractitioner’s 70th birthday.Furthermore many medicalinsurance companies

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withdraw recognition at thisage. However, future changesin the law may make it aninfringement to discriminateon the grounds of age.

111. As the MAC may face requestsfrom consultants or GP’s whowish to practise after reaching70 years, it must decide itspolicy. Hospital groups haveadopted different attitudes tothis matter and some may notwish to continue to allowpractice after the age of 70years. The IHF have producedGuidelines to assist whichstate that the ultimatedecision is referred back tothe MAC.

112. It is clear that acceptance ofconsultants over the age of70 years will depend on thetype of practice and thecompetence of the doctor. Itis recognised thatcompetency is particularlydifficult to measure and alsothat loss of physical andcognitive abilities withincreasing age may be subtleand hard to detect. The MACmay agree to ongoingprivileges subject to closerannual review by the MACalthough the precise natureof this review is poorlydefined. The MAC shouldconsider all relevant aspectsof the practitioner’s practiceand consider the safety andprotection of patients as theirmain priority.

10. (G) Suspension of ConsultantPractising Privileges

113. Suspension of a consultant’spractising privileges in anindependent hospital mayhave to be considered incertain circumstances. Thepredominant cause for thiswould be if the conditions orundertakings do not providethe necessary degree ofprotection for the patients.Great care and sensitivitymust be employed in thesedecisions and the MAC shouldnote that the suspension of aconsultant is reported toother hospitals where theconsultant works.

hospital which may have torestrict privileges forcommercial reasons (i.e. thehospital may also be excludedfrom payment).

c) When a consultant isreported to the GMC

118. The policy of the GMC inhandling complaints againstconsultants has changed sinceSeptember 2005. Allcomplaints are triaged in toStream One (more seriouscomplaints which could raisean issue of impaired fitness topractise) or Stream Two (lessserious complaints, whichwould not normally raiseissues of fitness to practice). InStream One cases referencesand information will be soughtfrom all the independent andNHS hospitals where theconsultant is affiliated. In thissituation the MAC Chairmanshould advise the CEO aboutthe consultant’s performancebased on local information anda review of the consultant’sfile.

119. The reason for the GMCcomplaint should bediscussed locally by the CEO,MAC Chairmen and relevantGovernance and specialityMAC members.. In general itis not recommended that aconsultant be suspended untilthe full GMC ruling has beenmade unless there are seriousclinical charges or there isstrong local evidence whichcasts some doubt on theconsultant’s performance. Itmay be that the MAC willconsider some partialrestrictions on the consultantwhilst awaiting the outcomeof the GMC enquiry.

120. Stream Two complaintsagainst consultants will bereferred back to the NHS Trustfor investigation under NHSprocedures. Employing andcontracting authorities will beinvited to refer the case backto the GMC if informationemerges which changes thecomplexion of the complaintto one in which there may bedoubt about the doctorscontinued fitness to practice.

114. The acceptance of practiceprivileges policy, in someprovider hospitals, precludesthe practitioner fromindependent and professionalrepresentation at appealmeetings. This is inherentlyunfair and against naturaljustice.

115. Suspension may be necessary • When a consultant loses his/her GMC

licence to practise• When a consultant loses his/her

insurance recognition• When a consultant is reported to the

GMC• When a consultant is suspended in

his/her NHS Trust or another privatehospital

• When a consultant is in breach ofhis/her contractual relationship withthe hospital

• When a consultant is found by the MACto be behaving inappropriately

• When a consultant is found by the MACto be acting incompetently

a) When a consultant loseshis/her GMC licence topractise

116. It is self evident that loss orsuspension of GMCrecognition will mean loss ofpractising privileges.Restoration of theconsultant’s licence topractice may result in his/herreapplication for practisingprivileges. In thiscircumstance the MAC willneed to carefully consider thecircumstances of the GMCsuspension.

b) When a consultant loseshis/her recognition by aprivate medical insurer

117. On occasions consultantshave lost recognition by aninsurance company. Thereasons for this have beenvarious and are usually dueto financial disputes ratherthan clinical issues. The MACshould be clear about thecause of the de-listing andsupport the consultant. Ifallegations of fraud are beingmade against the consultantthe MAC should not becomeinvolved, as the consultantwill seek representationelsewhere. In certain casesthe removal of a majorinsurance recognition willcreate an impossiblemanagement issue for the

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121. Stream Two complaints thatarise from within theindependent sector or affectconsultants without a NHSappointment will be referredback to the GMC althoughthis policy is under review

d) When a consultant isexcluded in his/her NHSTrust or another privatehospital

122. The reason for thesuspension should bereviewed. In general it is notrecommended that anautomatic suspension ismade unless there are seriousclinical charges or there isstrong local evidence whichcasts some doubt on theconsultant’s performance. Aswith a complaint to the GMCthe MAC may consider somepartial restrictions on theconsultant if there are clinicalimplications to the originalsuspension.

e) When a consultant is inbreach of his/her contractualrelationship with the hospital

123. If a consultant should breachhis/her contractualrelationship with the hospitalthere may be a case forsuspension of practisingprivileges. Some hospitalshave given authority to theCEO to act independently butthis should be done inconsultation with theChairman of the MAC. Clearbreaches, such as repeatedfailure to comply with hospitalprotocols (i.e. operationconsent forms) or failure tocomplete the necessaryconsultant documentationdata set, could give rise to asuspension.

124. Difficulties may arise over“conflicts of interest” whichhas been introduced to manypractising privilegescontracts. There may beglaring examples of this suchas a consultant(s) opening analternative facility in directcompetition with the hospital.Other situations may be lessclear and consultants shouldfor example not be derived ofrights because they choose to

utilise an alternative facilityfor some of their patients orif their utilisation of hospitalfacilities is less than others.

125. Another contractualstatement is that consultantsshould “support the hospital’swider quality assuranceobjectives by referringpatients requiringinvestigation to radiologistsand pathologists within thehospital’s established andquality assured network”.This could preclude thepractitioner from referring hispatients to centres for specialexpertise and opinion notavailable within the hospital’sestablished and qualityassured network. Consultantshave the right to referelsewhere in the bestinterests of the patient butmust be certain about theclinical standards of any sucharea of referral.

f) When a consultant is foundby the MAC to be behavinginappropriately

126. Inappropriate consultantbehaviour is a difficultproblem. Substance abuse,physical or mental problems,social or behavioural issueswill need sensitive handling.Non-compliance such asrepeated failure to attendwhen summoned for clinicalproblems or persistent failureto comply with hospitalregulations over notekeeping, consent forms orother documentation may(after suitable warnings andcounselling) be grounds foraction against a consultant.

127. The MAC Chairman shouldappoint a suitable seniorcolleague(s) or take the leadhimself in assessing andassisting colleagues facingsuch problems. Depending onthe nature of the problemthere may be a need toimmediately suspend aconsultant. The GMC mayneed to be consulted at anystage of the investigation andguidance on this is availablefrom the GMC websites anddirectly.

a) When a consultant is foundby the MAC to be actingincompetently

128. Suspension of a consultantfor incompetence needscareful professionalassessment. Usually thisfollows a specific incident orit may arise after a train ofevents. Partial restriction ofprivileges may be employedin some cases. It is obviouslywise and just to ensure thatall the details of the issue arefully assessed. Rarely animmediate suspension has tobe implemented by the CEOand MAC Chairman. The GMCmay need to be consultedearly in the investigation andguidance on this is availablefrom the GMC websites anddirectly.

10. (H) New Clinical Techniques129. Another function of the MAC

dictated by the NationalMinimum Standards is overthe introduction of newtechniques and advice mustbe given onI. the introduction of new clinical

techniques to the hospital, includingthe training requirements formedical practitioners to undertakethe technique;

II. the equipment required and thetraining/experience required byother clinical staff to support thetechnique(s).

130. New clinical techniques referto any invasive or radiologicalprocedure which has not beenemployed previously in thehospital. Such proceduresmay be new to the consultant;some may or may not beperformed in other hospitalsbut generally this would notbe a widespread technique.

131. Each hospital group will haveits own policy but the generalsteps are likely to be I. Request for the technique to the

CEO by a consultant(s) which mustbe backed by some evidence thatthis has been referenced by NICE(NICE Interventional ProceduresRegister www.nice.org.uk/ip)

II. CEO to consider if he/she wishes tosupport the technique depending onresources

III. CEO refers the question to the MACwhich must consider theacceptability of the technique(based on national guidelines), thecompetency of the consultant(s), the

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possible adverse clinicalconsequences, the information forpatients and others, the manner inwhich informed consent will beobtained and the impact on nursingand other resources

IV. Specific consent for procedureswhere the risks and benefits areunclear have been developed by NICE(http://www.nice.org.uk/page.aspx?o=212184)

V. The MAC may recommendtemporary acceptance of thetechnique but should then refer thisto the HCGC to monitor and auditthe technique (or do so itself)

VI. The CGC should report back to theMAC as the results of audit becomeavailable

VII. The MAC should constantly reviewthe technique and advise the CEOaccording to changing information.

132. In the event of a clinicalemergency which maydemand the new techniquethe CEO and MAC Chairmanmay give temporary approvalfor its use.

10. (I) Resident Medical Officers(RMO)

133. Resident medical officers(RMOs) in private hospitalshave traditionally been eitheremployed on a permanent ortemporary basis or appointedin association with NHSTrusts or academicdepartments on a part timebasis. The interview processfor these posts will thereforevary but it is assumed thatthe medical bona fides andsuitability of the appointeewill have been confirmed. Itwould be desirable for anMAC representative to bepresent at the interview but itis recognised that this maynot always be possible.

134. All RMOs must fulfil thecriteria for health,registration and probity asset by the employing hospitalwhich should also provideprofessional indemnity.However, as there may beconflicts over clinical issues itis advisable for all RMOs tohave their own professionalmedical defenceindemnification.

135. RMOs should have a clear jobplan with a proper inductionand orientation course at theindependent hospital. TheEuropean Working Time

sector may mean that moreteaching will be carried out inprivate hospitals. It isconceivable that some RMOposts will become recognisedas part of training, probablyas part of a modularprogramme and in rotationwith other NHS centres. Thiswill require careful review andattention to the training asopposed to the servicerequirements of these RMOposts.

10 (J) Surgical or other Assistants– Practical and Training Issues

139. Most independent hospitalwill have policies covering therole of surgical assistants.There needs to be a methodof recording attendance andverifying the bona fides ofthe assistants. This will needto include their health status,medical indemnification andprofessional qualifications.

140. No surgical assistant cancarry out an independent rolein clinical care and must besupervised at all stages. Theultimate responsibility will fallupon the consultant in allclinical matters. As trainingopportunities may becomemore formalised in theindependent sector there willbe a need to refine theresponsibilities of thesetrainees.

10. (K) Foreign and Non-ConsultantContracted Medical StaffWorking Independently

141. Future changes in consultanttraining (leading to a CCT)and the possibility ofapplicants from Europe orelsewhere requestingprivileges will need furtherconsideration. Theemployment of UK doctors byindependent hospitals at asub-consultant grade (otherthan Resident MedicalOfficers) has been mooted.Any doctor working withinthe hospital would have to beunder the professionaljurisdiction of the MAC andneed to satisfy the samecriteria as all otherapplicants.

Directive will needconsideration and suitablerest periods andaccommodation must bearranged. The MAC Chairmanor a designate should ensurethat the hand over of patientsbetween shifts of RMOs isefficient.

136. RMOs should not be givenresponsibilities beyond theircapability and if possible orwhen necessary they shouldbe sent on recognisedcourses (i.e. resuscitation). Insome hospitals specificteaching programmes havebeen developed for the RMOs.Such teaching may be basedon examination requirementsor on the specific ward workof the RMOs (i.e.tracheostomy care). Somehospitals have intensivistRMOs restricted to the ICUand in this case they shouldreport directly to theconsultant intensivist incharge of the unit or theconsultants responsible foreach patient.

137. The relationship between theRMOs and the generalconsultant staff is differentthan in the NHS and tensionscan arise overcommunications, emergencyadmissions and specificpolicies. The MAC Chairmanshould therefore appoint oneor more consultant mentorsfor the RMOs (not necessarilyfrom within the MAC) andthese consultants shouldmeet with the RMOs on aregular and as required basisto discuss confidentialprofessional issues. Conflictsor difficulties should bereported to the MACChairman who should actaccordingly. The mentorand/or the MAC Chairmanshould be prepared to providea professional reference forthe RMOs.

138. Future changes inpostgraduate medical training(Modernising MedicalCareers) and the shift of largevolumes of elective NHSsurgery in to the independent

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142. A more immediate issue isforeign doctors working inIndependent SectorTreatment Centres (ISTCs)who would not normally fallunder the MAC jurisdiction.The employment status ofthese doctors is different inthat they are contractedemployees falling within theorganisation’s corporate andclinical governancestructures. Within an ISTCthere may be an MAC butaccountability andresponsibility lies with theRegistered Manager.

143. The MAC may be asked toreview the details of theseforeign doctors who may beon contract to workindependently for variablebut often short periods withinprivate hospitals. Whilst suchdoctors may have fulfilledcertain basic legalregistration requirements andeven hold variouscertifications of specialisttraining from abroad, it maybe very difficult for the MACto reliably give impartial andprofessional advice as to theexpertise of such doctors. Insuch instances it isrecommended that the MACmake no comment about thedoctors concerned. The MACshould not become involvedin any form of interview ofsuch doctors. The MACChairman should make itclear to the management thatthey are unable to advise orto take any responsibility forthe appointments.

144. In the event that themanagement appoints suchdoctors the MAC should insistthat all clinical workloads areproperly monitored and thata careful post operative andpost discharge audit ismaintained. The MAC, via itsGovernance team, shouldreview all complaints andcomplications and the resultsof all audits. The MAC shouldnot hesitate to report andrecommend action to themanagement as they would inany adverse clinical scenario.

The MAC should not beprejudiced or drawn in topolitical conflict but alwaysact in the best interests ofthe patient.

145. The ultimate responsibility ofthe MAC is to maintain patientsafety and clinical excellence.There is a danger that doublestandards could apply andthus the MAC should actfirmly to maintain standards.

11 FUNCTIONS OF THEMAC RELATING TOPROFESSIONALISSUES

146. The professional functions ofthe MAC may be grouped asfollows:• The MAC and Management Interface• The MAC and Insurance Interface• Clinical Guidelines, Audit and

Monitoring Quality Assurance• Investigation of Clinical Incidents• The MAC and Consultant Issues

11 (A) The MAC and ManagementInterface

147. The MAC Chairman is in apivotal but ambivalentrelationship withmanagement. The MACChairman will take the overallresponsibility for clinicalgovernance (with the help ofothers such as the CGC andHCGC) and must work closelywith the whole MAC, CEO,CNO and others. In this rolethe MAC Chairman andindeed the whole MAC mustalso be the mouthpiece fortheir professional colleagues.The MAC Chairman must tryand square this circle byhaving a reasonably highprofile and by heading offproblems. Many hospitalmanagers have little clinicalknowledge and the MACChairman should ensure thatmanagement is fully informedof the clinical repercussionsof any decisions that theyshould make.

148. Many issues arise out ofcommunication problems andperiodic Newsletters andgeneral consultant meetingswill help and are requred forHQS endorsement. The

Chairman must be preparedto meet, inform and persuadecolleagues when necessary.Maintaining an appropriatebalance is perhaps the mostdifficult of all MAC functionsand every matter must beconsidered on its merits. TheMAC Chairman must beunwavering in support ofcolleagues when the situationdemands but also must besupportive of managementwhen there is a clearunremitting consultanttransgression.

11. (B) The MAC and InsuranceInterface

149. Private medical insurers arecommonly in discussion withhospitals and consultantsover reimbursements.Generally these are not issuesfor the MAC but some trendssuggest that the MAC maybecome increasingly involved.

150. Fraudulent claims byhospitals and consultantscannot ever be condoned butas the insurers are increasingtheir surveillance of thismatter there is concern thatgenuine mistakes of codingcould lead to fraud charges.The MAC may be called uponfor evidence and shouldexercise judgement andprecision in their responsebut should not becomeembroiled in legal disputes.

151. Apart from responding tocoding inconsistencies theMAC Chairman shouldencourage all consultants togive the patient a properestimate of fees (althoughthis may not always bepossible for clinical reasons)and try to ensure thatextortionate fees are notbeing charged. The FIPOdocumentation may help bygiving all parties anexplanation of their positions.

152. In some cases the consultantwill appeal to the MAC ifchallenged about theappropriateness of the care(i.e. the length of stay, thespecific indications for theprocedure or need for

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admission etc). In these casesthe MAC Chairman shouldseek opinions from the MACspecialist member and othersbefore responding.

153. Problems have also beenreported over insurancepolicies with a ‘six week rule’restriction, which bansprivate care if the NHSwaiting list is less than 6weeks for the specificproblem. Difficulties arisewhen an emergency presentsto the private hospital orconsultant that needsimmediate treatment andthus a duty of care exists.Even in more controlledcircumstances it is not alwayspossible to know what thespecific waiting list is at anymoment or what geographicallimits there are to thisrestriction. The onus is beingincreasingly placed upon theconsultant to make thisdetermination but this is nota consultant responsibility. Itis in the hospital’s interest tomake available up to dateinformation on local waitinglists. Failing this consultantsshould not complete thissection of the insurance formand refer the matter back tothe insurer.

154. Some consultants have been“de-listed” by certaininsurance companies. Thereasons for this have usuallybeen over financial disputesrather than clinical matters. Insome cases consultants insupport specialties (i.e.anaesthetics) have been forcedto work without receivingreimbursement. Consultants infront line specialties (i.e.surgeons who need to bookpatients in to hospitals) aredifferent as the hospital maybe drawn in to the dispute andnot receive payment for theconsultant’s patients. This maymean that the consultant willnot be able to admit thesepatients to the hospital. TheMAC Chairman cannot bedrawn in to this dispute unlessthere has been a clinicalbackground to the de-listing.

programme. Nurseadministered clinics (i.e. pre-assessment clinics) should bereviewed. Nurse empowermentand an increasing role ofnurses in clinical therapies is atrend that will increase even inthe independent sector whichis traditionally a consultantbased service. Such servicesmust come under the HCGCand the MAC in terms ofgovernance.

159. Many private and NHShospitals are part of the QUIP(Quality Indicator Project) aninternational programme ofexternal audit. This suppliessome of the basic and genericdata on the whole hospital asrequired under the CareStandards Act and theHealthcare Commission (i.e.deaths, returns to theatre,unplanned readmissions etc).Such data is relatively crudegeneric aggregatedinformation and may be ofsome limited value.

160. The clinical quality assuranceprogramme is a function ofthe MAC, which shoulddiscuss with the managementhow the hospital should bebenchmarked. Some externalreviews are costly and somanagement must beinvolved. The MAC shouldencourage cooperation withexternal registries andbenchmarking wheneverappropriate. NCEPOD (theNational Confidential Enquiryinto Patient Outcomes andDeaths) does not now requirehospitals to submit data onall deaths and are insteadfocussing on ‘topic’ audits.

161. Some other nationalregistries and databases arelisted below and whilst datareturns are variable supportof these will lead to an openand transparent ethos.Examples of registries whichrecord data but which do notprovide much comparativeresults are as follows:I. Cancer Registries II. NCEPODIII. Human Fertilisation & Embryology

AuthorityIV. National Joint RegistryV. National Tonsillectomy AuditVI. UK Heart Valve registry

155. There is the possibility thatinsurance reimbursementsmay become linked to specificcare plans and it is possible insome circumstances that thecare of the patient could becompromised. This is adeveloping situation.

11. (C) Clinical Integrated CarePlans, National Guidelines,Audit and Monitoring QualityAssurance

156. There is increasing demandfrom purchasers and patientsfor cost effective andintegrated clinical carepathways. These should bebased on national guidelinesand interpreted locally byclinicians. The MAC shouldensure that care plans areprofessionally led and basedon best evidence. The MACshould resist the introductionof care plans by those withoutside vested interests.There may be conflicts overissues such as the type ofprosthesis that should beused and the MAC shouldalways obtain the best expertopinion and only act in thepatient’s best interest. If allother clinical issues are equalthen it would be reasonableto recommend the most costeffective approach to the useof prostheses. GMC guidanceon financial and commercialissues is contained in “GoodMedical Practice”.

157. Individual clinical units shouldbe encouraged to engage inaudits and in general thisshould be a bottom upprocess rather than animposed one. The HCGCand/or the MAC may wish toset up specific audits. Thesemay be part of an ongoingprogramme or in response tospecific problem. Auditsshould be encouraged butresults should be anonymised.The MAC should be aware ofall audit results and may needto take action as aconsequence of these reports.

158. The Chief Nursing Officer maywell engage in specific nursingaudits and these should beencouraged and incorporatedin to the overall governance

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162. There are several externalindependent benchmarkingaudits which supply morepowerful returns such as;I. British Society of Interventional

CardiologyII. British Society of Cardiothoracic

Surgeons III. Paediatric Cardiac DatabaseIV. Intensive Care National Audit

Research Centre V. London Health ObservatoryVI. Nosocomial Infection National

Survey

11. (D) FIPO’s Role in ClinicalGovernance and Audit

163. The results of these andother audits should bebrought together by the MACand may be used if ofsufficient size and statisticalreliable in hospital reportsand for promotionalpurposes. Some hospitalgroups aggregate the databetween hospitals. There isan argument for the wholeindependent sector toaggregate data and FIPO hasagreed to co-ordinate thisunder FIPO CGAG (FIPOClinical Governance AdvisoryCommittee). It is vital that allsuch data is professionallyinterpreted beforepresentation.

11. (E) Investigation of ClinicalIncidents

164. Apart from Stream Twocomplaints referred to theGMC the MAC may need toinvestigate other clinicalincidents or complaintsgenerated locally. In eachcase of the latter the MACwill need to consider whetherthere are concerns thatshould be reported to theGMC or whether matters canbe best handled at local level.

165. Each hospital should have anappropriate system ofgovernance which ensuresthat clinical incidents arerecorded and investigatedpromptly. Normally this wouldbe through the HCGC, whichreports to the CEO and theChairman of the MAC and thefull MAC Committee.

166. In all clinical incidents theCEO acting on MAC adviceshould advise the relevant

consultant(s) as soon aspossible and should give aclear written indication of theconcerns. The consultant(s)should be given any relevantstatements or informationabout the incident and shouldbe invited to comment uponthese.

167. In some clinical incidents thematter is so serious that theMAC Chairman and CEO(having also taken whateverother urgent advice as isnecessary) may decide toimmediately suspend orpartially withdraw practisingprivileges from a consultant.In some cases there may havebeen a legal action taken bythe patient or relatives or acomplaint to the GMC. Inthese circumstances it maybe inappropriate for thehospital to undertake its ownenquiry but a non-prejudicialaction may have to be takento curtail privileges.

168. Clinical incidents should begraded according to severityby the governance teamand/or the MAC (Chairman,deputy or committee). Thegrading of severity can bebased on the systemdeveloped by the NationalPatient Safety Agency(Appendix 6). All incidentsshould be investigated in anappropriate and impartialmanner. Only in the mostsevere circumstances shouldadmission or partial rights bewithdrawn immediately by theMAC Chairman who willadvise the CEO. The MACChairman should always takeadvice from relevant specialtycolleagues.

169. Clinical incidents may eitherbe an “Act of God” or part ofa clinical trend for anindividual consultant. If thereis doubt about an incident ortrend the MAC Chairmanshould instigate a furtherinvestigation. Suchinvestigations may include areview of other aspects of theconsultant’s work and couldtake several forms dependingon circumstance and the

degree of severity or anxietyover the case. The actiontaken may be either:I. Ongoing assessment by the

governance team or MAC II. An internal inquiry - involving

designated hospital consultants withothers

III. An external inquiry – involvingoutside experts from relevantcolleges or associations

IV. An immediate review by the MACChairman and/or MAC colleaguesand managers.

170. If a clinical incident is minor,but suspect, the MAC maywarn the consultant, ask forfurther audits or informationand review the reports fromthe HCGC. It is important toidentify trends early but it isrecognised that there may bestatistical blips in relativelylow workloads.

171. In more serious cases the MACmay set up a suitable panel ofinquiry which may be eitheran internal or external review.In all inquiries there is a needto maintain absolute fairness,impartiality and confidentiality.It should be noted that theresults of the inquiry and thefact that it has taken place willultimately placed in theconsultant’s personal filewhich will become availablefor review by outside bodiesand also at appraisal.

172. An internal inquiry teamshould consist of the CGC, theChairman of the HCGC (if notthe CGC) and one or tworelevant specialistconsultants from the MAC orhospital. In general it is betterif the MAC Chairman is notdirectly involved at this stagebut receives the report laterfrom the panel. The internalpanel should review allrelevant clinical data andcases, take evidence fromstaff and interview or takeevidence from theconsultant(s) concerned. Allthose giving evidence shouldhave the right of bringing afriend or representative tothe panel. A report should beissued and the consultant(s)concerned should be giventhe opportunity to commentbefore the report is sent tothe MAC.

Guidelines for Medical Advisory Committee Chairmen and Members in the Independent Sector

20

173. For an external review theappropriate Royal College(s)should be approached tonominate a suitableconsultant assessor. Thehospital should appointanother consultant in thesame specialty but notdirectly connected to thehospital. If there are multi-disciplinary issues to reviewthen more experts arerequired. The hospital shouldappoint a Chairman for thispanel who should not bedirectly involved or workingat the hospital. A practisingclinician with suitable skills ispreferred although notnecessarily in the samespecialty.

174. The MAC Chairman and CEOmust ensure that the panelhasI. a clear and focused remitII. all the necessary notesIII. administrative helpIV. written guarantees of

indemnification V. written guarantees of

reimbursement

175. The MAC Chairman and CEOshould meet with the panel inorder to explain the situationand set the remit of theinquiry and to provide thenecessary documentation.Where doubt exists a legalopinion may be obtainedbefore the panel meets.

176. The CEO should inform theconsultant(s) under review ofthe proposed inquiry at anearly stage. All other relevantwitnesses and theconsultant(s) concernedshould be asked to submit awritten statement and

III. Complete suspension of privileges+/- recommendation for retrainingprocess through appropriateCollege.

IV. GMC action in the extreme (notingthe duty of all doctors to report anycolleague who is in their view unfitto practise).

179. MAC Chairmen should notethat the hospital is obliged toreport any suspendedconsultant to his/her NHSTrust and to otherindependent hospitals wherehe/she may work.

180. All hospital groups shouldhave an Appeal process andsuspended consultants shouldbe advised of their rights touse this process.

11. (F) Interpersonal ConsultantDisputes

181. The MAC may be asked toarbitrate in disputes betweenconsultants. This may involvereferral of patients,management issues or bebased on personalantagonism. Formalcomplaints to the MAC maybring these difficult mattersunder the committee’spurview. The MAC Chairman,MAC members and the CEOshould take advice from theBMA and its ethicsdepartment and even legaladvice before acting. Outsidecounsellors and experts maysometimes be brought in toresolve issues. Approaches tothe GMC could escalatematters but in this and inother clinical issues the MACshould not shirk from itsresponsibility if the needshould arise.

informed that they may beasked to appear to answerquestions. All should bewarned off their rights andthat they may have with thema medical defence unionrepresentative, friend, tradeunion representative orlawyer. These representativesshould have a right to crossexamine any witness. Theinquiry is not a court and noone is under oath. However,failure to attend by anyconsultant under review couldlead to a suspension.

177. The inquiry panel (internal orexternal) should take evidencefrom witnesses and theproceedings should berecorded. The administratorshould be responsible forproducing a draft of theproceedings which the PanelChairman should develop intoa report. This report shouldanalyse the clinical incident(s),report on causation and makerecommendations. All panelmembers should agree ormake their own conclusionsknown.

178. Depending on the outcome ofany such inquiry the MACChairman would be bestadvised to consult carefullywith relevant clinicalcolleagues and the MACbefore recommending actionto the CEO. Such action mightinvolve for the independentconsultant concerned: I. Local reviews of further outcomes

+/- some form of local mentoring II. Partial withdrawal of privileges for

specific procedures +/-recommendation for retrainingprocess through appropriateCollege.

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Guidelines for Medical Advisory Committee Chairmen and Members in the Independent Sector

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FIPO is supported by the following organisations and/or their private practicecommittees• Association of Anaesthetists of Great Britain & Ireland

• Association of Coloproctology of Great Britain & Ireland

• Association of Independent Radiologists

• Association of Surgeons in Training

• British Association of Aesthetic Plastic Surgeons

• British Association of Otorhinolaryngologists – Head & Neck Surgeons

• British Association for Surgery of the Knee

• British Association of Plastic Surgeons

• British Hip Society

• British Medical Association

• British Orthopaedic Association

• British Orthopaedic Training Association

• Federation of Surgical Specialty Associations

• FIPO – National Medical Advisory Committee

• Hospital Consultants and Specialists Association

• London Consultants’ Association

• NHS Private Healthcare Association

• Sussex Association of Consultants

• UK & Ireland Society of Cataract and Refractive Surgeons

The Board of FIPO as at October2005

Mr Geoffrey GlazerChairman of FIPO, ChairmanLondon Consultants’ Association,Chairman MAC Wellington Hospital,Member BMA Private PracticeCommittee

Mr Robin AllumBritish Orthopaedic Association

Mr Grant BatesSecretary Inter-SpecialtyProfessional Practice Committee,Federation of Surgical SpecialtyAssociations

Mr Ciaran BradyAssociation of Surgeons in Training

Mr Dai DaviesBritish Association of PlasticSurgeons

Dr William Harrop-GriffithsAssociation of Anaesthetists ofGreat Britain & Ireland

Mr Derek MachinChairman of the BMA PrivatePractice Committee

Mr Ian McDermottBritish Orthopaedic TraineesAssociation

Mr Martin StoneMAC Chairman, St Joseph’s Private Hospital, Gwent

Mr Robert TranterChairman of the Private PracticeCommittee of HCSA

APPENDIX 1

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APPENDIX 2 The Care Standards Act 2000Summary of the main points affecting MAC Functions.

MAC Responsibility“The MAC is responsible forrepresenting the professionalneeds and views of the medicalpractitioners to the RegisteredManager” (A5.1)

“The MAC meets quarterly as aminimum and formal minutes arekept of meetings” (A5.2)

MAC – Clinical Performance Review“The MAC reviews twice a year as aminimum, information collated onthe clinical work undertaken at thehospital...” (A5.4)• Deaths• Unplanned readmission• Unplanned returns to theatre• Unplanned transfers• Adverse clinical incidents• Post-op DVT• Post-op infection rates

Clinical Performance Review and UKQIP Quality Indicator Project1,800 hospitals worldwidereporting on;• In-patient mortality• Unplanned readmission• Unplanned returns to operating

theatre• Surgical site infections• Unplanned transfers

Practice Privileges (C10.2)• All consultants will be

interviewed, a record of theinterview retained and writtenreferences obtained

• Identification must be confirmed • References must be from the two

most recent employers• Relevant qualifications must be

verified by validation at theinterview

Consultant AppraisalThe Regulation

• “Any medical practitioner withpracticing privileges receivesregular and appropriateappraisal...” (18(3))

The Standard

• “All medical practitioners haveannual appraisals and are re-validated in line with the GMC’srequirements” (A3.2)”

Practice Privileges ReviewThe Standard

• “Practicing privileges are reviewedfor each practitioner every twoyears, as a minimum and may bereviewed more frequently as aresult of concerns about practiceor complaints received by theestablishment” (C10.6)

Clinical Practice Standards• “There are written policies and

procedures to ensure thatsurgeons comply with theNational Joint Registry” (A20.6)

• “The full details of all implantedmedical devices are recorded inthe patient’s individual recordsand on a master list held in theoperating theatre dept. A copy ofthis information is passed to thepatient” (A20.7)

• “The anaesthetist is present inthe operating theatre throughoutthe operation and on site until thepatient has been discharged fromthe recovery room” (A22.7)

• “The person undertaking thesurgical procedure ensures thepatient has given valid consentfor the proposed surgery and/oranaesthesia and ensures therelevant consent forms aresigned” (A21.5)

• “While a patient is receiving level1 critical care, the responsibleconsultant visits the patient aminimum of twice daily” (A29.5)

• “Where level 2 or level 3 criticalcare is not provided within thehospital, contingency emergencytransfer arrangements are inplace that are documented andagreed in advance with each ofthe appropriate specialist units towhich patients may betransferred.” (A29.10)

Management of Patient ConditionsC3.1)“The management of specificconditions takes account of theevaluations by the National Institutefor Clinical Excellence (NICE) inrelation to effective clinical practiceand patient safety and specificclinical guidelines from the relevantmedical Royal Colleges, healthcareprofessional organisations and theNHS National Service Frameworks.”

Regulation 9 (1)(j)

• Ensuring that where research iscarried out in the establishment,it is carried out with consent ofany patients involved, isappropriate for the establishmentand is conducted in accordancewith up-to-date and authoritativepublished guidance on theconduct of research projects.

Review of quality of treatmentRegulation 17 (1)

• “The registered person shallintroduce and maintain a systemfor reviewing at appropriateintervals the quality of treatmentand other services provided in orfor the purposes of theestablishment”

Treatment Information• “Information materials for

patients are written in concise,plain language and explain in non-technical language what theprocedure involves and treatmentalternatives” (A1.1)

• “Written information for patientsabout the relevant surgery ortreatment is made available forthem to take away afterconsultation at the hospital” (A1.2)

• “The written information given atthe consultation includes generaland procedure specific risks andcomplications associated with thesurgery or other treatment” (A1.3)

Treatment Information• “Documented post-operative

instructions are given to patientsto take home after theprocedure/operation” (A1.4)

• “Patient information materials areagreed by the Registered Personbefore being published and madeavailable to patients” (A1.5)

Monitoring Quality (C4.1)• Participation in national

confidential enquiries• Effective information and clinical

record systems• Procedures for identifying and

learning from adverse healthevents and near misses

• A complaints procedure

This is essence of the FIPO Leafletdirected to patients and outliningtheir Rights and Responsibilities.This reflects FIPO’s concern to putthe patient first.

FIPO is committed to promoting:• the highest quality of patient care• close and effective patient-doctor

relationships• Independence and freedom of

choice for patient and doctor• transparency in all aspects of

your care

The leaflet was approved by theorganisations supporting FIPO, theMedical Protection Society and thePatient Liaison Group of the RoyalCollege of Surgeons of England.

For supplies of this leaflet pleasecontact mpsmarketing@mps.org.uk

HELPING THE PROFESSIONALSTO HELP YOU

Only by working together canpatients and doctors secure thebest outcome. Clearcommunications and acommitment to honouringresponsibilities are the keys tosuccess.

As a patient in the independentsector in the UK, whether inpatientor outpatient, you can expect:

1 Treatment by a recognisedspecialist(s)with all thenecessary expertise to care foryou.

2 Treatment from the specialistof your choice. Your generalpractitioner (GP) or anotherspecialist can help you choosethe right doctor for you. Yourchoice should not be restrictedby third parties e.g. aninsurance company.

3 Treatment in an appropriatehospital on the advice of yourspecialist or GP, noting thatsome insurance policies placerestrictions on certainhospitals.

4 Treatment in facilities thatmeet government standardsand which respect your privacyand confidentiality, and provideall appropriate assistance(including the right to requestchaperoned examinations)andcan meet the specific needsthat arise from your disability,ethnic background or otherfactors.

5 To see information and recordskept about you provided doingso would not infringe anyoneelse ’s legal rights.

6 Up to date treatmentcomplying with recognisednational standards andmonitored to ensure the qualityof care.

7 To have a timely and accurateassessment of your condition.

8 To receive a clear explanationof the proposed treatmentincluding material risks, sideeffects and any alternatives totreatment and to have yourquestions fully answered.

9 To have a second opinion aboutyour condition if you so wish.

10 To have the opportunity tocomment about any aspects ofyour care and to receive aprompt response to anycomplaint made.

11 Transparency about chargeswherever possible, whichincludes:

• a fair estimate of potentialfees from your initialconsultant which will includeas far as can be ascertainedpotential charges for otherspecialists who may beinvolved in your care,including anaesthetists andthose who provide diagnosticor other background servicessuch as radiologists andpathologists. It must berecognised that in many casesan accurate financialprediction is difficult to make,if not impossible, prior to afull clinical diagnosis nor is itpossible to anticipate everypotential clinical event thatmight occur.

• an estimate of potentialhospital charges may beavailable from your consultantalthough for your own peaceof mind these should bechecked with the hospitalconcerned. You should alsoclarify whether the costs of anextended stay for clinicalreasons are covered by anyhospital package deal.

• a fully itemised account fromall your doctors and thehospitals, reflecting the termsagreed with the insurancecompany, if they apply.

12 To receive full reimbursementfrom your insurer for alltreatment within theconstraints of your particularpolicy.

As a patient we would ask you:13 To provide all relevant clinical

information and other detailsnecessary for your care tothose entrusted with yourtreatment.

14 To co-operate with the stafftaking care of you and reportany change in your clinicalcondition.

15 To tell staff if you are uncertainor do not understand anyaspect of your treatment.

16 To take medicines asrecommended and seekmedical advice before stoppingor changing treatment.

17 Make sure that you understandthe full implications ofdeclining or stopping medicaltreatment.

18 If you have parentalresponsibility for a minor, toexercise this carefully and withfull consideration and attentionto the needs of the child.

19 To understand the limitations,restrictions and exclusions ofyour insurance policy and toanswer fairly and openly (withthe help of your consultant orGP if necessary) any insurancecompany queries about yourcondition or anticipatedtreatment.

Guidelines for Medical Advisory Committee Chairmen and Members in the Independent Sector

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APPENDIX 3 Patients Rights and Responsibilities

25

20 To understand that acontractual relationship existsbetween you and your doctors(including those clinicians whoprovide background diagnosticor other services such asanaesthetists, intensive carespecialists, radiologists orpathologists) and also thehospital where you are treated.In some cases the hospital willmake a direct charge thatincludes some of theseservices. You will not becharged twice. You have aseparate contractualrelationship with the hospitalwhere you are treated.

21 To accept responsibility for theprofessional and other feesgenerated and for their timelypayment. In the event that yourinsurance policy is notcomprehensive then anyfinancial shortfalls becomeyour responsibility. If yourpolicy has a specific excess(meaning that you areresponsible for a proportion ofthe charges)then that mayneed to be paid either to thehospital or to the doctorstreating you according tocircumstances.

22 To give adequate notice if youare unable to attend anappointment and to understandthat charges may be made forsuch visits if you have notgiven a reasonable notice ofcancellation.

Guidelines for Medical Advisory Committee Chairmen and Members in the Independent Sector

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Consultants are responsible forcollecting their own data and formaintaining their own portfolio.This material may be derived fromvarious sources. It is helpful for allpositive data to be collated (forexample patient letters or otherprofessional recommendations).The data collected shouldnormally include the following, byreference to the appropriateheadings of Good MedicalPractice:

The Independent Hospital shouldbe prepared to provide much ofthe statistical data listed underGood Clinical Care and any otherexamples of good or bad practice.

Good clinical care• A practice profile indicating the

procedures performed • Clinical indicators (including

deaths, transfers-out, returns totheatre, infections etc for theacute sector; and physical assault,use of seclusion, use of restraintetc for mental health) whether viathe UK Quality Indicator Project(UKQIP®) or an alternativesystem;

• Any results of the Hospital’smedical records audit andGovernance Team;

• Any adverse occurrencesinvolving the consultant and theoutcome (if possible evaluated onthe basis of the criteria set by theNational Patient Safety Agency);

• Any areas of concern brought tothe attention of the MedicalAdvisory Committees (MAC’s) (e.g.adherence to hospital clinicalpolicies);

• Any limitations on practice –whether voluntary or imposed.

Maintaining good medical practice• Examples of participation in

appropriate provider basedcontinuous professionaldevelopment (CPD); this mightinclude individual developmentactivity, locally-baseddevelopment and participation incollege or speciality associationactivities.

Relationships with patients• Any completed investigated

complaints involving theconsultant, and the outcome;

• Any relevant significant results ofpatient questionnaires or followup surveys.

Teaching and training (within theindependent practice)• Example of documentation where

teaching does occur: a summaryof formal teaching/lecturingactivities any recorded feedbackfrom those taught.

• Supervision/mentoring duties.

Working with Colleagues• Copies of, or extracts from, any

relevant surveys• Any completed investigated

incidents• Relevant feedback from

appropriate clinical colleagues.

Probity1

• Copy of Criminal Records Bureaudisclosure

• Self-certification by the appraiseethat there are no mattersrequiring to be drawn to theattention of the appraiser, (ordetails of any matter arising).

Health• Self-certification by the appraisee

that there are no mattersrequiring to be drawn to theattention of the appraiser, (ordetails of any matter arising)

APPENDIX 4

1Letter to confirm I (Name) confirm thatthat there no matters concerning myprobity/health that I wish/need to bedrawn to the attention of (Name)Appraiser

This TEMPLATE Agenda is clearlyonly an outline but it will ensure acommon structure to meetings.Governance reports should includeall the required reports and anyother audits, complaints etc thatneed to be brought before theMAC.

1. Apologies

2. Minutes of last meeting

3. Welcome or election of MAC Officials

4. Matters arising not dealt withelsewhere

5. Matters arising from theMinutes

6. Governance Team Report andPresentation

7. CEO’s Report

8. Senior Nurse Manager’sReport

9. Chairman of the MAC Report

10. To consider applications forconsultant practicingprivileges

11. To consider renewal ofconsultant practicingprivileges

12. Any other business

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APPENDIX 5 Template Agenda for an MAC Meeting

Guidelines for Medical Advisory Committee Chairmen and Members in the Independent Sector

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Descriptor Description

Almost Certain Will undoubtedly recur, possibly frequently

Likely Will probably recur, but is not a persistent issue

Possible May recur occasionally

APPENDIX 6 Risk Grading Tool for Clinical Incidents

Risk = Very Low Low Moderate High

Action plans must be drawn up for high and moderate risks. Such risks when identified will be reported to theClinical Governance Committee or directly to the CEO and MAC Chairman.

Table 1. Definition for likelihood (within the local organisation)

Likelihood None Minor Moderate Major Catastrophic

Most LikelyConsequence

Almost certain

Likely

Possible

Unlikely

Rare

(Adapted from National Patient Safety Agency Grading Tool)

N.B. The scoring is subjective and should be ideally the opinion of more than one person familiar with the area.