A private hospital that treats thousands of NHS patients put their safety at risk, says a new report by the health watchdog. Staff told inspectors that meeting financial targets was considered more important.
In the latest official criticism of a hospital run by major UK provider BMI Healthcare, the Care Quality Commission (CQC) rated Fawkham Manor hospital in Kent as “inadequate” - the worst possible ranking.
Staff told the CQC that financial targets were prioritised over patient safety at the hospital, where NHS patients make up almost half the caseload and where a senior surgeon is being investigated for carrying out unnecessary and substandard surgery - as revealed by the Bureau last month.
During several visits to Fawkham Manor last August and November, inspectors witnessed the wrong patient being taken to theatre, and staff going into theatres without cleaning their hands or making thorough pre-operative checks. Theatre equipment, including that for use in emergencies, was “poorly maintained”.
The leadership team “did not understand risks” and patients were “at high risk of avoidable harm”, they concluded. Fawkham Manor treated about 2,000 NHS in-patients and 8,600 NHS outpatients in 2015-16.
The head of Fawkham Manor was aware theatre staff were not always going through pre-operative checklists designed to protect patients, said the report, but "failed to take appropriate action to address the issue."
Management teams did not take sufficient action to stop repeat mistakes being made, said the report. For example, two incidents involving the wrong patient being taken to theatre happened within a short time of each other, showing the first incident had not been fully investigated and insufficient action had been taken.
On the final CQC visit staff were still not consistently adhering to the infection control policies requiring them to be “bare below the elbows”. At least one member of staff was seen in theatre wearing a long-sleeved top.
“Staff told us meeting financial targets was seen as a priority at the expense of quality and safety,” inspectors said, and that “the hospital was only concerned about the amount of patients they operate on.”
In the last three years major failings have been found at a string of hospitals run by BMI, which employs more than 6,000 consultants across the UK and last year made operating profits of £28.7 million.
Police investigate a senior surgeon
The CQC brought forward a planned inspection of Fawkham Manor after learning police were investigating senior orthopaedic surgeon Mohammed Suhaib Sait for fraud.
Sait is accused of carrying out unnecessary and substandard operations on NHS and private patients, which he and the hospital financially benefited from.
He is also accused of overcharging for his work – work which the hospital then billed the NHS for.
Staff at Fawkham Manor hospital told the Bureau they warned managers about Sait over a number of years but claim no significant action was taken until police were alerted by an insurer last July. He was then suspended and the CQC informed of the situation.
Inspectors visited Fawkham Manor three times in August 2016 and, after hearing from a whistleblower, made a fourth unannounced inspection, last November.
They said “staff did not always feel they could raise concerns or have confidence their concerns would be listened to”.
Dartford MP Gareth Johnson said a close family member had been operated on in 2016 by Sait as an NHS patient, but later received a second opinion which suggested the treatment may not have been necessary.
"If a hospital is being paid by the NHS to treat NHS patients, it clearly should take responsibility for what happens to those patients,” Johnson said.
"The CQC report published today paints a picture of a hospital that did not listen to staff concerns or take action when serious incidents came to light. I am deeply concerned by these serious revelations."
String of failings at BMI hospitals
CQC and coroners’ reports show Fawkham Manor is not the only underperforming hospital in the BMI chain.
Various reports show BMI’s internal systems have repeatedly failed to prevent doctors at its hospitals breaking rules in ways which could endanger patient safety. Across many of BMI’s 54 facilities in England, CQC inspectors have raised concerns about insufficient pre-operative checks, poor incident handling or inadequate arrangements to cover emergencies.
Besides Fawkham Manor, 17 BMI hospitals are currently rated as “requiring improvement” by the CQC.
Leadership at BMI hospital The Manor, in Bedford, is currently rated inadequate due to a failure to recognise and respond to serious incidents. Recent inspections of BMI Huddersfield, BMI Three Shires and BMI Southend - all rated as requiring improvement - found widespread governance and safety issues.
Some of the most shocking failures to date were uncovered at BMI’s Mount Alvernia hospital in Guildford in 2013.
Inspectors, acting on a whistleblower tip-off, found some doctors failing to wash hands and operating in blood-stained shirts, giving patient the wrong treatment, acting in an “intimidating way” and operating on people without consent. One child was put at “significant risk of serious harm” after coming in for minor surgery then not being seen for seven hours after developing complications.
Managers were “dismissive of staff concerns and blocked action to improve the situation, the inspectors found”.
BMI Healthcare’s executives told the CQC they were “unaware” of many of the incidents uncovered and “unsure at the time about where monitoring of the hospital had failed”.
Despite the regulator’s damning report, 80-year old patient John Crittall died at the hospital a year later, partly as a result of neglect. Amongst a litany of failings the coroner found surgeons had adopted an unorthodox clinical practice without any basis in evidence.
In the most recent CQC report last November, the hospital was rated good overall but still “requires improvement” on its safety.
Potential conflicts of interest and promotional accounts
The number of surgical procedures carried out on NHS patients in the private sector has risen steeply in recent years, from 350,000 in 2012 to 530,000 last year. Department of Health (DoH) accounts show the NHS paid the private sector £8.7bn for services last year, 7.6% of the DoH’s total budget.
Almost half of the patients treated by BMI – whose boss Jill Watts got £1.4 million in pay and benefits in the last financial year – are NHS referrals.
The issues at BMI hospitals raise questions about the extent of oversight of NHS contracts with independent providers. More than one third of the UK’s hip and knee replacements are now carried out in the private sector.
A recent bulletin published by the Royal College of Surgeons highlighted the distinctive risks facing patients being treated in private hospitals compared with the NHS.
Requirements for reporting and auditing data are different in the independent sector as are the arrangements for managing clinical problems.
The bulletin’s author professor, Colin Leys of health thinktank the Centre for Health and Public, said: “It’s unacceptable for patients in private hospitals not to be protected by the same reporting requirements as NHS hospitals.
"It’s especially unacceptable for NHS patients to be treated in them without this protection and without clinical governance arrangements free from conflict of interest.”
Members of consultant forums responsible for managing clinical problems in private hospitals - known as medical advisory committees (MACs) - may “share a financial interest with the colleagues whose practice they are supposed to police,” he explained.
Several Fawkham Manor staff members told the Bureau they had repeatedly raised concerns about orthopaedic surgeon Mohammed Sait - including with the hospital’s MAC - but the surgeon was only suspended by BMI after a whistleblower approached insurer AXA PPP, which informed the police.
The bulletin also pointed out private hospitals’ “quality accounts” - which are meant to be candid reports on the quality of their services - are not externally audited (unlike those by NHS trusts) and “can read like promotional material”.
Fawkham Manor’s quality account for 2015/2016 says 100% of patients were risk assessed before having operations yet the Bureau has seen incident reports filed in that period stating some patients did not complete pre-operative checks.
And John Crittall’s death in Mount Alvernia hospital in 2014 was found to be partly due to hospital neglect, yet the hospital’s quality accounts stated that there were zero patient safety incidents during that period.
BMI Healthcare, which is jointly owned by South African firm Netcare and private equity company Apax Partners, made a profit of £28.7 million last year. But the company’s margins are under pressure.
In recent years BMI has responded to falling numbers of insurance-holders by taking on more NHS patients.
As the company’s chief executive Jill Watts told investors in 2016, financial constraints on the NHS will mean even more opportunities for companies like BMI.
However the change in direction has come at a cost: NHS patients bring in smaller profits than the privately-funded.
At BMI Huddersfield hospital a 2016 CQC inspection found risks relating to falling masonry and water safety had not been addressed. Local managers’ plans for improvement “did not appear to be a corporate priority” and “financial challenges” were putting good quality care of patients at risk, inspectors said.
Three deaths in 2015
In 2015 three patients died at BMI hospitals in circumstances where failings were identified.
Sally Ann Tooze-Froggatt died following “multiple missed opportunities” to prevent her death at BMI Lancaster hospital in 2015.
At BMI Alexandra in Cheshire, 51-year-old Amanda Ellams, attended the hospital for a hernia repair in February 2015 and died four days after the operation, having been discharged with low blood oxygen levels. It emerged at the inquest the surgeon did not know what drugs Mrs Ellams was taking before the operation.
A month before Mrs Ellams’ death, Barbara Harrison died at the BMI Alexandra due to “misadventure”. The coroner noted that during surgery to repair her oesophagus, batteries for a vital piece of equipment were found to be flat resulting in a “panic situation”. Nurses had earlier failed to respond to “rapid and obvious” swelling of Mrs Harrison’s face and neck.
BMI Lancaster was last reported on by the CQC in 2013, and BMI Alexandra was last reported on in 2014. The CQC says it has inspected all but one of BMI's hospitals since a new rating system was introduced in December 2014 - but many of the reports are still "being finalised".
Fawkham Manor 'working to address concerns'
A spokesperson for Fawkham Manor Hospital told the Bureau that since the initial inspection it had been working to address the areas of improvement identified.
"Patient safety is our absolute priority, and we will not accept practices that fall short of the expectations that we – and our patients – have of the hospital," he said.
On other hospitals, a spokesperson for BMI Healthcare said:
“These are unrelated issues at hospitals which are many miles away and are not interdependent.”
Insurer AXA PPP said following the CQC report that it had suspended its recognition of the hospital with immediate effect.
A spokesperson said: "The suspension will remain in place until such time we are satisfied that the hospital has properly addressed the CQC’s concerns."