Robust governance and processes in private practice 

Years of under-resourcing, the fallout of the pandemic, and the increasing needs of an aging population mean that the NHS is a challenging environment in which to work. However, its foundations are solid.

For example, there are robust systems for ensuring that patient safety incidents are investigated and learning points actioned. Trusts and Integrated Care Boards have established policies for the investigations into concerns relating to the capability and conduct of staff. New joiners are required to attend an induction programme and there is ready provision of CPD and mentorship.

Healthcare professionals are surrounded by systems, processes, governance, and colleagues who can provide support when something goes wrong.

What about when you face an issue or concern in private practice? Often, it can be less clear.  

Consider this case from the Medical Protection files: 

Dr A, a consultant psychiatrist in private practice, approached Medical Protection following a patient complaint to the General Medical Council (GMC). Dr A explained that he had found the patient difficult to manage. He repeatedly emailed Dr A, and had been calling his secretary daily for some months. Dr A had attempted to set boundaries whilst addressing the clinical need, and had been considering a transfer of care. He had sought advice from colleagues within the clinic, and it was only when he received an email of complaint that he realised the organisation lacked a formal complaints team. 

Many of the patient’s concerns were unfounded, but Dr A was worried that the reference to an absence of local clinical protocols was something that could lead to criticism. He acknowledged that his response had been short, a reflection of his frustration with the situation.

The Medicolegal Consultant allocated to Dr A’s case talked him through the GMC process, and instructed a solicitor to assist in drafting a full response at the Rule 7 stage of the process. The case was closed with no further action, however the stresses of a GMC complaint may have been avoided if the complaint was handled in a more effective and timely manner at a local level.   Dr A was advised to consider membership of an organisation such as the Independent Sector Complaints Adjudication Service.

Clinical care 

Clinicians rely on both local and national guidelines to ensure that patients are managed appropriately. Having an agreed framework ensures that patients receive evidence-based care that takes account of both resource and setting, whilst allowing flexibility so that the approach can be adapted to individual need. Consultants in private practice may function as essentially sole providers, or may form part of a wider network of clinicians. Contractual and governance arrangements are very variable. There may be little incentive to conduct time-consuming (and costly) audits and appraisal may take place outside the organisation. 

High-profile cases have highlighted the dangers such a lack of formal oversight can have. It is far easier for clinical concerns to go unrecognised in the private sector. Conversely, our experience is that individual clinicians are also potentially more vulnerable. In NHS hospitals, the Maintaining High Professional Standards framework provides a clear structure for the investigation of a doctor (even if its recommendations are rarely followed to the letter). Private disciplinary processes are much more variable, and doctors can face harsher consequences as a result. 

Private healthcare providers are increasingly seeking to establish committees tasked with the investigation of clinical concerns, and those involved should ensure that they are clear as to the remit and composition of the committee, that they have appropriate experience and accurate minutes are kept. 

Colleagues and communication

In the NHS, healthcare professionals have ready access to a network of colleagues from whom advice and guidance can be sought. Tricky cases can be discussed, and senior clinicians can be called in to assist at any point. Such support may not be available in the private sector, and medicolegal risk is therefore higher. 

In private practice, the clinician can be much more accessible to the patient. Being able to contact a clinician directly, or at least more directly in the NHS, may be one of the appeals of private healthcare for patients. However, the resulting administrative load can be overwhelming, and it can be harder to maintain appropriate boundaries.

Care must be taken, however, when communicating directly with patients. The usual data protection legislation, i.e. Data Protection Act and GDPR, must be adhered to as well as any local policies. Using personal mobile phones or WhatsApp, for example, may cause some issues as it is difficult to control what may be sent to you. Images may end up being stored on personal devices and/or even in the cloud and this can cause issues for clinicians, particularly if they are deemed to be intimate. Information that is relevant to clinical care, for example any advice given to patients, should form part of the clinical records, and so consideration should be given as to what should be transferred into the notes. 

Although applicable to some clinicians more than others, it is very important that patients are clearly signposted on where and how they may be able to access appropriate care outside of your or the clinic’s usual working hours. Any safety netting advice should also be clearly documented. 

Risk management

Clinical governance comprises of several areas, with some models referring to the seven pillars.  From a medicolegal perspective, having robust processes around complaints and incidents is key to optimising patient safety, patient satisfaction as well as reducing medicolegal risk for the clinicians involved. Induction, audit and programmes of continuing professional development are also important. 

Organisations should consider how they might best support those who work with them when things go wrong. Having a robust complaints procedure is key to ensuring that patient concerns are addressed and resolved appropriately. A failure to do so can result in ongoing patient dissatisfaction, possible breakdown in the therapeutic relationship or even the profession, and a risk of the complaint escalating to the regulator. In some cases, patients may approach the press or turn to social media to express their concerns. Adequate indemnity is key (for both the organisation and the individual) as the payout for a successful clinical negligence can run to many millions. 

Top tips 

• Be open rather than defensive when receiving complaints, this can help to de-escalate the situation
• Ensure clear communication with a patient while investigating their concerns, including agreeing on an appropriate and reasonable timeframe for a response
• Conduct an objective and thorough investigation into the concerns, e.g. by reviewing the relevant records, obtaining statements etc. 
• Reflect on the concerns and explain clearly the conclusions reached and the reasons behind this, communicating any learning points or changes that will be implemented as a result  
• Demonstrate empathy, use clear language, and a neutral tone, apologising where appropriate   
• Ensure familiarity with processes and policies when joining a new organisation
• Participate in regular audit and CPD
• Be clear as to pathways for escalation and develop networks for sharing clinical expertise and advice