Independent Practice Committee (IPC) update July 2018

The IPC met on 22 June 2018, here's an update on the discussions of issues affecting those working within the independent sector. 

Handover to new Chair

After four years on the Association Council and two years as Chair of the IPC, Guy Jackson is now at the end of his term. Mathew Patteril will be taking over as Chair from September 2018. Guy offers his thanks to all involved for support and advice over the last few years.

IPC guideline/handbook

Much has changed in the sector since our Independent Practice Guideline was written in 2008. We're in the final stages of updating the guideline and the period for member consultation has closed. We hope this will be a useful resource for members in independent practice, especially those new to it or looking to start.

IPC survey

In 2017 we conducted a survey of members within independent practice. 157 members replied, helping us form a picture of anaesthetic practice within the independent sector, as well as identifying some of the issues affecting members. We've now produced a report summarising the answers, which will soon be available on the IPC webpage. We plan to repeat the survey every two years to review trends over the coming years and inform the activity of the IPC.

Private Medical Insurers (PMIs) and 'fee assured' status of anaesthetists

We've received a number of member enquiries suggesting increasing activity of the PMIs looking to restrict anaesthetic fees. Both new and established consultants are being targeted by different PMIs looking to persuade clinicians to be 'fee assured'. We are working with other organisations including the Federation of Independent Practitioner Organisations (FIPO) and the British Medical Association to ensure the interests of consultants are defended. Further news in due course.

Member enquiries

Some recent issues highlighted by our members include:

1. Private Medical Insurers and 'fee assured' status of anaesthetists (as above)

2. Pre-operative anaesthetic consultations

We are aware of significant variations in practice nationally for the remuneration of pre-operative consultations and management between PMIs. Practises around pre-operative management have changed significantly in both the NHS and independent sectors. The Association is supportive of members seeking appropriate remuneration for pre-operative management within the independent sector, and we are aware of the difficulties faced by some. We are in the process of writing guidance on this to help explain the importance of this aspect of patient care to PMIs, and the standards within NHS practice that should be transferable to the independent sector.

3. Ramsey Hospital NHS Terms and Conditions

Member query regarding Ramsey Hospital NHS terms and conditions, specifically relating to the episodic fees set out in the Fee Scales. Concern that fee covers all of the following stated activities:

• Surgeon: pre-operative consenting appointment, surgery and any and all attendances during patient's in-patient stay as well as any returns to theatre, management of post-operative complications and any further work required where the patient is re-admitted for a reason relating to their original treatment

• Anaesthetist: anaesthetic review as appropriate, surgical episode and post-operative attendance and any returns to theatre, management of post-operative complications and any further work required where the patient is re-admitted for a reason relating to their original treatment

Our response

The Association, any anaesthetic group or individual may have an opinion as to the role of the anaesthetist in ongoing care of a patient, but that may differ substantially from the independent hospital they work in. There may also be differences in opinions as to rates of remuneration.

A hospital has the right to dictate their terms of engagement in the same way an anaesthetist can take or leave the work offered (they cannot be made to do the work).

We hope there is a process of negotiation to get to a point where both parties are happy with the working arrangements. Increasingly independent hospitals undertaking NHS work are dictating terms and fees that are not attractive to anaesthetists (or surgeons).

The Association has no influence over this and is not able to negotiate terms and remuneration nationally. The Association has written guidance from 2008 and we are in the process of rewriting this guidance. The draft statement about anaesthetist responsibilities is below. Clearly this is at odds to the Ramsey T+Cs that the member forwarded.

We would encourage anaesthetists to explain to Ramsey hospital what service you (as an individual or a group) provide for the fee proposed. There may be a need to talk and negotiate. Document clearly what you offer following those discussions. Ultimately if you are not willing to accept their terms and conditions we would advise not undertaking the work. 

Draft wording for AAGBI Independent Practice Guideline 2018:

The anaesthetist has an ongoing clinical responsibility to their patients that continues into the postoperative period. However, this responsibility has limits, and we suggest that the anaesthetist makes the limits clear to the surgeon, other healthcare professionals involved in the patient's care, and the independent hospital management. Such limits may be:

• Until postoperative high dependency or intensive care is no longer needed or is handed over to an intensivist or another anaesthetist

• For patients not requiring intensive or high dependency care, the limits of the anaesthetist's care may be when the patient is:

o Awake and discharged from the recovery room

o Physiologically stable and satisfactory

o Free from significant postoperative pain, nausea and vomiting

o Not receiving intravenous opioid treatment, e.g. patient-controlled analgesia

o Not receiving neuraxial or peripheral local anaesthetic infusions

o Free from the short-term effects of peripheral or neuraxial nerve blocks

Any care provided by an anaesthetist beyond these limits may be separately chargeable if the patient has been warned of this before treatment. It is reasonable to expect an anaesthetist to be available for a patient for the period during which the early and predictable complications of surgery may occur. However, we suggest that this period should not normally exceed 24–48 hours and should certainly cease at the discharge of the patient from hospital.