Private Health Information Network (PHIN) and complying with the Competitions and Markets Authority Order: An update for BOA members

Andrew Manktelow

Andrew Manktelow is a Consultant Orthopaedic Surgeon working within Nottingham University Hospitals NHS Trust, with a specialist interest in primary and revision hip surgery. A past President of the British Hip Society, Andrew has been on the BOA Council since 2019. Contributing to the Orthopaedic Committee Andrew reports to BOA Council on matters relevant to the Independent Sector.

With recent changes in process, a renewed impetus on delivery and with many having started their consultant life and work in private practice since the CMA Order of 2014, many BOA members will be unclear of what has been mandated by the CMA. In this article we aim to help colleagues understand their roles and obligations in this area explaining how recent developments will shape the process.

Background

Following a two-year investigation, the Competitions and Markets Authority (CMA) published a report in April 2014. This document identified a series of parameters surrounding consultant fee information, hospital and consultant performance, that the CMA required to be made available to inform patients as they sought to obtain the best available care in the Independent Sector (IS). This information was to be collated and published by the Private Health Information Network (PHIN). Private healthcare providers are required to collate and send data to PHIN and to fund PHIN’s processes. PHIN has always recognised that consultants need to be involved in producing data relating to their practice. Over the years PHIN has looked to engage with consultants in orthopaedics, and indeed all surgical specialities, to ensure that the data provided is accurate and validated prior to publication.

Alongside other representative bodies, the BOA has been in conversation with PHIN over many years identifying concerns with data validity and data volume. The challenges that surround data interpretation, with minimal case mix adjustment and the complexity of providing meaningful Patient Reported Outcome Measures (PROMs) has been discussed. With the UK National Joint Registry (NJR), orthopaedic surgeons are already fully engaged and routinely involved in data collection. NJR Consultant Level Reports have become increasingly robust and helpful, allowing joint arthroplasty surgeons to review their practice within the appraisal process. Data collection and reporting outcome measures is also common away from arthroplasty practice, in foot and ankle, hand, shoulder and spine surgery. Orthopaedic surgeons are ahead of the game, demonstrated perhaps by a higher level of engagement than other surgical specialities with the PHIN process.

What data is required to be made available?

At the time of the original CMA Order it was identified that data on the following should be made available: surgeon volume, length of stay, infection rates, re-admission rates, revision surgery rates, mortality rates, unplanned transfers, patient feedback measures, links to registries and audits, improvements in health outcomes and frequency of adverse events.

PHIN has had variable success in collating and publishing data in these different areas, though remains clear in its objective to make progress in as many as are felt reasonable. With regard to performance, PHIN has been successful in publishing data relating to surgeons’ volume and length of stay. Recent progress has been made with PROMs, though other areas have proved more of a challenge.

In addition to clinical indicators, the CMA was keen that surgeons’ fees should be made available to ensure that patients are aware of any likely financial liability. There are significant challenges in this area. While out-patient fees are relatively easy to ascertain, Private Medical Insurers (PMIs) now increasingly influence and restrict consultants’ fees. Different PMIs have varying levels of remuneration for the same intervention. Additional complexity surrounds surgeons’ fees for ‘self-pay’ patients. Identifying the exact costs different hospital groups and different providers charge for the same procedures creates issues with open competition, making publishing this data a challenge. While this was not specifically required by the Order, it would seem more helpful if patients were able to compare the prices of a complete package of care transparently, including all consultant, anaesthetic and hospital fees.

Initially, it was hoped that much of the data would be relatively easy to collect. The true complexity has become more obvious over time. For example, PROMs collection could potentially seem straightforward. However different PROMs measures, collected at different times and via different mechanisms makes direct comparison a challenge. Adequate numbers of different procedures by different surgeons are required. As such, PROMs data on hip and knee surgery is going to be published at site level rather than at consultant level.

More recently PHIN has identified areas of the Order that could be a challenge to deliver to the CMA. These included issues surrounding revision rate and mortality, which are both very difficult to assess without meaningful case mix adjustment.

Debate continues around what is best published at hospital and consultant levels. An example would be never events, something the CMA were keen to publish data on. Never events should be reported without blame and frequently indicate a system failure rather than issues with an individual consultant. Never events are probably best reported at hospital rather than at consultant level. There is a pre requisite that data published should be meaningful and helpful. Therefore data that has to be explained is unlikely to be useful and could confuse patients.

The BOA position

The BOA has identified challenges in large scale publication of private and NHS health information data, not least regarding data quality, interpretation and presentation. The BOA remains keen to see robust and accurate data, presented in a manner that can be interpreted and understood, supporting the provision of a reliable, meaningful and useful resource for patients.

The BOA encourages surgeons to engage, to review and validate data submitted. The BOA has argued that the PHIN on-line portal should be user-friendly and easy to navigate, allowing consultants to flag and correct inaccuracies easily. For the reasons detailed above, it has always been the BOA’s position that certain data, such as revision rates, should not be published at an individual consultant level. The Royal College of Surgeons1 has also made clear the requirement for surgeons to engage and contribute to the PHIN process.

Data collection and validation

Processes by which data is collated and submitted varies. Surgeons are often not involved in validating data submitted to PHIN on their behalf by the private hospitals. Data is submitted to PHIN four times a year and is made available for publication around a month after submission. The BOA has been in conversation with various stakeholders aiming to improve this process. Surgeons must be in a position to access and review data, ensuring it is valid and accurate, possibly even before it is submitted. This should improve engagement and confidence in this process.

At present, surgeons are required to review and to ‘sign off’ their data before data is published on the PHIN website. With confidence, engagement and verification of data variable, many surgeons who are active in the IS, do not have data published on the PHIN website. PHIN have made a decision that, in future, data will be published automatically unless a problem has been identified, though have reiterated that data published must be accurate and should not mislead patients or undermine consultants.

In moving ahead with this process, PHIN points out that surgeons should understand this data collection and provision was mandated by the CMA Order. This is designed to help our patients as they seek care within the IS. Pilots looking at how presumed publication is introduced are planned. These will review sequencing timelines detailing the risks, mitigations and issues involved as presumed publication becomes part of the PHIN strategy to implement the CMA Order.

The present situation

At the time of the current publication period (July 2021 – June 2022), 2,294 consultant orthopaedic surgeons appear in the data. 64% have created a profile about themselves. 37% have reviewed and verified their data for publication. 78% have submitted an approved fee structure information for publication. 37% have received a sufficient volume of feedback to allow a score to be published on PHIN’s website. It is reassuring to see that 98% of those consultants with sufficient feedback have achieved a patient satisfaction of 90% or higher and 84% have achieved a similarly good patient experience score. It would appear patients are happy with the care that they receive from orthopaedic consultants.

Recent changes and the future direction

During the time of the COVID pandemic, PHIN made a policy decision to take a backseat, feeling that consultants had enough to deal with. More recently, there has been a change in direction. The CMA has strengthened its expectation that the Order is to be delivered. PHIN has engaged with stakeholders to ensure that the process is made more urgent. Part of that process has been to review consultant engagement. The BOA have had an opportunity to contribute to that process.

Consultant engagement

PHIN has a stated aim to build confidence and trust in the data submitted, validated and published. Improving mechanisms by which data inaccuracy issues can be addressed. PHIN is keen for consultants to review the new portal, providing virtual sessions to help colleagues negotiate the process. PHIN plans to review whether other members of the surgical team and medical secretaries could input and verify profile data to the portal. It is understood that consultants are not a homogenous group and have different practices and levels of activity within the IS. More targeted communication is planned with additional improvements made to the PHIN consultant portal.

Recent changes in PHIN strategy

Under a changed PHIN leadership, there is a renewed impetus to ensure that the CMA Order is delivered. Healthcare providers who fund PHIN are also keen to see progress. In 2022, a delivery plan was submitted by PHIN to the CMA, with a stated aim to deliver the Order within the next four years. The CMA responded, re-iterating the importance of the process, suggesting ongoing reviews with intermediate deadlines to ensure delivery. The CMA has already taken enforcement action for failure to comply and has described how a more robust approach will be taken with consultants who do not comply with their obligations. It is therefore important that consultants are aware of what is required and act accordingly.

The Federation of Independent Practitioner Organisations (FIPO) has provided a helpful briefing note detailing consultants’ responsibilities with regard to data submission and validation2. In the document it is identified that the only performance metrics to be made available to the public on the PHIN website are volumes of procedures and length of stay. Although it is important that colleagues check and validate their data, the document points out that PHIN cannot publish data it knows to be incorrect. Any inaccuracies should be identified. Correcting inaccurate data is not the consultant’s personal responsibility and should be undertaken by the provider. It has been noted that support for this correction can vary.

Summary

The requirement to provide meaningful and helpful data to patients as they seek care in the IS was mandated within the 2014 CMA Order. Consultants have an obligation to engage with the process and to facilitate the provision of meaningful information. Having taken a back seat through the COVID pandemic, PHIN has re-energised its processes to deliver the Order. Consultants should understand how data is collected and what data is submitted on their behalf. IS care providers should engage in that process, seeking to simplify how data is validated and specifically how any inaccuracies are rectified. While PHIN will move towards presumed publication, it recognises that no data will be published if it is known to be inaccurate. The CMA is taking a more robust approach and those that do not engage are likely to hear from the CMA directly.

References

1. Royal College of Surgeons of England. Working in the Independent Sector. A guide to good practice. May 2022. Available at: www.rcseng.ac.uk/standards-and-research/ standards-and-guidance/good-practiceguides/working-in-independent-sector

2. Federation of Independent Practitioner Organisations (FIPO). PHIN and your responsibilities. Briefing note. September 2022.