The Paterson Inquiry exposed what the sector already knew: governance fails at the boundary between organisations, not within them. This series maps where accountability breaks down across private healthcare — and what infrastructure would prevent it.
Essential reading for private hospital groups and health insurers. See also: Private Healthcare | For Insurers
Ian Paterson operated across multiple private hospitals and an NHS trust for over a decade. The inquiry that followed his criminal conviction found that governance failures were not caused by a lack of regulation — CQC, the GMC, and NHS England all had oversight. They were caused by the fact that no single organisation could see the full picture. Each institution governed what happened within its walls. Nobody governed what happened between them.
This is the boundary problem. And it is structural, not exceptional. Every private healthcare operator — from single-site hospitals to PE-backed groups, from insurer networks to the consultant who splits a week between NHS and private — operates across organisational boundaries where clinical accountability, data governance, and regulatory responsibility fragment.
The series follows a deliberate architecture. It begins with the provider domain — how practising privileges create the first governance gap, and how the NHS-private interface exposes patients to two constitutional systems with no governed crossing. It then examines the insurer domain — the ungoverned constellation of provider networks, the clinical-commercial boundary at pre-authorisation where medical necessity meets policy wording, and the Seven Flows methodology that makes these risks measurable. It covers the technical domain — the digital front door where clinical consultations become commercial pathways, and why DCB 0129/0160 clinical safety standards stop at the boundary where risk is highest. It concludes with the regulatory convergence — six separate regulatory pressures (FCA Consumer Duty, CQC restructuring, MPAF, PHIN/CMA, HSSIB, and the DCB standards review) all arriving at the same structural gap within twelve months.
The golden thread is the Seven Flows — seven governance functions (Identity, Consent, Provenance, Clinical Intent, Responsibility, Service Routing, Outcome) that must be present at every organisational crossing for a boundary to be safe. Where a flow is absent, systemic risk accumulates. The Constitutional Crossings framework maps where these flows break down at each boundary type. Together, they provide a clinical governance framework for inter-organisational risk in private healthcare — the framework that does not yet exist anywhere else.
From practising privileges to the digital front door
The Paterson Inquiry exposed what private healthcare already knew: governance fails at the boundary between organisations, not within them. From practising privileges to insurer networks, the CQC/FCA regulatory gap, and the four boundaries every patient pathway crosses.
Bupa, AXA, Vitality, Aviva — four routing models, billions in premiums. Seven crossings in a typical insured pathway mapped against the Seven Flows. The GP boundaries broken in both directions, and why the FCA Consumer Duty changes the equation.
The consultant recommends treatment. The insurer decides whether to authorise it. Between them sits a governance domain governed by neither CQC nor FCA. Medical necessity, pre-authorisation, the insurer's clinical team, and why the Consumer Duty changes everything.
Every privately treated patient crosses the NHS-private boundary at least twice. From prescribing walls to data governance asymmetry, the no-mixing rule to the return crossing — the governance infrastructure gap mapped against all Seven Flows.
Virtual GP services integrated with insurers create the least visible boundary in private healthcare. Clinical data enters commercial infrastructure, referrals flow one way into insurer networks, and the crossing from CQC-regulated consultation to FCA-regulated pathway has no regulatory framework.
DCB 0129 and DCB 0160 are the most rigorous clinical safety standards for health IT in the world. They do not reach private healthcare boundaries. What boundary clinical safety assessment would look like — and why the methodology already exists.
Seven governance questions at five boundary crossings. A 7×5 maturity matrix that makes the gap measurable. Identity, Consent, Provenance, Clinical Intent, Responsibility, Service Routing, and Outcome — assessed at every crossing in the insured pathway.
FCA Consumer Duty, CQC restructuring, MPAF, PHIN/CMA, HSSIB, and the DCB standards review — six regulatory pressures converging on the organisational boundary. Why the organisations that build boundary governance now will shape the standards rather than scramble to meet them.
Architecting Neighbourhood Health
10 articles mapping the boundary governance model for multi-organisation healthcare. Written for NHS neighbourhood teams — but the methodology applies equally to private provider networks, insurer constellations, and post-acquisition integration.
Julian Bradder
CEO, Inference Clinical
julian@inferenceclinical.com
Inference Clinical's Boundary Risk Assessment evaluates governance at every organisational boundary — post-acquisition integration, NHS sub-contracting, insurer interfaces, and diagnostic partnerships.
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