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CQC threatens to send 'OFSTED-style' letters to patients in poor practices as Field unveils findings from first 1,000 inspections

The CQC is considering ‘OFSTED-style letters’ to patients of practices where it has found unacceptable failings or inadequate care, as the chief inspector for primary care unveiled the findings from its first 1,000 inspections and his plans for the regime from April 2014.

Professor Steve Field revealed that inspectors found problems with a third of the first 1,000 practices the CQC has inspected, and detailed a catalogue of failings, including maggots found in treatment rooms, out-of-date vaccines kept in fridges with no temperature monitoring and a case where two GP partners reported each other to the GMC for incompetence.

However, GP leaders warned that the sample of practices inspected did not necessarily represent the true picture of general practice as there had already been concerns raised about the vast majority of them. GPs also said this was a wake-up call for the Government to increase resources for practices.

This came as the CQC revealed that all future inspections will include a GP and a nurse, and it will ask how ‘caring’ practices are as part of the regime beginning in April.

The vast majority of the first wave of inspections were targeted, with some random inspections, and it found 34% of practices had failed one of the inspection standards, with 10 having very serious failings.

Professor Field said: ‘We’ve asked [inspectors in the first 1000 cases] to look at things which are really important from a safety point of view, and around about a third have problems. The really serious ones, at the moment, are less than 2%. But [that’s] because we’ve done some targeted ones, and some random ones… I think the message is “we can all do better”, but some practices are brilliant and we haven’t looked at the brilliant ones, systematically.’

Practices who flagged up potential concerns have been targeted in this first wave of checks and Pulse has reported previously how this is likely to skew the number of practices who have failed to achieve inspection standards.

CQC inspections at a glance

  • The CQC found that one-third of GP practices were in need of improvement
  • The inspection teams found maggots in a treatment room and out-of date vaccines in fridges with no temperature monitoring
  • Professor Steve Field said he is considering ‘OFSTED-style’ letters to every patient of poorly performing practices
  • The inspectors will ask whether the practices are ‘caring’ and show compassion for patients
  • Every team will include a GP and a nurse, who will be trained from January 2014 onwards
  • Inspectors will visit 25% of the practices in every CCG within six months from April 2014
  • Practices will have to publish results of their inspections in their waiting rooms
  • The CQC will focus on out-of-hours providers from January

Professor Field said he was searching for ways to ensure patients ‘really know’ when their practice is inadequate, and he said the OFSTED system of writing to pupils in a language they understand was ‘a great one’.

The results of practice inspections will have to be displayed in waiting rooms and the CQC will publish them on their website, with the first ratings due to be published in October.

He said: ‘As part of the new contract changes they have to be published by the practice and put into the waiting room, I will write an open letter to practices, to the patients in each practice – hopefully using the press - that will be published on their website.’

He added: ‘There is a question, about whether I should personally write to all the patients in the really, really bad practices, in the inadequate practices, and we’re looking at whether that’s feasible.’

‘Because in OFSTED they write a letter to, to the junior school pupils and the senior school pupils in a language they understand.’

‘I think the principle is a great one, so it will be an open-letter to patients. If there’s a practice which is really, really inadequate, the question which I’m toying with in my mind is how you make sure patients really, really know. ‘

Professor Field was setting out the CQC’s new approach for inspecting general practice at the release of its report, ‘A fresh start for the regulation and inspection of GP practices and GP out-of-hours services’.

The document confirmed that the inspection teams will be testing whether practices are ‘caring’, as first revealed by Pulse this year, as well as questions around whether they are safe, effective, responsive and well-led.

Professor Field had previously identified that conducting inspections without a GP present was ‘flawed’, and the new system is being brought into address this.

The report makes a commitment that teams of inspectors will include GPs, a nurse and sometimes patients.

It states: ‘Our inspections will be led by expert inspectors, with clinical input led by GPs. The teams will include an inspector, a GP, a nurse and/or a practice manager and a GP registrar. Teams may also include an expert by experience – someone who uses a GP practice or has a particular experience of care that we want to look at.’

Professor Field said: ‘We’re going to set up an academy inside CQC and spend a lot of resource. Just like when I was a college examiner, or a trainer inspector. We’re going to train the GPs, the patients and the nurses, and the inspectors - together and separately - to gain skills.’

The new inspection regime will begin with a total investigation of GP out-of-hours services, which the report says ‘face particular challenges in providing safe, compassionate care’.

GP practices will begin being inspected through the new approach from April 2014, with inspectors visiting 25% of the practices in every CCG within six months. The CQC hopes to have inspected and rated every surgery in England by April 2016.

GPC chair Dr Chaand Nagpaul said he was encouraged by the high standards of care the first wave of inspections had found. He added: ‘While most patients receive high quality care from their GP, we need to understand where and why shortcomings in a small number of practices exist, and the BMA is committed to working with the chief inspector to improve standards. It’s important, however, that anecdotes of poor practice are not be used to distort the reality which is that the overwhelming majority of hard-working GPs provide high quality care which is appreciated by patients.’

‘The ultimate aim of this process must be to provide necessary support for improvement and empower all GP practices to reach the highest possible standard of care. As part of this, we need to seriously look at the infrastructure and resource constraints many practices face, as these are often the main roadblocks to improving standards in general practice.’

Dr Andrew Mimnagh, a GP in Merseyside and chair of Sefton LMC said a general practice’s financial circumstances must taken into account before the CQC act on the findings of an inspection. /he said: ‘It sort of begs the question, as they’re inspecting things like premises which have been traditionally underfunded. It does become a bit of a self-fulfilling prophecy, of “we didn’t invest in primary care and we’re closing your doctor down”… it seems a bit like give a doctor a bad name then hang him.’

Health secretary Jeremy Hunt said that that the first wave of inspections showed the majority of patients ‘received good quality care’ from their GP, but stressed there were ‘areas of concern’.

He said: ‘[The first inspections] have shown that many people receive good quality care from their GP, however they also highlighted areas of concern and some examples of very poor care, with 34% failing at least one of the required standards, and in 10 practices there were very serious failings that could potentially affect thousands of people.’

‘The findings from these inspections are helping the chief inspector develop his plans for changing the way the CQC inspects general practice, particularly focusing inspections on the things that matter to patients.’


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  • chief inspector Steve Field - online

Readers' comments (39)

  • If we as GPs think that we are too underfunded to offer quality care or premises, then I suggest that we shut our surgeries and join practices that are successful as salaried GPs !
    To honestly say that we cannot provide quality care because we are "underfunded" is a travesty. Let's be real folks, there are a few practices that should not really exist or care for patients and I am pleased that Steve is getting on with the job with a gusto and I am sure that part of the outcomes should be pressuring NHSE to fund new monies for additional premises and perhaps CQC rated dependent funding mechanisms. Let's be optimistic about this rather than show sarcasm to this process and pretend that all is well. Unfortunately, the truth about underperformance and poor quality care is often shoved under the carpet and diplomatically hidden by our profession.

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  • Let's admit today without ensuring vaccines and the required drugs are up to date and kept correctly,you have a defibrillator and an oxygen cylinder and the surgery is clean you should not be offering a GP service. The main loss of respect is the 'appointment system '.... Open surgeries and availability are the essence of Primary/ GP care, and give Patients the reassurance and review as necessary, what they need and want. ....Alas, an 'own goal' , one of many , encouraged by the Academics/ Royal Colleges and committee types within the GP profession.

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  • As a GP trainee I've been shocked to find so many out of date drugs. Before our inspection we had a big sort out and some of the GPs weren't really bothered. They were only throwing things out because of the inspection. I expect the practice will have passed. I think many GP's are out of touch and stuck in a time 20 years ago.

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  • @10.41 yes the appointment system is archaic. How can any working person phone at 8am for an appointment? At that time they'd either be working or on the way to work or dropping off children. In any case most of the appointments will have gone to non working people who have time to call into the surgery. Working people need a better chance.

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  • Re 11.02
    The appointment system is stupid, yes....but archaic, no!
    In fact the " phone at 8 am " is a relative new wheeze called advanced access and was hailed by DoH as the answer to all our problems. In the worst cases the chance to book in advance was removed altogether. The real answer is more GPs, more appointments available for patients to book as they wish, when they wish. No matter how hard you squeeze, and what shape the tube, there is only so much toothpaste.

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  • So what are the CQC going to do next year once everyone has thrown out their old drugs, recharged the defibrillator, ordered oxygen, removed all maggots and screwed the doors back on?

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  • Abdul QADRI

    Professor Field said he was searching for ways to ensure patients ‘really know’ when their practice is inadequate, and he said the OFSTED system of writing to pupils in a language they understand was ‘a great one’.
    There is no excuse whatsoever if maggots are found in the treatment room in one practice. Also if the vaccines are out of date and kept in the fridge that is not acceptable. I would have thought that following the last few years of QOF visits, these kinds of things should have been checked. I recall preparing for the QOF with the Practice Manger and the Practice Nurse. My Practice Nurse would make sure to check the temperature of the fridge and Vaccine dates on regular basis. She would make sure to inform the Doctor or the Practice Manger if anything needed to be changed. The practices that have failed to do this basic checks need to ask themselves a simple question: Did they follow the QOF requirements at the time of annual visit?
    Having said that, it is so painful to see how Professor Field’s remarks have already damaged the reputation of the hard working GPs up and down the Country. There are around 7500 Practices in the UK and 1000 have been inspected. One third of those i.e. around 330 have been found to have failed in one of the so called standards inspection. Maggots were found in the treatment room of one practice. Now see the immediate impact in the press for our patients:
    Dangerous GP surgeries are named and shamed
    Inspectors carrying out first spot checks of family doctors in England find maggots in treatment rooms and queues so long that patients brought in stools to sit on
    Their report concludes that hundreds of patients’ lives are being put at risk by an “unacceptable” variation in quality. The inspectors also highlighted a worrying lack of competence among GPs, saying that some were simply “not up to it”. Doctors unable to use basic life-saving equipment. Some GPs were accused of “tick-box” attitudes that left cancers undiagnosed. Prof Steve Field, the chief inspector of GPs warned that hundreds of lives could be at risk because of the failings. Last week NHS data on 4,000 practices showed that half of patients diagnosed with cancer were not fast-tracked to see a specialist within two weeks. Problems getting an appointment and a reliance on “tick-box” systems meant too many cases of cancer were being missed, Prof Field said. “If people have symptoms — if they might have cancer — if they are turned away they might not go back,” he added. Roger Goss, of the campaign group Patient Concern, said the failings were “unbelievable and inexcusable”. The nine practices found by the CQC to have the most serious failings were: All were ordered to make urgent improvements or close.
    I honestly don’t know where to start. CQC Boss is comparing our patients like Pupils who need to know about the standard of the Practices they are registered with. He wants to inform them the language they can understand. British Public is not so stupid & know where to register in NHS. They also know if they are not happy with the Practice, they can easily leave the practice without any notice and register with another Practice. It would be interesting to know the reaction of the patients of those so called failed practices. It also begs a question as to why Patients are still registered at those so called failing Practices. Patients nowadays are smart enough to know when to complain against a Practice as there are Clinical Negligence Lawyers advertising every dayto approach them on the National TV. Besides GPs themselves know the consequences of their clinical negligence. They can be reported to the GMC and loose the license to Practice.
    The current attitude by the CQC will deter Junior Doctors to peruse a career in General Practice. The population of GPs over the age of 60 Years is growing and they had enough of the scrutiny and I am afraid might decide to leave early. There is already confusion about the way Appraisal and Revalidation is being conducted. There have been so many changes brought in to the General Practice. To have a GP and Nurse in the Inspection team is nothing new. We used to have same kind of Inspection Team when QOF used to visit Practices. If ticking the boxes is criticized by Prof Field, One can ask him to look into the Target templates as Doctors payment depends on those boxes. There is already shortage of Locums and the Gross root GPS like I are dismayed by this initial threatening report.
    By naming and shaming the 9 Doctors will not solve anything but make our Medical Graduates to think twice to join General Practice. Incidence of stress related illness is rising among GPS and I am afraid if constructive approach is not adopted by CQC and Revalidation Agencies, future of General Practice in UK is looking bleak.
    Finally I will say this:

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  • Anyone can apply to be a CQC inspector and you don't need any nursing / medical background!

    Perhaps if some of them worked in a practice for six months, they would realise that staff are too busy looking after patients to worry about some of the silly things that inspectors check on.

    We have reached the point where there are too many chiefs and not enough indians!

    shame they don't pounce on some of the dirty hospital they rate as excellent but it is always the GP's that get a bashing!

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  • Will they be looking at community mental health teams too? That's where CQC is really needed. Excellent programme on psychopaths on ITV at the moment - certainly recognise a lot of characteristics in the psychotherapist I was referred to - any maggots there?

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