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On a mission to root out 'the mad and the bad' among GPs

As the Care Quality Commission assumes power this week, we ask its chair about her plans for general practice.

By Gareth Iacobucci

As the Care Quality Commission assumes power this week, we ask its chair about her plans for general practice.

Mad, bad and dangerous to know is the title of the recent autobiography by polar explorer and ex-SAS hard-man Sir Ranulph Fiennes.

It is also how some GPs are described by the new regulatory chief Baroness Young, although only, she insists, a minority.

Baroness Young, as chair of the new Care Quality Commission, is charged with implementing a tough new regulatory regime across health and social care – including, for the first time, general practice.

Yet the woman at the helm insists the CQC, which officially assumes power this week with the demise of the Healthcare Commission, can bring a rigorous focus to quality across the profession without becoming public enemy number one.

‘At the end of the day, if GPs aren't willing to play their role in service improvement, we will have to take regulatory action,' says the Baroness, as she sets out her mission in an interview with Pulse at the commission's imposing headquarters, commanding views over the River Thames in London's Southbank.

‘In any regulated service, there's always a few folk who are not up to it,' she says. ‘There will be a few who are just mad, bad and dangerous to know, but I hope that will be a minority.'

Impossible to ignore

Back in 2007, when Pulse first revealed the extent to which the CQC would shake up the regulatory landscape, there was a sense that the new body meant little to the majority of GPs, sane or otherwise.

Indeed there was widespread uncertainty about whether most GPs would even come under its powers.

Yet despite fears over the enormous cost, estimated by the Department of Heath at more than £30m a year, it has been decided that all GPs will be expected to register with the new body by 2010/11.

And after being handed what Baroness Young has herself described as ‘draconian' powers, the CQC is suddenly not so easy to ignore.

Baroness Young says one of the first jobs of the organisation in primary care will be to draw up a ‘risk profile' for all GPs.

The concept - a bit like a Framingham score for poor practice or Harold Shipman tendencies – would see information collated from a range of sources.

It would assess risk based on levels of complaints, surveys of patients and staff, the CQC's own regular inspections and from balanced scorecard assessments carried out under its auspices by PCTs.

‘As we build up those risk profiles, we'll be able to spot those poor providers with greater accuracy, help them improve or, if they won't improve, to take regulatory action and enforcement,' she says.

Such policing of the profession could even see GPs jailed in extreme cases, although for the vast majority it will simply mean greater scrutiny of performance, including in clinical practice and prescribing.

But the Baroness has backtracked on a previous suggestion that this would mean NICE guidance becoming mandatory for GPs.

And she insists the CQC is also busy working with the RCGP to avoid duplication between its planned system of checks and the college's practice accreditation scheme.

The RCGP has been reassured that its own scheme – which will assess practice systems to ensure they keep emergency bags up to date, follow up patients who don't collect prescriptions and regularly assess their medical equipment - will feed into the regulatory work of the CQC.

But the Department of Health has made it clear GPs will also have to face a series of independently-determined indicators to rubber-stamp their quality.

Baroness Young says it is too early to say exactly what the Government's indictors will be, but that they will be based on a CQC manifesto including safeguarding outcomes, patient experience, quality of life, public health and access.

‘Generally speaking, GPs know themselves where there is poor practice and the ones who are providing good quality service don't want the reputation of the whole system to depend on a few people who are not,' she adds.

In fact, the recent Scottish LMCs conference saw a motion passed calling on underperforming GPs - the mad and the dangerous - to be rooted out.

Baroness Young stresses the key focus will be on quality and information, with GPs facing the prospect of having to provide quality accounts to patients, an idea first mooted by Lord Darzi in his next stage review.

‘If a practice is accredited, it would be really good if once a year they tell their users how they're doing. There might be some particular local issues where their community has said "we want you to have a look at this", she says.

GPs will have to declare quality on a range of nationally comparable criteria, with full payment on their contract possibly hinging on whether they meet them.

With regulation seemingly coming at them from angles, GPs may wonder when they might have time to treat their patients.

This is particularly true of single-handed and small practices, who some fear may not have the infrastructure to cope with the growing burden of regulatory demand.

The Baroness acknowledges this concern and lends her backing to the RCGP's federated model as one way of helping struggling small practices to keep up.

‘There's always been the debate about single-handed GPs and their ability to deal with issues beyond their individual practice,' she says.

‘But they have to be able to spare the time to engage with the system to reassure themselves they are meeting the right quality standards. It may well be that federations are the answer.'

Baroness Young pledges to try and adopt ‘a light touch' wherever possible in regulating single-handers, but she also makes clear she has no intention of making the process too easy for GPs.

It's not as though she is a stranger to a spot of controversy.

She did, after all, serve as chief executive of the Environment Agency from 2000 until 2008, and in the latter stages was at the centre of a storm of controversy over its alleged failure to protect homes caught up in the catastrophic floods of 2007.

She survived calls for her head then, and knows she has an equally big - and high-profile – job ahead of her as chair of the CQC, too.

Clinical quality

‘Of all the elements of the healthcare system, primary care is the one about which there is least information for patients and least assurance of the quality of services.

‘The public don't just want us to look at opening hours and whether the receptionist was nice to them. It's got to be across all the parameters including clinical quality.'

But all this regulation will come at a cost, and who pays is a thorny issue.

The GPC wants the work involved in gaining registration with the CQC to be paid for under the contract, while the Baroness says she would like to see GPs incentivised to do the college's accreditation system - as one way of easing overall costs.

Baroness Young cautions though that all decisions on funding will be subject to negotiations with the Government. Given previous form, another protracted round of discussions seems inevitable, although she is keen to get moving quickly.

‘I'm hoping we'll make fairly fast progress. If you look at the timescale for GP registration and the timescale for GP service accreditation, we haven't got long to go.'

And on that note, our allotted time is up, and Pulse must dutifully make way as the Baroness prepares to rush off to another meeting.

There's work to be done and the profession will not regulate itself – at least, not for much longer.

Baroness Young: "GPs providing a good service do not want their reputation to depend on a few who are not" Baroness Young:

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