Is the inspection of GP practices like the inspection of schools?
John Cable believes his experiences inspecting schools serve as a useful comparison to general practice
I write as a patient, a member of a Patients Participation Group, and a person with previous experience of inspecting schools. The following comments are prompted by the comparison that is often made between in the inspection of schools by Ofsted and the inspection of GP practices by the CQC.
Is the inspection of GP practices like the inspection of schools? Obviously, there are similarities. In both cases, inspection is carried out by relevant professionals, using a published framework of criteria, but leaving room for professional judgement. In both cases, the published criteria may be of value to the institutions themselves for their internal management. In both cases, a vast amount of information and judgement is eventually consolidated into a point on a simple scale - in the medical case ‘outstanding’, ‘good’, ‘requires improvement’ or some euphemism for ‘rubbish’.
But there are differences, and these relate mostly to what an inspector can actually inspect. During a school inspection, the inspector spends most of his time in classrooms, trying to assess the quality of the teachers’ teaching and of the children’s learning - for these are what education is essentially about. The main function of a GP surgery is to make patients better when they are ill - and to help prevent them getting ill in the first place - but this is vastly more difficult to assess, even with the help of records. In order to form a valid judgement about the accuracy of a doctor’s diagnoses and the appropriateness of the recommended treatments, an inspector would need to be present at scores of patient consultations. But this would be impractical, even if it were acceptable on other grounds.
‘Effectiveness’ is simultaneously the most important and the most difficult to assess
So the health inspector is forced back onto more remote performance indicators such as ‘the percentage of patients with atrial fibrillation who are currently treated with anti-coagulant drug therapy.’ (One would perhaps be more interested to know how many patients were sent home with a bottle of aspirin when they really had pneumonia. But even that information is unavailable.)
The health inspector can also assess whether there are systems and procedures in place to promote things like the safe storage of drugs, and she can make some attempt to assess how well these procedures are followed. It can be good for these things to be checked by an outside inspector from time to time. But a practice may be good at safety procedures and still fail in more important matters, like the quality of diagnosis and treatment. And an inspection report that gives too much weight to the things that can easily be checked may be missing what is truly important.
A CQC report on a GP practice currently sets out to answer five questions:
- Are services safe?
- Are they effective?
- Are they caring?
- Are they responsive?
- Are they well-led?
No doubt these are all good questions to ask - or they would be with a little more explanation - but they are not all equally easy to answer and ‘effectiveness’ (does the patient actually get better?) is simultaneously the most important and the most difficult to assess with the means available. One might, therefore, hope for a degree of caution, if not humility, in any pronouncement under this heading.
So it hardly inspires confidence in the whole inspection process to find that our local practice has been judged ‘ineffective’ (in the jargon ‘requires improvement’) on the basis of gaps in the nurses’ training schedule, which anyway is really a matter of input rather than effectiveness.
John Cable is a former teacher and schools inspector, now a member of his local Patient Participation Group