Practices were promised a new style of regulation from the CQC by chief inspector Professor Steve Field, with GP-led teams, less bureaucracy and better support for practices.
But two months into testing of his new regime some practices are reporting that the process remains an exhausting experience.
GPs who have faced the new regime so far have described 12 hours of grilling from a team of inspectors, with unexpected demands for data that they have struggled to locate and, in some cases, questions about policies – such as a ‘restraint policy’ – they never realised they needed.
Pulse has also been told of inspectors climbing on top of cupboards to search for dust and placing ‘comments boxes’ in waiting rooms, the contents of which they refuse to allow GPs to read.
This comes after Pulse revealed GPs could see inspectors sitting in on patient consultations as part of the new regime. It has emerged that the regulator is struggling to drum up enough GP inspectors to lead its teams, and that those who have been employed may not have received any formal training.
Additional burden
Professor Field told Pulse last year he would introduce an inspection system that ‘reassures the public, but does not add to GPs’ bureaucratic burden’. Testing of his new regime has begun in 200 practices in 12 CCG areas across England, before an official launch in October.
Professor Field’s changes include inspections carried out by CCG area, practices receiving two weeks’ notice of an inspection instead of two days and larger inspection teams including one GP.
The inspectors will gather information from sources in advance of the inspection and will issue an ‘Ofsted-style’ rating of ‘outstanding’, ‘good’, ‘requires improvement’ or ‘inadequate’ that practices will have to display in their waiting room.
Although pilot practices will not receive this overall rating, they will be given a report of their inspection, which the CQC has confirmed will be publicly available.
‘The inspectors asked if we had audited that system to make sure nothing was slipping through the net. The answer was that we hadn’t.’
Dr Nick Turner
The regulator says it is too early to reveal any details from its evaluation of the pilots and refuses to release the names of the first practices, but Pulse has learned that practices involved in the pilots have had mixed experiences.
Dr Nick Turner, a GP in Tiptree, Essex, whose practice underwent a new-style inspection in April, says the day was time-consuming, but not wholly negative.
He says: ‘We asked administrative staff to carry out certain tasks that GPs have previously done, and the inspectors wanted to know if we had audited these. One involved opening mail that would have been dealt with in the past by GPs.
‘The inspectors asked if we had audited that system to make sure nothing was slipping through the net. The answer was that we hadn’t.’
‘In a small, busy, practice you will have a long day, because at the end there will be paperwork and reports to catch up on that you haven’t had time to do. If you can get a locum in to see patients that could ease the situation,’ he adds.
Another practice in Wessex found inspectors climbing on top of cupboards to check for dust and asking for data the practice did not hold.
Dr Linda Mahon-Daly, a GP in Colchester, Essex, says that the inspection was ‘fair’, but lasted from 8am until 7pm.
She says: ‘The lead inspector was inexperienced – it was the first time she had led an inspection. And some information they wanted would not be held by most GP practices.
‘For example, they asked for the percentage of our patients who have had bowel cancer screening, mammographies and cervical cytology screening. We did provide them with some screening data, but I’m not sure many other practices would have this information.’ (full account at the end of this article)
Over the top
Wessex LMCs director of primary care Carole Cusack, says the workload from the inspections was ‘pretty phenomenal’ and some GPs were ‘grilled to within an inch of their lives’, but that the majority of practices in her area found the new inspections ‘okay’.
She says some GPs were asked to print and hand over more than 30 policies, including those for health and safety, fire safety, infection control and complaints.
Dr Helen Terrell, a GP in Maidstone, Kent, says although she found the day tiring, she was ‘pleasantly surprised’ by how the inspection went, and she found the inspectors helpful.
‘I got the impression they don’t actually want to see us fail, but they do have statutory rules and regulations, with boxes that must be ticked,’ she says.
But the revelation that practices undergoing the pilot inspections will have to undergo inspection again before April 2016 has caused anger.
Ms Cusack says: ‘I think [the pilots] might be useful, but the pressure that practices are under at the moment to just get appointments given out, and get the right number of GPs in, and get the treatment room sorted, and look at complex conditions and the avoiding unplanned admissions DES – they’ve got a lot on their plate.
‘And they’ll have to go through this yet again – I don’t think they’ll be looking forward to this very much at all.’
Inexperienced inspectors
The experience of the inspectors is a real concern for GP leaders. Pulse revealed last month that GPs only need six months’ general practice experience before becoming an inspector, due to a shortage of GPs to lead inspection teams. Locum GPs who are being used to fill gaps in the inspections are not receiving any formal training, and have instead been sent a training pack, information on the methodology and a phone call.
The CQC says it has only been using a ‘tiny’ number of locum GPs to plug gaps in inspection teams, and that it would be evaluating the make-up of inspection teams during the pilot, but GPC regulations lead Dr Robert Morley says that is not good enough.
Dr Morley says: ‘They are using locums and salaried doctors, but you need someone with experience in running a practice – preferably a GP partner.’
Dr Dean Marshall, GPC negotiator and GP in Midlothian, adds: ‘There are clear issues around reports we’re getting of GPs carrying them out with no training.
‘There seems to be a major issue with almost panic emails going out, trying to get anyone to do an inspection. So that can’t be reassuring for practices.’
‘If we’re trying to make the NHS run better, deciding how often you wash your curtains isn’t the number one thing.’
Dr Dean Marshall
GP leaders have also raised concerns about the ‘damaging consequences’ of publishing ‘Ofsted-style’ ratings for practices.
GPs voted to ‘vehemently oppose’ the new rating system at the LMCs Conference in May and the GPC recently hit out at the CQC for ignoring its concerns that the ratings could set some areas on a ‘spiral of decline’.
Dr Morley argues the ratings could have a ‘negative effect’ on GP morale, leaving a ‘gulf’ between those labelled ‘good’ and others given a ‘requires improvement’ rating.
He says: ‘Sometimes the quality of patient care in a region relates to commissioning decisions or the acute hospitals or the quality of social services. Or it relates to public health problems that may be more prevalent in some areas than other. GPs shouldn’t be judged on things like these that are outside their control.’
Dr Turner adds that the ratings could ‘derail some practices that don’t perform well’. He says: ‘I wouldn’t want there to be a high threshold for a practice to get a good rating. Some practices operate under difficult circumstances and that needs to be taken into account.’
Professor Field says practices have 10 working days to review draft reports, raise any concerns about inaccuracies or make representations about evidence used to inform decisions.
He says: ‘If a GP practice or GP out-of-hours provider believes the published process has not been followed properly and wants to request a review of one or more of their ratings, they must inform the CQC of their intention to do so once the report is published.’
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But most GPs would prefer it not to reach that stage, with many questioning the value of the new regime and calling for a rethink before the CQC enforces the changes officially in October.
Dr Marshall argues the new regime brings little to ease GPs’ concerns about the overall value of CQC inspections – particularly as Professor Field recently suggested they should be widened to look at other elements, such as the ‘transition’ of young people to adult care services.
Dr Marshall says: ‘It’s an administrative burden we don’t need when we’re struggling to cope with demand from patients. It seems to me the CQC still doesn’t seem to be trying to fit seamlessly with the running of the actual NHS.
‘So what is the added value? And do they recognise, at all, the current situation for practices, and will they actually consider how they can cause the least disruption to people who are trying to provide a service to patients.
‘If we’re trying to make the NHS run better, deciding how often you wash your curtains isn’t the number one thing.’
‘Some information they wanted would not be held by most GPs’
Dr Linda Mahon-Daly, a GP in Colchester, Essex:
‘The inspection was thorough and fair, but long-winded, with the inspectors staying from 8am until 7pm.
The lead inspector was inexperienced; it was the first time she had led an inspection. And some information they wanted would not be held by most GP practices. They asked for the percentage of our patients who have had bowel cancer screening, mammographies and cervical cytology screening. We did provide some data, but I’m not sure many other practices would have this information.
They also asked for comprehensive records of joint-visiting by GPs and community matrons or midwives. We do these visits, but don’t record them as joint visits in our diaries. It’s not enough just to tell the inspector you are doing a certain thing – you have to prove it with records. I think a lot of GPs might struggle with this, because their record-keeping isn’t up to scratch. They don’t keep proper records of audits, re-audits, or actions taken or reviewed.
One inspector – a GP – asked to look at anonymised medical records to check our note taking and recording template use, along with vaccination histories and summaries. They also looked at our repeat prescribing protocols and repeat dispensing. But in general, they didn’t ask for anything a well-organised practice would not have access to.’
