An appraisal: What has the CQC achieved?
The regulator has now inspected every practice in England, but have there been any benefits to justify its costs, asks Jaimie Kaffash
In 2013, when the CQC was first formulating its ideas for practices to be given ‘Ofsted-style’ ratings, the chief inspector for primary care, Professor Steve Field, told Pulse that he wanted to make general practice the ‘best in the world’.
He said he would be a ‘champion’ for general practice: ‘I think you will find us making statements about resources, about contracts, about lack of workforce’, he said.
Two and a half years later and the regulator has just finished inspecting all 7,000 GP practices in England. The final results, obtained by Pulse, found that 90% of practices have been rated ‘good’ or ‘outstanding’.
GP inspections has helped deliver improved care
Professor Field points to the numbers of practices that have improved during this time, according to its own inspections. The CQC says that of the 203 practices that initially received a rating of ‘inadequate’ or ‘requires improvement’, 131 were rated ‘good’ on re-inspection as of July 2016.
‘It is clear that the GP inspection programme has helped deliver improved care for people right across the country,’ Professor Field tells Pulse. ‘Three-quarters of practices rated as inadequate improved sufficiently on re-inspection to receive a higher rating.’
But the chief inspector is appraised very differently by the leaders of the GP profession. The BMA and the RCGP have been outspoken against CQC inspections, with the college at one point calling for them to be temporarily suspended to relieve pressure on practices and the GPC demanding they be scrapped altogether.
GPC regulation spokesperson Dr Robert Morley says inspections have subjected practices to ‘enormous cost, workload and bureaucracy’. He adds: ‘It’s clear the massive cost and disruption to practices is completely unwarranted and disproportionate – it just confirms what is already known through other means.
‘There is simply no need to have in place the simplistic, misleading and damaging CQC rating system and it should be abolished.’
And figures obtained by Pulse reveal that the whole programme has cost £100m - with £64m spent on inspections in general practice. Much of this bill has been footed by practices themselves – £20m a year according to the BMA – costing the average practice some £3,000 in CQC fees every year. NHS England has now agreed to reimburse these costs in full in 2017/18 – but only four years after the GPC first asked them to do so.
Perhaps more importantly, practices have faced costs beyond the CQC fees themselves. One GP told Pulse their practice spent £8,000 in fees and preparation for inspections, while another said they had to spend £10,000 to install new floors and carpets across three different sites. Other practices went as far as to take on permanent employees specifically to maintain CQC-related data.
Indeed, Dr Jane Lothian, former LMC medical secretary and clinical director of Northumbria Healthcare NHS Foundation Trust goes further, saying the burden of inspection has been ‘one of the drivers behind mergers for small practices’.
Inevitably, patient care has been affected. Practices have cancelled around 15 appointments preparing for inspections on average, totalling around 112,500 appointments across the country, a Pulse survey in 2015 revealed.
And the pressures of preparation can pale in comparison with the stress of the inspection itself. One GP told Pulse the day of the inspection was the ‘worst of her career’.
It’s all a massive box-ticking exercise
Meanwhile, the CQC has struggled to be seen as a ‘champion’ of general practice. The regulator made headlines in November 2014, when it claimed that one in six practices was ‘risky’. This claim turned out to be based on flawed intelligence but still resulted in individual practices being named and shamed in local and national press. Professor Field later had to issue an apology and retract the ‘risk ratings’ – but the damage had been done. But even this embarrassment didn’t stop him telling the Daily Mail in December 2015 that he was ‘ashamed’ and general practice had ‘failed as a profession’.
It may be that the stress suffered by GPs, the cost, the shaming of the profession and the loss of appointments are the price to be paid for the promised driving up of standards. But GPs have cast doubt on whether the CQC is actually improving the quality of care. They point out that a low rating could simply indicate that a practice did not deal well with the CQC inspection, rather than being a sign it is providing substandard care.
GP leaders point to less onerous and more supportive regulatory regimes in the other three UK nations. Indeed, Welsh LMC representatives recently voted in support of their inspectorate.
Pulse inspects the inspectors
Dr Morley says: ‘It’s all a massive box-ticking exercise of no value to quality of care. Indeed, it’s the opposite, as it detracts from patient care, plus it puts huge stress on GP partners and staff, especially practice managers.’
One of the biggest criticisms is summed up by RCGP chair Professor Helen Stokes-Lampard: ‘GPs have been concerned at the CQC’s emphasis on administrative processes, rather than on issues that matter most to patients.’ Common objections include a greater focus on procedures – including the right forms being signed and fridges being monitored – than on patient care.
Even the CQC has conceded that it looks at factors other than patient care when it comes to awarding ratings. Speaking in December 2015, the CQC’s deputy inspector of general practice Ruth Rankine said even ‘inadequate’ practices can be providing good care but fail on ‘governance’ if ‘processes are not in place’. And Professor Field has admitted an ‘outstanding’ rating can depend on presentation as much as anything.
But he insists that the regulator is focusing on ‘what matters most to GPs – providing high-quality care to their patients’. He explains: ‘What may seem like simple process issues may indicate problems elsewhere.’
And Professor Field is drastically reducing the frequency of inspections for many practices and will be consulting later this month on a more ‘outcomes-focused method of regulation’.
But his critics maintain the time and effort invested could have been used directly to improve the practices targeted by the CQC. Professor Stokes-Lampard tells Pulse: ‘GPs have raised the issue of the costs of running the CQC – money that could be spent on frontline care.
‘Many practices are struggling with factors beyond their control, such as recruitment. The college has demonstrated how expert, timely and appropriate intervention can identify the solutions.’
Professor Stokes-Lampard is keen to stress that the CQC has been prepared to listen to the college and its members’ concerns, and says the RCGP is advising the commission on how to introduce ‘lighter-touch’ regulation in the next stage of its inspection programme.
As the chief inspector sets out the future direction of the CQC, he will be aware of the need to command much greater respect among a profession that is far from convinced by the performance of the regulator to date.