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At the heart of general practice since 1960

Is the CQC’s inspection regime fit for purpose?

Peter Higgins says the regime guarantees high standards in practices but Dr Peter Swinyard argues that the inspections completely miss the point

YES

The CQC has given us clearly defined measures by which practices can be reviewed.

The actions of inspectors are consistent, proportionate and fair in most circumstances; we are rarely surprised by the conclusions they reach.

Even though our profession has labelled inspections as another drain on precious time, the vast majority of practices sail through with little trouble. And while practices risk being branded ‘not safe’ in the local newspaper, they equally have the chance to be publicly praised.

The system should be commended for providing an invaluable system to flag up practices that are compromising patient safety. Practices identified as ‘requiring improvement’ shouldn’t have survived so long without basic governance systems – this breaches the requirements of their contract.

For instance, none of us would want to be treated in a practice where staff aren’t aware of a nurse’s career history, or whether she has been CRB checked. The same would go for a surgery where staff have no training or professional development, or where there is no feedback to improve services.

In many of these cases, GPs might be up to date with their clinical skills, but let down by a lack of organisation. The CQC gives these few practices a wake-up call, which previous systems failed to do.

The CQC is an essential component of the reform that has seen commissioners drive down contract prices and providers cut costs to stay in business. It was created to safeguard quality and give an independent, consistent and uniform view on quality of care, and it is succeeding in doing so, even though it still faces a significant challenge to prove this.

The CQC’s regime is far more effective than that run by PCTs, and I’ve witnessed this first hand working with the new regional managers on behalf of my LMC. We formed an early alliance to get an insight into how they would tackle inspections so we could advise practices on how to prepare. We also invested heavily in workshops and reference material. CQC managers and inspectors in turn have been sensitive in introducing this regime and sympathetic to practices as they adapt to the new requirements.

We don’t need to fear an organisation that is committed to quality and high standards. Instead, we should turn this to our advantage by lobbying for resources to improve our practices.

Peter Higgins is chief executive of Lancashire and Cumbria LMC.

NO

The CQC’s method of prioritising box-ticking over improving quality of care will never make for a robust inspection process. Much of its inspection regime is built around looking at statistics that are seldom put in context. Take the scurrilous ‘risk ratings’, which should have been an internal management tool and yet were published with little explanation, damaging practice reputations. Some of the criteria are bizarre – it’s still not clear why ratings are reliant on QOF results for retired indicators when the framework is voluntary.

The damage of a poor CQC report is immense. Although practices put in ‘special measures’ are given support, no amount of extra help will make up for the negative consequences of being publicly named and shamed. Recruitment is already difficult and it’s hard to imagine good staff wanting to work in a practice tainted by a negative report.

Moreover, you only have to look at the plethora of expensive software solutions designed to help practices pass inspections to realise there is real paranoia among GPs about preparing for a review. Does the CQC think the time spent drawing up a stack of protocols filed in the back office has done anything but take resources away from the job of looking after patients? 

We also must not forget that the cost of inspections is detrimental at a time of severely falling GP incomes. GPs are the only NHS doctors who have to pay for inspection. We get no reimbursement.

What the CQC is failing to measure is the one factor that really matters – the quality of the consultation. Various proxies for consultation standards – QOF scores, patient feedback ratings, NHS Choices feedback, and the Friends and Family Test – are all likely to misleadingly suggest low quality because they take place without moderation, checks or balances. CQC inspections check whether you’ve got the right drugs in the cabinet, but can do little to ensure that a GP is prescribing these properly. They check how many internal meetings a practice has recorded, without any idea of what has been discussed. I accept that the CQC is trying to move away from this to talking to staff and patients, but the protocols are still required.

CQC inspections would work much better if inspectors dispensed with the tick boxes and sat in consulting rooms, congratulating their colleagues on the areas where they performed well, and advising on urgent improvements.

Dr Peter Swinyard is a GP in Swindon and chair of the Family Doctor Association. 

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Readers' comments (13)

  • "Peter Higgins says-
    The actions of inspectors are consistent, proportionate and fair in most circumstances."

    That's not the feedback we get at the practice managers group, reporting back that inspectors seem a law to themselves and each different inspector deals with things very differently, often pointless bureaucratic over trivia. I totally dispute that they are consistent and proportionate. Some inspectors are failed managers who seem determined to prove themselves by causing trouble for people who are genuinely able to manage.

    "Peter Higgins says-
    Even though our profession has labelled inspections as another drain on precious time, the vast majority of practices sail through with little trouble."

    What? Have you got absolutely no idea of the VAST amount of practice management time that has been consumed creating paperwork for the CQC? The high level of worry and stress that is being caused? Little trouble? I can't believe you said that.

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  • I have lost weeks of my life to stress of inspection. Practice risk rated Band 1. Local newspaper rings me up asking 'what's gone wrong? Why are you failing?' The day they were published. Have spent hours diffusing patient concerns and worries. Inspectors arrived the week after Xmas- we got 'the call' on 22 December. Christmas was cancelled.

    As practice manager I was interrogated relentlessly from 8:30 am to 2:30 pm by three different members of inspection team, without pause for lunch, a cuppa or even a pee!

    So stressful. It's set back our business development plan by at least 3 months, including planned changed to appointment system, which has arguably worsened the patient experience.

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  • I would echo "anonymous, practice manager 10.16pm". We too had band 1, based on outdated QOF and prescribing data not reflecting current performance. We are about to spend days/weeks working to address the mostly bureaucratic issues picked up by the inspectors.This to be added to the hours already spent scouring the draft report spotting and evidencing inaccuracies and reporting back. Meetings with the CQC, LMC, CCG, PPG... all while trying to maintain the day job.

    I can't say that our experience locally is that inspectors are consistent. While they have a "crib sheet" to work to, it seems that other issues gleaned and interpretation of practice and culture are entirely open to the personal difference of each inspector. We cannot be inspected and rated based on opinion of anyone other than the people that matter - our patients.

    Exhausted, disheartened and disappointed.

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  • "Cqc gave us a glowing report" . As someone who had worked in that practice i can tell you thier care ( they didnt much) was crap.
    " cqc gave us a list of things to do" actually they are a fantastic practice .... They just care more about patients than ticking boxes. Again i' d worked in the practice. They were clinicians, good ones, not beaurocrats.

    I offered to talk to the inspectors once, they listened , (they had no choice cos i stood in front of them and demanded thier attention... )...But they said they didnt take any notice of what anyone but the practice team and what the patients said, and i was there as a locum gp so knew nuffink.

    Even as a partner they couldnt be bothered with what i said as i was not the senior partner

    So the truth of cqc is they are not abt good caring clinical practice they are about how good the manager and senior partner are at ticking boxes, producing paperwork, and talking the talk. They dont even pretend to care about good clinical care.

    Not fit for purpose, not evidence based, no evidence of actual outcomes, huge evidence of harm resulting from thier descents.

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  • I've only read the headline so far, but I already know the answer. It's 2 letters, beginning with "N".

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  • NO NO NO NO...4 months on we are STILL waiting for our report.... this is after and incorrect banding which was corrected ..you cannot argue with evidence ,,, I spent from 7.30am to 9pm with this rabble on the inspection day but they had no idea.......no wonnder we are all leaving,,,,,those who say yes I have to ask what planet are they on?????

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  • No. Perhaps inspecting their own invested interests might give a rating. The cqc drive business - disposable curtains, alarms, lockable cupboards, fires safety inspectors, infection control companies, drb (!!!) and a whole myriad of hawks who have nothing to do with me and the patient. Funding drops and this is a sinister way the government will make you invest out of your own pocket in UK general practice. All very murky.

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  • The injustice of the NHS is compounded by the CQC. One practice gets over £500, another £ 90 per patient, yet they are both compared like for like and the poor £90s get a slating to add insult to injury. I just hope GP land comes to collapse soon - it is so discriminatory and unfair.

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  • " none of us would want to be treated in a practice where staff aren't aware of a nurse’s career history, or whether she has been CRB checked"

    Speak for yourself. I grew up in a world where people trusted each other and were considered innocent until proven guilty.

    "GPs might be up to date with their clinical skills, but let down by a lack of organisation" ....or perhaps completely overwhelmed by continuing government micromanagement and yet another NHS reorganization?

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  • "For instance, none of us would want to be treated in a practice where staff aren’t aware of a nurse’s career history, or whether she has been CRB checked"

    How on earth did we manage for decades without it? Answer that Dr Higgins.

    Oh yes, Dr Harold Shipman would have passed CRB, so a fat lot of good that would have done.
    In fact I expect his patients' adoration would have gained him a glowing CQC report.

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