The CQC’s inspection and monitoring methodology ‘may inadvertently disadvantage’ ethnic minority-run GP practices and lead to ‘inequities’, the regulator has admitted.
Ethnic minority-run GP practices are more often in deprived areas and therefore have lower funding and face greater health inequalities, a new report from the regulator said.
These practices are also more likely to be run by single-handed GPs, resulting in ‘challenges in support, resourcing and capacity’.
The report concluded: ‘Our primary purpose is to ensure that people receive safe, high-quality health and care services. However, some aspects of CQC’s inspection and monitoring methodology may inadvertently disadvantage practices due to the factors above, leading to inequities.’
It added that going forward the CQC ‘must ensure we are doing everything we can to encourage improvement, rather than risking perpetuating the cycle of inequality’.
CQC said it intends to focus on ‘ensuring that we reflect factors that could disproportionately (although not exclusively) disadvantage ethnic minority-led GP practices in our decision-making processes, without compromising on expected standards of care for people’.
‘These factors include operating single-handedly and professional isolation. This will enable us to recognise more responsive care and good leadership where a GP practice is operating in more challenging circumstances.’
The report looked at reviews of CQC’s data and processes, an online community of 36 ethnic minority GPs, a survey of 771 GP practices, a survey of 57 CQC inspectors and focus groups with CQC inspection teams (attended by eight inspectors, four inspection managers and four GP specialist advisors). It also discussed findings with ‘key stakeholders’.
Worryingly, the investigation suggested that ethnic minority GPs felt CQC inspections were intrusive, like a ‘threat’ and a ‘punitive process rather than an opportunity to review, learn and grow’.
They also felt that patients were ‘more likely to raise a complaint about an ethnic minority GP than a White British GP’ and that the CQC fails to understand the ‘unique challenges’ faced by ethnic minority-led practices.
And some felt reluctant to challenge CQC decisions due to ‘a possible risk of victimisation, poorer ratings or re-inspection if they choose to raise complaints’.
Also concerning, over a quarter (26%) of GP inspectors surveyed by the CQC perceived there was a difference in ratings for ethnic minority-run practices (although a larger share – 37% – disagreed, and a further 37% gave a neutral response).
The CQC’s survey of GP practices found that:
- Ethnic minority practices were more likely to say that GPs in their practice had suffered negative effects on their physical and mental health, personal and/or family life and an increase in staff illness ‘as a result of the inspection process’
- Ethnic minority practices were more likely to agree that ‘the quality of care improved following a CQC inspection, ‘as it can affect the practices’ ability to achieve national targets’ which the CQC use in assessments, for example vaccine or screening uptake
- 31% of ethnic minority-led practices agreed or strongly agreed their inspection outcome was adversely affected by ethnicity, compared with only 0.3% of non-ethnic minority-led practices
The report cautioned that ‘due to limitations in the data available to us from all partners in the system’ the CQC had been ‘unable to fully explore the nature of the relationship, or existence of any causal link, between ethnic minority-led GP practices and regulatory outcomes such as ratings and frequency of inspection’.
But it concluded: ‘The findings show that there is work for us to do to ensure we achieve our strategic and equality objectives and deliver our core purpose to ensure we encourage practices that need support to improve.’
British Association of Physicians of Indian Origin (BAPIO) GP forum chair Dr Kamal Sidhu said the CQC’s survey of ethnic minority GPs ‘confirms our concerns that inspections are simply a burden on general practice and a huge source of strain on the staff’.
He added: ‘It is unfortunate that so many feel unable to challenge CQC decisions despite their lack of confidence in the ratings.
‘This report must lead to meaningful change especially with massively overstretched and exhausted staff who have been working very hard throughout the pandemic.’
A survey by BAPIO last Autumn found that more than 70% of GPs from minority ethnic backgrounds would describe CQC inspections as ‘traumatic’.
BMA GP Committee chair Dr Farah Jameel said: ‘It is welcome that the CQC recognises that a one-size-fits-all approach to regulation, that focuses on outcomes without due regard for context, does not work, and that it has committed to look at its own processes to ensure that practices are supported, rather than penalised for challenges outside of their control.
‘This change in approach is vital for understanding the pressures all practices, including those run by ethnic minority doctors, are under.
‘We look forward to working with the CQC to ensure that these commitments are being followed through to support the profession, especially at this most challenging time, and to make regulation fit for purpose.’
Actions the CQC intends to take to reduce inspection inequality include
- As part of a new role inspecting Integrated Care Systems (ICSs), the CQC intends to ‘address where local systems need to provide more support to ensure that primary care meets the needs of everyone in their population’.
- Work to ‘understand the systemic factors that have the potential to adversely affect the ability of some ethnic minority-led GP providers to deliver high-quality, safe patient care and better health outcomes for their populations’.
- Reviewing ‘what can be done within the wider system to ensure that singlehanded practices are not unduly disadvantaged by the circumstances in which they work’.
- Reviewing ‘whether the current arrangements for supporting GP practices are effective for those in areas of deprivation that are experiencing disproportionate pressures, such as professional isolation and lack of funding.
- Consider how to ‘encourage and work with all GP practices to access support to improve’.
- ‘Review and refine’ how it assesses GP practices and reach judgements about quality and ratings, and ‘strengthen how we consider the context in which a GP practice works’.
- Reviewing how is uses ‘evidence about the efforts that GP practices are making to respond to the health inequalities of their practice populations as well as the outcomes of those efforts’.
- Ensuring to ‘reflect factors that could disproportionately (although not exclusively) disadvantage ethnic minority-led GP practices in our decision-making processes, without compromising on expected standards of care for people’, with factors including ‘operating single-handedly and professional isolation’.