In every profession there are a few bad apples. In mine, perhaps more than a few.
And general practice is no different. There has been talk for years of ‘unacceptable variation’ between practices. Former RCGP president Sir Donald Irvine spoke of the situation in the 1980s, in his book The Doctor’s Tale. ‘It was all very well for the patients of good practices, but hardly right for those who were not,’ he wrote.
True, although the reasons are rarely as simple as a binary ‘good-bad’ distinction. The variation in practice funding was smaller in Sir Donald’s time – no PMS or APMS contracts, no QOF or MPIG. Sure, there were demographic variations, but not the widening inequalities or the burden of complex disease that today’s practices must cope with. Nor was the whole health service struggling with the longest and most damaging budget squeeze in its history.
But despite this complex picture, the CQC inspection regime carries on slapping labels on practices. After two and a half years, Pulse reveals todaday the final results of the first wave of CQC inspections. The vast majority of practices have been found to be ‘good’, but one in 10 has been labelled as ‘requiring improvement’ or ‘inadequate’.
Of course, the CQC would argue that someone has to scrutinise practices and tackle instances of bad care, and that its very presence has encouraged practices to up their game. But arguably, publicly labelling a practice as failing worsens its predicament, making it harder to improve, retain staff and apply for additional funding. Yes, the CQC has a ‘special measures’ regime whereby a practice can access additional support – at a price – but by then the damage may have already been done. There is little appreciation that a practice may be struggling for other reasons, and it may simply not be in a position to meet all the CQC’s requirements.
Indeed, many would argue the CQC measures the wrong things. Of course having care plans in place, regular staff appraisals and checks on the vaccines fridge are important, but can these truly measure quality of care? And as well as the potential damage caused by a bad rating, is there not also a risk of complacency if a practice has a good rating?
And there is an opportunity cost. Not just the £100m spent on the inspections programme, but also the hours of preparation by practices, the appointments cancelled on inspection day and the energy poured into compliance that might have been better used elsewhere to improve patient care.
Add to this a recent BMA survey that found a quarter of GPs are less inclined to raise concerns about practice pressures for fear of CQC intervention, and a picture starts to emerge of a commission that, despite its stated intentions, may have effectively made general practice less safe.
Now I don’t expect the CQC to listen to me – I wouldn’t be surprised if my face is pinned to a dartboard in somewhere in its office – but I do challenge the commission to take a long hard look at Sir Donald’s words. If all this is about improving patient care, then surely the CQC has a duty to ensure it is not making things worse.
Nigel Praities is editor of Pulse