The CQC brings ‘fear and panic’, and can push primary care staff to consider resignation — even when the eventual outcome is positive. Continuing our investigation into the dire impact of a CQC inspection, GPs who have undergone the ordeal explain why the system needs urgent reform
Splashed across the front page of the Shropshire Star was a story to strike fear into the hearts of patients.
‘Nearly one in six GP surgeries in Shropshire are to be fast-tracked for new Government inspections next year after concerns emerged about patient care,’ it begins.
Below was a list of 11 practices that had been earmarked through CQC (Care Quality Commission) intelligent monitoring as being of ‘highest perceived concern’.
Among them was the Belvidere Medical Practice in Shrewsbury.
The Belvidere, like more than a quarter of practices in Shropshire, was rated ‘outstanding’ by inspectors who visited the following summer. This news also made the Shropshire Star but, funnily enough, it did not get such prominent placing as when the original list was published in November 2014.
It is just one of the reasons why Mary McCarthy (pictured below), a GP at the practice and Shropshire local medical committee chair, loathes intelligent monitoring, which she considers neither intelligent nor good at monitoring.
‘At best the data is misleading. At worst it’s inaccurate,’ she says. ‘And it’s all part of a phenomenally awkward process that starts off with the assumption that you are failing.’
Dr McCarthy was running a hospital diabetes clinic the day the inspectors came, but she witnessed the panic and paranoia in the run-up to the inspection.
‘The team really went to extraordinary lengths, working weekends and into the nights, to make sure everything was exactly as it should be,’ she says. ‘The cleaner was brought in three times a day to make sure everything was spotless at all times.
‘The sheets I used to preserve patients’ modesty during examinations were whipped away and replaced with paper. People were incredibly nervous.’
Although her team was rated ‘outstanding’, Dr McCarthy says she has as little faith in this judgement as she did in the ‘intelligent’ data that red-flagged her practice in the first place.
‘There’s a saying in Ireland: “You don’t increase the weight of a pig by weighing it.” And I think, similarly, CQC inspections simply instigate a culture of fear that adds nothing to general practice and, if anything, has an adverse effect.’
Spirit of fear
When Mark Corcoran (pictured, below right) heard the date of the CQC pilot inspection at his Bristol practice, he had mixed feelings.
He realised with relief that he would be on annual leave that day in August 2014. But he also felt guilty that his colleagues would have to shoulder the burden and stress.
‘My experience with CQC inspectors is that they come with a negative attitude, looking for problems,’ says Dr Corcoran, who is the Avon LMC chair as well as a GP partner at Christchurch Family Medical Centre in Bristol.
‘It creates a spirit of fear and panic, and that in itself is quite destructive even if a practice is extremely well prepared and has a wonderful presentation.’
Eight hours of face-to-face patient care were lost on the day of the inspection at Christchurch Family Medical Centre, a not insignificant loss for a practice, like so many others, that is struggling with a fast-growing list, increasing workload and a nationwide recruitment crisis.
Home visits were delayed and paperwork left to the following day despite the best efforts of the team to ensure patients were not affected.
‘When I came back my colleagues were emotionally exhausted,’ says Dr Corcoran. ‘They had started first thing in the morning and continued long after hours. It was very draining for everybody.’
Because the new regimen was still being trialled, no rating was given but staff were told they would have been rated ‘good’ with some ‘outstanding’ elements.
However, that cuts little ice with Dr Corcoran, who has counselled many a traumatised healthcare professional through his LMC work.
‘It’s not a formative process; it’s a hostile, combative process, which is regrettable,’ he says.
‘One practice nurse I spoke to was shocked by the negativity of a nursing inspector who harangued her for two hours until finally the nurse said “Hang on a minute. I thought I was supposed to have the opportunity to show you the good things we do here too”.’
Another practice told Dr Corcoran that it would have to be reinspected because a box of hypodermic needles was out of date by less than a week.
‘OK, it was almost a week out of date. But this seems quite a trivial thing when in every other way the practice was brilliant,’ he says.
Although Dr Corcoran has high praise for the CQC’s lead inspector in the area, Odette Coveney, who has been helpful and approachable in reviewing some of the controversial judgements of her team, the regulator itself is not fit for purpose, he says.
‘I think LMCs should inspect practices,’ he says. ‘They are statutory organisations that have existed before the days of the NHS and their original purpose was to maintain appropriate standards in general practice.
‘Most importantly, they would work with practices to improve patient care rather than obsessing over rituals and procedures, minutiae and micro-management.’
Don’t crack jokes with CQC inspectors.
That’s what Helen Mutch learned the day her Bristol practice was examined by the regulator.
The lead inspector wanted to know why she did not have a sign in her room offering patients a chaperone.
Dr Mutch, who has been a GP for 25 years, pointed out that there were chaperone signs in the waiting room and the corridors and that she always offered one to her patients and they always declined.
‘By the time they get behind the curtain and take their clothes off the moment’s kind of passed,’ she said with a chuckle. ‘But maybe we could put a poster on the ceiling saying: “It’s not too late to ask for a chaperone.”’
The lead inspector did not seem amused. ‘I thought she might at least smile, but nope, not a flicker,’ laughs Dr Mutch, six months on from the dreaded inspection.
‘It was a horrible day, one of the worst I can remember,' says Dr Mutch. 'We were expecting a rigorous inspection; we were expecting it to take the whole day. But we weren’t expecting such relentless negativity and criticism.
‘At no point did the lead inspector say “Yes, that’s great” and move on. It was always “Yes, that’s good but you could do better”.
‘By the end of the day the morale of the team was crushed. We really felt demolished.’
The staff were convinced they were about to be rated ‘requires improvement’ but after an agonising three-month wait — during which the practice manager considered resigning — the practice was rated ‘good’ overall.
Indeed, it was rated ‘good’ in all categories except for safety, which was given an orange blob for ‘requires improvement’.
The practice is challenging this assessment which, Dr Mutch says, is owing to uncompleted Disclosure and Barring Service checks on a volunteer (who ultimately never took up the role) and a receptionist who has worked at the practice for more than 20 years.
‘She is not clinical staff so it seems a bit unfair to deem us unsafe,’ says Dr Mutch.
Taken for granted
The practice has also submitted a request for the overall rating to be reviewed.
One of the many reasons is the lack of credit it has received for its patient champion, a member of staff who coordinates self-care initiatives to improve the health of the community.
The patient champion is shared with three other local practices, all of which got an ‘outstanding’ mention in their CQC reports for the scheme. However, there is no ‘outstanding’ mention for the Lennard Surgery, which spearheaded the scheme in the first place.
‘The nursing inspector also told us our advanced nurse practitioner, who does our acute visiting, gave outstanding service,’ says Dr Mutch. ‘But none of her comments are mentioned in the final report. It’s as if she was never even there.’
Dr Mutch says she was not surprised by the comments of CQC chief inspector of general practice Professor Steve Field last December when he said that GPs had failed as a profession.
‘The inspectors are actively looking for poor practice,’ she says. ‘When they see excellent practice, it is taken for granted. They certainly don’t celebrate it.’
Few things have undermined public confidence in GPs quite so unfairly as intelligent monitoring.
By its own admission, the CQC’s system for prioritising inspections is a simplistic tool.
It uses data from QOF, the GP Patient Survey and other sources to compare diagnosis, prescribing and referral rates, patient feedback and other factors in England’s 8,000 practices and flags up anomalies that may indicate poor standards.
What it cannot do is judge quality, differentiate between demographics that could skew the statistics or recognise practices that have opted out of QOF on NHS England advice.
So GPs were understandably appalled in November 2014 when the regulator used it to rank practices according to the risk they might pose to patients — and then published that information before the practices had even been inspected.
‘One-in-six GP surgeries is failing,’ was the inevitable headline in the Daily Mail.
Almost immediately the CQC had to apologise for wrongly identifying 60 practices as high risk using the system.
Four months later, the regulator apologised to GPs across the country and announced it was scrapping the risk bandings altogether after the BMA pointed out the folly of branding practices a risk to patients based on crude, and often flawed, data.
BMA GPs committee deputy chair Richard Vautrey says: ‘We pointed out from the beginning that some practices placed in the worst category had abnormal patient populations, for example, and others could be explained by natural variation in the data.
‘It was frustrating that they took so long to recognise the accuracy of what we were telling them. For many practices the damage was done by then.’
The CQC now uses the intelligent monitoring data only to identify ‘large’ or ‘very large’ variations ‘for further inquiry’ with no presumption that these put patients at risk.
Dr Vautrey says: ‘It is certainly an improvement from the original iteration but the criteria are still very narrow, giving no insight into quality from a patient and clinical perspective.
‘We would like to see a much better system of reviewing GP practices and not just another stick to beat them with.’