According to the first major evaluation of the CQC’s ‘Ofsted-style’ regime, GP practices that receive a negative response or rating after an inspection do not have the the support they need and struggle to respond to recommendations. In some cases, this has left practices with no choice but to close.
The report by the King’s Fund says: ‘It can be the case that GP practices that receive an enforcement action or an "inadequate" rating are those that do not have the capability or resources to respond, and cannot make progress.
'In some instances, these can be single-handed practices where the GP realises that they cannot continue to practise any longer or are unable to make the necessary improvements. They will voluntarily cancel their registration, retire or merge the practice into a larger practice that can support them.’
GPonline reported last year that of 329 GP practices placed into special measures following the first round of CQC inspections in general practice, 68 - more than one in five - closed down. Many were able to improve, however, with more than 40% initially placed in special measures recovering to achieve 'good' or 'requires improvement' status.
GPC chair Dr Richard Vautrey said ‘historic underfunding’ and lack of support from local CCGs - or previously PCTs - had left some practices with no choice but to close.
In one case where the CQC inspected and then closed a GP practice, staff working in the local health system said they had been aware of performance issues but ‘didn’t have the evidence or power to address it’, the King's Fund report found.
A member of CQC staff quoted in the report said: ‘Strangely people came forward and said oh yeah, we always knew they were rubbish. All the GPs in the area knew that they were really poor, NHS England knew they were poor, the CCG said we knew they were poor, but we didn’t have the power to do anything about it.’
This, the report argues, highlights the potential for CQC to 'develop its model in different ways in each sector' and the importance of ‘investing in recruitment and training of [CQC] staff to create an inspection workforce with the credibility and skills necessary to foster improvement through close relationships.’
Dr Vautrey added: ‘Inspections can be disruptive for practices and their staff, and the associated workload takes GPs away from providing direct patient care. It is therefore positive that this report recognises the flaws in this system and proposes that regulators’ efforts would be better spent providing ongoing support and dialogue with practices in order to ensure the best care for patients.’
Only a small number of practices faced potential closure following a CQC inspection, with just 2% of practices deemed 'inadequate' from 2013-2017. A total of 8% were rated 'requires improvement' and the vast majority (83%) were rated good or outstanding.
Dr Vautrey described this as ‘testament to the hard work of GPs and their teams’.
Ruth Robertson, report author and senior fellow at the King’s Fund said: ‘Although we heard general support for their new approach, we also uncovered frustrations with the process, some unintended consequences and clear room for improvement.
Impact on quality
‘We found that the CQC’s approach works in different ways in different parts of the health and care system. When the CQC identifies a problem in a large hospital there is a team of people who can help the organisation respond, but for a small GP surgery or care home the situation is very different. We recommend that the CQC develops its approach in different ways in different parts of the health system with a focus on how it can have the biggest impact on quality.’
CQC chief executive Ian Trenholm said: ‘Unsurprisingly, this [report] highlights the complexity of our role in encouraging improvement within the wider set of influences on provider performance; not least the provider’s own improvement capability, and the availability of external improvement support.
‘We know that people do not access health and social care in silos and need a regulatory model that is able to drive up quality across systems and it is good to see this explicitly recognised by the report. We are already placing greater emphasis on relationship management, the development of system-wide approaches to monitoring quality, and the introduction of CQC insight and intelligence driven assessment to make sure we meet this need.'
The report found that the CQC system of inspection only had ‘small and mixed effects’ on performance indicators in general practice.