Martin Hodgson looks at what intelligent monitoring is and how it relates to Care Quality Commission (CQC) inspections and ratings.
The CQC has published its first set of intelligent monitoring data relating to general practice. It stated that the publication has generated “considerable interest” from the public and the media, and that it will repeat the exercise and update the data on a quarterly basis.
The new CQC inspection regime
Intelligent monitoring is part of the new inspection regime being introduced by the healthcare regulator.
The new system was introduced from October following the publication of A Fresh Start for the Regulation and Inspection of GP Practices and Out-of-Hours Services.
The approach is based on inspectors asking five “key questions” about each GP practice.
Is it safe?
Is it effective?
Is it caring?
Is it responsive to people’s needs?
Is it well led?
Inspection teams are larger than before and include clinical experts, other professionals and “experts by experience.” Following inspections, a rating for each service provider will be agreed and judgments will be made on whether the care provided is:
The overall result will be built up from ratings for each of the five key questions.
In the new inspection system, the CQC says that it will make more systematic use of people’s views and experiences, including their complaints.
Intelligent monitoring involves the CQC using various methods to collect such information about a service prior to inspection, providing inspectors with an idea of how services are being delivered and what may need to be followed up during a site visit.
People's views are gathered from a range of sources, such as:
individual comments received from the public
local voluntary and community organisations
clinical commissioning groups (CCGs) and NHS England area teams
local Healthwatch teams.
Intelligent monitoring is designed to help the CQC to identify the areas of greatest concern and prioritise their inspections.
The CQC analysis
Drawing from the intelligent monitoring already completed, the CQC published its analysis of various sources of publicly available evidence on general practices.
The CQC states that it did this to show that it is an “intelligence-driven, independent, open and transparent” regulator.
The CQC analysis of the data placed 7276 general practices into bands numbered one to six according to the risks identified on thirty-eight risk indicators. Band one indicates the highest perceived risk and band six the lowest. This enabled the CQC to conclude that the majority of practices are of low concern with over half, almost 3800, placed in band six and 82% (6076 practices) placed in the lowest four bands.
The original analysis placed 864 practices in band one, and 336 in band two, meaning that the intelligent monitoring analysis raised concerns about these practices.
The CQC stated that the 1200 practices in bands one and two would be considered for follow-up and inspection from next year.
Risk indicators included such factors as:
unnecessary A&E admissions
high use of antibiotics
coronary heart disease incidence
emergency cancer admissions
not hitting flu vaccination targets
how sleeping pills are prescribed
dementia diagnosis rates.
However, December saw the CQC write to practices saying that, following work with NHS England, it had reviewed its data and, as a result, had made a number of changes. It claimed that the vast majority of GP practices are not affected by these changes but that 60 practices previously placed in bands 1 and 2 will now move to bands of lower priority for inspection. It also apologised for the concerns raised.
In its press release, the CQC underlined the fact that the bandings from the intelligent monitoring analysis did not represent formal ratings judgments as these can only be made following inspections.
Initial reaction to the analysis saw some misinterpretation that the analysis represented a “league table” related to ratings judgments. Some questioned whether the information should be published at all.
In a statement released at the end of November 2014, the CQC sought to clarify the status of the analysis exercise and explain its reasons for publication.
It stated that the analysis was not based on judgments of services, explaining that, under the new regime, judgments are only made following full inspections using the new five-question test; that is, whether services provide safe, effective, caring, responsive and well-led care. Following these inspections, general practices will be rated as Outstanding, Good, Requires Improvement, or Inadequate, and the results will be published on the CQC website. Ratings started in October 2014, and will be completed on a rolling programme over the next two years until all practices are inspected and rated.
The CQC stated:
“As we have always explained, inspection is at the heart of our regulatory approach and so we can only judge a service once we have carried out an inspection — ie when we have seen the service for ourselves.
“This — and only this — is our regulatory judgment of the service.”
The intelligent monitoring analysis does not represent such judgments. Instead it is focused on information already gathered about practices prior to their inspection.
The CQC also stated that they will continue to work with GPs, their representatives and patient-focused organisations — including the Royal College of General Practitioners (RCGP), the British Medical Association and the Patients’ Association — in developing the “intelligent monitoring tool” and explaining how it should be interpreted and used.
The CQC confirmed that the intelligent monitoring tool will also be reviewed following the methodology change that led to the adjustment in banding for a small number of practices.
In his letter to practices written on 5 December, Professor Nigel Sparrow wrote:
“We continue to review all the feedback that we have received and it is important to highlight that this is the first release of intelligent monitoring for GP practices and we will continue to develop the approach. We are clear that some aspects of GP practice activity do not lend themselves well to the use of metrics, which is why intelligent monitoring should be viewed as part of our wider approach which includes:
inspection teams with specialist knowledge of general practice
comprehensive key lines of enquiry for inspectors, which have been published
intelligence-sharing with CCGs, Quality Surveillance Groups, NHS England area teams, LMCs, GP practices and the public
data collection from other sources such as NHS England’s primary care web tool, local Healthwatch, Public Health England practice profiles.”
However, response from GP representatives has been critical.
Dr Maureen Baker, Chair of the RCGP, said: “This is shocking news especially for the GP surgeries who have been wrongly labelled, and for the patients whose trust in their family doctors has been cruelly shaken.
“It is ironic that a system that was introduced supposedly to support patients has left them confused and let down. The damage caused by this episode will not easily be undone.
“The publication of these over-simplistic bandings has stigmatised hard-working, family doctors, who are trying their hardest in very difficult circumstances to provide the very best care for their patients.
“To discover that the data on which these banding decisions were based is severely flawed will further demoralise our hard-pressed GPs and destroy any semblance of confidence that they had in the inspection system.”
Rolling programme of inspections
The CQC announced that it will be inspecting NHS GP practices in a range of CCGs during January to March 2015. These areas are listed on the CQC website.
The CQC has asked people who live in the areas being inspected to let them know about their experiences using their GP practices. It provides a “Share Your Experience” online form for people to respond, and will also accept feedback by phone and email.
Such information will form part of the “intelligent monitoring” that is intended to help inspection teams focus their work.
Details of the bandings analysis can be found on the CQC website.