Last reviewed 29 May 2014

Last year the Care Quality Commission (CQC) published a new strategy, Raising Standards, Putting People First — Our Strategy for 2013 to 2016. The document looked forward to a range of improvements in the way that the CQC goes about inspecting and ensuring the quality of registered health and social care providers in England, including primary care services.

The strategy was written in response to a number of high-profile care failures. In it, the CQC stated that it would change its inspection process and introduce a new test for services, centred around five key questions.

  • Are services safe?

  • Are they effective?

  • Are they caring?

  • Are they responsive?

  • Are they well led?

The changes relating to primary care were originally published in A Fresh Start for the Regulation and Inspection of GP Practices and GP Out-of-hours Services. This was followed, on 9 April, by the CQC publishing new inspection handbooks for each sector and announcing that it was consulting on the contents pending implementation in October.

What are the proposed changes and what will primary care CQC inspections look like in the future?

Applying the five key questions to general practice

A Fresh Start and its follow-up handbooks provide guidance on the application of the five key questions with respect to primary care. The CQC states that these are based on the principle of looking at the things that matter to the people who use the services.

For example, asking if services are safe will include checking whether:

  • practices and clinics are clean and safe

  • medicines are managed properly

  • people are supported by practice staff, particularly those who are in need of safeguarding

  • practices learn from safety incidents, such as prescribing errors or missed diagnoses.

Asking if services are effective will include checking that:

  • patients are given the right diagnosis and treatment

  • the care of patients with long-term conditions is managed well

  • patients are referred properly to specialist services

  • patients and those who care for them are involved in decisions about their care.

Asking if services are caring will include checking that patients are treated with:

  • compassion

  • dignity

  • respect.

Asking if services are responsive will include checking:

  • whether practices assess and respond to the needs of the local population, including in relation to access to appointments

  • how the practice responds to feedback from people, for example through having an effective patient participation group

  • how medical records are stored and shared with the patient and other services.

Asking if services are well led will include:

  • checking that staff are supported and provided with training and supervision

  • looking at how well the practice works with other health and adult social care services in the area.

Putting people first

Inspectors are being asked to put people at the heart of their work and to look at how well services are provided for the following specific population groups.

  • Older people.

  • People with long-term conditions.

  • Mothers, babies, children and young people.

  • The working-age population and those recently retired.

  • People in vulnerable circumstances who may have poor access to primary care, for example homeless people, gypsies and travellers, and people with a learning disability.

  • People experiencing a mental health problem.


Inspectors will agree a rating for each practice. Judgments will be made whether the care provided at a practice is:

  • Outstanding

  • Good

  • Requires Improvement

  • Inadequate.

The overall rating will be built up from ratings for each population group of patients looked at and, within this, for each of the five key questions.

For practices to be Good or Outstanding, they will have to demonstrate that they are compassionate, caring, open, transparent, that they learn from their mistakes, seek to make sure there are no barriers to accessing care for the practice population and have a person-centred approach to care.

Ratings will be published so the general public can see them. The CQC will begin to publish ratings in October 2014 and all GP practices will be rated by April 2016. The CQC will expect practices to publicise the outcomes of inspection to their patients.

Key lines of enquiry

The five key question test will be supported by “Key Lines of Enquiry” (KLOE). These will consist of a series of mandatory and discretionary questions, which will be used by inspectors to inform their judgments.

The KLOE are set out in appendix B of the consultation handbook. They help to describe what an Outstanding, Good, Requires Improvement or Inadequate practice looks like in the context of each of the five questions.

KLOE will inform the making of consistent ratings judgments by inspectors, which will be based on a mixture of local information gathered about a provider, onsite inspection and what the CQC calls "intelligent monitoring".

Intelligent monitoring

Intelligent monitoring involves the CQC using various methods to collect information about a service and give inspectors a clear picture of how care is being delivered and what may need to be followed up.

People's views will be gathered from a range of sources, including:

  • national patient surveys

  • individual comments received from the public

  • partner organisations

  • local voluntary and community organisations

  • local Healthwatch

  • patient participation groups

  • carer groups and local NHS complaints advocacy services

  • holding drop-in sessions for patients

  • using comment cards placed in reception areas.

The CQC will also test approaches to gathering views from the public, including focus groups or listening events, social media, questionnaires and surveys of local organisations.

Expert-led inspections

A rolling programme of waves of inspections in each Clinical Commissioning Group (CCG) area across England has already begun. In these inspections, the new model will be tested and the CQC will gather feedback from GPs and from patients.

The guidance states that inspectors will visit each CCG area typically once every six months to inspect a number of practices within that area. By April 2016, the CQC aims to have inspected every practice and will consider how to link inspection frequency to ratings after this.

In addition to individual practice inspections, the CQC states that it will also look at themes across CCG areas. Examples provided by the CQC are out-of-hours care, the use of medicines in care homes and access to mental health services.

Inspections of practices will be led by expert inspectors with clinical input led by GPs. The guidance states that inspection teams will include an inspector, a GP, a nurse and/or a practice manager and a GP Registrar.

GP practices will usually get at least two weeks’ notice of the date of their inspection. Inspectors may return to some practices already inspected to follow up on any concerns identified in previous inspections.

An inspection manager will lead the inspections across each CCG area.

Care provided across services

The guidance states that one of the most important roles of the Chief Inspector of General Practice will be to oversee how well care services work across different sectors when more than one type of care service is involved.

Due to the importance of general practice in this respect, as part of a fully integrated local care system, there will be a particular focus on how GPs and other practice staff work with other health and social care providers.

Responding to poor care

The CQC states that it will use the full range of enforcement powers available to it in response to primary care services that provide poor care to make sure they improve. These will be used in conjunction with new government regulations that will set out "fundamental standards", below which the quality of care must not fall.

Other organisations, such as NHS England Area Teams and CCGs, have a role to play in monitoring the quality of GP practices, and the CQC states that it will be working to develop its relationship with them so that activity is not duplicated.

GP out-of-hours services

Comparable processes will apply to GP out-of-hours services. However, in completing inspections, the guidance states that the CQC recognises that out-of-hours care is part of a wider system of urgent care services, such as walk-in centres, minor injury units and A Inspections of services will therefore consider the quality of communication between out-of-hours care and other local services, including GP practices, care homes and emergency services.

Inspections of GP out-of-hours services will be incorporated into CCG area programmes.

Timetable for implementation

According to the CQC, evidence from both the consultation and the current wave of inspections will be used to refine the approach taken for subsequent waves, which will start in July. The new approach will be fully implemented from October 2014.

The CQC will continue to work closely with NHS England nationally, and with CCGs and Area Teams locally, in the development of the new inspection framework.

New fundamental standards

The Francis Inquiry report recommended the introduction of new fundamental standards of safety and quality, below which care should never fall. A proposed set of standards were included in draft regulations; these were subject to a consultation, which finished in April.

The draft Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 are intended for enactment in October, when they will replace the current essential standards of quality and safety.

Further information

The NHS GP Practices and GP Out-of-hours Services Provider Handbook and details of the current consultation can be found on the CQC website.