Last reviewed 9 November 2015
The Care Quality Commission (CQC) has published its first report on the state of health and social care since it first adopted its new inspection system. Martin Hodgson looks at the key findings of this report and considers the future challenges it outlines for primary care.
The CQC’s recently published report on The state of health care and adult social care in England 2014/15 is the first since the implementation and roll-out of the new CQC inspection and rating system. This new system has seen inspectors visiting services and applying a five key question test to assess the extent to which services meet Fundamental Standards of care. Inspectors then arrive at an overall rating for each service where regulated services are provided.
Although the CQC’s report only covers the period between 1 April 2014 and 31 May 2015, and has not yet rated all services, the latest report provides an early opportunity under the new inspection regime for the CQC to draw some conclusions about the quality of the services they are responsible for regulating.
Key to reading the CQC report is the grading system that has been a central part of the new inspection system. Ratings are based on the five key question test, which asks if a service is:
Once inspectors have reached conclusions regarding each of these questions, services are given a rating, which is one of: “outstanding”, “good”, “requires improvement” or “inadequate”.
The CQC has taken the overall results across all sectors and come to the conclusion that the new inspection regime is having a positive effect in driving up standards, stating that many services rated as requiring improvement actually do show improvement on a re-inspection. The report also shows that, during the period studied, inspectors moved to stop the provision of poor service by taking 1,179 enforcement actions. This included 63 non-urgent cancellations of registration, and 27 urgent suspensions.
Results for primary care
The report states that 85% of GP practices were rated as “good” or “outstanding” in the period covered. CQC remark on “many practices finding innovative ways of meeting the needs of their local population.”
CQC report fewer than one in eight practices needing improvement and a “small proportion” (4%) of GP practices being rated as inadequate. They comment that, while this represents a very small number of providers, the quality of care in some cases was “shocking” and in all these cases enforcement action was taken.
The report states that GP practices deliver a better quality of care when “sharing learning” takes place and “joined-up care through multi-professional networks” is provided.
Features identified in the report as common in “outstanding” practices include:
effective leadership — manifested in a strong shared vision among practice staff, effective staff training and support, and a positive, patient-centred culture
effective working with multi-professional colleagues, including those from other organisations
extra services empowering patients to self-manage long-term conditions and acute minor illnesses
support for patients and carers with their emotional needs.
Features common throughout inadequate practices include:
isolated working – not working closely with other local services to share learning and provide a wider mix of services
a lack of vision for the organisation and clarity around individuals’ roles and responsibilities
a poor culture of safety
disregard for HR processes (for example, Disclosure and Barring Service checks)
limited access to advice and treatment
lack of practice nurses or very low number of practice nurse sessions.
When reading the report, it must be noted that the CQC only started applying the new test criteria to primary medical services (including GP practices and out-of-hours services) in October 2014. As such, the report only captures data concerning 976 providers, or 11% of the sector.
The report also acknowledges that 2014/15 has seen health and social care systems and organisations coming under increasing pressure from changing care needs and financial demands on public services. In particular, the report notes the pressure on services to deliver significant efficiency savings while at the same time meeting the more complex needs of an older, changing population.
The report notes that of CQC’s key questions, providers were most likely to receive an “inadequate” rating for the key-question on safety. The report states that this included 6% of primary care services, while an additional 25% of GP practices and GP out-of-hours services rated as “requires improvement” on this question.
CQC state that poor ratings for safety in primary care most commonly involved:
failures in investigating incidents properly and learning from them to prevent them from happening again
ineffective safety and risk management systems
evidence of poor medicines management.
The report also states that, according to inspection results, there is a direct correlation between the quality of leadership in a service and the overall quality of a service. CQC analysis reveals that ninety-four per cent of services rated as “good” or “outstanding” overall also received these grades for their leadership. Similarly, 84% of services rated as “inadequate” overall also scored poorly for their leadership.
CQC interpret this as showing that the way in which an organisation is led, and the culture and values that guide it, have a deep and far-reaching impact on the overall quality of service that people receive. They conclude that good leadership at all levels of an organisation is required to deliver care that is consistently safe, effective, caring and responsive.
Looking to the future, the report suggests that the problems that have put so much pressure on primary care services in recent years are unlikely to improve and that regulated sectors will face “significant challenges” in the next few years.
The CQC state that, in order to survive, services will require “resilience, innovation and creativity” supported by “great leadership.” They raise concerns that many services “do not yet have the leadership and culture required” to deliver safe, high-quality care.
The regulator urges providers from all health and social care sectors to:
build a “collaborative culture” that reaches out to service users
be “open and transparent,” learning from mistakes and ensuring information and data are to hand to make good decision
ensure that services have the right “staff and skill mix” in place to ensure that care is always safe.
The report states that the CQC are “highly supportive” of NHS England’s Five Year Forward View strategy and recognises that, in many parts of the country, the best care systems are those where “health and social care go hand in hand.”
In particular, the regulator states that it supports collaboration where good services share their experiences with others that want to improve.
Responding to the report, Royal College of General Practitioners (RCGP) Chair Dr Maureen Baker said: “Yet again, the headlines present a very distorted view of what is really going on: that the overwhelming majority of GP practices are doing an excellent job of delivering safe care to the highest possible standards.
“Patients — and GPs — can be reassured that over 85% of GP services inspected so far have been rated “good” or “outstanding” and 96% of GP services were rated “good” or “outstanding” for caring.
“Where practices are struggling to meet quality standards, it is often due to factors beyond their control, such as lack of funding, significant increases in patient consultations and difficulties in trying to recruit sufficient GPs to meet patients’ needs.
“The biggest threat to patient safety is tired doctors and GPs are worn out as a result of working flat out to manage rocketing patient numbers with ever dwindling resources.”
Dr Baker refers back to “flawed band ratings” which severely undermined the confidence of GPs and patients in the CQC inspection system and suggests that more work still needs to be done to repair the damage caused. She also calls for the CQC to focus on the issues that are really important to general practice and to work with the RCGP to ensure that practices are appropriately resourced.