UK general practice has operated in a largely scrutiny-free arena historically. As independent contractors, GPs’ relationship with the NHS has been managed mainly via a nationally negotiated contract.
External quality assessments and independent audits have rarely if ever been rigorously pursued and, as individual clinicians, GPs have faced little external accountability other than to the GMC, their patients and the law.
PCTs’ remit ending
In today’s consumerist society where there is less public deference to professionals, calls for greater accountability in the wake of Shipman, higher expectations from patients and pervasive and unfavourable perceptions about GPs' 'high pay' have prompted changes.
For example, PCTs in England - to be replaced by clinical commissioning groups and the NHS Commissioning Board (NHSCB) next April - now have a more intrusive remit over practices that extends to detailed review of QOF and enhanced services claims, prescribing costs, referral patterns, and the like. GPs also have annual appraisals, promoting greater involvement in audits and clinical governance.
There is the National Clinical Assessment Authority (NCAS) that ‘supports’ any UK clinicians in the UK whose practice is deemed below par. Further pressures on practices have been generated by politically imposed changes such as the Choose and Book and extended hours initiatives.
The future promises even more external regulation. From April 2013 all English practices must be registered with the Care Quality Commission (CQC). It operates by issuing a range of standards and granting organisations approval to provide services if they comply with the standards.
Once registered, practices can expect routine CQC inspections, both announced and unannounced. Areas of non-compliance must be addressed by practices by submitting detailed action plans which the CQC will follow up to ensure they are implemented.
Results of the CQC’s findings and inspections will be in the public domain, and non-compliance is likely to be highlighted in the media. CQC standards include:
- Infection control
- Patient engagement
- Complaints systems
- Safeguarding children and vulnerable adults
- Record keeping
- Staffing arrangements
- Clinical governance
- Medicines management
- Consent to treatment arrangements
The coming months will also see the introduction of revalidation. This will lead to even greater pressure on GPs to demonstrate ongoing high standards of professional practice and continuing development. Failure to meet its requirements could potentially result in the GP losing their GMC registration. This fitness-to-practise licensing could thus jeopardise clinicians’ continuing ability to work.
Another twist in the external regulation tale lies with the newly created NHS Commissioning Board. Its activities will include standards monitoring and performance review of primary care organisations. This will centralise and strengthen considerably how the NHS exercises control over GP practices.
How will these controls work?
The basic building blocks for monitoring general practice are clear. However, there are doubts over how the new regulated environment will actually function. These relate to the role of CCGs; evidence practices must produce; how failing practices are handled and the use of IT.
Fundamental to CCGs’ success is applying peer pressure to improve performance and services while maximising the use of resources in their localities.
CCGs’ focus undoubtedly will be on areas such as clinical pathways, referral rates, use of hospital resources and prescribing spend as well as on practices giving cause for concern.
Overlap and collaboration
Monitoring by CCGs seems certain to increase the level of external attention in how practices are operating. Also the NHSCB is likely to devolve to CCGs a large part of its responsibility for overseeing primary care.
But this raises the question of the extent to which the CQC’s regulation of practices will overlap and duplicate CCGs’. The CQC has indicated it will be seeking input about quality issues from a range of sources. So close collaboration and information sharing by CCGs and the CQC seem likely.
Every practice will need to assemble the substantial mass of data monitoring required for these various monitoring processes: for every new monitoring element there will be a corresponding demand for more information from practices.
For example, the CQC has developed provider compliance assessments for registered organisations. These consist of 100 plus sets of summary CQC standards, each one of which must be self-assessed for the degree of compliance.
Specific up-to-date evidence must also be provided as examples of how the organisation is meeting the standards. Feeding just this bureaucratic beast obviously means more work.
The corollary of increased monitoring and audit is that inevitably some GPs and practices will be found to be falling short of required standards. But how any ‘failure management’ regime will operate at local level and where responsibility for it will lie is not yet clear.
Smaller practices and older GPs in particular may find with the demands of regulation keeping up very challenging, making some practices vulnerable to merging, being taken over or disappearing altogether.
The focus for most practices has been on improving clinical and patient management IT with much less emphasis on developing the management information systems needed for external monitoring.
This emphasis must change. Using IT systems to rationalise and store all the documentation and evidence necessary to show CQC compliance is an ideal place to start and will facilitate regular updating, easier evidence retrieval and communication of key policies and procedures to the practice team.
GP practices will need to adapt and respond to this new and growing monitoring landscape. It will not be enough to provide high standard patient care: the emphasis will be on the corroborating evidence
- Richard Banyard is director of CQCassist that provides support for GP practices for CQC registration.