GP inspections: are sanctions holding back improvement in poor areas?BMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k682 (Published 14 February 2018) Cite this as: BMJ 2018;360:k682
GP partners working in England’s deprived areas who have had negative feedback after inspections by the health and social services regulator have told The BMJ how they were left feeling demoralised, unsupported, and on the brink of giving up.
One GP said he thought that the Care Quality Commission failed to take account of the challenges his practice faced, another that being put under special measures made hiring staff even more difficult and improvements near impossible to achieve (box 1).
GPs’ responses: CQC criticism was like “a kick in the teeth”
The BMJ spoke to a partner at one practice that the CQC placed under “special measures” and that remains under scrutiny. The GP, who wished to remain anonymous, said the inspection that led to the action had been “particularly unsupportive.” The sanction felt like “a kick in the teeth,” the partner said, and made it hard to hire new staff.
“We were being inspected for a second time, and all the staff thought we were in a much better place than we had been on the previous inspection. But then we got absolutely hammered. Speaking to other people, we found that the reasons we were put into special measures were not consistent compared with other practices.
“Being rated in special measures was almost what tipped us over the edge, because it suddenly meant that recruitment was incredibly difficult. I seriously considered handing back the contract at that point. Having worked incredibly hard to try to turn round the practice and worked all the hours that God sent, to then be told that you’re the worst of the worst was pretty demoralising.”
Another GP whose practice in an area of high deprivation was deemed to be “requiring improvement” said he believed that the CQC did not give due recognition to the constraints the practice was working under. “We felt there wasn’t much in the inspection that reflected the individual circumstances of our surgery. A surgery’s inspection should reflect the demographic they work in and the needs of the community. And I’m not convinced that the CQC have that right.
“Looking at our local area, it’s telling that a practice that got an “outstanding” rating had a very good PMS [personal medical services] contract and was able to put a lot of extra investment into extra resources. We aren’t a high income practice. Because of our patients’ demands, we offer well above the average number of appointments a week, and we struggle with access and demand. We don’t have that extra income to invest in other services because we have to be staffed at a certain point.”RETURN TO TEXT
But is it the inspection regime that’s at fault, the way individual practices are funded, or the overall primary care budget?
Richard Vautrey, chairman of the BMA’s General Practitioners Committee, said that in many cases the practices that have been subject to CQC enforcement action have historically been those receiving the least funding. “There is a direct correlation between quality and the funding practices receive,” he said.
Vautrey called for the CQC to do more to advocate for general practice rather than issuing sanctions (box 2). He said that the regulator itself had identified a link between funding and quality, adding that it would be “a cop-out” for the regulator not to argue for increased funding: “If CQC genuinely care about quality, then part and parcel of that should be advocating for the necessary funding to be able to increase the quality of care that practices are able to deliver to their patients.”
The CQC issues warning notices when it deems that the quality of the care a general practice provides “falls below what is legally required.” The CQC sets a deadline for improvement, depending on the nature of the breach. If practices fail to improve in the given timeframe, they can face tougher action, including suspension or removal of registration.RETURN TO TEXT
Ruth Rankine, the CQC’s deputy chief inspector of general practice, emphasised that the regulator often highlighted outstanding care being delivered by practices serving deprived areas, including in its State of Care in General Practice 2014 to 2017 report.1 Rankine said, “Inspection colleagues spoke of outstanding practice being delivered in deprived areas and in the face of social challenges. They had seen practices with clear strategies to deal with these issues and committed practice teams that that were passionate about improving care for people. Practices can face different challenges and circumstances; what matters is the way in which they identify and respond to local needs.”
Michael Marmot, director of University College London’s Institute of Health Equity and an internationally recognised expert in health inequalities, said that an obvious comparison could be made between between the CQC’s regime and Ofsted’s rankings of school performance, in which more sanctions are issued to schools in deprived areas.
“If the purpose is to get better services, then it seems to me you’re more likely to get better services by encouraging, supporting, and advocating than you are by punishing and shaming,” he said. “The CQC could have a more constructive advocacy role.”
Marmot said that The BMJ’s findings (box 3) indicated that GP funding should be reallocated so as to provide more support to practices serving deprived populations. This was particularly pertinent given that cuts to local government budgets, which cover areas such as social care, housing, education, and public health, have been heaviest in deprived areas, he pointed out.
Methods and findings
For its analysis The BMJ submitted a request under freedom of information legislation to the CQC, asking for details of all practices that had been subject to some form of enforcement action in 2014-15, 2015-16, and 2016-17.
The BMJ then analysed details of the 170 practices that faced sanctions, including which decile category of deprivation they fell in (fig 1), using the government’s official index of multiple deprivation (IMD), which ranks all 33 000 neighbourhoods in England from most to least deprived.RETURN TO TEXT
“Cuts to local government are putting an extra burden on the NHS. The fact that the cuts have been severe in deprived areas makes it particularly hard for these practices,” Marmot said.
In 2014 a group of GPs in Tower Hamlets in east London, one of the country’s most deprived boroughs, examined annual consultation rates among one million people registered at general practices in east London, grouped by quintiles derived from the national index of multiple deprivation.2 They found that someone aged 50 in the most deprived quintile consults at the same rate as someone aged 70 in the least deprived quintile. For Tower Hamlets, they estimated that a fair formula that allowed for the additional workload related to deprivation would provide 33% more funding.
Kambiz Boomla, one of the GPs behind the analysis, said that there was a compelling case for changing the weighting of the funding formula, given the greater level of need in deprived communities. He told The BMJ, “When the funding formula gets redone, I feel that it needs to reflect the [care] need and utilisation as independent factors. There needs to be weighting for the already existing extra workload that deprived patients bring. But there also needs to be an additional weighting for unmet need that cannot currently be met.”
Patrick Hutt, a GP in Hackney, east London, who coauthored a 2010 King’s Fund paper on tackling inequalities in general practice,3 said it had been well documented that GPs working in areas of high deprivation faced increased demand on their services.
“The [BMJ] findings suggest that more support should be given to GPs working in areas of deprivation,” he said. “This is essential if general practice is to fulfil its potential in tackling the social determinants of health.”
Vautrey said the BMA’s GP committee and NHS England were involved in an ongoing review of the GP funding formula but that evidence so far gathered by the BMA indicated that changing the formula in itself wouldn’t solve the difficulties in general practices ni deprived communities.
“If you make changes to the formula in the current financial climate, then you end up creating winners and losers,” he said. “Any changes to the formula need to be done at a time of rising investment.
“It fundamentally comes down to the lack of funding that the health service as a whole has—and we need to address that, so we can target additional resources in a more appropriate way.”