Whilst the regulation of healthcare professionals can be traced back to Henry VIII’s support for the eradication of quack medicine and the creation of the Royal Colleges from the 16th century onwards, it is perhaps surprising to note that independent regulation of the healthcare system is only fifty years old. More surprising to some is the fact that the regulation of general practice in England was only introduced as recently as 2013. Prior to this responsibility being given to the Care Quality Commission (CQC) under the provisions of the Health & Social Care Act 2008, there was no regulation of general practice that assured the quality of care on behalf of patients.
The extension of healthcare system regulation to general practice has not been without its difficulties. The decision of CQC in its early years to prioritise the registration of GPs over core inspection functions was criticised by Robert Francis QC in his report into events at Mid-Staffs. Meanwhile, the GP representative bodies mounted a vigorous rearguard action questioning the very fitness of CQC to regulate their slice of the healthcare economy. The subsequent appointment of Professor Steve Field as Chief Inspector of General Practice was very much a move to secure a critical voice within the CQC tent and to address a long-standing cultural resistance to independent scrutiny and oversight.
‘The state of care in general practice 2014-2017’ was published by CQC as a record of its first three years in regulating the quality of service delivered by GP providers. The report acknowledged the immense challenges facing GPs, but emphasised that general practice consistently received the highest ratings when compared to other services across the healthcare sector. Whilst the “majority of people in England” were viewed as receiving “good quality care”, the report nonetheless identified that a significant minority of practices needed to improve.
In 2014, Steve Field referred to the “very tiny percentage” who were “letting the rest down”, and announced an intention for CQC to introduce a ‘Special Measures’ regime for practices rated as ‘Inadequate’ and failing to demonstrate improvement after six months. By 2015, a practice in Liverpool became the first to close its doors following a cancellation of registration by CQC. The sharp end of the ‘Special Measures’ regime has since affected a small but rising number of practices that repeatedly fail to demonstrate compliance with the statutory regulations.
However, for many others it’s the improvement journey that focuses the mind, be that the transition from ‘Requires Improvement’ to ‘Good’, or from ‘Good’ to ‘Outstanding’. Such ratings are important not only in terms of reputations and stakeholder perceptions, but also inward investment through collaborative partnerships and venture capital. Key to the ‘Outstanding’ destination is leadership, a quality evaluated by CQC through the ‘Well-Led’ domain of its KLOE framework. Practices that can evidentially demonstrate leadership, sound governance, innovation and sustainability should be the ‘holy grail’ for all GPs.
Regulatory compliance is a business critical activity that is dismissed at peril. Whether the imperative is recovery from ‘Special Measures’ or the drive for continuous improvement leading to an ‘Outstanding’ rating, regulation should feature as a standing item in governance discussions and any forward business planning. Whilst many patients view their local practice as simply part of the NHS family, the reality for GPs as independent contractors providing NHS services is quite different. The acute hospital trust down the road may be ‘to big to fail’, but no such safety net exists for general practice.
GPs are responding to the rapidly changing healthcare landscape through their active participation in Local Medical Committees (LMCs), collaborative strategies to shared challenges through Federations, and by an increasing profile provided by the emerging Primary Care Networks. However, there is a sense that system regulation, as opposed to professional regulation, remains a poorly understood area of external scrutiny and accountability. Expert guidance and advice is often required to address immediate weaknesses in regulatory capacity, capability and competence, and from a more long-term perspective to help build regulatory sustainability.
At Healthcare Regulation UK, we work across the healthcare sector to support providers achieve both compliance and improvement. A particularly rewarding commission involved our collaboration with Push Dr, a national digital platform that provides an innovative solution to GP access through ‘virtual consultations’. Following its recent CQC inspection, Push Dr was rated as ‘Good’ overall, with a rating of ‘Outstanding’ in the ‘Well-Led’ domain. Our collaboration with Push Dr was very much a collective effort in which a ‘critical friend’ approach was warmly embraced and used to promote quantifiable improvements in not only the regulatory agenda, but in the underpinning business model itself.
We have also just recently completed a strategic level review of a more traditional GP practice in which we have identified areas for corrective action and improvement in advance of an imminent CQC inspection. Again working closely with the practice we have established an action plan to ensure that compliance is demonstrated and best practice showcased.
GPs are using the representative forums and networks available to them to advance their interests as independent contractors and businesses, but still more can be done to square the circle of system regulation. Although the indications are that GPs are increasingly accepting the overriding public interest argument for system regulation, practices nonetheless need to engage more with specialists in the field and mitigate the avoidable risks of a negative inspection through proactive action.
Condition improving is a fair assessment of the current situation, but more remains to be done to ensure that general practitioners realise the potential benefits of informed engagement with healthcare system regulation.
Julie King, Company Director & Consultant