Can’t Question Commonsense?

By | 21st May 2016

Care Quality Commission

I have written at least a couple of times in the past about the Care Quality Commission or CQC. This was originally set up by the government to monitor the quality of care in care homes. Its role has gradually been expanded to include almost all care institutions.

My first article, many years ago, was less than complimentary. I observed that the CQC did not actually commission anything, it merely policed the care being provided. It didn’t really inspect against true quality standards but how well homes adhered to government guidance. And finally, I noted that it didn’t actually look after or care for anything.

A couple of years later, after its role had encompassed general practice, I wrote a more sympathetic (& groveling) article from the side of the CQC. A few of our patients actually work for the CQC and I have been impressed with their dedication and started to understand the difficulties of inspecting institutions from their perspective.

Funding

Like the rest of the NHS they’re strapped for cash, actually, their funding is probably worse than most. They also have to adhere to pretty rigid guidelines when inspecting and reporting on homes, hospitals and general practices. In other words, they are simply doing the bidding of the government and have little flexibility to interpret things differently from their perspective.

Finally, they have a thankless task – if you receive a good or outstanding rating then they’ve simply inspected you appropriately and anyone could have done that – all they’ve succeeded in doing is telling everyone what everybody already knew but have spent a lot of money in doing so. Incidentally, that money is paid directly out of practice profits!!

However if you are rated as ‘requires improvement’ or (worst case scenario) ‘inadequate’ it is apparent that the inspectors just didn’t do their job right and the institution will appeal. I end up asking myself who in their right mind would ever want to be a CQC inspector. I can’t imagine there’s ever been an organisation which has said thanks for putting us through the ringer its really made a big difference and you know what we really deserved that inadequate rating.

Raise standards

The real value of the CQC is to identify the 1% of practices who are so bad that they risk the lives of their patients – sadly there was not a rigorous structure in place before the CQC which could fulfill this function.

The experience from the care industry in general is pretty sobering. I remember starting out in general practice 25 years ago and wondering about opening up a nice little care home on the side. One of the things that kyboshed my plan was that it was unethical for doctors to recommend to patients their own care home. But 25 years ago there was at least some money in the care industry and there were thousands of care homes; most of them with less than half a dozen residents. But over the last few decades, in an attempt to raise standards, regulations have been imposed on the industry which has caused the vast majority and all of the small homes to close.

Today managing a care home appears to be a quick way to end up bankrupt or in prison!! There are some pretty strict laws which protect the rights of vulnerable adults, ie all your residents. To keep your residents safe and healthy is not cheap. When you live in a care home it is because, for one reason or another, you are unable to care for yourself. You require 24-hour care 365 days a year.

Care costs

I’ve done some pretty back of the fag packet calculations which end up with the cheapest cost that care can be delivered is about £550-600 per week. This may seem a lot but you have to remember that the biggest portion of your expenses will be on your staff and £600 per week is only about £3.50 per hour.

I think it’s just about possible to make ends meet at present – but councils are being ever more squeezed and they still pay for many residents. However, the ticking time-bomb for residential care is the living wage. At present the only way the care industry survives is being able to employ staff on minimum wage, a 25% hike up over the next 4 years will bankrupt every care home in the country!!

This may sound as though I’m some sort of fascist who isn’t prepared to pay staff a reasonable amount for the hard work that they do – hopefully that isn’t the case, I’m merely pointing out the unforeseen consequences of what seemed like a good idea. In 5 years’ time we will not have any care homes to look after the most vulnerable members of society.

Manpower crisis

At the same time of course, General Practice is going through a recruitment and manpower crisis. I think I might have mentioned previously about the chronic underfunding and undervaluing of primary care over the last decade. Thankfully the government has now started to appreciate the disaster that is unfolding before our eyes and is looking to invest £2.4 billion in general practice over the next 4 years – which will make a huge difference. Hopefully by then all of our junior doctors will not have moved abroad.

All of which brings me back to the CQC, because last month we had our inspection. As usually with such things the timing was not ideal, we were given a couple of weeks’ notice and quite frankly the amount of preparatory work for an inspection could be so overwhelming that you’re simply better off just accepting the first date given and simply getting on with it.

A lot of local practices had also been inspected recently and we were expecting a rigorous but not too onerous inspection. By the time the day was finished I felt utterly spent. I had no doubt whatsoever that the practice had been thoroughly inspected. We now await our rating.

I say inspected but in reality it is the systems which are inspected, such as how often are the examination curtains changed and do they have an expiry date on them. On the surface it is difficult to understand how changing your curtains reduces the risk of infection when a patient has shared a waiting room with sick patients already. But ours is not to reason why.

Thank you!

Many thanks to those patients who are members of the patient group for taking time out of the middle of their day to feedback their thoughts and experiences to the CQC inspection team.

We were given some feedback at the end of the day which left me suspecting that ‘requires improvement’ or ‘inadequate’ might feature heavily in the final report. But I’m reassured by those patients who work for the CQC that it is pretty difficult to guess what the inspectors are really thinking, and just because some of your systems may not all be in place doesn’t mean they’re about to close you down.

We will be rated on 5 areas – safety, effectiveness, care, responsiveness and leadership. I guess the one that really counts is care and I would feel really disappointed if we scored badly in that area, but who knows.

We will get our rating in the next month or so and of course I will update in a future newsletter – however we are also obligated to advertise our ratings to our patients, which much be pretty galling when everything requires improvement. Having said all of that the actual process of going through an inspection, as arduous as it was, was actually worthwhile and has made a positive difference to the practice.

Post note

I’ve just returned from a weekend away and missed the fact that one of our local practices ended up on the front page of the Daily Echo following their damning CQC report. I’m sure they must be devastated, by all previous measures they were/are a high performing practice – almost perfect scores for their QOF, high levels of patient satisfaction and better than average patient outcomes.

I can’t imagine how the doctors and staff must feel (hopefully I won’t find out too soon) but this is not what General Practice needs when we are in the midst of a recruitment crisis. It makes me think that going into general practice might be a quick way to end up bankrupt or in prison.

I wonder whether we’ll be looking back at 2016 in 20 year’ time and noting that previously there were lots of GPs who worked in lots of little practices, but they all went out of business to be subsumed by huge impersonal conglomerates.

Let’s hope I’m wrong

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