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Wednesday 28 September 2016
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Between the devil and the CQC

Insight: Legal

KATHIE APPLEBEE
BA(Hons) MSc DMS

Management Consultant

Strategic Management Partner (part-time)
Tamar Valley Health, Cornwall

Kathie juggles her own primary care consultancy, which includes being Chairman of the National Vision User Group and an RCGP Clinical Commissioning Champion, with a part-time partnership in a large, rural practice with its own pharmacy. After nearly 30 years spent working nationwide with practices and PCTs, she can testify to the fact that each year in general practice is busier than the last. When not working, Kathie rides on Bodmin Moor and tries to forget about work

Most practice managers will already be aware that the Care Quality Commission (CQC) has been established to regulate health and adult social care in England. However, managers may be less familiar with much of the detail that will affect how practices will need to demonstrate their quality in future.

The CQC system of regulation is based upon a set of universal quality and safety standards – known as the Essential standards of quality and safety.(1) These standards focus on the outcomes that patients, staff and visitors should be able to expect from their dealings with providers – including general practices.

Practices will usually be registering to provide the following services:

  • Treatment of disease, disorder or injury.
  • Diagnostics and screening procedures.
  • Surgical procedures.
  • Family planning.
  • Midwifery and maternity.
  • 
Transport services, triage and medical advice provided remotely.

Full details of these can be found in the CQC publication The scope of registration, which contains flowcharts illustrating the scope of the requirements.(2) (For example, the Surgical Procedures chart shows that 'lumps and bumps' done using local anaesthesia are exempt.)

All general practices in England must be registered with the CQC by 1 April 2012, and will be invited to begin applying for registration from October 2011. Although registration will be a free, one-off process, practices will then be required to pay an annual fee to remain on the register, which, at the time of writing, has not been agreed. In November 2010, a CQC consultation proposed a fee of £1,500 for dental practices and suggested that GP practices may be in the same category, although further details are expected in the autumn.

The scope of registration
Legal entities providing regulated health or social care services must register with the CQC.(2) These may be individuals, partnerships or organisations – for partnerships, all partners must be included in the registration. Individual locations, such as branch surgeries within a group practice, need not be registered separately, although they will need to be declared.
GP partnerships (independent organisations working under contract to the NHS) must have a 'registered manager'. This person is described as the one who is in charge of the day-to-day running of the service, presumably the practice manager in most practices, unless there is someone else who is a better fit for the above requirement.

The registered manager must be of "good character; physically and mentally able to manage the activity, taking into account reasonable adjustments or plans that may be needed to enable them to do so; suitably qualified, skilled and experienced; and able to provide certain information".(2)

In order to check this, the CQC will normally require an interview (presumably to take place during the inspection of the practice, although this has not been stated) and be provided with: proof of identity; Criminal Records Bureau (CRB) disclosure; employment history, including evidence of conduct (such as references) and reasons for leaving (where the work involved children or vulnerable adults); records of qualifications; and evidence of health, such as a medical reference.

Practices that provide services elsewhere – for example, healthcare in prisons – must register, even though the host (the prison) will be registered. If the practice hosts services such as private physiotherapy, it will need to clarify (through a contract or service level agreement) the relative responsibilities to ensure that it is not responsible for any CQC breaches by the service provider. Providers should register separately but might be able to use the practice registration – hence the importance of clarifying the contract to ensure that the provider either takes their own responsibility, through registration, or adheres to the practice registration requirements.

If the practice provides services within a hospital, such as a community hospital, it can either seek 'practising privileges' and come under the hospital's arrangements, or use its own registration. The former means following all the hospital requirements for clinical governance, record keeping, etc. For the latter, this might require an additional area of registration, for example, Acute Services (code ACS) – see below for further information regarding 
service types.

Implications for practices
Practices that fail to meet the required standards can face enforcement action by the CQC, so this registration is not a matter to be taken lightly. All practices will be subject to ongoing inspections, and any changes in structure, including partnership changes, will require re-registration and may precipitate further inspections. However, the CQC has stated that it will "take a proportionate approach to managing this situation."(2)

The preparation goes beyond devising a few new protocols to show the inspectors when they call. Each practice will be visited sometime in the two-year period following registration, and they will need to demonstrate that the required standards are embedded within the culture and systems of the practice rather than just on display in a 
smart folder.

The guidance document states that it is not necessary to provide evidence "routinely". For example, it is dependent on: the size of the practice; the range and complexity of the services provided; the needs and numbers of those using these services; the range of staff employed and their working practices; and the systems used for information, such as computer systems or audit processes.(1)

Implications for managers
It is essential that the responsible manager understands the regulations and plans the timetable leading to registration and managing a successful inspection. This is a large project, which is colliding with the demands of GP-led commissioning, so the timing could hardly be worse.

However, the scale of the requirements has prompted many localities to work together to achieve registration and there is, as always, much independent advice being offered. However, do start with the CQC website (see Resources), which provides comprehensive information. You can also contact the CQC who will help with any queries that you may have.

Understanding the regulations
The Guidance About Compliance document is divided into a number of parts and is clearly laid out. The first part provides information about the scheme and how to use the compliance guidance, and includes a helpful glossary of key terms. It also advises which parts of the guidance are relevant for each type of provider: general practice service types are classified by the codes DCS and DTS.(1)

The regulations are grouped into six areas, 
as follows:

  • Involvement and information.
  • Personalised care, treatment and support.
  • Safeguarding and safety.
  • Suitability of staffing.
  • Quality and management.
  • Suitability of management.

Within these areas are listed outcomes, such as Outcome 1: Respecting and involving people who use services. These outcomes are not concerned with professional standards (these are the responsibility of the various professional bodies), but with the outcomes for protection and care that those receiving our services would like to be able to expect as a matter of routine.

The outcomes are accompanied by a series of prompts designed to explain what standards are required. If you find these prompts difficult to follow – for example, if your practice operates in an innovative manner and therefore differs from the guidance – you may need to contact the CQC (or your local primary care trust adviser) to discuss how best to deal with this.

Each outcome description starts by describing the relevant regulations it is seeking to help organisations meet. This is followed by the associated outcomes – what it is that people should be able to expect and receive – and then the prompts, which are designed to help us work out what it is we need to do to achieve compliance with the regulations.

Try not to read these from a practice perspective ("I must write a protocol for this") but from a patient's perspective. How would you know that an elderly relative had received the required standard of care from their practice? For example, under Outcome 5: Meeting nutritional needs, 5D states:

"People who use services benefit from clear procedures followed in practice, monitored and reviewed to ensure they:
Are only subject to fasting (for example before an operation or procedure) for the minimum possible period, and the service will ensure they have adequate hydration as soon as possible afterwards. Nutrition should be provided as soon as possible where facilities exist, or appropriate advice and opportunity is offered where those facilities do not exist."

This could mean that patients having fasting blood tests would have protected early-morning appointments reserved for such tests, and would routinely be offered a drink and perhaps a biscuit following their test.

The section headed Prompts for all providers to consider is obviously applicable to all, but many of the outcomes also contain a further area called Additional prompts for specific service types. Each of these prompts applies only to specific services – for example, 1K is applicable to the average practice:

"The outcome of diagnostic tests and assessments will be explained and discussed with them in a way which they are able to understand and which enables them to make informed choices about their care, treatment and support, where this is the role or responsibility of the service undertaking the test."

Getting it right
The CQC is very focused on what patients want to receive rather than on how the practice is structured and run. For example, an organisation chart may be helpful, but only if this is linked to the individuals within that organisation who will be required to take action to meet the regulations by achieving the required outcomes.

Note that the outcomes and prompts all use verbs to illustrate what is needed and how to achieve it. You can test any evidence that you collect by checking that this describes how things happen or are done rather than just listing passive requirements.

As with any project, the manager will need to tackle it systematically, trying hard not to panic at times! It is not rocket science but it does require attention to detail and the ability to understand the regulations and requirements. It also requires sustainability to ensure that the practice is able to maintain its registration once achieved – you may find the NHS Institute for Innovation and Improvement (see Resources) helpful for this. For one thing, this should help to ensure that the biscuit tin reserved for fasting patients after their blood tests always contains fresh biscuits, not just when the inspector calls.

References

1. Care Quality Commission. Guidance about compliance. Essential standards of quality and safety. London: CQC; 2010.

2. Care Quality Commission. The scope of registration. London: CQC; 2010. Available from: www.cqc.org.uk/scopeofregistration

Resources
Care Quality Commission
www.cqc.org.uk
Tel: 03000 616161
Email: enquiries@cqc.org.uk

NHS Institute for Innovation and Improvement
Ensuring continuity in improvement
www.institute.nhs.uk/sustainability_model/general/welcome_to_sustainability.html