"My chief message is: don't panic," says Professor David Haslam, a GP and clinical adviser to the Care Quality Commission (CQC), with which all providers of primary care services in England will need to be registered by 1 April 2013.
It is this legal requirement – for practices to assure patients they meet essential standards of quality and safety – to which the former chair of the Royal College of GPs refers. Those assurances are perhaps more necessary than ever as the spotlight glares down upon the regulator. A critical National Audit Office (NAO) report in early December slammed the "struggling" CQC for missed registration deadlines, "failing" inspection activity and for not achieving value for money. The report also spoke of the CQC's "difficult task" and this is no understatement. As the quality regulator of all adult health and social care providers, the CQC has a mammoth – and pressing – undertaking.
This may in part explain the decision to delay the deadline for General Medical Services (GMS) practice registration (originally April 2012 – still the deadline for out-of-hours GP providers), as indeed might the difficulty experienced with dental practices, when issues such as troublesome form-filling tasks and criminal record bureau (CRB) checks led the British Dental Association to declare the experience as a "fiasco that seems to lurch from one crisis to another". Then, in the last issue of MiP, Dr Laurence Buckman, Chair of the British Medical Association's (BMA) GPs' Committee, warned of "substantial" compliance work for general practices, with the "burden" falling on practice managers.
All this has arguably left the CQC with as much public relations work to do with general practices as ensuring the registration process achieves its ambition of being, in Professor Haslam's words, "as logical, as straightforward and intuitive, minimising paper work and so on, as we can possibly make it".
Indeed, while fears of a high volume of compliance work have led some practices to seek assistance from fee-charging consultancy providers, senior CQC officers suggest this is unnecessary. Victoria Howes, GP Registration Design Team Leader at the CQC, says that most surgeries will already be maintaining high-quality care and will have no need for outside help to prove that. "Practices that are already delivering a good service will be absolutely fine," she said. "They shouldn't need to hire external consultants."
Professor Haslam concurs: "Most practices really care about what they do and want to demonstrate they provide safe, effective care. The vast majority are doing that and have very little to be worried about by CQC registration."
Premises and 'non-compliance'
Nonetheless, practice managers have raised concerns that the CQC is keen to address. One such concern is over premises not compliant with the Disability Discrimination Act (DDA) – in particular, this affects surgeries operating from older buildings with a protected status, which are prevented from upgrading their premises to allow wheelchair access or other desirable improvements.
Howes says this will not prove a significant barrier to successful registration, since practices will be able to declare non-compliance here. "As long as you can produce an action plan to say how you will manage the risks, this will be fine," she says.
But does that mean the CQC will expect practices at some later stage to ensure their premises comply with the DDA? (CQC registration is a one-off activity, but monitoring and compliance will continue on an ongoing basis.) No, says Vickie Wilkes, CQC Regulatory Policy Officer, so long as the practice can demonstrate that it is managing the associated risks. "If a practice hasn't got DDA access but the patients are safe and happy with their care, the practice would actually be 'compliant' as opposed to 'non-compliant'".
Professor Haslam explains: "The action plan would be that if you agreed, for instance, to visit people who couldn't get into the premises, you wouldn't have solved the premises [issue], but you would have solved the problem for the individuals. And we're interested in the individuals."
So long as the practice is actively managing any potential risks to patients, managers should not necessarily feel uneasy at declaring 'non-compliance' on a particular aspect. "If someone ticked all the 'non-compliance' boxes and was planning to do absolutely nothing about it, we would flag that up as a very significant risk to people who use the system and we would be much more interested in them," says Professor Haslam. "But if they've declared non-compliance and are acting on it, that's a lower risk."
An area of particular relevance to practice managers is the role of the 'registered manager', defined by the CQC in its introductory guidance as "the person in day-to-day charge of one or more regulated activities".(1) In most cases this is expected to be the GP partner, as the named provider. However, this could equally be the practice manager – it is up to the organisation, though an advantage of a GP in this role is that, as a General Medical Council (GMC) registered professional, they would not need a CRB check, unlike a practice manager.
But whoever is selected should not be in doubt of the responsibility they will shoulder. If the CQC found the practice to be putting patient safety at risk, the registered manager would generally be held accountable for the organisation – so would need, as Professor Haslam says, "to be as much as possible on top of what's going on in the practice."
What if the registered manager was unaware that, say, a GP was putting patient safety at risk? "That's a very good question," says Professor Haslam. "It is complex. Our fundamental starting point is safety for the people who are cared for in the system. At the same time we don't want to damage the reputations of people who might be responsible but didn't know what was going on. And there is no doubt that in practices over the years there have been scandals involving a single partner that nobody in the practice knew about."
Wilkes says the CQC would look at each case on an individual basis and work out where the culpability lies. "If an individual GP was putting patients at risk we would refer this to the GMC and work with them to ensure the safety of patients. If the practice as a whole was believed to be providing care that fell below essential levels of quality and safety, or if the registered manager was aware of the problems with a particular GP and did nothing to protect patients, then the registered manager may be held responsible. But it really would depend on the individual circumstances of such a case."
Provider Reference Group
No doubt anxious to avoid the experience with dental practices, the CQC seems genuinely desirous to engage with general practices. "We want to make it work, we want to give as much guidance and help to practices as we can," says Howes, who adds that the CQC will be increasing its communications with primary care from January 2012.
Practices will be invited to start submitting registration documents to the CQC from July 2012. In the meantime, the CQC has established a Provider Reference Group that practice managers can sign up to, via its website (see Resource), which serves as a forum group for feedback and questions.
The CQC, of course, will need to deal with the huge variety in general practice. Won't this be a problem? The variation amounts to small beer for the quality regulator of the entire health and social care service in England. "We regulate St Thomas' Hospital and a nursing home with two beds," says Professor Haslam. "If we can manage those two, we can manage various practices."
Care Quality Commission. An introduction to registration with CQC for providers of NHS general practice. London: CQC; 2011. Available from: http://www.cqc.org.uk/organisations-we-regulate/gps-and-primary-medical-...
Care Quality Commission