Pulse takes on October’s talking points – where does the CQC go following two damning reviews, and what do we know about North West London’s ‘integrated neighbourhood teams’
Where does the CQC go from here?
Any GP, any clinician, or anyone who has ever interacted with the CQC could have told you the results of the two reviews into the professional body that happened this month before they were published. Admitting that your methodology may ‘inadvertently disadvantage’ ethnic minority-run GP practices and focussing on trivial matters such as waiting room carpets and cuddly toys can do that to an organisation’s reputation. You can know something, but sometimes it is just nice to have it all in writing. And even better if you can have it in writing twice.
That’s what happened to the CQC this month. The watchdog was the subject of two reviews – one commissioned by the Government and the other internal. Both came to similarly damning conclusions: the CQC in its current form is not working.
The internal review followed an interim report from July led by North West London ICS chair Dr Penny Dash. This report found a ‘lack of consistency’ and transparency in the CQC’s ratings of GP practices. It also raised concerns about the new single assessment framework.
The findings from this month’s internal review, led by former chief inspector of hospitals Professor Sir Mike Richards, suggested that:
- The use of one-word ratings for GP practices should be evaluated
- Far fewer inspections were carried out than in previous years
- Measures of patient experience collected by GP practices and hospitals should be standardised to make evidence between providers comparable
- There are too few staff working in the primary care inspection units leading to inspection delays
These are more than 30 recommendations in total. One particularly interesting point made was that the CQC should revert back to its previous organisational structure. Last year, the watchdog went through a restructuring which moved staff from three directorates with a focus on specific sectors into teams operating at local level. The internal report concluded that the previous structure ‘should be reinstated as soon as reasonably possible’ and that chief inspectors should have an expertise in the sector they are working in.
The Government-commissioned review also echoed this, saying that the CQC will never be able to ‘deliver on its objectives’ if the current structure is maintained. This independent review, also led by Dr Dash, was announced by DHSC in May. Regarding the new organisational structure of the CQC, she said that the ‘loss of expertise’ meant that providers did not trust the outcomes of reviews. Dr Dash also doubled down on findings she had made in the internal interim report, concluding that CQC’s ability to identify poor performance had deteriorated, there were considerable delays in re-inspections, and a dramatic reduction in activity.
This review made seven recommendations to the watchdog, including clarifying how rankings are calculated, making results more transparent, pausing the assessments of ICSs temporarily to carry out more provider assessments and reviewing the single assessment framework. Again, there is also a focus on ‘rebuilding expertise’ within the CQC to improve relationships and credibility with providers.
When we last wrote about the CQC following the interim report, one of the concerns that emerged was the organisation’s preoccupation with managing relationships between itself and secondary care providers, rather than the actual function of inspecting. With both these reports, it seems that the internal structures and relationships are prohibiting meaningful and effective inspections of healthcare providers.
The CQC has accepted the findings of both reviews and said it will work with colleagues, providers, patients to develop a plan to deliver these changes, and ensure it is ‘realistic’ about what can be delivered when. That’s all very well – and a necessary statement to make – but undoing a culture mired in administrative and relational dilly-dallying will be quite the task.
What do we know so far about ‘integrated neighbourhood teams’?
The Fuller Stocktake is starting to affect services, two years after it first came on the scene. Last week, Pulse exclusively reported that North West London (NWL) ICB has drawn up ‘first-of-its-kind’ plans to introduce ‘integrated neighbourhood teams’ (INTs). All providers in the area, GP practices included, are being asked to create plans to ‘enact the vision’ that will see 25 INTs each look after a population of 50,000 to 100,000 residents.
Each of the 25 INTs will have an ‘integrator function’ role – which will be undertaken by either a person or small team – to oversee practical operations such as business intelligence, organisational development and workforce. This ‘integrator function’ will have to come from general practice, community providers or local authorities.
In terms of the actual functioning of the INTs, a single reception channel will provide access to core services such as: general practice, care navigation, community mental health, adult social care, dentistry, optometry and more. The 100 or so staff will ‘work towards hub arrangements’ for a ‘single neighbourhood hub’ that will create a ‘no wrong front door approach.’
The ICB itself has recognised the ‘challenges’ that implementing integrated neighbourhood will bring. There are 45 PCNs in NWL ICB, yet the plans have laid out 25 INTs meaning that PCNs will have to join up in some/all areas in ‘cross-border arrangements.’ There is nothing else in the document acknowledging PCNs, leaving questions remaining as to how the two domains will lap onto each other and interact.
We could address and dissect the very obvious and ever-present elephants in the room: where will these 100 staff come from? (The ICB recognises it as a challenge to use the existing workforce to ‘drive forward the level of change we need alongside the delivery of services day to day.’); Does a ‘single neighbourhood hub’ mean a single roof, and if so how will estates large enough, modern and fit for use be provided? (The ICB will seek to use existing ‘high quality’ estates when possible, but these will not likely be in place until 2026 at the earliest); And, how will the INTs be funded? (Londonwide LMCs says a funding stream ‘has not yet been identified’ but it has been reassured that the general practice budget will be ring fenced.)
But what is more concerning is the proximity of these integrated neighbourhood teams to the controversial NWL same-day access hubs that were shelved earlier this year following backlash from GPs regarding patient safety, quality of care, and logistics. NWL ICB told Pulse that the plan for integrated neighbourhood teams is ‘not directly related’ to the same-day hubs. However, GPs in North West London are being told to come up with plans to ensure that the £5m that was tied to the same-day hubs is not lost. As this funding was ringfenced for general practice access, ideas on how to spend it have to be tied to improving patient access. Surgeries in North West London are giving patients surveys asking about whether they can access urgent appointments when needed, continuity of care, and how they feel about their GP surgery ‘collaborat[ing] with their neighbouring GP surgeries to offer a broader range of services.’
Perhaps it is just cynicism. But the two endeavours of INTs and the need to use up the same-day-access hub money within the same ICB seem like converging paths to the same eventual point. Whether they will eventually feed into the other is a question for another day.
In the wider context, it is not clear what is driving this. When the Labour manifesto promised to trial ‘neighbourhood health centres’, it failed to provide many details, with the party repeating that existing services would be brought together under one roof (no further specifics were given when Pulse reached out.) It is unclear if NWL’s integrated neighbourhood teams are specifically rooted in the Fuller Stocktake, or are forming part of the ‘trialling’ promised by Labour.
But GPs in North West London will be left pondering whether ‘no wrong front door’ means that workload will still get dumped at their welcome mat.
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Widespread delusion that you can inspect your way to quality; the reverse is probably true, except perhaps with the extremes of poor practice.
The CQC wastes huge amount of our most valuable resources, clinician time and staff goodwill. The financial squandering is almost trivial in comparison.
That it still exists demonstrates just how hard genuine reform is in the face of vested interests – those who benefit from the cqc’s continued existence will fight to preserve their self interest, their power and privileges with vigour.