Written evidence submitted by The Care Quality Commission (FGP0364)

Introduction

 

1.      The Care Quality Commission (CQC) is the independent quality regulator of health and adult social care in England. Our purpose is to make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage these services to improve.

 

2.      We continue to deliver a risk-based approach to inspection[1], while taking action to increase system capacity. Alongside our risk-based inspection activity we will continue our ongoing monitoring of services[2]. We’ll use this to identify risk and signal where we may need to take further action to ensure that people are receiving safe care and offer support for providers. We recognise that the priority for all providers is to deliver safe, good quality care to people who use their services. We will support providers that are responding to pressures on the system by making balanced, risk-based decisions in partnership with the people who use health and social care services so they can carry on using services while keeping them as safe as possible. We do not currently plan to return to routine frequency-based inspections. (We will however, be postponing on-site inspections[3] of acute hospitals, ambulance services and general practice until the New Year to support the acceleration of the booster programme announced on 12 December 2021 – except in cases where we have evidence of risk to life, or the immediate risk of serious harm to people).

 

Our focus on a person-centred future

 

3.      We want to be an advocate for change, with our regulation driven by people’s needs and their experiences of health and social care services. People need to see how their voice can make a difference to the safety and quality of the services they use and how we and the wider health and social care sector reflect their experience in our work.

 

4.      People’s feedback is crucial to building trust with the public, motivating people to share their experiences. We want to help build a new culture among the public, health and care providers, and all our partners, that welcomes, values and acts on feedback.

 

5.      This means focusing on what matters to the public, and to local communities, when they access, use and move between services. Working in partnership with people who use services, we have an opportunity to help build care around the person and we want to regulate in a way that makes that happen.

 

6.      As part of our new role proposed in the Health and Care Bill[4], we want to offer meaningful independent assurance to the public and Parliament about how Integrated Care Systems (ICSs) deliver safe, high-quality care to their local population. We have been working closely with the Department of Health and Social Care, NHS England and other stakeholders to start to develop some of the details around this important role. We expect our work to focus on assessing leadership, integration of services and care pathways, as well as quality and safety. It is vital that our new role adds value in improving services for people and does not duplicate NHS England’s existing oversight activities.

 

7.      These new powers, as well as separate proposals in the Bill regarding assurance of how local authorities deliver their duties under the Care Act, will support us to deliver the objectives in our new strategy[5] by allowing us to look more effectively at how the care provided in a local system is improving outcomes for people and reducing inequalities in their care.

 

8.      Our regulatory approach will be driven by people’s needs and experiences. This means we will work in partnership with people who use health and social care services, their families, voluntary sector organisations, health & social care providers and other key stakeholders as we design our approach to looking at systems over the coming months.

 

Our regulation

 

9.      The overall ratings picture of GP practices in our State of Care[6] publication in October 2021 showed General Practice to be good overall Outstanding 5%, Good 90%, Requires Improvement 4% and Inadequate 0.5% in July 2021. (Percentages may not add to 100 due to rounding).

 

GP inspection activity during the pandemic

10.  Since the start of the pandemic we have taken a risk-based approach to our inspections.  Where we have undertaken inspections to update ratings, this has predominantly been for practices rated inadequate, with the number of practices in special measures reducing. Given that we have been responding to risk and not routinely been inspecting practices rated requires improvement, good or outstanding, our current ratings may not show the full picture of the quality of care. However, we have continued to monitor services, often with little or no need for the provider to engage with CQC directly, so that we can continue to provide public assurance about the quality of care provided.

 

11.  Themes of concern from our regulatory activity include; a backlog of records/referrals not made in a timely manner, including two week waits; lack of systems and processes to identify vulnerable or at-risk patients; issues relating to access; poor staff support, including appraisals and training; closed cultures poor response to complaints and significant events when things go wrong; poor follow up of patients with complex or long-term conditions, including medicine management.

 

Concerns about pressures on the GP sector

12.  Through our regulatory activity and from conversations with the sector, we are concerned that general practice is under considerable pressure and that this is impacting on individuals, teams and leaders. This leads to concerns about the impact these pressures may have on the delivery of high quality, safe care.

 

13.  Pressures relating to access have been worsened by increasing demand and backlogs and where patient expectations are not being met. This is causing anger and frustration directed at practice staff.

 

14.  We know that sharing concerns at the right time can make it easier to make links between pieces of information that tell us a problem is emerging. This indicates potential risks for the future of general practice and the care that GP colleagues and their teams strive to deliver.

 

15.  In addition, information has also been provided to us through our GP Reference Group (GPRG). The concerns raised demonstrate the considerable pressure GP practices are under and how this is impacting on individuals, teams and leaders. There is also concern about how this will have a knock-on impact on patients and the care they receive. We heard examples of:

 

16.  We will seek to explore how we may work jointly to support the sector with NHSE and alleviate the pressures it is facing, focusing on how relevant concerns can be addressed in a proactive way.

 

Access to general practice

17.  We carried out preliminary inspection and engagement activity (May/June 2021), to better understand how GP practices have been working to ensure access to services during the pandemic. We found that, in line with guidance, practices had moved to a triage model for everyone seeking an appointment, to help to keep people safe from infection and to avoid vulnerable people coming into contact with people who were COVID-positive.

 

18.  Most commonly the triage process took place by telephone, either involving a member of reception staff or a clinician (usually a nurse, advanced nurse practitioner or GP). Some practices had more than one layer of triage, with an initial screen by reception staff being followed up by a clinician.

 

19.  Sometimes, the triage process took place through an online service. Our inspectors raised concerns about this in a small number of practices, such as describing staff who were “unsupported by their technological systems to provide a fully effective service” or noting that “patient satisfaction with this [triage] approach was mixed”. Some practices, which were unable to provide online triage, had removed online appointment booking facilities in order to triage patients by telephone.

 

20.  Findings from our inspections have noted issues with telephone systems, resulting in long hold times, people being cut off while waiting, and repeated engaged tones causing frustration for people trying to get through.

 

21.  Other practices have tried to address this by increasing their phone line capacity or upgrading their telephone systems to meet need. Some have used newer telephone systems to actively monitor their telephone waiting times. A practice in London, for example, had live telephone performance information displayed on a screen in the waiting area. The manager of this practice was also able to review the performance from a dashboard.

 

22.  Concerns around access in general practice continue to be a significant theme in the high volumes of concerns that we receive through our Give Feedback on Care service. We have developed a risk-based inspection approach, focused on access, to support us to respond to the information we receive in a timely and proportionate way and to better understand and report the challenges a practice might be facing around access. However, as stated above, we will be postponing inspections over the coming weeks and we will only inspect in cases where we have evidence of risk to life, or the immediate risk of serious harm to people as referred to at the beginning of this submission.

 

The role of General Practice in the health and social care system

 

23.  As the way health and social care is delivered changes, moving towards a more integrated approach through the Health and Care Bill, general practice’s role in that delivery becomes ever more important, providing a gateway to the rest of the NHS.

 

24.  Increasingly primary care providers are working more collaboratively (via formal and informal arrangements) to deliver services to meet the needs of their populations. Through our regulation and engagement, we have seen that collaborative working arrangements (including primary care networks [PCNs] and providers delivering primary care at scale) continue to vary significantly in terms of their maturity.

 

25.  We have seen the significant contributions that primary care (and PCNs in particular) have made in response to the pandemic but this has meant that other aims of PCNs have not yet been realised.

 

26.  We know that GPs and GP providers are integral to the health and care system and are fundamental to supporting the health needs of their communities. In developing our new assessment framework to support us to deliver on our strategic ambitions, we want to ensure we are better able to assess and reflect how services are collaborating with other services and working as part of the wider health and care system.

 

General practice response to the pandemic

 

27.  Like all health care services, general practice has had a crucial role to play in supporting the health needs of their communities throughout the pandemic, as well as keeping people safe. GP practices, following national directives and drivers from government, have had to accelerate innovation, such as moving rapidly to remote consultations, to respond to the pandemic.

 

28.  Since December 2020 GPs have been instrumental in the rollout of the COVID-19 vaccination programme, with GP practices and primary care networks at the forefront of this critical task. Many different local services have worked together at speed on a programme that has shown the NHS at its most versatile and with a patient-centred focus.

 

29.  Data from NHS Digital[7] up to the end of October 2021 showed that, after dropping considerably in April 2020, the total number of GP appointments started to rise from June 2020 with the end of the first national lockdown, and by September 2020 was broadly in line with figures for the previous year. The cyclical pattern for GP appointments has mirrored again in 2021 (outside of the lower numbers that occurred during the second lockdown), rising again to match pre-pandemic levels, and in some cases rising above, from June 2021.

 

30.  The pandemic has had an impact on patient behaviour, with 42% of respondents to the 2021 GP patient survey[8] confirming they had avoided making a GP appointment.

 

31.  This was reflected in a Healthwatch report from March 2021[9], which found that people were worried about “overloading” services and not speaking to their GP practice unless they felt their health issue was of extreme importance. This was especially prevalent in feedback from older people.

 

Workforce, retention and recruitment

32.  The GP workforce needs to be able to cope with the backlog of patients due to the pandemic. Workforce data from NHS Digital shows some areas of concern. Although the total number of full-time equivalent GPs from September 2020 onwards is higher than it has been previously, the number of qualified permanent GPs, which excludes GPs in training grade and locums, has been falling, with figures in June 2021 nearly 3% lower than they were in June 2017.

 

33.  To help mitigate workforce issues in general practice, the Additional Roles Reimbursement Scheme (ARRS)[10] provides funding for primary care networks to recruit 26,000 additional roles to create bespoke multidisciplinary teams to support people where it is most needed. It is important that local systems, including GP practices, have the capacity to make sure that these new roles are supervised and supported to meet the ambitions of the scheme.

 

34.  Workforce plans will need to consider population demographics to avoid further exacerbating inequalities in access and treatment outcomes. Patients and the public expect high quality care; they also expect staff to be well-trained, professional, culturally aware and from varied backgrounds. Providers also have an obligation to ensure that staff are competent to carry out their new roles.

 

35.  The United Kingdom’s exit from the European Union means the health and care sector now has limited access to the pool of EU workers. The ARRS provides a great opportunity to address workforce shortages. It represents a significant change for GP providers, as they will deploy staff they may not directly employ, but who deliver patient care on their behalf. However, it therefore also poses significant risk in terms of accountability and oversight. From our inspections of GP practices, we know that problems around accountability and oversight already exist in the sector. There is a risk that the ARRS could exacerbate these problems if they are not appropriately mitigated.

 

36.  Effective governance arrangements will need to be developed for the recruitment, supervision and training of all staff recruited under the ARRS.

 

Sector evaluation of access to services

37.  In the 2021 GP patient survey (fieldwork conducted between January and March 2021), 68% said it was ‘easy’ to get through to someone at their GP practice on the phone compared with 65% in 2020. Nearly 71% of respondents described their experience of making a GP appointment as ‘good’ in the 2021 survey, compared with 65% in 2020. 83% said they had a good experience of their GP practice in 2021, similar to the results across the previous three years. 67% were satisfied with appointment times compared with 63% in 2020. Nearly nine in 10 respondents to the survey said their healthcare professional was good at listening to them (89%), giving them enough time (89%), and treating them with care and concern (88%).

 

38.  However, these survey results do not reflect everyone’s experience. Given the primary purpose of this data, thematic analysis of information received via our Give Feedback on Care service[11] has not taken place. However, preliminary considerations of, phone calls and social media between April and December 2020 and more recently data in October 2021, found that a significant theme from people who contacted CQC about access to GP services was the inability to make an appointment. People described finding it difficult to figure out the best or ‘correct’ way to contact practices. When calling by phone, people told us they were often on hold or in a queue for a long time. Some people found that, when they did make a telephone appointment, the doctor did not call them during the allotted time or at all, and they had to go through the booking process again.

 

39.  In our provider collaboration review (PCR) ‘ensuring the provision of cancer services’[12] we found that while access to cancer care in the pandemic had been different for many people, some people struggled more than others to get the care they needed. The patient journey, including screening, diagnosis and treatment, were all affected by reduced capacities and sometimes the availability of medicines was also impacted. Additionally, we heard that people appeared to be less likely to contact medical professionals if they experienced cancer symptoms, which potentially led to diagnoses of cancer at later stages. On review of 98 GP case records, we found that 4% of patients had evidence of delay in referrals being made. We saw that 54% of the 98 patient records showed a physical examination before a referral to secondary care.

 

40.  Further data and information on access to services can be found in the results from the GP patient survey[13]; Health Watch report: GP access during Covid-19[14]; and the Royal College of General Practitioners’ August 2021 statement[15].

 

Inequalities

41.  In our provider collaboration review of services for people with a learning disability[16], we heard that remote consultations were more accessible for some people with a learning disability and their families and carers, as they removed the barriers imposed by travelling to appointments, particularly cost and time.

 

42.  In our provider collaboration review looking at cancer care, we heard that, since many people with cancer are immunosuppressed due to their treatments, remote interaction helped ensure their safety and alleviate anxiety.

 

43.  However, all the local systems we spoke to recognised that there are significant challenges using remote consultations, including digital poverty, poor access to the internet, English not being a first language, and variation in digital literacy. The PCR regarding cancer services also highlighted a greater risk for people from Black and minority ethnic communities, older and disabled people and people living in deprived areas.

 

44.  Other issues raised included concerns about confidentiality, and difficulties in building a relationship with a person using the service or identifying signs of deterioration in health and wellbeing when not being able to examine them.

 

45.  The pandemic has created a steep learning curve for some GP practices in terms of remote access. We support the RCGP’s call for an evaluation of what ‘good’ looks like for digital triage systems, co-designed with patients and clinicians, to ensure that they do not exacerbate health inequalities.

 

46.  One of the principles in Healthwatch’s report[17] on digitally excluded people’s experiences of remote GP appointments calls for traditional models of care to be maintained alongside remote methods and support.

 

47.  The sector needs to think about the future impact of remote or digital appointments, to make sure everyone gets the appropriate access, including face to face appointments, to meet their needs safely.

 

Partnership working

 

48.  NHS England and the Department of Health and Social Care (DHSC) have published a plan[18] to support areas and individual practices to improve access. We have committed to working with the NHS to support systems to make required improvements across practices which are not meeting people’s needs, including:

 

The focus of a future model for general practice

 

49.  The future of general practice should focus on being person-centred, delivering responsive, compassionate, personalised care across a local community, that works in an integrated way with the acute services.

 

50.  Care needs to be holistic and consider the range of people’s needs, to include their physical, mental and emotional health. It needs to empower and enable people to manage their health conditions, so they achieve the best outcome. We know that people who are most able to manage their health conditions had fewer emergency admissions than the people who were less able to and had fewer attendances at A&E and fewer GP appointments.

 

51.  The model of care needs to be flexible and continue to evolve to meet the needs of the changing demographics of the population, the growing complexity created by multimorbidity, the adoption and spread of new innovations, and the changing expectations of the public. For instance, evidence shows that people living in more deprived areas often have the greatest health needs, but the current approach to general practice does not always reflect this and there is a variation in the number of GPs across different regions.

 

52.  Ultimately, new models for urgent and emergency care are needed in which people receive the care they need where and when they need it and are less likely to be inappropriately funnelled into emergency departments – and where primary care services are able to focus on those with complex comorbidities, rather than patients who could be better treated in other settings and by other allied health professionals, such as community pharmacists.

 

53.  CQC is committed to working in partnership with stakeholders in the changing health and social care landscape, to ensure we understand the needs and sentiment of the sectors we regulate and the professionals working within the system.

 

 

ENDS

 

Dec 2021

8

 


[1] https://www.cqc.org.uk/guidance-providers/how-we-inspect-regulate/update-our-chief-inspectors-our-regulatory-approach-10

[2] Our monitoring approach: what to expect | Care Quality Commission (cqc.org.uk)

[3] https://www.cqc.org.uk/news/stories/cqc-postpone-inspections-acute-hospitals-general-practice-until-new-year-support

[4] https://bills.parliament.uk/bills/3022

[5] https://www.cqc.org.uk/about-us/our-strategy-plans/new-strategy-changing-world-health-social-care-cqcs-strategy-2021

[6] https://www.cqc.org.uk/sites/default/files/20211021_stateofcare2021_print.pdf

[7] https://digital.nhs.uk/data-and-information/publications/statistical/appointments-in-general-practice/october-2021

[8] https://www.gov.uk/government/statistics/gp-patient-survey-2021-results

[9] https://www.healthwatch.co.uk/report/2021-03-22/gp-access-during-covid-19

[10] https://www.england.nhs.uk/gp/expanding-our-workforce/

[11] https://www.cqc.org.uk/give-feedback-on-care

[12] https://www.cqc.org.uk/publications/themes-care/provider-collaboration-review-ensuring-provision-cancer-services

[13] GP Patient Survey 2021 Results - GOV.UK (www.gov.uk)

[14] GP access during COVID-19 | Healthwatch

[15] https://www.rcgp.org.uk/about-us/news/2021/august/college-sets-record-straight-on-face-to-face-gp-appointments.aspx

[16] https://www.cqc.org.uk/publications/themed-work/provider-collaboration-review-care-people-learning-disability-living

[17] https://www.healthwatch.co.uk/report/2021-06-16/locked-out-digitally-excluded-peoples-experiences-remote-gp-appointments

[18] https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2021/10/BW999-our-plan-for-improving-access-and-supporting-general-practice-oct-21.pdf