Improving GP practice ratings

In recognition of the NHS’s 70^th birthday, the Care Quality Commission has published a series of case studies of individuals and services within the NHS which have made a significant impact on the care people receive. As part of this review, the CQC selected 10 GP practices across the country that have achieved significant improvement in the judgments they received from their initial inspection to their most recent inspections.

Nine of the 10 practices were originally rated as inadequate and placed into special measures; all of them improved to an overall rating of good on their last inspection. One practice improved from a rating of requires improvement to outstanding.

If practices have received a less than satisfactory rating from the CQC, it may assist them to recognise familiar problems and learn what other practices have done to overcome them. While the CQC is not above criticism in its approach to inspections and subsequent findings, it is nevertheless the regulator which inspects and judges service providers. We, therefore, consider it helpful to review the CQC’s own thoughts on what has assisted GPs in improving each practice’s performance.

The practices reviewed all accepted that they had significant problems, which were often based on a lack of clear policies and procedures which would assist in mitigating risks to patients. Recognising that there were significant problems was the first step for practices in making improvements. In addition, the CQC found the following elements to be common to all 10 practices in helping them to achieve improvement:

Strong leadership

The CQC has stressed that good leadership is critical to improvement and moving forward; while GPs provide the clinical leadership, it was very important that each practice has strong leadership from a practice manager with the time and skills to lead the practice team. The CQC concluded that a good practice manager, working in tandem with a senior GP, can deliver change.

Providing assurance

Across the practices the CQC spoke to, there was common recognition that practices needed to put robust policies and processes in place in order to assure themselves that risks to patients were mitigated. Where practices may have already had policies in place, their priority was to ensure that policies were implemented properly, which meant that staff knew about them, understood them and followed them. As well as reducing risks, improved systems enabled practices to provide a better service for people using the surgery. This included, for example, ensuring that significant events and lessons learned from them were recorded properly; the competent handling of complaints; following up blood test results effectively; the effective handling of alerts and notifications (leading to quicker patient reviews); and reviewing patients’ medicines appropriately.

Staffing and training

The CQC frequently identified staffing and training issues in the underperforming practices. These issues included a shortage of staff, people not being clear about their roles, training not being taken up or delivered, staff not having appraisals, and poor recruitment procedures (which included lack of DBS checks). It was found that offering more training opportunities for staff brought clear benefits to patients. At one surgery, for example, training in dementia awareness for staff resulted in improved diagnosis rates. In addition to training, it was found that engaging staff in decisions that affect the practice also led to improvements in service. Making sure every member of the practice team understood their own and others’ roles and responsibilities was also important in a well functioning practice.

Teamwork and communication

Good teamwork and communication is a necessary element in any successful organisation. The case studies show that a good or outstanding GP practice needs to work as a team – better teamwork leads to better care for patients. This includes clinical, administrative and managerial staff working together with a shared vision, values and commitment to improving.

Lack of clarity about roles and lack of information about what different teams in the practice were doing were issues that the CQC noted in early inspections of the 10 featured practices. More regular practice and clinical meetings, where minutes are recorded, were also features of a number of the improvement stories.

Good teamwork also meant that practices were working as a multidisciplinary model, including recognising the value of nursing teams in taking some of the clinical workload off GPs.

Involvement of patients and the local community

The CQC recognised that professional isolation is a common root cause for a practice receiving a poor rating. It was found that by tapping into networks available to them, practices can learn from others and share their own experiences. Improvements can be made by seeking feedback from patient groups and the local community, for example, one practice in the case study successfully used patient groups to successfully redesign aspects of its service.

Using external support to help improvement

The CQC stressed that practices should not hesitate in asking for support locally or nationally, as well as from other practices that are good or outstanding. Almost all the featured practices received some form of external support to help them make the necessary improvements. This was identified as being invaluable, particularly for smaller practices where staff were already stretched. For some practices the support came from the RCGP; one had support from NHS England’s Vulnerable Practice Scheme and others employed external consultants. Local stakeholders such as the clinical commissioning group and the local medical committee also helped some practices.

The CQC noted how difficult it was for smaller practices to deliver and sustain improvement. This meant that a number of the practices in the case study progressed and improved by working in partnership with or by merging with larger practices.

At Ridouts, we often see that even where policies and procedures are in place, a lack of clear documentary evidence to demonstrate the existence of those policies leads to CQC making adverse findings against services. It is important that all improvements to a practice are well documented and are updated to evidence that they are in place.

CQC inspectors will look for documentary evidence to support its conclusions and the failure to document improvements will almost certainly lead to adverse findings being made by the CQC.