Parliamentary under secretary of state for quality at the Department of Health Lord Howe, has a brief to cover primary care. He tells Victoria Vaughan what’s in store for practices and what role CCGs should play
The quality of hospital care has been a focal area for the NHS this year, starting with the Francis report into the appalling care at Mid Staffordshire NHS Foundation Trust, to an investigation into 14 hospitals which have high mortality rates, and the appointment of Professor Sir Mike Richards as the chief inspector of hospitals.
Yet it is primary care where the majority of NHS work is expected to be done. There has been the recent appointment of Professor Steve Field as chief inspector of primary care, and of course all practices had to register with Care Quality Commission (CQC) by April this year and will face inspections.
Already the CQC has completed 586 inspections and of those 64 services have been found non-compliant.
But is primary care quality likely to face the same scrutiny seen elsewhere?
Minister for primary care and quality Lord Earl Howe says ‘yes’.
“I do not see primary care as having somehow missed the spotlight, in terms of the quality agenda. Quite the reverse, actually.
“I think that there are several ways in which primary care quality will rise in prominence in the agenda over the coming months. Not least of those is the appointment of Professor Steve Field as the chief inspector of general practice.
“Part of his job will be to apply ratings to individual GP practices. Additionally, if we look more generally at the agenda for measuring outcomes, and the outcome indicator sets that clinical commissioning groups (CCGs) will be working to, quite a lot of that will relate to primary care and what GP practices can deliver locally.
“Those indicators are, in part, designed to reflect the NHS outcomes framework – which will be a national framework of outcomes – but also the indicators that are relevant to a local area, which can be very much the kinds of things that primary care contribute to.”
Howe thinks that publication of this information will enable practices to benchmark themselves against each other, and for CCGs to perform one of their roles – to support GP practices that may be finding it more difficult to deliver services effectively.
The role of practice development is one that both the Department of Health and NHS England are keen to see, however CCGs are taking it on to varying degrees.
Howe says: “It will be in the interests of the CCG to encourage [practice development], to make sure that the budget that they receive for commissioning is cost-effectively spent.”
There are feelings of unease about that slipping into performance management especially as CCGs do not hold GP contracts.
Howe says that a failing practice will come to light through the publication and availability of key indicators on performance, prescribing rates and complaints – data that has already been collected – and that CCGs will need to think of the best way of bringing those practices up to an acceptable standard.
“I always think about something a general practitioner once said to me: what got him up in the morning was his pride in the service that he was delivering to his patients. If a GP is made aware that he or she is below the standard that their fellow GPs are delivering, particularly locally, their professionalism will not let that rest; they will want to ensure that they are helped in order to bring their practice up to the right level. That is where I see the conversations coming in.
“It may be that they can be supported by neighbouring practices in some way. They could be struggling for perfectly legitimate reasons. They may want access to technology or equipment, they may want guidance in that area, or whatever the case may be. Therefore, I see the CCG as having a role in brokering that kind of dialogue with other practices locally. I think that in the first incidence it will be an informal process of peer influence.”
And if that doesn’t work Howe points towards revalidation as a way of delivering “appropriate guidance and, if necessary, training to underperforming doctors”.
The chief inspector of primary care has already taken up post at the CQC and, taking a lead from what Mike Richards is doing in his sister role for hospitals, it is thought that he will work to grade GP practices in a similar way Ofsted does for schools: outstanding; good; requiring improvement; and inadequate.
“I think the other aspect of the chief inspector’s work in primary care will be, very much, to champion the views of patients and judge how well providers of primary care are protecting the interests of patients, by putting quality at the heart of everything that they do and assessing not just what they see when they go into the practice, but taking the temperature of the water from patients locally about how they view their primary care service. Part of that will come from the ‘Friends and Family’ test, but not exclusively because I think local Healthwatch will have a significant role here.
“Of course, the chief inspector is not there to replicate or second guess the work of the General Medical Council or the General Dental Council, as regards the professional competence of practitioners. It is about the service that a practice delivers overall.”
How should practices and CCGs be preparing for this new inspector on the block?
“I think that a great many primary care practices need not be anxious at all. Business as usual will be considered by Steve Field to be excellent, because we know that many, many GP practices are delivering. However, perhaps, if they have worries about the way their practice is organised – systems, filing, anything that is worrying them about basic hygiene – how easy or difficult is it for patients to access the surgery, perhaps they should take a look at the patient comments that they get, and in that way prepare themselves for an inspection. I am sure that Steve will be conscious of the need to issue as much guidance as he can to general practice about this.”
The often-voiced complaint that it’s not fair to compare practices as they have widely varying factors from size to deprivation holds no sway with Howe.
“It is not a valid criticism. It does matter what patients think about the service they are getting, it does matter what outcomes
are being produced by a practice; the relevance of that does not vary across urban and rural areas.
“Of course there will be different health problems, but prescribing rates are an issue wherever you are, the efficiency and effectiveness of a practice matters wherever that practice is located. Of course there will be differences in the make-up of the patient population in that area, but I do not see that a reason, or, dare I say, an excuse to abdicate from a process which, actually, clinicians ought to welcome. They ought, and I know many do, to be keen to know how well they are performing in relation to their peers, and how favourably their patients respond to what they are doing.”
There is more scrutiny of general practice on the horizon as there is more expected from it, yet there are concerns that a minority of NHS funding is channeled into primary care.
“Funding matters critically in this context, but it is not the only thing that matters. We have said that the funding for the integration transformation fund will be dependent on plans that are worked out jointly between commissioners and providers in health and social care for a genuinely integrated service. It is that cross-disciplinary, cross-sector dialogue that has to underpin this whole exercise.
“They will submit a plan or strategy which will be signed off, or overseen, by the health and wellbeing boards as being credible and deliverable. Only on that basis will the money be forthcoming. It is not a matter of doling out money; the plan that underpins it has got to show how resources are going to be deployed to best effect across health and social care. This is about one of the ‘P’s in the QIPP [quality, innovation, productivity and prevention] acronym: productivity.
“Money is tight, we know that. We know that, for a number of years, there has been general agreement about shifting care from acute settings in to the community. Everyone, at least in name, has signed up to that. Only a comparatively small number of health economies have actually made that shift. Some have done so very successfully, and this integration transformation fund system is designed to actually give a kick start to the rest of the NHS, to get further faster on this road.”
Money for the £3.8 billion transformation fund comes from: £1 billion existing NHS support for social care, including £200 million additional investment in 2014/15; £2 billion additional investment from the NHS for improving care and support for frail older people and people with disabilities in 2015/16; £350 million capital funding (including the disabled facilities grant); £430 million of NHS funding to support carers and for reablement (helping people get fit after an injury).