Clifton House and Nook Group Practice joins our hospitals Trust and the Kirklees community services provider Locala in receiving a Care Quality Commission judgment of “requires improvement” – while both Greater Huddersfield and Calderdale Clinical Commissioning Groups have been put in special measures by NHS England because of their inability to meet its financial targets.
Inspectors rated the practice as good for caring, but overall they rated the service as inadequate, on the basis that it requires improvement for responsiveness and they judged it inadequate for safety, effectiveness and well led.
If multiple NHS organizations are “failing” their Care Quality Commission inspections perhaps this has a bigger meaning. Maybe it becomes impossible to provide decent and safe care when staff and services are being cut because of a shrinking budget.
Woodhouse Hill Surgery in Fartown – also run by the Clifton House and Nook Group Practice provider, Dr Ilyas Ahmad – is rated good by the Care Quality Commission. This practice is run on a Personal Medical Services contract which, until recent cuts, attracted more funding than the traditional General Medical Services contract which is what the Clifton House and Nook Group Practice has.
Dr Ilyas Ahmad took over the Nook Group Practice after the last Dr left and it was without a permanent doctor for a while.
The Care Quality Commission says that the Clifton House and Nook Group Practice
“will be inspected again within six months if they are still operating.”
GP practices dropping like flies
GP practices around the country have been dropping like flies over the last year and many people believe this is by design rather than accident, as NHS commissioners and quangos push to create large superpractices to form part of Accountable Care Organisations that operate on new fixed population-based contracts and deliver “Care Closer to Home” by new grades of less-qualified professionals using “new care pathways” that limits the role of GPs and other primary care clinicians to box tickers.
National Crisis in General Practice
There is national crisis in General Practice, which is the result of government policy and decisions.
As Professor Stephen Hawking has recently written, following his talk about the state of the NHS at the Royal College of Medicine the other week,
“There is overwhelming evidence that NHS funding and the numbers of doctors and nurses are inadequate, and it is getting worse. The NHS had a £2.4bn shortfall in funding in 2015-16, bigger than ever before. NHS spending per person will go down in 2018-19. According to the Red Cross, the NHS is facing a humanitarian crisis. There is a staff recruitment crisis.”
Greater Huddersfield GPs have little confidence in local Commissioners’ plans
Greater Huddersfield Clinical Commissioning Group, which is responsible for contracting GP services for the area, has said in its GP Forward View plans:
“There is a national and local workforce challenge. GPs are in short supply and large proportion of the nursing and practice management and support function workforce are approaching retirement. There are excellent staff within primary care but demand is rising, presenting a challenge to morale and retention of the current workforce.”
However, Greater Huddersfield GPs have little confidence in the Greater Huddersfield Clinical Commissioning Group, whose GP Forward View proposes massive changes to GP services in order to make them fit with proposed cuts to hospital services.
In plans that have been rejected by both the public and the Joint Health Scrutiny Committee (which recently referred them to the Independent Review Panel), Huddersfield’s District General Hospital is to be knocked down and replaced by an acute and emergency hospital in Halifax and a small planned care hospital with outpatients services, to provide planned care for both Greater Huddersfield and Calderdale (along with an urgent care centre.)
As fewer services would be available in hospitals as they admit fewer patients, Greater Huddersfield Clinical Commissioning Group expects local GPs to reorganise themselves to deliver primary care “at scale” – ie for large populations.
Their GP Forward View says,
“The key priority is for the development of a primary care centre serving the population of central Huddersfield, to be designed based on the need for additional capacity for an increasing number of services being provided out of hospital, whilst providing the opportunity for these practices to be collocated alongside community services, and potentially mental health and third sector organisations….The development is in a central location with excellent transport links and pharmacy provision.”
Dr Bert Jindal, the Medical secretary of the local GPs’ organisation, Kirklees Local Medical Committee, complained at a Councillors‘ Scrutiny Committee meeting last month that the LMC had not been involved in any discussions about the reconfiguration proposals or the hospital Trust’s Full Business Case. Among their many concerns, the Local Medical Committee are worried about the impact of a greater workload on GP services and community nursing. There is a workforce crisis in General Practice nationally and not enough staff to run existing GP services and primary care.
The Greater Huddersfield Clinical Commissioning Group’s GP Forward view says,
“It is essential that there is investment in primary care and development of new ways of working to ensure our member practices remain resilient and sustainable” –
But its spending on GP contracts is marginally declining this year and next – even though a key part of GH CCG’s primary care strategy is to:
“…help support the movement of care from hospital to out of hospital settings. We must invest in increasing primary care capacity to enable that to happen.”
This involves “ a new offer in primary care including supporting patients to manage their own conditions…”
Warning that the Clifton House and Nook Group Practice may not still be operating in six months time, since if there is not enough improvement the Care Quality Commission will move to close the service, the Care Quality Commission report highlights a number of areas of concern including:
Inspectors could see that whilst the lead clinician had the required training in safeguarding, inspectors did not see evidence that mandatory training in safeguarding, health and safety, fire safety, basic life support, infection control and information governance had been completed by all staff. Data showed some patient outcomes were low compared to the national average. There was no meaningful audit activity to drive improvements to patient outcomes.
Information about services and how to complain was available. However, detailed responses to complaints were not recorded and there was no evidence of learning from complaints being shared across the staff team.
The provider could not produce a gas safety certificate for either the premises or for the boiler at the Clifton House site.
Alison Holbourn, Deputy Chief Inspector of General Practice for the North, said:
“The practice told us they had a clear aspiration to deliver high quality care and promote good outcomes for patients. However, inspectors did not see effective progress against areas identified within the provider’s business development plan. For example, tasks to establish a practice website had been achieved but staff appraisals were still overdue.”
“The surgery gave us assurances that they had adequate numbers of staff in order to provide responsive services. When we reviewed the number of appointments available over two random weeks we saw that appointment capacity was variable and that GP clinics were sometimes cancelled at short notice due to a lack of clinical staff.”
“It is important that the people who are registered with the Clifton House and Nook Group Practice can rely on getting high quality care and due to the concerns identified during the inspection, CQC has placed this service into special measures. It will be inspected again within six months if they are still operating. The service will be kept under review and if needed could be escalated to urgent enforcement action and if there is not enough improvement we will move to close the service.”
Care Quality Commission – top down regulation that doesn’t have to be this way
The Care Quality Commission is an NHS quango set up in 2009 by combining three old regulators. Its remit is to cover both NHS and social care, but with less money. Old regulation was mainly paid for by the government, now it is paid for by those being regulated. For practices like Clifton House and Nook Group Practice that have a “branch”, the surgery has to pay two sets of fees – in 2016 the fee was £4, 839.
Many GPs see the Care Quality Commission as part of draconian inspection culture that is destructive of much that constitutes what has been best in our NHS.
Dr Margaret McCartney, a GP and author, writes in her 2016 book The State of Medicine (p184),
“The experience of inspection reads to me like institutional bullying…These experiences arise from several culture clashes. The values of inspectors (in favour of filing, paperwork and rigid protocol over evidence) do not match those of practice staff (a preference of continuity of care, time with patients, experience and pragmatism, topped with vocation (which forms a large part of personal identity). A top-down data-driven desire for uniformity finds itself at odds with grassroots experience.”
There are other, better ways of regulating General Practice. In Scotland, Healthcare Improvement Scotland does the same kind of work as the Care Quality Commission, but in a way that “encourages and draws on professional values” and that
“runs on an understanding of assumed co-operation. Visits from staff tend to be low-key, discursive and formative. Its reports highlight good practice and recommend what could improve, and the tone is essentially non-confrontational.” (Margaret McCartney,p 186)