1. 1 CQC’s approach to GP practice inspections and use of data Professor Nigel Sparrow OBE Senior National GP Advisor Care Quality Commission 13 th National Multi-specialty Meeting 20 January 2015 London

2. 2 Our purpose and role Our purpose We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve. Our role We monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety and we publish what we find, including performance ratings to help people choose care. We will be strong, independent, expert inspectorate that is always on the side of people who use services.

3. 3 Developing the changes We co-produced the changes by working closely with our partners, providers, key stakeholders, the public and people who use services: A new start consultation – June 2013 Primary Medical Services signposting document – Dec 2013 GP and GP OOH advisory and reference groups *** Public steering groups/focus groups *** Provider and public online communities *** GP co- production/population groups GP and OOH provider handbook consultation – April 2014

4. 4 Our new approach

5. What are we doing differently? Inspection teams of specialist inspectors, GPs, practice nurses or/practice managers Inspections of a number of practices carried out in a CCG area over a 2-4 week period. Introductions of ratings for GP practices telling patients whether they are Outstanding, Good or whether they Require Improvement or are Inadequate. Strengthening our Intelligent Monitoring of providers using nationally held data and local intelligence. New ways of gathering patient views both before and during inspection. Develop a clear approach to responding to failing practices, working with NHS England.

6. Our key questions We will no longer focus solely on whether providers are compliant or non-compliant with regulations. Our focus is on five key questions that ask whether a provider is: Safe? – people are protected from abuse and avoidable harm Effective? – people’s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence Caring? – staff involve and treat people with compassion, kindness, dignity and respect. Responsive? – services are organised so that they meet people’s needs Well-led? – the leadership, management and governance of the organisation assure the delivery of high-quality care, supports learning and innovation, and promotes an open and fair culture. 6

7. For each of the five key questions there are between 3 and 5 Key Lines of Enquiry (KLOE) There are a standard set of KLOEs for GP practices and GP out-of- hours services For each KLOE we have provided characteristics of good They support consistency of what we look at under each of the five key questions and focus on those areas that matter most KLOEs are supported by guidance on the key things to consider as part of the assessment; these are called prompts There are a small number of differences under things to consider for GP practices and GP out-of-hours 7

8. Population groups Inspectors will judge how well services meet the needs of six different population groups: Older people People with long-term conditions Families, children and young people Working age people, those recently retired and students People living in vulnerable circumstances People experiencing poor mental health (including people with dementia). 8

9. 9 Ratings: four point scale High level characteristics of each rating level Innovative, creative, constantly striving to improve, open and transparent Consistent level of service people have a right to expect, robust arrangements in place for when things do go wrong May have elements of good practice but inconsistent, potential or actual risk, inconsistent responses when things go wrong Severe harm has or is likely to occur, shortfalls in practice, ineffective or no action taken to put things right or improve

10. 10 How do we decide a rating?

11. 11 Ratings Grid (out of hours example)

12. Use of data in Intelligent Monitoring 12

13. Intelligent monitoring Intelligent monitoring is a tool to help our inspectors understand the areas of care that need to be followed up. Looks at set of indicators including patient experience and statistical measures of performance. The indicators relate to the five questions we ask all services. The indicators will be used to raise questions, not make judgements – our ratings do that. 13

14. 14 Intelligent Monitoring indicators by domain DomainsIndicators Caring7 Effective28 Responsive2 Total37

15. 15 List of data sources for indicator guidance for GP Intelligent Monitoring ePACT - Electronic Prescribing Analysis and Cost GPPS - The GP Patient Survey HES - Hospital Episode Statistics HSCIC - Health & Social Care Information Centre ICIP - Information Centre Indicator Portal NICE - the National Institute for Health and Care Excellence NHS BSA - the NHS Business Services Authority NHS Comparators - an analytical service for commissioners and providers and pulls together activity and costed data through the Payment by Results (PbR) tariff from the Secondary Uses Service (SUS) information from The Quality and Outcomes Framework (QOF) GP practice demographic population profile data

16. New approach roll-out 16

17. Timelines Published signposting document setting out high level proposals Dec 2013 First wave of GP out-of-hours providers (approximately 30 providers) Jan – Mar 2014 Public consultation on draft inspection handbook and Wave 1 of testing (200 practices in 12 CCG areas) April – June 2014 Wave 2 of inspections ongoing testing and refining of our revised approach July – Sept 2014 Oct 2014New approach fully implemented. Ratings awarded. By April 2016 Every NHS GP practice and NHS GP out- of-hours inspected and awarded ratings

18. 18 Where we could improve: Ensure the inspection includes a focus on the positive- outstanding Feedback session-ensuring balanced (not just focussed on the negative) Consistency in information requests pre and post inspection (and consistency in guidance) Being mindful of our approach to interviewing staff (practice staff may not be experienced with being interviewed before) The need for structured inspection days, being mindful of the impact on the practice Ensuring we provide practices with notice (eg 2 weeks) and consider flexibility for mitigating situations Feedback from practices following the pilot

19. New approach roll-out GP practice inspections commenced from 1 October 2014. We have so far inspected 781 practices under the new approach These inspections include ratings.

20. 20 Final handbook and consultation response – published 9 October and available on our website Revised Key Lines of Enquiry and Rating Characteristics (clearer, more detailed prompts, removed duplication between key questions). Refined definitions of the six population groups. Improved, refined descriptions of Outstanding, Good, Requires Improvement and Inadequate for safe, effective, caring, responsive and well-led. Final handbook

21. 21 Pre-inspection information request. At the start of the inspection the practice/OOH provider spends half an hour presenting to the inspection team about their practice – what works well and where they need to improve, focusing on the population groups and the five key questions. Introduces special measures (piloting from October). Final handbook – changes to methodology

22. What to expect from an inspection We will send the practice a letter two weeks before we inspect (unless we are responding to concerns) and our inspector will call the practice. On the day, we will ask the practice to tell us (and give evidence) about the good care they give, and will want to talk to staff and patients to find out more. At the end of the inspection, we will provide brief feedback to the practice. We will write up our report and send it to the practice for factual accuracy before we publish it on our website. 22

23. 23 Special measures – support for practices rated as inadequate

24. Special measures All GP practices that are found to be inadequate will be placed in special measures and offered a package of help to improve at the earliest opportunity We have been working with NHS England and the Royal College of General Practitioners who will give support to practices that are placed in special measures. Our priority is in making sure patients receive safe, high-quality and compassionate care and in supporting services to improve 24

25. Key Lines Of Enquiry