As most practice managers across England will no doubt be aware, all providers of health and social care across the country will need to register with the Care Quality Commission (CQC). Most providers are now registered but the Department of Health has agreed that registration of providers of primary medical services, including GP practices, will be postponed until April 2013. Providers of out-of-hours services however, are still required to register by April this year.
Having led on the registration process for a large London primary care trust (the community function has now merged with an acute trust) in April 2010, I can confirm that the process is not as onerous as it first seems: the evidence required to demonstrate compliance with the regulations is not new and all well-run organisations and practices should already have the evidence, systems and processes in place to confirm compliance.
However, the process will no doubt involve planning and preparation to avoid stress in the run-up to the deadline, especially as practices will be involved in other major changes in April 2013 – not least the emergence of authorised clinical commissioning groups (CCGs) as primary care trusts (PCTs) are abolished.
One of the main obstacles practices are likely to encounter is engaging the whole team, who will undoubtedly see the additional workload as yet another bureaucratic process. Communication both about the requirements for registration and ongoing monitoring is vital to avoid problems later on.
Registration is a legal requirement but most practices will already have processes in place for the Quality and Outcomes Framework (QOF) indicators putting them in a good position to demonstrate compliance with the regulations/standards.
I have outlined below how we successfully planned for registration – and survived!
Steering group
We first set up a steering group to oversee the registration process. This consisted of the director of nursing (chair), the medical director, service managers, heads of clinical services, the head of clinical standards and the clinical audit manager. The remit of the group was to develop an action plan outlining key activities, who was responsible for completing those activities and the timescale of their completion. The steering group monitored the action plan.
Such an arrangement could be adapted by a large practice or a group of practices joining together to oversee the registration process, with representatives from each practice responsible for completing the key activities at local level.
The steering group’s specific actions included:
- Identifying evidence already available to support compliance for each CQC outcome (the CQC website outlines the outcomes relating to the regulations in the legislation governing the CQC – see Resources).
- Developing a risk assessment template for teams within the PCT (eg, inpatient units, district nurses, health visitors and allied health professional teams) to carry out risk assessments of their services against the outcomes, to identify gaps in compliance and agree an action plan to address the gaps.
- Setting up a series of workshops for teams (as above). These were aimed at managers and clinicians at field level to explain the registration process, including ongoing monitoring, and to support in the risk assessment process.
- Developing templates to support staff, including a risk-assessment template for each outcome with suggested ‘prompts’ to help teams identify gaps in compliance, and an action plan template highlighting the additional evidence needed, how this would be identified and who was responsible for overseeing implementation.
- Carrying out mock CQC inspections of services. This familiarised staff with the process, preparing them for an actual CQC visit and highlighting potential gaps in compliance.
Challenges encountered
The requirement to register with the CQC was not an option and there was little flexibility in the timescale for registration. The registration process itself was cumbersome, and while the CQC Relationship Managers were helpful it was difficult at times to get the relevant information. However, this should not be such a problem for practices, as the registration process has now been simplified in response to feedback from providers already registered.
While we were confident that we had the evidence to confirm compliance with the outcomes, it was collated and stored in a variety of formats and not all in the same place. The challenge for us was to ensure that each service had the evidence readily available in the event the CQC should ask for additional information.
The time taken to prepare for registration cannot be overestimated. We started in August 2009 and the registration deadline was March 2010. This put additional pressure on service managers who had recently undergone a reorganisation. The challenge for us was to bring together all reporting requirements to avoid fragmentation, duplication and the risk of staff seeing the registration process as yet another bureaucratic process.
Lessons learned
- We would have started the preparation earlier. This would have given us more time to work with staff and prepare them for the additional work at a busy and stressful time.
- We learned the importance of using information already collected for a variety of other purposes as evidence of compliance. Practices will find this useful – the CQC recognises that the range of qualitative information already collected for QOF indicators and other performance-related purposes can be used as evidence to demonstrate compliance with the 16 core standards of quality and safety.
- We also learned the importance of setting up a system for collating all information that we relied on to confirm compliance and to keep it up-to-date at all times. Also that policies and procedures must be kept updated and readily available to staff with evidence that they are used in practice.
- Ensuring that monitoring and evaluation systems are built in and that lessons learned from complaints, patient feedback and audits are used to improve practice.
- One of the most important lessons we learned was that registration with the CQC is not just about systems and processes: it is about being able to demonstrate that you are meeting the outcomes and ensuring that the services provided to patients are relevant to their needs and are of high quality at all times.
Suggested actions for registration preparation
The CQC has indicated that it will produce tools and guidance to help practices prepare for registration at a later date.
Meanwhile, it might be worth considering groups of practices working together to share ideas and review evidence to reduce the burden on individual practices. After all, why produce several versions of a policy when one could be produced with each practice adapting it to their own specific requirements?
To influence developments and shape the CQC processes, practice managers may want to consider joining the Provider Reference Group (see Resources). This is an online community that gives you the opportunity to get involved and test out key process as they are developed. The CQC will use the feedback to help shape the way they work with primary medical services before changes are implemented.
An introduction to registration with the CQC was published in October 2011 and provides useful information on the implementation process for practices.(1)
Key actions
Develop a strategy early. This will reduce the stress in the run-up to registration in April 2013. This should include the following actions:
- Identify an overall lead to collate the information required to confirm registration, to complete the registration process and to be the point of contact for the CQC.
- Involve the whole practice team in bringing together the information required to demonstrate compliance with each outcome. You might want to delegate outcomes to different members of the team.
- Make sure that everyone in the practice, including patients, knows about the CQC and understands the requirements for registration (if the CQC visit they are most likely to see and speak to the receptionist and patients first!).
- Check the primary medical services section of the CQC website regularly for updates (see Resources).
- Review all your current policies and procedures to ensure they are fit for purpose. Ensure they are implemented in practice and that all staff know how to access them and how they are used in practice. However, compliance with the regulations is not just about documentation – it is about ensuring that the patient experience is central to the service.
- Identify the regulated activities that you provide.
- Collate all the evidence that you currently have to support compliance with each of the outcomes for these regulated activities – for example, evidence that you gather patients’ views and use them to improve practice, risk management, safeguarding, outcomes and guidelines that support practice, staff support systems including education/training/supervision/appraisals, facilities management, health and safety, infection control, management of complaints/incidents and lessons learned, clinical audits carried out and changes to practice. All of your QOF information will also be vital here.
- Assess your services against each of the regulated activities/core outcomes and develop an action plan to address any gaps.
- Set up a system to store all the evidence that you are relying on to confirm your compliance.
- Develop a ‘Statement of Purpose’ – a description of the services you provide.
- Develop and publish information to patients about registration with the CQC.
- Review your action plan regularly and provide feedback to staff.
- Complete the stages of registration and submit the online application on time, ensuring sign off by all the partners (information about the stages of registration and the online application will be published well in advance of the registration deadline).
Post registration
- Develop a system to ensure ongoing compliance with the outcomes.
- Link outcomes to the QOF indicators and other performance frameworks.
- Communicate/notify the CQC of any changes/variations/certain events in services – eg, a change in the registered manager, a new service added/no longer provided or a change to location.
Conclusion
A full description of each of the regulated activities is set out in the Scope of Registration document on the CQC website.(2) You will need to read each of these descriptions before deciding which activities to apply for.
It will not be necessary to submit the evidence of compliance on registration but practices will be required to confirm against each outcome whether they are compliant (or not). Where gaps in compliance have been identified an action plan will need to be submitted at the same time, demonstrating how the gaps will be addressed and to what timescale.
Practices will only need to register once – it is not an annual process. However, the CQC recently indicated it is anticipating that as many as 10% of GP practices are at “significant risk of non-compliance” and could be inspected. This assumption is based on pilots run last year.(3)
The CQC has also indicated that it will investigate practices if they have differing evidence from the General Medical Council, local involvement network (LINk) groups or primary care commissioners.(3)
Practices must therefore ensure that the evidence they rely on for registration is readily available should the CQC ask to see it or visit, consistent with that held by other organisations, and that they are compliant with the regulations at all times.
Siobhain O’Donnell has led on clinical governance for several PCTs, setting up systems and processes across a range of service areas, including independent contractors. She now works as a self-employed project manager and was commissioned to lead on the successful CQC registration of a large London PCT in 2010.
References
1. Care Quality Commission. An introduction to registration with the CQC for providers of NHS general practice. London: CQC; 2011. Available from: http://www.cqc.org.uk/organisations-we-regulate/gps-and-primary-medical-…
2. Care Quality Commission. Scope of Registration. London: CQC; 2011.
3. House of Commons. Public Accounts Committee hearing, 25 January 2012. Available from: http://www.publications.parliament.uk/pa/cm201012/cmselect/cmpubacc/c177…
Resources
CQC – GPs and primary medical services
www.cqc.org.uk/primarymedicalservices
CQC – Provider Reference Group
www.cqc.org.uk/prg
