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Surviving regulation

9 February 2013

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The first article in this series began to explore the myriad of challenges facing practices and their managers by exploring the importance of appreciating the difference in being a member of a clinical commissioning group (CCG) and the essential nature of the constitution. 

The next elephant in our sights, or even bearing down on us with ears flapping and trumpeting disconcertingly, is regulation. Practices have always been regulated I often hear colleagues saying “why should we be worried about this round?” It is true that practices have always been regulated by the contractual terms of their general medical services (GMS) or personal medical services (PMS) contract. Training practices have had regular re-approval visits against agreed criteria. We have all had quality and outcomes framework (QOF) visits or post payment verification visits. But I would suggest that there are a number of reasons why as practice managers we need to view current regulatory changes in a different light:


  • There has never been so much data readily available from such diverse sources.  Not all of this is 100% accurate, but when put together it will paint a picture of your service and its ability to care for patients safely and appropriately
  • A lot of this data is not requested but extracted by various mechanisms and with the move from the quality management and analysis system (QMAS) to the calculating quality reporting service (CQRS) at a more frequent interval. CQRS will support not only QOF but also extractions for CQF, DES and LES payments and locally commissioned services.
  • As per the wonderful Einstein quote, “not everything that can be counted counts, and not everything that counts can be measured.” Without soft intelligence, the combined view of various data sources may give a view of your service that differs from your own or even your patients’.
  • We have to acknowledge that there may be unexplained variations between practices. It is good to know if you are an outlier and understand how demographics may affect variation.
  • Patients are increasingly consumers of healthcare and expect to be assured about the quality of the care they receive. They will have increasing rights to access their medical records and ask questions about care.
  • The care quality commission (CQC) will be working with quality risk profiles on practices and will be fulfilling the public expectation of visiting practices to verify compliance.
  • Following Mid Staffs and the outcome of the inquiry in the Francis report, regulation is not going to become lighter and patients should be able expect that it is done thoroughly – this is a key area to apply the old “would you want your mother/son/daughter treated here?” test.
  • We live in a new era and it is cheaper both financially and in terms of reputation to ensure compliance than be proved not to be compliant.
  • Wake up and smell the coffee – it is here, it is a reality, so engage and do it well. 


So which bites of the elephant do we take first? (Apologies to all vegetarians – this is all purely theoretical). Most of us have been chewing over CQC and are hoping that is comfortably digested with no nasty after-effects during inspection visits. There are also the general practice standards that our good friends at NICE have developed with the aim that service providers and patients can readily access information about the performance of their organisation, as an evidence base for clinical practice but also to support commissioners to be confident of the high quality and efficacy of the services they commission. Then just in time for Christmas, on 3 December 2012, revalidation went live with a legal requirement for the nation’s 230,000 licensed doctors to show they are up to date and fit to practise. The key driver behind revalidation is the appraisal and the GP portfolio. There is an essential role for practice managers in making sure that there is a coherent, accessible and robust quality management system in their practice to support their GPs in revalidation.   

When we horizon scan can we see any respite? Well that may depend whether Monitor decide that general practices require provider licences, what potential competitive processes for enhanced services may look like, not forgetting the delights of external reviews of patient satisfaction. It is too out-of-the-box to think that regulation may be applied to managers of healthcare at some time in the future?

Before everyone starts reaching for the pension application forms, lets think logically. The definition of regulation I like best is “a rule designed to control the conduct of those to whom it applies.” We know the rules that underpin our practices. The other two terms which we should understand are “assurance” and “performance management”. 

Assurance is defined as “a positive declaration intended to give confidence.” To be assured, the external regulators will need to see a good level of green glowing on the quality dashboard for your practice. If the glow is of a red hue then the performance management approach defined as “includes activities to ensure that goals are consistently being met in an effective and efficient manner” may be adopted. So it is in our interests to understand the external view and how the regulatory data is collected. As practice managers we know the rules, whether health and safety, infection control, information governance or clinical governance, should be up-to-date and be able to justify that the systems we use deliver safe and effective patient care. But do we need different systems to know what is happening in our practices? No we don’t; not only would this be nonsense it would also increase the potential for black holes to appear with resulting consequences. 

I spoke to a chief executive recently who said he would spend in excess of £1.5 million annually complying with regulation. Do we want to make an industry out of evidencing how our practice team operates or do we need one comprehensive quality management system that is lean enough not to become over burdening and smart enough to alert you when things need to be reviewed? We need to take quality seriously and embed good practice into our organisational culture. It may well be that as primary care transforms and adapts to the pressure of the new system that practices will take a more collective approach towards not only commissioning but provision and shared services. If this is the case what is the role of practice management – will we need more managers with a higher level of specialist knowledge in finance, public health, IT or human resources? Will our role split into those who thrive in more strategic roles and those whose shine in operational and administrative roles? Clinical quality is very much the responsibility of everyone in the practice, not just the clinically qualified staff and as services are delivered for wider populations we will need to be assured that our patients are safe where ever they go in the local system. This is a management challenge that could also be a huge opportunity, but we need to ask whether as practice managers we are we fit for purpose in leading our practices into this new era. What are our CPD needs and how do we develop the right skill set to succeed? 

Those managers who have woken up to these opportunities will be the ones leading the herd, and in the next article we will look at the demands of developing the workforce who will be needed to deliver the movement of care out of hospital. 

Caroline Kerby is co-lead of the NHS Alliance General Practice Network.