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An Inspector Calls

Friday 26 April 2019

Last Thursday afternoon, I sat down together with the Practice Manager in my consulting room for our first Annual Regulatory Review (ARR) call with the CQC. Since April 1st, these calls now form part of the new and targeted inspection regime. I mentioned them some months ago after a meeting between the LMC executive and the CQC. The idea is that the call allows a conversation between practice and inspector so that changes in service provision or anything else potentially affecting registration status can be highlighted. There’s nothing to be particularly alarmed about- the CQC website lists the framework of the ‘interview’ and questions to be asked, although the responses might elicit some further probing, if and as appropriate. Prior to the call, the inspector will have looked at other evidence they have available such as QOF data, NHS patient survey information, and any complaints or comments about the practice. The outcome of the call can’t affect a practice’s CQC rating- that can only change following an inspection visit. Within a few weeks, the practice receives notification of whether or not an inspection visit will follow. Any such inspection will focus on aspects arising from the call, and the more formal inspections (five-yearly for most practices) will still occur. Essentially, then, the aim for the provider is to get through the hour or so that the call takes, without much repetition, significant hesitation or worrying deviation that might pique the inspector’s curiosity. What could possibly go wrong?

Most of the questions generally start with ‘has there been any change in ….?’ and work through the various familiar CQC sections (are you effective, well led, responsive etc.). The website makes clear that many of the answers are likely to be ‘no’, and that it’s OK to say so. It certainly sounds better than a terse ‘no comment’. The inspector was writing as we spoke; it doesn’t take long to say ‘no’- so there were disconcerting periods of silence when I had to stop myself blurting something out just to fill the uneasy hush.

One significant change at North Petherton is that one of our number now does vasectomies, a skill he brought with him from his previous practice in the county. This evidently rang a bell at the other end of the line. Was this just for the benefit of our patients, or was he taking referrals from around the county? If you’re registered to provide minor surgery, I wouldn’t have thought it mattered particularly whose scrotum you were chiselling into (forgive me), but it appears that if the attached patient has been referred to our colleague from elsewhere, then that might open a whole new bag of worms (forgive me once more). We haven’t heard yet whether they want to come and talk to him about his hobby.

It had already been a productive day. Harry and I had met for our ‘early doors’ Costa catch-up and mused how the GP Board profile might change over the coming year, before I headed to the LMC office and found myself embroiled in a social media skirmish with the Spanish whilst waiting for the computer to fire up. It’s easily done.

Have you pondered how much of your day is spent waiting for the computer to do something, or indeed, anything? As the pace at which we work increases, the IT just seems to get slower and slower. It’s quicker to hand-sign a days-worth of prescriptions than to do so electronically, even allowing for the time it takes to steal and mislay a receptionist’s favourite pen and stopping every now and then to massage cramp from your fingers. The EMIS wheel of doom is spinning more than it’s not, and I’m always exercised by the message at the top of the screen telling us that ‘EMIS web is not responding’, as if we hadn’t noticed. The practice IT system feels positively frisky, however, compared to the speed of some of the computers in the LMC office.

Turning on from a cold start usually allows time for at least two cups of tea or coffee, and injudiciously ‘saving’ an Office document, having absent-mindedly forgotten that it’s going to render the system unusable for the next 20 minutes or so, can dim the lights in the rest of the building. So, when early on Thursday I found my efforts to log-on thwarted, I checked Twitter on my iPad, and saw that it was the anniversary of the day in 1947 when Royal Navy blew up 7000 tons of unused German explosives on the German island of Heligoland. Ah yes- I’d read about this: one of my literary heroes, Alan Coren, wrote about being taken out into a London garden and being instructed to cock an ear to the North-East, where he clearly heard the rumble from 300 miles away. I tweeted back that it had been quite a bang, and within a few minutes had a reply from somebody or something called ‘Gibraltar Español’ who wanted to know whether I was planning to do the same with Gibraltar when the UK was ‘faced with the reality of decolonisation?’.

Gosh. Normally questions into the LMC office relating to the ‘reality of decolonisation’ bemoan the shortage in community pharmacies of Skinsan antibacterial wash or Bactroban nasal ointment. I haven’t yet checked with Jill or Barry, who between them know almost everything, or checked the constitution, but I’m fairly sure that blowing up Gibraltar falls some way outside the remit of the LMC chairman.

Before my hot date with the CQC, we headed out for lunch at ‘Taart’, a newish café in North Petherton, to celebrate a very significant birthday in the ranks of the LMC executive. It looks and feels like a vegetarian haunt, and markets itself as ‘vegan-friendly’ - lots of quiches and salads on display, all listed on brown paper menus on clipboards (a sure sign) and yet I was intrigued that it was evidently doing so well in Pethy, of all places; I know my burghers like their burgers. The reason might be a speciality garnish that they added to several of the dishes: bacon. That’s my sort of vegetarianism.

If only every meeting I go to could be like Wednesday’s Primary Care Joint Committee meeting at Monks Yard. It was expertly chaired by (The Right Honourable) David Heath, who has had an interesting professional life. An optician by training, he became leader of Somerset County Council in the late 80’s, and then went onto become a Liberal Democrat MP for Somerton and Frome, serving as Minister of State for Agriculture and Food in the coalition government. As is customary, we started with the confidential bit, Part B, when sensitive items were discussed, prior to which the public had to be excluded. She said she would be in the coffee shop downstairs so we could call her back when we got to Part A. In the event we’d finished both parts, including dispatching and retrieving the public gallery, within seven minutes. Can’t we get David back into Parliament and onto Brexit?

There was, as ever, a rub. This was the last meeting of the PC Joint Committee, as the CCG now has full delegation for commissioning Primary Care, and those seven minutes had been to formally wrap up the previous arrangements, before we went on to discuss the Terms of Reference and Memoranda of Understanding for the new Somerset Primary Care Commissioning Committee that will be taking over the reins, with less involvement of, and reducing oversight by, NHS England. There are still important details to be clarified, including how this new CCG committee interacts with the PAG (Performance Advisory Group) when concerns about professional performance are considered. An interesting nugget from the financial section was that CCG budgets nationally had been top-sliced by £238 million to pay for GP indemnity, which translates to £2.2 million for Somerset that will no longer be available to invest in local services, above the £1.50 per patient that flows into Primary Care Networks.

I’ve had more IT shenanigans this week. I must have sat on my phone at some stage and erroneously sent meeting invites for a ‘Whole System Clinical Service Strategy Group meeting’ on the 14th of May in South Petherton to most of my contacts and have since been batting away replies and issuing apologies to bemused friends and colleagues. I guess some people might still turn up, and so they’ll probably need a bigger room. Do you think I should warn them?

My ongoing problems with NHS mail have defied logic, advanced cursing, and the best brains at the CSU. I have two nhs.net addresses and having them both on my iPhone and iPad seems to have upset the fragile equilibrium, with the result that my password stops working or I get locked out with disarming regularity, often several times a day. I’ve removed my surgery account from my IOS devices, and that felt like a Good Thing, but I needed to free up some cyber-time anyway as I’ve even more to read now. After literally years of ranting, we can at last see the CCG bulletin items as attachments that can be read on any computer. Many thanks to colleagues at the CCG (especially Geoff Sharp and Will Harris) for their unstinting efforts over the months and years to nail this particular irritant.

Yesterday, Barry and I were at Musgrove to join a wide-ranging group looking at the emerging PCNs (primary care networks) from the perspective of the acute trusts. What were the difficulties that could be anticipated in working with the new organisations, and what practical steps could the Alliance (T and S/SomPar) take now to mitigate any potential problems? We stuck post-it notes on a wall, as is customary at such events, and although we may not have come up with many concrete proposals whilst we were there, it was encouraging to see and hear how proactive our Trust colleagues were being in anticipation of the brave new world.

May promises to be very exciting, for all sorts of reasons.

(the month, not the PM. Obviously)

Nick

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