Failing GPs: A Pandora's Box?

Stethoscope Image copyright TEK IMAGE/SCIENCE PHOTO LIBRARY

There are nearly 8,000 GP practices in England, employing more than 35,000 doctors.

But despite the NHS being perhaps the most information-rich health system in the world, we have little clue which are good and which are bad.

Poor performance - as one influential doctor put it to me - has been "tolerated" for far too long. Until now.

What the Care Quality Commission is trying to do with its failure regime for GP practices marks uncharted territory for the health service.

Yes, GPs have always in theory faced the prospect of being closed down if they are not up to scratch, but the reality is that that process has taken place behind the scenes.

The management bodies that hold GP contracts - NHS England since last year and before that primary care trusts - have always been able to terminate them. But no records are held centrally about where or how often this has been done.

By promising to inspect every practice by March 2016, publish the results and take action against all those that fall in the bottom, inadequate category, the CQC will shine the spotlight on failing practices like never before.

GPs in numbers
There are nearly 8,000 GP practices in England The Care Quality Commission will inspect all of them by March 2016
England's practices employ just over 35,500 doctors The GP patient survey showed 4.8% rated their experience as poor
There are 340m GP consultations a year, representing 90% of patient contacts in the NHS The target for GPs in training is 3,250 a year - but the numbers have been hovering 500 below that
They will get one of four ratings - outstanding, good, requires improvement and inadequate Between 2007 and 2012 1.25% of GPs got a warning or sanction from the General Medical Council

So what are inspectors likely to find? That question is very hard to answer. To pave the way for the new system, the CQC carried out a series of inspections on about 900 practices last year.

Problems were identified in about a third, but that figure needs to be treated with caution.

The groups inspected were partly chosen because they were known to be high risk and in many cases the failings were not on the sort of scale that would prompt the failure regime to be enacted. The concerns raised included criminal records checks not being carried out or poor systems to incorporate patient feedback.

Instead, those involved in the process expect the number of failing GPs will be below the 10% mark.

That chimes with the evidence from the official GP patient survey carried out for NHS England. The latest data from July showed 1.2% of patients rated their overall experience as "very poor". When you include those that said it was "fairly poor" the figure was nearer 5%.

Image copyright Science Photo Library

But in many respects identifying how many poor performing practices there are may well turn out to be the easy bit. Dealing with the aftermath of that process could prove much harder.

Hospitals are already undergoing this failure process. But when they are put into special measures they are buddied with well-performing trusts and have improvement directors assigned to them.

It will simply not be possible for the system to provide that level of intensive support to failing practices because of the numbers involved. They are, in effect, being told to shape up or ship out.

That, of course, has consequences for patients. In its announcement, the CQC was quick to point out that they would not suffer as new GPs would be found to take over failing sites or alternative practices found.

That is easier said then done. A recent report by Health Education England has shown in a number of areas - particularly outside the South East - the NHS is finding it difficult to recruit GPs, while existing practices are having problems meeting demand as the latest warnings about waiting times demonstrate. The CQC may just have opened a Pandora's Box.