On 28 March 2019, the Care Quality Commission (“CQC”) published a report setting out its findings based on a programme of comprehensive inspections of independent doctor and clinic services which provide primary medical care in England.
CQC looked at a sample of inspection reports for inspections carried out between 1 January 2017 and 5 October 2018. The analysis of those reports highlighted some common themes. It was identified that whilst many services are meeting the regulations, a number of services are not. The biggest concern identified was the failure to provide safe care.
The purpose of the Care Quality Commission
CQC is responsible for regulating the services that independent doctors and clinics provide. This includes registering, ongoing monitoring, inspecting and reporting on those services. When inspecting the services, CQC judges whether a provider is meeting the requirements under the regulations. CQC assesses services following the key lines of enquiry, to see whether they are safe, effective, caring, responsive and well-led.
In the report, CQC noted that a number of independent services are not providing safe care to their patients and there were some themes identified across services.
One of those areas was the failure to share information with other professionals, such as the patient’s NHS GP. CQC expects providers to ask patients to consent to sharing details of all private consultations with their GP. The General Medical Council (“GMC”) guidance on using and disclosing patient information states that “appropriate information sharing is an essential part of the provision of safe and effective care.” Providers should have a policy in place for sharing information and CQC state that this should include asking patients for details of their GP and obtaining their consent to share information.
Safeguarding training required
CQC identified that, in some services, there was a lack of understanding of the responsibility of clinicians in relation to safeguarding. It states that providers need to have clear policies in place to protect people. It is vitally important that staff need to be aware of relevant guidance and training must be provided to ensure a good understanding of safeguarding practices.
Poor prescribing practices
Another area of concern was in relation to safe prescribing practices. There was evidence of some services prescribing medicines without a strong evidence base or prescribing unlicensed medicines. CQC reminds providers that if these medicines are prescribed, there must be a clear record of the rationale behind the prescription and the patient must also be informed of the licence status and side-effects. It is important that providers have prescribing policies in place and prescribing audits should be carried out to monitor the quality of prescribing practices. Particular reference is made to prescribing antibiotics. The Government has announced a plan for antimicrobial resistance which means that clinicians need to keep up to date with evidence on the appropriate use of antibiotics.
Record keeping requirements
Concerns were also raised about record keeping. There were examples of inadequate record keeping practices which included incomplete records and records not made in English. Good Medical Practice, published by the GMC states that records must be “clear, accurate and legible”. Where records are not kept in English, this could potentially compromise safe care for patients if staff are unable to understand the content of the notes.
Patient consent is a must
Inspections also consider the effectiveness of care given by providers. In the report, CQC noted that a common issue was the failure to obtain consent from patients. It is important when providing care and treatment to patients that they are able to understand the purpose, benefits, risks and other options so that they can make an informed decision and therefore give informed consent to the treatment. That consent must be clearly recorded. A further area of concern in relation to effective care was the lack of appropriate referrals. Where referrals were made, these were either not recorded or the patient was provided with an “open referral letter” instead of the service taking responsibility to hand over the care to a specific consultant.
Whilst CQC noted that there were very few concerns in relation to the key question ‘Is the service caring?’, there were a small number of services that needed to improve privacy and confidentiality.
CQC also considers whether a service is responsive. It noted that, as patients are paying for services, they can expect prompt access to consultations and treatment and this was seen to be a strong area in the independent sector. However, CQC did note concerns across a small number of services relating to the availability of complaint information and complaints handling. There were also concerns about some services regarding the accessibility of information and access to buildings.
Finally, CQC considers whether a service is well-led. This includes consideration of a number of areas including governance arrangements, culture and leadership. It identified some worrying trends including the lack of good governance and the need to improve or update policies and procedures in key areas such as safeguarding, infection control and business continuity. There were also concerns about ineffective audits and lack of sharing of information and learning.
CQC conclusion and forthcoming ratings
The report comments that, overall, there was limited awareness of regulatory requirements and a limited appreciation of wider professional responsibilities. It was considered that an underpinning reason for poor information sharing and record keeping in some services was a lack of support for the sector to access more up to date IT systems with greater functionality. CQC acknowledges that independent doctor and clinic services are diverse and face particular challenges, such as the potential for professional isolation and lack of support systems.
Previously, CQC has not had the power to rate all types of independent services. However, from April 2019, it will start to rate services. This means that not only are providers required to comply with the regulations, but there is also an added pressure of striving to achieve a Good or Outstanding rating. The ratings applied will be used by patients to make informed choices about the independent services they choose.
Of course, for those services which are found to be non-compliant, there is a risk of enforcement action by CQC.
Providers who are registered with the GMC must also always be cautious that a failure to comply with the regulations may result in referral to the GMC given the overlap between the requirements in the regulations and GMC guidance, including Good Medical Practice.