Saul Miller is a GP in Wooler, Northumberland.
My two-partner practice was inspected by the Care Quality Commission (CQC) in late 2019 and found to be good. A year later my partner retired and I became single-handed for a while. A reinspection was triggered: good again. Finding a new partner in early 2022, another reinspection was triggered: still good.
In summer 2022 we merged with several other practices to form a bigger partnership running several sites. After a tough first year, this has worked out better than we could have hoped for and it feels already as though things might always have been this way. But then I receive a bill for thousands for the privilege of being registered still: CQC believes I am still single-handed, despite having inspected the partnership that followed. And despite (finally) having registered the merged partnership with me as part of it.
“… the Dash Review has, in an interim report, found significant failings in the internal workings of CQC …”
I am taken aback. Did registering the merged partnership and its sites not automatically mean the component practices were recognised to have ceased to exist? How could the CQC inspect our partnership in 2022, find it to be running an effective ship, yet still say that ship never left the slipway?
I am not alone: the Dash Review has, in an interim report, found significant failings in the internal workings of CQC that have led to a substantial loss of credibility.1 But still this gets me thinking about the centrality of trust.
The case of Harold Shipman triggered a lot of soul-searching in the profession — indeed in the country — over 20 years ago because he had breached trust for so many of his patients in the most awful way — by killing them.2 Many articles over the subsequent years questioned what exactly had changed as a result.3 One direct consequence was revalidation linked to annual appraisals, though a widespread belief has persisted that this would not prevent further breaches of trust.4
My merged partnership comes out differently in its different sites in the recent GP Patient Survey. In Northumberland, small rural practices running a more traditional model of general practice appear to do better than bigger practices in towns. What is also noticeable is the broadening range of results: on the question of finding it easy to contact the practice on the phone, the variance between practices’ results is 13% to 99%.
“… systems are necessary but not sufficient.”
I am quite sure this represents something of the inverse care law — practices in areas with patients with the greatest needs being more at risk of being overwhelmed by the demands on them.5,6 But it also shows something of how many patients are losing faith in their ability to get help when they need it.
COVID-19 caused a surge in the number of people dying at home, and the trend has strengthened since.7 In 2023, the figure was 28% of all deaths occurring at home. Indeed, with another 21% occurring in care homes,8 nearly half of all deaths are now happening in primary care. That surely represents another aspect of our rising burden — those dying outside hospital average four or five contacts in their final month — but, in a post- Shipman world, it surely also suggests patient trust?
This is where it all comes together: systems are necessary but not sufficient. Humans are inventive and can find too many ways to get around systems for it ever to be possible to rely on those alone. Inspections, contracts, appraisals, revalidation, whatever — whether or not they help, they do not supplant trust.
Again and again we learn — when trust fails, systems fail.
More positively: for any system to thrive, trust must remain alive.
References
1. Department of Health and Social Care. Review into the operational effectiveness of the Care Quality Commission: interim report. 2024. https://www.gov.uk/government/publications/review-into-the-operational-effectiveness-of-the-care-quality-commission/review-into-the-operational-effectiveness-of-the-care-quality-commission-interim-report (accessed 30 Aug 2024).
2. Carter H. Harold Shipman, guilty of 15 murders. But did he kill 150? The Guardian 2000; 1 Feb: https://www.theguardian.com/uk/2000/feb/01/shipman.health4 (accessed 30 Aug 2024).
3. Field R, Scotland A. Medicine in the UK after Shipman: has “all changed, changed utterly”? Lancet 2004; 364 Suppl 1: S40–S41.
4. Moghal N. Medical appraisal and revalidation — a pretence that is reassurance, not assurance. Health Service Journal 2019; 18 Mar: https://www.hsj.co.uk/quality-and-performance/medical-appraisal-and-revalidation-a-pretence-that-is-reassurance-not-assurance/7024648.article (accessed 30 Aug 2024).
5. Hart JT. The inverse care law. Lancet 1971; 1(7696): 405–412.
6. Watt G, Brown G, Budd J, et al. General practitioners at the Deep End: the experience and views of general practitioners working in the most severely deprived areas of Scotland. Occas Pap R Coll Gen Pract 2012; (89): i–40.
7. Scobie S, Julian S, Bagri S, Davies M. What primary and community services do people who die at home receive? 2024. https://www.nuffieldtrust.org.uk/news-item/end-of-life-care-blog (accessed 30 Aug 2024).
8. Scobie S, Bagri S, Julian S, Davies M. What end of life care do people who die in a care home receive, and how has this changed over time? 2024. https://www.nuffieldtrust.org.uk/news-item/what-end-of-life-care-do-people-who-die-in-a-care-home-receive-and-how-has-this-changed-over-time (accessed 30 Aug 2024).
Featured photo: Garden of Tranquility in 2007 by Gerald England. A memorial garden to Harold Shipman’s victims. Used under licence CC BY-SA 2.0.
