Title: What impact has regulation had on the quality of care in general practice? Lessons from general practice inspections, reports, and ratings.
Funder: Department of Health and Social Care

Abstract: Background: Since October 2014 the Care Quality Commission (CQC) inspects GP practices in England, publishing a report and rating. By April 2017 all GP practices will have been inspected and rated for the first time. Up to 15% (1200) of these will have received an inadequate' or requires improvement' rating.Regulatory inspections of general practice with public reporting represents a major national policy intervention. It has utilised an estimated 60 million, in CQC and GP practice related costs, but has generated significant resistance. Claims have been made that it is unhelpful to quality improvement, particularly in underperforming practices.However, evidence on the impact of inspections is scarce, and the factors which contribute to their effectiveness or otherwise have not been fully investigated. Current evidence on the relationship between inspections, public reporting and quality improvement in healthcare is largely from hospital settings, which are distinct from GP practices.Aims: I aim to address the following:Q1. What is already known about the role and impact of inspections in general practice organisations; specifically, what works, for whom, in what context, how and why?Q2. Using mixed-methods: Q2a. What GP practice related characteristics are associated with the initial overall CQC rating? Why and how does this association exist in GP practices rated inadequate' or requires improvement'? Q2b. What GP practice related characteristics are associated with the improvement or otherwise in overall CQC rating on re-inspection? Why and how does this association exist in GP practices rated inadequate' or requires improvement'? Q2c. Can impacts from CQC inspections, reports and ratings be detected across different measures of quality, and from the perspectives of different stakeholders? Have any impacts detected been sustained? Why and how do these impacts occur in GP practices rated inadequate' or requires improvement'? Q3. What lessons can be drawn from the answers to Q1 and Q2 for quality assurance and quality improvement in general practice?Plan of investigation: The project will have three work-streams which will produce five peer-reviewed papers, summaries and recommendations for stakeholder groups, and a PhD thesis. There will be patient, public and other stakeholder involvement throughout. This aims to enable collaborative enquiry and reflection, to ensure the ongoing relevance, effective dissemination, and implementation of findings.Work-stream I (Q1) A realist review of the literature using RAMESES guidelines (Paper 1). Work-stream II (Q2a,b&c) Quantitative Bi-variate/multi-variate analyses to identify associations between GP practice characteristics and initial CQC rating in all GP practices (Paper 2). Bi-variate/multi-variate analyses to identify associations between GP practice characteristics and ability to improve or otherwise CQC rating on re-inspection in all GP practices (Paper 2). Interrupted-time-series analyses to identify changes associated with CQC inspection and different measures of quality of care in all GP practices (Paper 3). Qualitative Focus group discussion with patients, GPs, and practice staff at six purposefully selected GP practices rated inadequate' or requires improvement', and interviews with local GP leaders. (Paper 4). Work-stream III (Q3) Findings from work-streams I and II will be brought together, to provide lessons and recommendations (Paper 5). Anticipated benefits to patients, the public and NHS: Understanding the impact of inspections and public reporting on the quality of general practice, and the factors which enabled quality improvement or otherwise, in particular, in poorly performing practices where patient care is considered at highest risk, is necessary to inform evidence-based policy and practice.Patients will benefit as findings will help improve the quality of care they receive by shaping how quality assurance and quality improvement are undertaken in general practice. The NHS will benefit through the development of more effective mechanisms to quality assure general practice and support quality improvement.

Lay abstract: Background: The Care Quality Commission (CQC) inspects the quality of health and social care in England. It provides information to help people choose where to go for care, and to encourage the improvement of care by those who provide it. Since October 2014 GP practices in England are inspected, reported on, and rated by the CQC. Aims: To investigate what impact GP practice inspections have had on the quality of care in general practice. To improve patient care through the identification of lessons which will inform and shape how general practice is regulated in the future. Methods: A review of existing evidence on inspections in general practice will be undertaken to understand what has/has not previously worked, in what circumstances, for whom, how and why. National data on GP practice characteristics will be analysed to understand if there is a link between GP practice characteristics and CQC ratings. Trends in different measures of quality of care (e.g. patient experience, appropriate prescribing) will be analysed to understand what impact inspections have had over time. Patients, GPs, practice staff and local GP leaders at GP practices rated as inadequate' or requires improvement' will be interviewed to understand in greater depth the impact of inspections in poor performing practices. Dissemination: Findings will be published in academic journals, presented at national and international conferences, as well as policy-making and patient events. Patient, public, and other key stakeholder involvement throughout this project will ensure the project remains relevant, and that the findings which emerge are timely and applicable.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE