Practices need to be responsive to patient needs – both individual and collective – something that I’ll focus on in this article.
A good question to start with is ‘are your policies designed to be responsive to patients with special needs, especially under Equality legislation?’ The Key Line of Enquiry (KLOE) includes some very direct requirements for access to services and responding to complaints. There is clarity over imminent end of life care and how the practice must deal with those issues, a clear carry-over from the `effective` KLOE where end of life planning in the final year is covered.
Considering the volume of guidance available through the BMA/MDU/MPS and on the CQC’s Nigel’s Surgery, it is sometimes surprisingly difficult to find the evidence that a practice has responded to that wealth of information. That’s surprising, not least because complaints that are properly dealt with save hours of practice manager time, as anyone who has had to put forward a file to the Health Ombudsman can testify. Similarly, keeping the practice away from costly and complicated legal action is a major incentive to nip issues in the bud early by saying sorry when something has gone wrong.
Using complaints as a source of feedback on practice processes that have not worked, and acting to rectify them, is also a way to make services run more smoothly and thereby cheaper and less time-consuming. The introduction of a system based in reception to record low-level dissatisfaction not resulting in a formal complaint is a great way to show the practice recognises the need to make possibly small changes to procedures and takes notice of all feedback.
How easy is it for anyone to complain? The Inspection team will be looking for your policy and process on your website and it’ll check to see if leaflets/forms are freely accessible out in reception (and not behind the counter where the patient has to ask a staff member for a complaint form because they want to complain about that person!).
There are also only two routes to lodge a complaint – to the practice directly or through NHSE – and while PALS or other organisations might be a source of advice, they are unable to deal with complaints. Candour in responding to a complaint is essential. Nobody should be punished for making a complaint and most certainly any reference to a complaint must never be added to a clinical record. You can be sure this will be followed through on an inspection, as will the trail of organisational learning that results from both complaints as well as Significant Events. The Complaints Procedure [PLUS] provides detailed information about the management of complaints and is available for practices in Northern Ireland, Scotland and Wales.
Access is a serious topic of concern as funds are squeezed and replacement clinical staff are harder to find. Centralised data collection now looks at appointment availability, as well as the results of surveys, and that will all feed into the intelligence set used by CQC before they conduct an inspection.
Access to practice services by people with disability or sensory impairment (Accessible Information Standards are a legal requirement remember!) will need to be individually tailored. Patients with complex and multiple long-term conditions need to be catered for both as individuals and as groups. So, can you justify – from the patient’s point of view – being brought back repeatedly to see different people in the practice nursing team for different LTCs, rather than having everything dealt with in one visit? Harking back to effective – are your nursing staff multi-skilled or are you allowing them to only deal with their favourite work and ignoring wider patient needs? The Deaf Patient Access Policy [PLIUS] may prove useful for practices.
Is the practice making use of technology – not just IT and digital innovations such as Skype or e-Consult – but also technology such as ways of working like triage, quick-access appointment systems and Physician Assistants/ANPs? Ease of access to appointments that are reasonably convenient to patients is not simple for a practice to achieve, but will be looked at.
Also, if you have taken up any initiatives, have you properly evaluated them to see if they’ve worked and can you demonstrate this to an inspection team using before and after figures? On the same issue, do you know how long patients have to wait once they arrive for an appointment? Is one nurse or GP always over-running, keeping patients waiting and generating dissatisfaction or complaints? And more especially, have you done anything about it?
The KLOE has quite a bit to cover on choice and in particular issues around end of life choices which seems to be a hot topic for CQC at the moment and has prompted some major changes. It is relatively easy for an inspection team to ask to see care plans and whether choices and decisions are properly obtained (the `consent` link to Effective), documented and supported. End of life issues are no longer exclusively a secondary care issue as more of their work moves out into the community. That a patient can choose a comfortable and dignified end is a responsibility now often back with the practice so adequate documentation needs to be kept.
Have you asked patients what choices (treatment, access etc.) they would like to be able to make and do you provide them? It is all about properly knowing what your practice is doing and whether it matches patient needs and thereby offers choice, whether on an individual basis or for groups. Assess patient choice using the referral choice audit [PLUS].
The multi-skilled nurse is a prime example of identifying a gap in patient choice – the choice whether to attend one slightly longer appointment where all the LTCs are dealt with at one time, or to be repeatedly called back two or three times for the same weight/BP/blood/urine to be measured and tested and medication reviews, all for different conditions. It raises the question whether your clinic system is past its sell-by date and whether for example childhood immunisations should be done on the same visit as health checks. Not all practices are this joined-up! It may also help to improve immunisation take-up in a practice where they are below target or national figures.
We could discuss the difference between needs and wants for a very long time, but can the practice justify how it has adjusted its services to what its patients need? The tie-in with planning under well-led is obvious and this KLOE looks for the practice to have at least considered flexibility, continuity of care and patient choice in how they provide services. Ask yourself if your patients and their families receive personalised care that is responsive to their needs and if so, can you demonstrate that it reflects individual as well as population needs? Are those services being provided from appropriate premises with easy physical access and safe under all circumstances? Can you prove it (mains electrical five-year tests certificates; Legionella tests and monitoring; premises and processes risk assessment – and of course your infection control annual audit)?
One size fits all is not appropriate for the provision of health services, only for retail. Are reasonable adjustments made for individual circumstances and conditions? Not every area has the benefit of a homeless patient service so does your practice refuse to register homeless people because you have nowhere to send correspondence? Or have you made an arrangement with a local church or voluntary organisation that their address can be used to register a homeless person and be the place where you send letters for them to collect?
Responsive, as in other KLOEs, carries on the theme of co-ordinated action. It requires the practice to offer support to patients moving between treatment providers and the practice and as mentioned elsewhere, providing other organisations with timely, accurate and complete information to facilitate the patients` treatment. It also reminds the practice that under the Accessible Information Standards it is obliged to advise any organisation they are referring a patient to of their communication needs. There is little point in a Community Care provider trying to make an appointment with one of your patients over the telephone if they are deaf!
Most practices believe they are fully responsive but often being too close to a problem results in unintentional blindness. It takes a good practice to be able to step outside of the “here and now” and be reflective and objective about itself. It is one of the major benefits of the CQC system that it allows a practice to see itself as others see it and to respond accordingly, positively rather than defensively.
Missed part of the series? Catch up with the rest of “The inspection insider” series here.
Helpful document for your CQC inspection: CQC guidance