The Shehadeh Medical Centre in Tilbury responds to 'inadequate' CQC report

We were unable to speak to the centre before going to print for their reaction, but here Dr Emil Shehadeh gives his take on the report which placed his practice into special measures, branding it “inadequate”.

So now we know: before the CQC, GPs were putting patients’ lives at risk! Are we to feel sorry for patients who were cared for by inadequate GPs before the CQC was invented? The idea of the CQC is good, and I know a few good GPs who work for the CQC. However, the CQC’s practice is far from perfect.

My practice rating is largely due to the CQC finding “inadequate” paperwork and read-coding on the computer. This doesn’t mean that what they failed to find was actually absent. Both my buildings are very clean and our cleaning firm is aware of CQC standards. Their report did not meet the CQC standard, though it is obvious to all that the surgeries are very clean. We have been concentrating on patient care not paper care. I do not believe we are unsafe or uncaring nor do we provide less than good access. I believe we have been misjudged.

My practice is only one of four practices in all of Thurrock to meet the prescribing incentive targets. We are amongst the most cost effective prescribers. We are amongst the most prudent antibiotics prescribers. We have always been amongst the best in most prescribing and medicine management measures. We do well on the QOF. These achievements do not just happen. Nor do they reflect lack of method or inadequate or unsafe prescribing. Two mentally ill patients on Lithium who refuse to have a blood test is no reason to write a whole practice off. Last time we withheld a medication from a mentally ill patient who refused to have their blood test, they ended up being sectioned on a psychiatric ward, for lack of medication.

From my point of view the CQC is another wrecking-machine demolishing general practice. They are the new boy on the block brandishing their weapon carelessly like a bully. They have the power to potentially ruin reputations and seem to relish it. Even in the face of obvious errors on their part, and they have had egg on their faces in the past, they are determined to publish and damn. Only NHS institutions can get away with such irresponsible and unjust conduct.

From my point of view, CQC stands for Crush, Quarter and Cast away. They are deaf, not dextrous and demonic demolishers.

Despite a few things being explained to them, the report reads like they never heard, or even listened. They confused academic meetings with practice meetings, despite the difference being explained. They were supposed to share their concerns at the end of the visit. They only shared about one fifth of their concerns. Thus we were judged in absentia and without a chance to respond. The way they inspect is unique and makes no sense. How they reach conclusions is shrouded in mystery. They asked what we were most proud of, and never mentioned our achievements. They asked for audits to be sent in advance, but never looked at them, till the visit. They seemed to have come with an agenda to destroy, perhaps armed with “intelligence” from a dysfunctional CCG and Area Team, against both of whom my practice has serious complaints, neither dealt with adequately.

One of the marks of quality is openness: the CQC obtains intelligence about a practice from the AT (Area Team) and the CCG. Despite asking, I have not been told what those two organisations have fed the CQC. When they delivered the report in person, discussion was barred. How else are they going to minimise mistakes made by themselves. They apparently encourage criticism. When I pointed out how difficult it was to make sense of their action section, they almost bit my head off.

The elderly: We have some 230 patients on our elderly and vulnerable register. They have care plans which are reviewed monthly. The CQC ignored this. Some of them are discussed in a bimonthly MDT (Multi-Disciplinary Team) meeting, whose minutes are good enough for all the practices in Thurrock, but not the CQC. Our diabetic patients have traditionally had the best diabetic control in Thurrock. Yet because the CQC found two patients whose HbA1c had not been done yet (we had another 4 months to the end of the GP year), the CQC damned us for it!!! I have no idea how they concluded that we do not look after the mentally ill (our QOF score is good), or young people or families. They accused us of barring more than one problem per consultation, when in reality this rule only applies to the walk-in clinic, and even that rule is broken regularly, both for patients with more than one problem and for relatives with no appointment. We do so at the risk of delaying other patients.

The CQC is so anxious to demolish general practice that they criticise where credit is due. They seem to wear dark glasses and see everything as dark when it is quite light. My wife and I, recognising that it is difficult to obtain good locums in the UK, choose to assist the practice when we are on holiday, by interpreting and filing the daily blood and radiology results using remote access. This reduces the risk to patients. We deserve a medal. The CQC wrongly concluded that we leave the practice uncovered. As a contract holder, I would always carry ultimate responsibility, whether I am in England or Spain. That is one of the curses of general practice. But it does not mean that I cannot go on holiday, much less so that I cannot choose to help the practice whilst I am on holiday. Why does that draw criticism?

Some errors the CQC made are too concrete to miss: the practice minutes practice meetings. This is a fact. They claimed we did not display patient leaflets regarding bereavement services. We did. They claimed staff did not have designated tasks. My staff do. We are accused of providing inadequate access, yet we have proven that we provide adequate access. Even though these are facts on the ground, evident to any neutral observer, the CQC can choose to ignore them. They have the power to ignore them. Even though I have complained and asked the CQC to unpublish their rating whilst the case is being reconsidered, the poor rating is still in the public domain, causing some patients un-necessary anxiety.

The report attributes fault to the practice despite the problem being outside the practice control. The translation service is provided by NHS England. Sometimes the translators’ language skills are poor. Why is this my practice’s fault?!! There is a nationwide manpower crisis in general practice. This affects the availability and quality of locum doctors. Nor does the CQC help this crisis. Why should any single practice be blamed for such national deficiencies?

Objectivity:

Just because a substandard nursing home makes unsubstantiated allegations about my practice, does not mean that their allegations are true. Just because one elderly man believes we do not care about him because he is too old, does not mean that this is the case. And just because a few patients complain that they are only allowed to discuss one problem, does not mean that their claim is true. Just because a few patients claim that they find it difficult to see a doctor of their choice (never mind that we have six doctors to choose from on two locations) that makes for poor quality! The CQC did not discuss these issues with us on the day of inspection. I could have provided objective evidence to the contrary. But the Pharaohs need no discussion. They are all powerful and do as they please.

Unprofessional:

The distinction between an associate trainer and a trainer became a huge point of conversation during the visit. One of my trainees was asked whether she knew that I was not a “qualified” trainer. Firstly I am a qualified trainer, having completed my training 15 years ago. Due to new legislation the deanery adopted the title of “associate trainer”. Secondly how careless is it to ask a trainee such a confidence shattering question!? Fortunately my trainee was perfectly happy with the training she received from us.

Time seems to mean nothing to CQC. They took five months to produce a report whilst giving us two weeks to respond to it. CQC has a Pharaohnic aura, inspiring fear into GPs. They have made many blunders since their inception, but continue to terrorise. Advice from three independent parties was for me not to argue with the CQC but to comply and provide policies and protocols. This I did, and I believe if we were to be inspected today, we would be rated well over the adequate mark, even by the CQC standard. I have since rebelled and have complained. The CQC rating is unfair. Their method is questionable. Their lack of openness goes against the essence of quality which they apparently represent. Their lack of objectivity renders their judgement unreliable.

I have shared some of the CQC concerns with some of my patients. They were totally perplexed, because the CQC is too blue skies for the down-to-earth concerns of the average patient. Do patients give a damn about a cheesy mission statement, or an annual statement!?Do they give a damn that I have verbally informed my staff of my intention to retire, and not done so in writing?! Never mind that the AT, as my tenants, have failed to sign a lease with me for 5.5 years, and that this is the main source of uncertainty about when I retire!

My staff and I are proud of what we have achieved in Thurrock, planting two training practices, with little help from the PCT (indeed resistance and sheer ill-will) providing a safe and professional environment, expanding services over the years on one of the lowest budgets in Thurrock, managing NHS resources more prudently than most. I wish we were perfect, but no one is. My challenge to the CQC is this: if nit-picking is your motto, give me any practice you have passed and I can fail them within ½ an hour, because no one is perfect.

Due to underfunding by the PCT (Primary Care Trust) and now the AT, I have been too busy to supervise the management team and policies and protocols (not the practice, just the paperwork) have had to play second fiddle. Let the CQC worry about paper care. I am and will, till I retire hopefully very soon, concentrate on patient care, and will always walk tall and proud of what I and my team have achieved in Thurrock. Whilst we have complied with the CQC, the CQC report has been, and will always be, an unpleasant distraction.