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What has CQC to say about Inequalities and Public Engagement in General Practice?

October 5, 2017

My earlier blog looked at the recent NHS England Inequalities Resource (reducing inequality in access to general practice services) and noted how disappointing it was. As I said at least its there.

Now the Care Quality Commission have produced their three year report on the State of General Practice

I have looked at this report through the lens of Inequality and public engagement because both of these still feel:

  • Undeveloped
  • On the margins of mainstream activity
  • variable in terms of ownership and practice

The CQC report covers all England and the period 2014 to 2017 – during this time pressure on general practice has increased and the environment has changed fundamentally – not the least because now the commissioning of general practice is done jointly by NHS England and Clinical Commissioning Groups.

Health Inequalities and Public Engagement

To its credit the report does engage with both patient and public involvement and health inequalities.

It does this mainly by giving a range of case studies showing how individual practices have changed the way they work so that they are more accessible and provide relevant services often through working in a more holistic way with disadvantaged communities. Examples include GPs serving homeless people, migrants and economically disadvantaged communities – I reproduce a couple of case studies below.

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A similar approach is taken with regard to patient engagement – although there are fewer case studies here:

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What is the problem?

While case studies are always useful they are not sufficient. At their best they speak to people who are already to some degree convinced about an issue. Their strength (an example of real practice) is also their weakness – they can too easily be dismissed as not being relevant because “things are different here”.

I wonder if part of the problem rests with CQC – with their inspectorate probably not sufficiently comfortable with assessing effective practice with regard to public involvement and good practice on inequality and maybe not sufficiently convinced of the relative importance of these areas.

More importantly I think that CQC lack of theory of change here. They are sitting on a three years worth of data on every practice in England. The fact that CQC have provided case studies is a clear indication that there is variation in practice with regard to inequality and public engagement – yet CQC don’t say this! If CQC really want to help drive better practice with regard to inequality and engagement they need to use the information they hold more openly and more effectively.

It is quite different assessing the quality of mainstream services whose role is already accepted – such as the quality of primary care compared to assessing progress in implementing good practice in areas that are still to some degree on the margins – such as inequality or public engagement.

CQC need to use the intelligence they hold to challenge individual practices AND Clinical Commissioning Groups. Case Studies are not enough – organisations need to be able to see how they stand compared to their peers and understand that this information is in the public domain.

What needs to happen

  • At a CCG/local authority level it would be good to understand how PPG activity and practice compares with peers within and across health and care systems
  • We need to know how consistent good practice is across GPs serving socio-economically deprived communities and what CCGs/Accountable Care Systems should be doing to support this.
  • Finally, I think examples of bad practice (they don’t need to be named) can also be very powerful – giving evidence to show why this is not acceptable.

What do you think?


7 Comments leave one →
  1. malcolmrigler permalink
    October 17, 2017 08:28

    In “occasional paper Number 64” from RCGP Dr John MacDonald states that “alongside existing Primary Care Services there needs to be developed a huge and sustained educational​ programme if patients are to become involved in their treatment and care”. It would be good if the CQC was reminded of this and reminded too that political education of Patient Participation Groups must be part of such “education programmes​”. Malcolm

  2. October 17, 2017 09:38

    In my research, I have found lack of equity in accessing GP services and the bucks stop at booking an appointment with the GP’s. Please have a look at some of the findings and recommendations from the AWAZ Cumbria research report “BME People: Equity in Accessing GP Services in Carlisle” at

  3. Rob Dalziel permalink
    October 17, 2017 10:52

    Hi Mark

    This might be of interest

    It is a proposal from the Black Country Healthwatch Researchers group (about to be sent to Healthwatch England shortly) on health and inequalities

    Healthwatch, health and inequalities
    Where do we stand?

    The Black Country Healthwatch Researchers are from Dudley, Walsall, Wolverhampton and Sandwell in the West Midlands and Staffordshire. At one of our recent meetings there was a long and at times very passionate discussion of Healthwatch, its researchers and our stance on inequalities, how they impact on people’s health and what to do about them.

    We decided it would be good to try to stimulate and contribute to a wider discussion and determination of exactly where we could or should position ourselves with regard to recognising, researching and thinking about inequalities and their impacts on health and wellbeing and the way that health and social care services have to work to deal with physical and mental ill-health.

    Squaring the circle: where do we exactly stand on the possibilities for researching and thinking about inequalities? We know that in 2014/15 there were around 11 million people trying to get by on incomes of less than 75 percent of the Minimum Income Standard, a benchmark of income adequacy. These people are in poverty with incomes well below what is needed to meet material needs and contribute to society.

    Indeed, the lower a person’s social position the worse is his or her health likely to be. In England, people living in the poorest neighbourhoods will, on average, die 7 years earlier than people living in the richest neighbourhoods and the average difference in disability free life expectancy is 17 years. And the many people who are currently dying prematurely each year as a result of health inequalities would otherwise have enjoyed in total between 1.3 and 2.5 million extra years of life.
    • It would be good to get a broader perspective and views on these findings from Healthwatch researchers and others with an interest in inequalities and their implications for health and care services.

    Social status, healthcare and outcomes: what do we know and what do we need to be saying? A person’s chance of enjoying good health and a longer life is, in large part, determined by the social and economic conditions in which they were born, grow, work, live and age. And the NHS itself recognises that avoidable health inequalities are – by definition – unfair and socially unjust.

    The United Kingdom NHS is at the top of international comparisons when it come to the care that it provides but is second from last in terms of ‘healthy lives’, measured on three indicators: mortality amenable to healthcare, infant mortality and healthy life expectancy – all influenced by broader social and economic factors.
    • It would be interesting and useful to get the views of Healthwatch researchers and others with an interest in inequalities, health and healthcare on how we should be reacting to such findings.

    Health as a social movement, putting pressure on systems, raging and roaring: How are or should Healthwatch researchers and others with an interest in inequalities, their impacts on health, and implications for healthcare be responding to different opportunities to think about and scrutinise relevant facts and figures? And how do we variously interpret (or not) the stories that we gather from people on health and social care matters. How can stories help us to assess what the role of the social movement is or could be in a health and care context?

    The social movement as a large and informal grouping of organisations and individuals that is focused on action to address specific health and social care issues. More specifically, how do we Acknowledge or respond to the social movement work that is about the action that they might take to carry out, resist, or undo a social change and then take action on different fronts?

    What next?
    • Black Country Healthwatch researchers to lead on the development of a session on research, health and inequalities at the Healthwatch England Conference in 2018.
    • Invite Sir Michael Marmot to come to the Healthwatch England Conference in 2017 as a keynote speaker to talk about inequalities and what they mean for health and healthcare services.
    • Aim to improve our understanding of the relationships between policy, health and inequalities.
    • Aim to improve our understanding of what’s happening elsewhere in terms of policy, health and inequalities.
    • Explore the implications of the findings drawn from discussions on policy, health and inequalities for Healthwatch and researchers and make suggestions or recommendations for action in the future.
    • Produce a report on findings and implications.

    All the best


    • October 17, 2017 10:55

      Cheers Rob – it is great to see that local Healthwatch are promoting this agenda – frankly local pressure like this helps national agencies (like CQC, NHSE and PHE) feel more motivated/confident to raise their game!

  4. Liz Twelves permalink
    November 4, 2017 09:19

    Thanks for this Mark, your writing is always useful and generates much thought. The culture in practices is so variable and therefore the attitudes and beliefs of staff towards different people and segments of people within their populations. Some insight into this through the lens of inequality in any assessment might also illuminate the barriers to primary care and onward care.

    • November 24, 2017 10:12

      Thanks Liz – sorry to be slow in responding to your comment – your comment resonates for me. The whole issue of attitudes and believes is a really tricky area – and not acknowledged in guidance and assessment. There is too often an assumption that the only real drivers are government policy and “evidence”. best wishes – Mark

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