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Tilbury doctor blasts CQC after latest inspection report

GOVERNMENT health inspectors, CQC have returned to inspect the Dr Shehadeh Medical Centre in Tilbury.

The centre was placed in special measures just a few months ago but on their return, the watchdog has rated many aspects of the centre as "Good"

YT asked Dr Shehadeh for his response.

Here is his response in full.

The Infallible CQC and Poor Me.

I have been asked to comment on the second CQC inspection of my practice in Tilbury, published on 03.12.2015. Some may find this account lengthy. But thousands of our patients have asked questions about the CQC report.

Carol and I are very grateful for their moral support and acknowledgement of our hard work. It is adequate that our patients appreciate the quality of care we give. It is for them that I have prepared such a detailed response, so they have a fuller understanding of this strange beast, the CQC, who is out to protect them from evil doctors, such as me.

Two Different Inspector Teams, From Two Different Planets

I can say that the second report is a better reflection of where we are. For starters, the inspection team were more open and more objective. They were respectful. They allowed us to present our case at the beginning, which we were not invited to do at the last visit. Unlike the first inspectors, they discussed most things in advance with us, before the report was sent to us for correction.

Their report was produced in reasonable time, unlike the deplorable lateness of the last inspection report. They were fair and accepted most of the evidence we offered, completely unlike the last inspectors, who simply dismissed evidence. The first GP inspector spent about 20 minutes with me, thus judging my prescribing largely in absentia, and rather superficially. Our data shows that our diabetic management is excellent. Yet he criticised us because two patients had not had their blood test for over a year. Two out of six hundred patients! Nor did he ask me for an explanation. Did he look to see how often we had chased these people to have their blood tests? This is not objective judgement. The second GP spent at least one hour with me, if not longer. He actually allowed me to show him evidence. Nor was he dismissive.

We had already agreed with the second inspectors that we are hamstrung by weak management. Therefore the report did not contain any surprises. Whereas the first inspector did not share most of their “findings “ with us on the day, as they should have done, the second inspector did. Nor were we allowed to respond to or engage with the first inspector when they delivered the final report. That is the opposite of objective.

Is The NHS A Level Playing Field?

However, neither inspection took into account our difficult circumstances, and that is more a criticism of the CQC than the inspectors. They expect the same standards from every provider regardless of disparity of resources. This is akin to expecting a Paralympian to run in the Olympics against able-bodied competitors. We inherited two lists (out of three) that had no management and no budget for management. We were asked to boost the team. We appointed managers, more nurses, a healthcare assistant, a nurse practitioner, and more doctors. We improved practice performance and access by miles.

We saved the NHS hundreds of thousands, and continue to do so every year. Yet the PCT, refused to uplift our budget to meet the additional services. For years we have performed well above average, and yet our funding has always been below average. Then we developed two training practices, with a promise from the PCT to be completely and fully supportive. Yet the PCT failed to inform us of certain grants and then obstructed our application for grants, preferring the money to go to other regions than this most needy of regions. That grant would have reduced the financial burden of the two developments.

They refused to pay expenses which are routinely paid by PCTs in the UK. I gave up a thriving private practice in order to dedicate my resources to developing two NHS training practices in Thurrock, the first in the history of Tilbury. The NHS never remotely matched my commitment.

Their support was feeble at best. Where other PCTs willingly offered support, our PCT ensured support was denied us. We survived through hard work. But throughout this time, we have had to choose between paying the mortgages on the one hand and employing doctors and fortifying the management structure on the other. For the CQC to come and criticise my management structure is harsh and unjust. They should forward their criticism to the NHS bosses who have failed us, reneged and hampered our progress, depriving us of our oxygen.

The CQC’s Reluctance to Acknowledge Excellence

Throughout the second inspection, we were hearing comments to the effect that this could not be a practice in special measures. We heard the word “outstanding” repeatedly with respect to the clinical aspect. Our management of chronic diseases such as diabetes, COPD and our hospital admission figures are better than both the local and national averages, despite our recent reliance on locums and despite the questionable habits of trainees.

Our cancer diagnostic rate was much better than average. Our safeguarding work was impressive. Our prescribing is one of the best. Yet we were denied the “outstanding” grade. We were marked “good”. An “outstanding” would have almost been too critical of the last CQC report and rating, because these figures were available at the first inspection, but were totally dismissed. That is as far from objective as East is from West.

The CQC has Blind Spots:

In the first report, the inspector was clearly clueless about how academic/teaching meetings are held and recorded. Her report implied she expected minutes of academic meetings. I explained that medical academic meetings are not normally minuted. She never asked for a record of such presentations, or an attendance record, both of which we keep faithfully and use in our e-portfolios and appraisals.

The second inspector, who were much better acquainted with general practice, asked about the Friday academic meeting. I showed the GP inspector a copy of a recent presentation and would have shown them attendance records had they asked, which had already been shown to the first inspector and sent to the CQC in evidence. Yet again, in the second report, we were criticised about the same thing. Fortunately the second inspector had the fairness to correct this report error.

Failure to Deal with Complaints:

My complaint against the first visit was kicked into the long grass, until the day the second report was published! Was the CQC hoping the second report would make up for the defects of the first report?! That is the only thing that explains their long silence.

But I am not going to give up so easily. I have a voice recording of a meeting with senior CQC staff, who admitted mistakes were made by the first inspectors, and yet they did not have the integrity to admit it in their written response. They simply ignored most of the points raised in the meeting. But I will not give up till they deal with them, and do so fairly.

These senior CQC managers, just like the first inspectors, did send me their report on time, rendered written reports dissimilar to their verbal feedback, and let us down by reneging on their promise to personally hand to me their findings. Does the CQC really stand for quality? Perhaps nominally, because they expect standards from providers that they themselves regularly fail to meet.

Hollow Claims of Objectivity and an Implicit Claim to Infallibility?

The constant theme in my experience of the CQC is that whilst they claim to be objective, they are deeply lacking objectivity. Further, the CQC behaves as if its inspectors were virtually infallible. It seems to be so comprehensively covered with Teflon that no criticism seems to stick. They are adept at producing the usual insincere verbiage in the face of their fatal flaws, which would normally make the most thick-skinned people blush.

If we say we have a record of minutes, and the inspector says we do not, the inspector wins, even though the evidence is there for everyone to see. We are automatically deemed to be liars, whilst the CQC inspectors are the epitome of virtue and rectitude. We were accused of forbidding patients from discussing more than one problem in a consultation.

Firstly this was never fed back to us on the day. If it had been, we would have given evidence to the contrary. When we explained that this only applied to the walk-in clinic, to reduce the stress of a lengthy wait, and we further provided evidence that despite this rule we often allow several problems to be discussed, even in the walk-in clinic, our evidence was flatly rejected, because it challenges the inspector’s sense of infallibility, and it would pull us out of the low rating with which they had already tainted us.

Nor are some inspectors appropriately trained. Two months’ training in data analysis is what they get? They write reports, which are read by Prof Fields or his team, who make the final decision. But if the report is inaccurate in the first place, how can Prof Field be sure that his rating is fair?! One is not allowed to question the CQC rating. By contrast, a school child can ask for their exam papers to be remarked. A doctor, whose CQC ratings have potentially serious consequences, has fewer rights than a school child.

However, one can question the CQC process or objectivity. And when you do, after a very long wait, you may be lucky to get a stock answer, showing even more lack of objectivity, and greater sense of infallibility. They are simply too perfect to be wrong. Curiously, no matter how many mistakes they admit to having made, on neither occasion were the inspectors willing to upgrade the rating. Whilst fewer errors were made by the second inspectors, who also were decent enough to explain their decision, the number of admitted errors by the first inspectors, let alone the ones they have simply dismissed, warrant an uplift. But they are too infallible to upgrade a practice rating.

The first report, claims that our access is inadequate. When I sought to challenge that in writing, it was claimed by the inspector that “the report does not dispute the services you offer or that you have responded to patient concerns regarding accessibility”. Yet her bosses acknowledged to me in the voice-recorded meeting that her report does criticise our access. Despite this, her report stands unchanged, and we stand condemned, because a CQC inspector is infallible.

I have repeated this and other points to the CQC in writing and verbally. Yet I have been asked to repeat them again in writing!!! I believe this is a tactic designed to cause attrition and an end to my quest for fairness. I am not going to tire. Indeed I deem it a moral duty to challenge the CQCs initial sloppy inspection and report.

CQC, the Epitome of Objectivity?

Interestingly, Prof Fields defends his organisation’s performance by stating that they cannot be that bad if they pass circa 75% of practices they inspect. Isn’t that rather warped logic? And what is the threshold below which the CQC should review their approach? 70%, 60%, or even 90%? What underlines that rationale?

The fact is the CQC is passing practices they should fail and failing practices they should pass, precisely because they are not objective, and their inspectors are inconsistent, and frankly sometimes unsuitable for the task. Objectivity demands reliable evidence, not mere opinions or accusations. Do we permit patients to discuss more than one problem per consultation? Look at a random sample of consultations, and see how many problems are discussed in a consultation. This is objective. But to make an accusation based on misreading some notice about a special clinic, is not objective. But it is how we were treated by the first CQC inspectors, without objectivity.

The CQC uses patient surveys to rank GP practices. I have made the point in both inspections that the satisfaction surveys are misleading, because they measure popularity, not quality. I have twice maintained that they are inversely related to quality. Strangely, today a study was published showing that GPs who are strict with antibiotic prescribing, are less popular in their satisfaction surveys. How much more un-objective can one get.

Inconsistencies Amongst Inspectors:

With reference to the first inspection, in a press release, the CQC stated “Effective cleaning systems must be undertaken ”. The same cleaning report format was accepted by one inspector in another local practice, and rejected by the inspector in ours. One inspector judges one of the best prescribers as being inadequate, whilst marking “good” people who admittedly neither do, nor think they should do medication reviews. One inspector imposes a personal opinion on how minutes should be taken, whilst another is not interested in the least.

The first inspector GP insisted that we should consent joint injections in writing. I advised that the medical defence union says it is not necessary. The first report criticised us for not consenting patients in writing before joint injections. Yet in my voice recorded meeting with very senior inspector managers, it was acknowledged that a written consent was not necessary.

The second GP inspector acknowledged a written consent is not necessary. Yet this remains a criticism in my initial report and in the CQC press release. The initial CQC report, and naturally my practice rating is based on personal opinion, not on reliable facts.

One inspector accepts an MDT minutes template for one practice, whilst another rejects the same template out of hand and believes they are un-original, implying that we have doctored the minutes. One inspector marks a practice as having good leadership, when the team is about to crumble round the inspectors’ ears; yet another marks a practice, that is held together very effectively against all odds, as “inadequate”. These ratings are therefore hostage to chance, and to the whims of inspectors.

The CQC Prevaricates:

In the initial press release, Janet Williamson, Deputy Chief Inspector of General Practice and Dentistry in CQC’s Central region said: “We know that Dr Emil Shehadeh has acknowledged the areas where action must be taken.”. The truth is I acknowledged some of the areas, bur disputed many. I still have an ongoing complaint because I disagree with their process and therefore with their rating and their recommendations. I deemed their report as lacking objectivity. The CQC is a bully. If you do not agree with them, they can close you down. I have had no choice but to have an action plan.

But for Ms Williamson, who had never set foot in my practice, to claim that I acknowledged the areas where action needs to be taken, is misleading. I acknowledged some areas, not “the areas”. Indeed my action plan often stated that we “will continue to…”, because despite their erroneous report, we were already doing the right thing.

The press release of the first inspection further adds “CQC is working closely with NHS Thurrock CCG and NHS England to support the practice, which is provided by Dr Emil Shehadeh, while it addresses the issues identified by the inspection.”. I have no idea what “working with” or “support” means.

The CCG have never been in touch with me about the CQC. Indeed one of their board members was shut down because of lack of compliance with CQC. The second inspectors were not given any data by the CCG, despite a clear request.

As for NHS England, the heirs of SWE PCT, it was they who deprived us of support in the first place, obstructing the flow of grants to Thurrock diverting them to the rich North Essex instead.

It was they who deprived us of our freed up resources. It was they who refused to honour their promise to uplift the contract value. It was they who refused to compensate us for placing the walk-in centre under our roof. It is they who demanded that I provide space for their staff, yet they imposed a 10 year short lease, when the mortgage is for 20 years.

It is they who have shamefully and carelessly been causing Carol and I endless stress by continuing to fail to sign the tenancy lease, despite many pleas from us over the years to please sign the lease.

We should have retired two years ago. NHS Essex’ failure to sign the lease as my tenants, has prevented us from retiring, despite their knowledge this is affecting our health.

Support? What Support??? We have had no support from NHS England or Thurrock whatsoever. I had a visit from the Area Team medical director, who advised me I should not be so critical of the CQC, without telling me what her advice is based upon.

She also told me that if I have an action plan I must be in agreement with the CQC. Apart from this claim being irrational, it is inaccurate and totally out of place. I have no idea what the point of that meeting was, other than to allow NHS Essex to tick a box.

The first inspector’s report implied that we should have automatic doors throughout the surgery, which I incidentally think is bonkers. I applied to NHS England for an improvement grant. Predictably, they turned us down! They advised us to contact the RCGPs for a mock CQC, which would have cost us £5,000.00.

In like fashion, the first inspection report deemed us as having inadequate medication reviews. This view was shared with us on the day of inspection. I disputed that vigorously, stating that the absence of a read-code is not the same as the absence of work. I admitted that we could do better with respect to taking a tougher line with patients on lithium and methotrexate having frequent blood tests.

But I insisted that our medicine management is one of the best in the CCG. Yet the inspector refused to amend the report claiming: “Finding remains as evidence is not disputed on the day or inspection or in FAC.”. Nothing could be further from the truth. I hotly disputed their judgement, and objected about the GP inspector rudely dismissing my opinion.

In the interim between the two inspections, I introduced a system of ensuring that patients undergo regular blood tests for certain hazardous drugs. I demonstrated that despite energetically chasing some patients, they continue to fail to comply!!! What does that prove? That I am a failed doctor?! Should I send the police to arrest these patients and force them to have blood tests? Have the CQC inspectors read about deprivation?! And what is more dangerous, continuing to take these medications or stopping them?

Quality? Give me a Break!

The CQC vaunts quality. It is part of their name. Yet quality is something they themselves lack for all the reasons I have mentioned. Their processes are faulty. They do not practice openness. They do not listen. They have no respect for time. They lack the humility to admit they have made mistakes. Clarity is not in their DNA. Their manual is as legible as a legal reference book, full of references to clauses which refer to other clauses, which in turn refer to other clauses, without ever rendering a clear or useful sense. Try and use their links! A veritable nightmare. Some of their staff are very rude. Who is responsible for the CQC quality?! Who inspects the CQC inspectors? I would do it for free.

Why Do We Need the CQC?

At best, the CQC is highlighting shortages of staff in the NHS. This is the constant in these reports. They failed the world famous Addenbrookes Hospital and the London Ambulance Service for lack of staff. Our management team could do with a GP with management responsibility. But our budget does not permit us to do so, because of years of underfunding. And yet, it is the providers that are criticised for these shortages. England has one of the lowest nurse: patient ratios in Europe. Our doctors are abused every day of the week and treated like slave labour. Why else would they be leaving for greener pastures abroad? Mr Hunt boasts that we are the most cost effective health service in the world. But that is because, to our shame, we invest less than most of our peers, and demand too much from our health care professionals. Strangely, Mr Hunt boasts when he should blush. The word “warped” comes to mind again.

If the shortage of NHS staff is already known, why do we need an expensive, ineffective CQC to remind us of the understaffing the NHS is guilty of? Is it not to shift attention from the politicians’ failure to invest, and turn the spotlight on overworked, underpaid doctors and nurses and other providers as if they were shirking their responsibilities? Worse still, the CQC has no fair or effective framework for those being assessed to express a view. My first inspection was marked by failure of the inspectors to allow us to respond. The CQC is just a tool for NHS bosses to deceive the public into thinking that their health is being jeopardised by their GPs and other providers, when in truth it is in the irresponsible tight fists of the purse holders, politicians.

Is the CQC a Dirty Tool?

The CQC claim to be guided by local intelligence. My practice’s local intelligence (clinical data) has been better than most in Thurrock. The data is in the public domain for anyone to inspect. SWE PCT declared our practice, the best practice in Thurrock. We have been declared as the practice with the most improved access, when our access was not bad to start with.

Our prescribing is amongst the best. If the CQC really used local intelligence such as the clinical data, they would have inspected us last, and would not have given us such a low grade. Why have we been the second Tilbury practice to be inspected and inspected twice, whist others with inferior local intelligence, have not been inspected at all or were inspected later?!

If the aim of CQC is to improve quality and protect the public, our practice should have been the last to be inspected in Tilbury. There is obviously dirty politics at play. I am too outspoken for some people. This inexplicable choice, combined with the un-objective way we have been initially judged, makes me strongly suspect that the CQC are the dirty glove moved by a mischievous hand, totally disinterested in quality or care.

Why We Do Not Need the CQC

How are we going to encourage some of the most intelligent members of society to become doctors when their future is darkened by the sceptre of unfair judgement being passed on them by such a hopeless and hapless organisation as the CQC, and make those doctors pay for such a dubious privilege?! The CQC fees are going up by a huge percentage. Why would anyone want to go into general practice?! For the last two years, we have had 14% fewer applications for medical schools. Some regions fail to fill half of their GP training posts. The clumsy CQC is not helping. The CQC has helped me change my career plans. Before CQC, I was going to retire and come back as a part time partner or salaried GP. The CQC have snuffed out any such desire from both me and Carol.

Finally, it is time the CQC asked themselves whether they perform a useful function in healthcare? Are they really objective? Are they really as infallible as they carry themselves? Is the financial burden they constitute to financially strained providers, not better spent on patient care? In my opinion, the CQC should radically reform themselves or else do the honourable thing: dismantle and find a more useful role in society, both individually and collectively?

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