Samir Dawlatly: What are the costs of the public sector’s tickbox culture?

One of the responses of the Department for Education to the problem of radicalisation of pupils in schools has been to increase the number of Ofsted inspectors. The issue of home schooled pupils raised the faintly ridiculous prospect of Ofsted inspections of family homes. It seems that the culture of regulation by inspection is pervasive in more than one public sector. As a GP working in England, my “Ofsted” is the Care Quality Commission (CQC).

A colleague of mine, who up until recently was of the view that the need to measure was important for the assurance of quality, recently visited Denmark and was told by the immediate past president of the Danish College of General Practitioners that the Danish are inherently a trusting people, and that this trust underpins a key difference between UK and Danish GPs. They do not have the multitude of inspections that we have here in the UK, although CQC style inspections are due to be introduced.

Furthermore, their GP trainees have fewer assessments. Interestingly, a key screening process for entry into Danish GP training schemes relies on a supervising GP (training doctors in the equivalent of our foundation year two GP rotations) to determine if the trainee was “trainable” through a holistic process. It seems that the Danish trust their doctors and each other to do their jobs properly.

As a result, it could be argued, GPs in Denmark are passionate about their work and brimming with innovative ideas. Professional pride provides the incentive to deliver quality care for patients. And, although many UK GPs care about doing a good job and wish to do what is best for their patients, there is invariably pressure from the Quality and Outcomes Framework (QOF), the CQC, clinical commissioning group schemes, revalidation, the friends and family test, and so on. The lack of regulatory forces seems to enable Danish GPs to be focused on what is best for their patients, while a UK GP would find it challenging not to think about QOF even before hearing the patient agenda and also hard not to be side tracked by the multitude of enforced measures.

Perhaps the CQC is merely a symptom of a culture that is inherently untrusting and which feels the need to measure all things that are measurable, even when it is near impossible to define, let alone measure, what quality holistic general practice looks like. It is likely that the opportunity costs of over-assessment—such as the time lost preparing for CQC visits—exceed any gains from having these measures and inspections in place, however well intentioned they are.

I have no doubt that UK GPs are over-assessed. It is likely that a great deal of effort and looking beyond our own systems and methods will be required to reverse the current clipboard, tickbox culture. We already have enormous trust from our patients. Perhaps we deserve the same amount of trust from the government and its Quangos?

With thanks to Dr Ed Ng, GP, Sutton Coldfield.

Samir Dawlatly is a GP partner at Jiggins Lane Medical Centre. He is on the management board of Our Health Partnership and co-clinical director of QCAPS referral improvement scheme. All views expressed are his own. He can be found on Twitter as @sdawlatly.

Competing interests: I have read and understood BMJ policy on declaration of interests and declare the following interests: I am a member of the RCGP online working group on overdiagnosis.