The GP who hid from me

One of the first GP practices I ever inspected, the doctor hid from me.

Not metaphorically. Actually hid. This was 2013, the first few months of CQC regulating general practice, and I turned up unannounced like we did. Showed my ID at reception, explained who I was, asked to have a word with the GP when they had a moment.

The receptionist went to tell them. The GP did not come out.

I waited. Patient went in, patient came out. Still no GP. I am sitting in the waiting room next to a man with a suspicious cough and a six-month-old copy of Country Living, starting to wonder if I had been forgotten. Eventually it became clear the GP had decided the safest course of action was to remain in the consulting room and simply outlast me.

They were not hiding anything. There were no skeletons. They were just terrified, because general practice had only just come under regulation and nobody had told them what an inspector could actually do. So in the absence of information, they did what any reasonable person does when a stranger with a lanyard appears unannounced asking questions. They barricaded in and waited for me to give up.

I did not give up. We do not give up. It is, regrettably, the whole job.

What I found out later was that while I was sitting there with Country Living, the practice had been frantically phoning around for advice on what their rights were. So the two of us spent that morning doing the exact same thing from opposite sides of a door. Both of us on the phone to someone. Both of us going “right, but what is he actually allowed to do though.”

We got there in the end. The GP came out. Lovely doctor, as it turned out. Ran a perfectly good practice. Had simply never been told that the inspector was not, in fact, there to ruin their life.

The fear in that room was so much bigger than anything that was actually at stake. And it has stayed with me through every inspection since: people are not frightened of inspection because they are doing something wrong. They are frightened because nobody has told them what to expect.

I told that story on LinkedIn this week and several people wrote back assuming it was specific to the 2013 GP-commencement wave. The fear was that sharp, the explanation went, because general practice had only just come into regulation and nobody had a routine yet. Once a sector has been regulated for a few years, the thinking went, the fear settles down.

That is partly true. The first inspections in any commencement wave (dental in 2011, GP in 2013, the independent-sector waves that followed) were sharper. Practitioners had no friends who had been inspected to ring up for advice. There were no blog posts. The royal colleges were still working out what to say. So the fear ran higher because the information was thinner.

But it did not actually settle down nearly as much as people assume. Eleven years later, I was still arriving at services where the registered manager had cleared their afternoon for the inspection and could not eat lunch. Services that were running perfectly competently, with no specific reason to be alarmed. The fear had stopped being about the regulator being new and had started being about something else.

What I came to think the fear was actually about, in those services, was that the team did not have a clear picture of what their own evidence trail looked like. They knew they had been running the service properly. They could not be sure their records reflected that, because the records lived in eight places. Some of them were in folders. Some were in someone's email. Some were in the head of the senior nurse who happened to be on annual leave that day. The fear was not really of the inspector; it was of the moment the inspector asked to see something and the team having to start hunting for it.

From the inspector's side, fear is one of the things you notice first because it shapes the whole day. A team that arrives at the opening conversation in the fear-state speaks in shorter sentences. They answer questions slightly too quickly. They reach for the policy folder when you ask an open question. They apologise for things that do not require an apology. They sometimes tell you things that were not what you were asking about, because silence feels worse than over-explaining.

A team that is not in the fear-state arrives at the same conversation differently. They ask what specifically I had on the agenda. They mention, unprompted, the thing that was on their mind this week. They show me records when I asked for them without first explaining why those records were not ideal. They sometimes asked me a question back, which is a small thing that signalled an enormous difference in how the day was going to go.

The difference was almost never about how well the service was actually being run. The two groups overlapped heavily. Services in the fear-state often turned out to be running perfectly competent care; services that were calm sometimes turned out to have substantive problems. The fear-state was mostly a separate variable, and it tracked closely with how clear a picture the leadership team had of their own service.

Worth saying explicitly: inspectors are not there to catch you out. The framework does not reward inspectors for findings. The training is structured the other way: inspectors who walk in already convinced are trained out of it because their findings will not survive review. The actual job is closer to a structured listen.

What I came to do, on any given day, was form an honest view of whether the service was running safely. Not whether the paperwork was perfect. Whether the records reflected what the team was actually doing. Whether the leadership team knew what was happening in their own service. Whether the patterns in the records suggested a service that was learning. The framework gave me five key questions; the structured listen gave me an answer on each one. The rating fell out of the answers.

None of that requires fear from the provider. Most of it works better without it. A team that is calm enough to think clearly during the opening conversation gives me more accurate information faster, which means the inspection lands closer to the truth of how the service is actually running. The teams that ended the day with Good or Outstanding ratings were, again, not the bravest teams. They were the teams who had a clear picture of their own service before I arrived.

The thing I came to call the lights-on state, in my head and then in conversations with the team I now work with, is the state where a service has its own records in such order that the inspector arriving is not the most disruptive thing that happens to the leadership team that week. The records exist. They live in one place. They are current. The team has been reading them already. What the inspector asks to see, the team can produce in seconds because the team is already looking at it.

Services in the lights-on state are not exempt from findings. Inspectors still find things. But the findings get found by the inspector and the team together, in the same conversation, in real time. The team sometimes spots the finding before the inspector does and surfaces it themselves. That is an enormous tonal difference. It changes the inspection from a hunt into a collaboration. It also produces fairer outcomes, because nothing is hidden under pressure that should have been visible.

The lights-on state is also the steady state of running a competent service for its own sake. The same trail that the inspector reads at inspection is the trail the leadership team reads every month at the governance meeting. The same trail that answers the “what is on your mind this week” question at the start of an inspection is the trail that the registered manager has been reading on Monday morning. The point of the trail is not the inspection. The inspection is just one of the moments where the trail gets read.

Thirteen years later, that is the entire reason I built what I am building now. Not to catch anyone out. To turn the lights on, so that when an inspector does walk in, it is the least surprising thing that happens all week.

Verivius is continuous-governance software. The substance of it is unremarkable: incidents, complaints, safeguarding concerns, statutory notifications, risks, improvement actions, supervision, documents, people. The lifecycles you already know. What it does that matters is keep all of them in one place, link them to each other so the chain from event to action to evidence is readable, and put the things the leadership team should be looking at every month onto a single screen the leadership team actually reads.

The platform does not do anything inspectors did not already want providers to do. It just makes it harder to lose track of doing it. Most of the services I inspected over thirteen years had every piece of evidence they needed somewhere; they were losing inspections because the piece they needed in a given conversation was in a different folder from the one open on the desk. The fix for that is not better paperwork. It is one trail that all the paperwork rolls up into.

That is the lights-on state. And the registered-manager experience of running a service in that state is calm in a way that registered managers in the fear-state sometimes assume is impossible. It is not impossible. It is what running the service openly across a year produces.

Though I will say. If you are a GP reading this and you have ever hidden from an inspector. Your secret is safe with me.

On what actually happens in the first half hour of an unannounced inspection: the first thirty minutes. On what inspectors are actually reading for in the records: what CQC inspectors actually look for in incident records. On the well-led question (the one that decides ratings more often than any other): the well-led question, from the inspector's chair.