All Tongue Tie Providers Now Need to Register with the CQC - Outcome & Implications for Parents

Many people still don't truly understand the whole hoo-ha with the CQC.  The confusion I think is the result of a number of factors; the embellishment of whispers, passed along morphing into a "ban" and resulting in a rather bizarrely worded petition to "reinstate providers" - so I've tried to form an analogy that might help give a better understanding.

In your local area is a private road that connects a housing estate to a busy working area. Nobody really knows who the road belongs to, only that some have permission to use the road and some don't need permission. There's a list of prohibited activities that can't be undertaken on the road - for example dancing and shouting, but walking isn't mentioned.

The police don't do anything about people walking on the road, since it isn't causing anybody any problems. The risks to the public of people walking down the road are minimal, because only people who work at the end of the road are carefully walking down it, and in 20 years, there's been no problem; all "walkers" are trained in road safety and their regulatory body ensures they follow standards, to use roads in a safe and responsible manner. A local group check on two occasions if they can use the road and the police reply that they can.

One day, a member of aforementioned local group contacts the police call centre independently to ask if he needs permission to use the road. The call handler (who has no idea about the road in question as they haven't heard of it before), gives the standard response which is to have a look at the local maps, ownership deeds and decide for themselves.

The person takes this back to the local group - concerned they now don't have permission to use the road. The local group contacts the police again, asking for confirmation they legally have express permission to use the road. The call handlers again say it's up to them to decide - there isn't a blanket rule as when it comes to roads, some need permission and some don't..

The group hires a barrister to ask the police for a definite yes or no answer - can we walk down this road without permission?  Who owns this road? Is it technically illegal to trespass? If so can you give us permission to trespass until we've planned an alternate route?  If we are acting illegally, will you, the police take action to stop any of us?

The police state that the road is privately owned, which can be in no doubt if we look at the deeds. The law states most need permission to walk down it - and no they can't give permission without application, because they don't own the road and can't break the law themselves.

They state if someone is acting illegally, of course they may take action to stop them, however if those who have always walked that way, choose to continue walking that way until they find an alternate route, they can consider each person passing on their own merits. For example, if they're from the area and are in the process of applying for permission to pass, are governed by the road safety regulatory body, following the rules and are insured to be in the area - the police can choose not to take any further action.

Frenulotomy has been undertaken by midwives and nurses in the UK for 20 years. Ironically the only fatality reported is at a CQC regulated hospital.  There seems to be confusion that registering with the CQC makes practices safer - and there are some areas of healthcare where this is true.  However tongue tie has historically always been performed by sole registered, insured, healthcare professionals, with an absence of significant adverse effects. If you have a complaint, you contact the healthcare provider's regulatory body (NMC, GMC etc) - this is still the case when CQC registered.

The CQC is designed to regulate hospitals, GPs, Care homes and suchlike - "to monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety".  The OFSTED of healthcare, they are body bound to act in the interest of the public.

Hospitals, clinics etc employ a lot of staff, not all are HCP, they need to know places are following safety protocols and have ways of monitoring satisfaction in the setting.  If we look at their fundamental standards - how many even apply to a self-employed midwife treating 3 tongue ties per week in someone's home? 

When it's one or two people working alone as registered healthcare professionals, their own training and insurance ensures fundamental standards of quality and safety are met -they're not bloody Bupa!

As soon as the ATP started pinning down the CQC, some members (including the chair herself) started completing their CQC applications. - knowing they would have little choice but to deem tongue tie a surgical procedure. By virtue of the law and their own guidance, when backed into a corner, they had little choice but to require registration.

The question is, what happens next?

The costs of preparing and maintaining CQC registration are huge (the application form alone takes weeks to complete, in part again because it's really designed for larger organisations with "staff policies", not a "one-man band").  No doubt some who just did a few here and there will decide not to continue in practice - and for those who do register, these costs will likely be passed on to parents.  Many who ceased practicing before Christmas as advised by the ATP, may have already had such an impact to their business and earnings from which it could be difficult for them to recover.

This is likely to make tongue treatment less attainable to those least able to afford it, leading the way for larger clinics and hospital treatments over the personal one to one service many have valued for so long.

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I spoke with the CQC 18.2.19 and clarified the following (posted initially on the Infant UK tongue tie group)

1) Since pressed legally, the CQC now really have little choice but to regulate frenulotomy. They recognise that it's low risk, has been practiced for years and so on, and as such wasn't an area of interest to them; however, legally it's impossible for them to argue that scissors, a frenulum and blood isn't surgical. Therefore, when asked to define the legal position - they've had to concede pin holding HCPs need to register. The CQC don't write the laws (parliament do), they interpret and enforce them.
.2) The only exemptions in terms of "practicing privileges" apply to doctors with GMC registration (as outlined in numerous pieces of legislation). Petitioning parliament would be the only way to potentially extend this exemption to other HCPs. Similarly if people wanted to propose frenulotomy should be on the list of exempt procedures (like toenails for example), they'd need to do the same.

3) They didn't/don't automatically expect midwives/nurses who are certified/insured and co-operating with the CQC, to stop practicing privately whilst applications are completed/processed. Under the law they cannot give permission for a "grace period", however they do decide who they do/don't prosecute and any action has to be in the public interest. Note - THERE IS NOT A BAN as some have claimed.

4) The CQC ONLY regulate registered healthcare professionals. In this RA osteopaths will require registration, however they do not regulate lay healthcare professionals eg IBCLCs, thus they will not be required to register.

5) If contacting the CQC, please remember those that answer are call handlers. Please ask to speak to the registration team for detailed information.

6) ETA: For the avoidance of doubt, frenulotomy does not fall under the regulated activity ‘maternity and midwifery services’, even where it is carried out by a midwife. Tongue-tie is a condition that is usually picked up in infancy, as a difficulty to breast feed and attach to the breast. Older children or adults may require the treatment related to speech difficulties and, where this is the case, the condition is treated by other healthcare professionals. Treating it is not part of midwifery care. It is post-natal care (see NICE interventional procedures https://www.nice.org.uk/guidance/IPG149).

Click here for Letter ATP received from the CQC and sent to ATP members

The UK, Frenulotomy, Private Services & the CQC - Separating Fact from Fiction

The UK "tongue tie world" was thrown into chaos just before Christmas, when the Association of Tongue Tie Practitioners (ATP) sent an email to all their members in private practice.

They reported that confusion had arisen over whether the Care Quality Commission (CQC - regulators of health and social care in England), considered tongue tie a surgical procedure that required CQC registration.

The ATP states that in both 2011 and 2013, the CQC had reassured them registration wasn't required. However recently, they've received reports that practitioners who contacted the CQC independently, have been advised it’s up to them to establish whether they need to register using the framework published.  

Further communications between at ATP and CQC, have so far not resulted in obtaining the blanket guidance for all practitioners that the ATP seek.

As a result the ATP sought legal advice. Whilst this was under investigation over Christmas, the ATP warned if practitioners were not registered, yet it turned out they needed to be - they could face a hefty fine and even prison.  

The ATP of course would be neglectful not to share the legal information gleaned with their members. Since they formally provide guidance regarding registration, they're quite rightly likely to be concerned about potential litigation issues that could arise as a result of any advice they give. They recommended this course of action for all healthcare practitioners that were not CQC registered.

Since it may take months for applications to the CQC to be processed, they also provided a suggested letter members could use to inform others why their frenulotomy services had temporarily ceased.  

This information was disseminated to members, some of whom ceased practice.

As updated guidance from the CQC has been published since 2013, this could mean, as the ATP highlighted in their email, that a good chunk of practitioners have potentially been misadvised - resulting in them practicing without the appropriate registration for years. Concern was also raised the CQC could take retrospective legal action if and when members applied.

What hasn't happened:

I've heard all sorts of rumours over the last couple of weeks - that the ATP had forced suspension of services, that the government?! had decided nobody was regulating frenulotomy and so had banned private practice, through to claims anyone practicing without CQC registration was acting illegally!

Clearly some forgot that all healthcare providers with a pin are already really rather regulated - so unless your friend's non-registered uncle is having a bash down the pub, we were always far from the worryingly unsafe situation some are now suddenly purporting.

Who are the ATP?

We should clarify as there has been some confusion recently online, the ATP is not a governing body or regulatory in nature. The ATP was formed by a group of tongue tie practitioners and is a committee run, member organisation. They're perhaps best known for the UK directory, or list of their members who provide tongue tie services - although their scope is larger than this as they state they aim to increase tongue tie awareness, support parents to obtain safe, effective care and so on.  All practitioner members of the ATP must submit evidence of training and insurance. 

Tongue tie providers can therefore choose to become a member, but there is no requirement to do so.  Similarly of course, both members and non-members can choose to follow guidance from the ATP, or seek their own legal counsel.

Several providers I know (including ours), had already made contact with the CQC independently, typically when setting up their practice or moving to a clinic base. All seem to have been advised (as per recent reports), that the onus was on them to read the guidance and establish whether registration was required.

Because the framework is complex and different exemption pathways exist, for example here and here (with further details and caveats in other sections and sub-sections), some providers have already separately sought legal advice long before this recent news from the ATP.

Some practitioners have already faced investigation and answered to the CQC.  

I was notified early in 2018 that IFS (Milk Matters) were under investigation for unlawfully undertaking "Treatment of disease, disorder or injury" and "Surgical Procedure".

We probably shouldn't have been surprised as after I made THIS Facebook post here, I received this (ironically a year ago to the day!):

After providing all the required information/evidence about our setup, practitioner and so on (including offering to register ASAP if required) - the complaint was dismissed with no further action needed.  

Our legal guidance received since the ATP email therefore, is that we have already satisfactorily addressed this issue direct with the CQC.  

The latest legal advice the ATP shared with members, in response to some continuing to practice, can be found in the form of an email from their barrister:

"I am afraid it (frenulotomy) is registerable as far as independent practitioners are concerned and an offence to carry it out without registration (subject to the medical practitioner exemption, explained in the advice)."[sic]

Their opinion is frenulotomy is registrable and if you don't meet the required exemptions, to not do so would be an offence.  Logical.  This however is not the same as saying all providers need to register.

It also makes the next move by the ATP yesterday incredibly confusing.

The chair Sarah Oakley writes:

Why, I wonder, do parents need to ensure a provider is CQC registered? 

The onus is not on patients to ensure their healthcare professional holds appropriate CQC registration, because they can't be expected to be aware of exemptions or the laws surrounding registration.  Despite what has been suggested recently - parents visiting a non-registered CQC provider are NOT "colluding in an illegal act".  Providers who fail to register when they need to however, can face prosecution.

What are the benefits of using a practitioner that is CQC registered rather than exempt from needing to register?  

The ATP may need to expand further and provide evidence supporting their rationale, should they be challenged legally regarding this recommendation. I can't imagine paying members (who have been advised by their own solicitor they are exempt from needing to register) will be massively impressed at this point.

It's even harder to understand the recommendations in terms of benefits to parents, as this leaves us for the most part with surgeons and dentists - the very group from which parents on the UK Infant Tongue Tie Group report the lowest satisfaction levels, when it comes to frenulotomy and infant feeding.

More about the CQC

Given what I've read in recent days, I think there is much confusion about what the CQC actually does - Here you can see what CQC fundamental standards are.

Despite what many seem to think, the CQC won't undertake complaints from those dissatisfied with their private care (as outlined here).  

"We cannot make these complaints for you or take them up on your behalf. That may seem confusing but it’s because we don’t have powers to investigate or resolve them."

The CQC inspect and ensure the provider is qualified, that general clinical standards are met and so on, but should someone be unhappy with a treatment received - whether CQC registered or not, complaints would be addressed to the relevant governing body eg the General Medical Council, Nursing and Midwifery Council or General Dental Council.

One might argue - why doesn't everyone just register with the CQC anyway, even if they don't need to, surely this is win win all round?

The problem with this is the vast majority of tongue tie providers work alone or with a colleague - yet the CQC is setup to regulate large hospitals, care homes and suchlike.

If a provider has 2 bases (working say half a day from each), the annual cost for registration to the CQC is in the region of £4000. 

In addition to this, sources quote anywhere between forty and hundreds of staff hours are needed to apply for and prepare for an inspection (rather like when Ofsted at inspecting schools).  If we pitch that even at forty hours (which would likely be unrealistically low for someone with no experience of the process), that's around a further £2500.

If we then consider the insurance to undertake tongue tie independently is already expensive (as you might imagine), plus other "hidden costs" like accountancy fees, ongoing CPD hours to keep up to date with current practice, conferences and re-certification costs for IBCLCs and so on) - many may soon find it's not financially viable to practice.

It would also be very difficult to argue any benefits in terms of safety, of everyone blindly registering with the CQC even if they're eligible for exemption.  

Frenulotomy has been performed extensively in the UK since the 1990s and is considered an extremely safe procedure which can be performed in the home (like a heel prick/neonatal blood-spot or blood test) - complications are considered very rare (NICE: Division of ankyloglossia (tongue-tie) for breastfeeding). 

Independent nurses and private health visitors in any great number are relatively new in terms of private UK services, from the perspective of member interests - an urgent dialogue regarding clarifying current and possible further exemptions with the CQC would seem prudent before issuing guidance.  

Assistance for different types of provider in navigating the exemptions seems necessary - yet instead we're seeing recommendation every private practitioner in the UK should race to register or be deemed "legally unsafe" and avoided by parents.  

This seems both reactionary and unnecessary to many I've discussed this with, leaving both practitioners and parents stuck.  One health professional I spoke with who is CQC registered for other activities, said they'd expect practitioners to explore all routes thoroughly for CQC exemption, offering yourself up for regulation unnecessarily they felt was madness.  Whilst unfortunately nobody was prepared to speak "on the record", this is clearly a large can of worms lacking a lid.