Q&A: An inspector calls

Professor Steve Field joined the Care Quality Commission as chief inspector of general practice in October 2013 but has long been a key player in NHS reform in England.

In 2011 he chaired the NHS Future Forum which led to key changes in the bill that became the Health and Social Care Act. He then took on the role as deputy national medical director of the NHS Commissioning Board, with lead responsibility for addressing health inequalities in line with the NHS Constitution.

Professor Field was also chairman of council of the Royal College of General Practitioners between 2007 and 2010.

He continues to practise as a GP at Bellevue Medical Centre in Birmingham and is also chairman of the National Inclusion Health Board which is working to improve health outcomes among the homeless, migrants, sex workers and other vulnerable groups. He is an honorary professor at both the University of Birmingham and the University of Warwick and received a CBE for his services to medicine in the 2010.

How do you think the new approach to general practice inspections by the CQC will lead to improvements in primary care in England?

When I became chief inspector of GPs last year, for me the focus of CQC inspections was very much about looking at and reporting on what GP practices were doing wrong or could improve on rather than celebrating the good and outstanding in the sector. Although there will always be a place for identifying inadequate care to protect people at risk, I think by also celebrating the best we can help raise the bar for others and help them to serve their communities better. We must not tolerate inadequate practice. The vast majority of practices are trying to provide good care. I hope by sharing good examples, we can encourage and promote better practice across the sector.

What was the main element lacking in the old inspection regime?

One change that we are currently piloting is for a clinician to always be part of the team, therefore having an experienced GP present and where possible a practice nurse or practice manager as well. This way we can ensure that at inspection we are asking the right questions and that we are focusing on the things that truly matter to patients: is the practice safe, effective, well-led, caring and responsive to people’s needs? And not just checking that a particular practice has the correct processes and procedures in place.

What are some of the typical failings the pilot inspections are revealing?

As wave one of our GP practice inspections have started recently, it is a little too early to be able to report back on this yet.

What one thing do you think would lead to a significant improvement in GP out-of-hours services?

The one area that keeps coming up during inspections and seems to really define a good service is strong clinical leadership that is responsive and a service that understands and reaches out to local communities. As well as this, attempts to work with other agencies like Macmillan nurses or local hospitals to share intelligence and good practice are also important. A recent RCGP poll found that 96 per cent of GPs feel that morale has decreased in the past five years.

How do you think that can be addressed while also ensuring the high standards of primary care aimed for by the CQC?

There are many reasons why GPs have low morale – our old approach did not normally include GPs on inspections and the guidance on how to be compliant was not written specifically for GPs. We hope that a new model which is being developed with the sector and will include GPs on every inspection will be better and more tailored to general practice, and will take into account the context of general practice. We will also be celebrating good and outstanding practice and sharing that widely.

Worries have been expressed that the new inspection regime with Ofsted-style ratings will be demotivating for GPs. Do you think this is a valid concern?

We will highlight where practice is good or outstanding and will celebrate good practice as well as identifying inadequate practice. There isn’t one overall rating – the ratings we intend to apply, subject to consultation, will reflect the complexities of general practice and will highlight within each practice what is working well and what might need to improve.

Some GP leaders have also responded negatively to plans for CQC inspectors to sit in on some GP consultations. Is this a “step too far”?

I think it’s important to emphasise a couple of things here. The power to observe care being given was granted in the Health and Social Care Act 2008 (which came into force for GP practices last April) and it can be used as part of evidence gathering during inspection as well as reviewing records, policies and other documents, listening to staff, and pathway tracking patients through their care. Although it is a power we have, it’s one that has only been used very, very rarely especially in our inspections of GP practices. (I personally am not aware of one occasion where it has been used since last April). If we were to use it then it would only be with the express consent of all those involved and the care would also be observed by the experienced GP who will always be on a CQC inspection of a practice.

Do you think health inequality is growing within the UK? How is the CQC helping to address this issue?

One of the key lines of enquiry that we will be looking at in the new inspection regime will be the prevention of ill health for all people. Also the population group focus of our inspections enables us to look at how services are provided to all people. My old role before coming to CQC, was the deputy health director for NHS England leading on addressing health inequalities. I continue to chair the National Inclusion Health Board, which champions the health of vulnerable people including the homeless, sex workers and travellers. While CQC cannot tackle social determinants of health directly, we can ensure that practices provide care that is safe, effective, well-led, caring and responsive to all people’s needs, including vulnerable people.

Can you tell us of any changes planned for dental care inspections?

I have recently appointed a deputy chief inspector, Janet Williamson, who will have responsibility for dental care. We are currently recruiting for a senior national dental advisor. We are looking at the way that we inspect dentists in much the same way that we have looked at and begun to make changes to GP practice inspections. There will be what we call a ‘signposting document’ outlining changes later in the year and I would encourage keeping an eye out for that publication.

You still see patients as a GP. How do you find the time with all your other commitments?

I continue to work part time in a GP surgery, seeing patients on a Friday morning. I do this because I love general practice. It keeps me grounded, and the feedback from patients is that they would like me to continue. It is of course very difficult continuing in clinical practice, but I have very supportive partners and staff in the surgery, and my scope of practice has reduced over the years.