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‘I want to reduce the burden on GPs’

The chief inspector of general practice tells Joe Davis he wants to move towards a more ‘mature system’ of regulation 

prof steve field 3x2

As the CQC’s new inspection regime for general practice passes its first anniversary, Professor Steve Field remains adamant that the new approach is working.

The regulator’s chief inspector is keen to stress its success and its positive impact on patient care when Pulse finally gets to speak to him – after more than a year of requests.

But it comes after a difficult year for the Birmingham GP. The chief inspector’s reputation reached an all-time low among GPs with the misguided publication of internal CQC ‘intelligent monitoring’ reports late last year. The CQC’s flagship scheme was eventually found to have used seriously flawed data and the regulator had to scrap its practice ‘risk ratings’ and apologise.

The RCGP has called for a halt to CQC inspections and the BMA proposes that the regulator be scrapped in its entirety. But Professor Field is still in post, and seemingly more energised than ever. Pulse speaks to him as he plans a public consultation on the future of CQC inspections, and a possible ‘lighter touch’ regime.

You recently mooted the idea of introducing a ‘lighter touch’ to CQC regulation of GPs. What is the thinking behind this?

I wouldn’t call it a lighter touch. By the end of September next year all practices will have been inspected at least once and we’re looking at how we develop this model in general practice, social care, dentistry, mobile doctors, hospitals and mental health trusts.

The CQC is going through its strategy for the next five years. We’re thinking about how often practices need inspecting in order to maintain their rating.

So practices achieving a ‘good’ or ‘outstanding’ rating can expect to be re-inspected in months or years?

My hunch is that they wouldn’t be re-inspected any more frequently than every three years.

Will the second wave of inspections be scaled back?

No. We’ve been through the practices once so they wouldn’t need the level of interrogation again. We know they’ve got all the policies and are ‘good’ so the emphasis is different. We’ll be looking at how we predict if practices are underperforming so that we don’t have

to inspect as frequently. We listen to CCGs and Healthwatch and we use intelligent monitoring. Monitoring and prediction have proved very good behind the scenes.

Intelligent monitoring had a turbulent start, though.

It did, yes. The question is, what’s the frequency of re-inspection? The answer is probably between three and five years for practices that were rated ‘good’ or ‘outstanding’. We will be consulting and working with the profession to see whether that is where we move to – because I want to reduce the burden on practices as much as I possibly can.

Is the move towards a model of less frequent inspection a result of a lack of resources?

Less frequent inspection was always my plan. We’re not scaling back as we didn’t set a date for re-inspection of ‘good’ and ‘outstanding’ practices. We’re finding that ‘inadequate’ practices need a lot of revisits and practices that ‘require improvements’ are usually re-inspected – depending on what their problems are – within three months to a year.

GP leaders have warned that labelling practices as ‘inadequate’ or ‘requires improvement’ – can make their situation worse because they can’t recruit, and might receive breach notices from NHS England. How do you respond?

In many of these surgeries we’re finding people have known they’ve not been performing well for many years. What we’re doing is standardising around the country. We’re thrilled that the RCGP is involved in about a third of special measures practices to provide support. We’re pleased that in some areas NHS England is providing extra support and we’re really pleased that the first practice in the ‘special measures’ regime (Priory Avenue Surgery, Reading) is already starting to improve care.

We are hoping that by the time we’ve been through all the practices, many of the very poor practices will be on the road to improvement. We’re also noticing a lot of practices are merging. We’re finding bigger provider organisations like Lakeside (Corby), and Whitstable, Kent. Sometimes acute trusts take them over, like at Priory Avenue Surgery. We’re finding improvement is being encouraged and the model of care is developing and changing. What we’re trying to demonstrate is that ‘special measures’ is about shining a light and we’re pleased it appears to have a galvanising effect.

What evidence is there that the CQC’s inspection regime is improving patient care?

We’ve got lots of evidence but we know that Priory Avenue Surgery has improved. I believe it would not have done if it hadn’t been put in special measures. This is the first practice that has been through our system. It’s not the first ‘inadequate’ practice to improve, but it is the first ‘special measures’ practice.

But that’s just one practice.

When we’re inspecting now, the quality of the practices we’re going to is much better than when we started the pilot. We were finding basic standards were a problem in almost a third of practices, but we’re not finding that now.

We’re also hearing when we talk to GPs that they’re doing more clinical audits, linking with other surgeries, and even doing mock CQC visits before we go in, so they are thinking about those standards.

As a GP yourself, can you understand the profession’s hostility towards the CQC?

Of course I can. I can understand the scepticism – and I’ve been working on this for years. I have been shocked at how bad a very small proportion of practices are and have been pleased that the majority are rated ‘good’. That’s been a real success for general practice and when we’ve got most of the practices up to ‘good’ we can start to look at doing things differently when we inspect.

The emphasis will be on continuous improvement because they’ve all reached the ‘good’ level. It won’t necessarily have to be the same focus on the finer details because the practices might be able to work with us on co-regulation, so they can say ‘we have a policy on recruitment and this is the evidence’. We want to try to reduce what you call the bureaucracy as we don’t have to do as much of that because they will be ‘good’. But until we’ve been through the process once we can’t say that. It’s not light touch; it’s actually a more mature system.

CV

Age

56

Family

Married with twin daughters

Education

1982 Graduated with a degree in medicine from the University of Birmingham Medical School

Career

1986-present Working as GP, currently in inner-city Birmingham

1995-2001 Regional advisor and director of postgraduate GP education, West Midlands Deanery

2001-2007 Regional postgraduate medical and dental dean, West Midlands Deanery

2007-2010 Chair of the RCGP

2011-2012 Chair of NHS Future Forum; led bill changes that became the Health and Social Care Act

2011-2015 Chair of the NHS Inclusion Health Board, Department of Health

2012-2013 Deputy national medical director, NHS England

2013-present Chief inspector of general practice, CQC

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Readers' comments (34)

  • Took Early Retirement

    ‘I want to reduce the burden on GPs’

    Well take your organization and go forth and multiply mate.

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  • This guy and his cronies is one of the reasons I left the UK to practice abroad

    He doesnt work for th grassroots but his own knighthood; People who can't hack the job try to hide in corners and make others lives difficult; The prof is one of these people; telling others how to be good GPs when they themselves only do the bloody job 2 or 3 sessions per week;

    thanks Prof, im out of the west midlands now; far beyond your reach and remit!!!!

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  • Dear Prof field
    you are increasing pressure without the resources to follow in the worst crisis of recruitment and morale ever seen in general practice.
    This will worsen the service that patients get.
    Unfortunately you are too blinded by your own political ambition and self importance to care

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  • What a load of hypocritical spin.

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  • This comment has been moderated.

  • Prof Field doesn't have much if any space to manoeuvre.He has to do what the government tells him;a bit like the head butler

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  • "The chief inspector of general practice tells Joe Davis he wants to move towards a more ‘mature system’ of regulation "

    does that mean the inspections were immature previously then?

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  • Prof Field, please read these comments and digest them. Your profession profoundly disagree with your methods and are suspicious of your motives.

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  • The inspection process is farcical. GP inspectors have less than an afternoon of training on 'judgement exercises' for which the standards are unknown and 'left to discretion'. The CQC is responsible for mental ill-health in GPs, practice managers and nurses. As above, Steve Field and Nigel Sparrow should hang their heads in shame.

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  • keep up the good Prof Field !

    you deserve your pay and final salary - thanks to you and other doctor 'leaders' most of the GPs I know are demoralized and fed up and as a result in the area I work in - there is a massive shortage of GPs which means my locum rates have gone up. Soon I will be able to pay off my mortgage and change career. So please can you have a word with your pals at NHSE, NICE, RCGP, GMC, DOH and ask them to stick the knife in further (you all seem to sing from the same hymm sheet) so that my rates can go up further? At this rate in 2 years my mortgage will be paid out for :)

    I'm hoping to get a cushy job in one those quangos where I can sit behind a desk, not do any frontline patient contact, write lengthy important sounding reports, dictate to those in the front-line and get paid for it and wait for my OBE!

    yours
    Sir Anonymous GP

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  • What a cynical statement from Prof Field. He spins it to make it sound like he is the good guy who will reduce the burden on GPs, when in fact he is the one who helped create such a burden in the first place.

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  • CQC, appraisal, NHSE, Revalidation are the reasons why my contemporaries - GPs in their 40's are reducing hours, looking abroad and keeping a VERY close eye on their pension pots. You should take a long hard look at what your organisation is doing to GPs and GP - and be ashamed.

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  • Editor: Your moderation of comments is excessive. In my moderated post on this thread, I challenged the prof to consider his own role in arriving at the current parlous state of GP. Not libellous, not defamatory, not personally insulting. I just asked him to reflect. Isn't that what we are all supposed to do these days?????

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  • Prof, ah-aah

    Saviour of the Universe!

    But prof, we only have 30 seconds to save the earth!

    Yes, some doctors will do almost anything sitting on committees and quangos to avoid direct patient contact

    You know what, I've been thinking of doing just that myself - scaling down my 23 years of 9 sessions to virtually nil, and instead earning a fortune spending all day saying Hi to a bunch of smiley self-important bores sitting around tables with coffee machines entering shit into i-pads plotting the destruction of my colleagues.
    Prof, when you leave, I'm up for your job!

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  • The witchfinder general has become slightly less sadistic,what a relief!

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  • I really struggle to understand how anybody who has been a proper GP and done real work looking after patients could sell out and do this government dirty work.

    Do you really need the money that much?
    If so go back to being a real doctor and do some locum shifts (there are lots of them out there) earn yourself an honest living again and regain the respect of your colleagues.

    Think back to when you started at medical school, is this really what you wanted to do with your medical qualification?

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  • This comment has been removed by the moderator.

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  • Why feature this on the website at all? It is not newsworthy and we can all do without this irritation.

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  • Not even one redeeming comment and several removed.
    Let me know before he comes to NI so that I can jump ship even sooner than planned
    Seems there will be no GPs to CQC in a while anyhow so he will be out of a job. May even have to go back to treating the punters.

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  • Dear Steve,

    There is no doubt that a tiny handful of GP practices could be labelled as unsafe. Just as a tiny proportion of doctors are also unsafe. In order to mitigate against these circumstances, obviously some kind of performance management is required.

    But this system requires literally hundreds of hours of work to achieve success for a practice which is already performing well.

    The pressures we are under are so immense with underfunding and recruitment issues, yet we have been forced to spend our over stretched hours on this.

    I am also fairly shocked to discover that you were instrumental in bringing about the health and social care act; an act which has fragmented the NHS and encouraged the market like never before.

    It is clear where your political bread is buttered.

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  • Quangocrats are shameless people, the more people who tell them they are wrong the more they are convinced of their own apotheosis over the great unwashed.

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  • "We know that standards are improving..." because through word of mouth alone people are getting a better understanding of the meaningless hoops you force people to jump through.
    Do not think your not finding problems has any connection to an improvement in patient safety - the reverse is far more likely.

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  • I am more interested in the fist in the photo. Is it a 'Field' fist or it is a fist breaking though into the photo which looks like it is going to biff him in the smacker.....

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  • When NHS GPs are gone or are so depleted that they cease to function as an effective unit the poor and vulnerable will suffer once more.

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  • Dear Witchfinder General of General Practice,
    Thanks for reducing morale to an all time low.

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  • Dear Professor or should I say Witchfinder General of General Practice,
    Thanks for wasting our time in pointless bureaucratic exercises . Thanks for reducing morale to an all time low and for those unfortunate practices judged inadequate (witches) thanks for watching them burn at the stake. We dont need you -the vast majority of practices self regulate .

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  • Interesting that the one example he gives of a measure of quality is whether or not a practice has a recruitment policy. Why on earth does this matter and how does this affect patient care??!!

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  • Will those who comment here and criticise the CQC please now tell everyone whether they think their practice is perfect, beyond improvement and they know that for a fact? Managing `professionals` - ie people who are trained to know better than anyone else - is a whole area of study in itself and cognitive dissonance is not an attractive trait. Come on GPs - recognise that you can improve and look on a CQC visit as a means to recognise what you cannot see yourselves.

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  • Professor Field can point to one practice which is improving. Pulse has reported the cost of these inspection as £13.3 million pounds. This is the direct cost, on top of which is the cost to practices of preparing for inspection. This is using a sledgehammer to crack a nut. Undoubtedly at any given time there are some practices who are struggling more than others. They need support. This would be a much better way of spending the £13.3 million than funding the CQC to further regulate an already much regulate profession. GPs are not stupid. We have made our views known through our representative organisations: the RCGP and the BMA, as quoted in the article.

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  • Fine
    Resign then
    Then disband this pathetic organisation of bum polishers and pen pushers
    Then put the millions saved into REAL patient care

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  • Do the decent thing. Resign.

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  • Prof.Field should understand that inspections on their own will not remedy the shortcomings of any underperforming GPs.
    The remedy is to visit and talk to, and understand the difficulties that a particular GP may be facing.This should be very frank and without threat.Then make suggestions and offer concrete help,like money or additional staff or better premises or education.
    At best the CQC inspection MAY be a way of identifying underperforming GPs .Local health boards should be able to identify under performers from their data and act to prevent them failing, well in advance.In fact, there is no need for the CQC at all !!

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  • Great to hear all is well and hope you sorted out fees
    We spent £70 k on staff and upgrades of good equipment all for expensive box ticking.
    My dentist doubled his fees after inspection..we might close

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  • Dear Prof Field
    Come and visit my practice and I will show you that big is not always beautiful.
    With CQC inspections looming surgeries have to spend time to get ready for inspection- for CQC to do box ticking exercise.
    Once the inspection is over then what
    Five star practices are they really five star just because CQC says so?
    We know few bad apples which CQC /NHS England are aware of but can not get them to perform and all remaining practices are made to suffer. How many of these bad apples belong to the big wigs in CCG?

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  • just received our "first draft" report following the new light touch visit - which seemed to go well but then the report!

    Is it the same practice I ask myself? How can we get glowing reports from patients & even the inspectors but end up with indadequate - must try harder??????

    But then -why should I worry because the great lord high inspector in chief has personally endorsed it! - has he hell - about as likely he has read it as they were really singing on top of the pops.... - if he has read it how can he agree with his designated inspector that we require improvement when all the stats are better than the CCG/national average & majority in high 90%!

    This is a shambles

    sadly I cant put my name to it at this stage for a very real fear of reprisal.

    If I wasn't so financially stuffed and tied to the practice I would walk tomorrow & they can kepp the F****** NHS.

    Happy New Year Steve & your elves - hope you have a really horrid year! Perhaps you will even get inspected by people who understand general practice - then again better if the CQC does it!

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