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Interview: Steve Field on inspection and the “joy of being outstanding”

20 March 2014

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The new chief inspector of primary care, Steve Field, tells Victoria Vaughan how he intends to make poor general practice a thing of the past

There’s a new sheriff in town. His mission is to inspect all primary care services and make it known if they fall below standard. He is determined to root out poor general practice and thereby reduce variation. If his vision succeeds there will be no hiding place.

The Care Quality Commission’s (CQC’s) chief inspector of primary care Professor Steve Field has been charged with inspecting more than 7,000 practices in England in the first nationwide process to evaluate the standards of care provided by GPs. His responsibilities also include dentistry, child safeguarding, prisons and secure environments, detention centres, controlled drugs legislation and medicines and integrated care.

The former chair of the Royal College of GPs is driven by a sense of social justice stemming from his upbringing on a council estate. “I want high-quality care for people who I grew up with as well as everywhere else”, he says.

At his CQC debut where he unveiled plans for the new inspection regime he was unabashed at mentioning various headline-grabbing general practice transgressions: consultation rooms with no doors; maggots; widespread issues around access; maggots; unregulated fridges used for vaccine storage; and maggots “and that [the maggots] was in a good practice” he adds.

He pushed home the consequences of the seemingly benign issue of fridge temperatures by saying that if a pregnant women contracts German measles, and thinks she has had the rubella vaccine, but in fact has no immunity as it was stored at a temperature which rendered it ineffective, then she could go on to have a rubella baby, blind and deaf.

The new inspections, involve Ofsted-style ratings of outstanding, good, needs improvement or inadequate which must be displayed in a prominent place in the practice. An “inadequate” rating combined with the lifting of practice boundaries and yet to be confirmed plans that Field will write to all patients of poorly rated practices, may have a significant effect on list size and practice viability as patients become more discerning.

He is at pains to say that the majority of general practice is good and that inspections so far of 1,000 practices – in which 34% were found to be noncompliant in the regulations and 10 practices had serious failings – have focused on those where concerns have been raised. However his vision of CQC inspections is one of zero tolerance on poor practice.

Ofsted has been a particular inspiration.

“Until a few years ago people were very scared of the [inspection] visit, but now it is all about the pride of being outstanding.

“There are two things that I like from the Ofsted idea: we can rate but celebrate excellence, as well as sort out practices that are not very good. It is not our role to be the developmental support organisation and, to be honest with you, NHS England are the contractors. So we are here to protect the patients. I see myself completely on the side of the public; the patients and the patients’ children and grandchildren, because some of the things that happen in healthcare can affect the next generation as well,” he says.

The other thing Field has picked up from the schools regulator is that following an inspection a letter is sent to pupils outlining the highlights and the issues.

While Field admits that writing to all patients is “prohibitive” he is “thinking about writing an open letter to the practice” that would be published on both the practice and CQC websites and in the local press.

More recently he has suggested that he may write to all patients of an inadequate practice to “make sure they [knew] about it”.

There has been criticism of the inspections which have taken place since April 2013, the deadline by which all practices had to be registered with CQC. They centre on the lack of experience of the inspection team and the short 48-hour notice period.

Field, who still practices as a GP on Friday morning at Bellevue Medical Centre on the outskirts of Birmingham, outlines the new model which will aim to tackle some of these issues.

It will involve inspectors and deputies in each of the four big NHS regions. Beneath them they will have a series of very senior managers, who will have a relationship with three or four clinical commissioning groups (CCGs) and inspection team, which is” where we are putting most of the effort”, he says.

The inspectors will be trained in the CQC academy which will work in a similar way to the medical colleges, providing exam-type feedback, for all staff including social care and hospital inspection teams led by chief inspector of social care, Andrea Sutcliffe and chief inspector of hospitals, Sir Mike Richards. Plans include core training and assessment on decision making as well as sector-specific and leadership training. “It will be fantastic,” says Field.

The teams will not just be trained, they will have first hand experience of general practice. They will involve a nurse or a practice manager and a trained “expert by experience”, which is a patient, a GP and GP registrar.

“One of the issues we have inherited is that the actual regulations are quite complex. The amount of work practices have to do is perceived to be onerous; there wasn’t clinical input into the visits, and sometimes inspectors concentrated on detail rather than focusing on some of the important things. We have got no evidence that anybody has missed anything, but I think [It will help to have] a GP on every visit.”

“Some of the reports I have read have been a bit too detailed about things which, for me personally as a GP, are not desperately worrying. But the way they are reported sometimes also shows a lack of insight,” he says.

This is cold comfort to patients of the practices that have been through inspection so far, however the new style regime will carry out repeat inspections of these practices in its first two years starting from April 2014.

The CQC is planning to visit each clinical commissioning group (CCG) every six months and inspect about a quarter of their practices to ensure it meets the deadline of April 2016 to have visited all practices in England.

As well as a CCG’s member practices there will be other health services in any given area such as a prison or a mental health trust. Following initial feedback from GPs about these Field intends to theme subsequent inspections. 

“In the second six months, not only will we look at practices, but we will also look at the relationship between the practice and mental health, substance misuse, or prescribing in care homes for example. In addition to that we are also going to have some national themed issues; so at the moment we have been looking at the children to adult transition.”

In fact there is no limit to the areas that Field wants to look into as he reels off a list including urgent care, hospital discharge, the frail elderly, women, mums and babies, the working age population, the very vulnerable – “I am still chairing the National Inclusion Board” – the homeless, prostitutes and travellers, out-of-hours and end-of-life care. 

From April 2014 practices will have to satisfy five key areas: are they safe, effective, caring, responsive to people’s needs and well led. The actual report on the practices will be written by the inspector, with the GP’s input, and the practice must publish its ratings when the report is published.

Each inspection is expected to take an inspector three days with the GP’s role covering the day-long practice visit only. 

As well as this overall rating the CQC is consulting on giving separate ratings for particular groups of patients.

“When I first started looking at this I thought it might be okay to say something is outstanding, but the feedback from a number of GPs we have spoken to is actually they quite like the idea of having it more granular. So, if you were in Eastbourne, which is mostly elderly you would want to be a practice that was good for the elderly,” he says.

But the trick of how to get feedback from various patients is yet to be cracked. At the moment Field is considering public meetings.

If a practice is identified as having poor care it then falls to the CCG and NHS England’s area teams to help improve it.

The model is that the CQC’s senior manager will work with CCGs, which have a legal responsibility to improve care, and the area team which also has a similar duty as the GP contract holder.

“This is not just about the standards. GPs fail for a number of reasons. It can be attitude, it can be [personal] health, it can be a lack of investment. We will get a feel for what is happening across a CCG area. We are not a campaigning organisation at all. And we are not the improvement organisation.

“CCGs have a responsibility; they have access to NHS Improving Quality, but also individual practices and the individual GP has a responsibility,” he says.

Field points to Tower Hamlets as a good example as they invested in federations of practices as well as “sorting” out the poor practices.

“People want and need us to do something, but also they want an independent scrutiny to say, ‘This is outstanding,’,” he says. 

Notice of an upcoming inspection is also likely to be increased from the current 48 hours.

“My feeling at the moment is that we should give more notice. The reason behind that is, from the point of view of a practising GP, I understand the disruption; a big team coming for a day in the practice, even one that is my size of practice, which has less than 8,000 patients, would be hugely disruptive.

“We are not trying to catch people out. So I think we should give notice. It certainly will be more than the 48 hours which are given at the moment. I think you need to know at least the week before … However, if we hear of serious things, we will go without notice, and if we want to review a practice we will go without notice.”

Access is an ever-present problem in general practice and while Field says, “It isn’t something that we will inspect on” he qualifies it by adding that “if you want to be an outstanding practice” you need to be ‘responsive and well led’, which may mean giving seven day access.

“Now, it might be in an area where patients do not want seven days; it might be like my practice, where it is very difficult because we haven’t got the staff to manage that.

“But it is also about out-of-hours because if you had a shared medical record and you had access to a GP and they had the record, that is actually starting to move towards a more seven-day service for your patients. But, no, we do not expect every practice to open Saturdays and Sundays; I believe that what we will do is move to either federated practices, with practices working together, or to bigger practices… but I do not think we have the right, the role or the responsibility to dictate the model.”

The CQC has the power to suspend a practice’s registration to the CQC, meaning it cannot operate. In extreme circumstances it may prosecute but Field reassures that primary care need not fear. “People are scared at the moment, but they do not need to be scared of what we are doing,” he says.

This article was originally published in The Commissioning Review.