As a general rule, inspectors are not popular – at least not among those who they are inspecting.
But then good inspectors know that their job is not always to win hearts and minds, but to call things as they find them in the wider public interest, even if they ruffle a few feathers in the process.
And that principle must certainly have been in the back of the mind of those on the selection panel when they appointed Steve Field to become England’s first chief inspector of GPs last year.
They needed someone tough enough to devise and implement the first comprehensive performance assessment and management regime for a notoriously independent and recalcitrant profession.
They needed someone who was part of the profession but not bound by its vested interests. And they needed someone who understood that – in politics rather than medicine – just because a doctor tells you something doesn’t always mean it is in your best interests.
And Dr Field, an engaging but undeniably tough Birmingham GP, fitted the bill rather well. The former chair of the Royal College of GPs had already survived a baptism by fire when he led the independent review into the Government’s highly controversial health reforms in 2011.
His NHS Future Forum proved to be admirably robust and did much to improve the mess that was the Health and Social Care Act. But along the way he faced professional (and sometimes personal) attacks from both sides that wanted to influence him by means fair and sometimes foul.
Looking back now he describes that time as “the hardest I’ve ever worked” before adding “since I came here”. “It was the first time I’d done anything really political rather than clinical,” he says.
“I was independent and having to stand up to some of the politicians who wanted to do things one way or the other. But when the Prime Minister asks you to do something, that’s what you do.
“It doesn’t mean politically you are for or against anything. But people make assumptions.”
In his new job he is fully aware that when his new GP inspection regime goes live in October he could be in the firing line again. Teams of five people – including a GP, a practice manager or nurse and an “expert patient” – will visit every GP surgery in the country and for the first time rate them as outstanding, good, needs improvement or inadequate. Those judged inadequate will be placed in to special measures and will be shut down if things don’t improve. And that could prove very controversial – locally and even nationally.
Already, trial inspections have shown that a small, but significant, number of practices are under-performing.
“We are unfortunately seeing some very unacceptable practice,” Dr Field says. “There is also a big variation of care even though the majority is really good. But the poor care affects hundreds of thousands of patients. My aim is to ensure that the public have a really good service whoever they are and wherever they are.”
Dr Field says some of the problems they have been finding recently include out-of-date medicines, drugs not stored at the correct temperatures and some practices not having in place the multi-disciplinary teams needed to deliver proper care.
“The biggest problems we’re finding is medicines management,” he says. “We’re finding a lot of practices that have out of date drugs including emergency medications. Not having drugs is also a problem. If you take your child in for a vaccination you want to know it is being stored properly and know that you’re having the right vaccine.
“But if your child collapses because they are allergic to something in the vaccine you’d like to know that the surgery has got adrenaline to resuscitate you quickly and not wait for an ambulance.”
Dr Field admits that many GPs do not like this level of oversight or criticism of their professional conduct.
“A lot of people had a go at me personally because they thought I was having a go at GPs – but actually if your vaccines are out of the temperature range they might not work. If that’s the case you’re affecting hundreds of children and many adults.
He adds: “There are a fair number of GPs who are scared and there are some who don’t like the principle of being inspected because they’ve been inspected in the past by health authorities or PCTs and often those were not really professional encounters, so their experience is not good in some areas.” But he adds that he is hopeful that when the full inspection regime is up and running the profession will be won round.
“Part of what we’ve got to do is encourage improvement – it’s not just about the bottom 2 per cent. We are learning every day, and by the time we go live in October we will have got there.”
And, interestingly, unlike most chief inspectors, Dr Field will himself be inspected as he is still a partner in a GP practice in Birmingham and still see patients at least one morning a week. But he thinks that is a strength, as he hopes that his inspection regime will be regarded as a way of improving standards in the profession as a whole – of which he very much feels still apart.
“Most GPs probably don’t really know what really bad practice can be like for patients,” he says.
“And if we have got very poor practice – even in small numbers that is not good for the profession as a whole.”
It is too soon to say what new inspection regime will achieve or if – after the scandal of Mid Staff fades – there is the political will to sustain it given how expensive it will be.
But one thing is pretty clear: Steve Field looks resilient enough to call it as it is and is quite prepared not be to liked if that’s what is needed.